Effect of Foster Care Intervention on Trajectories of General and Specific Psychopathology Among Children With Histories of Institutional Rearing: A Randomized Clinical Trial
Open accessAbstract
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.
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Disruptive behavior disorder/externalizing symptoms during childhood and adolescence were lower in foster care youth compared to youth randomized to CAUG.
“Disruptive behavior disorder/externalizing symptoms (e.g., ADHD, conduct disorder) during childhood and adolescence were also lower in foster care youth compared to youth randomized to the CAUG (Humphreys et al., 2015;Wade et al., 2018).”
From Resilience following severe early life neglect: A review of longitudinal evidence from the Bucharest Early Intervention Project (2026) · cites this paper as Wade et al., 2018
The Latent Growth Model of P, INT, and EXT reports significantly fewer externalizing problems in the foster care group than in the care-as-usual group by age 16. It also reports no difference at age 8, so the unqualified claim that symptoms were lower during childhood and adolescence overstates this paper's findings. (LLM, conf=0.88)
Experimental — accuracy not yet measuredFoster care intervention was associated with moderate improvements in externalizing symptoms.
“Strong improvements in attachment disorder symptoms; moderate improvements in externalizing symptoms and adaptive functioning; weak improvements in internalizing symptoms for boys (strong for girls)”
From Resilience following severe early life neglect: A review of longitudinal evidence from the Bucharest Early Intervention Project (2026) · cites this paper as Wade et al., 2018
The intervention showed a sleeper effect on externalizing problems, matching previous analyses.
“Instead, with the exception of externalizing problems for which we observed a sleeper effect consistent with previous analyses in subsets of these data (17,43), we found that the benefits of foster care were similar throughout development.”
From A Comprehensive Multilevel Analysis of the Bucharest Early Intervention Project: Causal Effects on Recovery From Early Severe Deprivation (2023) · cites this paper as [43]
Except for externalizing problems, the benefits of foster care remained similar throughout development.
“Instead, with the exception of externalizing problems for which we observed a sleeper effect consistent with previous analyses in subsets of these data (17,43), we found that the benefits of foster care were similar throughout development.”
From A Comprehensive Multilevel Analysis of the Bucharest Early Intervention Project: Causal Effects on Recovery From Early Severe Deprivation (2023) · cites this paper as [43]
Children with institutional rearing histories tend to have higher average internalizing and externalizing behavior in adolescence.
“Children raised in institutional settings have, on average, higher levels of internalizing and externalizing behavior in adolescence (Colvert et al., 2008; Humphreys et al., 2015; Wade, Fox, Zeanah, & Nelson, 2018) as well as high rates of inattention and over-activity, particularly among males (Humphreys et al., 2015; Stevens et al., 2008).”
From Early caregiving quality predicts consistency of competent functioning from middle childhood to adolescence following early psychosocial deprivation (2021) · cites this paper as Wade, Fox, Zeanah, & Nelson, 2018
Measurement invariance over time for the psychopathology factors was established in a previous investigation.
“This previous study established measurement invariance on these factors over time.”
From Telomere Length and Psychopathology: Specificity and Direction of Effects Within the Bucharest Early Intervention Project (2020) · cites this paper as [31]
The latent psychopathology factors were successfully reproduced at both time points, and measurement invariance had been previously demonstrated.
“we were able to successfully reproduce the latent psychopathology factors at both time points and have previously demonstrated measurement invariance.31”
From Telomere Length and Psychopathology: Specificity and Direction of Effects Within the Bucharest Early Intervention Project (2020) · cites this paper as [31]
Neglect confers significant risk for psychopathology.
“Neglect confers significant risk for psychopathology (Wade et al., 2018)”
From Adolescent cognitive control and mediofrontal theta oscillations are disrupted by neglect: Associations with transdiagnostic risk for psychopathology in a randomized controlled trial (2020) · cites this paper as Wade et al., 2018
Removal from neglect early in life did not yield differences in transdiagnostic risk for psychopathology by age 8, but instead impacted the developmental trajectory of such risk across the adolescent period.
