BRITISH JOURNAL OF PSYCHIATRY !2001), 179, 97^103

Specificity and heterogeneity in children's selected at random from within bands stratified according to age of entry to the responses to profound institutional privation{{ UK, and a comparison group of 52 non- deprived within-UK adoptees placed before the age of 6 months for details see Rutter MICHAEL L. RUTTER, JANA M. KREPPNER and THOMAS G. O'CONNOR et aletal, 1998,1998).). Of these, 156 children from on behalf of the English and Romanian Adoptees $ERA) study team* Romania and 50 within-UK adoptees had complete data-sets and were used for analyses where these were required. Four- fifths of the Romanian adoptees had been reared in institutions for most of their life and nearly all had been admitted to Background The sequelae of Studies of children suffering profound institutions in the neonatal period mean profound early privation are varied. institutional privation in infancy and early age of admission was 0.34 months). The childhood have shown that it results in major conditions in the Romanian institutions Aims Todelineate the behavioural developmental impairment, that there is were generally extremely bad see Kaler & patterns that are specifically associated considerable developmental catch-up follow- Freeman, 1994;Castle et aletal, 1999;Johnson, ingingadoption into well-functioning families, 2001);and the condition of most of the with institutional privation. and that there are clinically significantficantsigni children on arrival in the UK was also very MethodMethod A group of165 children sequelae in some of the children Chisholm poor. Their mean weight was 2.4 standard et aletal, 1995;Ames, 1997;Fisher et aletal, 1997;,1997; deviations below the mean with over half adopted from Romania before the age Chisholm, 1998;Rutter et aletal, 1998, 2001; below the third percentile) and the retro- of 42 months were compared at 4 years O'ConnorO'Connor et aletal, 2000). However, the studies spectively administered) Denver scale and 6 years with 52 non-deprived UK also show that, at least in relation to specific produced a mean quotient of 63, with children adoptedininfancy.Dysfunctionadoptedin infancy.Dysfunction outcomes, there is considerable hetero- three-fifths functioning in the severely retarded range. By the time the children was assessed for seven domains of geneity in response. Thus, in our own study, for children who experienced at least 2 years reached the age of 4 years substantial functioning.The groups were compared of institutional privation in infancy, the catch-upcatch-uphadhad occurred, with the mean on which, and how many, domains were measured IQ scores at 6 years ranged from weight and Denver quotient both being impaired.impaired. the severely retarded range to high superior nearnearnormalnormal for UK children Rutter et aletal,, O'ConnorO'Connor et aletal, 2000). Because the pub- 1998). Eighty-one per cent of the adoptive ResultsResults Attachment problems, lished reports all consider outcomes in re- parents of Romanian children who were inattention/overactivity, quasi-autistic lation to specific impairments, it is not approached to participate in the study features and cognitive impairment known whether thechildren who fare well agreed to do so. on one type of outcome also fare well on were associated withinstitutionalwith institutional others. It is necessaryto determine the privation, but emotional difficulties, poor extent to which impairments tend to be peer relationships and conduct problems pervasive across domains and to ask what MeasuresMeasures were not.Nevertheless, one-fifth of proportion of profoundly deprived children The assessments at age 6 years comprised a achieves generally normalpsychological children who spentthe longesttime in standardised investigator-based interview functioning. Equally, it is not knownknown that included among other things) institutions showed normal functioning. whether profound institutional privation systematic questions on attachment dis- results in a general increase in all forms of order behaviours O'Connor et aletal, 1999,,1999, Conclusions Attachment disorder psychopathology or whether there are cer- 2001), completion of parent and teacher behaviours, inattention/overactivity and tain behavioural patterns or syndromes that versions of the Rutter behavioural scales quasi-autistic behaviour constitute are particularly strongly associated with early Elander & Rutter, 1996;Hogg et aletal,, institutional privation patterns. privation. The aim of this investigation was 1997) and individually administered to use findings from a follow-up study to McCarthy Scales of Children's Abilities Declaration of interest The age 6 years) of institution-reared Romanian McCarthy, 1972). In order to assess poss- research was supported by funds from children who were adopted into UK ible autistic features, the parents completed the Department of Health, the Medical families to answer these questions on speci- the Autism Screening Questionnaire ASQ; ficity and heterogeneity in children's re- BerumentBerument et aletal, 1999). In addition, the Research Council and the Helmut Horten sponses to profound institutional privation. Autism Diagnostic Interview ± Revised Foundation.Foundation. ADI±R;Le Couteur et aletal, 1989;Lord etet alal, 1994) was given by a researcher experi- METHOD enced in its use M.L.R.) when parental interview reports suggested the possibility Subjects *Celia Beckett,Jenny Castle,Carla Croft,Judy Dunn and of autistic features see Rutter et aletal, 1999).,1999). Christine Groothues. The sample comprised 165 children adopted In order to obtain a categorical measure {{See editorial, pp.93^94, thisissue. from Romania before the age of 42 months, of probable dysfunction in each of seven

