Psychiatric outcomes in young children with a history of institutionalization

Children raised in institutions, considered an extreme example of social deprivation, are one group through which we can better understand the impact of neglect on child health and development. The Bucharest Early Intervention Project (BEIP) is the first randomized, controlled trial of foster care as an intervention for institutionalized children. In this review we describe the mental health outcomes from the BEIP. Specifically, we report findings on attachment styles, attachment disorders, emotional reactivity, and psychiatric symptomatology for children in the BEIP. We describe the impact of the foster care intervention on these outcomes and also describe how outcomes differ by gender and by length of time spent in the institution. In addition, we explore the influence of genetic variation on individual outcomes and recovery from early severe social deprivation, as well as the role of differences in brain development in mediating later psychiatric morbidity. The results from the BEIP confirm and extend the previous findings on the negative sequelae of early institutional care on mental health. The results also underscore the benefit of early family placement for children living in institutions.     

Sleep Disruption in Young Foster Children

In the current study, sleep actigraphy and parent-report measures were used to investigate differences in sleeping behavior among four groups of 3- to 7-year-olds (N = 79): children in regular foster care (n = 15); children receiving a therapeutic intervention in foster care (n = 17); low income community children (n = 18); and upper middle income community children (n = 29). The children in therapeutic foster care exhibited longer sleep latency and increased variability of sleep duration than the upper middle income community children. In addition, there was an indication of a treatment effect: the therapeutic foster care children slept longer than the regular foster care and low income community children and had earlier bedtimes, fell asleep earlier, and spent more time in bed than the regular foster care children. The results are discussed in terms of the effectiveness of early intervention for enhancing sleep in foster children.     

Foster care, residential care and public care placement patterns are associated with adult life trajectories: population-based cohort study

Objectives

Childhood experiences of public care may be associated with adult psychosocial outcomes. This study aimed to evaluate the associations of four public care exposures: type of placement, length of placement, age at admission to care and number of placements, as well as the reasons for admission to public care with emotional and behavioural traits at age 30?years.

Methods

Participants included 10,895 respondents at the age 30 survey of the 1970 British Cohort Study (BCS70) who were not adopted and whose care history was known. Analyses were adjusted for individual, parental and family characteristics in childhood.

Results

Cohort members with a public care experience presented lower childhood family socio-economic status compared with those in the no public care group. After adjusting for confounding, exposure to both foster and residential care, longer placements and multiple placements were associated with more extensive adult emotional and behavioural difficulties. Specifically, residential care was associated with increased risk of adult criminal convictions (OR?=?3.09, 95% CI: 2.10–4.55) and depression (1.81, 1.23–2.68). Multiple placements were associated with low self-efficacy in adulthood (OR?=?3.57, 95% CI: 2.29, 5.56). Admission to care after the age of 10 was associated with increased adult criminal convictions (OR?=?6.03, 95% CI: 3.34–10.90) and smoking (OR?=?3.32, 95% CI: 1.97–5.58).

Conclusion

Adult outcomes of childhood public care reflect differences in children’s experience of public care. Older age at admission, multiple care placements and residential care may be associated with worse outcomes.     

The effect of task complexity on planning in preterm-born children

Abstract

Objective: Planning is an important executive function (EF) skill that is fundamental to the capacity to achieve everyday goals that require a series of intermediate steps. This study examined the effect of preterm birth on planning skills in early and middle childhood using Tower problems that made different cognitive workload demands. Method: We administered a novel touchscreen Tower of Hanoi task (Monkey Tree Task; MTT) in three age cohorts (3, 6, and 9 years) to 485 children born between 2000 and 2010 (105 extremely low birth weight [ELBW], 248 late preterm [LP], and 132 term-born [Term]). Results: Children born with ELBW completed significantly fewer Tower problems with higher cognitive demands than children born at Term or LP. Likewise, Term- and LP-born children completed more Tower problems than children born with ELBW. In the youngest cohort, Term-born children solved Tower problems more efficiently than either preterm group, and LP-born children solved problems more efficiently than those born with ELBW. However, there were no group differences in efficiency in the older age cohorts. Significant correlations between our MTT measures and performance on other EF tasks were found. Conclusions: The MTT captured significant performance differences in planning skills between children born term vs. preterm. This study provides important information on the impact that cognitive workload, as a function of Tower problem complexity, has on planning skills in preterm children. This study adds to a growing body of research that distinguishes LP birth as having subtle, but distinguishable, adverse neuropsychological outcomes at earlier ages.     

