Following the fall of Romania’s Communist dictator Nicolae Ceausescu in 1989, the world was shocked to learn of the appalling conditions in the country’s orphanages. Those of us old enough to have watched the news bulletins remember them alongside the reports of Ethiopian famine from a few years earlier, because the images of children abandoned and without hope just can’t be unseen.

Many of the Romanian orphans were adopted into UK families and this provided researchers with a unique opportunity to study the effects of this early deprivation on long-term psychosocial and physical outcomes of the adopted children. The English and Romanian Adoptee (ERA) project is a longitudinal, multi-method investigation, initially led by Michael Rutter (Rutter et al, 2007).

Yesterday The Lancet published a follow-up study of this work (Sonuga-Barke et al, 2017), which presents data from this same cohort of Romanian children but now in their young adulthood (22-25 years). We know from other research that early-life deprivation is associated with developmental and mental health disorders in childhood, but this new evidence provides new knowledge about how these effects can persist into adulthood.

Edmund Sonuga-Barke kindly joined me for half an hour via Skype yesterday. You can listen to my interview with him below.

Methods

This longitudinal study followed up two groups of children who were first assessed in childhood (at 6, 11, and 15 years old) and then in young adulthood (aged 22-25 years):

• The first group were children raised in Romanian institutions from soon after birth to up to 43 months who were later adopted into stable and caring families in the UK. This group was divided into two sub-groups, those who had spent:
  • <6 months in an institution (n=67 at age 6 years; n=50 at young adulthood)
  • >6 months in an institution (n=98 at age 6 years; n=72 at young adulthood)
• The second (comparison) group consisted of UK adoptees who had not experienced any early life deprivation (n=52 at age 6 years; n=39 at young adulthood).

Table 1: % of participants included in analysis at each time point

	6 years old	11 years old	15 years old	22-25 years old
Romanian < 6 months	99	97	93	75
Romanian > 6 months	100	98	91	73
UK	100	100	90	75

Developmentally appropriate standardised procedures (questionnaires and interviews for adoptees and their parents, and direct measures of IQ) were used to measure:

• Symptoms of autism spectrum disorder
• Inattention and overactivity
• Disinhibited social engagement
• Conduct or emotional problems
• Cognitive impairment (IQ score <80)

The Lancet press release refers to this as a landmark study and you have to admit, they’ve got a point. This work is unique because it compares the developmental course of a wide range of social, behavioural and cognitive measures in children who experienced appauling physical and social circumstances before adoption with that of adopted children who did not experience any such deprivation.

Results

• Children severely deprived <6 months and non-deprived UK adoptees had similarly low levels of problems.

Compared with controls, children severely deprived >6 months had:

• Persistent detrimental effects on behavioural and social development; symptoms of autism spectrum disorder, disinhibited social engagement, inattention and overactivity through to young adulthood (pooled p<0·0001 for all)
• A higher proportion of:
  • low educational achievement (p=0·0195)
  • unemployment (p=0·0124)
  • mental health service use (<11 years p=0·0120, 11–14 years p=0·0032, 15–23 years p=0·0003)
• High rates of cognitive impairment when they were aged 6 years (p=0·0001) and 11 years (p=0·0016), but interestingly this remitted to normal rates at young adulthood (p=0·76)
• On the other hand, emotional problems (depression and anxiety) showed a late onset pattern with a significant increase between ages 11 and 15 years to young adulthood (p=0·0005)
• One in five people from this severely deprived group did not experience any mental health problems into young adulthood. This remarkable finding should inspire future research into the resilience of this population, which may help us to develop better interventions for others. The next steps of the research will involve an in-depth genetic analysis of the most exposed adoptees who did not develop mental health problems, to distinguish whether genetic and epigenetic differences contribute to resilience.

Overall, the findings from this work are extensive and there will be a number of publications focusing on the different outcomes. A study on ADHD has already been published (Kennedy et al, 2016) and further papers are in press on disinhibited social engagement and other topics.

