Repetitive behaviours in neglected, deprived children reversible with improved care

Stereotypies – repetitive behaviours such as rocking, flapping, spinning objects and head banging – are commonly seen in people with autism or mental retardation. They can also be acquired by children exposed to severe neglect and deprivation, along with declines in IQ, mental health and language. A new study led by Charles A. Nelson, PhD, Director of Research in the Division of Developmental Medicine at Children’s Hospital Boston, found stereotypies in more than 60 percent of orphaned or abandoned children in institutional care in Bucharest, Romania – but also showed that these behaviours often abated when the children were placed in quality foster care.

The study, published in the May Archives of Pediatric and Adolescent Medicine and accompanied by an editorial, was part of the decade-old Bucharest Early Intervention Project. This project was the first randomised, controlled trial to demonstrate that placing an institutionalised child with a well-screened and monitored foster family can partially reverse the cognitive and behavioural declines caused by neglect and social deprivation. Improvements were seen particularly when the child was placed in foster care before age 2, suggesting that there is a sensitive period in cognitive development when intervention is critical.

In the current study, Nelson and colleagues evaluated 136 children with a history of early institutional care, comparing those who were placed with foster families with those who remained in the institution. They conducted baseline cognitive, behavioural, brain and language assessments just before the placement (at an average age of 22 months), repeating the tests when the children were 30, 42 and 54 months old.

Follow-up testing showed that the younger a child was when placed with a foster family, and the longer the placement had lasted, the greater the reduction in stereotypies. Among those placed before 12 months of age, only 25 percent had stereotypies at 30 months, and virtually all were free of stereotypies at 54 months. In contrast, among children placed in foster care after the age of 24 months, 74 percent had stereotypies at 30 months and 43 percent at 54 months. Children in foster care who continued to have stereotypies had greater impairments in cognition and language than those whose stereotypies abated. With time, stereotypies also tended to abate in the children who remained in the institution, but their stereotypy scores remained significantly higher than in the foster-care group.

Stereotypies may provide a "proxy" for serious neurologic, cognitive or behavioural disorders that could help in triaging large groups of children in institutions, or orphaned by war or natural disasters such as the Haiti earthquake, says Nelson, allowing identification of those most in need of intervention when resources are limited. UNICEF estimates that there may be as many as 70–100 million worldwide who are orphaned or abandoned, of which at least 8,000,000 live in institutions. "Stereotypies give you a cause to dig more, to do testing," he says. "They can be taken as a sign of more insidious brain damage."

No one knows what alterations in brain function are causing the stereotypies, though some stereotypies are thought to involve the basal ganglia, a part of the brain involved in motor function. Nelson hopes in future work to study children with stereotypies further using brain imaging and electrophysiology techniques.

An accompanying editorial discusses the application of the findings to the US child welfare system, suggesting that the emotional injuries caused by failed relationships, failed attachment and traumatic disruptions "produce neurobiological alterations whose treatment is more likely to be successful with interventions that target attachment failure than the symptoms of disruptive behaviours targeted by medications."

The study was funded by the John D. and Catherine T. MacArthur Foundation, the Binder Family Foundation, the Richard David Scott Chair and the Doris Duke Charitable Foundation.

(Source: Children’s Hospital Boston: Archives of Pediatric and Adolescent Medicine: May 2010)