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. Author manuscript; available in PMC: 2021 Aug 1.
Published in final edited form as: Dev Psychopathol. 2021 Feb;33(1):18–28. doi: 10.1017/S0954579419001500

Early caregiving quality predicts consistency of competent functioning from middle childhood to adolescence following early psychosocial deprivation

Katherine L Guyon-Harris 1, Kathryn L Humphreys 1,2, Devi Miron 1, Florin Tibu 3, Nathan A Fox 4, Charles A Nelson 5,6, Charles H Zeanah 1
PMCID: PMC7332404  NIHMSID: NIHMS1541200  PMID: 31896375

Abstract

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 associated with attaining and maintaining competent functioning (i.e., outcomes within typical levels) from middle childhood to adolescence following exposure to early institutional care. 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. Participants were grouped based on whether they were always versus not always competent and never versus ever competent age 8 through 16 years. Adolescents with a history of institutional care were less likely to be consistently competent compared to those who were family reared. Among those exposed to early institutional rearing, maintaining competent functioning 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.

Keywords: Institutional rearing, competence, resilience, adolescence, caregiving

Worldwide, institutional care remains a common form of care for abandoned and maltreated children. As many as 8 million children worldwide less than 18 years of age are currently living in institutional care (Lumos Foundation, 2015). Research on the negative impact of institutional care across domains of functioning (i.e., cognitive, biological, and socioemotional) is well established, as is the capacity for altered trajectories towards more positive developmental outcomes when children are removed from institutional care and placed into families (for a review, see Nelson, Fox, & Zeanah, 2014). However, the majority of research concerning the effects of institutional care on development has been conducted with young children. Given the large population of children growing up in institutional care, it is imperative to understand the effects of early psychosocial deprivation in adolescence as well as the conditions that support typical development from middle childhood to adolescence following this unique and particularly harmful form of adversity.

What constitutes “typical” development following adversity varies throughout the developmental literature. One study examined what they termed “resilience” in young adulthood following childhood abuse and neglect as achieving success in six out of eight domains of functioning: employment, homelessness, education, social activity, psychiatric disorder, substance abuse, arrests, and self-reported violent behavior (McGloin & Widom, 2001). Based on their criteria, 22% of adults who had experienced maltreatment in childhood met the threshold for resilient functioning, compared to 41% of comparison adults. The authors also found that females were more likely than males to demonstrate resilient functioning. This person-centered approach to assessing functioning across a wide variety of domains allows for greater flexibility in how children come to be classified as functioning adequately compared to using a single indicator of competent functioning.

Few studies have examined the functioning of adolescents following exposure to early deprivation. Deficits in social relationships are perhaps among the clearest in finding associations between institutional care in childhood and functioning in adolescence. Adolescents who experience early psychosocial deprivation in the form of institutional care often experience difficulties in their relationships with caregivers (Guyon-Harris, Humphreys, Degnan, et al., 2018; Guyon-Harris, Humphreys, Fox, Nelson, & Zeanah, 2018; Hodges & Tizard, 1989; Humphreys, Nelson, Fox, & Zeanah, 2017; Vorria, Ntouma, & Rutter, 2015), as well as with peers and other family members (Guyon-Harris, Humphreys, Fox, Nelson, & Zeanah, 2019; Hodges & Tizard, 1989). Increased risk for psychopathology during adolescence following institutional care has also been reported. Children raised in institutional settings have, on average, higher levels of internalizing and externalizing behavior in adolescence (Colvert et al., 2008; Humphreys et al., 2015; Wade, Fox, Zeanah, & Nelson, 2018) as well as high rates of inattention and over-activity, particularly among males (Humphreys et al., 2015; Stevens et al., 2008). Additionally, poorer school performance among adolescents with a history of institutional care compared to those reared in their biological family has also been reported (Attar-Schwartz, 2009; Vorria et al., 2015). Aside from psychological and academic concerns, children with a history of institutional care are also more likely than their never institutionalized peers to have health difficulties in early adolescence that limit their ability to function (Humphreys et al., 2018). In sum, deficits in social, psychological, academic, and physical functioning in adolescence have been reported among adolescents with a history of institutional care.

Despite the substantial increased risk for negative outcomes following institutional care in adolescence, some adolescents attain positive outcomes despite early adversity. In a sample of young adolescents (age 13 years) who received institutional care in infancy, more favorable outcomes across four domains (attachment relationships, cognition, behavioral adjustment, and use of psychological services) were associated with higher quality of care received in the institution and spending less time in institutional care (i.e., being adopted out of the institution at an earlier age; Vorria et al., 2015). Care received in the institution was measured as the amount and quality of appropriate interactions between the child and institution staff as well as sensitive caregiving received by the child. Furthermore, being adopted after age 24 months, relative to prior to this age, was associated with more hyperactive behavior and greater use of psychological services compared to children adopted prior to age 24 months or those raised in their biological families.

