Inattention/Overactivity Following Early Severe Institutional Deprivation: Presentation and Associations in Early Adolescence

Article (PDF Available)inJournal of Abnormal Child Psychology 36(3):385-98 · May 2008with25 Reads
DOI: 10.1007/s10802-007-9185-5 · Source: PubMed
Abstract
The current study examined the persistence and phenotypic presentation of inattention/overactivity (I/O) into early adolescence, in a sample of institution reared (IR) children adopted from Romania before the age of 43 months. Total sample comprised 144 IR and 21 non-IR Romanian adoptees, and a comparison group of 52 within-UK adoptees, assessed at ages 6 and 11 years. I/O was rated using Rutter Scales completed by parents and teachers. I/O continued to be strongly associated with institutional deprivation, with continuities between ages 6 and 11 outcomes. There were higher rates of deprivation-related I/O in boys than girls, and I/O was strongly associated with conduct problems, disinhibited attachment and executive function but not IQ more generally, independently of gender. Deprivation-related I/O shares many common features with ADHD, despite its different etiology and putative developmental mechanisms. I/O is a persistent domain of impairment following early institutional deprivation of 6 months or more, suggesting there may be a possible pathway to impairment through some form of neuro-developmental programming during critical periods of early development.
Inattention/Overactivity Following Early Severe Institutional
Deprivation: Presentation and Associations
in Early Adolescence
Suzanne E. Stevens & Edmund J. S. Sonuga-Barke &
Jana M. Kreppner & Celia Beckett & Jenny Castle &
Emma Colvert & Christine Groothues &
Amanda Hawkins & Michael Rutter
Published online: 27 October 2007
#
Springer Science + Business Media, LLC 2007
Abstract The current study examined the persistence and
phenotypic presentation of inattention/overactivity (I/O) into
early adolescence, in a sample of institution reared (IR) chil-
dren adopted from Romania before the age of 43 months.
Total sample comprised 144 IR and 21 non-IR Romanian
adoptees, and a comparison group of 52 within-UK adoptees,
assessed at ages 6 and 11 years. I/O was rated using Rutter
Scales completed by parents and teachers. I/O continued to be
strongly associated with institutional deprivation, with conti-
nuities between ages 6 and 11 outcomes. There were higher
rates of deprivation-related I/O in boys than girls, and I/O was
strongly associated with conduct problems, disinhibited attach-
ment and executive function but not IQ more generally, in-
dependently of gender. Deprivation-related I/O shares many
common features with ADHD, despite its different etiology and
putative developmental mechanisms. I/O is a persistent domain
of impairment following early institutional deprivation of 6
months or more, suggesting there may be a possible pathway
to impairment through some form of neuro-developmental
programming during critical periods of early development.
Keywords Inattention/overactivity
.
Early deprivation
.
Romanian institutional rearing
.
International adoption
Introduction
Inattention, overactivity (I/O) and impulsiveness, the cluster
of behavioral features that form the diagnostic core of Attention
Deficit/Hyperactivity Disorder (ADHD), are amongst the most
common clinical indications amongst children raised during
their early years in institutions (e.g. Goldfarb 1945;Tizardand
Hodges 19 78;Fisheretal.1997;Royetal.2000, 20 04).
Probably some of the most compelling evidence for I/O as
a specific outcome of institutional care has come from the
English and Romanian Adoptees (ERA) study (Kreppner
et al. 2001; Rutter et al. 2001). ERA, like a number of recent
projects (Gunnar and van Dulmen 2007; Marcovitch et al.
1995;Maclean2003), examined the putative causal role that
early adverse experiences associated with institutional depri-
vation play in determining developmental outcome (see Rutter
and ERA Study Team 1998;OConnor et al. 2000). The
ongoing study comprises a large representative sample of
Romanian children who were raised in the severely deprived
conditions of the state institutions of the Ceauşescu regime in
Romania at the end of the 1980s before they were adopted by
families living in the UK. The grave nature of the situation in
J Abnorm Child Psychol (2008) 36:385398
DOI 10.1007/s10802-007-9185-5
S. E. Stevens
:
E. J. S. Sonuga-Barke
Developmental Brain-Behaviour Unit, School of Psychology,
University of Southampton, Southampton, UK
S. E. Stevens
:
E. J. S. Sonuga-Barke
:
J. M. Kreppner
:
C. Beckett
:
J. Castle
:
E. Colvert
:
C. Groothues
:
A. Hawkins
:
M. Rutter
MRC Social, Genetic and Developmental Psychiatry Centre,
Institute of Psychiatry, Kings College London,
London, UK
E. J. S. Sonuga-Barke
Child Study Center, New York University,
New York, NY, USA
S. E. Stevens (*)
SGDP Centre, Box PO.80, Institute of Psychiatry,
Kings College London, De Crespigny Park,
London SE5 8AF, UK
e-mail: s.stevens@iop.kcl.ac.uk
which the children were reared was apparent in the marked
developmental delay and poor physical state of the children
at the time of entry to the UK. Many children demonstrated
catch-up in the physical and intellectual domains by the time
they were 46 years of age although residual deficits per-
sisted in a significant minority of children (Rutter and ERA
Study Team 1998;OConnor et al. 2000) and psychological
dysfunction and psychiatric morbidity were common within
the sample. Deficits were surprisingly specific and unusual
in pattern and found to be associated with duration of time
spent in the depriving conditions of the Romanian institu-
tions (Rutter et al. 2000, 2001). In this regard, four domains
of impairment were implicated: cognitive impairment, dis-
inhibited attachment, quasi-autism and, most significantly for
the current paper , I/O. Considerable individual continuity in
normality and impairment was found between ages 6 and
1 1 years, with pervasive and persistent impairment across
multiple domains of functioning in those children who had
experienced at least 6 months_ institutional rearing (Kreppner
et al. 2007). There were also specific, persistent adverse
effects into early adolescence on cognitive impairment
(Beckett et al. 2006) and disinhibited attachment (Rutter
et al. 2007a) in this group who had experienced extended
deprivation, and clinically significant rates of quasi-autistic
patterns (Rutter et al. 2007b). Additionally , there was a
significant increase in emotional difficulties by age 11 that
was strongly associated with previous impairment in the
deprivation specific problem areas identified at age 6 (Colvert
et al. in press).
