Children reared in an institution are found to have increased vulnerability to psychopathology diagnoses between childhood and adolescence, according to a study published in JAMA Psychiatry. Early assignment to foster care can help mitigate this risk..

The investigators of this longitudinal, intent-to-treat, randomized study sought to assess the presence and trajectories of latent psychopathology factors (general, internalizing, and externalizing) among children who were reared in institutions. Furthermore, the investigators evaluated whether randomization to foster care is associated with a reduction in negative psychiatric outcomes from childhood through adolescence.

The study sample included a total of 220 children aged 6 to 31 months at baseline, who were recruited from 6 institutions in Bucharest, Romania. All participants underwent baseline testing; 136 were randomly assigned to receive care as usual (n=68) or foster care (n=68). Participants were matched to a sample of never-institutionalized children as a control group. Psychopathology was the primary outcome measured using the MacArthur Health and Behavior Questionnaire, with teachers and caregivers reporting additional symptoms. Follow-up assessment of the participants occurred at the mean ages of 8, 12, and 16 years. Latent bifactor modeling was used to estimate the trajectories of general risk factors over time, as well as internalizing and externalizing risk factors associated with psychopathology.

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Comparing groups at age 8, the care as usual group (mean=0.41; 95% CI, 0.17-0.67) and the foster care group (mean=0.3; 95% CI, 0.04-0.53) had higher general psychopathology than the never-institutionalized group (mean=-0.4; 95% CI, -0.56 to -0.18). At age 16, the foster care group (mean=0.07; 95% CI, -0.18 to 0.29) had lower general psychopathology than the care as usual group (mean=0.37; 95% CI, 0.13-0.60).

Examining externalizing psychopathology factors, the results of the care as usual group and foster care group showed increasing divergence over time: by age 16, the foster care group (mean, -0.3; 95% CI, -0.58 to -0.02) demonstrated fewer problems than the care as usual group (mean, 0.05; 95% CI, -0.25 to 0.36). Examination of internalizing psychopathology factors revealed no differences.

Limitations of the study included a small sample, which may have limited the ability of the authors to detect certain outcomes, as well as missing data over time. The assessment of psychopathology also depended on ratings provided by teachers and caregivers, which could have potentially introduced bias. Finally, the authors used a unique sample of institutionalized children, and the findings may not be generalized to other forms of early childhood adversity beyond pervasive deprivation.

The authors concluded that institutionalization increases the risk of psychopathological trajectories between early childhood to adolescence. While the difference between institutionalization and foster care was not evident on general psychopathology at age 8 years, by age 16 years, children in foster care had a far less problematic trajectory than children who were institutionalized. Early assignment to foster care may help partially mitigate the effects of severe psychosocial deprivation on trajectories of psychopathology.


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 Psych. doi:10.1001/jamapsychiatry.2018.2556.