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Over the last 20 years, we have learned much about the extent to which early-life deprivation affects the mental health of children and adolescents. This body of evidence comes predominantly from studies of children raised in institutional care. The Bucharest Early Intervention Project (BEIP) is the only randomized controlled trial designed to evaluate whether the transition to family-based foster care early in development can ameliorate the long-term impact of institutional deprivation on psychopathology during vulnerable developmental windows such as adolescence. In this review, we detail the extent to which early deprivation affects mental health during this period, the capacity of family-based care to facilitate recovery from early deprivation, and the mechanisms underpinning these effects spanning social-emotional, cognitive, stress, and neurobiological domains. We end by discussing the implications and directions for the BEIP and other studies of youth raised in institutions.

Childhood neglect is associated with impairment across multiple domains of development. Because types of neglect co-occur and are correlated with abuse, most research cannot address the specific effects of psychosocial neglect. This limitation matters because some scholars have advocated that child protection measures should be employed only when a child is physically endangered. Here, we review evidence for the effects of psychosocial neglect on development derived from studies of young children raised in institutions. In these caregiving environments, children are physically safe and receive instrumental care, but the social, emotional, and cognitive components of caregiving are impoverished. The damaging and often lasting effects of these caregiving environments on young children's development underscore that psychosocial neglect should be considered as dangerous to child well-being as physical maltreatment. Efforts to reform child protection must do so with full appreciation of the consequences of young children's exposure to prolonged psychosocial neglect.

Background Experiences of adversity in early life are associated with increased risk for negative outcomes; yet, the impact of early adversity on any given child is difficult to predict given the considerable heterogeneity in functioning found even among children with similar exposures. Thus, although early adversity is associated with increased risk for negative outcomes on average, many children are resilient. While researchers have highlighted individual differences in children's internal characteristics that may relate to risk and resilience, external characteristics of the environment that differ between children are mutable factors that are also important for understanding heterogeneity in children's outcomes. Objective We propose that caregiver regulation of children's emotions is a key modifiable feature of the environment that promotes resilience to and recovery from early adversity. Specifically, given the critical role of caregiver regulation of emotions in early life for children's ability to understand and recover from adverse experiences, we highlight three levels of intervention focused on fostering healthy development in young children by targeting the availability, consistency, and quality of caregiver regulation, respectively. Results We provide a classification system designed to guide decision making about the level of intervention needed to support a given child's needs in terms of ultimately supporting the goal of receiving effective caregiver regulation. Implications This framework may be useful for guiding the priority of treatments, as well as making clear the needed menu of options to support children following adversity, in addressing specific concerns related to ensuring effective caregiver regulation to promote resilience. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

OBJECTIVE: The COVID-19 pandemic and mitigation strategies amplified racial and income-based health disparities, profoundly shifted family life, and altered delivery systems for support services. We report pilot data from a telehealth adaptation of Mom Power, an evidence-based, attachment-informed multifamily preventive intervention (clinicaltrials.gov: de-identified). METHOD: Virtual Mom Power (VMP), adapted for economically marginalized, predominantly Black mothers and their young children (n = 9) was implemented in New Orleans, an early COVID-19 hotspot with an entrenched history of structural racism and trauma. We outline our approach to adaptation of curriculum and service delivery, using a trauma-informed lens. RESULTS: Maternal reports of maternal and child functioning from pre to post were consistent with improvements in maternal depressive and posttraumatic stress symptoms and child competence, comparable to outcomes from in-person trials. Feasibility and acceptability data were strong. DISCUSSION: Preliminary results and reflections on process suggest that telehealth service delivery of a multifamily preventive intervention, with attention to decreasing barriers to online access and consideration of culture and context, facilitated engagement while maintaining fidelity and effects on intervention targets. Future research using larger samples, randomized controlled design, and multi-method assessment should continue to guide dissemination of reflective, group-based telehealth parenting programs.

We examined whether family care following early-life deprivation buffered the association between stressful life events (SLEs) and executive functioning (EF) in adolescence. In early childhood, 136 institutionally reared children were randomly assigned to foster care or care-as-usual; 72 never-institutionalized children served as a comparison group. At age 16 years, adolescents (n = 143; 54% female; 67.1% Romanian) self-reported recent SLEs, completed a battery of memory and EF tasks, and completed a go/nogo task in which mediofrontal theta power (MFTP) was measured using electroencephalogram. More independent SLEs predicted lower EF and more dependent SLEs predicted lower MFTP, but only among adolescents with prolonged early deprivation. Findings provide preliminary evidence that family care following early deprivation may facilitate resilience against stress during adolescence on EF.

Hypotheses concerning the biologic embedding of early adversity via developmental neuroplasticity mechanisms have been proposed on the basis of experimental studies in animals. However, no studies have demonstrated a causal link between early adversity and neural development in humans. Here, we present evidence from a randomized controlled trial linking psychosocial deprivation in early childhood to changes in cortical development from childhood to adolescence using longitudinal data from the Bucharest Early Intervention Project. Changes in cortical structure due to randomization to foster care were most pronounced in the lateral and medial prefrontal cortex and in white matter tracts connecting the prefrontal and parietal cortex. Demonstrating the causal impact of exposure to deprivation on the development of neural structure highlights the importance of early placement into family-based care to mitigate lasting neurodevelopmental consequences associated with early-life deprivation.

