Normality and Impairment Following Profound Early Institutional
Deprivation: A Longitudinal Follow-Up Into Early Adolescence
Jana M. Kreppner, Michael Rutter, Celia Beckett,
Jenny Castle, Emma Colvert, Christine Groothues,
and Amanda Hawkins
King’s College London
Thomas G. O’Connor
University of Rochester
Suzanne Stevens and Edmund J. S. Sonuga-Barke
King’s College London and University of Southampton
Longitudinal analyses on normal versus impaired functioning across 7 domains were conducted in
children who had experienced profound institutional deprivation up to the age of 42 months and were
adopted from Romania into U.K. families. Comparisons were made with noninstitutionalized children
adopted from Romania and with nondeprived within-U.K. adoptees placed before the age of 6 months.
Specifically, the validity of the assessment, the degree of continuity and change in levels of functioning
from 6 to 11 years, and the factors in the pre- and postadoption environment accounting for heterogeneity
in outcome were examined. Pervasive impairment was significantly raised in children experiencing
institutional deprivation for ?6 months of life, with a minority within this group showing no impairment.
There was no additional significant effect of duration of deprivation beyond the 6-month cutoff, and few
other predictors explained outcome. The pattern of normality/impairment was mainly established by 6
years of age, with considerable continuity at the individual level between 6 and 11 years. The findings
are discussed in terms of the possibility of a sensitive period for development.
Keywords: early deprivation, sensitive period, psychological functioning
Supplemental materials: http://dx.doi.org/10.1037/0012-16126.96.36.1991.supp
Developmental theories provide several contrasting propositions
about what may be expected with respect to psychological change
and continuity when there is a radical change in the rearing
environment from very poor to generally good quality. Thus,
emphasis has been placed on people’s continuing responsivity to
the environment through the period of development in childhood
and adolescence and into adult life (Clarke & Clarke, 1976, 2000).
There is support for this view from the evidence that children
exposed to abuse and neglect can improve markedly in their
cognitive functioning after adoption in middle childhood into
well-functioning families (Duyme, Arseneault, & Dumaret, 2004;
Duyme, Dumaret, & Tomkiewicz, 1999). Long-term follow-ups
into adult life of seriously antisocial adolescents have similarly
shown important changes in adult life that appear responsive to
experiences during that age period (Laub & Sampson, 2003;
Sampson & Laub, 1993). Turning points for the better or the worse
can and do occur post childhood (Rutter, 1996).
By contrast, over recent years there has been a growing body of
evidence from both human and animal studies that, in some cir-
cumstances, seriously adverse experiences in very early childhood
can have enduring effects that may result from either a type of
biological programming of the brain during a sensitive period of
development or, alternatively, damage to neural structures (Bate-
son & Martin, 1999; Greenough & Black, 1992; Gunnar, Morison,
Chisholm, & Schuder, 2001; Hubel & Wiesel, 2005; McEwen &
Lasley, 2002; Meaney & Szyf, 2005; Parker, Nelson, & the Bu-
charest Early Intervention Project Core Group, 2005; Rutter,
2006c; Rutter et al., 2004; Weaver et al., 2004; Wismer Fries,
Ziegler, Kurian, Jacoris, & Pollak, 2005). This body of work does
not deny the effects of later experiences, but it does postulate
limitations. Although not spelled out in most writings, there ap-
pears to be an implicit assumption that the effects are universal. It
Jana M. Kreppner, Michael Rutter, Celia Beckett, Jenny Castle, Emma
Colvert, Christine Groothues, and Amanda Hawkins, Social, Genetic and
Developmental Psychiatry Research Centre, Institute of Psychiatry, King’s
College London, London, England; Thomas G. O’Connor, Department of
Psychiatry, University of Rochester; Suzanne Stevens and Edmund J. S.
Sonuga-Barke, Social, Genetic and Developmental Psychiatry Research
Centre, Institute of Psychiatry, King’s College London, and Developmental
Brain-Behaviour Unit, School of Psychology, University of Southampton,
The data collection phase of the study was supported by grants from the
Helmut Horten Foundation and the U.K. Department of Health. Ongoing
support is provided by grants from the Department of Health, the Nuffield
Foundation, and the Jacobs Foundation. We are most grateful to all the
families who have generously given their time to participate in this study
and whose comments and suggestions have been very helpful in the
interpretation of findings. We are glad to express our thanks to our external
advisory group, whose input has been invaluable. The views expressed in
this article are ours and do not necessarily represent those of the funders.
Correspondence concerning this article should be addressed to Jana M.
Kreppner, MRC SGDP Centre, PO 80, Institute of Psychiatry, King’s
College London, Denmark Hill, London SE5 8AF, United Kingdom.
2007, Vol. 43, No. 4, 931–946
Copyright 2007 by the American Psychological Association
should be noted, however, that despite attempts to generalize such
neural effects to all experiences in childhood (Gerhardt, 2004;
Schore, 1994), the research findings are explicit in showing that
this is not so (Bruer, 1999).
A third related developmental issue concerns the concept of
sensitive periods. During the 1960s, research into imprinting phe-
nomena in birds had led to the postulate of fixed immutable critical
periods in which later development was, in effect, “fixed” by
experiences in early life. Systematic studies cast serious doubt on
this notion (Bateson, 1966; Hinde, 1970), and the idea fell out of
fashion. However, research findings on biological programming
have shown that it would be mistaken to reject the phenomenon of
marked age-related variations in children’s responses to experi-
ences—variations that might reflect either differences in suscepti-
bility or in patterns of response. The former are illustrated by
reactions to hospital admission (Rutter, 1981), and the latter by the
effects of unilateral brain lesions on language functioning
(Vargha-Khadem, Isaacs, van der Werf, Robb, & Wilson, 1992).
Nevertheless, although the reality of sensitive periods is no longer
in doubt, very little is known about their limits, or about the
A fourth body of theory and research has focused on marked
variations in children’s responses to adversity—differences that
have given rise to the concept of resilience (Luthar, 2003; Luthar,
Cicchetti, & Becker, 2000; Rutter, 2006b, in press). Once more,
empirical research findings provide support. Both naturalistic and
experimental studies in humans and other animals have shown the
reality of huge individual differences in outcome following all
manner of environmental hazards. Genetic research in recent years
has shown that an important part of the mechanism involved
concerns gene–environment interaction (Moffitt, Caspi, & Rutter,
2006; Rutter, 2006a; Rutter, Moffitt, & Caspi, 2006; Stevens,
Sonuga-Barke, Asherson, Kreppner, & Rutter, 2006). However, it
is unlikely that this fully accounts for the variation.
In order to test these developmental propositions, some form of
natural experiment that pulls apart variables that ordinarily go
together is required (Rutter, 2007; Rutter, Pickles, Murray, &
Eaves, 2001). The fall of the Ceaus ¸escu regime in Romania in
1989, and the subsequent adoption into generally well-functioning
families of children who had spent their first few years in institu-
tions that were both severely understaffed and provided conditions
of extreme pervasive deprivation, provided such a natural experi-
ment (Rutter & the English and Romanian Adoptees [ERA] Study
Team, 1998). In order to fulfill the criteria of adequate natural
experiments, several conditions need to be met. First, there must be
a major discontinuity in qualities of the rearing environment, with
the change of environment both rapid and accurately timed. The
adoption of Romanian children clearly met that condition. In most
cases the children moved from the institution to their adoptive
home without any intervening change. In the institutions, most
children were confined to cribs or cots with high sides, had no
toys, had very little interaction with staff or other children, and
experienced impersonal feeding of gruel through propped-up bot-
tles with large teats and group washing by means of hosing down
with cold water (Castle et al., 1999; Children’s Health Care Col-
laborative Study Group, 1992; Reich, 1990). At the time of enter-
ing the United Kingdom, a high proportion of the children were
severely undernourished and developmentally delayed (Rutter &
the ERA Study Team, 1998), and many had infections and other
medical problems (Beckett et al., 2003). The findings on children
adopted from Romanian orphanages into families in the United
States and Canada were closely comparable (Ames, 1997; Benoit,
Jocelyn, Moddeman, & Embree, 1996; Fisher, Ames, Chisholm, &
Savoie, 1997; Johnson et al., 1992; Maclean, 2003; Morison,
Ames, & Chisholm, 1995). The quality of the adoptive families in
the United Kingdom is evident through the fact that they had to go
through a rigorous social service screening and approval process,
through the very low rate of subsequent adoption breakdown, and
through the more limited measures available on family functioning
(Castle et al., 2006; Colvert et al., in press; Rutter & the ERA
Study Team, 1998).
