Effects of institutional rearing and foster care on psychopathology at age 12 years in Romania: follow-up of an open, randomised controlled trial
Open accessAbstract
Background Early social deprivation can negatively affect domains of functioning. We examined psychopathology at age 12 years in a cohort of Romanian children who had been abandoned at birth and placed into institutional care, then assigned either to be placed in foster care or to care as usual.Methods We used follow-up data from the Bucharest Early Intervention Project (BEIP), a randomised controlled trial of abandoned children in all six institutions for young children in Bucharest, Romania. In the initial trial, 136 children, enrolled between ages 6-31 months, were randomly assigned to either care as usual or placement in foster care. In this study we followed up these children at age 12 years to assess psychiatric symptoms using the Diagnostic Interview Schedule for Children (4th edition; DISC-IV). We also recruited Romanian children who had never been placed in an institution from paediatric clinics and schools in Bucharest as a comparator group who had never been placed in an institution. The primary outcome measure was symptom counts assessed through DISC-IV scores for three domains of psychopathology: internalising symptoms, externalising symptoms, and attention-deficit hyperactivity disorder (ADHD). We compared mean DISC-IV scores between trial participants and comparators who had never been placed in an institution, and those assigned to care as usual or foster care. Analyses were done by modified intention to treat. This trial is registered with ClinicalTrials.gov, number NCT00747396.Findings We followed up 110 children from the BEIP trial between Jan 27, 2011, and April 11, 2014, and 49 children as comparators who had never been placed in an institution. The 110 children who had ever been placed in an institution had higher symptom counts for internalising disorders (mean 0·93 [SD 1·68] vs 0·45 [0·84], difference 0·48 [95% CI 0·14-0·82]; p=0·0127), externalising disorders (2·31 [2·86] vs 0·65 [1·33], difference 1·66 [1·06-2·25]; p<0·0001), and ADHD (4·00 [5·01] vs 0·71 [1·85], difference 3·29 [95% CI 2·39-4·18]; p<0·0001) than did children who had never been placed in an institution. Compared with 55 children randomly assigned to receive care as usual, the 55 children in the foster-care group had fewer externalising symptoms (mean 2·89 [SD 3·00] for care as usual vs 1·73 [2·61] for foster care, difference 1·16 [95% CI 0·11 to 2·22]; p=0·0255), but symptom counts for internalising disorders (mean 1·00 [1·59] for care as usual vs 0·85 [1·78] for foster care, difference 0·15 [-0·35 to 0·65]; p=0·5681) and ADHD (mean 3·76 [4·61] for care as usual vs 4·24 [5·41] for foster care, difference -0·47 [-2·15 to 1·20; p=0·5790) did not differ. In further analyses, symptom scores substantially differed by stability of foster-care placement.Interpretation Early foster care slightly reduced the risk of psychopathology in children who had been living in institutions, but long-term stability of foster-care placements is an important predictor of psychopathology in early adolescence.Funding National Institute of Mental Health and the John D and Catherine T MacArthur Foundation.
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Neglect, particularly prevalent in those with a history of institutional care, has been linked to distinct stress physiology, including dysregulation of the hypothalamic-pituitary-adrenal (HPA) axis, especially in ways that could affect metabolic regulation.
“However, neglect, which is particularly prevalent in those with a history of institutional care, has been linked to distinct stress physiology, including dysregulation of the hypothalamic–pituitary–adrenal (HPA) axis (Humphreys et al., 2015; McLaughlin et al., 2014), especially in ways that could affect metabolic regulation.”
From Long-term cardiometabolic effects of early institutionalization and foster care: Evidence from the Bucharest Early Intervention Project (2026) · cites this paper as Humphreys et al., 2015
Split into 2 atoms — 0 confirmed, 2 partially supported, 0 disputed, 0 misattributed, 0 unverifiable. Expand the claim to see per-atom verdicts.
Experimental — accuracy not yet measuredDisruptive 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 Humphreys et al., 2015
The Results (page not available in our copy) report fewer externalising symptoms at age 12 in children randomized to foster care than in the care-as-usual group; the Discussion says this difference was accounted for by boys. The broader claim of lower disruptive-behavior symptoms throughout childhood and adolescence is not established by this follow-up, and the Results explicitly report no foster-care versus care-as-usual difference in ADHD symptoms. (LLM, conf=0.90)
Experimental — accuracy not yet measuredEarly factors (e.g., neural patterns, caregiving quality, placement stability, executive functioning) during childhood have been shown to later predict resilience outcomes (e.g., psychopathology, cognition) during adolescence.
