Objective: to assess the impact of early deprivation due to institutionalization on child development.
Design: prospective cohort study. Natural experiment.
Setting: United Kingdom
Study population: children in the English and Romanian Adoptees Study. Longitudinal study on the development of children adopted from Romanian orphanages by United Kingdom families in the early 1990s and followed up to adulthood.
Risk factor assessment: Romanian adoptees were divided into those that spent fewer than 6 months in an institution (Rom<6) and those that spent more than 6 months (Rom>6). A group of United Kingdom adoptees (UK) that had not experienced deprivation was used for control. The authors used mixed-effects regression models for ordered-categorical outcome variables to compare symptoms, levels and trends between groups, and also contrasts of simple effects (χ² and McNemar) to assess differences in binary outcomes or covariates as well as the co-occurrence of symptoms among outcome domains. They investigated missing data by means of multivariate tests.
Outcome measurement: outcomes were measured by means of developmentally appropriate standard questionnaires, interviews with parents and adoptees, and direct measures of the intelligence quotient (IQ), symptoms of autism spectrum disorder (ASD) (15 items from the Social Communication Questionnaire), attention-deficit hyperactivity disorder (ADHD) (revised Rutter scale at ages 6 and 11 years, Strength and Difficulties Questionnaire at age 15 years and Conners Behavior Rating Scale at age 22-25 years), disinhibited social engagement, conduct or emotional problems, and cognitive impairment (IQ < 80) (McCarthy scales at age 6 years, Wechsler scales at all other ages). The authors also documented the use of mental health services, educational achievement, employment status, and socioeconomic status of the parents. They administered the Parental Attachment Questionnaire to parents and the Parent and Peer Attachment Questionnaire to young adult adoptees. A DNA sample was collected for analysis at age 15 years.
Main results: the Rom<6 and the UK groups had similarly low levels of symptoms at most ages, so they were pooled for the comparative analysis. In contrast, the Rom>6 group had consistently higher rates of ASD features (relative risk* [RR] at 6, 15 and 25 years: 2.7/0.9/3.1), disinhibited social engagement (RR: 2.7/could not be calculated/5.1), and ADHD (RR: 2.6/2.4/4.3). The risk of cognitive impairment in the Rom>6 group, which was substantially high compared to the rates in the combined Rom<6 and UK group at ages 6 years (RR: 3.1; 38.8% versus 12.7%) and 15 years (RR: 2.36; 28.1% versus 11.9%), decreased in the young adult age group (RR: 0.7; 5.6% versus 7.9%). Conversely, self-reported emotional symptoms exhibited a delayed increasing trend, with minimal differences at ages 11 and 15 years and marked increases in young adults, with effects that were similar to those observed in the ratings reported by parents. There was also a higher proportion in the Rom>6 group of individuals with low educational achievement, unemployment and greater use of mental health services compared to the UK group. Only one fifth (n = 15) of individuals in the Rom>6 group showed no evidence of problems in any of the evaluations.
Adjustment of the models for sex and birth weight did not change the results. In the Rom>6 group, more than one fifth of the subjects had two or more problems during childhood and adolescence; however, this proportion decreased significantly to 8.5% in young adulthood.
Conclusion: despite the resilience exhibited by some adoptees and the remission observed in adulthood in some cases, prolonged early deprivation was associated with long-term deleterious effects on the wellbeing of the individuals under study, and did not improve despite years of adequate nutrition and support provided by adoptive families.
Conflicts of interest: disclosed in the original text.
Funding sources: Economic and Social Research Council, Department of Health, National Institute for Health Research Central Commissioning Facility, Medical Research Council, Jacobs Foundation and Nuffield Foundation.