In a previous report, competent functioning was examined cross sectionally drawing from the Bucharest Early Intervention Project (BEIP). The BEIP is a randomized controlled trial (RCT) of high-quality foster care as an alternative to institutional care. The BEIP sample was initially assessed during infancy and early childhood (mean age = 22 months). Following a baseline assessment, institutionalized children were randomized to foster care or to care as usual in the institution. Assessments were conducted at 30, 42, and 54 months, at which time the RCT officially concluded. Follow-up assessments were conducted at ages 8, 12, and 16 years, making the BEIP a useful study for exploring the impact of early caregiving on the stability of competent functioning across adolescence following institutional care.

In the previous analysis of the BEIP sample, 12-year-old children were evaluated on a composite of competent functioning across seven domains: family relationships, peer relationships, physical health, mental health, academic performance, substance use, and risk-taking behavior (Humphreys et al., 2018). Children randomized to removal from institutional care and placement into foster families, particularly prior to age 20 months, had higher rates of overall adaptive functioning compared to those placed in family care at later ages or those who remained in institutional care. Our goal of the present study is to provide a longitudinal perspective on these findings. Thus, the present study extends past work using the BEIP sample which examined competence only at age 12 years (Humphreys et al., 2018), by including competence data at two additional time points across childhood and adolescence (ages 8 and 16 years). In addition, in the present study we examined associations between the stability (and instability) of competent functioning across time and in relation to caregiving quality.

To our knowledge, only one study has examined factors involved in attaining and maintaining competent functioning following severe early deprivation. Kreppner and colleagues (2007) examined the conditions necessary to maintain “normal” functioning from childhood (age 6 years) into early adolescence (age 11 years) across seven domains: quasi-autistic patterns, cognitive impairment, inattention/overactivity, disinhibited attachment behavior, conduct problems, peer problems, and emotional problems. They reported that patterns of normality and impairment were established early (by 6 months of age), and continuity was common. Children who were adopted out of institutional care before age 6 months, were significantly more likely to maintain normal functioning (defined as absence of psychiatric disorders and cognitive impairment) from childhood to early adolescence compared to children who remained institutionalized beyond age 6 months. Therefore, reducing the amount of time children spend in institutional care may help children maintain competent functioning from childhood into early adolescence.

Adolescence represents a period of rapid change both behaviorally and neurobiologically (Blakemore & Mills, 2014; Fuhrmann, Knoll, & Blakemore, 2015; Sawyer et al., 2012). Furthermore, adolescence is a time of dramatic social role changes critical to the successful transition to young adulthood. Although a handful of studies have begun to examine the conditions that support competent functioning in adolescence among previously institutionalized adolescents, we are not aware of any studies that have examined the conditions necessary to maintain competent functioning from middle childhood into adolescence. Given that resilience (i.e., the development of competence despite exposure to early deprivation) is believed to be a dynamic process subject to adaptation and change over time (Masten, 2014; Masten & Cicchetti, 2010), it is important to consider functioning following adversity at multiple time points across development. Furthermore, past work has focused heavily on the age at which children are adopted out of the institution as an indicator of early caregiving experiences, though other factors such as the quality of care children receive may plausibly be involved. In the present study, we examined patterns of competent functioning across three time points (ages 8, 12, and 16 years) and several indicators of early caregiving quality (observed caregiver interactive behavior, percent time in institutional care, and placement disruptions) as predictors of longitudinal stability of competent functioning.

Previous findings (reviewed above) suggested that children with a history of institutional care tend to have lower levels of competent functioning in early adolescence compared to never institutionalized community children (Humphreys et al., 2018). Furthermore, children adopted out of institutional care at a younger age tend to have higher levels of competence and more sustained competence in adolescence compared to children who remain in institutional care for longer periods of time (Humphreys et al., 2018; Kreppner et al., 2007; Vorria et al., 2015), and in one study, similar levels of competence compared to never institutionalized adolescents (Vorria et al., 2015).

Hypothesis 1 – History of Institutional Care (i.e., ever vs. never institutionalized groups).

Our first goal was to examine differences in consistency of competent functioning from age 8 to 16 years between children with a history of institutional care (ever institutionalized) and community comparison children (never institutionalized group) with no history of institutional care. Adolescents with histories of institutional rearing will be less likely than the never institutionalized children group to be consistently competent (i.e., competent at all assessments) across middle childhood and adolescence.

Hypothesis 2 – Intent-to-treat (ITT; i.e., care as usual group vs. foster care group).

Second, we examined longitudinal competence between the care as usual group and foster care group. As a test of the RCT intervention, care as usual group adolescents will be less likely than the foster care group to be consistently competent across middle childhood and adolescence.

