Charles A. Nelson III Professor of Pediatrics, Neuroscience and Psychiatry,

1. The Effects of Early Institutional Care on Child and Brain Development:Lessons from the Bucharest Early Intervention Project (BEIP) Charles A. Nelson III Professor of Pediatrics, Neuroscience and Psychiatry, Harvard Medical School Professor of Education, Harvard University Richard David Scott Chair, Boston Children’s Hospital • Webinar presented 30 April 2019 to Right to Family for All Children & Dangers of Residential Care & Group Home Placement, International Human Rights Law and Findings from Research & Experience

2. The Problem • ~140 million of orphans and vulnerable children (OVC) worldwide • UNICEF (conservatively) estimates 8 million children worldwide living institutions (orphanages) • Most common form of care for orphaned and abandoned children in many parts of the world (Central and South America, Asia, Eastern Europe and Russia, and many African countries)

3. Children in Institutions: The Global Picture CzechR9,56113 Russia20 400,000 95% have a living parent 98% have a living parent Moldova 2,95515 96%16 have a living parent Bulgaria 3,26217 98%18 have a living parent Ukraine19 117,600 14 85% have a living parent Nepal25over 15,000 Japan 26 60% have a living parent 35,000 Turkey12 20,000 Morocco 21 65,000 77% have a living parent 4,500 orclose Bolivia8 15,000 54% have a living parent Rwanda23 2,500 78% have a living parent 90% have a living parent SriLanka24 21,000 at least 90% have a living parent Paraguay9upto 5,000 Brazil11 50,500 Argentina10 17,000

4. This map shows the percentage of children in institutions who have at least one living parent. Many of these children could return to their birth parents with the right support. Russia30 Turkey12 95% 60% Bulgaria18 98% Nepal25 85% Moldova16 CzechR14 96% 99% Cambodia27 Ghana22 77% 90% Haiti29 80% Indonesia31 Rwanda 94% 21 Bolivia 8 54% Paraguay9 78% SriLanka24 94% 90%

5. History of Institutional Care: A “Preferred” form of care for orphaned and abandoned children • Antiquity - Informal adoption • Dark ages - Monasteries and nunneries • Middle Ages and Renaissance - Beginning of foundling homes • 18th-19th Century – Institutions • 20th-21st Century – Foster care

6. First White House Conference on Children January 25-26, 1909

7. First White House Conference on Children As to the children who for sufficient reasons must be removed from their own homes, or who have no homes, it is desirable that, if normal in mind and body and not requiring special training, they should be cared for in families whenever practicable.... Such homes should be selected by a most careful process of investigation, carried on by skilled agents through personal investigation and with due regard to the religious faith of the child. After children are placed in homes, adequate visitation, with careful consideration of the physical, mental, moral, and spiritual training and development of each child on the part of the responsible home-finding agency is essential. Children should be placed in families – not in institutions

8. First White House Conference on Children So far as it may be found necessary temporarily or permanently to care for certain classes of children in institutions, these institutions should be conducted on the cottage plan, in order that routine and impersonal care may not unduly suppress individuality and initiative.... It secures for the children a larger degree of association with adults and a nearer approach to the conditions of family life, which are required for the proper molding of childhood. If children cannot be in families, they should be in as “family-like” a setting as is possible.

9. The best conditions for the infant thus require a home and a mother. The further we get away from these vital necessities of beginning life, the greater will be our failure to get adequate results in trying to help the needy infant. Strange to say, these important conditions have often been overlooked, or, at least, not sufficiently emphasized, by those who are working in this field.

10. So this is an old problem…. • For which new solutions are desperately needed…

11. We have known for at least 50 years that children reared in institutions… • …are at dramatically increased risk for a variety of social and behavioral problems: • disturbances of social relatedness and attachment • externalizing behavior problems • inattention/hyperactivity • deficits in IQ and executive functions • syndrome that mimics autism • Growth stunting (next slide) • Developmental problems believed to result from deprivation inherent in institutional care

12. Effects of Institutionalization on Growth 17 year old girl 14 year old girl Institutionalized children lose ~1 month of linear growth for every ~1 month in an institution (photo courtesy of Dana Johnson, MD, Ph.D.)

13. Why institutionalized rearing may be bad for the brain • Regimented daily schedule • Non-individualized care • Sensory, social-emotional, cognitive, and linguistic deprivation • No response to distress • Unchecked aggression • Lack of psychological investment by caregivers • High child/caregiver ratio • Rotating shifts of caregivers

14. The Bucharest Early Intervention Project seeks to: Examine the effects of institutionalization on the brain and behavioral development of young children Determine if these effects can be remediated through intervention, in this case: foster care Improve the welfare of children in Romania by establishing foster care as an alternative to institutionalization Principle Investigators Charles H. Zeanah, MD Charles A. Nelson, Ph.D. Nathan A. Fox, Ph.D.