This study examined longitudinal data from the Bucharest Early Intervention Project, a randomized controlled trial of foster care as an alternative to institutional care following exposure to severe psychosocial deprivation. We report data from 135 participants assessed in early adulthood (age 18 y). We find that 16 y after randomization occurred, those who had been randomized to high-quality foster care had significantly higher IQ scores (9 points, 0.6 SD) than those randomized to care as usual. Mediation analyses provide evidence that the causal effect of the intervention on cognitive ability in early adulthood could be explained, in part, by higher-quality caregiving and attachment security. These findings indicate that early investment in family care as an alternative to institutional care leads to sustained gains in cognitive ability. Fostering caregiving relationships is a likely mechanism of the intervention. In addition, exploratory analyses indicate that stable placements throughout childhood are associated with the greatest long-term gains in cognitive ability. Whether early interventions for infants and young children lead to lasting change has significant implications for decisions to invest in programs aimed at improving children’s developmental outcomes.

Institutional rearing negatively impacts the development of children's social skills and executive functions (EF). However, little is known about whether childhood social skills mediate the effects of the foster care intervention (FCG) and foster caregiving quality following early institutional rearing on EF and social skills in adolescence. We examined (a) whether children's social skills at 8 years mediate the impact of the FCG on the development of EF at ages 12 and 16 years, and (b) whether social skills and EF at ages 8 and 12 mediate the relation between caregiving quality in foster care at 42 months and subsequent social skills and EF at age 16. Participants included abandoned children from Romanian institutions, who were randomly assigned to a FCG (n = 68) or care as usual (n = 68), and a never-institutionalized group (n = 135). At ages 8, 12, and 16, social skills were assessed via caregiver and teacher reports and EF were assessed via the Cambridge Neuropsychological Test Automated Battery. Caregiving quality of foster caregivers was observed at 42 months. FCG predicted better social skills at 8 years, which in turn predicted better EF in adolescence. Higher caregiver quality in foster care at 42 months predicted better social skills at 8 and 12 years, and better EF at 12 years, which in turn predicted 16-year EF and social skills. These findings suggest that interventions targeting caregiving quality within foster care home environments may have long-lasting positive effects on children's social skills and EF.

Children reared in institutions experience severe psychosocial deprivation, resulting in lasting consequences for social and emotional development. This study evaluated growth trajectories of self-regulation from ages 8 to 16 among previously institutionalized children randomized to foster care (foster-care group; FCG) or to remain in institutional care (care-as-usual group; CAUG) compared with a never-institutionalized group (NIG). We then tested a developmental pathway by which growth in self-regulation reduces general psychopathology at age 16 for the FCG relative to the CAUG. The FCG experienced modest growth in self-regulation over adolescence and “caught up” to the NIG by age 16. The beneficial effect of foster care on psychopathology operated through growth in self-regulation; part of this effect was further mediated by reduced peer difficulties for the FCG. Findings reveal that the effects of foster care on self-regulation emerge over adolescence and that growth in self-regulation is a mechanism by which foster care mitigates the impact of institutionalization on psychopathology.

OBJECTIVE: Early psychosocial deprivation increases the risk of later cognitive and psychiatric problems, but not all deprived children show these difficulties. Here, we examine the extent to which psychosocial deprivation increases the risk of later cognitive and psychiatric difficulties and the downstream consequences of this for risk-taking behavior in adolescence. METHOD: Children abandoned to institutions early in life were randomly assigned to care-as-usual or a foster care intervention during infancy. A separate group of never-institutionalized children was recruited as a comparison sample. The current follow-up study included 165 children (51% female), 113 with a history of institutionalization and 52 with no such history. At age 12, caregivers reported on children’s psychiatric difficulties, and their IQ was assessed by standardized testing. At 16 years, risk-taking behavior was assessed from youth self-reports. RESULTS: Latent profile analysis revealed three subgroups of children with varying levels of cognitive and psychiatric difficulties: Low-Morbidity (n = 104, 62.7%), Medium-Morbidity (n = 46, 27.9%), and High-Morbidity (n = 15, 9.4%). Nearly half of the institutionalized children belonged to the High- or Medium-Morbidity subgroups; and institutionally-reared children were significantly more likely to belong to one of these profiles than never-institutionalized children. Compared to the Low-Morbidity subgroup, membership in the Medium-Morbidity profile was associated with higher levels of risk-taking behavior at age 16 years. CONCLUSIONS: Children who experience psychosocial deprivation are considerably more likely to present with elevated cognitive and psychiatric difficulties in early adolescence and, for some children, this elevation is linked to heightened risk-taking behavior in adolescence.

Early adversity has been shown to sensitize individuals to the effects of later stress and enhance risk of psychopathology. Using a longitudinal randomized trial of foster care as an alternative to institutional care, we extend the stress sensitization hypothesis to examine whether early institutional rearing sensitizes individuals to stressful events in adolescence engendering chronic low-grade inflammation. At baseline, institutionalized children in Romania (ages 6–31 months) were randomly assigned to foster care or to remain in usual care within institutions. A group of never-institutionalized children was recruited as an in-country comparison sample. At ages 12 and 16, participants reported stressful events. At age 16, Interleukin-6 (IL-6) and C-reactive protein (CRP) were derived from blood spots. Among children assigned to care as usual, more stressful events at age 12, but not age 16, were associated with higher IL-6. In the same group, stressful events at age 16 were associated with higher CRP, though these effects attenuated after adjusting for covariates. These associations were not observed in the foster care or never-institutionalized groups. The findings suggest that heightened inflammation following stress exposure is one pathway through which early neglect could compromise physical health. In contrast, early family care might buffer against these risks.