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specific domains of functioning, the data and often complains of aches and pains Conduct problems were dealt with as follows. see HoggseeHogg et aletal, 1997). These were dealt The scores on the Rutter parents' and with according to the distribution of scores teachers' scales were standardised as for Attachment problems in the within-UK adoptees sample. Children hyperactivity and emotional difficulties. with scores in the top 5% on either or both The conduct items were: often destroys Three items from the parental interview ± of the parents' and teachers' scales were own or others' property;frequently fights definite lack of differentiation between treated as having emotional difficulties. or is extremely quarrelsome with other adults;clear indication that the child would children;is often disobedient;often tells readily go off with a stranger;and definite lies;has stolen thingsthings on on one one or or more more lack of checking back with the parent in Autistic features occasions in the past 12 months;disturbs anxiety-provoking situations ± were scored other children;bullies other children; as 0 for `no abnormality', 1 for `probable Using the ASQ and the ADI±R, 20 children blames others for things;is inconsiderate problem' and 2 for `definite problem'. were diagnosed as showing quasi-autistic of others;kicks, bites other children see These were summated to produce a com- features Rutter et aletal, 1999). As this HoggHogg et aletal, 1997).,1997).Children who scored posite score ranging from 0 to 6, and a provided the combination of total screening in the top 5% of scores in the UK sample cut-off of 4 or more was used to indicate coverage of both groups and individual distribution on either scale were categorised dysfunction. diagnoses, this categorisation was used. as showing conduct problems.

Inattention/overactivity Cognitive impairment The Rutter scales completed by mothers The general cognitive index GCI) of the and fathers were standardised and then McCarthy Scales was used as the measure. averaged to produce a single parent score Children who scored at least 2 standard Statistical analysis see Kreppner et aletal, 2001). The teachers' deviations below the UK sample's mean Between-group differences in the pro- scale was similarly standardised. The were treated as showing cognitive impair- inattention/overactivity items on the portion of children showing dysfunction ment. The UK sample mean was 117, with on each of the seven domains were examined parents' scale were: very restless, has a standard deviation of 18. Twice the difficulty staying seated for long;squirmy, using Fisher's two-tailed exact test and one standard deviation 36) subtracted from degree of freedom. Within-group differ- fidgety child;cannot settle to anything for 117 equated to a score of 81;accordingly more than a few moments and inattentive; ences according to age of entry to the UK all children with an IQ of 81 or less were were examined for a linear trend on a chi and easily distracted. The teachers' scale included in this domain of dysfunction. included all the preceding items plus: square comparing entry at under 6 months, excessive demands for teacher's attention; 6±24 months, and over 24 months nnˆ58,58, 59 and 48 respectively). Polychoric corre- and fails to finish things started ± short Peer difficulties attention span. Using the distribution of lations were used to examine the associ- scores in the within-UK adoptees sample, Peer difficulties were assessed through a ation among the binary domains of three categories were created for the combination of the Rutter parents' and dysfunction variables. parents' and teachers' scales separately with teachers' scales, together with nine items Cluster analysis was used to examine a score of 0 for a score below the median, 1 from the parental interview. The three the ways in which children in the Romanian for a score between the median and the top items in the parents' scale were `not much adoptees sample showed similarities in their 10% cut-off, and 2 for a score in the top liked by other children', `tends to be patterns of dysfunction. The technique is 10% of the range. Pervasive inattention/ solitary' and `does not get on well with valuable for grouping individuals according overactivity required a score of 2 on either other children'. The mother and father to shared patterns of psychopathology. The the parents' or teachers' scale and a score scales were combinedinto a parental seven dichotomous variables were cluster of 1 or 2 on the other scale. Children with composite, using the approach described analysed using Ward's method of agglom- a missing score on one scale were not for inattention/overactivity.inattention/overactivity. The three items eration based on squared Euclidean included in the `pervasive' category. in the teachers'scale were `not much liked distance Aldenderfer & Blashfield, 1988). by other children', `tends to be on own' A four-cluster solution was chosen based and `cannot work in a small peer group'. on coefficient of linkage, practical con- Emotional difficulties The nine parental interview items were: siderations such as sample size) and inter- The scores on the Rutter parents' and group play;differentiation between pretability. The cluster analyses were then teachers' scales were standardised in the children i.e. clear preferences, with one rerun using alternative indices of similarity same way as for hyperactivity. The emo- or more special friends);popularity;age in order to determine the consistency of tional difficulties items were: has had tears preference of peers;harmony of peer inter- the cluster profiles. All approaches gave on arrival at school or has refused to go action;teased by other children;teases patterns closely similar to those displayed into the building in the past 12 months; others;picked on/bullied;and picks on/ in Fig. 1. As an additional check, cluster gives up easily;often worried, worries bullies others. Peer group difficulties were analyses were repeated using continuously about many things;often appears miser- regarded as present if the score on any of distributed dimensions, rather than binary able, unhappy, tearful or distressed;cries the three measures was in the top most categories, again with similar findings easily;tends to be fearful or afraid of new deviant) 5% of the distribution for the UK further details available from the authors things or new situations;stares into space sample.sample. upon request).