The second key condition is that social selection should be
minimal. A major limitation of most earlier studies of institution-
reared children is that serious biases arose from two different
sources. First, many children had been admitted into institutional
care after the early years, with the inevitable uncertainties over the
extent to which admission was influenced by the children’s own
handicaps or by difficulties that preceded institutional admission.
Second, whether or not children remained in the institution was
influenced to an important extent by their own qualities. The
consequence of these two biases is that there will be unavoidable
difficulties in determining which sequelae are due to institutional
experiences and which to individual features that preceded insti-
tutional admission or which influenced later adoption. Neither bias
applied to any marked extent in the case of adoptions from Ro-
manian institutions. In the vast majority of cases, institutional
admission had been in the early weeks of life, so far as is known
no children were adopted prior to 1989, and it was very rare for
children to leave institutional care to return to their biological
families, if this occurred at all (Rutter & the ERA Study Team,
Less is known about possible factors influencing the choice of
children by prospective adoptive parents. Romanian authorities
controlled which children could be considered for adoption, and
prospective parents had only limited choice. The adoption situation
was also highly unusual in that many parents were seeking to adopt
a child for altruistic motives stemming from compassion over the
terrible plight of the institutional children portrayed in the media,
rather than wanting a child as a solution to their infertility. Ac-
cordingly, it was evident that, although some parents sought to
choose a child whom they thought might develop well, others
deliberately chose children who were obviously suffering (Beckett
et al., 2006).
The third condition for an adequate natural experiment is that
longitudinal data should be available to determine within-
individual change over time, and not just between-group differ-
ences. This was provided in the U.K. study of Romanian adoptees
in which there are prospective data from age 4 to age 11 (with a
further assessment at age 15, which is currently under way; Beck-
ett et al., 2006; Rutter & the ERA Study Team, 1998). It was also
provided in the parallel Canadian studies (see Maclean, 2003). In
order that the longitudinal data should allow an adequate test of
developmental hypotheses, it is also necessary that attrition be
minimal and that the original sample was representative of the
population at risk. Both were so in the U.K. study.
The fourth condition is that the sample should include sufficient
variation for competing possible risk and protective factors to be
compared in a systematic fashion. The design of the English and
KREPPNER ET AL.
Romanian Adoptee (ERA) study was determined by the decision
to have as the main focus the possible importance of variations in
the age at which the children left institutional care. Random
sampling within age bands was used to provide a range extending
up to 42 months for the age of leaving institutions (see Rutter &
the ERA Study Team, 1998). Assessments at the time of U.K.
entry showed that the sample also varied in other important ways.
Thus, although the Romanian children as a group had a mean
weight far below normal—indicating gross subnutrition—not all
children were seriously undernourished. This provides the oppor-
tunity to contrast, for example, the prognostic importance of du-
ration of institutional care with that of level of subnutrition. Sim-
ilar variations applied to indices such as developmental level and
The overall background to the present research is provided by
findings on intercountry adoption (see Gunnar, van Dulmen, & the
International Adoption Project Team, 2007; Maclean, 2003; van
IJzendoorn & Juffer, 2006). As Maclean (2003) has pointed out,
research designs need to be shaped by the questions to be tackled,
and in particular, comparison groups need to be chosen with these
in mind. There is no one ideal comparison group that serves all
purposes. It is necessary, therefore, to be quite explicit on what the
ERA study was, and was not, designed to accomplish. As already
indicated, the main interest concerned the use of a natural exper-
iment to test competing developmental hypotheses with respect to
the long-term effects of early institutional deprivation. In order to
do that, a comparison group of adopted children who had not
experienced institutional deprivation was needed (the choice of
adoptees of a general population sample was determined by the
need to control for the possible effects of adoption). A sample of
within-U.K. adoptees who were placed before the age of 6 months
was chosen in order to achieve a best scenario adoption compar-
ison. It follows that this design means that the findings are not
informative on the quite different (but equally important) issues of
how the psychological development of adoptees compares with
that of nonadopted children, and of how this might vary according
to their age at adoption.
This article concentrates on the outcome at age 11 according to
the pervasiveness and persistence of malfunction across a wide
range of psychological domains. The focus on this issue was much
influenced by Luthar’s (Luthar, 2003; Luthar et al., 2000) astute
observation that conclusions about apparent resilience could be
misleading because the focus was on good functioning in some
areas, with a lack of attention to poor functioning in others. Her
arguments, like ours, include no assumption that the mediating
mechanisms will be the same for all outcomes. These are being
considered in other articles dealing with cognition (Beckett et al.,
2006), use of services (Castle et al., 2006), quasi-autistic patterns
(Rutter et al., 1999), disinhibited attachment (Rutter et al., 2007),
language (Croft et al., 2007), and inattention/overactivity
(Kreppner, O’Connor, Rutter, & the ERA Study Team, 2001).
Here, instead, the focus is on the broader issue of the extent to
which early depriving institutional rearing is compatible with
normal functioning at age 11 and the parallel question of which
features predispose to pervasive malfunction across several psy-
Thus, this article starts first with a critical examination of
whether “normal” functioning is indeed truly normal and whether
pervasive malfunction is truly pervasive and substantially handi-
capping. Having assessed the validity of both as adequately as
possible, we then turn to testing the four psychological theory
propositions that we described at the outset of the introduction.
Accordingly, the first hypothesis is that the outcome at age 11
should be strongly associated with the postadoption environment
because it had lasted for a much longer time than the preadoption
institutional deprivation. The second hypothesis is that biological
programming and neural damage in the early years will have
meant that the outcome at age 11 is largely determined by the early
institutional deprivation and that its effects will be enduring from
age 6 to age 11 with little influence from individual differences in
the postadoption environment. Conversely, if psychological devel-
opment were equally influenced by experiences at all age periods,
pre- and postadoption measures would have a significant impact
Based on a related body of research, the third developmental
proposition concerned the timing of a sensitive period. Therefore,
the third hypothesis states that the outcome at age 11 would be
strongly influenced by the timing of the move from the institu-
tional environment to the adoptive home. However, developmen-
talists such as Dennis (1973) and Kagan (1979) have presented
somewhat contrasting ideas on the effects of a sensitive period. On
the basis of rather limited evidence, Dennis (1973) proposed a
cutoff of 2 years—apparently based on the assumption that the
effects of institutional deprivation would be irreversible after that
age. Kagan (1979) suggested a somewhat similar age cutoff, but
with an entirely opposite set of expectations. He proposed that the
effects of deprivation that were confined to the first 2 years would
prove to be evanescent because children’s cognitive ability to
process their experience was so limited in infancy. Against this
background, we examined possible variations in outcome, not just
in terms of a 2-year cutoff but also in relation to other age cutoffs.
Finally, the fourth body of theory was concerned with the
marked variations in children’s responses to adversity. Accord-
ingly, the fourth hypothesis specifies the expectation of consider-
able heterogeneity of outcome but leaves open the question of the
influences fostering resilience.
We selected 165 Romanian children adopted before the age of
43 months from 324 children whose applications were legally
processed through the U.K. Department of Health and/or the Home
Office between February 1990 and September 1992. The sample
was stratified according to the age of the children at the time of
entry to the U.K. and was balanced for gender. The target was to
obtain 13 boys and 13 girls placed between 0 and 3 months of age
and 13 boys and 13 girls placed between 3 and 6 months of age.