OBJECTIVE Early psychosocial deprivation is associated with increased risk for psychopathology, yet few studies have examined outcomes in adolescents. METHOD At baseline (M age 22 months), 136 children from Bucharest, Romania, living in large institutions, were randomized into foster care (FCG) or to care as usual (CAUG). Caregivers completed psychiatric interviews regarding their children (52 FCG; 51 CAUG) at age 16 years (M = 16.67 years; SD = 0.78) to assess past year diagnoses and symptom counts. In addition, never-institutionalized community comparison children (n = 47) were included. RESULTS Ever-institutionalized children had higher rates of meeting criteria for any psychiatric disorder and higher symptom counts of internalizing, externalizing, attention-deficit/hyperactivity, and substance use disorders compared to never-institutionalized children (ps < .05). Using intent-to-treat analyses, we found that children in the CAUG had more than twice the rate of psychiatric disorders than children in the FCG (OR = 2.48, 95% CI [1.12, 5.48]). Furthermore, children in foster care who remained in their original placement did not significantly differ in their rates of psychiatric disorders compared to never-institutionalized children. CONCLUSIONS There are many ways children can be separated from parents, including placement into institutional care. The current findings indicate that such placements are associated with significant risks for psychopathology. Moreover, we provide causal evidence for the long-lasting positive effect of foster care in reducing the risk of psychopathology in adolescence, especially among those in stable placements. These results provide strong evidence that early and stable placements into quality foster care may mitigate risk for psychopathology following severe early psychosocial deprivation. (PsycInfo Database Record (c) 2020 APA, all rights reserved).

Worldwide, millions of children live in institutions, which runs counter to both the UN-recognised right of children to be raised in a family environment, and the findings of our accompanying systematic review of the physical, neurobiological, psychological, and mental health costs of institutionalisation and the benefits of deinstitutionalisation of child welfare systems. In this part of the Commission, international experts in reforming care for children identified evidence-based policy recommendations to promote family-based alternatives to institutionalisation. Family-based care refers to caregiving by extended family or foster, kafalah (the practice of guardianship of orphaned children in Islam), or adoptive family, preferably in close physical proximity to the biological family to facilitate the continued contact of children with important individuals in their life when this is in their best interest. 14 key recommendations are addressed to multinational agencies, national governments, local authorities, and institutions. These recommendations prioritise the role of families in the lives of children to prevent child separation and to strengthen families, to protect children without parental care by providing high-quality family-based alternatives, and to strengthen systems for the protection and care of separated children. Momentum for a shift from institutional to family-based care is growing internationally—our recommendations provide a template for further action and criteria against which progress can be assessed.

Adverse developmental outcomes for some children following institutional care are well established. Removal from institutional care and placement into families can promote recovery. However, little is known about how positive outcomes are sustained across adolescence among children with histories of severe deprivation. The present study examined the caregiving conditions that are associated with attaining and maintaining competent functioning (i.e., outcomes within typical levels) from middle childhood to adolescence following exposure to early institutional care. The participants included children with and without a history of institutional care who had competence assessed at ages 8, 12, and 16 years across seven domains: family relationships, peer relationships, academic performance, physical health, mental health, substance use (ages 12 and 16 years only), and risk-taking behavior. The participants were grouped based on whether they were always versus not always competent and never versus ever competent at ages 8 through 16 years. Adolescents with a history of institutional care were less likely to be consistently competent than those who were family reared. Among those who were exposed to early institutional rearing, maintaining competent functioning from 8 to 16 years was associated with spending less time in institutions and receiving higher-quality caregiving early in life. Ensuring high quality early caregiving may promote competent functioning following early deprivation.

Attachment theory and research are drawn upon in many applied settings, including family courts, but misunderstandings are widespread and sometimes result in misapplications. The aim of this consensus statement is, therefore, to enhance understanding, counter misinformation, and steer family-court utilisation of attachment theory in a supportive, evidence-based direction, especially with regard to child protection and child custody decision-making. The article is divided into two parts. In the first, we address problems related to the use of attachment theory and research in family courts, and discuss reasons for these problems. To this end, we examine family court applications of attachment theory in the current context of the best-interest-of-the-child standard, discuss misunderstandings regarding attachment theory, and identify factors that have hindered accurate implementation. In the second part, we provide recommendations for the application of attachment theory and research. To this end, we set out three attachment principles: the child’s need for familiar, non-abusive caregivers; the value of continuity of good-enough care; and the benefits of networks of attachment relationships. We also discuss the suitability of assessments of attachment quality and caregiving behaviour to inform family court decision-making. We conclude that assessments of caregiver behaviour should take center stage. Although there is dissensus among us regarding the use of assessments o attachment quality to inform child custody and child-protection decisions, such assessments are currently most suitable for targeting and directing supportive interventions. Finally, we provide directions to guide future interdisciplinary research collaboration. info:eu-repo/semantics/publishedVersion