“Early factors (e.g., neural patterns, caregiving quality, placement stability, executive functioning) during childhood have been shown to later predict resilience outcomes (e.g., psychopathology, cognition) during adolescence (Debnath et al., 2020;Humphreys et al., 2015;McDermott et al., 2013;Sheridan 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 Humphreys et al., 2015
The Discussion says stable, high-quality foster care predicted reduced psychopathology at age 12 among children who had experienced early institutional deprivation. The cited paper does not establish the sentence’s other examples—neural patterns or executive functioning as predictors, or cognition as an adolescent outcome. (LLM, conf=0.87)
Experimental — accuracy not yet measuredThe 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 [17]
The Introduction reports no foster-care effect on externalising symptoms at 54 months, while the age-12 Findings report fewer externalising symptoms in the foster-care group. The Discussion says this later finding *might* represent a sleeper effect, rather than establishing that it did. Our copy also does not establish the claimed consistency with previous analyses of subsets of these data. (LLM, conf=0.86)
Experimental — accuracy not yet measuredAmong children who received the intervention, individual differences in the timing of placement into foster care between 6 and 33 months and in placement stability were associated with outcomes in several areas.
“Consistent with previous analyses of discrete timepoints and domains (15-17, 19, 29), we found that, among children who received the intervention, individual differences in timing of placement into foster care between the ages of 6-33 months and the stability of this placement were associated with outcomes in several areas.”
From A Comprehensive Multilevel Analysis of the Bucharest Early Intervention Project: Causal Effects on Recovery From Early Severe Deprivation (2023) · cites this paper as [17]
The Discussion reports that placement stability was associated with internalising and externalising symptoms among children assigned to foster care. It does not report an association between outcomes and differences in the timing of foster-care placement between 6 and 33 months; its findings are limited to psychopathology rather than outcomes across several areas. (LLM, conf=0.84)
Experimental — accuracy not yet measured
Foster 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 Humphreys et al., 2015
Within the foster care group, stability of placement with the original study-sponsored foster family has been previously linked with children's outcomes.
“Within the foster care group, the stability of placement with the original study-sponsored foster family has been previously linked with children's outcomes (17,22).”
From A Comprehensive Multilevel Analysis of the Bucharest Early Intervention Project: Causal Effects on Recovery From Early Severe Deprivation (2023) · cites this paper as [17]
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 [17]
Children with histories of severe neglect show marked problems in many other domains, including psychopathology, social competence, emotional reactivity, and academic achievement.
“children with histories of severe neglect show marked problems in many other domains, including psychopathology (34), social competence (35), emotional reactivity (36), and academic achievement (37)”
From Long-term effects of institutional rearing, foster care, and brain activity on memory and executive functioning (2019) · cites this paper as [34]
In prior work, the authors found that foster care reduced externalizing psychopathology among BEIP children, with the effect confined to boys.
“Previously, we demonstrated a reduction in externalizing psychopathology for BEIP children randomized to foster care,12 which was limited to boys.”
From High-quality foster care mitigates callous-unemotional traits following early deprivation in boys: a Randomized Controlled Trial (2015) · cites this paper as [12]
A recent study found that children who remained in stable foster care had improved mental health outcomes compared to those who had multiple disruptions in their care.
“A recent study found that children who remained in stable foster care had improved mental health outcomes compared to those who had multiple disruptions in their care”
From Normalization of EEG activity among previously institutionalized children placed into foster care: A 12-year follow-up of the Bucharest Early Intervention Project (2016) · cites this paper as Humphreys et al., 2015
Stability of care decreased internalizing and externalizing symptoms in this sample at 12 years.
“stability of care decreased internalizing and externalizing symptoms in this sample at 12 years (Humphreys et al., 2015).”
From Normalization of EEG activity among previously institutionalized children placed into foster care: A 12-year follow-up of the Bucharest Early Intervention Project (2016) · cites this paper as Humphreys et al., 2015
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 Humphreys et al., 2015
Children with institutional rearing histories have high rates of inattention and over-activity, particularly males.
“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 Humphreys et al., 2015
Disruptions in attachment and affective development contribute to high internalizing psychopathology among children raised in deprived early environments.
“These disruptions in attachment and affective development contribute to high levels of internalizing psychopathology among children raised in deprived early environments.(31, 38–40)”
From Neglect as a violation of species-expectant experience: neurodevelopmental consequences (2017) · cites this paper as [40]
Children raised in deprived environments exhibit elevations in anxiety, depression, ADHD, aggression, and substance abuse.
“Children raised in deprived environments exhibit elevations in many forms of psychopathology, including anxiety, depression, ADHD, aggression, and substance abuse.(38, 40, 139)”
From Neglect as a violation of species-expectant experience: neurodevelopmental consequences (2017) · cites this paper as [40]
ADHD is strongly associated with institutional rearing and persists after removal from institutional care after age 6 months.