For the older children, the target was to obtain 10 boys and 10 girls
for the age bands ranging from 6 to ?12, 12 to ?18, 18 to ?24,
24 to ?30, 30 to ?36, and 36 to 42 months. In the older age bands
(?24 months), the available numbers fell below target, and in
these circumstances we took all children into the sample. Overall,
81% of the parents of the Romaian adoptees who were approached
agreed to participate. A small number (n ? 21) of the 165 Roma-
nian children were adopted from family settings without having
experienced institutional rearing, albeit they had experienced
NORMALITY/IMPAIRMENT AFTER INSTITUTIONAL REARING
deprivation in many other respects (see O’Connor, Rutter, Beckett,
et al., 2000). Although the main focus in this article is on the 144
children who were reared from infancy in very depriving institu-
tions, the group of non-institution-reared Romanian children
serves as an additional comparison group as it allows for the direct
comparison between two groups of children from similar under-
privileged family backgrounds during the time period in question
but which differ in terms of specific risks associated with institu-
The Romanian children were compared with a group of 52
children born and adopted within the U.K. before the age of 6
months. None of the children in the within-U.K. adoptee group had
been exposed to early deprivation, neglect, or abuse. The choice
for this comparison group was on the grounds that it would be
possible to control for the experience of adoption per se and
rearing in above average homes without prior exposure to nutri-
tional and/or psychological deprivation. The families of the within-
U.K. adoptees were approached through a range of local authority
and voluntary adoption agencies. Because the ERA study was
supplied with names of within-U.K. adoptees from adoption agen-
cies only after they had contacted the families themselves and
obtained their agreement, we do not have exactly comparable
figures on the participation rate in that sample. It is estimated that
approximately half of the families approached agreed to partici-
For 193 of 217 (89%) children, data had been obtained at both
ages 6 and 11 for all seven areas of functioning (i.e., the outcome
measures). There were no differences in participation between the
within-U.K., institution-reared Romanian, and non-institution-
reared Romanian subgroups (i.e., 94%, 86%, and 88%, respec-
tively, participated). Across the entire sample, children with miss-
ing data did not differ from those without missing data in terms of
their gender (i.e., 33% of children with missing data were boys and
67% were girls; 52% of children without missing data were boys
and 48% were girls; Fisher exact test p ? .10) or adoptive family’s
social class (i.e., 85% of families in both groups had professional,
managerial, or other skilled, nonmanual occupations). The children
with missing data at 11 years of age but complete data on the seven
domains at 6 years of age (n ? 14) were no different from the
children with complete data at both ages in their rates of normality
and impairment at 6 years of age (i.e., 57% and 54%, respectively,
showed no impairment at 6 years). Within the Romanian sample,
there were no differences in terms of the children’s age at entry to
the U.K. between those with and those without missing data (i.e.,
mean ages of entry were 16 and 15 months, respectively).
Adoptive parents from both the Romanian and U.K. samples
were generally above average in their educational attainments,
although there was some spread (Beckett et al., 2006; Rutter et al.,
2004). Neither such variations nor the reasons for adoption (i.e.,
infertility or altruism) were significantly associated with outcomes
(O’Connor, Rutter, Beckett, et al., 2000), and they did not relate
significantly to our measure of normality and impairment at age
11. Most children had been placed in institutions in the first weeks
of life (the mean age of entry was 0.34 months, SD ? 1.26; see
Rutter & the ERA Study Team, 1998), making it unlikely that the
reason for their admission to institutions was manifest handicap. It
appeared from all reports that severe economic adversity played
the major role in the decision to place the children into institutional
care (Children’s Health Care Collaborative Study Group, 1992;
Reich, 1990; Rutter & the ERA Study Team, 1998).
There were 4 children in the institution-reared Romanian sample
and 1 child in the within-U.K. adoptee sample who presented
severe and pervasive impairment at the time of the research visits.
Because of the severity of their impairment, the standard battery of
assessments was unsuitable and was only administered in part.
These 5 cases were included in the first set of analyses, which
presented overall rates of normality and impairment. The rationale
for this was that for all 5 children there was a clinical diagnosis of
pervasive impairment. However, these 5 children were excluded
from all subsequent analyses dealing with individual areas of
impairment and analysis of heterogeneity in outcome.
Outcome Measures: Normality and Impairment
Seven domains of functioning were investigated, which are
described in detail in the online supplemental materials. These
were chosen on two main grounds. First, we included the four
patterns that, at age 6 years, were most strongly and specifically
associated with institutional deprivation—namely, cognitive im-
pairment, quasi-autistic patterns, inattention/overactivity, and dis-
inhibited attachment (Kreppner et al., 2001; O’Connor, Rutter,
Beckett, et al., 2000; O’Connor, Rutter, & the ERA Study Team,
2000; Rutter et al., 1999, 2007; Rutter, Kreppner, & O’Connor,
2001). These had also been evident in other studies of institution-
reared children (Goldfarb, 1945; Hodges & Tizard, 1989a, 1989b;
Maclean, 2003; Province & Lipton, 1962; Roy, Rutter, & Pickles,
2000, 2004; Skuse, 1984; Spitz, 1945; Wolkind, 1974). Second,
we included the three areas of psychopathology that have been
found to be most prevalent in general population studies—namely,
conduct, emotional, and peer relationship problems (Green,
McGinnity, Meltzer, Ford, & Goodman, 2005; Meltzer, Gatward,
Goodman, & Ford, 2000). It should be noted that these involve
substantial co-occurrence across domains (Agnold, Costello, &
Erkanli, 1999; Caron & Rutter, 1991). These seven domains cover
most of those that are common at age 11 and that give rise to
substantial impairment. We have not included features such as
stereotyped repetitive movements (Beckett et al., 2002), which are
commonly associated with institutional deprivation but do not
show strong persistence after leaving the institution and tend not to
be associated with major social impairment if there is no associ-
ation with malfunction in other domains. Equally, we have not
included psychopathological patterns such as eating disorders or
schizophrenia that are of major clinical importance at later age
periods but are not common at age 11.
Criteria for when impairment existed were set in accordance to
two conditions. First, it was important to determine the cutoff for
impairment for all measures in a way that allowed for comparisons
across ages. Second, it was necessary to determine the cutoff
criteria in a way that allowed for comparisons across domains.
Thus, across all measures the 85th (or 15th) percentile was chosen
as the cutoff for impairment. The only exception was for quasi-
autistic features, where clinical diagnosis was the criterion. Nor-
mality was present when a child did not reach cutoff in any of the
seven domains. Multiple impairments were defined by a child
reaching cutoff in two or more of the seven domains of functioning
KREPPNER ET AL.
(more details on the seven measures are provided in the online
Validation Measures: Service Use
Parents were asked to provide information on whether or not
mental health professionals were consulted for the adopted child
(Castle et al., 2006). If so, information was provided on what type
of diagnoses was given, how many consultations or sessions took
place, whether medication was prescribed, and whether parents felt
that there was improvement. We considered two or more mental
health sessions to be a meaningful validation of an existent prob-
lem. There was a comparable assessment of special educational
provision in either mainstream or special schools (see Castle et al.,
2006). Major provision was categorized as present if, up to the age
of 11 years, the child had attended a special school, had received
a formal statement of recognized educational needs (resulting in
substantial extra individual help in an ordinary school), or had
been held back a year.