Autonomic nervous system reactivity has been posited to be a mechanism contributing to social and emotional problems among children exposed to early adversity. Leveraging data from the Bucharest Early Intervention Project, a longitudinal randomized controlled trial of foster care versus institutional care of abandoned children in Romania, we assessed whether altered sympathetic reactivity to peer rejection feedback in early adolescence mediated the relation between early institutional rearing and peer problems in later adolescence. We also assessed whether adolescent friendship quality or randomized placement in foster care early in life moderated these associations. Participants include 68 institutionalized children randomized to care as usual, 68 institutionalized children randomized to foster care, and 135 never-institutionalized children. At age 12, participants reported friendship quality with respect to a best friend and completed a social rejection task while electrocardiogram and impedance cardiography were recorded. Sympathetic nervous system reactivity to rejection feedback was assessed using preejection period (PEP). At ages 12 and 16, peer problems were reported by parents. Mediation analysis revealed that less PEP reactivity to social rejection at age 12 partially mediated the association between early institutionalization and greater peer problems at age 16. Further moderated mediation analysis revealed that this indirect effect was evidenced among previously institutionalized youths with low, but not high, quality friendships. We did not observe foster care intervention effects. These findings suggest that altered sympathetic reactivity to social rejection might be a mechanism linking early institutionalization to social difficulties into adolescence, however, positive adolescent friendships may buffer these effects. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Homer's Odysseus was forced to sail through a straight between 2 terrifying monsters: Charybdis, a giant whirlpool that threatened to devour the ship and crew, and Scylla, a 6-headed monster with rows of sharklike teeth who devoured men whole if they came within her grasp. Similar to Odysseus, clinicians who are treating maltreated children and their families often find themselves attempting to navigate between polarized interests and dangerously intense reactions within themselves. Powerful feelings are often elicited by maltreated children and caregivers who have experienced intersecting layers of personal, intergenerational, and often historical traumas as well as by action or inaction of complex systems. Child protective services and juvenile/family courts-which have their own language, values, and priorities-make decisions for reasons that are distinct from and sometimes in conflict with the clinical perspective of child mental health professionals.

BackgroundChildren reared in institutions experience profound deprivation that is associated with both heightened levels of psychopathology and deficits in executive functioning (EF). It is unclear whether deficits in EF among institutionally-reared children serve as a vulnerability factor that increases risk for later psychopathology. It is also unclear whether this putative association between EF and psychopathology is transdiagnostic (i.e. cuts across domains of psychopathology), or specific to a given syndrome. Thus, we examined whether global deficits in EF mediate the association between severe childhood neglect and general v. specific psychopathology in adolescence.MethodsThe sample consisted of 188 children from the Bucharest Early Intervention Project, a longitudinal study examining the brain and behavioral development of children reared in Romanian institutions and a comparison group of never-institutionalized children. EF was assessed at age 8, 12, and 16 using a well-validated measure of neuropsychological functioning. Psychopathology was measured as general (P) and specific internalizing (INT) and externalizing (EXT) factors at age 12 and 16.ResultsInstitutionally-reared children had lower global EF and higher general psychopathology (P) at all ages compared to never-institutionalized children. Longitudinal path analysis revealed that the effect of institutionalization on P at age 16 operated indirectly through poorer EF from ages 8 to 12. No indirect effects involving EF were observed for INT or EXT at age 16.ConclusionsWe conclude that stable, global deficits in EF serve as a cognitive endophenotype that increases transdiagnostic vulnerability to psychopathology in adolescence among those who have experienced profound early neglect.

Psychosocial deprivation is associated with the development of socially aberrant behaviors, including signs of disinhibited social engagement disorder (DSED). In longitudinal studies, signs of DSED have been shown to decrease over time, especially as children are removed from conditions of deprivation. What is less clear is whether signs of DSED in early childhood are associated with poorer functioning in early adolescence, including among children who no longer manifest signs of DSED at this age. In a sample of 136 Romanian children from the Bucharest Early Intervention Project (BEIP), who were exposed to early psychosocial deprivation in the form of institutional care, we examined caregiver-reported (ages 30, 42, and 54 months and 12 years) and observer-rated (age 54 months) signs of DSED. Competent functioning in early adolescence (age 12 years) was assessed across seven domains (i.e., family relationships, peer relationships, academic performance, physical health, mental health, substance use, and risk-taking behavior). A diagnosis of DSED in early childhood was associated with reduced competence in early adolescence. Furthermore, this association was significant even when signs of DSED diminished by age 12 years. We conclude that signs of DSED in early life are associated with reduced likelihood of competent functioning many years later in adolescence, even if signs of the disorder remit.

OBJECTIVE: Children exposed to institutional rearing often exhibit problems across a broad array of developmental domains. We compared the consequences of long-term high-quality foster care versus standard institution-based care which began in early childhood on cardiometabolic and immune markers assessed at the time of adolescence. METHODS: The Bucharest Early Intervention Project is a longitudinal investigation of children institutionalized during early childhood (ages 6 to 30 months at baseline) who were subsequently randomized to either high-quality foster care or continued institutional care. At age 16, 127 respondents participated in a biomarker collection protocol, including 44 institutionalized children randomly assigned to receive care as usual, 41 institutionalized children randomized to be removed from institutional care and placed in high-quality foster care in infancy, and a control group of 42 demographically-matched children raised in biological families. Outcomes included body mass index (BMI), systolic and diastolic blood pressure, C-reactive protein, interleukin (IL)-6, IL-8, IL-10, tumor necrosis factor-α, glycosylated hemoglobin A1c, and Epstein Barr virus antibody titers. RESULTS: Early institutional rearing was not associated with differences in cardiometabolic or immune markers. Randomization to foster care and age of placement into foster care were also unrelated to these markers, with the exception of BMI z-score, where children assigned to care as usual had lower BMI z-scores relative to children assigned to foster care (−0.23 vs 0.08, p=0.06), and older age at placement was associated with lower BMI (β=−0.07, p=0.03). CONCLUSIONS: The impact of institutional rearing on measures of cardiometabolic health and immune system functioning is either absent, or not evident until later in development. These findings provide new insights into the biological embedding of adversity and how it varies developmentally and across regulatory systems and adversity type. CLINICAL TRIAL REGISTRATION: NCT00747396