Hypothesis 3 – Placement.

Third, we examined differences in longitudinal competence between foster care group children who were placed early (i.e., prior to the age of 20 months) compared to later and between those who remained in a stable foster care placement through age 16 years and those who did not.

Hypothesis 3a – Age at placement.

Given that past work has highlighted the importance of early removal from institutional care for promoting later competent functioning, foster care group adolescents placed into foster care prior to the age of 20 months will be more likely to be consistently competent across middle childhood and adolescence compared to foster care group adolescents placed at or following the age of 20 months.

Hypothesis 3b – Stability of placement:

As a test of the importance of caregiving stability, foster care group adolescents in their original BEIP foster care placement (stable foster care group) will be more likely to be consistently competent across middle childhood and adolescence compared to foster care group adolescents who experienced a disruption from their original foster care placement (disrupted foster care group).

Hypothesis 4 – Early experiences.

Our fourth and final goal was to examine early experiences as predictors of longitudinal competence. Early experiences, as assessed by observed ratings of higher quality caregiving, by less time spent in institutional care, and by fewer placement disruptions, will predict consistency of competent functioning from 8 to 16 years among adolescents with a history of institutional care.

Method

Participants

The original BEIP trial included 136 children placed in institutional care at or shortly following birth as well as 72 never institutionalized children. The 136 children with a history of institutional care are referred to collectively as the ever institutionalized group. The first assessment (baseline) occurred when children were on average 22 months of age (range=6-31 months). Follow-up assessments were conducted at ages 30, 42, and 54 months, at which time the RCT officially ended. Additional follow-up data were collected at ages 8, 12, and 16 years. Additional community comparison children were recruited to supplement the never institutionalized group and ages 8 (n=61) and 16 (n=2) years. Across ages 8, 12, and 16 years, complete data are available on 78 ever institutionalized children and 35 never institutionalized children (see Figure 1).

Figure 1.

Figure 1.

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CONSORT flow diagram.

Procedures

Following the baseline assessment, children were randomly assigned to either the foster care group (n=68) or the care as usual group (n=68), who remained in institutional care. The RCT followed an intent to treat (ITT) design, therefore, analyses were based on the original randomization group. The study deferred all decisions about placement to Romanian child protection authorities, and over time, there were a number of changes in placement, as indicated in Figure 1. Foster parents were recruited in Romania and trained by BEIP personnel to provide high quality care to the children, which included explicit encouragement to care for the children as if they were their own (Smyke, Zeanah, Fox, & Nelson, 2009; Zeanah et al., 2003). Foster parents were supported by social workers in Bucharest, Romania throughout the trial who regularly received consultation from clinicians in the United States. Consent for participation was obtained at the beginning of the study and at each subsequent assessment from each child’s legal guardian. Assent was obtained from each participant at ages 8, 12, and 16 years.

Data for the present study were drawn from adolescent (ages 12 and 16 years), caregiver (ages 42 and 54 months, and ages 8, 12, and 16 years), and teacher (age 8 years) reports. Caregiver reports were completed by the biological, foster, or adoptive mother in the case of foster care group adolescents as well as for the care as usual group adolescents who were placed into families throughout the course of the study. For adolescents in institutions, caregiver reports were completed by a staff member who best knew the adolescent. Teacher reports were completed by the adolescent’s primary teacher at the time of assessment. All questionnaires were translated into Romanian, then back translated into English, and assessed for meaning at each step by bilingual research staff. Observations of the children interacting with preferred caregiver were videotaped at age 42 months and later coded by raters masked to participant status or study design (see McGoron et al., 2012).

Measures

Competence measures

Social Skills Rating System (SSRS; Gresham & Elliott, 1990).

The SSRS is a caregiver report of social and behavioral functioning. Internal consistency and good convergent validity have been established (Gresham, Elliott, Vance, & Cook, 2011). Items from the SSRS contributed to the family relations domain of competent functioning at ages 8 (α=.74), 12 (α=.77), and 16 years (α=.89).

MacArthur Health and Behavior Questionnaire (HBQ; Essex et al., 2002).

The HBQ is a report of child health and emotional and behavioral adjustment. A report from teachers only was obtained at age 8 years. Caregiver and teacher reports were obtained at ages 12 and 16 years. The HBQ has been used with institutionally reared children (Wiik et al., 2011) and has demonstrated good psychometric properties (Ablow et al., 1999). Items from the HBQ contributed to assessments of the peer relations (8 years α=.84, 12 years α=.81, 16 years α=.89), academic performance (8 years α=.91, 12 years α=.91, 16 years α=.88), physical health (a single item was used, no alpha value available), and mental health impairment (8 years α=.92, 12 years α=.87, 16 years α=.91) domains at ages 8, 12, and 16 years.

