Serotonin transporter linked polymorphic region (5-HTTLPR) genotype moderates the longitudinal impact of early caregiving on externalizing behavior.

We examined caregiver report of externalizing behavior from 12 to 54 months of age in 102 children randomized to care as usual in institutions or to newly created high-quality foster care. At baseline no differences by group or genotype in externalizing were found. However, changes in externalizing from baseline to 42 months of age were moderated by the serotonin transporter linked polymorphic region genotype and intervention group, where the slope for short-short (S/S) individuals differed as a function of intervention group. The slope for individuals carrying the long allele did not significantly differ between groups. At 54 months of age, S/S children in the foster care group had the lowest levels of externalizing behavior, while children with the S/S genotype in the care as usual group demonstrated the highest rates of externalizing behavior. No intervention group differences were found in externalizing behavior among children who carried the long allele. These findings, within a randomized controlled trial of foster care compared to continued care as usual, indicate that the serotonin transporter linked polymorphic region genotype moderates the relation between early caregiving environments to predict externalizing behavior in children exposed to early institutional care in a manner most consistent with differential susceptibility.

Adoptive parents can be unprepared for the challenges in caring for children with reactive attachment disorder.

Implications for practice and research: Adoptive parents experience significant challenges in caring for children diagnosed with reactive attachment disorder. Informing prospective adoptive parents about attachment issues and providing concrete assistance to develop healthy attachment relationships may decrease some of the frustration experienced by parents and children affected with the disorder. Future research could address factors contributing to the diagnosis of reactive attachment disorder as well as best practices for ameliorating the disorder.

Indiscriminate behaviors in previously institutionalized young children.

OBJECTIVE: This study included 54-month-old children with a history of institutional care. Our goal was to: (1) examine differences in indiscriminate social behaviors in children with a history of institutional care compared with home-reared children; (2) test whether foster care reduces indiscriminate social behaviors in a randomized controlled trial; and (3) examine early predictors of indiscriminate behaviors. METHODS: Participants were 58 children with a history of institutional care and 31 never-institutionalized control (NIG) subjects enrolled in a randomized controlled trial of foster care for institutional care, assessed from toddlerhood to 54 months. Indiscriminate social behaviors were measured naturalistically by using the Stranger at the Door procedure. RESULTS: In the Stranger at the Door procedure, children with a history of institutional care left with a stranger at higher rates than NIG subjects (33% vs. 3.5%; P < .001). Children in the care as usual group left more than NIG subjects (41.9% vs. 3.6%; P ≤ .001). The differences between the foster care group (24.1%) and the care as usual group and between foster care group and NIG were not significant. In a logistic regression, early disorganized attachment behaviors, baseline developmental quotient, and caregiving quality after randomization contributed to variance at 54 months. In the same analysis using only children with a history of institutional care, only disorganized attachment contributed significantly to 54-month indiscriminate social behaviors (Exp[B] = 1.6 [95% confidence interval: 1.1-2.5]). CONCLUSIONS: Observed socially indiscriminate behaviors at 54 months were associated with prolonged exposure to institutional care. Young children raised in conditions of deprivation who fail to develop organized attachments as toddlers are at increased risk for subsequent indiscriminate behaviors.

A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder.

OBJECTIVE: The authors examined signs of emotionally withdrawn (inhibited type) and indiscriminately social (disinhibited type) reactive attachment disorder in Romanian children enrolled in a randomized trial of foster care compared with institutional care and in a comparison group of never-institutionalized children. METHOD: At baseline and when children were ages 30, 42, and 54 months and 8 years, caregivers were interviewed with the Disturbances of Attachment Interview to assess changes in signs of reactive attachment disorder in three groups of children: those receiving care as usual (including continued institutional care) (N=68); those placed in foster care after institutional care (N=68); and those who were never institutionalized (N=72). The impact of gender, ethnicity, and baseline cognitive ability was also examined. RESULTS: On the Disturbances of Attachment Interview, signs of the inhibited type of reactive attachment disorder decreased after placement in foster care, and scores were indistinguishable from those of never-institutionalized children after 30 months. Signs of the disinhibited type were highest in the usual care group, lower in the foster care group, and lowest in the never-institutionalized group. Early placement in foster care (before age 24 months) was associated with fewer signs of the disinhibited type. Lower baseline cognitive ability was associated with more signs of the inhibited type in the usual care group and more signs of the disinhibited type in both groups. CONCLUSIONS: Signs of the inhibited type of reactive attachment disorder responded quickly to placement in foster care; signs of the disinhibited type showed less robust resolution with foster placement. Lower baseline cognitive ability was linked to signs of reactive attachment disorder.