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groups, however, was evident in the pres- ence or absence of any dysfunction, rather than in the pervasiveness of dysfunction across domains. What characterised the Romanian adoptees sample were the particular domains involved in the pervasive dysfunction pattern. Almost always, this involved some admix- ture of attachment problems, inattention/ overactivity and quasi-autistic problems. In contrast, in the UK sample pervasive impair- ment usually involved either conduct or emotional disturbance plus another problem, but not one of the patterns that was distinc- tive of thethetive institutional privation children. Of the 40 children in the Romanian Fig. 11Fig. Percentage extreme score across seven outcomes according to cluster membership. adoptees group who showed impairment on just one domain, 13 did so on attachment RESULTSRESULTS Table 2 summarises the findings on problems, 11 on inattention/overactivity, 7 the number of domains showing dys- on peer difficulties and 6 on cognitive Of the seven domains of dysfunction function in the two groups, together with impairment with only an additional 3 on when the children were aged 6 years, three the association with age at entry within the other domains). Of the 6 children in the emotional problems, peer difficulties and Romanian sample. As would be expected within-UK adoptees group with impair- conduct problems) showed no difference in any general population sample, a sub- ment on just one domain, 2 showed it on in rate between the adoptees from Romania stantial minority of the UK adoptees emotional difficulties, 2 on inattention/ and the within-UK adoptees Table 1). For showed dysfunctiondysfunction in at least one overactivity, 1 on conduct problems and 1 each of these three domains, there was no domain. Less than four-fifths were free of on attachment problems. association, within the Romanian adoptees dysfunction on any domain.Nevertheless, Table 3 presents the polychoric corre- sample, with the children's age at the time dysfunction was substantially more likely lations among domains of dysfunction of entry to the UK. In sharp contrast, the to be present in the Romanian adoptees, within the Romanian adoptees sample. other four domains attachment problems, and the proportion without dysfunction The interTheintercorrelationscorrelations are no more than inattention/overactivity, quasi-autistic prob--prob on at least one domain was significantly moderate in most instances but there was lems and cognitive impairment) were all lower in those who came to the UK when a stronger correlation 0.66) between much more common in the Romanian they were older. Of those leaving Romania autistic features and cognitive impairment sample and, in each case, there was a signi- after their second birthday, between a fifth and between autistic features and peer ficant association with age at entry, the rate and a quarter were free of any measurable difficulties 0.59). Cognitive impairment of problems being much higher in those dysfunction at 6 years of age. The trend showed a near-zero correlationcorrela withtionwith who left Romania when they were older. for more dysfunction, and more pervasive emotional difficulties and with conduct The implication is that the former three dysfunction, in Romanian adoptees and problems. Attachment problems had their domains are not particularly associated for an association with age at entry was strongest correlation with inattention/over- with institutional privation, whereas the apparent at all levels of frequency of dys- activity 0.47). There were only 6 children latter four seem to be. function. The main difference between the in the Romanian sample with emotional