Academic performance.

The academic performance competence domain at ages 8, 12, and 16 years was based on information from two sources. The first source was BEIP staff reports of whether the adolescent was in a regular or special school setting. The second source was three items from the HBQ pertaining to school performance in math, reading/language arts, and general school performance assessed at ages 8 (teacher report), 12 (caregiver report), and 16 (caregiver report) years (see values for internal consistency above). Adolescents were classified as competent in the academic performance domain if they were in a regular school setting and also scored within one standard deviation of community comparison adolescents on the items from the HBQ pertaining to school performance.

Self-Endangering Behavior Scale (SEBS; Schechter & Fisher, 2006).

The SEBS is a caregiver-report of self-endangering behavior (e.g., climbing high on furniture or trees, putting objects into electrical sockets). Psychometric data on this scale are limited, however, good internal consistency was demonstrated across all 27 items in the present sample (α=.71). The SEBS was administered at age 8 years. Twenty items from the SEBS contributed to the risk-taking behavior domain at age 8 years (α=.60).

Youth Risk Behavior Survey (YRBS; Centers for Disease Control and Prevention, 2001).

The YRBS is an adolescent-report of engagement in risky behavior including drug and alcohol use and general risk-taking (e.g., not wearing a seatbelt), supplemented with culturally relevant risk-taking behaviors among adolescents in Romania (e.g., provoking street dogs). The YRBS was administered at ages 12 and 16 years. At age 16 years, items regarding risky sexual behavior were added to the survey (e.g., engaging in sexual intercourse without a condom). Successful use of the YRBS in previous research has been documented (Aklin, Lejuez, Zvolensky, Kahler, & Gwadz, 2005; Lejuez, Aklin, Zvolensky, & Pedulla, 2003; MacPherson, Magidson, Reynolds, Kahler, & Lejuez, 2010). Items from the YRBS contributed to the substance use and risking-behavior domains at ages 12 (α=.64) and 16 years (α=.80).

Competent functioning.

Prior to conducting the main study analyses, we created a composite of competent functioning at each age (8, 12, and 16 years) based on functioning in the domains of family relations, peer relations, academic performance, physical health, mental health, substance use, risk-taking behavior. However, substance use was not included in the 8-year composite, which was based on six domains (i.e., family relations, peer relations, academic performance, physical health, mental health, risk-taking behavior). Details regarding how competence was assessed in each domain are presented in Table 1 (descriptive information for each competence domain is available in supplemental Table 1).

Table 1.

Competence Domain Assessment Across Waves

Family relations Peer relations Academic performance Physical health Mental health Substance use Risk-taking behavior Overall competent functioning
Age 8 Within 1 standard deviation of community adolescents on a scale comprising 11 items from the SSRS (caregiver report) Within 1 standard deviation of community adolescents on a scale comprising 10 items from the HBQ (teacher report) In a regular school setting and within 1 standard deviation of community adolescents on a scale comprising 3 items from the HBQ (teacher report) Health has never interfered with functioning (teacher report) Within 1 standard deviation of community adolescents on a scale comprising 7 items on the HBQ (teacher report) Not included Within 1 standard deviation of community adolescents on a scale comprising 20 items from the SEBS (caregiver report) Threshold met for 5 or 6 domains
Age 12 Within 1 standard deviation of community adolescents on a scale comprising 8 items from the SSRS (caregiver report) Within 1 standard deviation of community adolescents on a scale comprising 8 items from the HBQ (caregiver report) In a regular school setting and within 1 standard deviation of community adolescents on a scale comprising 3 items from the HBQ (caregiver report) Health has never interfered with functioning (caregiver report) Within 1 standard deviation of community adolescents on a scale comprising 8 items on the HBQ (caregiver report) Using no substances, used tobacco only, or used alcohol only (adolescent report) Within 1 standard deviation of community adolescents on a scale comprising 6 items from the YRBS (adolescent report) Threshold met for 6 or 7 domains
Age 16 Within 1 standard deviation of community adolescents on a scale comprising 11 items from the SSRS (caregiver report) Within 1 standard deviation of community adolescents on a scale comprising 10 items from the HBQ (caregiver report) In a regular school setting and within 1 standard deviation of community adolescents on a scale comprising 3 items from the HBQ (caregiver report) Health has never interfered with functioning (caregiver report) Within 1 standard deviation of community adolescents on a scale comprising 8 items on the HBQ (caregiver report) Not a regular smoker (tobacco), not engaging in binge drinking (adolescent report) Within 1 standard deviation of community adolescents on a scale comprising 6 items from the YRBS (adolescent report) Threshold met for 6 or 7 domains
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At age 8 years, each participant was grouped based on whether their composite score was above the threshold for competent functioning (i.e., competent in at least five of the six domains). A binary variable was created with a score of “0” indicating adolescents who did not meet the threshold of at least five domains and “1” indicating adolescents who met the overall competence threshold. At ages 12 and 16, a composite score was created based on seven domains and adolescents were grouped based on whether they met the threshold for competent functioning (i.e., competent in at least six of the seven domains). A binary variable was created separately for ages 12 and 16 years with a score of “0” indicating adolescents who did not meet the threshold of at least six domains and “1” indicating adolescents who met the overall competence threshold. A descriptive report is provided of the number and percent of adolescents who met the threshold for competent functioning at each assessment (i.e., ages 8, 12, and 16).