Explanatory and Predictor Variables
Duration of deprivation.
by a continuous measure of the children’s age (in months) when
they entered the U.K. (for the Romanian adoptees). In addition,
duration of deprivation was expressed in categorical terms, with
one group of Romanian children having been adopted below 6
months of age (Romanian 0 to ?6), a second that was adopted
between 6 and under 24 months (Romanian 6 to ?24), and a third
that was adopted at 24 up to 42 months (Romanian ?24). With the
latter categorical variable, group comparison was possible with the
within-U.K. adoptees, who were all placed with their families
before the age of 6 months (within-U.K. 0 to ?6) and with the
non-institution-reared Romanian sample. We employed an addi-
tional measure of actual time spent in institutions expressed in
months. Although this measure was highly correlated with age at
entry to the U.K. (Pearson’s r ? .94, p ? .001, n ? 144), it was
meaningful to include it in our analyses as a few children were
removed from an institution and lived with their prospective adop-
tive U.K. families in Romania for some weeks before entry to the
U.K. was cleared. In addition, some of the children who were
mainly reared in institutions had some periods of family care (i.e.,
80 of 144 had spent their entire life in institutions prior to adoption,
53 of 144 had spent more than half their life in institutions, and
only 11 of 144 had been in institutions for less than half their life).
Quality of care in the institutions.
care in the institution(s) was assessed through the parental inter-
view at the time of the first visit to the family (i.e., either at age 4
or age 6). Adoptive parents were asked to describe the conditions
in the institution in which the child they adopted had been living.
Their responses were coded on a 4-point scale: very poor ?
frequent change of staff and/or individual care strongly discour-
aged, poor ? some individual care but frequent staff changes,
adequate ? child predominately cared for by same person, and
good ? individual care by the same person (note that none of the
institution-reared children received a rating of good).
Obstetric problems and birth weight.
interview with the adoptive parent provided information on obstetric
and birth difficulties. Obstetric problems in the institution-reared
Duration of deprivation was indexed
The quality of individual
Specific items in the
Romanian sample were coded as present when there were confirmed
reports either that a child was born markedly prematurely (n ? 13),
the mother was known to have been an alcoholic (n ? 2), or the
mother experienced marked stress during pregnancy (n ? 2). Birth
weight was derived from a combination of reports from adoptive
parents and where possible from independent records (i.e., intercoun-
try adoption records). Low birth weight was categorized as less than
or equal to 2,500 g; this was chosen as a cutoff because of the poorer
standards of postnatal care that existed in Romania in the late 1980s.
Data on birth weight were available for 127 of the 144 institution-
reared children adopted from Romania.
Measures of children’s state at time of U.K. entry.
children’s weight at time of entry to the U.K. was used as an index
of the degree of subnourishment, and head circumference at the
time of entry was used because previous research has shown that
it is a reasonably good index of brain volume (Cooke, Lucas,
Yudkin, & Pryse-Davies, 1977; Wickett, Vernon, & Lee, 2000;
Winick, 1976). These physical measures were taken from assess-
ments carried out when the children arrived in the U.K. or as part
of the entry clearance process that involved assessments in Roma-
nia. The physical measures were entered into the Child Health
Growth Programme to assess the measures relative to population
norms (Boyce & Cole, 1993; based on Buckler, 1990). This metric
provides a continuous standardized measure of physical develop-
ment in terms of standard deviations above or below the U.K.
population norm for their age. Second, the degree of developmen-
tal delay at time of entry to the U.K. was assessed through the
Denver Developmental Scales (Frankenberg, Van Doornick,
Lidell, & Dick, 1986), which were completed retrospectively by
the parents at the time of the first assessment (at 4 or 6 years).
Further information on the reliability, validity, and assessment
strategy of these measures and their use in the present sample can
be found in O’Connor, Rutter, Beckett, et al. (2000) and Rutter and
the ERA Study Team (1998). Third, the child’s initial health at
arrival was also assessed through the interview with the adoptive
parent at the time of the first visit. Specific items in the interview
covered a range of potential health problems associated with
institutional care. Major health problems at time of placement
(present in 48 of 144 institution-reared children) included gastro-
intestinal, respiratory, and other health problems due to malnutri-
tion, and blood-borne viruses (see Beckett et al., 2003, for details).
Fourth, vocalization and language on arrival was assessed through
specific items on the language subscale of the Denver Scales (see
Croft et al., 2007). For children who were age 18 months or over
on arrival a distinction was made between those children who did
and those who did not imitate speech sounds or words with a
Measures indexing catch-up in physical development.
sures of head circumference and weight assessed at 6 years of age
expressed in standard deviations from the norm were used as
indices of degree of recovery from early institutional deprivation,
as substantial catch-up in physical development was reported in
the study sample following adoption (O’Connor, Rutter, Beckett,
et al., 2000; Rutter & the ERA Study Team, 1998).
Adoptive family risk.
Risk in the adoptive family was derived
from seven measures, which were each coded for presence or
absence of risk and subsequently summed to generate a composite
score (see online supplemental materials for details; also see
Colvert et al., in press). In brief, the measure comprised informa-
NORMALITY/IMPAIRMENT AFTER INSTITUTIONAL REARING
tion on whether or not adoptive mothers changed their partner, on
whether negativity and difficulties existed in the marriage, and on
adoptive parents’ mental health. Information was obtained through
parental reports based on questionnaire and interview assessments.
The composite measure was used both as a continuous measure
and in the form of a cutoff measure indexing whether or not risk
was present in the adoptive home.
Background of adoptive parents.
the mothers’ cognitive abilities using the National Adult Reading Test
(Nelson & Willison, 1994). This is a nonphonetic reading task of 50
words of increasing difficulty that is highly correlated with IQ (Bird,
Papadopoulou, Ricciardelli, Rossor, & Cipolotti, 2004). Details of the
adoptive parents’ educational qualifications were also gathered and
classified on the basis of a 3-point scale for fathers and mothers
combined: low ? neither mother nor father had a degree or profes-
sional qualification, medium ? at least one parent had university/
professional qualifications, and high ? both parents had a university
degree or professional qualification or above.
An assessment was made of
The procedures for the assessments at 6 years of age have been
reported in detail (see Kreppner et al., 2001; O’Connor, Rutter,
Beckett, et al., 2000; O’Connor, Rutter, & the ERA Study Team,
2000; Rutter, Kreppner, & O’Connor, 2001). The assessments of
parents and children when children were 11 years of age were con-
ducted in a similar fashion to the assessments at 6 years of age. In
brief, members of the research team contacted parents prior to the
child’s 11th birthday. Families who agreed to participate in the
follow-up phase at 11 years of age were visited at home on two
occasions. First, a comprehensive interview was conducted with the
primary caregiver, and a set of behavioral and family relationship
questionnaires was completed. Second, a formally trained researcher
conducted a comprehensive assessment of the child’s social, cogni-
tive, and physical development, including standardized cognitive and
neuropsychological testing, semistructured interviews, and behavioral
observation. In addition to the parental and child assessments, ques-
tionnaires were also sent to all children’s teachers to gain information
about their behavior and functioning at school.
Results are presented first in relation to the validation of our
measures of normality and multiple impairment, then in relation to
the psychological hypotheses laid out in the introduction.
Validity of Measures of Normality and Impairment
Validity was examined in two different ways. First, we em-
ployed information relating to professional service use in order to
test whether freedom from impairment was valid. Of the 40 chil-
dren in the institution-reared Romanian group who remained free
of impairment over time, only 1 child (2.5%) had received more
than one mental health session. There was only 1 child of the 40
(not the same one who had received more than one mental health
session) who received major educational provision. In contrast, of
the 29 institution-reared Romanian children who had persistent
multiple impairments, 22 (76%) had more than one session with
mental health professionals, 19 of whom were given a diagnosis
involving attachment difficulties, autism related difficulties, and/or
inattention/overactivity. Twenty-one children in this group re-
ceived major educational provision (18 of these 21 had also seen
mental health professionals more than once). The difference be-
tween the proportion of children who consulted a mental health
professional in the group remaining free of impairment and the
group with persisting multiple impairments was significant, n ?
1/40 (2.5%) versus n ? 22/29 (76%), Fisher exact test p ? .001.
The difference between the two groups in terms of the proportions
receiving major educational provision was also significant, 2.5%
versus 72%, Fisher exact test p ? .001.