Long-term depression and suicidal ideation outcomes subsequent to emancipation from foster care: Pathways to psychiatric risk in the Métis population

Major depressive episode (MDE) and suicidal ideation (SI) associated with history of foster care placement (HxFCP), and mediating effects of psychosocial and socioeconomic factors through which placement may confer psychiatric risks in the years subsequent to emancipation were examined in a national sample of 7534 Métis. More than one third of emancipated respondents reported past year MDE, a prevalence rate nearly 50% higher than the rate of MDE among Métis respondents without a history of placement in foster care. The 25% lifetime prevalence rate of SI in the emancipated group was more than twice the rate observed in the non-fostered group. Direct effects of HxFCP on post placement MDE and SI were significant in multivariate logistic regression analyses, even when effects of childhood predispositional risk factors were controlled statistically. Emancipated individuals were unduly affected by psychosocial and socioeconomic disadvantages signifying pathways that linked foster care placement history and psychiatric status. Main mediators of the effects demonstrated using effect decomposition procedures were self-esteem, income, and community adversity. The findings warrant consideration of foster care history in clarifying the complex etiologies of suicidal ideation and major depressive episode in the Métis population and risk factors ensuing in the intervening years as integral to the process linking placement to long-term psychiatric outcomes.     

年轻人离开原生家庭后安置不稳定性及可能的心理健康影响

背景:收容机构中的儿童青少年和同龄人相比可能存在较差的心身健康水平.稳定的机构照料环境对改善早期童年经历所致破坏性影响是非常重要的,童年经历包括心理创伤、虐待和忽视.目前,澳大利亚或其他国家很少有关收容机构中儿童青少年的安置稳定性高质量研究的数据.目标:首次针对澳大利亚在收容机构生活中的儿童青少年进行系统的背景、照料类型、和安置稳定性特征的调查.方法:2014年收集了墨尔本市区的四家民间儿童青少年社区服务机构的数据.样本包括322名年轻人(女性占52.8%),年龄在12-17岁之间[平均年龄=14.86,(SD=1.63)年].结果:在收容机构中,相对于社区收容照料类型(35.7%),大多数年轻人(64.3%)是基于家庭养育照料模式(即寄养、治疗型寄养照料、青少年照料模式、亲属照料、以及认领照料).然而,与所有收容照料的孩子相比,这个年龄组被社区收容比例是较高的(5%).第一次被社区收容的平均年龄为9岁(SD=4.54).不同的照料类型均无性别差异.其中有248人(76.9%)曾在收容照料系统中有一个以上的安置场所,有117人(36.5%)经历了超过5个安置场所.相对于家庭养育照料者,社区收容的儿童青少年经历了更显著的安置不稳定性(χ2=63.018,p<0.001).结论:安置不稳定性在收容照料机构是常见的现象.需要一个稳定的照料环境来改善被虐待儿童所导致的心理创伤和健康影响.精心设计并以干预为基础的研究能够增加安置稳定性,包括强化对儿童青少年收容照料者的治疗能力.     

A comparison of mental health problems in kinship and nonkinship foster care

OBJECTIVE: Knowledge of the emotional and behavioural problems of children in kinship foster care is scarce. No data on such problems in European countries have been published. This study compares child psychiatric problems and placement characteristics of children living in kinship and nonkinship foster care. METHODS: A total of 214 children in kinship and nonkinship foster care, aged 4-13, participated in the study. The Child Behavioral Checklist (CBCL) was completed by their foster parents and demography and placement information was collected. RESULTS: Of the nonkinship group, 51.8 % scored above the borderline on the CBCL Total Problem score, as did 35.8% of the kinship group. The kinship group had fewer previous placements, were more often fostered within their local community and had more contact with their biological parents. Kinship foster parents had lower social status, in terms of educational level.Variables significantly related to high level of the CBCL Total problems score were male gender and location of foster home outside community of birth family. Positive outcome was significantly associated with placement within the child's own community, which in turn was related to kinship placement. CONCLUSIONS: Placement in kinship foster care should be considered as a viable possibility.     