The threshold for competent functioning at age 12 (i.e., 6+ domains out of 7) was previously established in Humphreys and colleagues (2018) and validated against IQ and physiological reactivity to stress. Children who met the threshold for competence had high IQ scores and greater diastolic blood pressure and pre-ejection period reactivity. In determining a cut-off, the goal was to adopt a threshold that classified individuals as competent overall who were doing well in all or nearly all of the areas of competence. Multiple cut-offs were examined, and it was ultimately discovered that 6+ domains for ages 12 and 16 years and 5+ domains for age 8 years were the thresholds that were neither too lenient nor too restrictive.

The binary competence variables (0=“not competent”, 1=“competent”) created at ages 8, 12, and 16 years were used to create to longitudinal competence comparisons: Always competent versus not always competent and never competent versus ever competent. The always competent category comprised adolescents who met the threshold for competent functioning at ages 8, 12, and 16 years whereas as the not always competent category comprised adolescents who were competent at zero, one, or two assessments. The never competent category comprised adolescents who never met the threshold for competent functioning at age 8, 12, or 16 years whereas the ever competent category comprised adolescents who met the threshold for competent functioning at one, two, or three of the time points.

Predictor variable measures

Observational Record of the Caregiving Environment (ORCE; NICHD early child care research network, 1996).

Caregiving quality at age 42 months were assessed using the ORCE, which is an observational measure of caregiver behavior coded from videotaped interactions between a child and their preferred caregiver. An overall caregiving quality variable was created by averaging qualitative scores of sensitivity, stimulation of development, positive regard for the child, flat affect (reverse coded), and detachment (reverse coded). A detailed report of the use of this measure in the BEIP is available elsewhere (Smyke et al., 2007).

Percent time in institutional care and placement disruptions.

For each child, we determined the placement history, including the number of months spent in institutional care. This information was used to calculate the percentage of the child’s life that was spent in institutional care from placement into the institution through age 54 months. We also tracked each change (disruption) in placement (e.g., from a foster placement back to the institution, from the institution into a biological family, etc.) for each child through age 54 months.

Other measures

Wechsler Preschool and Primary Scale of Intelligence – Revised.

Child cognitive ability at age 54 months years was assessed using the Wechsler Preschool and Primary Scale of Intelligence – Revised (WPPSI-R; Wechsler, 1989). The WPPSI-R is a widely used performance-based assessment of cognitive abilities in young children ages 36-87 months. For the purposes of the present study, the estimated full-scale IQ score was used.

Preschool Aged Psychiatric Assessment.

Total psychiatric symptoms (internalizing, externalizing, and ADHD) were assessed at age 54 months using the Preschool Aged Psychiatric Assessment (PAPA; Egger et al., 2006), which is a caregiver report. For the purposes of the current report, a total symptom score was used.

Ethical Considerations

The BEIP study design was reviewed and approved by the three institutional review boards of the principle investigators as well as the local Commission on Child Protection in Bucharest, Romania. Additionally, the BEIP was conducted in collaboration with the Institute of Maternal and Child Health of the Romanian Ministry of Health. The special ethical considerations of this study have been extensively reviewed and discussed by us and by others (Miller, 2009; Millum & Emanuel, 2007; Nelson et al., 2014; Rid, 2012; Zeanah, Fox, & Nelson, 2012)

Data Analysis

We required complete competence data across all three waves of assessment for inclusion in the present report, and no data estimation procedures were used. This resulted in a large loss of participants but greater accuracy in reporting competence. Of the 55 care as usual group adolescents assessed at age 16 years, 35 (64%) had compete competence data age 8 through 16 years. Of the 53 foster care group children assessed at age 16 years, 43 (81%) had compete competence data. Of the available 50 never institutionalized adolescents assessed at age 16, 35 (70%) had compete competence data. See Figure 1 for more information on attrition. All following analyses were based on the longitudinal competence comparisons: always competent versus not always competent and never competent versus ever competent.

Prior to main study analyses, differences across the longitudinal competence categories (always versus not always and never versus ever) among the entire sample and within the ever institutionalized group only were reported based on sex (male vs. female). Cross tabulations of sex by longitudinal competence category were analyzed using the chi-square test.