Recovering from early deprivation: attachment mediates effects of caregiving on psychopathology.

OBJECTIVE: Children exposed to early institutional rearing are at risk for developing psychopathology. The present investigation examines caregiving quality and the role of attachment security as they relate to symptoms of psychopathology in young children exposed to early institutionalization. METHOD: Participants were enrolled in the Bucharest Early Intervention Project (BEIP), a longitudinal intervention study of children abandoned and placed in institutions at or shortly after birth. Measures included observed caregiving when children were 30 months of age, observed attachment security at 42 months, and caregiver reports of children's psychopathology at 54 months. At 54 months, some children remained in institutions, others were in foster care, others had been adopted domestically, and still others had been returned to their biological families. Thus, the children had experienced varying amounts of institutional rearing. RESULTS: After controlling for gender, quality of caregiving when children were 30 months old was associated with symptoms of multiple domains of psychopathology at 54 months of age. Ratings of security of attachment at 42 months mediated the associations between quality caregiving at 30 months and fewer symptoms of psychopathology at 54 months. CONCLUSIONS: Among deprived young children, high-quality caregiving at 30 months predicted reduced psychopathology and functional impairment at 54 months. Security of attachment mediated this relationship. Interventions for young children who have experienced deprivation may benefit from explicitly targeting caregiver-child attachment relationships.

Genetic sensitivity to the caregiving context: the influence of 5httlpr and BDNF val66met on indiscriminate social behavior.

Evidence that gene×environment interactions can reflect differential sensitivity to the environmental context, rather than risk or resilience, is increasing. To test this model, we examined the genetic contribution to indiscriminate social behavior, in the setting of a randomized controlled trial of foster care compared to institutional rearing. Children enrolled in the Bucharest Early Intervention Project (BEIP) were assessed comprehensively before the age of 30 months and subsequently randomized to either care as usual (CAUG) or high quality foster care (FCG). Indiscriminate social behavior was assessed at four time points, baseline, 30 months, 42 months and 54 months of age, using caregiver report with the Disturbances of Attachment Interview (DAI). General linear mixed-effects models were used to examine the effect of the interaction between group status and functional polymorphisms in Brain Derived Neurotrophic Factor (BDNF) and the Serotonin Transporter (5htt) on levels of indiscriminate behavior over time. Differential susceptibility, relative to levels of indiscriminate behavior, was demonstrated in children with either the s/s 5httlpr genotype or met 66 BDNF allele carriers. Specifically children with either the s/s 5httlpr genotype or met66 carriers in BDNF demonstrated the lowest levels of indiscriminate behavior in the FCG and the highest levels in the CAUG. Children with either the long allele of the 5httlpr or val/val genotype of BDNF demonstrated little difference in levels of indiscriminate behaviors over time and no group×genotype interaction. Children with both plasticity genotypes had the most signs of indiscriminate behavior at 54 months if they were randomized to the CAUG in the institution, while those with both plasticity genotypes randomized to the FCG intervention had the fewest signs at 54 months. Strikingly children with no plasticity alleles demonstrated no intervention effect on levels of indiscriminate behavior at 54 months. These findings represent the first genetic associations reported with indiscriminate social behavior, replicate previous gene×gene×environment findings with these polymorphisms, and add to the growing body of literature supporting a differential susceptibility model of gene×environment interactions in developmental psychopathology.

Stereotypies in children with a history of early institutional care.

OBJECTIVES: To investigate the prevalence of stereotypies in children with a history of early institutional care, evaluate the efficacy of a foster care intervention compared with institutional care on the course of stereotypies, and describe correlates in language, cognition, and anxiety for children who exhibit stereotypies. DESIGN: Randomized controlled trial. SETTING: Institutions in Bucharest, Romania. PARTICIPANTS: One hundred thirty-six children with a history of early institutional care. Intervention Comparison of a foster care intervention with continued care as usual in an institution. MAIN OUTCOME MEASURES: The presence of stereotypies as well as outcomes in language, cognition, and anxiety. RESULTS: At the baseline assessment prior to placement in foster care (average age of 22 months), more than 60% of children in institutional care exhibited stereotypies. Follow-up assessments at 30 months, 42 months, and 54 months indicated that being placed in families significantly reduced stereotypies, and with earlier and longer placements, reductions became larger. For children in the foster care group, but not in the care as usual group, stereotypies were significantly associated with lower outcomes on measures of language and cognition. CONCLUSIONS: Stereotypies are prevalent in children with a history of institutional care. A foster care intervention appears to have a beneficial/moderating role on reducing stereotypies, underscoring the need for early placement in home-based care for abandoned children. Children who continue to exhibit stereotypies after foster care placement are significantly more impaired on outcomes of language and cognition than children without stereotypies and thus may be a target for further assessments or interventions.

