In the communist era,
Romanian orphanages were the stuff of nightmares. Squalid sanitation, scant
food—above all, profound neglect: The little inmates of these institutions got
just minutes a day of close attention from caregivers.
With the fall of the
dictator Nicolae Ceaușescu in 1989, the gates of Romania opened and a flood of
adoptees came to England. To gauge their social and clinical needs, the British
government asked psychiatrist Sir Michael Rutter, a member of the Dana Alliance
for Brain Initiatives, to conduct a study.
“He saw a unique
opportunity for a prospective natural experiment,” says Edmund
Sonuga-Barke, professor of developmental psychopathology at King’s College
London and a principal investigator in the English
and Romanian Adoptee study (ERA). Prior
research had explored the effects of early emotional and social deprivation.
“What’s unique here is that we know the timing—when children went into the
institution, when they came out—and how severe the deprivation was,” he says.
tracked 165 Romanian children adopted into high-functioning English families,
and compared their neurodevelopmental, behavioral, and cognitive progress at 6,
11, and 15 years to 54 adoptees from well-run English and Irish institutions.
The Romanian adoptees were further divided into those who'd been
institutionalized for 6-43 months, and those whose stays had been shorter.
The children are grown
up now, and the project's
latest findings, based on assessments at 22-24 years and published in
January 2017 in the Lancet, are ground-breaking: the first large study
to observe the effects of severe childhood deprivation in young adulthood.
evaluations, the Romanian group had substantially more problems than their
English counterparts. Their IQs were much lower initially. Autistic symptoms
were widespread; 10 percent met diagnostic criteria for autism spectrum
disorder (ASD). Many had marked overactivity and attention deficits; in
adolescence, ADHD prevalence was four times higher in Romanian than English
adoptees. Generally, such deficits were marked only in the children who'd been
institutionalized for 6 months or longer.
In the latest
assessment, several patterns emerged, Sonuga-Barke says. "Cognitive
impairments normalized [improved to standard levels] even in the long-stay
adoptees—a unique finding, considering these kids started with IQs of
difficulties, however, persisted. Autistic symptoms remained severe in those
earlier diagnosed with ASD, and hadn’t resolved fully among others in the
Attention and overactivity
problems worsened; ADHD was now 7 times as prevalent in the Romanian as the
English group. "This goes against expectation," Sonuga-Barke observed.
"Typically, as children with ADHD go to adulthood, symptoms decrease
substantially. We saw an increase."
Most surprising, he
says, was the emergence of depression and anxiety symptoms. "They came
from out of the blue. Until adolescence, very few kids in the sample had
emotional problems." They were more common and severe in the over-6-month
group, and in adoptees with earlier attention or autistic-type symptoms.
The Romanian group,
accordingly, used more mental health services. Their educational attainments
were lower and unemployment rates higher.
These latest findings
are "fascinating and depressing," says Charles Nelson, professor of
pediatrics at Harvard University. "Many of these kids are still having the
same problems they had in early life. Their persistence into adulthood is
intriguing scientifically, but from a humane perspective, really sad."
The brain on
When the study
started, Sonuga-Barke says, "everyone was thinking about maladaptive
behaviors, learned in the institution, that would resolve in a very enriched
environment." That problems persist into young adulthood, he says, argues
"a deep-seated, neurobiological basis.
"What we've done
is reframed the potential causes of neurodevelopmental disorders, suggesting
that they are not all genetically driven but can follow environmental routes,
and can be more persistent."
Now, Sonuga-Barke says,
his group is beginning to explore the neurobiology that may underlie these
Data on such questions
has emerged from another study of children from Romanian orphanages, begun about
a decade after ERA when conditions were no longer so dire.
The Bucharest Early
Intervention Project (BEIP) is a randomized clinical trial: 136 children,
age 6 to 31 months, were assigned to live in foster families that received
training and support, or to remain in their institutions. The control group were
children reared in their biological families.
"We wanted to see
the extent to which the hazards children encountered due to psychosocial
deprivation could be ameliorated by placement in a better environment," says Nelson, principal investigator for the project
The researchers looked
at some of the same behavioral and psychological parameters as the ERA. In
addition, they tracked structural and functional brain development via EEG and,
later, MRI. "This had never been done before" in a similar
longitudinal study, Nelson says. "It gets closer to the mechanism."