TaTable b l e 1 Seven domains of dysfunction at 6 years of age in Romanian and within-UK adopted children

DomainsRate in Romanian Rate in within-UK Between-group Association with age adoptees adoptees differences at entry to UK

%% nn %% nn Fisher's exact PP $two-tailed)$two-tailed) ww22 trendstrends PP

Attachment problems 20.7164 3.852 0.003 11.130.001 0.00 1 Inattention/overactivity 25.3162 9.652 0.019 9.040.003 Emotional difficulties 3.7 162162 9.652 NS 0.03NS Quasi-autistic features 12.1165 0.052 0.005 4.610.032 Cognitive impairment 14.0157 2.0 5050 0.018 14.610.001 Peer difficulties 18.9164 9.652 NS 0.450.45NS Conduct problems 8.0162 9.652 NS 0.97NS

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TaTable b l e 2 Romanian and within-UK adopted children: percentages of children with with impairment impairment in in 0, 0, 1, 1, 2 2 or or 3 3 or or more more domains domains

Number of domains in which Within-UK Romanian adoptees, age at entry into UK ww22 trendstrends PP there is impairment adoptees $$nnˆ50)50) 556 months $$6months nnˆ56)6^24 months $nnˆ35)24^42 months $nnˆ45)45)

0$nnˆ112) $%) 78.0 69.6 43.6 23.9 34.810.001 1$nnˆ46) $%) 12.0 17.9 23.6 37.0 19.790.002 2$nnˆ20) $%)20)$%) 2.02.0 7.1 12.7 17.4 9.750.002 3ormore$nnˆ28) $%)28)$%) 8.0 5.4 20.0 21.7 6.730.009

TaTable b l e 3 Polychoric correlation among domains of dysfunction in Romanian adoptee sample DISCUSSION Escape from dysfunction AttachmentAttachment Inattention/ EmotionalEmotional Autistic CognitiveCognitive Peer In order to determine whether children who problems overactivity difficulties features impairment difficulties experience prolonged early institutional privation could nevertheless show normal Attachment problems psychological function at age 6 years, Inattention/overactivity0.47 several years after leaving the depriving Emotional difficulties0.16 0.16 0.29 environment and after being adopted into Autistic features 0.250.24 0.81 generally well-functioning adoptive homes, Cognitive impairment0.20 0.260.26 0.050.050.66 we assessed dysfunction across seven differ- Peer difficulties 0.30 0.480.480.39 0.59 0.470.47 ent domains that were relevant at that age, Conduct problems 0.380.49 0.46 0.36 0.03 0.68 occurred with a reasonable frequency and could be assessed with reasonable Correlations based on dichotomous variables; nnˆ157.157. reliability. Normal functioning was defined according to the stringent criterion of no difficulties but 5 of these showed a quasi-aquasi- problems and inattention/overactivity abnormality on any of the seven domains. autistic pattern, giving rise to a high poly- apart from one child who also showed an As would be expected, over a fifth of the choric correlation. emotional difficulty). The mean age at children in the non-deprived within-UK Figure 1 shows the cluster analysis for entry was 10.3 months for cluster 2, 18.4 adoptee sample failed to show normal Romanian adoptees. The largest cluster months for cluster 1, 22.3 months for functioning on this very strict criterion. nnˆ74) was cluster 2, in which there was cluster 3 and 20.0 months for cluster 4.4.cluster Two findings stand out with respect to no dysfunction on any of the seven The only significant contrast was thatthat the Romanian sample. First, the proportion domains Table 4). Cluster 1 was the one between cluster 2 and the other three with normal functioning among those who with the greatest pervasiveness of dysfunc- clusters. The effect of age at entry was left Romania before the age of 6 months tion, with about half of the children or similarly shown in the trend across the three was nearly as high 70%) as in the within- more) showing difficulties in attachment, age-age-at-entryat-entry groups. Thus, the proportion UK adopted sample. Second, even among inattention/overactivity,inattention/overactivity, peer relationships in the late-placed group over 2 years) was the children who were over the age of 2 and conduct.A few also showed quasi- 15% in cluster 2, compared with 38% in years when they left Romania, between a autistic featuresor cognitive impairment. cluster 1, with 52% in cluster 3 and with fifth and a quarter showed normal func- Cluster 3 is largelydefined by the presence 39% in cluster 4. tioning on all seven domains. It is some- of both quasi-autisticquasi-autistic features and cog- There were no gender differences among times supposed that lasting damage is nitive impairment.Cluster 4 comprised thethesevenseven domains or among the four inevitable after prolonged early institutional children who showed only attachment clusters.clusters. privation, but our results run counter to