Predictors of Outpatient Mental Health Service Use—The Role of Foster Care Placement Change

This study examined the relationship between placement change and outpatient mental health service use. It is based on (1) conceptual propositions about the impact of the foster care living context on mental health service use, and (2) empirical knowledge about the adverse consequences of placement change. Results of the study, which were based on a cohort of 570 children in foster care in San Diego County, suggest an association between placement changes in child welfare and use of outpatient mental health services. Specifically, an increase in the number of placement changes predicted a greater rate of outpatient mental health visits. The study further found that children who experienced behavior-related placement changes received more outpatient mental health visits than children who experienced placement changes for other reasons. Follow-up analyses of the 144 children who experienced any behavior-related placement changes further indicated that the rate of outpatient mental health service use almost doubled in the 90 days following the first behavior-related placement change. Findings from this study have implications for the practice, policy and research fields in child welfare as well as mental health.     

Normalization of EEG activity among previously institutionalized children placed into foster care: A 12-year follow-up of the Bucharest Early Intervention Project

Extreme social and cognitive deprivation as a result of institutional care has profound effects on developmental outcomes across multiple domains for many abandoned or orphaned children. The Bucharest Early Intervention Project (BEIP) examines the outcomes for children originally placed in institutions who were assessed comprehensively and then randomized to foster care (FCG) or care as usual (CAUG) and followed longitudinally. Here we report on the brain electrical activity (electroencephalogram: EEG) of 12-year-old children enrolled in the BEIP. Previous reports suggested improvement in resting EEG activity for the group of children placed in the foster care intervention, particularly those placed before 24 months of age compared to children who were randomized to CAUG or those placed into families after this age. At 12 years, differences between those in the FCG and those in the CAUG persist in the alpha band (8–13 Hz), but not in higher frequency bands (i.e. in the beta band; 15–30 Hz), except in those children placed into the FCG who remained in high quality care environments over the course of the study. These findings highlight the importance of maintaining a stable high quality caregiving environment, particularly for children exposed to early psychosocial deprivation, for promoting healthy brain development.     

The role of placement experiences in mediating the criminal consequences of early childhood victimization

The disposition of a large sample of early childhood abuse and neglect cases was followed up via criminal records. The majority of the children were placed outside the home, primarily in foster care. Kinds of placement and factors affecting placement decisions were examined. Differences in arrest rates were found between children placed solely because of abuse or neglect and those placed for abuse or neglect in conjunction with delinquency. Similar results were found for foster care placement. Placement alone did not appear to increase risk of criminal behavior.     

Effectiveness of early behavioral intervention in public and mainstream settings: The case of preschool-age children with autism spectrum disorders

Despite the demonstrated positive outcomes of early intensive behavioral intervention (EIBI) among children with autism spectrum disorders (ASD), several challenges to its implementation on a large scale and in community settings remain. In order to maximize the accessibility and cost-effectiveness of its services, a regional public agency serving children with ASD implemented two consecutive programs: a 1 year pre-program for parents (intensive sessions followed by 1 hour per week of individual coaching) and an early behavioral intervention (EBI) program with less than optimal weekly intensity (16–20 hours) delivered in mainstream day care settings. The outcomes of these programs were assessed among 93 children. Their IQ, adaptive behavior, and socioaffective competencies were found to have improved after 12 months in the EBI program. Their autism symptoms had also decreased marginally. Although the pre-program did not have observable effects on children's outcomes, their parents reported positive impact on their well-being and family life. These results demonstrate the feasibility and sustainability of offering EBI to large, unselected populations. However, the pre-program may need to be offered more intensively in order to yield positive outcomes for children. Delivering EBI services in mainstream settings may foster the development of skills linked to social integration.     

