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Charles A. Nelson III Professor of Pediatrics and Neuroscience Harvard Medical School Richard David Scott Chair Childrens Hospital Boston
Broad Context
World-wide, there are 70 to 100 MILLION orphaned or abandoned children, at least 8 MILLION of whom live in institutions And, as war and AIDS continues to ravage the planet, as well as the world-wide recession, must anticipate number of orphaned or abandoned children will only increase.
Determine if these effects can be remediated through intervention, in this case: foster care
Project Background
Study Design
First ever randomized controlled trial of foster care as intervention for social deprivation associated with institutionalization Began with >180 children but after pediatric exam narrowed this to 136 institutionalized children between 6 and 31 months initially assessed at baseline (Mean Age=20 months)
68 randomly assigned to remain in institution (CAUG) 68 randomly assigned to foster care (FCG)
Also recruited 72 never-institutionalized children (NIG) matched on age and gender serve as controls
Domains of Assessment
Physical Development
Language
Social Functioning/Social-Emotional Development Characterization of Caregiving Environment
Cognition
Temperament Attachment Brain Function (EEG, ERP) Brain Anatomy (MRI) Genetics/Epigenetics Mental Health Problems
Ethical Considerations
Tens of thousands of institutionalized young children mostly abandoned very early Opportunity to study importance of early experiences in young children
Ethical Issues
Could not identify enough foster care families for all children and thus, were permitted to do random assignment of only some children Received permission from local authorities, caregivers, and all US institutions Implemented policy of non-interference when possible, children changed from original group assignment (e.g., from institutional care to family care)
Study Findings
Cognitive Development
Assessed at baseline using Bayley Scales of Infant Development (BSID) The Bayley measures a child's level of development in three domains: cognitive, motor, and behavioral
100 74
40
20 0 Baseline
100
Mean DQ/IQ
80
60 40 20 0 42 Months
103
86
77
N 57 61 52
Point 3: How does DQ/IQ differ for children in foster care as a function of age at placement?
100 95 90 DQ/IQ 85 80 75 70 0-18 18-24 24-30 30+
0-18 18-24 24-30 30+ N 14 16 22 9
Age at placement
age 2.
Duration of time in foster care does not influence outcome; effects carried by timing.
Nelson, C.A., Zeanah, C.H., Fox, N.A., Marshall, P.J., Smyke, A., & Guthrie, D. (2007). Cognitive recovery in socially deprived young children: The Bucharest Early Intervention Project. Science, 318, 1937-1940.
Used the Wechsler Intelligence Scale for Children (WISC-IV) This is a detailed IQ test that provides information about specific cognitive domains as well as a full scale IQ score
Variable
M (SD)
M (SD)
M (SD)
Verbal Comprehension
Perceptual Reasoning
87.48 (15.87)
83.81 (13.87)
81.22 (13.98)
82.30 (14.61)
110.18 (18.95)
106.79 (15.32)
Working Memory
87.80 (15.49)
83.88 (13.87)
108.92 (16.29)
Processing Speed
81.19 (12.92)
78.38 (11.72)
91.76 (14.16)
Full Scale IQ
81.46 (15.32)
76.16 (14.11)
107.00 (16.54)
Fox, N.A., Almas, A.N., Degnan, K.A., Nelson, C.A., & Zeanah, C.H. (2011). The effects of severe psychosocial deprivation and foster care intervention on cognitive development at 8 years of age: Findings from the Bucharest Early Intervention Project. Journal of Child Psychology and Psychiatry, 52(9), 919928.
Interim Summary
Earlier effects appear to carry forward in large part to age 8 years, although Has been a bit of decline in the FCG and Has been a bit of an increase in CAUG.
BUT, this is also a different test than used at earlier ages so it is hard to compare 8 year data with earlier data.
Psychiatric Morbidity
Did the foster care intervention decrease the rates of psychiatric disorders for ever institutionalized children?
ADHD
25%
20% 15% 10% 5% 0% ADHD CAUG FCG NIG
10%
5%
0%
ODD/CD CAUG FCG NIG
Depression
5% 4%
3%
2% 1% 0%
0%
Any anxiety disorder CAUG FCG
Girls in both the IG and FCG groups had significantly fewer psychiatric symptoms and disorders than boys In the foster care group, girls showed greater reduction in overall emotional disorder symptoms, and anxiety symptoms, in particular, than boys In fact, the vast majority of reduction psychopathology with the foster care intervention can be accounted for by responses in the girls, not the boys
Timing of Placement
Summary
Higher rates of psychiatric disorders and impairment in children who have been institutionalized compared with children in the community No significant difference in rates of ADHD or disruptive behavior disorders in children in the institution versus those in foster care Children in the foster care group had significantly lower rates of emotional disorders, anxiety disorders, RAD, and impairment (trend) than children who remained in the institution Being a girl may be a protective factor No evidence of effects of timing on rates of psychopathology or impairment
Zeanah, C.H., Egger, H.L., Smyke, A.T., Nelson, C.A., Fox, N.A., Marshall, P.J., & Guthrie, D. (2009). Altering early experiences reduces psychiatric disorders among institutionalized Romanian preschool children. American Journal of Psychiatry, 166, 777-785.
Conclusions
Children raised in institutions during early development demonstrate significantly impaired physical, cognitive, language, social-emotional, and brain development compared to community children Insofar as we have been able to look at our data, our model of foster care as an intervention appears to effectively ameliorate many of the negative sequelae of institutionalization Although not allfor example, we are seeing only small effects on executive functions. Which is consistent with our mental health outcomes (e.g., high prevalence of ADHD and no effect of foster care)
General Conclusions
Institutional care has a very deleterious effect on nearly all aspects of brain, biological and psychological development Placing previously institutionalized children into families improves overall level of functioning. Although extent of recovery in some domains regulated by timing (age at placement)
Based on these findings, we may wish to think about whether orphaned or abandoned children should ever be placed in institutions, at least early in life.