The Scientific Basis for Family-Based Care: Lessons from the Bucharest Early Intervention Project

2. The Scientific Basis for Family-Based Care: Lessons from the Bucharest Early Intervention Project Presentation to The Way Forward Project –Summit November 8, 2011 Nathan A. Fox, Ph.D., Distinguished University Professor, University of Maryland

3. Principles of Brain Development Genetics supplies basic blueprint for brain development. Experienceadjusts the blue print and shapes the architecture of its neural circuits

4. An Accelerated View of Brain Development 15 1/2 wks 22 weeks 23 weeks ~25 weeks 27 weeks Full term brain Adult http://medstat.med.utah.edu

5. Synaptic Density 03-012 At Birth 6 Years Old 14 Years Old Rethinking the Brain, Families and Work Institute, Rima Shore, 1997.

6. Communist era in Romania began in 1945 1965 - Nicolae Ceausescu comes to power. 1989 - Ceausescu executed in coup 1965-1989 Ceausescu instituted policies designed to turn agrarian Romania to industrial, urban society. Result: drastic decline in the standard of living , and a huge increase in abandoned children

7. Results of Ceausescu’s 1966 Policy • Child abandonment became disaster - families could not afford to keep their children, and turned them over to the state • Government launched institutions to serve as safe haven/training camp for children to grow to be industrious citizens. • 1989: >170,000 children had been institutionalized

8. BIG QUESTIONS What are the effects of institutional rearing? If negative, can they be reversed by placing children in families? If yes, is there a sensitive period whereby this must occur? Why is addressing these questions important?

10. UNICEF estimates 100,000,000 orphans worldwide 8,000,000 children being raised in institutions Most common form of care for orphaned and abandoned young children world wide: Asia, Middle East, Central and South America Eastern and Western Europe Why study alternatives to institutional care?

11. Study design 3 4 2 5 6 1 Institutional Group NIG n=72 CAUG n=68 FCG n=68 After baseline assessment (pre-group assignment), comprehensive follow up performed at 30, 42, 54 months and 8 years

12. Foster care intervention Recruited and trained to become attachment figures for children Supported by Tulane clinicians, weekly consultations • Goal was to have foster • care that was: • Effective • Affordable • Replicable • Culturally sensitive • Informed by latest • findings

13. Baseline Findings IQ Brain Attachment

14. Cognitive Development (at baseline) Smyke et al (2007), J. of Child Psych. & Psychiatry

15. EEG Activity at baseline IG institutionalized children never institutionalized children NIG Marshall, Fox, et al (2004) J. of Cog Neuro

16. Quality of Attachment to primary Caregiver at baseline Fully formed attachment relationships Community 100% Institution 3% Zeanah et al , (2005) Child Development

17. Foster care intervention Recruited and trained to become attachment figures for children Supported by Tulane clinicians, weekly consultations • Goal was to have foster • care that was: • Effective • Affordable • Replicable • Culturally sensitive • Informed by latest • findings

18. Main effects of intervention

19. IQ Expressive and receptive language Height and weight Stereotypies Expression of positive emotions Security of attachment Reactive attachment disorder Emotional disorders EEG coherence ERPs to emotional stimuli Summary of Positive effects Of Intervention

20. …but timing matters Some examples….

21. How does IQ differ for children in foster care as a function of age of entry? * N 0-18 14 18-24 16 24-30 22 30+ 9 Age at placement Nelson, et al (2007) Science

22. 3.80μV2 2.44μV2 Does Brain Activity (EEG) Change as a function of intervention and timing? (84 months) FCG > 24 CAUG NIG FCG < 24 Vanderwert et al (2010) PLoS One

23. Secure vs. Insecure by age of placement42 Months Smyke et al (2010) Child Development

24. Conclusions Being raised in an institution during the first few years of life can lead to a significant derailing of development, across many domains Placement in foster care <24 months leads to better outcomes in most (but not all) domains Policy recommendations: Institutional care should be considered a last resort and if children are young when placed there, efforts should be made to move them to permanent families as early in life as possible

25. THE END