Modification of depression by COMT val158met polymorphism in children exposed to early severe psychosocial deprivation.

OBJECTIVE: To examine the impact of the catechol-O-methyltransferase (COMT) val(158)met allele on depressive symptoms in young children exposed to early severe social deprivation as a result of being raised in institutions. METHODS: One hundred thirty six children from the Bucharest Early Intervention Project (BEIP) were randomized before 31 months of age to either care as usual (CAU) in institutions or placement in newly created foster care (FCG). At 54 months of age, a psychiatric assessment using the Preschool Age Psychiatric Assessment (PAPA) was completed. DNA was collected and genotyped for the COMT val(158)met polymorphism. Multivariate analysis examined the relationship between COMT alleles and depressive symptoms. RESULTS: Mean level of depressive symptoms was lower among participants with the met allele compared to those with two copies of the val allele (P<0.05). Controlling for group and gender, the rate of depressive symptoms was significantly lower among participants with the met/met or the met/val genotype [adjusted relative risk (aRR)=0.67, 95% CI=0.45, 0.99] compared to participants with the val/val genotype, indicating an intermediate impact for heterozygotes consistent with the biological impact of this polymorphism. The impact of genotype within groups differed significantly. There was a significant protective effect of the met allele on depressive symptoms within the CAU group, however there was no relationship seen within the FCG group. CONCLUSIONS: This is the first study, to our knowledge, to find evidence of a genexenvironment interaction in the setting of early social deprivation. These results support the hypothesis that individual genetic differences may explain some of the variability in recovery amongst children exposed to early severe social deprivation.

Growth and associations between auxology, caregiving environment, and cognition in socially deprived Romanian children randomized to foster vs ongoing institutional care.

OBJECTIVES: To determine effects of improved nurturing compared with institutional care on physical growth and to investigate the association between growth and cognitive development. DESIGN: A randomized controlled trial beginning in infants (mean age, 21.0 months; range, 5-32 months), with follow-up at 30, 42, and 54 months of age. SETTING: Institutionalized and community children in Bucharest, Romania. PARTICIPANTS: One hundred thirty-six healthy institutionalized children from 6 orphanages and 72 typically developing, never-institutionalized children. INTERVENTION: Institutionalized children were randomly assigned to receive foster care or institutional care as usual. OUTCOME MEASURES: Auxology and measures of intelligence over time. RESULTS: Growth in institutionalized children was compromised, particularly in infants weighing less than 2500 g at birth. Mean height and weight, though not head size, increased to near normal within 12 months in foster care. Significant independent predictors for greater catch-up in height and weight included age younger than 12 months at randomization, lower baseline z scores, and higher caregiving quality, particularly caregiver sensitivity and positive regard. Baseline developmental quotient, birth weight, and height catch-up were significant independent predictors of cognitive abilities at follow-up. Each incremental increase of 1 in standardized height scores between baseline and 42 months was associated with a mean increase of 12.6 points (SD, 4.7 points) in verbal IQ (P < .05). CONCLUSIONS: Foster care had a significant effect on growth, particularly with early placement and high-quality care. Growth and IQ in low-birth-weight children are particularly vulnerable to social deprivation. Catch-up growth in height under more nurturing conditions is a useful indicator of caregiving quality and cognitive improvement.

Placement in foster care enhances quality of attachment among young institutionalized children.

This study examined classifications of attachment in 42-month-old Romanian children (N = 169). Institutionalized since birth, children were assessed comprehensively, randomly assigned to care as usual (CAU) or to foster care, and compared to family-reared children. Attachment classifications for children in foster care were markedly different from those in the CAU. Importantly, children placed in foster care before 24 months were more likely to have secure attachments and if placed earlier were less likely to have disorganized or insecure-other attachments. Cognitive status predicted greater likelihood of organized attachment in the CAU and greater likelihood of secure attachment in the foster care and never-institutionalized groups. Foster care is an important intervention to reduce the adverse effects following early deprivation.

