Quality Family Placement Has Dramatic Impact on Child Development, AJP Study Finds

Young children who were institutionalized at birth in Bucharest, Romania, and later placed into foster care families with psychosocial support had better outcomes across multiple domains than peers who remained in institutional care. Those better outcomes—including higher IQ scores and lower rates of psychopathology—persisted across two decades of follow-up assessments.

The results were from a comprehensive analysis of the Bucharest Early Intervention Project (BEIP) in AJP in Advance. Initiated in 2001, the BEIP is a collaboration between researchers at Tulane University, University of Maryland, Boston Children’s Hospital, Harvard University, Bucharest University, Vanderbilt University, and UNC-Chapel Hill.

The study provides the most robust data—and the first randomized, controlled study—supporting the superiority of family placement over institutional care, according to the authors. After preliminary results of the study were released, Romania banned institutional care for children under 24 months and later extended the ban to children under 7.

The “high quality” foster care intervention, in which parents received psychosocial support from social workers receiving expert consultation from American child care experts, is qualitatively different from American foster care.

“Millions of children worldwide experience psychosocial deprivation in institutions, and many more are neglected in their families of origin,” wrote lead author Kathryn Humphreys, Ph.D., an assistant professor of psychology and human development at Vanderbilt University, and colleagues. “[T]he BEIP provides unique evidence for the causal effects of deprivation and subsequent caregiving enrichment on development.”

Dramatic Effect on Disorders of Attachment Found

In the study, 136 children (aged 6 months to 31 months) who had been abandoned at or shortly after birth and placed in institutions were randomized to family foster care or continued institutional care. Within the foster care group, the mean age at placement into a study-sponsored foster care family was 22.63 months. A little more than half of the children were female.

The researchers assessed the children at ages 30, 42, and 54 months and at ages 8, 12, and 16 to 18 years. Of the 136 participants, 130 (65 in the foster care group and 65 in the care-as-usual group) completed at least one of these follow-up assessments. Overall, the researchers analyzed 7,088 observations that were made during the follow-up waves across these domains: cognitive functioning, physical growth, brain electrical activity, and psychopathology.

Compared with children in the care-as-usual group, those in the foster care group had significantly higher scores on the combined IQ, physical growth, and electroencephalograph (EEG) measures of brain activity, with the greatest effect on IQ. Children in the foster care group also had significantly lower symptoms of psychopathology, especially internalizing disorders (anxiety and depression).

The most dramatic findings from the analysis showed that family placement resulted in significantly lower rates of reactive attachment disorder and disinhibited social engagement disorder, underscoring the importance of quality parent-child relationships in mitigating the risks associated with neglect that may occur in institutionalized care. As with the findings on IQ and internalizing disorders, the strong effect of family placement on rates of attachment disorders persisted across 20 years of assessments.

“Some forms of psychopathology that seem to almost entirely occur after psychosocial neglect are reactive attachment disorder and disinhibited social engagement disorder,” said Humphreys at a press conference at APA’s 2023 Annual Meeting. “Being placed within a family reduced the symptoms of reactive attachment disorder to pretty much nonexistent, so we think that placing children into families is the cure for that form of psychopathology.”

Parents Received Help With Vexing Behaviors

Humphreys emphasized that when the study was first designed in 2001, Romania did not have an established foster care network. The intervention designed by the researchers intentionally recruited parents who were prepared to make a long-term commitment to the children—to care for them as though they were their own, she said.

Moreover, the intervention was grounded in findings from developmental research on enhancing caregiving quality in which social workers who received expert consultation from U.S. clinicians provided psychosocial support to foster parents. This included helping parents understand that their children’s challenging behaviors may be a result of previous institutionalization.

She said the sustained nature of the foster care intervention in BEIP and the focus on building trusting parent-child relationships over time—and the dramatic effect on attachment and social relatedness—are what make the BEIP stand out.

“A lot of research findings in child development are correlations,” she said. “That makes it hard to know what our field can offer [public policymakers] who have real power over kids’ lives. We can say X is correlated with this outcome, but we can’t say that changing X will result in this better outcome.

“That’s what I think is really special about our study, because it provides strong evidence that it is being placed in high-quality foster care that results in these better outcomes.”

Child psychiatrist Christopher Bellonci, M.D., senior policy advisor at the Baker Center for Children and Families in Boston, said he has followed BEIP since its inception. “This is an exceptional study that speaks to the power of human connection and the critical role that families play in rearing children,” he told Psychiatric News. “The fact that the team was able to create a foster care network that amounts to a best-case scenario or model of best practice for foster care is remarkable.”

Study Supports Investment in Quality Family Care

Bellonci, who is a past president of the Association of Children’s Residential and Community Service, pointed out that institutional care as it exists in Romania cannot be equated with American residential care for children with behavioral health needs. Moreover, the differences between the foster care system as created for the intervention in BEIP and the American foster care system are enormous.

“I am the first to say I want children in a supportive family setting whenever they can be,” he said in an interview. “But we don’t have enough quality foster care placements in the U.S. Some kids who do have access to supportive family placements still have significant enough psychiatric and behavioral problems that they can’t be placed there.

“Are there things we can learn from what the team in Bucharest has done as a best-case example? Absolutely. I would love to create that for every kid in the United States. I think we want to look especially at the specific qualities of parental care these children received and how the team was supporting the families.”

Humphreys said that among policymakers everywhere there is the question of whether to devote limited resources to improving institutional care—increasing the ratio of children to nurses—or investing in expensive high-quality foster care.

“If you are going to ask people to make large-scale investment in new systems, you need to have the data to support that change,” Humphreys said. “We think our study is compelling evidence for investing in family-based care.” ■