Prezentare CAN Distribuita Studentilor Apr. 2012

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The Effects of Early PsychosocialDeprivation on Brain andBehavioral Development

Charles A. Nelson IIIProfessor of Pediatrics and Neuroscience

Harvard Medical SchoolRichard David Scott ChairChildrens Hospital Boston


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Broad Context World-wide, there are 70 to 100 MILLION

orphaned or abandoned children, at least 8MILLION of whom live in institutions And, as war and AIDS continues to ravage the

planet, as well as the world-wide recession,must anticipate number of orphaned or

abandoned children will only increase.


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The Bucharest EarlyIntervention Project seeks to:

Examine the effects of institutionalization onthe brain and behavioral development ofyoung children

Determine if these effects can be remediatedthrough intervention, in this case: foster care


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Project Background


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Poverty #1 reason forchild abandonment(UNICEF)

Following fall ofCeausescu regime, largenumbers of children

adopted internationally Families not prepared

for range of disabilitiesthat afflicted these

children

1989: The fall of the Ceausescu regime170,000 children reside in state institutions


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Children adopted from institutionsdemonstrate a number of problems,

such as:Disturbances and delays in social/emotional

development (particularly attachment)

Aggressive behavior problems

Inattention/hyperactivity

Syndrome that mimics autism

Growth stunting (see next slide)*

*Sir Michael Rutter argues that this collection of behaviors should be considereda syndrome.


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14 year old girl17 year old girl


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Study Design First ever randomized controlled trial of foster care

as intervention for social deprivation associated withinstitutionalization

Began with >180 children but after pediatric exam

narrowed this to 136institutionalized childrenbetween 6 and 31 months initially assessed atbaseline (Mean Age=20 months)

68 randomly assigned to remain in institution (CAUG)

68 randomly assigned to foster care (FCG)

Also recruited 72 never-institutionalized children(NIG) matched on age and gender serve as controls


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Study Design o t) Following baseline assessment, children assessed

comprehensively at 9, 18, 30, and 42 monthsalimited 54 month assessment was performedanextensive assessment was performed at age 8, and

another is in the works at age 12.


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Domains of Assessment Physical Development

Language

Social Functioning/Social-Emotional

Development

Characterization of Caregiving Environment

Cognition

Temperament

Attachment

Brain Function (EEG, ERP) Brain Anatomy (MRI)

Genetics/Epigenetics

Mental Health Problems


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Key Characteristics ofFoster Care Intervention

Material Support Medical Support Ongoing

Monitoring Family Support

No Daycare

Foster Parent Training & LicensingStaff Support and DevelopmentLinks to Permanency Planning


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Ethical Considerations


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Why was the BEIP conductedin Romania? Tens of thousands of

institutionalized young children mostly abandoned very early

Opportunity to study importance of

early experiences in young children

Invited to conduct study by Ministerfor Child Protection

Romanian interest in developing

policies for intervening withabandoned children

institutional care versus fostercare


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Ethical Issues Could not identify enough foster care families for

all children and thus, were permitted to do randomassignment of only some children

Received permission from local authorities,caregivers, and all US institutions

Implemented policy of non-interference when

possible, children changed from original groupassignment (e.g., from institutional care to familycare)


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Study Findings


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Point 1: Mean DevelopmentalQuotient at Baseline

0

20

40

60

80

100

120

Baseline

Insitutionalized

Group

Never

Institutionalized

Group

74

100

MeanDQ


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Point 2: What happens to DQ/IQ at 42 monthsof age for all 3 groups?

0

20

40

60

80

100

120

42 Months

Care As Usual Group

Foster Care Group

Never Institutionalized

Group77

103

86

NCAUG 57FCG 61NIG 52

MeanDQ/IQ


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Point 3: How does DQ/IQ differ for children infoster care as a function of age at placement?

Age at placement

70

75

80

85

90

95

100

0-18 18-24 24-30 30+

DQ/IQ

N

0-18 14

18-24 16

24-30 22

30+ 9

*


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Summary of CognitiveDevelopment Institutionalization has a very detrimental effect.

Foster care appears to be effective in improving

cognitive function for those children placed beforeage 2 Duration of time in foster care does not influence

outcome; effects carried by timing.Nelson, C.A., Zeanah, C.H., Fox, N.A., Marshall, P.J., Smyke, A., & Guthrie, D. (2007).

Cognitive recovery in socially deprived young children: The Bucharest EarlyIntervention Project. Science,318, 1937-1940.


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Psychiatric Morbidity


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Did the foster careintervention decrease the

rates of psychiatric disordersfor ever institutionalized

children?


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ADHD

0%

5%

10%

15%

20%

25%

ADHD

CAUG FCG NIG

No difference betweenCAUG and FCG


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Disruptive Behavior Disorders

0%

5%

10%

15%

20%

ODD/CD

CAUG FCG NIG

No difference betweenCAUG and FCG


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Depression

0%

1%

2%

3%

4%

5%

Depression

CAUG FCG

CAUG vs FCGOR=2.3


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Any Anxiety Disorder

0%

10%

20%

30%

40%

50%

Any anxiety disorder

CAUG FCG

CAUG vs FCGOR=2.9


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Gender differences inpsychiatric symptoms Girls in both the IG and FCG groups had

significantly fewer psychiatric symptoms anddisorders than boys

In the foster care group, girls showed greaterreduction in overall emotional disorder symptoms,and anxiety symptoms, in particular, than boys

In fact, the vast majority of reductionpsychopathology with the foster care interventioncan be accounted for by responses in the girls, notthe boys


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Timing of Placement We found no significant effect of timing of

placement on rates of psychopathology or

impairment


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Summary Higher rates of psychiatric disorders and impairment in

children who have been institutionalized compared withchildren in the community

No significant difference in rates of ADHD or disruptivebehavior disorders in children in the institution versus those infoster care

Children in the foster care group had significantly lower ratesof emotional disorders, anxiety disorders, RAD, andimpairment (trend) than children who remained in theinstitution

Being a girl may be a protective factor

No evidence of effects of timing on rates of psychopathologyor impairment

Zeanah, C.H., Egger, H.L., Smyke, A.T., Nelson, C.A., Fox, N.A., Marshall, P.J.,& Guthrie, D. (2009). Altering early experiences reduces psychiatricdisorders among institutionalized Romanian preschool children. American

Journal of Psychiatry, 166, 777-785.


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Conclusions Children raised in institutions during early

development demonstrate significantly impairedphysical, cognitive, language, social-emotional, andbrain development compared to community children

Insofar as we have been able to look at our data, ourmodel of foster care as an intervention appears to

effectively ameliorate many of the negative sequelaeof institutionalization

Although not allfor example, we are seeing onlysmall effects on executive functions.

Which is consistent with our mental health outcomes(e.g., high prevalence of ADHD and no effect offoster care)


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General Conclusions Institutional care has a very deleterious effect on nearly

all aspects of brain, biological and psychologicaldevelopment

Placing previously institutionalized children into familiesimproves overall level of functioning.

Although extent of recovery in some domainsregulated by timing (age at placement)

Based on these findings, we may wish to think aboutwhether orphaned or abandoned children should everbe placed in institutions, at least early in life.

Prezentare CAN Distribuita Studentilor Apr. 2012

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