For the past 12 years we have conducted the first-ever randomized controlled trial (RCT) of foster care as an intervention for young abandoned children placed in institutions. Beginning with a sample of 136 Romanian infants abandoned to institutions early in life, we compared two groups. Half of this sample was randomly assigned to be removed from the institution and placed into a family/foster care intervention. The other half remained in the institutions receiving care as usual. We did not interfere with any placements deemed in the children?s best interest by child protection authorities in Bucharest. Over time, some children from both groups were adopted within Romania or reintegrated with their biological parents. Throughout we followed intent-to-treat analyses so that original group assignment defined group membership despite the fact that few of the ?care as usual? children remained in the institutions over the long run. A comparison sample of 72 never institutionalized children provided normative data. The original sample of institutionalized children has been followed through 12 years of age. We assessed the children's cognitive, social, psychiatric and brain outcomes at multiple assessment points across these 12 years. To date, the results indicate that a) early institutionalization leads to perturbations in the brain?s electrical (EEG) and structural (MRI) development, with profound deficits and delays in cognitive and socio-emotional behaviors, and an elevated incidence of psychiatric disorders and impairment, b) our intervention was broadly effective in enhancing children?s development, but c) for specific domains of neural activity, language, cognition and social-emotional functioning there appear to be sensitive periods mediating recovery. In the current proposal, we assess the children when they are 16 years of age and extend these analyses with the aim to predict mental health outcomes in two groups of children: those originally assigned to our Foster Care intervention [FCG] and those originally randomized to remain in the institution (Care as Usual Group [CAUG]) and we will compare their functioning to typically developing age-matched Romanian children (Never Institutionalized Group [NIG]). Using a variety of both brain and behavioral measures, we will 1) examine, at age 16, the long term impact of early institutionalization on mental health outcomes and the efficacy of our intervention in ameliorating the burden of mental health outcomes using an intent-to-treat design;2) examine how the dose of institutionalization (percent time spent in an institution) influences long term outcomes;3) examine sensitive periods in recovery from early institutionalization;and 4) focus particularly on risk taking behavior, substance use, and mental health outcomes.

Public Health Relevance

There are currently more than 70 million orphaned or abandoned children throughout the world. A common societal response to caring for such children is to house them in institutions. Children with histories of early institutionalization ar at risk for developing a variety of mental health problems that have their origin in abnormal social behavior. The current application will examine the long term effects of early institutionalization on mental health outcomes in two groups of children with a history of institutionalization, as well as explore sensitive periods in recovery from institutionalization.

National Institute of Health (NIH)
National Institute of Mental Health (NIMH)
Research Project (R01)
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Child Psychopathology and Developmental Disabilities Study Section (CPDD)
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Zehr, Julia L
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Children's Hospital Boston
United States
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Moulson, Margaret C; Shutts, Kristin; Fox, Nathan A et al. (2015) Effects of early institutionalization on the development of emotion processing: a case for relative sparing? Dev Sci 18:298-313
Nelson 3rd, Charles A (2014) Commentary: Becoming social--a commentary on Happé & Frith (2014). J Child Psychol Psychiatry 55:578-81
Levin, April R; Zeanah Jr, Charles H; Fox, Nathan A et al. (2014) Motor outcomes in children exposed to early psychosocial deprivation. J Pediatr 164:123-129.e1
McLaughlin, Katie A; Sheridan, Margaret A; Winter, Warren et al. (2014) Widespread reductions in cortical thickness following severe early-life deprivation: a neurodevelopmental pathway to attention-deficit/hyperactivity disorder. Biol Psychiatry 76:629-38
Theall, Katherine P; Brett, Zoe H; Shirtcliff, Elizabeth A et al. (2013) Neighborhood disorder and telomeres: connecting children's exposure to community level stress and cellular response. Soc Sci Med 85:50-8
Loman, Michelle M; Johnson, Anna E; Westerlund, Alissa et al. (2013) The effect of early deprivation on executive attention in middle childhood. J Child Psychol Psychiatry 54:37-45
Nelson, Charles A; Westerlund, Alissa; McDermott, Jennifer Martin et al. (2013) Emotion recognition following early psychosocial deprivation. Dev Psychopathol 25:517-25
Gershon, Richard C; Wagster, Molly V; Hendrie, Hugh C et al. (2013) NIH toolbox for assessment of neurological and behavioral function. Neurology 80:S2-6
Victorson, David; Manly, Jennifer; Wallner-Allen, Kathleen et al. (2013) Using the NIH Toolbox in special populations: considerations for assessment of pediatric, geriatric, culturally diverse, non-English-speaking, and disabled individuals. Neurology 80:S13-9
Weintraub, Sandra; Dikmen, Sureyya S; Heaton, Robert K et al. (2013) Cognition assessment using the NIH Toolbox. Neurology 80:S54-64

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