“ADHD is strongly associated with institutional rearing and persists following removal from institutional care after the age of 6 months.(38, 40, 140)”
From Neglect as a violation of species-expectant experience: neurodevelopmental consequences (2017) · cites this paper as [40]
Additional domains improved in children randomized out of institutional care include physical growth, attachment, stress reactivity, and internalizing symptoms.
“Additional domains that improved in children randomized out of institutional care include physical growth, attachment, stress reactivity, and internalizing symptoms.(34, 38, 40, 146)”
From Neglect as a violation of species-expectant experience: neurodevelopmental consequences (2017) · cites this paper as [40]
Internalizing psychopathology following early deprivation improves after removal from a deprived environment.
“In contrast, internalizing psychopathology following early deprivation improves following removal from a deprived environment(38, 40)”
From Neglect as a violation of species-expectant experience: neurodevelopmental consequences (2017) · cites this paper as [40]
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Self-citationEpigenetic correlates of neonatal contact in humans
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Early deprivation alters structural brain development from middle childhood to adolescence
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Social Origins of Developmental Risk for Mental and Physical Illness
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Future Directions in the Study and Treatment of Parent–Child Separation
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Self-citationEarly deprivation, atypical brain development, and internalizing symptoms in late childhood
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Self-citationNeurodevelopmental mechanisms linking ACEs with psychopathology
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“These results are inconsistent with those examining psychopathology outcomes in our sample at age 12 (Humphreys et al., 2015), where those children who remained in their initial foster care home showed fewer psychiatric symptoms.”
ResultSelf-citationStressful Life Events, ADHD Symptoms, and Brain Structure in Early Adolescence
Humphreys, K., Watts, E. L., Dennis, E., King, L. S., Thompson, P., & Gotlib, I. (2018) · Journal of Abnormal Child Psychology · doi:10.1007/s10802-018-0443-5 · Cited by 61 · see citing works
Self-citationStress sensitization among severely neglected children and protection by social enrichment
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Self-citationThe neglect–enrichment continuum: Characterizing variation in early caregiving environments
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Genome-wide Signatures of Early-Life Stress: Influence of Sex
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Early adversity alters brain architecture and increases susceptibility to mental health disorders
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Self-citationVanTieghem, M., Gabard-Durnam, L. J., Goff, B., Flannery, J., Humphreys, K. L., Telzer, E. H., Caldera, C., Louie, J., Shapiro, M., Bolger, N. P., et al. (2017) · Development and Psychopathology · doi:10.1017/s0954579417000153 · Cited by 53 · see citing works
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Humphreys, K. L., Esteves, K., Zeanah, C. H., Fox, N. A., Nelson, C. A., & Drury, S. S. (2016) · Psychiatry Research · doi:10.1016/j.psychres.2016.09.023 · Cited by 50 · see citing works
Self-citationUNPACKING THE BURDEN OF CARE FOR INFANTS IN THE NICU
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Vigilance, the Amygdala, and Anxiety in Youths With a History of Institutional Care
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Humphreys, K. L., Miron, D., McLaughlin, K. A., Sheridan, M. A., Nelson, C. A., Fox, N. A., & Zeanah, C. H. (2018) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12865 · Cited by 44 · see citing works
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Perceptions of Children in Residential Care Homes: A Critical Review of the Literature
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Humphreys, K. L., McGoron, L., Sheridan, M. A., McLaughlin, K. A., Fox, N. A., Nelson, C. A., & Zeanah, C. H. (2015) · Journal of the American Academy of Child & Adolescent Psychiatry · doi:10.1016/j.jaac.2015.09.010 · Cited by 41 · see citing works
“Previously, we demonstrated a reduction in externalizing psychopathology for BEIP children randomized to foster care, 12 which was limited to boys.”
