The Effects of Early Psychosocial Deprivation on Brain and Behavioral Development

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.

The Bucharest Early Intervention Project seeks to:

Examine the effects of institutionalization on the brain and behavioral development of young children

Determine if these effects can be remediated through intervention, in this case: foster care

Project Background

1989: The fall of the Ceausescu regime

170,000 children reside in state institutions
Poverty #1 reason for child abandonment (UNICEF)
Following fall of Ceausescu regime, large numbers of children adopted internationally Families not prepared for range of disabilities that afflicted these children

Children adopted from institutions demonstrate a number of problems, such as:

Disturbances and delays in social/emotional development (particularly attachment) Aggressive behavior problems Inattention/hyperactivity Syndrome that mimics autism Growth stunting (see next slide)*
* Sir Michael Rutter argues that this collection of behaviors should be considered a syndrome.

17 year old girl

14 year old girl

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

Study Design (cont)

Following baseline assessment, children assessed comprehensively at 9, 18, 30, and 42 monthsa limited 54 month assessment was performedan extensive assessment was performed at age 8, and another is in the works at age 12.

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

Key Characteristics of Foster Care Intervention

Foster Parent Training & Licensing Staff Support and Development Links to Permanency Planning Material Support Medical Support Ongoing Monitoring Family Support No Daycare

Ethical Considerations

Why was the BEIP conducted in Romania?

Tens of thousands of institutionalized young children mostly abandoned very early Opportunity to study importance of early experiences in young children

Invited to conduct study by Minister for Child Protection

Romanian interest in developing policies for intervening with abandoned children institutional care versus foster care

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

Point 1: Mean Developmental Quotient at Baseline

120 100 80 Mean DQ 60
Insitutionalized Group

100 74

Never Institutionalized Group

40
20 0 Baseline

Point 2: What happens to DQ/IQ at 42 months of age for all 3 groups?

120
Care As Usual Group

100

Mean DQ/IQ

80
60 40 20 0 42 Months

103

Foster Care Group

86
77

Never Institutionalized Group

CAUG FCG NIG

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

Summary of Cognitive Development

Institutionalization has a very detrimental effect.
Foster care appears to be effective in improving cognitive function for those children placed before

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.

What happens at age 8?

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

Descriptive Statistics for WISC Scores at 8 Years of Age

FCG (n=54) CAU (n=51) NIG (n=38)

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

No difference between CAUG and FCG

Disruptive Behavior Disorders

20% 15%

No difference between CAUG and FCG

10%
5%

0%
ODD/CD CAUG FCG NIG

Depression
5% 4%

CAUG vs FCG OR=2.3

3%
2% 1% 0%

Depression CAUG FCG

Any Anxiety Disorder

50%
40% 30% 20% 10%

CAUG vs FCG OR=2.9

0%
Any anxiety disorder CAUG FCG

Gender differences in psychiatric symptoms

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

We found no significant effect of timing of placement on rates of psychopathology or impairment

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.