A new model of foster care for young children: the Bucharest early intervention project.

The Bucharest Early Intervention Project is a randomized controlled trial of foster care as an intervention for young children who have spent most of their lives in institutions in Bucharest, Romania. The authors implemented an attachment-based model of child-centered foster care there, and a team of three Romanian social workers trained and supported foster parents in managing the complex challenges of caring for postinstitutionalized infants and toddlers. They received regular weekly consultation from US-based clinicians designed to guide their work with foster parents and children. From language development to toilet training to encouraging the development of the young child's ability to trust, foster parents received ongoing support to help these young children transition to family life. Developmental outcomes so far indicate significantly better outcomes for young children in this foster care program than children who remained in institutions. For some domains of development, earlier placement was associated with better outcomes but for others, timing of placement did not appear to matter.

Institutional rearing and psychiatric disorders in Romanian preschool children.

OBJECTIVE: There is increasing interest in the relations between adverse early experiences and subsequent psychiatric disorders. Institutional rearing is considered an adverse caregiving environment, but few studies have systematically examined its effects. This study aimed to determine whether removing young children from institutional care and placing them with foster families would reduce psychiatric morbidity at 54 months of age. METHOD: Young children living in institutions in Bucharest were enrolled when they were between 6 and 30 months of age. Following baseline assessment, 136 children were randomly assigned to care as usual (continued institutional care) or to removal and placement in foster care that was created as part of the study. Psychiatric disorders, symptoms, and comorbidity were examined by structured psychiatric interviews of caregivers of 52 children receiving care as usual and 59 children in foster care when the children were 54 months of age. Both groups were compared to 59 typically developing, never-institutionalized Romanian children recruited from pediatric clinics in Bucharest. Foster care was created and supported by social workers in Bucharest who received regular consultation from U.S. clinicians. RESULTS: Children with any history of institutional rearing had more psychiatric disorders than children without such a history (53.2% versus 22.0%). Children removed from institutions and placed in foster families were less likely to have internalizing disorders than children who continued with care as usual (22.0% versus 44.2%). Boys were more symptomatic than girls regardless of their caregiving environment and, unlike girls, had no reduction in total psychiatric symptoms following foster placement. CONCLUSIONS: Institutional rearing was associated with substantial psychiatric morbidity. Removing young children from institutions and placing them in families significantly reduced internalizing disorders, although girls were significantly more responsive to this intervention than boys.

The effects of foster care intervention on socially deprived institutionalized children's attention and positive affect: results from the BEIP study.

BACKGROUND: We examined the effects of a foster care intervention on attention and emotion expression in socially deprived children in Romanian institutions. METHODS: Institutionalized children were randomized to enter foster care or to remain under institutional care. Subsequently, the institutionalized and foster care groups, along with a community-based comparison group, were evaluated on emotion tasks at 30 and 42 months of age. Behaviors reflecting positive and negative affect and attention were coded from videotapes. RESULTS: Data indicated that at both age points, children who received the foster care intervention showed higher levels of attention and positive affect compared to children who remained institutionalized. Compared to the community sample, children in the foster care intervention showed higher levels of attention to the emotion-eliciting tasks at 42 months of age. CONCLUSIONS: The results of this randomized trial demonstrate the impact of a family-based intervention on the development of attention and positive affect.

Attachment disorders in family and social context.

Serious disturbances of attachment in young children have been increasingly studied in the past decade as they arise in atypical rearing environments. The purpose of this review is to provide an update on recent findings and to consider their implications. Research on children raised in institutions, children adopted out of institutions, and young children who have experienced neglect in families is considered. Reactive attachment disorder may be identified reliably in a minority of children being raised in severely neglectful environments. The emotionally withdrawn/inhibited pattern and the indiscriminately social/disinhibited pattern arise in similar conditions of risk, but respond differently to intervention and appear to have different correlates. Much has been learned about the emotionally withdrawn/inhibited pattern of reactive attachment disorder and the indiscriminately social/disinhibited pattern. Much less is known about so-called secure base distortions or relational disorders of attachment.

Predictors of permanent loss of custody for mothers of infants and toddlers in foster care.