TaTable b l e 4 Associations between clusters and domains impaired

Cluster DomainsDomains Mean no. of domains impaired per child AttachmentAttachment Inattention/ EmotionalEmotional Autistic Cognitive Peer ConductConduct problems overactivity difficulties features impairment difficulties problems

2$nnˆ74) 000 0000000000000.0.0 1$nnˆ29) 13 17 171 766225512 2.79 3$nnˆ23)23) 161 644113316 616 122.04.04 4$nnˆ31)31) 20 18 101 0000000 1.25

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that view. The chances of normal social between groups fell short of statistical was not the key risk factor further details functioning were substantially less the older significance.The finding that none of these available from the authors upon request). the child was at the time of leaving the three domainsof dysfunction showed any The finding that inattention/overactivity is institution, but some of the children who association with the children's age at entry also commonin children reared in group had the most long-lasting privation to thetotheUK also indicates that it is unlikely homes within the UK, where nutritional appeared to be functioning entirely that these particular areas of problem at 6 privation is not an issue, suggests that it normally by the age of 6 years. Of course, years of age were consequences of the may well be the psychological features of it would be wrong to suppose that there children's early institutional experiences. the institutional environment that are more are no scars and it is possible that there The children are too young for any firm important Roy et aletal, 2000). It remains to may be sequelae that become evident only conclusions with respect to late sequelae be determined whether the clinical picture at a later age. Nevertheless, the degree of but, at least up to the age of 6 years, these of inattention/overactivity in these children resilience shown was remarkable. Because do not seem to be a particular consequence is the same asin more `ordinary' varieties of our sample extended only up to an age of of the depriving institutional upbringing. attention-deficit or hyperkinetic disorders, entry of 42 months, we can draw no Accordingly,if such problems occur in and a follow-up study that is now in pro- conclusions on whether or not there is an young institution-rearedinstitution-reared children, they gress should throw light on this point. age at which recovery becomes extremely may arise for reasons that have little to do Meanwhile, the evidence suggests that the unlikely. Extrapolation from the linear with their early adverse upbringing. How- problems may lie more in dealing with social trends found on all analyses suggests that ever, this mightchange in later childhood group situations than with overactivity as the chance of normal functioning diminishes and adolescence, when the situations with such.such. progressively the older the child at the time respectrespecttoto both emotional disturbance and The third pattern particularly associ- when profound privation comes to an end, peer relationships are different. ated with a background of institutional but it is not known whether ± or when ± Although there was no single pattern privation was that of quasi-autistic features. that chance eventually ceases to exist. that characterised children who experienced Again, this appears surprising at first sight The findings on pervasiveness of dys- institutional privation, three main features because of the evidence that autism as diag- function make the additional point that, stood out, occurring both on their own nosed in children from more ordinary back- of the children showing some form of and in varying combinations. First, there grounds involves a strong genetic influence, impairment, nearly half showed impair- were attachment disturbances of various with little evidence of psychosocial features ment on only one domain, and only just kinds O'Connor et aletal, 1999, 2001). These playing a part in the causal process Rutter, over a quarter showed impairment on at were particularly characterised by a 2000). The clinical picture in the sample least three domains. Even within the group relatively undiscriminating social approach, of Romanian adoptees was, however, of children who were over the age of 2 a seeming lack of awareness of social somewhat different from that characteristic years when they arrived in the UK, only just boundaries and a difficulty in picking up of `ordinary' autism with respect to the over a fifth showed pervasive dysfunction social cues on what is socially appropriate tendency to improve between the ages of of that extent. or acceptable to other people. This is a 4 and 6 years and the extent of social pattern also identified in