One of the most
interesting variables was the age when the children were placed in foster care.
"We thought we'd find critical periods, but were a little surprised at how
strong they were," he says.
For example, in
cognitive, social and emotional development, those placed before the age of two
were virtually indistinguishable from the never-institutionalized group, while
those placed later had significantly more problems at 54 months and had
recovered little by 10-12 years.
As for brain
development, research published in Developmental and Cognitive Neuroscience in 2016 reported EEG
abnormalities, initially, in institutionalized children compared with controls.
But by age 12, EEG had largely returned to standard levels among children in
foster care, especially those placed early.
MRI studies at age
8-10 found reduced white matter volume in children who had been in an
institution. The gap was less for the foster care group.
carries information from one brain region to another; its structural integrity
may be more important than volume," Nelson says. As he and colleagues reported
in a 2017 Neuroscience paper, white
matter microstructure had largely normalized by age 8-10 among children in
foster care only. Among the areas where the intervention apparently improved
white matter development were circuits associated with anxiety and depression
symptoms. At age 12-14 years, such symptoms were linked to abnormal
microstructure in these circuits.
Looking into cells
Lifelong health is also
jeopardized by deprivation, suggests BEIP research reported in 2016 in
Psychiatry Research. Compared with controls and children placed in
foster care, those who remained institutionalized showed accelerated telomere
The telomere, a cap on the chromosome, grows
progressively shorter over the lifespan. "Many think [excessive]
shortening correlates with poorer health outcomes," Nelson says.
Other factors enter:
psychological problems associated with deprivation may predispose to risky
health behaviors; markers of inflammation and disordered glucose metabolism are
higher in institutionalized children.
"We'd better pay
attention to their health as these kids grow older," Nelson says.
Both the BEIP and ERA researchers have been
investigating cell-level changes to better understand processes underlying the
response to severe deprivation. While most children show damage, some do not.
In the ERA, 20 percent of the highest risk group, those institutionalized for
more than 6 months, had no difficulties at any assessment, childhood to early
Their resilience may
be explained, at least in part, genetically. One candidate is the serotonin
transporter gene, which has been linked to the modulation of stress and to
In the BEIP, children
who carried one or two short alleles of this gene responded most strongly to
their environment and to the intervention; placement in foster care was
more effective for them, compared with children with two long alleles.
In the ERA, similarly,
carriers of the short
allele manifested the most emotional problems after severe deprivation,
while those with two long alleles had least. ERA researchers are pursuing
genetic differences more broadly, with whole genome scans, Sonuga-Barke says.
Genetics does not
exclude other factors, such as treatment within the institution. A child with a
particularly attractive personality, for example, might have received better
care. Life stresses may also modulate response, both studies suggest.
mechanisms underlying deprivation effects, both groups have focused on
epigenetics. The ERA found methylation
changes that might affect expression of a gene putatively linked to
emotional symptoms. BEIP researchers identified epigenetic
variations in a gene associated with the stress response. The two teams
plan a joint project, pooling data to further explore this area.
multiple layers learned from these two studies," says Megan Gunnar,
director of the Institute of Child Development at University of Minnesota, who
has worked extensively with international adoptees. "It’s all about
relationships. Dynamic back-and-forth interactions allow the child's brain to
Levels of biological
stress in infants and young children are regulated by their relationship with
one or two other people. "In an institution, you remove that protective
system,” she says.
“In a supportive
relationship all the physical and cognitive stimulation the baby needs will be
there," she adds. These studies show what happens when you take that away.
The high percentage of Romanian adoptees who showed
autistic traits “raises interesting questions about the neurobiology of autism;
it suggests a final common pathway for genetics and deprivation,” she says.
The relative lack of emotional problems before
adolescence "speaks to the profound importance of parenting when young.
When the kids are older and the parental scaffolding is removed more and more,
they have to manage the world on their own, and need competencies that get
broken under conditions of early deprivation."
discovered in these studies is broadly applicable," Gunnar says. For one thing,
they help people understand why early experience matters.
kindergarten is far too late. In the BEIP, we see that kids who got out before
age two were able, by a number of indices, to make a good recovery.
“Earlier is better,” she says, “but these studies also
show the profound effects of improving the child's life at any point in