For hypothesis 1 (ever institutionalized group vs. never institutionalized group), the number and percent of never institutionalized and ever institutionalized children who were always versus not always competent and never versus ever competent were compared using the chi-square test. For hypothesis 2 (ITT), to test for intervention effects, these analyses were repeated comparing the number and percent of foster care group and care as usual group adolescents by each longitudinal competence category.

Analyses for hypothesis 3 were conducted within the foster care group. For hypothesis 3a (early placement) foster care group adolescents placed into foster care prior to age 20 months were compared in regards to longitudinal competence categories to foster care group adolescents placed at or after 20 months using the chi-square test.

Not all children who were initially randomized to the foster care group remained in their original MacArthur Foster Care network (MFC) placement throughout the course of the study. At ages 8, 12, and 16 years, each child was classified based on whether they were unstable in their placement (disrupted foster care), that is, removed from their original MFC placement and placed into another family or returned to institutional care, or stable (stable foster care), indicating that the child was still residing in their original MFC placement. The disrupted foster care and stable foster care were compared in regards to competence. However, prior to analyses, we first determined whether a child remaining in their original foster placement or being disrupted is dependent upon their level of functioning. Therefore, the disrupted foster care and stable foster care were compared on total psychiatric symptoms and cognitive ability at age 54 months as well as percent time in institutional care through age 54 months. Mean differences between groups were examined with independent samples t-tests. For hypothesis 3b (stability of placement), pending no significant group differences, the number and percent of children in each longitudinal competence category for the disrupted foster care and stable foster care were compared using the chi-square test.

Finally, for hypothesis 4 (early experiences), differences in early caregiving quality, percent time in institutional care, and placement disruptions based on longitudinal competence category were examined using independent samples t-tests with a Bonferroni correction of .025.

For all chi-square analyses, chi-square values, significance values at alpha level .05, and effect sizes (Cramer’s V) were reported. For independent samples t-test analyses, means and standard deviations for each group were provided along with t statistics, significance values at alpha level .05, 95% confidence intervals, and effect sizes (Cohen’s d) were provided.

Results

Cross-sectional data on the number and percent of children classified as competent at ages 8, 12, and 16 years are presented in supplemental table 2.

Prior to main study analyses, sex differences in competence were explored to determine whether sex should be included as a covariate in later analyses. Across the entire sample (never and ever institutionalized children combined), there were sex differences in the proportion of adolescents in the always competent versus not always competent categories (χ2[1]=4.64, p=.031, V=.203). Upon further probing, never institutionalized girls were more likely to be always competent (n=15, 79%) compared to never institutionalized boys (n=6, 40%). There were no sex differences for the never versus ever competent comparison (χ2[1]=1.45, p=.228, V=.113). Among the ever institutionalized group only, there were no sex differences between the always versus not always competent categories (χ2[1]=0.83, p=.362, V=.103) and never versus ever competent (χ2[1]=0.63, p=.429, V=.090) categories. Given that there were no sex differences in competence in the primary population of interest (ever institutionalized children) and that the effect size for a sex difference among the never institutionalized group was small, child sex was not included in analyses.

Never Institutionalized vs. Ever Institutionalized

The always competent versus not always competent comparison was examined first. From 8 to 16 years of age, never institutionalized group adolescents were more likely to be consistently (always) competent compared to ever institutionalized adolescents (χ2[1]=21.57, p<.001, V=.437; see Figure 2). In fact, 60% (n=21) of never institutionalized group adolescents were in the always competent category compared to just 17% (n=13) of ever institutionalized adolescents. Furthermore, ever institutionalized adolescents were more likely to be never competent compared to never institutionalized adolescents (χ2[1]=7.67, p=.006, V=.260; see Figure 2). Only 3% (n=1) of never institutionalized group adolescents were in the never competent category compared to 24% (n=19) of ever institutionalized adolescents.

Figure 2.

Figure 2.

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Percent of adolescents classified as always competent versus not always competent and never competent versus ever competent by group: a) never institutionalized compared to ever institutionalized, b) foster care group compared to care as usual group, c) early compared to late placement into foster care (ever institutionalized adolescents only), and d) Disrupted foster care placements compared to stable foster care placement (foster care group only).

Foster Care Group vs. Care as Usual Group

Adolescents in the foster care group were more than four times more likely to be always competent (26%, n=11) compared to those in the care as usual group (6%, n=2; χ2[1]=5.48, p=.019, V=.265; see Figure 2). There were no statistical differences between the foster care and care as usual groups in the never versus ever competent comparison (χ2[1]=0.06, p=.801, V=.028; see Figure 2). Foster care group adolescents were just as likely to be never competent (23%, n=10) as care as usual group adolescents (26%, n=9).