Risk-taking in adolescence has been often associated with early life adversities. However, the impact of such macrolevel factors on risk behavior has been rarely studied in humans. To address these gaps we recruited a sample of young adolescents who were part of a randomized control trial of foster care. Children institutionalized at or soon after birth were randomly assigned either to be removed from institutions and placed into a family or foster care intervention or to remain in institutions receiving care as usual. These children were subsequently followed up through 12 years of age and compared with a sample of children who had never been institutionalized. Using this sample, we examined the impact of early childhood deprivation on risk-taking behavior and explored the role of motivation (i.e., sensation seeking) and executive control (i.e., planning). Early psychosocial deprivation decreased engagement in risk-taking among young adolescents by reducing sensation seeking, a motivation often associated with risk-taking in adolescence. The impact of early psychosocial deprivation on sensation seeking and consequently on engagement in risk-taking was further reduced by its deleterious effects on executive control. These findings challenge the traditional view according to which risk behavior is a maladaptive response to adversities and suggest that it may represent adolescents' attempts to fulfill important motivations. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

This study examined whether early institutional rearing and attachment security influence the quality and quantity of friendships at age 16 in 138 participants, including children abandoned to institutions in Bucharest, Romania, who were randomized to care as usual (n = 45, 26 female), or foster care (n = 47, 25 female), and a never-institutionalized group (n = 46, 18 female). Adolescents in the foster care group with secure attachment to their foster mothers at 42 months were comparable to never-institutionalized adolescents in having more friends and more positive behaviors with their friend during dyadic interactions, compared to the foster care group with insecure attachment and care as usual group. Interventions targeting early child-caregiver attachment relationships may help foster the ability to build positive friendships in adolescence.

OBJECTIVE: Posttraumatic stress disorder (PTSD) is a debilitating condition which when left untreated, can have severe life-long consequences for an individual’s psychological, social and occupational functioning. Initial conceptualizations of PTSD were centered on adult presentations. However, the instantiation of developmentally appropriate PTSD for Young Children (PTSD-YC) criteria, tailored to preschool (aged 6 years old and under) children, represents an important step towards identifying more young children experiencing distress. Here we explore population-level prevalence of PTSD-YC, indexed via the Alternative Algorithm for PTSD (AA-PTSD). METHOD: We utilize population-representative data to test whether application of AA-PTSD criteria, relative to the DSM-IV PTSD algorithm, increases identification of 5-6 year old children with clinical needs, in both the general population (N=3202), and among looked-after-children (i.e., children-in-care; N=137) where the risk of mental health issues is greater. RESULTS: Notably, no 5-6 year old children in the general population sample were diagnosed with PTSD using adult-based DSM-IV criteria. In contrast, AA-PTSD prevalence was 0.4% overall, rising to 5.4% in trauma-exposed children. In looked-after-children, overall PTSD prevalence rose from 1.2% when applying adult-led DSM-IV criteria to 14% when using AA-PTSD. Of trauma-exposed looked-after-children, 2.7% met criteria for DSM-IV PTSD, compared to 57.0% when applying AA-PTSD. In both samples, use of the Alternative Algorithm to index PTSD-YC criteria markedly increased identification of children experiencing functional impairment due to symptoms. CONCLUSION: Results demonstrate the utility of the PTSD-YC diagnosis beyond at-risk and treatment-seeking samples. Use of PTSD-YC criteria very substantially improves identification of 5-6 year old children burdened by PTSD at the population-level.

Children who spend their early lives in institutions experience profound psychosocial deprivation that is associated with altered stress response system development. Here, we used data from a longitudinal randomized controlled trial of foster care for institutionally-reared children to examine whether caregiving quality and stressful life events in early adolescence (age 12) influence patterns of hypothalamic-pituitary-adrenal (HPA) axis and sympathetic nervous system (SNS) reactivity. Controlling for the effect of institutional care, higher caregiving quality at age 12 was associated with heightened cortisol and SNS reactivity. However, moderation analysis revealed that the latter effect was only observed among never-institutionalized children, whereas ever-institutionalized children demonstrated a persistently blunted SNS response regardless of recent caregiving quality. Among institutionally-reared children, stressful life events interacted with prior random assignment to foster care, such that those placed in foster care early in development had a SNS response that approximated never-institutionalized children when stressful life events at age 12 were low. In contrast, SNS reactivity was persistently blunted among those with prolonged deprivation, regardless of recent stressful life events. Early-life deprivation is associated with persistent blunting of stress response systems, but normalization may be achievable if stressful life events are limited following placement into enriched family-based care.

Background The quality of early caregiving experiences is a known contributor to the quality of the language experiences young children receive. What is unknown is whether, and if so, how psychosocial deprivation early in life is associated with long-lasting receptive language outcomes. Methods Two prospective longitudinal studies examining early psychosocial deprivation/neglect in different contexts (i.e., deprivation due to institutional care or deprivation experienced by children residing within US families) and receptive language as assessed via the Peabody Picture Vocabulary Test (PPVT) were used to assess the magnitude of these associations. First, 129 participants from the Bucharest Early Intervention Project, a randomized controlled trial of foster care as an alternative to institutional care in Romania, completed a receptive language assessment at age 18 years. Second, from the USA, 3342 participants from the Fragile Families and Child Wellbeing Study were assessed from infancy until middle childhood. Results Children exposed to early institutional care, on average, had lower receptive language scores than their never institutionalized counterparts in late adolescence. While randomization to an early foster care intervention had no long-lasting association with PPVT scores, the duration of childhood exposure to institutional care was negatively associated with receptive language. Psychosocial deprivation in US families was also negatively associated with receptive language longitudinally, and this association remained statistically significant even after accounting for measures of socioeconomic status. Conclusion Experiences of psychosocial deprivation may have long-lasting consequences for receptive language ability, extending to age 18 years. Psychosocial deprivation is an important prospective predictor of poorer receptive language. Trial registration Bucharest Early Intervention Project ClinicalTrials.gov Identifier: NCT00747396

