Foster care improves well-being, IQ of children under institutional care

Placement in families is beneficial to children who have been previously put in institutional care, according to the results of the analysis of the Bucharest Early Intervention Project (BEIP). In addition, the benefits of foster care have remained stable across the child’s development.

“Millions of children worldwide experience psychosocial deprivation in institutions, and many more are neglected in their families of origin,” the researchers said. “Against this backdrop, 6.7 million children have lost a parent or caregiver as a result of the COVID-19 pandemic.” [Lancet 2021;398:391-402; Pediatrics 2021;148:e2021053760; Lancet Child Adolesc Health 2022;6:249-259]

An intent-to-treat approach was used to analyse the cause effects of BEIP, the first randomized controlled trial of foster care as an alternative to institutional care. This trial included 136 children (baseline age, 6‒31 years) residing in institutions in Bucharest, Romania, who were randomly assigned to either foster care (n=68) or care as usual (n=68).

The researchers then assessed the children for IQ, physical growth, brain electrical activity (EEG), and symptoms of five types of psychopathology at ages 30, 42, and 54 months and 8, 12, and 16‒18 years.

A total of 7,088 observational data across follow-up waves were obtained. Children assigned to foster care demonstrated better cognitive and physical outcomes and less severe psychopathology than those who received usual care. [Am J Psychiatry 2023;180:573-583]

The beneficial effects of foster care on children remained stable across their development. Notably, being placed in foster care had the strongest influence on IQ, as well as on disorders of attachment or social relatedness.

The significant influence of the intervention on IQ was remarkable because the foster care intervention was not specifically designed to enhance cognitive functioning but rather to improve the relationship between the child and the caregiver, according to the researchers.

In terms of developmental cascades, early competence can further improve the child’s well-being in such a way that positive functioning extends to other domains over time. [Dev Psychopathol 2012;24:345-361; Dev Psychopathol 2010;22:491-495]

The intent-to-treat analyses of the current study fell short of showing the cascading positive effects of the foster care intervention, but the researchers found consistent benefits of foster care throughout the child’s development. [JAMA Psychiatry 2018;75:1137-1145; Lancet Psychiatry 2015;2:625-634]

“Specifically, the positive effects of the intervention on children’s functioning persisted across nearly two decades of follow-up assessments, during which children in both the intervention and care-as-usual groups experienced changes to their caregiving environments,” the researchers said.

Hence, the impact of the BEIP may be deemed “rapidly apparent” by age 30 months, sustained through late adolescence, with minimal evidence of fade-out over time.

“[W]e provide strong and conclusive causal evidence that children exposed to early deprivation benefit from high-quality family-based care and, more broadly, that the nature of the early caregiving environment has an extensive and lasting impact on development,” they said.

The BEIP uses a foster care model that encourages parents to make a psychological commitment to the child and differs from that used in the US, which focuses on the child’s instrumental care needs. [Nelson CA, Fox NA, Zeanah CH: Foster care intervention; in Romania’s Abandoned Children: Deprivation, Brain Development, and the Struggle for Recovery. Cambridge, Mass, Harvard University Press, 2014]

The BEIP model also incorporates regular support from social workers and US-based psychologists for foster parents, so they can provide proper care to children who are vulnerable to developmental and socioemotional difficulties.