Early vs. Late Placement into Foster Care

A total of 21 adolescents (32%) were placed into foster care prior to 20 months of age, and 44 (68%) were placed at or following 20 months of age. Despite differences in the proportion of early (45%, n=5) compared to late-placed (19%, n=6) adolescents in the always competent category, the association between early placement and the always competent versus not always competent categories did not reach statistical significance (χ2[1]=2.86, p=.091, V=.261; see Figure 2). The comparison between never competent versus ever competent for early and late placed adolescents also was not significant (χ2[1]=1.78, p=.182, V=.205).

Stable vs. Disrupted Foster Care Placement

Twenty-one (40%) adolescents remained in their original foster care placement through age 16 years and 32 (60%) were disrupted. There were no differences in the proportion of stable and disrupted placement adolescents between the always versus not always competent categories (χ2[1]=0.83, p=.362, V=.141; see Figure 2). Across middle childhood and adolescence, only 11% (n=2) of adolescents with a stable placement were never competent compared to 33% (n=8) of adolescents with a disrupted placement, however, the test was not statistically significant (χ2[1]=2.80, p=.094, V=.258).

As a check of the early childhood status of the disrupted and stable foster care groups at age 16 years, we compared these two groups at 54 months of age (prior to any disruptions) and found that there were no differences at that age between those who remained stable and those who subsequently disrupted on measures of total psychiatric symptoms (t[47]=1.95, p=.058, d=0.59), cognitive ability (t[47]=−0.82, p=.414, d=0.25), or percent time in institutional care through age 54 months (t[51]=−0.51, p=.610, d=0.15).

Associations Between Early Caregiving Quality and Consistency of Competence

Among ever institutionalized group adolescents, associations were explored between the longitudinal competence categories and caregiver quality at age 42 months, percent time in institutional care through age 54 months, and placement disruptions through age 54 months.

Adolescents in the always competent category were more likely to have had higher quality of caregiving behavior at 42 months of age compared to not always competent adolescents (t[35.8]=−5.00, p<.001). Always competent adolescents were also more likely to have spent less time in intuitional care through age 54 months (t[76]=2.77, p=.007). Relatedly, never competent adolescents spent more time in institutional care through age 54 months compared to adolescents who were competent during at least one of the assessment periods across middle childhood and adolescence (t[76]=2.43, p=.017). There were no differences in the number of placement disruptions between adolescents in the always versus not always competent categories or the never versus ever competent categories.

Discussion

Patterns of competent functioning were examined across three time points (ages 8, 12, and 16 years) along with several indicators of the early caregiving environment (observed quality of interactive behavior, percent time in institutional care, and placement disruptions). Adolescents with a history of institutional care were less likely to maintain competent functioning across middle childhood and adolescence compared to community children. A minority of ever institutionalized adolescents (17%) maintained competent functioning from age 8 to 16 years, but those who did maintain competent functioning were more likely to be in the group randomized to foster care than the care as usual group. Experiencing higher quality of early caregiving interactions and reduced exposure to institutional care were associated with sustained competence among this vulnerable group highlighting the importance of not only limiting time spent in institutional care but also ensuring the quality of early parent-child interactions.

Never Institutionalized vs. Ever Institutionalized and Foster Care Group vs. Care as Usual Group

Previously, we demonstrated that children with a history of institutional care tend to have lower levels of competent functioning in adolescence (age 12 years) compared to never institutionalized community children (Humphreys et al., 2018). The present study extended these findings by assessing competence at two additional time points (i.e., ages 8 and 16 years) in the service of examining consistency of competent functioning longitudinally, from middle childhood through adolescence. Not surprisingly, children with a history of institutional care were significantly less likely to be consistently competent from middle childhood through adolescence compared to never institutionalized community children. These findings are similar to competence following other types of adversity (e.g., severe pediatric medical conditions and physical disabilities), which documented patterns of continuity and change in competent functioning across childhood and into adolescence (Masten & Tellegen, 2012). However, there was a considerable number of children in the never institutionalized community group with variability in competence over time; only 60% were consistently competent across all three waves. Furthermore, across domains (depicted in supplemental table 2) similar proportions of never institutionalized and foster care group children were competent in the domains of family relations, substance use, and risk-taking behavior. Thus, competence varied considerably both across and within groups. Future research is needed on the consistency of competent function across middle childhood and adolescents among children both with and without a history of institutional care to increase confidence in these findings and further explore the mechanisms involved in the maintenance of competent functioning over time.

