The role of early life experiences in determining

adolescent outcome: Findings from the ERA Study

Dr Jana Kreppner

Developmental Brain Behaviour Laboratory, University of Southampton

Large scale profound global early deprivation in Romanian Orphanages pre-1990s

Possibly the most extreme large scale manifestation of early childhood deprivation in recent history

2

Profound global deprivation – severely restricted diet and little of no social or cognitive stimulation

ERA Study:• ‘Natural experiment’: Profound deprivation

followed by above average rearing in UK families. = opportunity to study effects of radical environmental change on child development.

• Change of environment rapid and easily timed

• Children placed in institutions in early infancy (so little selection on basis of child impairment)

• Children who were in institutions at the time were unlikely a ‘selective’ sample as prior to 1989/90 no children were adopted or return to biological families.

• Longitudinal data allows factors associated with successful adoption to be studied.

Health and psychological state at time of adoption• Malnutrition• A range of health problems

– Skin lesions and intestinal infections– Hepatitis B, HIV, heart conditions, lung damage from

infection; anaemia; rickets; ear infections; chest infections• Extreme developmental delay• Little or no language – even for the older children• Institutional behaviours – stereotypies, fears and

obsessions• Deficits in social responsiveness

The ERA study

5

• Scientific / theoretical questions• Degree of recovery when extremely depriving conditions in

early life were followed by generally good conditions in early/middle childhood?

• deficits or impairments: the kind ordinarily associated with stress or adversities or would there be specificities?

• What mechanisms might be involved in any enduring deficits that occurred?

The ERA study design

• age-stratified random sampling design (range of 0 - 42 months of age for UK entry)

NAge at

adoption (months)

Origin

Assessment (years of age)

4 6 11 15

52 0-6 UK x x x x21 variable Rom (family) x x x x46 <6

Rom (institutions)

x x x x53 6-24 x x x x45 >24 x x x

Prospective-longitudinal design

Cognitive Level at Entry to the UK and at 11 years (Institution-reared Romanian adoptees)

40

60

80

100

120

Me a

n a n

d co

nfid

enc e

in

t er v

a l

Denver Quotient at Entry to the UK

WISC IQ at Age 11

n=120

ERA – heterogeneity in outcomeIQ age 15 years

Step increase in risk for multiple impairment at age 11:

Kreppner et al. (2007)

Rates with impairment at age 6

Domain % in Romanian adoptees

% in within-UK adoptees

Fisher exact p

Quasi-autism 12.1 0.0 0.005

Attachment problems 20.7 3.8 0.003

Cognitive Impairment 14.0 2.0 0.018

Inattention/overactivity 25.3 9.6 0.019

Peer difficulties 18.9 9.6 NS

Emotional difficulties 3.7 9.6 NS

Conduct Problems 8.0 9.6 NS

Rutter, Kreppner, O’Connor (2001)

Summary of key findings across ages:

• Profound effects for most at time of adoption. • Remarkable degree of recovery by age 6 –

additional catch-up across time. • Deficits and impairment persisted in a substantial

minority (considerable heterogeneity)• Effects of length of institutional deprivation –

step wise increase with 6 month threshold effect. • Impairments took a surprisingly specific form:

Quasi-autistic tendenciesDisinhibited attachmentCognitive impairmentInattention/overactivity

Rutter & Sonuga-Barke, 2010

QA – behavioural description• Abnormal preoccupations and intense

circumscribed interests• Greater, albeit unusual, social interest and

flexibility– Substantial overlap with disinhibited attachment

• Persistence of pattern and impairment but features diminished in intensity into adolescence

Disinhibited AttachmentIntrusive social approach and disregard of social

boundaries• Lack of reticence/shyness with strangers• Readily goes off with strangers• Limited differentiation among adults• Lack of checking back with parent

…She tended to be markedly over familiar with adults, tried to join in adult conversations, cuddled up to men without appreciating the inappropriate nature of this action. When younger, she was strikingly overfriendly with strangers, going up to talk with them, and she was quickly ‘all over’ visitors to the family home. When older, that was less marked, but the social inappropriateness of interactions with peers and with adults remained.