The maltreating mothers of abused and neglected infants and toddlers were evaluated as part of an intensive intervention program. The purpose of this study was to examine cumulative risk versus specific risk factors that led to permanent loss of custody by mothers, predicated upon decisions by the Juvenile Court with regard to permanency planning. The following risk factors were analyzed as potential predictors of placement outcomes: maternal education, maternal history of abuse as a child, history of psychiatric difficulties, substance-abuse history, conviction history (excluding child-abuse charges), depressive symptomatology, degree of partner violence experienced, and cumulative number of risks the mother experienced. Results indicated that mothers who lost custody had significantly more risk factors than those who were reunified with their children. Cumulative risk was a stronger predictor than specific risk factors. Implications for intervention are discussed.

Cognitive recovery in socially deprived young children: the Bucharest Early Intervention Project.

In a randomized controlled trial, we compared abandoned children reared in institutions to abandoned children placed in institutions but then moved to foster care. Young children living in institutions were randomly assigned to continued institutional care or to placement in foster care, and their cognitive development was tracked through 54 months of age. The cognitive outcome of children who remained in the institution was markedly below that of never-institutionalized children and children taken out of the institution and placed into foster care. The improved cognitive outcomes we observed at 42 and 54 months were most marked for the youngest children placed in foster care. These results point to the negative sequelae of early institutionalization, suggest a possible sensitive period in cognitive development, and underscore the advantages of family placements for young abandoned children.

The caregiving context in institution-reared and family-reared infants and toddlers in Romania.

BACKGROUND: We assess individual differences in the caregiving environments of young children being raised in institutions in Romania in relation to developmental characteristics such as physical growth, cognitive development, emotional expression, and problem and competence behaviors. METHOD: Videotaped observations of the child and favorite caregiver in their 'home' environment were coded for caregiving quality, and this was related to child characteristics. Child emotional reactivity was assessed during responses to interactional tasks. Cognitive development was assessed from child responses to the Bayley Scales of Infant Development. Data regarding problem behaviors and competence were obtained from caregiver report. Children reared in institutions were compared on all of these measures to never institutionalized children to assist gauging degree of impairment. RESULTS: Children raised in institutions demonstrated marked delays in cognitive development, poorer physical growth, and marked deficits in competence. Individual differences in caregiving environment were associated with cognitive development, competence, and negative behavior among these young children being reared in institutions. CONCLUSIONS: These data confirm previous findings regarding deficits associated with institutional care and extend our understanding of the impact of individual differences in caregiving quality on the development of young children in institutions.

Attachment in institutionalized and community children in Romania.

This study examined attachment in institutionalized and community children 12-31 months of age in Bucharest, Romania. Attachment was assessed using ratings of attachment behaviors and ratings of caregiver descriptions in a structured interview. As predicted, children raised in institutions exhibited serious disturbances of attachment as assessed by all methods. Observed quality of caregiving was related to formation and organization of attachment in children living in institutions. These results held even when other variables, such as cognitive level, perceived competence, and quantitative interaction ratings, were controlled for. Ratings of attachment behavior in the Strange Situation and caregiver reports of signs of Reactive Attachment Disorder converged moderately. The implications of these findings for different perspectives on attachment are discussed.

Reactive attachment disorder in maltreated toddlers.

OBJECTIVE: To determine if Reactive Attachment Disorder (RAD) can be reliably identified in maltreated toddlers in foster care, if the two types of RAD are independent, and to estimate the prevalence of RAD in these maltreated toddlers. METHODS: Clinicians treating 94 maltreated toddlers in foster care were interviewed regarding signs of attachment disorder at intake in an intervention program. RESULTS: Using categorical and continuous measures, both types of RAD can be reliably identified in maltreated toddlers. Both continuous scores and categorical diagnoses indicated that a substantial minority of maltreated young children do exhibit signs of attachment disorders sufficient to meet criteria in DSM-IV and ICD-10. The two types were moderately convergent and at times co-occurred in the same child. Prevalence of RAD in this high-risk sample was 38-40%. Indiscriminate/disinhibited RAD was identified in children with and without an attachment figure. Within this maltreated group, toddlers whose mothers had a history of psychiatric disturbance were more likely to be diagnosed with attachment disorders. CONCLUSIONS: RAD may be reliably identified in maltreated toddlers. Emotionally withdrawn/inhibited and indiscriminate/disinhibited types of RAD are not entirely independent.