The study conducted in 2009 by Zeanah and colleagues researching Romanian preschool children attempted to measure whether switching children from institutional care to foster family care would decrease the prevalence of psychiatric disorders at age 54 months. This study is especially new and important to the field, as it measures and controls for the institutional caregiving setting before the child is fostered out, instead of focusing on the child once he or she leaves the institution. This study also assesses the onset of several psychiatric disorders instead of limiting the number of disorders studied to just one (Zeanah et al. 2009). In addition, under normal circumstances children are not randomized when selected by adopters, which potentially leaves the most heavily impaired children within the institution and out of the adoption study. This study randomizes the placement of the children into separate groups: those placed in foster care and those who remained in institutional care. For further control, the study also compares both of these groups to a group of never-institutionalized Romanian children of the same age (Zeanah et al. 2009).
The total number of participants recruited from the institutions was 187. Due to medical reasons for exclusion, adoption, drop-outs, and missing data, 111 children were included in the final form of the study: 52 were randomized to remain in institutional care and 59 were randomized and placed into foster care (Zeanah et al. 2009). This foster care program was established as a part of the study, as no substantial system was in place. Age, sex, birth weight and other factors were virtually identical between the two groups. The main difference between the two groups was the high ratio of children to caregivers in institutions, with institutions having less one-on-one time and less stable, emotional bonding than foster care (Zeanah et al. 2009). The researchers were interested in this difference and its role in the appearance of psychiatric disorders later in childhood at 54 months. At this age, these groups were compared to the control group of never-institutionalized children, which consisted of 59 children in the final number analyzed. Age, sex, place of birth, and other factors remained consistent with the first two groups, with major differences occurring in birth weight of the children being compared (Zeanah et al. 2009).
This study was a longitudinal study that tracked and compared the diagnoses of various DSM-IV-TR disorder symptoms between the groups according to the Preschool Age Psychiatric Assessment (PAPA). The PAPA is a caregiver report that relies on rigid, standardized questions. Symptoms of potential disorders were recorded and watched over time by the primary caregiver (or caregiver who knows the child best) to assess proper diagnoses if needed (Zeanah et al. 2009). The types of disorders measured for were divided into three categories: “externalizing disorders”, such as ADHD, oppositional defiant disorder, and conduct disorder, “internalizing disorders”, such as depression and anxiety disorders, and “any disorder”, which could include any of the aforementioned disorders in addition to sleep disorders, enuresis, encopresis, and reactive attachment disorder (Zeanah et al. 2009 pp 780).
The results of this study show a significant difference between both groups that came from the institutions from the outset (both those who remained in institutional care and those who were placed in foster care) and the never-institutionalized children. Those who had any experience with institutional care were much more likely to develop any kind of disorder that the study measured (Zeanah et al. 2009). This result suggests that children raised in institutional care are at higher risk for developing psychiatric disorders in childhood due to the less than ideal conditions and quality of care provided.
A second result of the study reveals differences between the children who were placed in foster care and the children who were chosen to remain institutionalized. Internalizing disorders were significantly more prominent in the group of children who remained institutionalized than the foster care group (Zeanah et al. 2009). This is the most intriguing finding of the study, as it suggests that placing an abandoned child in foster care may help protect him/her from childhood onset of depression and anxiety disorders (the internalizing disorders). The researchers noted that the foster care families involved in the study were instructed to be nurturing, which in combination with the stable and constant care of one or two parental figures, may have provided suitable conditions for attachment to form (Zeanah et al. 2009).
Attachment is defined as the “powerful bond of love between a caregiver and child (or between any two individuals)” (Belsky 2009 pp 111). This is an important idea to consider when discussing this study, as it is really one of the major factors that could be influencing the significant improvement of the rates of internalizing disorders in the foster care group of children. With the nurturing, stable environment that foster care provides over nonindividualized care in institutions, attachment is more likely to form. In her book Experiencing the Lifespan, Janet Belsky describes attachment as necessary to develop and interact with others normally in order to “live fully” (Belsky 2009 pp 111). This suggests that attachment in early childhood is essential not only for healthy childhood functioning, but is essential as a foundation to live the rest of the lifespan in similar fashion. In relation to the Zeanah study, the increased chances of the formerly institutionalized children forming attachment when placed in foster care is a great step forward in providing these children with the foundation to experience better future interpersonal relationships and protect against internalizing disorders.
Harlow’s classic study of motherless monkeys shows disturbances in this formation of attachment, and suggests possible explanations for the significant increase in psychiatric disorders found in childhood with a history of institutionalization. These baby monkeys were separated from their mothers at birth and were isolated in cages with a choice of two mothers: a soft cloth monkey mother that provided comfort but no food, and a wire monkey mother that offered no comfort, but provided food. The baby monkeys chose to cling to the cloth, comforting mother over the wire mother most of the time. However, without real motherly contact, these monkeys were not given the interpersonal tools to cope with other monkeys, mate, and have children of their own without insemination. Even then, the monkeys became abusive mothers themselves (Belsky 2009). This shows a severe outcome that suggests that children in institutional care who do not form proper attachments could more readily develop the psychiatric disorders measured in the study, which could coincide/influence the struggle to relate to others in forming meaningful relationships.
A limitation of the study is the possible differential treatment that may have occurred between boys and girls in foster care. Girls fared better overall in lower rates in any category of disorders, which was supported by the never-institutionalized control group. However, there was no significant difference between control group boys and girls in the measure for internalizing disorders, including depression and anxiety disorders (Zeanah et al. 2009). This contradicts the findings comparing the foster care and institutional care for the boys, which show results that the boys showed no significant improvement between foster care and institutional care with the internalizing disorders, while the girls did show improvement if placed into the foster care group (Zeanah et al. 2009). This could potentially be explained by differential treatment between boys and girls in the foster care setting. Foster parents may have been more supportive or nurturing toward girls, while being less understanding of depressive or anxious symptoms in boys. This could result in inflation of symptom reporting in boys, or alternatively become an environment where the true symptoms could worsen. While it is difficult to standardize foster care, perhaps another study can be done to investigate this potential bias further. If it is true that the expectations of caregivers toward boys and girls differ in relation to internalizing disorders, special education and precautions can be offered to foster families to help young boys adjust to their new lives.
This study done by Zeanah et al. is an important step to understanding how institutionalized care for abandoned children can be improved. The significant findings in the reduction of internalizing disorders by placing children in institutions into foster families hint that an emphasis on attachment formation in early childhood is important in the prevention of depression and anxiety, and possibly interpersonal problems throughout the lifespan.
Works Cited
Zeanah et al., Initials. (2009). Institutional rearing and psychiatric disorders in Romanian preschool children. Am J Psychiatry, 166(7), Retrieved from https://ctools.umich.edu/portal/site/da5a970e-dbf5-4f4d-8d72-d8280f4c505f/page/ba3077c6-365a-488b-b4e4-53384beccc55
Belsky, J. (2010). Experiencing the lifespan. New York, NY: Worth Publishers.