Crying represents a powerful signal for human newborns. How parents should respond has been a matter of debate, with some urging prompt responding and others expressing concern about spoiling. Despite the fervor of the debate, few longitudinal observational studies have addressed the question. A new study in this issue by Bilgin and Wolke provides important data about ignoring crying in early infancy and its predictive correlates. The results of their investigation are discussed in the context of attachment and behavioral theories.

Knowledge and understanding about the impact of cumulative adverse experiences on the health and wellbeing of children, adolescents, and adults has rapidly expanded over the past 30 years. Despite the invaluable attention and support this proliferation has drawn to the importance of early childhood experiences, we believe that it is time to move beyond broad indices of risk and toward more specific and individualized understanding of how risk exposures are linked to clinical outcomes in young children. Within infant and early childhood mental health, there is a need for greater specificity in linking adverse caregiving experiences in early life to psychopathology in children. We highlight a framework distinguishing experiences of trauma from experiences of deprivation and use the examples of posttraumatic stress disorder and reactive attachment disorder to demonstrate how greater specificity in our understanding of early adverse caregiving can lead to more accurate and targeted diagnosis and treatment for young children. Both researchers and clinicians benefit from an approach to gain a greater appreciation of the links between specific types of experiences and outcomes in the children that we serve.El conocimiento y la comprensión acerca del impacto de experiencias adversas acumuladas sobre la salud y bienestar de los niños, adolescentes y adultos se ha expandido rápidamente durante los pasados 30 años. A pesar de la inestimable atención y apoyo que esta proliferación ha derivado con respecto a la importancia de las experiencias de la temprana niñez, creemos que es tiempo de pasar más allá de los amplios índices de riesgo hacia una comprensión más específica e individualizada de cómo el hecho de estar expuesto a riesgo se conecta con los resultados clínicos en niños pequeños. Dentro el camp de la salud mental infantil, hay una necesidad por mayor especificidad para conectar las adversas experiencias de prestación de cuidado en la temprana parte de la vida con la sicopatología en los niños. Enfatizamos un marco de trabajo que distingue las experiencias de trauma de las experiencias de privaciones y uso de ejemplos del trastorno de estrés postraumático y el trastorno reactivo de la vinculación para demostrar hasta qué punto la especificidad en nuestra comprensión del temprano cuidado adverso puede llevar a un diagnóstico y tratamiento más acertado y dirigido para los niños pequeños. Tanto los investigadores como el personal clínico se benefician de un acercamiento para obtener una mayor apreciación de os lazos entre tipos específicos y resultados en los niños a quienes les servimos.Les connaissances et la compréhension sur l'impact d'une accumulation d'expériences adverses sur la santé et le bien-être des enfants, des adolescents et des adultes se sont rapidement étendues au fil des 30 dernières années. En dépit de l'attention précieuse et du soutien de cette prolifération qui ont montré l'importance des expériences de la petite enfance, nous pensons qu'il est temps de passer au-delà des indices généraux de risque pour désormais privilégier une compréhension plus spécifique et individualisée de la manière dont les expositions au risqué sont liées aux résultats cliniques chez les jeunes enfants. Au sein de la santé mentale du nourrisson, il est nécessaire d'avoir une plus grande spécificité dans le lien entre les expériences adverses de modes de soin au début de la vie à la psychopathologie chez les enfants. Nous mettons en lumière une structure qui distingue les expériences de trauma d'expériences de privation et utilisons les exemples du trouble de stress posttraumatique et du trouble de l'attachement réactif afin de démontrer la manière dont une plus grande spécificité dans notre compréhension peut mener à un diagnostic et à un traitement plus précis et plus ciblés pour les jeunes enfants. A la fois les chercheurs et les cliniciens bénéficient d'une approche qui nous fait gagner une plus grande appréciation des liens entre les types spécifiques d'expériences et les résultats chez les enfants que nous servons.Widrige Bedingungen im frühen Leben: Die Unterscheidung zwischen Trauma und Deprivation bei kleinen Kindern Das Wissen um die Auswirkungen kumulativer widriger Erfahrungen auf die Gesundheit und das Wohlbefinden von Kindern, Jugendlichen und Erwachsenen hat in den letzten 30 Jahren rapide zugenommen. Trotz der unschätzbaren Aufmerksamkeit und Unterstützung, die dieser Wissenszuwachs der Bedeutung frühkindlicher Erfahrungen entgegengebracht hat, glauben wir, dass es an der Zeit ist, über breite Risikoindizes hinaus zu einem spezifischeren und individuelleren Verständnis darüber zu gelangen, wie Risikoexpositionen mit klinischen Outcomes bei kleinen Kindern zusammenhängen. Im Bereich der psychischen Gesundheit von Säuglingen besteht ein Bedarf an größerer Spezifität bei der Verknüpfung von negativen Erfahrungen mit primären Bezugspersonen im frühen Leben und der kindlichen Psychopathologie. Wir legen unseren Fokus auf einen inhaltlichen Rahmen, der traumatische Erfahrungen von Deprivationserfahrungen unterscheidet, und zeigen anhand der Beispiele posttraumatische Belastungsstörung und reaktive Bindungsstörung, wie eine größere Spezifität in unserem Verständnis früher widriger Erfahrungen mit primären Bezugspersonen zu einer genaueren und gezielteren Diagnose und Behandlung von Kleinkindern führen kann. Sowohl Forschende als auch Praktizierende profitieren von dem Ansatz, die Zusammenhänge zwischen bestimmten Arten von Erfahrungen und Outcomes bei den Kindern, die wir behandeln, besser zu verstehen.幼少児期の有害な養育:幼児における心的外傷と剥奪の区別 児童、青年、成人の健康と幸福に対する累積有害体験の影響についての知識と理解は、過去30年間で急速に広がっている。この広がりが幼児期の経験の重要性にかけがえのない注意と支援を引き寄せているにもかかわらず、リスクに晒されるということが幼児の臨床結果にどのように関連しているのかということに対して、幅広いリスク指標を越えて、より特定的で個別の理解へと進むべき時であると確信している。乳幼児精神保健において、幼少期の有害な養育環境を児童の精神病理学と関連付けるには、より高い特定性が必要である。我々は、心的外傷体験を剥奪体験と区別する枠組みを明らかにし、心的外傷後ストレス障害と反応性愛着障害を使って、我々の早期の有害な養育の理解に関してより高い特定性が、いかに幼児に対する正確で的を絞った診断と治療を導くことができるかということを示す。研究者と臨床家の両者が、扱う子どもたちの特定のタイプの体験と結果の関連性より高い理解を得るための方法から利益を得る。.在过去的30年里, 人们对累积的不良经历作用于儿童、青少年和成人的健康福祉影响的认识和理解迅速增加。尽管儿童早期经历的重要性受到了宝贵的关注和支持, 但我们认为, 现在是时候超越广义风险指标, 更具体和个性化地理解风险暴露与幼儿临床结果的关系。在婴儿心理健康方面, 需要更具体地将早期生活中的不良护理经历与儿童的精神病理学联系起来。我们强调区分创伤经历和剥夺经历的观点, 并以创伤后应激障碍和反应性依恋障碍为例, 来证明我们对早期不良护理的理解中, 更高的特异性可以为幼儿提供更准确、更有针对性的诊断和治疗。研究人员和临床医生都从一种方法中受益, 这种方法可以更深入地了解我们所服务的儿童其特定类型的经历和结果之间的联系。.تقديم الرعاية السلبية في مرحلة مبكرة من الحياة: التمييز بين الصدمات والحرمان لدى الأطفال الصغار اتسع نطاق المعرفة والفهم بشأن أثر التجارب السلبية التراكمية على صحة ورفاهية الأطفال والمراهقين والبالغين على مدى السنوات الثلاثين الماضية. وعلى الرغم من الاهتمام والدعم الذي جذبه هذا التراكم في المعرفة إلى أهمية تجارب الطفولة المبكرة، فإننا نعتقد أن الوقت قد حان لتجاوز المؤشرات العامة للمخاطر ونتجه نحو فهم أكثر تحديداً وفردية لكيفية ارتباط التعرض للمخاطر بالنتائج السريرية لدى الأطفال الصغار. وفي مجال الصحة النفسية للرضع، هناك حاجة إلى مزيد من التحديد في ربط تجارب تقديم الرعاية السلبية في الطفولة المبكرة بطب الأمراض النفسية لدى الأطفال. نسلط الضوء على إطار يميز تجارب الصدمة عن تجارب الحرمان ونستخدم أمثلة اضطراب الإجهاد اللاحق للصدمة واضطراب التعلق التفاعلي لإظهار كيف أن تحديد طبيعة فهمنا لتقديم الرعاية السلبية المبكرة يمكن أن تؤدي إلى تشخيص وعلاج أكثر دقة واستهدافاً للأطفال الصغار. يستفيد كل من الباحثين والأطباء من اتباع منهج للحصول على تقدير أكبر للعلاقة بين أنواع محددة من التجارب والنتائج في الأطفال الذين نخدمهم.

