Practice
Teaching: Ethical Research to Help Romania’s Abandoned Children
Aimed at integrating cutting-edge psychological science into the classroom, Teaching Current Directions in Psychological Science offers advice and how-to guidance about teaching a particular area of research or topic in psychological science that has been the focus of an article in the APS journal Current Directions in Psychological Science.
More teaching resources in this Observer: Understanding Our Inner Darkness May Shed Light into Humanity’s Common Good
What happens when children experience parental neglect? As Romania’s communist regime collapsed in the late 1980s, wrenching stories of neglect emerged. Nicolae Ceaucescu had outlawed abortion and punished families who had fewer than five children, and many families had children they could not afford to raise. By 1990, over 170,000 Romanian children were institutionalized.
In many countries, abandoned children are placed with extended family or in foster care. But Romania believed its long tradition of institutionalized care was best. Rotating shifts of caregivers typically supervised 12 to 16 children each. Children were safe and fed, but lacked nurturing, emotionally responsive social relationships.
Psychologists know from animal research that early social neglect affects brain development, with cognitive, social, and emotional consequences. But how can we assess neglect in humans? Institutionalized children’s deficits might reflect pre-existing neurobiological conditions or early deprivation. Consider, then, one of psychology’s most important clinical trials, the Bucharest Early Intervention Project (BEIP; Nelson et al., 2023).
BEIP began when a Romanian government official invited three American developmental scientists to Bucharest. The research team studied 180 institutionalized children at about 22 months of age. The researchers assessed the children’s IQ, language development, mental health attachment security, physical development, and brain anatomy. After eliminating those with genetic or neurobiological disorders, 68 children were randomly assigned to a high-quality foster care program with local families, while 68 remained institutionalized. Foster care was non-existent in Bucharest so the research team recruited, trained, funded, and monitored foster care families. The researchers also tracked a community sample of children who had never been institutionalized.
Read all of the articles from the November/December Observer.
As of 2023, the participants are about 22 years old, and their outcomes are summarized in Nelson et al.’s Current Directions piece. First, the foster care children had better developmental outcomes on almost all dimensions. For example, compared to remaining institutionalized, the fostered children showed a 7 to 9 point increase in IQ. They also grew physically larger and had better attachment security, language, and peer relationships (Almas et al., 2015; Humphreys et al., 2020; Smyke et al., 2010). The foster children’s brain development also improved (Debnath et al., 2020; Sheridan et al., 2022). Only in a few domains, such as ADHD diagnosis and gray matter volume, did researchers not observe a benefit of foster care.
Second, the team documented critical developmental periods. The younger children were when placed into foster care, the more they benefitted. Children who started foster care before 24 months had the largest improvements.
The BEIP project can introduce students to the importance of responsive caregiving during human development. It also illustrates a strong research design, the randomized controlled trial (RCT).
BEIP also provides a rich ethics example. After describing the study’s historical context and major findings, invite students to consider ethical questions in small groups:
Some might question the ethics of conducting a randomized clinical trial on vulnerable children in a developing country. Based only on what you’ve heard so far, what concerns might you imagine?
As groups report out, categorize their questions (below). Then present additional information. Many ethics writers have argued that the BEIP passes ethical muster (Millum & Emmanuel, 2007; Miller, 2009).
| Ethical principle: | Your students may raise concerns about: | Relevant additional information: |
| Respect for persons concerns the requirement of informed consent, including the special protection of vulnerable populations. | 2-year-olds can’t give informed consent, and the children did not have a clear guardian | To protect vulnerable participants, the study ensured procedures were common and not known to cause harm. |
| Beneficence (In Canada, Concern for Welfare) considers the risks to research participants and the value of the knowledge for society. | Did the study withhold a beneficial treatment (foster care) from certain children? Is that fair? | Before the BEIP project, institutionalization was standard, so children in this group were not worse off than they would have been without the study. No foster care system existed in Bucharest, so BEIP initiated one. In fact, more children would have been assigned to foster care if they could have recruited more families. |
| Were children in the control group forced to stay in institutions? | No. Over the years, more than half of those in the institutionalized group were adopted, fostered, or reintegrated with biological families (they continued in the study). | |
| What happened to the foster care children at 54 months, when the BEIP stopped administrating the foster care program? | Children in the foster care group continued in foster care under the supervision of the Romanian government. No foster care child was returned to institutionalized care. | |
| Justice considers who bears the burden of research participation, especially compared to who benefits from it | This study targeted an extremely vulnerable population in a developing country, and the researchers were more privileged. Was this exploitative? | A member of the Romanian government initiated the study. While institutionalized children were targeted, they are also its beneficiaries. Moreover, Romania then changed its laws to forbid institutional care for children under age 2. |
| Institutional oversight. Research projects must be reviewed, approved, and monitored by institutional research boards (IRBs) | Was the research approved by an IRB? | Yes; the IRBs of three sponsoring U.S. universities reviewed the study plan; agencies in Bucharest also approved it. |
| Clinical equipoise. We shouldn’t do research in which participants are assigned to a treatment we know to be inferior. | Isn’t it obvious that institutionalized care is harmful? Why should we do this study at all? | It’s important to consider the local cultural context. Before the project, many in Romania believed that institutionalized care was superior. Furthermore, by using an RCT (the strongest possible research design) researchers could make the most persuasive case to influence Romanian policy. |
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Almas, A. N., Degnan, K. A., Walker, O. L., Radulescu, A., Nelson, C. A., Zeanah, C. H., & Fox, N.A. (2015). The effects of early institutionalization and foster care intervention on children’s social behaviors at age 8. Social Development, 24(2), 225-239.
Debnath, R., Tang, A. Nelson, CA, Zeanah, C.H., & Fox, N.A. (2020). Long-term effects of institutional rearing, foster care intervention and disruptions in care on brain electrical activity in adolescence. Developmental Science, 23(1), e12872.. doi: 10.1111/desc.12872
Humphreys, K. L., Gleason, M. M., Drury, S. S., Miron, D., Nelson, C. A., Fox NA, & Zeanah CH (2015). Effects of early deprivation on psychopathology at age 12 years: Followup of a randomized controlled trial. The Lancet Psychiatry, 2(7), 625-634. PMID: 26303560
Miller, F. G. (2009). The randomized controlled trial as a demonstration project: An ethical perspective. American Journal of Psychiatry, 166, 743-745.
Millum, J., & Emanuel, E.J. (2007). The ethics of international research with abandoned children. Science, 318, 1874-1875.
Nelson C. A., Fox N. A., & Zeanah, C. H. (2014). Romania’s abandoned children: deprivation, brain development and the struggle for recovery. Harvard University Press:
Sheridan, M. A., Mukerji, C. E., Wade, M., Humphreys, K. L., Garrisi, K., Goel, S., Patel, K., Fox, N. A., Zeanah, C. H., Nelson, C. A., McLaughlin, K. A., (2022). Early deprivation alters structural brain development from middle childhood to adolescence. https://doi.org/10.17605/OSF.IO/476M8
Smyke A, Zeanah, Fox NA, Nelson CA, & Guthrie D (2010). Placement in foster care enhances quality of attachment among young institutionalized children. Child Development, 81(1), 212-223. PMID: 20331663
Zeanah, C. H., Fox, N. A., & Nelson, C. A. (2012). Case study in research ethics: The Bucharest Early Intervention Project. The Journal of Nervous and Mental Disease, 200(3), 243-247.
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