Attachment security as a mechanism linking foster care placement to improved mental health outcomes in previously institutionalized children
Open accessAbstract
Background: Children reared in institutions experience elevated rates of psychiatric disorders. Inability to form a secure attachment relationship to a primary caregiver is posited to be a central mechanism in this association. We determined whether the ameliorative effect of a foster care (FC) intervention on internalizing disorders in previously institutionalized children was explained by the development of secure attachment among children placed in FC. Second we evaluated the role of lack of attachment in an institutionalized sample on the etiology of internalizing disorders within the context of a randomized trial. Methods: A sample of 136 children (aged 6–30 months) residing in institutions was recruited in Bucharest, Romania. Children were randomized to FC ( n = 68) or to care as usual (CAU; n = 68). Foster parents were recruited, trained, and overseen by the investigative team. Attachment security at 42 months was assessed using the Strange Situation Procedure, and internalizing disorders at 54 months were assessed using the Preschool Age Psychiatric Assessment. Results: Girls in FC had fewer internalizing disorders than girls in CAU (OR = 0.17, p = .006). The intervention had no effect on internalizing disorders in boys (OR = 0.47, p = .150). At 42 months, girls in FC were more likely to have secure attachment than girls in CAU (OR = 12.5, p < .001), but no difference was observed in boys (OR = 2.0, p = .205). Greater attachment security predicted lower rates of internalizing disorders in both sexes. Development of attachment security fully mediated intervention effects on internalizing disorders in girls. Conclusion: Placement into FC facilitated the development of secure attachment and prevented the onset of internalizing disorders in institutionalized girls. The differential effects of FC on attachment security in boys and girls explained gender differences in the intervention effects on psychopathology. Findings provide evidence for the critical role of disrupted attachment in the etiology of internalizing disorders in children exposed to institutionalization.
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Foster care intervention was associated with greater odds of developing a secure attachment relationship.
“Foster care intervention was also associated with greater odds of developing a secure attachment relationship (McLaughlin et al., 2012;Smyke et al., 2010)”
From Resilience following severe early life neglect: A review of longitudinal evidence from the Bucharest Early Intervention Project (2026) · cites this paper as McLaughlin et al., 2012
The Results (Intervention Effects on Attachment; page not supplied) report greater odds of becoming securely attached from baseline to 42 months for girls in foster care than for girls receiving care as usual (OR=6.6, p=.029). The same comparison was not statistically significant for boys (OR=2.2, p=.250), so the unqualified claim extends beyond the reported finding. (LLM, conf=0.88)
Experimental — accuracy not yet measuredFoster care intervention was linked to fewer internalizing symptoms during childhood and adolescence, particularly among girls.
“foster care intervention was linked to fewer internalizing symptoms during childhood and adolescence, particularly among girls (Bick et al., 2015;Humphreys et al., 2020;King et al., 2023;McLaughlin et al., 2012).”
From Resilience following severe early life neglect: A review of longitudinal evidence from the Bucharest Early Intervention Project (2026) · cites this paper as McLaughlin et al., 2012
The Results (Intervention Effects on Psychopathology; page not provided) report fewer internalizing symptoms in girls assigned to foster care than in girls receiving care as usual, but no such effect in boys. The Methods (Assessment; page not provided) place the psychiatric assessment at 54 months, so this paper does not support the claim's extension to adolescence. (LLM, conf=0.90)
Experimental — accuracy not yet measuredFoster care intervention was associated with weak improvements in internalizing symptoms for boys and strong improvements for girls.
“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 McLaughlin et al., 2012
The Results (Intervention Effects on Psychopathology) report lower internalizing symptoms in girls receiving foster care, but equivalent levels in boys receiving foster care and care as usual. The paper therefore supports improvement for girls, not the claimed weak improvement for boys. (LLM, conf=0.92)
Experimental — accuracy not yet measuredFoster care intervention in the BEIP is associated with increased quality of attachment.
“↑ Quality of attachment (McLaughlin et al., 2012;Smyke et al., 2010)”
From Resilience following severe early life neglect: A review of longitudinal evidence from the Bucharest Early Intervention Project (2026) · cites this paper as McLaughlin et al., 2012
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 [39]
Improvements in anxiety and depression after early deprivation are explained in part by development of secure attachment to a new caregiver among adopted children.
“Improvements in anxiety and depression following early deprivation are explained, in part, by the development of a secure attachment to a new caregiver among adopted children.(39)”
From Neglect as a violation of species-expectant experience: neurodevelopmental consequences (2017) · cites this paper as [39]
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“…spanning early childhood through adolescence, foster care intervention has been shown to promote more normative neural development following early institutionalization (Debnath et al., 2020, 2023; McDermott et al., 2013; McLaughlin et al., 2011; Moulson et al., 2009; Vanderwert et al., 2016).”
InfluentialSelf-citation
- Authors
- McLaughlin, K. A., Zeanah, C. H., Fox, N. A., & Nelson, C. A.
- Affiliations
- Boston Children's Hospital (US)
- Tulane University (US)
- Venue
- Journal of Child Psychology and Psychiatry
- Publisher
- Wiley
- Published
- 2011-07-07
- Volume
- 53
- Issue
- 1
- Pages
- 46-55
- ISSN
- 0021-9630 (ISSN-L)
- 1469-7610
- PMC
- PMC3193871
- OpenAlex
- W1752721459
- Cited by
- 171
- References
- 63
- Citations by year
- 2026: 7 · 2025: 5 · 2024: 2 · 2023: 10 · 2022: 8 · 2021: 7 · 2020: 41 · 2019: 36 · 2018: 8 · 2017: 13 · 2016: 4 · 2015: 10 · 2014: 11 · 2013: 5 · 2012: 3
- FWCI
- 16.43
- Type
- journal article
- Language
- en
- Open access
- green
- www.ncbi.nlm.nih.gov
- Locations
- Journal of Child Psychology and Psychiatry (publishedVersion)
- PubMed (publishedVersion)
- Europe PMC (PubMed Central) (acceptedVersion)
- PubMed Central (acceptedVersion)
- Funders
- Robert Wood Johnson Foundation
- John D. and Catherine T. MacArthur Foundation
- National Institute of Mental Health (R01MH091363, K01MH092526)
- Topics
- Social Sciences › Safety Research › Child Welfare and Adoption
- Social Sciences › Psychology › Social Psychology › Attachment and Relationship Dynamics
- Social Sciences › Psychology › Clinical Psychology › Child and Adolescent Psychosocial and Emotional Development
- Keywords
- foster care, institutionalized children, attachment security, internalizing disorders, child mental health, gender differences, mediating mechanisms, early childhood intervention
- MeSH terms
- Anxiety Disorders, Mental Disorders, Child, Institutionalized, Depressive Disorder, Female, Foster Home Care, Humans, Infant, Institutionalization, Internal-External Control, Male, Object Attachment, Psychiatric Status Rating Scales, Romania, Sex Distribution
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