A second test of validity was provided by means of a comparison
with typically developing children without problems in the general
population. We did this in two ways. First, where population norms
were available we compared the scores obtained in our normal-
functioning institution-reared sample with that of the population
norm. Second, we compared the mean scores of the institution-reared
children who were free of impairment at both time points against the
percentile ranks obtained from the distribution of scores within the
sample of within-U.K. adoptees who were free of impairment at both
time points, the latter being the most conservative comparison of
normality possible within our sample. The institution-reared children
who were free of impairment at both times had an average IQ of
100.65, with a score of 100 being representative of the population
norm. Their Social Communication Questionnaire (see Berument,
Rutter, Lord, Pickles, & Bailey, 1999; also Rutter, Bailey, & Lord,
2003) score was 2.76 and well below the cutoff of a score of 15. We
also calculated the total problem score from the Rutter Scales for
which cutoff criteria have been suggested (see Hogg, Rutter, &
Richman, 1997). The institution-reared children without impairment
had a mean total problem score reported by parents of 5.83 and
reported by teachers of 4.57. Again, both scores were well below the
suggested cutoffs of 11 and 9 for parents and teachers, respectively.
The mean scores from the Social Communication Questionnaire and
the total problems scale of the Rutter Scales for the institution-reared
children without impairments fell between the 50th and 75th percen-
tile ranks obtained from the distribution of scores in the problem-free
within-U.K. adoptee group (the differences between the mean scores
of the two groups were not statistically significant). The mean IQ
score of 100.7 of the problem-free institution-reared group fell be-
tween the 15th and 25th percentiles of the problem-free within-U.K.
adoptees’ distribution with a mean IQ of 108.9. The difference in
mean scores was significant, t(69) ? 2.64, p ? .05, although both
were within the normal range. There was also a difference between
the institution-reared children and the within-U.K. adoptees in terms
of disinhibited attachment, with the former showing slightly elevated
scores. Of the 40 problem-free institution-reared children, 6 (15%)
scored 1 or greater (but below the cutoff of 4) on a scale ranging from
0 to 6 compared with none of the within-U.K. adoptees (Fisher exact
test p ? .05). This is likely reflective of the fact that within the
institution-reared group, minor disinhibited attachment appeared to
have much the same meaning as marked disinhibited attachment,
whereas this was not so in the within-U.K. adopted sample (Rutter et
al., 2007). When we applied the less conservative criterion of being
compared the institution-reared problem-free group with the problem-
free within-U.K. adoptee group, the findings were essentially the
same as those presented above.
KREPPNER ET AL.
Is the Pattern of Multiple Impairments Exhibited by the
Institution-Reared Children Similar to or Different From
That of Other Noninstitutionally Deprived Groups?
An issue related to validity is the question of whether or not
multiple impairments had the same meaning in the institutionally
deprived and nondeprived groups. In order to make a meaningful
comparison between those children who had experienced prolonged
institutional deprivation and those who did not, and also to obtain a
representative number of children with multiple impairments in each
of these two groups, we pooled the nondeprived within-U.K. adoptees
with the non-institution-reared Romanian adoptees and the very early
(?6 months) adopted institutionalized Romanian adoptees (as it will
be shown in the following that these three groups did not differ
significantly from one another). We compared this group with the
pooled sample of the 6–42 months institutionally deprived children
on the possible patterns of overlap of impairments.
Three patterns of possible overlap of impairments at age 11
were examined. First, because institutional deprivation was asso-
ciated with specific behavioral disturbances including disinhibited
attachment (O’Connor, Rutter, Beckett, et al., 2000), quasi-autism
(Rutter & the ERA Study Team, 1998), and cognitive impairment
(O’Connor, Rutter, Beckett, et al., 2000), we examined whether a
larger proportion of the institutionally deprived group presented
impairment in these areas compared with the pooled comparison
group. Second, inattention/overactivity in combination with the
aforementioned disturbances has been linked to institutional
deprivation (Kreppner et al., 2001), but inattention/overactivity
without any of the above three institution-related disturbances may
be less likely to be associated with early institutional deprivation.
Hence a second pattern was considered in which inattention/
overactivity did not involve one of the three deprivation-specific
patterns but co-occurred with conduct, emotional, and/or peer
relationship problems. The rationale for doing this was that this
would constitute a pattern of overlap that is very common in
clinical populations (Agnold et al., 1999), and it was necessary to
examine whether this would be different for institutionally de-
prived children. Third, the two groups were compared in terms of
the proportion of children with a pattern of overlap involving none
of the above areas of impairment, hence including only conduct,
emotional, and peer relationship problems.
The data presented in Figure 1 suggest that among the children
with multiple impairments, a pattern involving quasi-autistic fea-
tures, cognitive impairment, and/or disinhibited attachment was
nearly twice as common in the group of children who suffered
institutional deprivation for more than the first 6 months of life
than in the pooled comparison group (68% versus 36%), but the
association fell just short of statistical significance (Fisher exact
test p ? .06). Inattention/overactivity without any of the above
three impairments but in combination with conduct, emotional,
and/or peer relationship problems was nearly three times as high in
the nondeprived group compared with the prolonged institution-
reared group (43% versus 15%). On the other hand, inattention
associated with one of the three supposedly deprivation-specific
patterns was more common in the institutionally deprived children
(33% versus 7%). Proportions of children showing overlap among
conduct, emotional, and peer relationship problems without im-
pairments in any of the other four areas were similarly small for
both groups at 11 years.
Rates of Normality and Impairment at 6 and 11 Years by
Adoptee Group and the Effects of Duration of
Table 1 shows that at both age 6 and age 11 smaller proportions
of children in the 6 to ?24 months and ?24 months adoptee
groups compared with the other three adoptee groups were free of
impairment, and correspondingly, larger proportions in these two
adoptee groups compared with the other three groups showed
multiple impairments. Overall the association between adoptee
group and level of impairment was significant at both ages (see
A number of follow-up analyses were necessary to confirm that
(a) the rates of children with and without impairment in the 6 to
?24 months and ?24 months adoptee groups were not statistically
different from one another; (b) the rates of children in the non-
institution-reared Romanian group, the within-U.K. adoptee group,
and the ?6 months institution-reared Romanian group were not
statistically different from one another; and (c) if both (a) and (b)
were true, then we needed to confirm that the rates in the 6?
months institution-reared Romanian groups combined were statis-
tically different from the other three groups pooled together. Bon-
ferroni’s correction was used to adjust for multiple testing (i.e.,
? ? 0.05/6 ? .0083).
The rates of children with or without impairments in the 6 to
?24 months and ?24 months institution-reared groups were not
significantly different from one another at either time: age 6, ?2(2,
N ? 92) ? 1.40, p ? .497; age 11, ?2(2, N ? 88) ? 2.25, p ? .324.
Additionally, the rates of children with or without impairment
across the ?6 months institution-reared Romanian, the non-
institution-reared Romanian, and the within-U.K. adoptee groups
were not statistically different at both ages: age 6, ?2(4, N ?
115) ? .345, p ? .987; age 11: ?2(4, N ? 110) ? 6.09, p ? .193.
Finally, the combined group of ?6 months institution-reared Ro-
manian children, non-institution-reared Romanian children, and
within-U.K. adoptees showed significantly higher rates of normal
functioning and lower rates of impairment compared with the
combined ?6 months institution-reared group at both ages: age 6,
?2(2, N ? 207) ? 34.89, p ? .001; age 11: ?2(2, N ? 198) ?
33.73, p ? .001.
A series of McNemar tests (McNemar, 1947) was conducted to
examine change over time in the rates of children without impair-
ment within each adoptee group. There was no significant change
over time for any of the institution-reared Romanian adoptee
groups: for the 0 to ?6 months group, p ? .508, n ? 40; for the
6 to ?24 months group, p ? .302, n ? 47; and for the ?24 months
group, p ? .180, n ? 39. Change over time was also not significant
for the non-institution-reared Romanian group (p ? .625, n ? 18)
or the within-U.K. adoptee group (p ? .549, n ? 49).