La santé mentale des enfants placés. Une revue de la littérature

In France more than 140 000 children live in foster homes under the responsibility of the French Child Protection Agency. These children have lived in environments that cannot be good for their development and have been separated from their families which have to have consequences on their mental development. A literature review in France and abroad was made to identify the profiles of these children, their risk factors, and the mental disorders they can present. French child protection is handled by smaller territories, called Départements of which there are more than 90 and count around 1 000 000 people each. The number of foster children differ byDépartement, as do the placement types and meaning of the placement. More than half of these children have suffered maltreatment prior to placement. Comparing them to children of the same age, they present more internalizing and externalizing disorders, more addiction problems and suicidal behaviors. Protection factors have nonetheless been identified, such as early age of placement and placement stability. The main inhibitors of good health care are the absence of a common regulatory framework, source of organization difficulties, and the lack of collaboration between health and social services.French cohort studies using validated tools are necessary to precise and confirm these results. They could then lead to national recommendations for mental health screening and care organization, as well as validation of protocols for specific therapies for foster children.     

Fostering futures: a preventive intervention program for school-age children in foster care

Children in foster care have social and emotional problems at rates three to ten times higher than those found in the general population. During the elementary school years (i.e. 5-12 years), research indicates that disruptive behavior in children in care can negatively impact social, emotional and academic development, as well as placement stability. Evidenced-based interventions to improve children's behavior and reduce parenting stress are necessary. This pilot study augmented an existing evidenced-based intervention (i.e. the Incredible Years) developed for birth families for use with foster caregivers. Results from 18 families indicate that foster caregiver-reported conduct symptoms were significantly lower for children whose families participated in the treatment group. A similar trend was found for the overall externalizing behavior. No significant changes were identified in parenting attitudes and stress. Participants reported high levels of satisfaction and acceptability with the program and outcomes. These findings indicate that foster caregiver training should be examined in larger, randomized control trials.     

Early adversity and neural correlates of executive function: implications for academic adjustment

Early adversity can negatively impact the development of cognitive functions, although little is known about whether such effects can be remediated later in life. The current study examined one facet of executive functioning - inhibitory control - among children who experienced institutional care and explored the impact of a foster care intervention within the context of the Bucharest Early Intervention Project (BEIP). Specifically, a go/nogo task was administered when children were eight years old and behavioral and event-related potential (ERP) measures were collected. Results revealed that children assigned to care as usual (i.e. institutional care) were less accurate and exhibited slower neural responses compared to children assigned to the foster care intervention and children who had never been institutionalized. However, children in both the care as usual and foster care groups exhibited diminished attention processing of nogo cues as assessed via P300 amplitude. Foster care children also showed differential reactivity between correct and error responses via the error-related negativity (ERN) as compared to children in the care as usual group. Combined, the results highlight perturbations in neural sources of behavioral and attention problems among children experiencing early adversity. Potential implications for academic adjustment in at risk children are discussed.     

Foster Care Involvement Among Medicaid-Enrolled Children with Autism

The prevalence and risk of foster care involvement among children with autism spectrum disorder (ASD) relative to children with intellectual disability (ID), children with ASD and ID, and typically developing children were examined using 2001–2007 Medicaid data. Children were followed up to the first foster care placement or until the end of 2007; a discrete time logistic regression analysis was conducted. Both the prevalence and risk of foster care involvement were greatest for children with ASD, and the prevalence increased substantially over the study period among children with ASD. Continued examination of the factors contributing to the higher risk of foster placement is warranted to unravel the complex circumstances facing these vulnerable children and their families.     

Preventive intervention for maltreated preschool children: impact on children's behavior, neuroendocrine activity, and foster parent functioning

OBJECTIVE: This article describes the results of a pilot study that evaluated the effectiveness of the Early Intervention Foster Care (EIFC) program in the period immediately following a child's placement in a new foster home. METHOD: Data were collected from an EIFC group, a regular foster care group, and a community comparison group-each with 10 participants-via questionnaires for children and their caretakers and salivary cortisol sampling. RESULTS: EIFC foster parents adopted and maintained positive parenting strategies, EIFC children's behavioral adjustment improved, and changes occurred in several salivary cortisol measures. Moreover, regular foster care children exhibited decrements in functioning in several areas over the same time period. CONCLUSIONS: Results are discussed with regard to how such research fits into a larger program of prevention research for high-risk preschool children.     

