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Original Investigation
November 2018

Effect of Foster Care Intervention on Trajectories of General and Specific Psychopathology Among Children With Histories of Institutional Rearing: A Randomized Clinical Trial

Author Affiliations
  • 1Division of Developmental Medicine, Boston Children’s Hospital, Harvard Medical School, Boston, Massachusetts
  • 2Department of Human Development and Quantitative Methodology, University of Maryland, College Park
  • 3Department of Psychiatry and Behavioral Sciences, Tulane University School of Medicine, New Orleans, Louisiana
  • 4Harvard Graduate School of Education, Boston, Massachusetts
JAMA Psychiatry. 2018;75(11):1137-1145. doi:10.1001/jamapsychiatry.2018.2556
Key Points

Question  Does foster care intervention mitigate the long-term effects of institutional rearing on latent dimensions of psychopathology?

Finding  In this randomized clinical trial of 220 children, 119 of whom had histories of institutional rearing, those assigned to early foster care intervention had less problematic trajectories of general and externalizing-specific psychopathology from middle childhood (age 8 years) to adolescence (age 16 years).

Meaning  Social enrichment early in development reduces the risk of psychopathology among children with histories of profound neglect during a period of significant social and biological change.


Importance  It is unclear whether early institutional rearing is associated with more problematic trajectories of psychopathology from childhood to adolescence and whether assignment to foster care mitigates this risk.

Objectives  To examine trajectories of latent psychopathology factors—general (P), internalizing (INT), and externalizing (EXT)—among children reared in institutions and to evaluate whether randomization to foster care is associated with reductions in psychopathology from middle childhood through adolescence.

Design, Setting, and Participants  This longitudinal, intent-to-treat randomized clinical trial was conducted in Bucharest, Romania, where children residing in 6 institutions underwent baseline testing and were then randomly assigned to a care as usual group (CAUG) or a foster care group (FCG). A matched sample of a never-institutionalized group (NIG) was recruited to serve as a comparison group. The study commenced in April 2001, and the most recent (age 16 years) follow-up started in January 2015 and is ongoing.

Intervention  Institutionally reared children randomized to high-quality foster homes.

Main Outcomes and Measures  Psychopathology was measured using the MacArthur Health and Behavior Questionnaire. Teachers and/or caregivers reported on symptoms of psychopathology in several domains.

Results  A total of 220 children (50.0% female; 119 ever institutionalized) were included in the analysis at the mean ages of 8, 12, and 16 years. A latent bifactor model with general (P) and specific internalizing (INT) and externalizing (EXT) factors offered a good fit to the data. At age 8 years, CAUG (mean, 0.41; 95% CI, 0.17-0.67) and FCG (mean, 0.30; 95% CI, 0.04-0.53) had higher P than NIG (mean, −0.40; 95% CI, −0.56 to −0.18). By age 16 years, FCG (mean, 0.07; 95% CI, −0.18 to 0.29) had lower P than CAUG (mean, 0.37; 95% CI, 0.13-0.60). This effect was likely driven by modest declines in P from age 8 years to age 16 years among FCG (slope, −0.12; 95% CI, −0.26 to 0.04) compared with CAUG, who remained stably high over this period (slope, −0.02; 95% CI, −0.19 to 0.14). Moreover, CAUG and FCG showed increasing divergence in EXT over time, such that FCG (mean, −0.30; 95% CI, −0.58 to −0.02) had fewer problems than CAUG (mean, 0.05; 95% CI, −0.25 to 0.36) by age 16 years. No INT differences were observed.

Conclusions and Relevance  Institutionalization increases transdiagnostic vulnerability to psychopathology from childhood to adolescence, a period of significant social and biological change. Early assignment to foster care partially mitigates this risk, thus highlighting the importance of social enrichment in buffering the effects of severe early neglect on trajectories of psychopathology.

Trial Registration  ClinicalTrials.gov Identifier: NCT00747396