Deprivation specific patterns (DSP)

Question: Are there specific sequelae of profound early institutional deprivation that differ from the effects of other stresses/adversities?

Definition: the concept of DSP is of a pattern that constitutes a distinctive early-appearing response to institutional deprivation that is rarely found in other groups, that is likely to involve an enduring biological effect, and that is not eradicated by post-adoption experiences.

Rates with DSP patterns across adoptee groups:

Pooled comparison

Institutional deprivation beyond 6 months

QA 0.9% 14.9%DA 7.0% 39.1%CI-dsp 0% 23.4%IO -dsp 0% 16.9%At least 1 DSP (n=51):

7.8% 45.7%

DSP

CI (12) IO (6)

None (135)

Missing (10)

DSP (51)

QA OR DA (24)

QA OR DA & IO (4)

CI&IO (3)

QA OR DA & CI & IO (9)

QA OR DA

& CI (14)

Pooled Comparison >6months IDNo DSP 106 (92.2%) 50 (54.3%)

DSP 9 (7.8%) 42 (45.7%)

Total (217)

Persistence of DSPs to age 15:

With DSPn = 9

At age 11 At age 15

Pooled comparison:

With DSPN = 2

Without DSPN = 7

With DSPN = 42

6-42 months ID:

With DSPN = 34

Without DSPN = 8

78%

22%

19%

81%

Rate of DSP in the subgroup without sub-nutrition:

1.3

45.5

05

101520253035404550

% w

ith D

SP pooled comparison

institutional care beyond 6 months

(Rutter, Kumsta, Schlotz & Sonuga-Barke, 2012)

Why was there such varied response to extended profound early ID?

• Pre-adoption characteristics? Birth weight Physical and developmental indices

at time of adoption

• Post adoption family environment?

• Genetic vulnerabilities?

Moderating role of Genes on Outcome:Example: DAT1 on ADHD symptoms

Stevens et al., 2009

-0.6

-0.4

-0.2

0

0.2

0.4

0.6

0.8

at entry 6 years 11 years

ADHD

SYM

PTOM

S

BOTH RISKS

DEP RISK

DAT1 RISK

NO RISK

6 YEARS 11 YEARS 15 YEARS

44 64 1

115

Gross Effects on Brain Development – head circumference

b = 1.07***

Length of Institutional Deprivation DSP

HC

Indirect effect b = 0.250*b = -0.89*** b = -0.28**

*p <.05, **p <.01, ***p <.001

But the mediating effect is small – there must be more subtle effects of deprivation on the brain to explain impairment.

b = 1.32***

Length of Institutional Deprivation DSP

Gross Effects on Brain Development – head circumference

Summary

…returning to the initial questions

• Degree of recovery when extremely depriving conditions in early life were followed by generally good conditions in early/middle childhood?

remarkable degree of early recovery (and evidence of additional late catch up) / effect of length of ID: harmful after-effects were rare in those adopted before the age of 6 months

• deficits or impairments: the kind ordinarily associated with stress or adversities or would there be specificities?

four patterns that were strongly associated with ID (>6 months) / impairments were unusual and distinctive (especially the social cognitive deficits observed in DA and QA)

• What mechanisms might be involved in any enduring deficits that occurred?

some evidence for moderation by genetic factors / preliminary evidence for lasting alteration to brain structure and function

Implications• Behavioural presentation of psychological

impairments may be difficult to distinguish from the ordinary varieties of psychopathology in the general population.

• Underlying aetiology may be different in important ways (e.g. in their neurobiology) that have important implications for treatment.

The ERA Team Age 15:Celia BeckettJenny Castle

Christine GroothuesAmanda HawkinsRobert KumstaWolff Schlotz

Suzanne Stevens&

Edmund Sonuga-Barke

Michael Rutter

FundingNuffield Foundation

Department of HealthHelmut Horten Foundation

Jacobs FoundationESRCMRC

Acknowledgments

THANK YOU!