Salivary cortisol: a possible biomarker in evaluating stress and effects of interventions in young foster children?

Young foster children undergo an early separation from their caregiver(s) and often experience severe stress before placement. However, a considerable part of the children do not show apparent signs of distress, making it difficult for the foster carer to be aware of the amount of stress in their foster child. Potential evidence for using salivary cortisol levels as a dimension to evaluate the amount of stress in young foster children is reviewed. Moreover, the applicability of salivary cortisol in the evaluation of stress-reducing interventions for young foster children is discussed. A systematic review was performed using the databases Medline, Psychinfo, Embase, Ebscohost, and Academic Search Premier. Nine studies were traced in which salivary cortisol was used to measure stress in children placed in family foster care or in adoptive families. Stress in general but also neglect, early loss of a caregiver, a younger age at first placement, and a higher number of placements were associated with an altered hypothalamic–pituitary–adrenal (HPA) axis function in foster children. Moreover, four studies on the effect of stress-reducing interventions on HPA-axis functioning of young foster children were found. These studies suggest that caregiver-based interventions can actually help to normalize the HPA-axis function in foster children, and that such changes co-occur with improved behavioral functioning. Although the results from the papers discussed in this review suggest that diurnal cortisol with a wake up and a bedtime measurement may be a relevant tool to evaluate stress in young foster children, this cannot yet be concluded from the present studies, because statistical data from the studies on foster care and adoption in this review were not robust and researchers used different methods to collect the salivary cortisol. Still, it is noteworthy that all studies did find the same pattern of reduced levels in relation to chronic stress (caused by maltreatment and neglect of the child).     

Behavioral outcomes for substance-exposed adopted children: fourteen years postadoption

From a life course perspective, studies of cumulative disadvantage often identify early risk factors as predictors of poor outcomes. This study examined the influence of prenatal substance exposure on children's externalizing behaviors at 14 years postadoption. Using Wave 4 data from the California Long-Range Adoption Study, the authors employed growth curve modeling to examine behavioral trajectories of 275 children as influenced by foster care status, age at adoption, and gender. Outcomes are measured using a shortened Behavioral Problem Index. Prenatal exposure predicted elevated behavior problems that increased normatively compared with nonexposed children, and were not found to trigger the negative behavior sequelae once feared. Foster children tended to fare better over the life course than those adopted through other means, except for children adopted at older ages. Adopted children's problem behaviors may be directly associated with the success of their placements. The authors discuss implications for practice and future research.     

Moderate versus severe early life stress: associations with stress reactivity and regulation in 10-12-year-old children

Early life stress (ELS) is expected to increase reactivity of the hypothalamic-pituitary-adrenocortical (HPA) axis; however, several recent studies have shown diminished cortisol reactivity among adults and children with ELS exposure. The goal of this study was to examine cortisol activity in 10-12-year-old internationally adopted children to determine if moderate and severe ELS have different impacts on the HPA axis. Salivary cortisol and two measures of autonomic activity were collected in response to the Trier Social Stress Test for Children (TSST-C). Three groups reflecting moderate, severe, and little ELS were studied: early adopted children who came predominantly from foster care overseas (early adopted/foster care (EA/FC), n=44), later adopted children cared for predominantly in orphanages overseas (late adopted/post-institutionalized (LA/PI), n=42) and non-adopted (NA) children reared continuously by their middle- to upper-income parents in the United States (n=38). Diminished cortisol activity was noted for the EA/FC group (moderate ELS), while the LA/PI group (severe ELS) did not differ from the NA group. Overall, few children showed cortisol elevations to the TSST-C in any group. The presence/absence of severe growth delay at adoption proved to be a critical predictive factor in cortisol activity. Regardless of growth delay, however, LA/PI children exhibited higher sympathetic tone than did NA children. These results suggest that moderate ELS is associated with diminished cortisol activity; however, marked individual differences in cortisol activity among the LA/PI children suggest that child factors modify the impact of severe ELS. Lack of effects of severe ELS even for growth delayed children may reflect the restorative effects of adoption or the generally low responsiveness of this age group to the TSST-C.