Possible gender differences were also examined across zero,
one, and two or more impairments. There were no significant
gender differences with respect to normality and impairment
within the institution-reared Romanian sample. At age 6, 40% of
girls and 52% of boys showed no impairments, ?2(2, N ? 136) ?
3.14, p ? .05; at age 11, 39% of girls and 48% of boys showed no
impairments, ?2(2, N ? 130) ? 1.31, p ? .05. Equally, the gender
differences were not statistically significant in the within-U.K.
adoptee sample, although there were somewhat more girls than
boys who functioned normally at age 11. At age 6, 78% of girls
NORMALITY/IMPAIRMENT AFTER INSTITUTIONAL REARING
and 69% of boys had no impairments, ?2(2, N ? 50) ? 3.22, p ?
.05; at age 11, 94% of girls and 70% of boys had no impairments,
?2(2, N ? 50) ? 4.62, p ? .05.
The finding that there was no difference in rates for normality
and impairment between the 6 to ?24 months and ?24 months
institution-reared Romanian groups and that both groups showed
significantly greater rates of impairment than the institution-reared
group adopted before 6 months of age was important. In other
words, the findings suggested that there was a significant negative
effect of institutional care when it lasted for at least the first 6
months of life but that there was little, if any, additional negative
effect of duration of deprivation thereafter. This finding of a
potential sensitive period with a cutoff at around 6 months of age
was explored further by categorizing age of entry in 6-month
bands and comparing rates of children with multiple impairments
(i.e., impairment in two or more domains) across these ages at
entry groups (see Figure 2). The data from age 11 presented in
Figure 2 clearly suggest a marked increase of rates with multiple
impairments in the group who entered the U.K. between 6 and 12
months (i.e., from 12% with multiple impairments in the ?6
months group to 50% in the 6–12 months age at entry group) and
no systematic increase thereafter. Chi-square analyses within the
6–42 months institution-reared group confirmed the absence of a
significant association between age of entry (categorized in
6-month age bands) and exhibiting two or more impairments at
both time points: age 11, ?2(5, N ? 84) ? 5.30, p ? .381; for
trends, ?2(1, N ? 84) ? 0.15, p ? .701. Even when we treated
level of impairment as a score (ranging from zero to seven do-
mains impaired) there was no association with age of entry within
the 6–42 months group at age 11 (r ? ?.02, n ? 84, p ? .846).
With respect to individual domains of functioning at 11 years,
none of the seven areas were significantly correlated with age of
entry or total amount of time spent in institutions within the 6–42
months adoptee sample. Although not illustrated here in a figure,
Pattern of dysfunction at 11 years among children with at least two impairments.
Normality and Impairment at Ages 6 and 11 Years by Adoptee Groups and Duration of Institutional Deprivation
Age and no. of
% within adoptee groups
Romanian ?6 months
6 to ?24 months
Romanian 24–42 months
(n ? 50)
(n ? 50)
(n ? 21)
(n ? 18)
(n ? 44)
(n ? 42)
(n ? 49)
(n ? 47)
(n ? 43)
(n ? 41)
At age 6 years, ?2(8, N ? 207) ? 37.06, p ? .001; at age 11, ?2(8, N ? 198) ? 42.78, p ? .001.
KREPPNER ET AL.
the findings from age 6 showed a similar trend across 6-month age
bands: at age 6, ?2(5, N ? 88) ? 5.55, p ? .352; for trends, ?2(1,
N ? 88) ? 1.60, p ? .205; and treating impairment as a score at
age 6, r ? .18, n ? 88, p ? .05.
Degree of Individual Continuity in Normality and
Multiple Impairments Over Time
Because of the apparent importance of a 6-month age cutoff, it
was necessary to examine individual continuity separately in the
groups of children entering the U.K. above and below the age of 6
months. Within the institution-reared Romanian sample entering
the U.K. before 6 months of age, most (73%) showed no impair-
ment at age 6, and most (79%) of these continued to show no
impairment at age 11 (see Figure 3). The degree of continuity for
this group was closely comparable with that observed in the
within-U.K. adoptee sample (i.e., 35 of 48 children [73%] showed
no impairment at age 6, and 31 of 35 children [89%] continued to
show no impairment at age 11). By contrast, of those entering the
U.K. after age 6 months (see Figure 4), only a third (34%) were
free of impairment at age 6, with 59% of that group remaining free
of impairment at age 11. Nearly half (44%) showed multiple
impairments at age 6, and three quarters (74%) of these continued
to do so at age 11.
The relatively high degree of continuity in impairment at an
individual level meant that there was little scope for studying the
onset and offset of impairment between ages 6 and 11. Within the
entire institution-reared Romanian sample (i.e., ages at entry rang-
ing from 0 to 42 months—data from Figures 3 and 4 combined),
there were only 15 (out of 68) children with at least one area of
impairment at age 6 who were free of impairment at age 11. Most
(n ? 12 or 80%) had entered the U.K. at over the age of 6 months.
Similarly, there were only 18 children who developed impairment
between ages 6 and 11. Of these, two thirds were at least 6 months
of age when they entered the U.K. There were no significant
differences in age at U.K. entry between the offset and onset of
impairment groups, although twice as many children showed onset
in the group entering the U.K. at ?6 months compared with those
in the ?6 months group (i.e., 12/29 or 41%, versus 6/29 or 21%).
The main conclusion must be that it is more meaningful to focus
on impairment at age 11.
Which Factors in the Pre- and Postadoption Environment
Were Associated With Normality and Multiple
Impairments at Age 11?
From the analyses above it is evident that one main factor
predicting outcome was the experience of institutional deprivation
for at least the first 6 months of life. Nevertheless, there was
considerable heterogeneity in outcome within the 6–42 months
institution-reared group, with a substantial proportion showing
normal functioning at 11 years. We analyzed next whether any of
a set of measures serving as indices of the pre- and postadoption
environment were significantly associated with age 11 normality
and impairment within this group of 6–42 months institution-
institution-reared Romanian sample by age of entry pooled in 6-month
Rates of children with two or more impairments within the
entering the U.K. at ?6 months of age.
Continuity and change in normality and impairment for institution-reared Romanian children
NORMALITY/IMPAIRMENT AFTER INSTITUTIONAL REARING
reared children. The plan for the statistical analyses consisted of
two steps. First, we examined whether any of the possible predic-
tor variables significantly differentiated between the children with
and without impairments (see Table 2). Second, we conducted
multivariate logistic regression analysis to assess the independent
and combined effects of the significant predictors of normality and
Rather surprisingly, none of the measures of duration of insti-
tutional deprivation, or of physical state or overall developmental
level on arrival to the U.K., differentiated between normality and
entering the U.K. at ?6 months of age.
Continuity and change in normality and impairment for institution-reared Romanian children
Predictors of Normality and Impairment at 11 Years in Institution-Reared Romanian Children Age 6 Months or More at U.K. Entry
Statistical significance testing
None 1 domain only2? domains
M (SD)nM (SD)n M (SD)n
Time spent in institutions (months)
Age of entry to the U.K. (months)
Weight at entry to the U.K. (in SDs)
Weight at 6 years (in SDs)
Head circumference at entry to U.K.
Head circumference at 6 years
Developmental delay at entry to U.K.
Mother’s NART (IQ)
Vocal at entry (only within ?18
months at entry sample)
Very poor quality of individual care
Adoptive family risk index
Physical health problems
Birth weight below 2,500 g
Parental education—both adoptive
parents having a university degree
or professional qualifications
68.4 (13/19)20.0 (2/10)20.0 (5/25) 10.15.001
aThe findings were not significant when using the continuous measure of family risk; no impairment: M ? 0.90, SD ? 1.29; 1 impairment: M ? 1.27,
SD ? 1.33; 2? impairments: M ? 1.40, SD ? 1.41; F(2, 81) ? 1.17, p ? .313.
