Effect of Foster Care Intervention on Trajectories of General and Specific Psychopathology Among Children With Histories of Institutional Rearing: A Randomized Clinical Trial

Abstract

Importance: It is unclear whether early institutional rearing is associated with more problematic trajectories of psychopathology from childhood to adolescence and whether assignment to foster care mitigates this risk.

Objectives: To examine trajectories of latent psychopathology factors-general (P), internalizing (INT), and externalizing (EXT)-among children reared in institutions and to evaluate whether randomization to foster care is associated with reductions in psychopathology from middle childhood through adolescence.

Design, setting, and participants: This longitudinal, intent-to-treat randomized clinical trial was conducted in Bucharest, Romania, where children residing in 6 institutions underwent baseline testing and were then randomly assigned to a care as usual group (CAUG) or a foster care group (FCG). A matched sample of a never-institutionalized group (NIG) was recruited to serve as a comparison group. The study commenced in April 2001, and the most recent (age 16 years) follow-up started in January 2015 and is ongoing.

Intervention: Institutionally reared children randomized to high-quality foster homes.

Main outcomes and measures: Psychopathology was measured using the MacArthur Health and Behavior Questionnaire. Teachers and/or caregivers reported on symptoms of psychopathology in several domains.

Results: A total of 220 children (50.0% female; 119 ever institutionalized) were included in the analysis at the mean ages of 8, 12, and 16 years. A latent bifactor model with general (P) and specific internalizing (INT) and externalizing (EXT) factors offered a good fit to the data. At age 8 years, CAUG (mean, 0.41; 95% CI, 0.17-0.67) and FCG (mean, 0.30; 95% CI, 0.04-0.53) had higher P than NIG (mean, -0.40; 95% CI, -0.56 to -0.18). By age 16 years, FCG (mean, 0.07; 95% CI, -0.18 to 0.29) had lower P than CAUG (mean, 0.37; 95% CI, 0.13-0.60). This effect was likely driven by modest declines in P from age 8 years to age 16 years among FCG (slope, -0.12; 95% CI, -0.26 to 0.04) compared with CAUG, who remained stably high over this period (slope, -0.02; 95% CI, -0.19 to 0.14). Moreover, CAUG and FCG showed increasing divergence in EXT over time, such that FCG (mean, -0.30; 95% CI, -0.58 to -0.02) had fewer problems than CAUG (mean, 0.05; 95% CI, -0.25 to 0.36) by age 16 years. No INT differences were observed.

Conclusions and relevance: Institutionalization increases transdiagnostic vulnerability to psychopathology from childhood to adolescence, a period of significant social and biological change. Early assignment to foster care partially mitigates this risk, thus highlighting the importance of social enrichment in buffering the effects of severe early neglect on trajectories of psychopathology.

Trial registration: ClinicalTrials.gov Identifier: NCT00747396.

Conflict of interest statement

Conflict of Interest Disclosures: Dr Fox reported receiving grant support from the National Institute of Mental Health, Eunice Kennedy Shriver National Institute of Child Health and Human Development, National Science Foundation, Environmental Influences on Child Health Outcomes (ECHO) Consortium, Russell Sage Foundation, Lumos Foundation, and Institute for Mental Hygiene; reported receiving royalties from Guilford Press and Harvard University Press; and reported receiving honoraria for lectures to professional audiences. Dr Zeanah reported receiving grant support from the National Institute of Mental Health, Palix Foundation, Irving Harris Foundation, Substance Abuse and Mental Health Services Administration, Lumos Foundation, and Institute for Mental Hygiene; reported receiving royalties from Guilford Press and Harvard University Press; and reported receiving honoraria for lectures to professional audiences. Dr Nelson reported receiving grant support from the National Institutes of Health, Jacobs Foundation, John D. and Catherine T. MacArthur Foundation, James S. McDonnell Foundation, Binder Family Foundation, Lumos Foundation, and Harvard University; reported receiving royalties from MIT Press and Harvard University Press; reported receiving honoraria for lectures to professional audiences; and reported receiving legal consulting fees. No other disclosures were reported.

Figures

Figure 1.. CONSORT Flow Diagram

Group assignment and follow-up measurement in the randomized clinical trial. BEIP indicates Bucharest Early Intervention Project; CAUG, care as usual group; FCG, foster care group; HBQ, MacArthur Health and Behavior Questionnaire; and NIG, never-institutionalized group.

Figure 2.. Latent Structure of Psychopathology as Estimated Using Latent Bifactor Modeling

In this conceptual model, all domains of psychopathology are set to load onto general (P) and their specific internalizing (INT) and externalizing (EXT) factors simultaneously. These factors are forced to orthogonality during model estimation. At each age (8, 12, and 16 years), this model offered the best fit to the data, and the pattern of loadings was similar (results are presented in eTable 4 in Supplement 1). ADHD indicates attention-deficit/hyperactivity disorder.

Figure 3.. Latent Growth Model Showing Trajectories of Psychopathology Across Groups

Trajectories of general (P) (A), internalizing (B), and externalizing (C) psychopathology from age 8 years to age 16 years. Bars represent observed means at each age. Lines represent model-estimated trajectories. Error bars are standard errors.