Millions of children worldwide are brought up in institutional care settings rather than in families. These institutions vary greatly both in terms of their organi­sational principles and structure, and in terms of the quality of care provided. Although institutions are universally recognised as providing suboptimal care­giving environments, consensus is still needed on how to interpret the evidence relating to the size, range, and persistence of the effect of institutional care on the development and wellbeing of children. This absence of consensus has led to disagreement as to whether policy should focus on eliminating, transforming, or improving institutions.We reviewed the literature on child institutionalisation and deinstitutionalisation from a global perspective. This review included a survey of historical and cultural trends and estimates of current numbers of children in institutional care, a systematic review and meta­analysis of developmental sequelae, and a largely qualitative review of factors found to predict individual variations in such outcomes. The numbers of children in institutional care have varied enormously over the years and from region to region, driven by a range of political, cultural, and socioeconomic factors. Millions of children worldwide are known to be housed in institutions.1 We found strong negative associations between institutional care and children’s development, especially in relation to physical growth, cognition, and attention. Significant but smaller associations were found between institutionalisation and socioemotional development and mental health. Leaving institutions for foster or family care is associated with significant recovery for some developmental outcomes (eg, growth and cognition) but not for others (eg, attention). The length of time in institutions was associated with increased risk of adverse sequelae and diminished chance of recovery. However, we could not disentangle the association between developmental outcomes and the duration of institutional care as opposed to its timing, which would be required to establish the precise boundaries of sensitive periods of development.Every effort should be made to minimise children’s exposure to institutional care. Reducing the number of children entering institutions and increasing the number leaving institutions is urgently needed. Where institutional care is considered absolutely necessary, the length of stays should be as short as possible, even if care is adequate. To this end, preventive approaches should be promoted, keeping children in birth families when possible. When not possible, care alternatives that are family based should be supported, including extended kinship networks, adoption, and stable, high­quality fostering. Policy recom­mendations to support the implementation of these care reform goals at the global, regional, and local levels are set out in a linked policy Lancet Commission2 published in The Lancet Child & Adolescent Health.