a parallel approach Rutter et aletal, 1999).,1999). Canadian study of adoptees from Romania Institutional privation was quite ChisholmChisholm et aletal, 1995;Chisholm, 1998). strongly associated with cognitive impair- Specificity of sequelae Second, there was the pattern of in- ment Rutter et aletal, 1998, 2000;O'Connor of institutional privation attention/overactivity. Of the 41 children et aletal, 2000). In 6 of the 22 children showing Across a large number of studies, the in the Romanian sample who showed this cognitive impairment, this occurred without relative non-specificity of the patterns of behaviour, nearly half 16) showed it in dysfunction on any of the other domains. psychopathology associated with psycho- association with attachment problems, but It was, however, much more common for it social stresses and adversity has been the 11 children showed only inattention/ to be accompanied by either quasi-autisticautisticquasi- general finding Rutter, 2001). Thus, overactivity and 8 showed it in association patterns present in 10 out of the 20 negative life events carrying long-term with quasi-autistic behaviour in 4 of the 8 children and in some cases with dysfunction threatthreathavehave been associated with a wide cases also with attachment problems). in other domains as well) or with attach- rangerangeofof psychiatric disorders Brown & Attention-deficit and hyperkinetic disorders mentmentdisturbancesdisturbances 7 children). At the age Harris,1989;Goodyer, 1990), and the same have usually been thought of as psychiatric of 6 years, there was nothing particularly appliesappliesto the experience of physical and conditions that are strongly influenced by distinctive about the patterns of impair- sexual abuse Kendall-Tackett et aletal, 1993;,1993; genetic factors, with psychosocial influences ment but distinctive features may be more Trickett & McBridge-Chang, 1995). playing only a subsidiary role in aetiology evident at age 11 years, when the children Accordingly, it might have been expected Taylor, 1994,1999). It is striking, there- are to be seen again. With the Romanian that prolonged institutional privation fore, that this has emerged as one of the adoptee sample, it is also noteworthy that would be associated with a general increase patterns most strongly associated with inattention/overactivity was more strongly in all forms of psychopathology. However, prolonged institutional privation. It could associated with attachment problems 17/ that is not what we found. Strikingly, there be, of course, that the key causal influence 41 cases) than with cognitive impairment was no increase in either emotional or derived from nutritional privation rather 7/41). Moreover, of these 7 children charac- conduct problems, and although the rate than psychological privation in the institu- terised by inattention/overactivity and cogni- of peer difficulties was twice as high in tions. On the other hand, more detailed tive impairment, 5 also showed attachment the Romanian adoptees, the difference analysesanalysessuggestsuggest that nutritional privation disturbance.

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In summary, profound institutional privation was particularly associated with CLINICAL IMPLICATIONS patterns involving attachment disturbance, inattention/overactivity, quasi-autistic fea- && Profound early institutional privation tends tends to to be be particularly particularly associated associated with with tures and cognitive impairment in varying attachment disorder behaviours, inattention/overactivity $especially when combinations, but it was not associated associated with attachment disturbances) and quasi-autistic behaviour. with any marked general increase in other forms of psychopathology. There is a need && Such privation is not followed by a significant increase in conduct problems, for more detailed study of these psycho- emotional disturbance or peer relationship difficulties other than in the context of pathological patterns;in the meantime, institutional privation patterns $see first implication), at least by age 6 years. clinicians need to be alert to their occur- rence and to the possibility that these && Profound institutional privation from infancy to age 3 years is still compatible with patterns derive from early institutional normal psychological functioning provided that the child has experienced several privation. It is important, too, that effective years in a good adoptive family. methods of intervention should be devel- oped for these privation-related problems LIMITATIONS RutterRutter et aletal, 2000).,2000). && So far, the children have been followed only up to the age of 6 years.

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