Transcript Jana Kreppner

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
Profound global deprivation – severely restricted diet and little of no
social or cognitive stimulation
2
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
• 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?
5
The ERA study design
• age-stratified random sampling design (range of 0 - 42
months of age for UK entry)
Assessment (years of age)
N
Age at
adoption
(months)
Origin
4
6
11
15
52
0-6
UK
x
x
x
x
21
variable
Rom (family)
x
x
x
x
46
<6
x
x
x
x
53
6-24
x
x
x
x
45
>24
x
x
x
Rom (institutions)
Prospective-longitudinal design
Cognitive Level at Entry to the UK and at 11 years
(Institution-reared Romanian adoptees)
120
100
80
60
40
Denver Quotient at
Entry to the UK
n=120
WISC IQ at Age 11
ERA – heterogeneity in outcome
IQ 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 tendencies
Disinhibited attachment
Cognitive impairment
Inattention/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 Attachment
Intrusive 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 postadoption 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%
None
(135)
DSP
QA OR DA (24)
DSP (51)
QA OR DA
& CI (14)
CI (12)
QA OR DA
& IO (4)
QA OR DA
& CI & IO
(9)
CI&IO
(3)
Total (217)
Missing (10)
No DSP
DSP
IO (6)
Pooled Comparison
>6months ID
106 (92.2%)
50 (54.3%)
9 (7.8%)
42 (45.7%)
Persistence of DSPs to age 15:
At age 11
Pooled
comparison:
6-42
months ID:
At age 15
78%
With DSP
n=9
Without DSP
N=7
22%
With DSP
N=2
19%
Without DSP
N=8
81%
With DSP
N = 34
With DSP
N = 42
% with DSP
Rate of DSP in the subgroup without
sub-nutrition:
50
45
40
35
30
25
20
15
10
5
0
45.5
pooled comparison
institutional care
beyond 6 months
1.3
(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
0.8
0.6
ADHD SYMPTOMS
BOTH RISKS
0.4
DEP RISK
DAT1 RISK
NO RISK
0.2
0
a te n try
6 ye a rs
1 1 ye a rs
-0.2
-0.4
6 YEARS
11 YEARS
15 YEARS
-0.6
Stevens et al., 2009
Gross Effects on Brain Development –
head circumference
44
4
6
11
15
Gross Effects on Brain Development –
head circumference
Length of
Institutional
Deprivation
b = 1.32***
DSP
Length of
Institutional
Deprivation
b = 1.07***
DSP
Indirect effect b = 0.250*
b = -0.89***
b = -0.28**
HC
*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.
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.
Acknowledgments
The ERA Team Age 15:
Funding
Celia Beckett
Nuffield Foundation
Jenny Castle
Department of Health
Christine Groothues
Helmut Horten Foundation
Amanda Hawkins
Jacobs Foundation
Robert Kumsta
ESRC
Wolff Schlotz
MRC
Suzanne Stevens
&
Edmund Sonuga-Barke
Michael Rutter
THANK YOU!