BackgroundSelf-citationWade, M., Parsons, J., Humphreys, K. L., McLaughlin, K. A., Sheridan, M. A., Zeanah, C. H., Nelson, C. A., & Fox, N. A. (2022) · Child Development Perspectives · doi:10.1111/cdep.12462 · Cited by 40 · see citing works
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Self-citationGuyon‐Harris, K. L., Humphreys, K. L., Degnan, K. A., Fox, N. A., Nelson, C. A., & Zeanah, C. H. (2018) · Attachment & Human Development · doi:10.1080/14616734.2018.1499208 · Cited by 38 · see citing works
Self-citationCaregiver–child proximity as a dimension of early experience
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Troller-Renfree, S., McLaughlin, K. A., Sheridan, M. A., Nelson, C. A., Zeanah, C. H., & Fox, N. A. (2017) · Biological Psychology · doi:10.1016/j.biopsycho.2016.04.008 · Cited by 35 · see citing works
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Self-citationJacobsen, H., Bergsund, H. B., Wentzel‐Larsen, T., Smith, L., & Moe, V. (2019) · Children and Youth Services Review · doi:10.1016/j.childyouth.2019.104603 · Cited by 34 · see citing works
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Self-citationInterventions that address institutional child maltreatment: An evidence and gap map
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Köpetz, C., Woerner, J. I., MacPherson, L., Lejuez, C. W., Nelson, C. A., Zeanah, C. H., & Fox, N. A. (2018) · Journal of Experimental Psychology General · doi:10.1037/xge0000486 · Cited by 31 · see citing works
Self-citationKing, L. S., Guyon-Harris, K. L., Valadez, E. A., Radulescu, A., Fox, N. A., Nelson, C. A., Zeanah, C. H., & Humphreys, K. L. (2023) · American Journal of Psychiatry · doi:10.1176/appi.ajp.20220672 · Cited by 29 · see citing works
“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.”
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Self-citationThe Developmental Origins of Opioid Use Disorder and Its Comorbidities
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Humphreys, K. L., Guyon-Harris, K. L., Tibu, F., Wade, M., Nelson, C. A., Fox, N. A., & Zeanah, C. H. (2020) · Journal of Consulting and Clinical Psychology · doi:10.1037/ccp0000613 · Cited by 26 · see citing works
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Dimensions of the language environment in infancy and symptoms of psychopathology in toddlerhood
King, L. S., Querdasi, F. R., Humphreys, K. L., & Gotlib, I. H. (2021) · Developmental Science · doi:10.1111/desc.13082 · Cited by 25 · see citing works
Self-citationA Comparison of Foster Care Reentry After Adoption in Two Large U.S. States
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Gayapersad, A., Ombok, C., Kamanda, A., Tarus, C., Ayuku, D., & Braitstein, P. (2019) · Child & Youth Care Forum · doi:10.1007/s10566-019-09506-8 · Cited by 21 · see citing works
Epigenetic mechanisms linking early-life adversities and mental health
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Children's Attention and Self-Regulatory Behavior Before and During the COVID-19 Pandemic
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Adverse caregiving in early life: The trauma and deprivation distinction in young children
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Self-citationFamily foster care and children’s outcomes in China: Evidence from a scoping review
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Friendship and social functioning following early institutional rearing: The role of ADHD symptoms
Humphreys, K. L., Gabard-Durnam, L. J., Goff, B., Telzer, E. H., Flannery, J., Gee, D. G., Park, V., Lee, S. S., & Tottenham, N. (2018) · Development and Psychopathology · doi:10.1017/s0954579418001050 · Cited by 12 · see citing works
Self-citation
- Authors
- Humphreys, K. L., Gleason, M. M., Drury, S. S., Miron, D., Nelson, C. A., Fox, N. A., & Zeanah, C. H.
- Affiliations
- Tulane University (US)
- Boston Children's Hospital (US)
- University of Maryland, College Park (US)
- Corresponding author
- Zeanah, Charles H
- ORCID
- Venue
- The Lancet Psychiatry
- Publisher
- Elsevier BV
- Published
- 2015-07
- Volume
- 2
- Issue
- 7
- Pages
- 625-634
- ISSN
- 2215-0366 (ISSN-L)
- PMC
- PMC4550037
- OpenAlex
- W2140775007
- Cited by
- 199
- References
- 42
- Citations by year
- 2026: 10 · 2025: 14 · 2024: 17 · 2023: 17 · 2022: 13 · 2021: 21 · 2020: 25 · 2019: 23 · 2018: 22 · 2017: 20 · 2016: 12 · 2015: 5
- FWCI
- 56.96
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- The Lancet Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- PubMed Central (acceptedVersion)
- Funders
- John D. and Catherine T. MacArthur Foundation
- National Institute of Mental Health (R01MH091363, MH091363)
- Topics
- Social Sciences › Safety Research › Child Welfare and Adoption
- Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Keywords
- institutional upbringing, foster care, institutionalized children, child abandonment, psychopathology, internalizing disorders, externalizing disorders, attention deficit hyperactivity disorder, Bucharest Early Intervention Project, child mental health, Romanian children, early intervention, child welfare policy
- MeSH terms
- Mental Disorders, Child, Child, Abandoned, Child, Preschool, Female, Follow-Up Studies, Foster Home Care, Humans, Infant, Male, Romania, Orphanages
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