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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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“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
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“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
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“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
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“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]
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“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]
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“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
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“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]
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“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]
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“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 the citing paper
“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]
In the citing paper
“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
In the citing paper
“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
In the citing paper
“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
In the citing paper
“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
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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]
In the citing paper
“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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“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 44
Self-citationTroller‐Renfree, S. V., Zeanah, C. H., Nelson, C. A., & Fox, N. A. (2017) · Child Development Perspectives · doi:10.1111/cdep.12251 · Cited by 42
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
Self-citationCaregiver–child proximity as a dimension of early experience
Barnett, W., Hansen, C. L., Bailes, L. G., & Humphreys, K. L. (2022) · Development and Psychopathology · doi:10.1017/s0954579421001644 · Cited by 40
Self-citationPham, T. S., Qi, H., Chen, D., Chen, H., & Fan, F. (2021) · Child Abuse & Neglect · doi:10.1016/j.chiabu.2021.105022 · Cited by 36
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
Self-citationLamm, C., Troller‐Renfree, S. V., Zeanah, C. H., Nelson, C. A., & Fox, N. A. (2018) · Neuropsychologia · doi:10.1016/j.neuropsychologia.2018.06.008 · Cited by 38
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
Herrman, H., Humphreys, C., Halperin, S., Monson, K., Harvey, C. A., Mihalopoulos, C., Cotton, S., Mitchell, P. F., Glynn, T., Magnus, A., et al. (2016) · BMC Psychiatry · doi:10.1186/s12888-016-1145-6 · Cited by 36
Drury, S. S., Howell, B., Jones, C., Esteves, K. C., Morin, E. L., Schlesinger, R. P., Meyer, J. S., Baker, K. C., & Sánchez, M. M. (2017) · Development and Psychopathology · doi:10.1017/s0954579417001225 · Cited by 33
Self-citationInterventions that address institutional child maltreatment: An evidence and gap map
Finch, M., Featherston, R., Chakraborty, S., Bjørndal, L. D., Mildon, R. L., Albers, B., Fiennes, C., Taylor, D., Schachtman, R., Yang, T., et al. (2021) · Campbell Systematic Reviews · doi:10.1002/cl2.1139 · Cited by 32
Clemens, V., Bürgin, D., Eckert, A., Kind, N., Dölitzsch, C., Fegert, J. M., & Schmid, M. (2020) · Psychiatry Research · doi:10.1016/j.psychres.2020.112778 · Cited by 31
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 34
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
“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.”
Self-citationNelson, C. A., Fox, N. A., & Zeanah, C. H. (2023) · Current Directions in Psychological Science · doi:10.1177/09637214231201079 · Cited by 31
Self-citationFox, N. A., Nelson, C. A., & Zeanah, C. H. (2017) · Psychodynamic Psychiatry · doi:10.1521/pdps.2017.45.4.441 · Cited by 29
Self-citationWade, M., Sheridan, M. A., Zeanah, C. H., Fox, N. A., Nelson, C. A., & McLaughlin, K. A. (2020) · Development and Psychopathology · doi:10.1017/s0954579420001327 · Cited by 31
Self-citationThe Developmental Origins of Opioid Use Disorder and Its Comorbidities
Levis, S. C., Mahler, S. V., & Baram, T. Z. (2021) · Frontiers in Human Neuroscience · doi:10.3389/fnhum.2021.601905 · Cited by 33
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
Self-citationShawar, Y. R., & Shiffman, J. (2023) · Globalization and Health · doi:10.1186/s12992-023-00975-0 · Cited by 26
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 27
Self-citationA Comparison of Foster Care Reentry After Adoption in Two Large U.S. States
Rolock, N., White, K. R., Ocasio, K., Zhang, L., MacKenzie, M. J., & Fong, R. (2018) · Research on Social Work Practice · doi:10.1177/1049731518783857 · Cited by 24
Seim, A. R., Jozefiak, T., Wichstrøm, L., Lydersen, S., & Kayed, N. S. (2020) · European Child & Adolescent Psychiatry · doi:10.1007/s00787-020-01673-7 · Cited by 28
Green, S. A., Goff, B., Gee, D. G., Gabard-Durnam, L. J., Flannery, J., Telzer, E. H., Humphreys, K. L., Louie, J., & Tottenham, N. (2016) · Journal of Child Psychology and Psychiatry · doi:10.1111/jcpp.12578 · Cited by 23
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Epigenetic mechanisms linking early-life adversities and mental health
Cánepa, E. T., & Berardino, B. G. (2024) · Biochemical Journal · doi:10.1042/bcj20230306 · Cited by 22
Children's Attention and Self-Regulatory Behavior Before and During the COVID-19 Pandemic
Raghunathan, R. S., Musci, R. J., Voegtline, K., Thomas, T. C., & Johnson, S. B. (2021) · Journal of Developmental & Behavioral Pediatrics · doi:10.1097/dbp.0000000000001027 · Cited by 20
Adverse caregiving in early life: The trauma and deprivation distinction in young children
Guyon‐Harris, K. L., Humphreys, K. L., & Zeanah, C. H. (2020) · Infant Mental Health Journal · doi:10.1002/imhj.21892 · Cited by 19
Self-citationBali, P., Sonuga‐Barke, E., Mohr‐Jensen, C., Demontis, D., & Minnis, H. (2023) · JCPP Advances · doi:10.1002/jcv2.12169 · Cited by 18
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Perry, N. B., Donzella, B., & Gunnar, M. R. (2021) · Psychoneuroendocrinology · doi:10.1016/j.psyneuen.2021.105578 · Cited by 17
Humphreys, K. L., Fox, N. A., Nelson, C. A., & Zeanah, C. H. (2017) · Springer eBooks · doi:10.1007/978-3-319-57990-0_6 · Cited by 16
Self-citationFamily foster care and children’s outcomes in China: Evidence from a scoping review
Xu, Y., Man, X., Zhang, L., & DeForge, B. R. (2019) · Children and Youth Services Review · doi:10.1016/j.childyouth.2019.104658 · Cited by 17
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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 13
Self-citation
Metadata
- 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 › Sociology and Political Science › 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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