ANOVA ? analysis of variance; NART ? National Adult Reading Test.
KREPPNER ET AL.
impairment at age 11 once the subgroups without institutional care
or whose institutional care lasted for less than 6 months had been
excluded. Similarly, neither weight at 6 years (used as an index of
overall physical catch-up) nor head circumference at 6 years (used
as an index of brain growth catch-up) was significantly associated
with normality or impairment at 11 years. In addition, information
regarding the postadoption environment (adoptive family risk in-
dex, adoptive mother’s IQ, and adoptive parents’ educational
qualifications) failed to differentiate between the children with
zero, one, or two or more impairments. Among the children age 18
months or more at U.K. entry, the presence or absence of mean-
ingful vocalizations was a significant factor. Two thirds of the
children with normal functioning at age 11 (68.4%) had such
vocalization, compared with only 20.0% of those with multiple
impairments. Most of the children were in institutions of extremely
poor quality, but the proportion was significantly lower in those
with normal functioning at age 11 (i.e., 44.8%, compared with
80.0% of those with one impairment and 73.7% of those with
multiple impairments). Neither health problems at entry nor ob-
stetric problems or weight at the time of birth predicted function-
ing at age 11. The child’s gender was also not associated with level
of functioning at age 11 (see Table 2).
Thus, only two variables out of the set of predictors in Table 2
were significantly associated with normality and impairment at age
11 (i.e., very poor quality of care and meaningful vocalization at
entry). Table 2 further indicates that the figures for the two
significant variables were comparable between the groups with
one and two or more impairments, but the proportions in these two
impairment groups were markedly different from the normal-
functioning group. Hence we collapsed the two impairment cate-
gories for multivariate logistic regression analyses, resulting in a
binary dependent variable (0 ? no impairment, 1 ? one or more
impairments). Considering the meaning of the two predictor vari-
ables, it made conceptual sense to examine whether meaningful
vocalization added anything to the effects of quality of care (as
opposed to examining whether quality of care was explicable from
meaningful vocalization). Moreover, quality of care was signifi-
cantly associated with children showing meaningful vocalization
at entry (see Croft et al., 2007). Stepwise multivariate logistic
regression analyses were conducted within the ?18 months sam-
ple (n ? 52). First, quality of care (0 ? very poor quality, 1 ?
other) was entered into the model, and at the second step, mean-
ingful vocalization was entered (0 ? absent, 1 ? present). In Step
1, quality of care made a significant contribution to the model,
?2(1, N ? 52) ? 4.76, odds ratio (OR) ? .27, p ? .05, suggesting
that those children who had experienced very poor quality care
were more likely to show impairments. In Step 2, only vocalization
was a significant predictor (OR ? .10, p ? .05), indicating that the
children who were vocal were less likely to show impairments.
Quality of institutional care was no longer a significant predictor
(OR ? .47, p ? .10). The final model was significant: ?2(2, N ?
52) ? 16.45, p ? .001.
Finally, the lack of a significant association between the degree
of subnutrition and the presence of multiple impairments was a
striking negative finding. In order to further examine this with
respect to age of U.K. entry, we compared the association between
subnutrition and multiple impairments at age 11 in the ?6 and ?6
months at entry groups (see Figure 5). Binary logistic regression
analyses entering weight at entry (?1.5 SD below the norm ? 0,
?1.5 SD below the norm ? 1) and age at entry (?6 months ? 0,
?6 months ? 1) as predictor variables and multiple impairments
(0 ? absent, 1 ? present) as the criterion showed that only age of
entry, but not weight at entry, was a significant predictor: age of
entry, (OR ? 6.75, p ? .001); weight at entry (OR ? .61, p ? .10);
model ?2(2, N ? 123) ? 18.80, p ? .001. Additional analysis,
which included the interaction term of Weight at Entry ? Age of
Entry, confirmed that the only significant predictor was age of
entry. It is evident that the main predictor of multiple impairments
is the age of the child at the time of leaving institutional care and
not the degree of subnutrition.
The first question we had to tackle concerned the validity of our
measures of normality and multiple impairment. The findings were
reasonably clear-cut. Most of the children showing no evidence of
impaired functioning on our criteria had not experienced a need for
either mental health or special educational services. Moreover,
their scores on all seven domains considered were far below the
usually accepted clinical cutoffs and were within the normal range.
We conclude that there is every reason to suppose that their
functioning was indeed normal according to standard criteria. Of
course, as with any group of typically developing children, they
may have had minor problems or transient difficulties, but these
had not given rise to the need for services. We conclude that a
substantial proportion of children exposed to profoundly depriving
institutional conditions do function normally at age 11. Moreover,
most of them had already been functioning normally at age 6.
The evidence similarly suggested that the designation of impair-
ment extending across two or more domains of functioning was
also valid. The great majority (76%) had received mental health
services, and there was a high degree of persistence between ages
6 and 11. We conclude that, despite at least 7 years’ rearing in a
well-functioning adoptive family, about half of the children con-
tinued to show multiple impairments.
Because multiple impairment was so infrequent in the noninsti-
tutionalized group of children adopted within the U.K., there was
only a very limited possibility of considering whether the partic-
ular pattern of multiple impairments found in institution-reared
children differed from that usually found in the general population.
Nevertheless, we compared the pattern of multiple impairments
presented by children experiencing prolonged institutional depri-
vation (i.e., for at least the first 6 months of life) with that exhibited
by the remainder of children with multiple impairments in our
sample (i.e., pooling together children from the within-U.K., non-
institution-reared Romanian, and ?6 months institution-reared
Romanian groups—who did not differ significantly from one
another). The findings suggested that the multiple impairments in
the group exposed to prolonged institutional rearing involved the
deprivation-specific patterns of cognitive impairment, quasi-
autism, and disinhibited attachment in over two thirds (68%) of
cases. By contrast, most cases of multiple impairments in the
children who had not experienced prolonged institutional depriva-
tion usually involved some mixture of conduct, emotional, or peer
relationship problems with or without inattention/overactivity. In
view of the small numbers, this difference in pattern should be
regarded as one worthy of further study but not one that can be
regarded as established at the present time.
NORMALITY/IMPAIRMENT AFTER INSTITUTIONAL REARING
Having shown the likely validity of our measures of normality
and multiple impairments, we focused next on the psychological
hypotheses that we sought to examine. The most striking finding
was the apparent 6-month threshold. When the institutional depri-
vation lasted for less than the first 6 months of life, there was no
detectable increase in the rate of multiple impairments over that
found in adopted children who had not experienced institutional
deprivation. This is in keeping with the findings from the parallel
Canadian study (Maclean, 2003), as well as with other studies of
severely deprived children (Clarke & Clarke, 1976, 2000). Al-
though the generally good outcome might seem surprising in view
of the profound level of deprivation in Romanian institutions, it
seems that apparently full recovery usually occurs when the
deprivation did not persist beyond the age of 6 months.
What was surprising was the marked stepwise increase in the
rate of multiple impairments for children whose institutional de-
privation lasted for the first 6 months and beyond. We undertook
analyses to test whether this could be an artifact of the children
selected for adoption, or of the families adopting them, but we
found no evidence that this was the case. The associated finding
was that the rate of multiple impairments did not rise further
according to any increase in duration of institutional deprivation.
To some extent, this contrasts with the findings that were reported
for age 6 years (Rutter, Kreppner, & O’Connor, 2001), but even at
that age the main contribution to the linear trend came from the
above and below 6 months distinction.
Because significant linear relationships had previously been
reported between duration of institutional deprivation and several
individual outcomes at age 6, a whole range of checks were
undertaken to ensure that the present negative finding was valid.