* Abbreviations: COVID-19 — : coronavirus disease CPS — : child protective services Although the public health benefits of social distancing, isolation, and quarantines are well-established and essential for reducing risk of transmitting the coronavirus disease (COVID-19), the disease caused by the novel coronavirus (severe acute respiratory syndrome coronavirus 2), there are also likely consequences for these practices when considering the impact of violence in the home. Reports of increased domestic violence after quarantine orders in China have revealed the interpersonal violence risks of isolation. Indeed, in a recent review of the psychological impact of quarantine published in The Lancet , the authors indicated increased anger, confusion, and posttraumatic stress symptoms, as well as evidence of increases in substance use, in those subjected to quarantine.1 These kinds of dysregulated emotions and substance use can increase violent behavior, especially within the family. Children’s exposure to intimate partner violence, whether directly witnessed or overheard, is harmful and may lead to posttraumatic stress disorder and other serious emotional and behavioral problems.2 Furthermore, intimate partner violence and child abuse often co-occur,3 … Address correspondence to Kathryn L. Humphreys, PhD, EdM, Department of Psychology and Human Development, Vanderbilt University, Nashville, TN 37203. E-mail: k.humphreys{at}vanderbilt.edu

Children that have experienced psychosocial neglect display impairments in self-monitoring and controlling their behavior (cognitive control) and are at broad, transdiagnostic risk for psychopathology. However, the neural underpinnings of such effects remain unclear. Event-related mediofrontal theta oscillations reflect a neural process supporting cognitive control that may relate to transdiagnostic psychopathology risk. Recent work demonstrates reduced mediofrontal theta in rodent models of neglect; however, similar findings have not been reported in humans. Here, 136 children reared in Romanian institutions were randomly assigned to either a high-quality foster care intervention and placed with families or remained in institutions; 72 never-institutionalized children served as a comparison group. The intervention ended at 54 months; event-related mediofrontal theta and psychopathology were assessed at 12- and 16-year follow-up assessments. Institutional rearing (neglect) predicted reduced mediofrontal theta by age 16, which was linked to heightened transdiagnostic risk for psychopathology (P factor); no specific associations with internalizing/externalizing factors were present once transdiagnostic risk was accounted for. Earlier placement into foster care yielded greater mediofrontal activity by age 16. Moreover, foster care placement was associated with the developmental trajectory of mediofrontal theta across the adolescent period (ages 12-16), which was, in turn, associated with greater reductions in transdiagnostic risk across this same period. These data reflect the first experimental evidence that the development of mediofrontal theta is impacted by removal from situations of neglect in humans, and further characterizes the importance of studying developmental change in mediofrontal theta during the adolescent period.

BACKGROUND: Children reared in institutions experience profound deprivation that is linked to impairments in social communication (SC). However, little is known about the long-term consequences of institutional rearing on SC through adolescence, and how SC deficits relate to broad-spectrum psychopathology. It is also unclear whether early removal from deprivation and placement into socially-enriched environments remediates these difficulties. METHODS: Children reared in Romanian institutions from the Bucharest Early Intervention Project were randomly assigned to care as usual or foster care intervention in early childhood. An age- and sex-matched group of never-institutionalized children was also recruited. SC data from 208 children at age 8 and 129 children at 16 were collected using the Social Communication Questionnaire. Psychopathology was assessed as saved factor scores for general (P) and specific internalizing (INT) and externalizing (EXT) problems. We examined (i) whether institutional rearing is associated with continued SC deficits into adolescence; (ii) whether early placement into foster care mitigates risk for SC problems; and (iii) associations between SC and psychopathology from middle childhood (age 8) to adolescence (age 16). RESULTS: Findings suggest that: (i) institutionally-reared children have significantly more SC problems than never-institutionalized children at age 16; (ii) children placed into foster care early in life have fewer problems with reciprocal social interaction compared to those with prolonged institutional rearing; and (iii) deficits in SC at age 8 partially account for the link between institutional rearing and general psychopathology at age 16. CONCLUSIONS: Early deprivation is associated with impairments in SC that persist into adolescence, with evidence for the remedial benefit of family-based care in the domain of reciprocal social interaction. Moreover, deficits in SC among ever-institutionalized children in middle childhood may increase the risk of broad-spectrum psychopathology in adolescence, thus providing one putative target for early intervention to safeguard against later psychiatric problems.

Infant mental health is considered synonymous with healthy social and emotional development. Important indicators of infant mental health include the young child’s capacity for emotion regulation, ability to communicate feelings to caregivers, and active exploration of the environment. These behaviors lay the groundwork for later social and emotional competence, readiness to enter school, and better academic and social performance. Assessment of infants’ mental health should involve characteristics of the infant’s caregiving relationships in the social and cultural contexts which are relevant. Treatment may be directed toward established problems or intervention efforts may be directed more broadly to prevent adverse outcomes.