Children raised in institutions are at increased risk for general and externalizing psychopathology years after their removal from the institutions, but the risk for psychopathology is attenuated between age 8 and 16 by early assignment to foster care, according to study results published in JAMA Psychiatry.

Children who experience early psychosocial neglect are at risk for a number of socioemotional, cognitive, and behavioral difficulties. Children raised in institutions have higher incidences of depression, anxiety, disruptive behavior disorders, and attention-deficit/hyperactivity disorder.

To determine the trajectory of psychopathology factors in institutionalized children, Mark Wade, PhD, of the Division of Developmental Medicine, Boston Children’s Hospital and Harvard Medical School in Massachusetts, and colleagues analyzed data from a longitudinal intent-to-treat randomized clinical trial conducted in Bucharest, Romania, in 6 institutions in which children underwent baseline testing at age 6 months and 31 months and then were randomly assigned to care as usual within the institution or a foster care group. A matched sample of never-institutionalized children was used as the comparison group.

Continue Reading

The study was initiated in April 2001 and the last follow-up was in January 2015. The primary outcome, psychopathology, was measured using the MacArthur Health and Behavior Questionnaire, with teachers and/or caregivers providing information on symptoms of psychopathology in several domains.

The study included 220 children; 50% were female and 119 had been institutionalized. The data from ages 8, 12, and 16 years were analyzed. At 8 years, the comparison group of never institutionalized children had significantly lower general psychopathology than either the institutionalized group or the foster care group, which did not differ from one another. Between age 8 and 16, the foster care group declined in general psychopathology, while the institutionalized group remained high and the comparison group low for this measure. After accounting for differences in general psychopathology, there were no differences between the 3 groups for internalizing psychopathology from age 8 to 16.  At age 8, the comparison group had significantly lower levels of externalizing psychopathology than both the institutionalized and foster care groups. However, between the age of 8 and 16, the foster care group showed significant declines in externalizing psychopathology, while no change was seen in the institutionalized group. By age 16, the foster care group was not statistically different from the never-institutionalized comparison group.

Related Articles

The reliance on teachers and caregivers to perform psychopathology assessments and the small sample size were study limitations.

The investigators argued that social enrichment early in child development reduces the risk for psychopathology in children with a history of profound neglect. They noted that the benefits of foster care vs institutionalized care accrue over time and “may promote healthy adaptation during a formative period of neurophysiological reorganization.”


Wade M, Fox NA, Zeanah CH, Nelson CA. Effect of foster care intervention on trajectories of general and specific psychopathology among children with histories of institutional rearing: a randomized clinical trial [published online September 26, 2018]. JAMA Psychiatry. doi:10.1001/jamapsychiatry.2018.2556