At age 6, there was some tendency (not found at age 11) for
outcomes to be slightly worse in the children with more prolonged
deprivation. The slight (and it was very slight) difference between
the age 6 and age 11 findings was due to the further partial
catch-up in cognitive functioning between ages 6 and 11 for the
most cognitively impaired children (Beckett et al., 2006); the
decrease in disinhibited attachment over the same age period
(Rutter et al., 2007); and the late development of new emotional
problems between ages 6 and 11, which were unassociated with
duration of deprivation (Colvert et al., in press). It should be
appreciated, too, that some of the earlier reports of the ERA study
did not differentiate the few Romanian children who had not
experienced institutional care from the majority who had (i.e.,
Rutter, Kreppner, & O’Connor, 2001), whereas this report does.
Three caveats need to be expressed with respect to the lack of a
dose–response relationship between duration of institutional depri-
vation and the rate of multiple impairments. First, it could be a
consequence of the older children being successful survivors. It is
known that there was a very substantial mortality rate in institu-
tions for young children. This means that the children who had
spent longer in institutions were those who had not died when they
were younger. There is no way of telling how big an effect this
was, but it could be an important factor. Second, we studied
duration only up to the age of 42 months. It is possible that there
could be a dose–response relationship beyond 42 months. It would
certainly be unwise to suppose that it does not matter if institu-
tional deprivation goes on longer. Third, although not evident in
our findings, it could be that there is a dose–response relationship
with more specific outcomes.
The possibility of either biological programming or neural dam-
age needs to be considered in relation to four main findings. First,
as already noted, there is the stepwise increase in the frequency of
multiple impairments associated with institutional deprivation that
lasts for at least the first 6 months of age. That is much more in
keeping with the postulate of some sort of intraorganismic effect
on brain functioning than the postulate of continuing responsivity
to environmental variations. Second, there is the finding of no
decrease in the level of multiple impairments between 6 and 11
years. Third, there is the marked continuity between these years
with respect to individual differences in impairment. Fourth, there
is the lack of any detectable impact of individual differences with
respect to qualities in the adoptive families. In addition, research
by other groups is producing increasing evidence of enduring
changes in the functioning of both the brain and the neuroendo-
crine system in response to early institutional deprivation (Gunnar
et al., 2001; Marshall, Fox, & Bucharest Early Intervention Project
Core Group, 2004; Wismer Fries et al., 2005). A recently com-
pleted pilot structural and functional imaging study of a subgroup
impairments at 11 years (within Romanian institution-reared sample).
Comparison of effects of age and weight at U.K. entry on percent of children with multiple
KREPPNER ET AL.
of children from the present sample points in the same direction
(Mehta et al., 2007). Although it would be premature to draw
conclusions about the mechanisms involved, it is justified to con-
clude that some form of biological change is likely and that its
more detailed study should constitute a research priority.
The one significant negative finding on mechanisms is that the
presence of pervasive impairment does not seem to be dependent on
the degree of subnutrition. The meaning of the lack of an effect of
subnutrition is considered in greater detail in a separate article dealing
with possible causal pathways between institutional deprivation and
psychological outcomes (Sonuga-Barke et al., 2007). With respect to
the findings in this article, we simply note that the main features
leading to lasting functional impairment need to be sought in the
psychological, rather than nutritional, aspects of the deprivation.
Both biological programming and neural damage hypotheses are
often interpreted as meaning that the effects are both universal and
immutable. Our findings do not support that view. Most crucially, our
results showed that a substantial proportion (about one quarter) of the
children who experienced profound institutional deprivation for the
seven broad domains and did not appear to need special services—
medical or educational. The only two variables that were significantly
associated with this individual variation in outcome were the presence
of even minimal language at the time of U.K. entry and the qualities
of the institution environment as reported by parents. These two
factors were significantly associated, but the language measure
showed the main effect. The finding is considered in more detail by
Croft et al. (2007), but in brief, the minimal language appears to
reflect some kind of cognitive reserve that is a function of degree of
institutional deprivation and that mainly relates to cognitive, rather
than behavioral, outcomes. Its relevance here is that, as with other
findings, it points to the individual variation in outcome being more a
finding also points to the likelihood of meaningful individual differ-
ences in how the institutional environment impinged on individual
children. Regrettably, the study provided no opportunity to measure
Two main caveats have to be expressed, however. First, indi-
vidual variations in responsivity to institutional deprivation may
reflect genetic, as well as experiential, factors. That is, gene–
environment interactions affecting susceptibility to environmental
influences may be operative (Rutter, 2003, 2006b; Rutter et al.,
2006). DNA samples are being collected now as part of the ERA
study, and such a mechanism will be examined in our future
analyses (Stevens et al., 2006). Second, the measures at age 11
provided little leverage on the possibility that either internal work-
ing models (or mental sets) or active coping strategies influenced
outcome. The assessment at age 15 will provide more scope for
assessing these possibilities.
Finally, we need to consider our lack of any findings that point
to the influence of postadoption experiences on outcome. Three
main points need to be made. First, the very large and remarkable
catch-up in psychological functioning after leaving institutions and
being adopted into mostly well-functioning families points to the
major beneficial impact of adoptions. Second, there were impor-
tant changes that took place between 6 and 11 years. Some of these
may have reflected no more than error variance, but some did not.
Thus, we found significant cognitive improvement in those who
were most cognitively impaired at age 6 (Beckett et al., 2006).
Third, the lack of evidence of importance of variations in the
postadoption environment with respect to multiple impairments is
likely to be a function in large part of the limited variation in the
quality of the adoptive family environment (there were very few
dysfunctional families), together with our limited measurement of
It will be appreciated that we have made little reference to other
studies of intercountry adoption. That is not because they are
uninformative. Indeed, their importance has been well-
demonstrated in authoritative reviews (Gunnar et al., 2007; Mac-
lean, 2003; van IJzendoorn & Juffer, 2006). Rather, it reflects the
fact that none have focused on examination of pervasive patterns
of impairment (although the Canadian study has some findings that
are relevant and, insofar as they are, point to similar conclusions—
Maclean, 2003). Meta-analyses have not examined the specific
effects of institutional deprivation (van IJzendoorn & Juffer,
2006), and the large-scale questionnaire study by Gunnar et al.
(2007) that did do so was cross-sectional and lacked evidence
regarding within-individual change. Adoption provides a good
example of a natural experiment, and more use needs to be made
of it to examine psychological hypotheses about the process of
development. Adoption tends to be thought of as a way of testing
for genetic mediation, but that is not at all the way that it has been
used here. Rather, the radical change in environment that is en-
tailed when profound institutional deprivation precedes adoption
creates a “natural experiment” (Rutter, Pickles, et al., 2001) that
may be used to test hypotheses about environmental mediation.
Our findings provide strong support for such mediation, but
equally, they point to the need to consider the possible changes in
the organism that provide for the persistence of effects—what has
sometimes been expressed as “how the environment gets under the
skin.” If there is to be adequate examination of possible mediating
and moderating mechanisms, however, there will need to be robust
biological, as well as behavioral, measures.
In conclusion, profound institutional deprivation lasting longer
than the first 6 months of life has major effects on patterns of
pervasive impairment at age 11. The pattern of normality and
impairment is mainly established by 6 years of age, with consid-
erable continuity at the individual level between 6 and 11 years.
Our assessment of normality and impairment seems valid, as
judged by use of professional services and population norms. The
key finding is the apparent 6-month cutoff associated with normal
versus impaired functioning: At both ages, about two thirds of
children adopted from institutional care before the age of 6 months
showed normal functioning, whereas only about one third of
children adopted after that age showed normal functioning, and
around half within that group showed multiple impairments. How-
ever, aside from the 6-month cutoff, there is continuing uncertainty
concerning the factors that lead to these huge individual differ-
ences in outcome. It is speculated that it may take some time for
institutional deprivation to exert its pervasively damaging effects,
but after approximately 6 months of life some form of intraorgan-
ismic change could have occurred that is difficult to reverse.
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