15. BEIP Study Design • First ever randomized controlled trial of foster care as intervention for social deprivation associated with institutionalization • >180 children screened • 136 institutionalized children between 6 and 31 months initially assessed at baseline (Mean Age=20 months) • 68 randomly assigned to remain in institution (CAUG); 68 randomly assigned to foster care (FCG); • 72 never-institutionalized children (NIG) matched on age and gender serve as controls • Following baseline assessment, children assessed comprehensively at 9, 18, 30, and 42 months…a limited 54 month assessment was performed…an extensive assessment was performed at age 8, and another at age 12; 16 year follow up has begun.

16. Bayley Scales of Infant Development (MDI) (at baseline) • Smyke AT, Koga SF, Johnson DE, Fox NA, Marshall PJ, Nelson CA, Zeanah CH, & the BEIP Core Group (2007). • Journal of Child Psychology and Psychiatry, 48, 210-218.

17. How does DQ/IQ differ for children in foster care as a function of age of entry? • Nelson CA, Zeanah CH, Fox NA, Marshall PJ, Smyke AT, & Guthrie D (2007).. Science, 318, 1937-1940.

18. Summary of IQ findings • Young children living in institutions show significant delays in IQ • Removal from institutions, particularly prior to 24 months of age, and placement into families remediates IQ deficits • Remarkably, many years (e.g., 12 year follow up) after the intervention began there are still positive effects on IQ

19. Psychopathology

20. Types of psychopathology at 54 months • Zeanah et al., 2009, American Journal of Psychiatry

21. Psychiatric Disorders at 12 Years • Humphreys et al., 2015 Lancet Psychiatry

22. Summary • At both 54 months and 12 years, see a very high rate of mental health problems among institutionalized children • But, internalizing problems (anxiety, depression) more common in young children; externalizing (acting out, disruptive behavior, etc) more common in older children • At both ages, see powerful effect of intervention on many domains of mental health, but not all; specifically, continue to see a very high rate (20%) of Attention Deficit-Hyperactivity Disorder (ADHD)

23. What about the brain? • Assume that the behavioral phenotype of the institutionalized child reflects alterations in underlying neural substrate; thus, • …turned to EEG and MRI

24. EEG activity at baseline InstitutionalizedGroup 3.80μV2 2.44μV2 Never Institutionalized Group • Marshall, et al (2004) J. of Cog Neuro

25. Does brain activity (EEG) change as a function of intervention and timing? - Age 8 Foster Care after 24 months Institutionalized Group Foster Care before 24 months Never Institutionalized Group • Vanderwert et al (2010) PLoS One

26. Summary • Children who received care as usual (CAUG) displayed deficits in brain electrical activity compared to the children randomized to foster care intervention (FCG). • Children who received the foster care intervention continued to show typical levels of brain activity through age 16 (although I only showed data through age 8). • The age of placement into foster care is associated with the increase of alpha power. Specifically, foster care placement before 24 months results more robust improvements in brain activity.

27. Stress response

28. Trier Social Stress Test • Delivered a speech about what makes a good friend in front of two teachers that they never met before • Preparation • Speech • Negative and neutral feedback • Math • With feedback about accuracy • McLaughlin KA, Sheridan M, Tibu F, Fox NA, Zeanah CH, & Nelson CA (2015). Proceedings of the National Academy of Sciences, 112 (8), 5637-5642

29. Cortisol reactivity (age 12) FCG vs CAUG t = 2.58, p = .010

30. Timing of placement (FCG only)

31. Summary • Care as Usual children fail to show appropriate autonomic and cortisol response to stressor; by contrast… • Children in foster care at age 12 show intervention effect (i.e., appropriate elevation in cortisol when stressed)

32. Lessons Learned from BEIP

33. Changes in Romania and Elsewhere • 2 years after project was launched and initial findings presented to Romanian government, legislation passed forbidding the institutionalization of children <2, unless severely handicapped; in 2014, this law changed to <3, and in 2018, it is now <7 years • Romania began to close down institutions • In 1989, >170,000 children in institutions • In 2000, ~100,000 • In 2013, ~20,000 • In 2019, ~<20,000 • UNICEF uses BEIP to convince governments throughout the world to stop institutionalizing children

34. Implications for Public Health • Institutional care varies a great deal, from region to region and country to country (nevertheless, regardless of how “good” or “bad” institutional care is, children coming out of such environments have certain things in common). • Nevertheless, we should consider institutional care to be a form of an extreme environment, in some cases no different than the child neglect that many children experience in many parts of the world (including the US).

35. The End • charles_nelson@harvard.edu