Early Placement into Foster Care and Stability of Foster Care Placement

It is possible that variability in longitudinal competence among children randomized to foster care could be partially explained by differences in the experiences of children in this group. We did not find support for the effect of early placement on consistency of competent functioning, despite the large proportion of early-placed adolescents with consistent competence (45%) compared to late-placed adolescents (19%) and a medium effect size. Therefore, we may have been underpowered in our ability to detect differences between these two groups. Notably, in the ERA study, there were higher rates of sustained “normal” functioning across childhood (from age 6 to 11 years) for children placed early, however, they used an earlier placement threshold of 6 months of age (Kreppner et al., 2007). We were not able to test the effect of placement prior to 6 months of age because no children in the BEIP were placed prior to 6 months of age.

We also failed to find an association between stability of foster care placement and longitudinal competence. However, there appeared to be meaningful differences in the proportion of adolescents who were never competent compared to ever competent with a medium effect size, despite these differences not being statistically different. We again may have lacked the statistical power to detect differences between groups.

Associations between Early Caregiving Quality and Consistency of Competent Functioning

There was substantial variability in competence across middle childhood and adolescence following a history of institutional care, in part explained by randomization to foster care. In addition, we found that two of the three measures of children’s early experiences—quality of early caregiving and percent time living in institutions through 54 months—predicted consistent competence (i.e., competence at all three waves across ages 8, 12, and 16 years). Additionally, percent time in institutional care also differentiated those children who were ever or never competent (i.e., competent at one or more assessment waves). Quality of caregiving, rather than percent time in institutional care, may therefore be a better predictor of stable patterns of competence. Our study replicates and extends previous work (Humphreys et al., 2018; Kreppner et al., 2007; Vorria et al., 2015) by demonstrating that children who receive higher quality caregiving early in life and spend less time being raised in institutions not only are more likely to achieve but also to maintain competent functioning.

Of course, there may be variability in profiles of competence within children. For example, some children may be more socially or emotionally competent whereas others may be more competent in academics. An important future direction of this work is to first examine whether different profiles of competence exist. Furthermore, associations should be examined between profiles of competent functioning and early adversity in caregiving as well as how differences relate to outcomes in adolescence and adulthood.

The link between sustained competence and early caregiving we found is similar to the report by Vorria and colleagues (2015) that quality interactions between children and institution staff that were characterized by appropriate and sensitive caregiving were associated with more favorable outcomes at age 13 years. Again, our findings extend this observation by indicating that early experiences predict consistent competence into mid-adolescence. The importance of high quality, early interactions with caregivers and other important adults for the development of competent functioning also aligns with work on competence following other types of stress and adversity in the Project Competence Longitudinal Study (Garmezy, Masten, & Tellegen, 1984; Masten & Tellegen, 2012). Thus, it is important for foster and adoptive families raising children with a history of institutional care to receive training and support as early as possible to ensure they are caring for children in a way that will foster healthy development. Caregiving quality in early childhood is a potentially important target of intervention for families caring for children with histories of institutional rearing.

There are a number of limitations of this study to be noted. Most importantly, the study is underpowered to detect a number of potentially important predictors of competence due to the available sample size from this longitudinal RCT. We are unable to recruit new participants for this trial, and thus emphasize effect sizes in conjunction with traditional Fisherian approaches. Second, our definition of competent functioning was externally validated at 12 years (Humphreys et al., 2018), but not previously at 8 or 16 years. Third, our results may not be generalizable to children in settings beyond those raised in Romanian institutions. However, we believe this work provides a framework for studying competence following deprivation in other cultures.

In conclusion, we find that institutional care is associated with reduced competence in middle childhood and adolescence and that maintaining competence across this period may be uncommon. For children with a history of institutional care, time spent in institutional care as well as the care they receive when interacting with their caregivers appear to be associated with greater resilience to early adversity. Although removal from institutional care as early as possible remains an important recommendation, it is also necessary to ensure that children are receiving high quality care from their caregivers as early as possible.

Supplementary Material

1

Table 2.

Comparisons between Always and Not Always Competent and Never and Ever Competent on Caregiving Variables

Always competent Not always competent
m (sd) m (sd) t (df) p-value Cohen’s d
Overall quality of caregiver behavior at 42 months 3.21 (0.26) 2.68 (0.58) −5.00 (35.80) <.001 1.18
Percent time in institutional care through 54 months 35.04 (17.16) 55.59 (25.59) 2.77 (76) 0.007 0.94
Number of placement disruptions through 54 months 3.08 (0.86) 2.77 (1.20) −0.88 (76) 0.381 0.30
Never competent Ever competent
m (sd) m (sd) t (df) p-value Cohen’s d
Overall quality of caregiver behavior at 42 months 2.67 (0.51) 2.79 (0.08) −0.74 (72) .461 0.33
Percent time in institutional care through 54 months 64.15 (26.19) 48.30 (24.23) 2.43 (76) .017 0.63
Number of placement disruptions through 54 months 2.74 (1.15) 2.85 (1.16) −0.36 (76) .717 0.10
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Supplementary Materials

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