Conclusions

The authors conclude:

Notwithstanding the resilience shown by some adoptees and the adult remission of cognitive impairment, extended early deprivation was associated with long-term deleterious effects on wellbeing that seem insusceptible to years of nurturance and support in adoptive families.

Limitations

This is an impressive piece of work and it deserves its status as a landmark child and adolescent mental health study in The Lancet. As with any study, it has some limitations:

• Over time, the researchers have not been able to include all of the original participants in every follow-up stage. The levels of drop out in the early years are actually extremely low (>90% at 15 years – see table 1 above), but this latest stage has seen a higher level of attrition with about three quarters of the original group still included. However, the researchers have shown that this drop-out is not due to higher levels of problems occurring in the individuals who are no longer involved.
• Outcomes were measured using different questionnaires, with different formats for response scaling used at different ages. Also, outcomes weren’t always recorded blind to the children’s status (e.g. parents reported outcomes), and some outcome measures were subjective (e.g. researchers’ assessment of social disinhibition).
• It’s possible that other early life risk factors have impacted on the neurodevelopment of the Romanian children, e.g. maternal substance misuse or other maternal stress during pregnancy. Again, give them their dues, the research team investigated this possibility and found “no statistically significant differences in birthweight, a perinatal marker of prenatal risk, between the two institutional groups, and adjustment for birthweight did not change results of longitudinal models”.
• Given that this is an observational study, the total number of participants is actually quite low. Of course this was enforced by the situation in which this ‘natural experiment’ took place and could not have been changed by the researchers. Given these relatively low numbers though, it’s not possible to say that there is no difference between the children severely deprived for <6 months and the non-deprived UK adoptees.

It’s worth mentioning that I asked Edmund Sonuga-Barke about many of the above limitations during our podcast interview (see the Soundcloud link above), so you can hear his responses to each point if you’re that way inclined. This part of the conversation takes place about 14 minutes into the interview.

Implications for practice

It’s tempting to draw comparisons between this population of deprived Romanian children and the millions of young people we see on our news bulletins every night; displaced by conflict, many without a family, often living in severe deprivation for many years. However, the conditions of the ERA study children were quite unique. It was originally described by Michael Rutter as a unique natural experiment, which makes it a hugely important piece of work, but not necessarily evidence that can be applied universally.

Clearly this work supports the drive towards early intervention, which is a cornerstone of a great deal of mental health policy these days. It also reinforces what we know about the importance of a safe and loving family unit.

Crucially, the ERA study also highlights the importance of documenting early-life adversity during clinical assessments, as this will help to plan services that better address these kinds of persistent and complex problems, including the careful planning that’s needed when these patients transfer from child to adult mental health services.

Links

Primary paper

Sonuga-Barke EJS, Kennedy M, Kumsta R, et al. (2017) Child-to-adult neurodevelopmental and mental health trajectories after early life deprivation: the young adult follow-up of the longitudinal English and Romanian Adoptees study. Lancet 2017; published online Feb 22. (Open Access)

Other references

Rutter M, Beckett C, Castle J, Colvert E, Kreppner J, Mehta M, … & Sonuga-Barke EJS. (2007) Effects of profound early institutional deprivation: An overview of findings from a UK longitudinal study of Romanian adoptees. European Journal of Developmental Psychology, 4(3), 332-350.

Kennedy M, Kreppner J, Knights N, Kumsta R, Maughan B, Golm D, Rutter M, Schlotz W, Sonuga-Barke EJ. (2016) Early severe institutional deprivation is associated with a persistent variant of adult attention-deficit/hyperactivity disorder: clinical presentation, developmental continuities and life circumstances in the English and Romanian Adoptees study. J Child Psychol Psychiatry. 2016 Oct;57(10):1113-25. doi: 10.1111/jcpp.12576. Epub 2016 Jun 6.

Photo credits

• By Thomas Black57 (Own work) [Public domain], via Wikimedia Commons
• kuldeep singh CC BY 2.0