“removal from neglect early in life did not yield differences in transdiagnostic risk for psychopathology by mid-to-late childhood (age 8), but instead impacted the developmental trajectory of such risk across the adolescent period”
From Adolescent cognitive control and mediofrontal theta oscillations are disrupted by neglect: Associations with transdiagnostic risk for psychopathology in a randomized controlled trial (2020) · cites this paper as Wade et al., 2018
Recent work demonstrates that neglect confers broad risk for psychopathology that cuts across diagnostic boundaries.
“recent work demonstrates that neglect confers broad risk for psychopathology that cuts across diagnostic boundaries (Wade et al., 2018)”
From Adolescent cognitive control and mediofrontal theta oscillations are disrupted by neglect: Associations with transdiagnostic risk for psychopathology in a randomized controlled trial (2020) · cites this paper as Wade et al., 2018
Removal from neglect yielded greater decreases in transdiagnostic risk across the adolescent period, such that significant differences became apparent by age 16.
“Removal from neglect yielded greater decreases in transdiagnostic risk across the adolescent period, such that significant differences became apparent by age 16 (Wade et al., 2018).”
From Adolescent cognitive control and mediofrontal theta oscillations are disrupted by neglect: Associations with transdiagnostic risk for psychopathology in a randomized controlled trial (2020) · cites this paper as Wade et al., 2018
Wade et al. (2018) reported a sleeper effect in which the benefits of removal from neglect were not fully apparent until much later in development.
“Wade et al. (2018) reported on a so called “sleeper effect”, in which the benefits of removal from neglect were not fully apparent until much later in development.”
From Adolescent cognitive control and mediofrontal theta oscillations are disrupted by neglect: Associations with transdiagnostic risk for psychopathology in a randomized controlled trial (2020) · cites this paper as Wade et al., 2018
Delayed benefits of foster care have previously been reported by Wade et al. (2018) in relation to adolescent psychopathology.
“Moreover, we note that such delayed benefits of foster care have previously been reported by Wade et al. (2018) in relation to adolescent psychopathology.”
From Adolescent cognitive control and mediofrontal theta oscillations are disrupted by neglect: Associations with transdiagnostic risk for psychopathology in a randomized controlled trial (2020) · cites this paper as Wade et al., 2018
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“Changes in resilient outcomes in various domains (e.g., psychopathology, executive functioning) across childhood and adolescence have been examined (King et al., 2023; Wade et al., 2018, 2019, 2020b).”
Self-citation
- Authors
- Wade, M., Fox, N. A., Zeanah, C. H., & Nelson, C. A.
- Affiliations
- Boston Children's Hospital (US)
- University of Maryland, College Park (US)
- Tulane University (US)
- Corresponding author
- Wade, Mark
- Venue
- JAMA Psychiatry
- Publisher
- American Medical Association (AMA)
- Published
- 2018-11-01
- Volume
- 75
- Issue
- 11
- Pages
- 1137
- ISSN
- 2168-622X (ISSN-L)
- PMC
- PMC6248099
- OpenAlex
- W2899819028
- Cited by
- 74
- References
- 41
- Citations by year
- 2026: 3 · 2025: 6 · 2024: 8 · 2023: 12 · 2022: 13 · 2021: 15 · 2020: 8 · 2019: 9
- FWCI
- 15.94
- Type
- journal article
- Language
- en
- Open access
- bronze
- doi.org
- Locations
- JAMA Psychiatry (publishedVersion)
- PubMed Central (publishedVersion)
- PubMed (publishedVersion)
- Funders
- National Institute of Mental Health (R01MH091363)
- Topics
- Social Sciences › Safety Research › Child Welfare and Adoption
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Keywords
- foster care, institutional upbringing, child psychopathology, general psychopathology, internalizing problems, externalizing problems, child development trajectories, child mental health outcomes, adolescence, middle childhood
- MeSH terms
- Adolescent, Behavioral Symptoms, Child, Female, Foster Home Care, Humans, Institutionalization, Internal-External Control, Longitudinal Studies, Male, Psychopathology, Romania, Orphanages
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