A number of features of the study design have helped to
facilitate the interpretation of these effects and served to
strengthen the conviction that they wer e specific to early
global institutional deprivation. These include: a relatively
large sample (N>150), the availability of detailed informa-
tion about the timing and extent of institutional care for
each child and their age at adoption, the measurem ent of
longitudinal outcomes at multiple follow ups (ages 4, 6, and
11 years with an age 15 phase underway) across a broad
range of assessment domains (intellectual, behavioral and
social), and a relative homogeneity in the sample with
regard to likely factors responsible for entry to institutions
and its timing. Most children entered the institutions within
the first two weeks of life and, although we do not have
any systematic information on the reasons for placement,
evidence from surveys conducted at the time (Childrens
Health Care Collaborative Study Group 1992) and the
early age at which the children were admitted indicate that
this was due to extreme poverty and social exclusion. More-
over, there was an absence of any formal fostering system
within Romania and, as far as is known, no children were
adopted from the institutions prior to 1989. Thus the sub-
sequent timing of adoption out of institutions was largely
determined by political, rather than individual selection, fac-
tors brought about by the fall of the Ceauşescu regime in
1989, following which adoption became possible. The study
also included a comparison group of children born and
adopted in the UK before the age of six months (N>50), and
a sampling approach that ensured three large, similarly-sized,
groups including Romanian children entering the UK and
placed with their eventual adoptive families during different
periods in the first 3 1/2years of life (i.e., entering the UK
before the age of 6 months, between 6 and 24 months and
24 months or over). This final element allowed the
relationship between duration of deprivation (used as a
proxy for dose of deprivation) and outcome to be estab-
lished. At ages 4 and 6, outcomes, including I/O, generally
demonstrated a linear-like doseresponse
relationship with
duration of deprivation. In addition, there was a striking
level of heterogeneity in outcomes. Many children, even in
the group with highest dose of deprivation, were well
adjusted and unimpaired. All in all, despite this heterogene-
ity, the ERA data support the idea that I/O at age 6 years was
a specific outcome of early institutional deprivation for
some, although not all, children.
The current paper had three aims: first, to examine the
persistence and continuity of the I/O pattern, and its specific
links with duration of deprivation from childhood into early
adolescence. As noted above, I/O was isolated as a specific
area of deficit at ages 4 and 6 years and was strongly asso-
ciated with duration of time spent in the extremely deprived
conditions of the Romanian institutions. The current paper
extends previous analyses in two ways: firstly, by looking
at persistence to age 11 and, secondly, by including the
most depri ved group (aged 24 months or over at adoption)
in the analysis of change over time. Persistence has not
previously been assessed in this group as they were too old
to be included in the 4 year old phase of the study. By age
11 all the children had spent at least 7 1/2years in their
adoptive homes. If the effects seen at age 6 persisted
despite this , the possibility that I/O represents a transient
behavioral reaction to deprivation becomes less likely and
the possibility that it reflects an early established and
fundamental brain-mediated effect becomes more likely.
Second, we aimed to characterize what is specific to the
deprivation-related I/O phenotype in order to contrast it with
I/O in the general non-deprived population. It has often been
supposed that deprivation-related I/O is a qualitatively dis-
tinct entity from I/O in the normal population owing to
different putative causal mechanisms, for instance as is seen
in children on the ADHD spectrum (Roy et al. 2004). By
definition it has a different etiology: nondeprivation-related
I/O is highly heritable and strongly related to susceptibility
genes. Where environmental factors are implicated these are
often related to pre- and perinatal adversity rather than post-
386 J Abnorm Child Psychol (2008) 36:385398
natal social and interpersonal factors, although the potential
role of prenatal and genetic factors in deprivation-related I/O
cannot be ruled out (Taylor and Warner-Rogers 2005). One
might therefore expect deprivation and nondeprivation-
related I/O to be mediated and moderated by different fac-
tors and have different patterns of associations. In order to
explore whether this is true we examined the association
between deprivation-related I/O and four factors consistent-
ly shown to be associated with nondeprivation-related I/O;
(i) its male preponderance, (ii) its cross-sectional and longi-
tudinal link with conduct problems, and its association with
(iii) low IQ and (iv) executive function deficits.
Gender imbalance Although the picture is far from clear
regarding the causes of gender differences in ADH D the
discrepancy in prevalence rates is undisputed, with ratios of
girls to boys reported to be between 1:2 and 1:9 (Youth in
Mind 2001; Heptinstall and Taylor 2002; Biederman et al.
2002). While there may be a degree of rater bias this cannot
explain the phenomenon fully (Maniadaki et al. 2005).
Girls may be more resilient in relation to risks for the devel-
opment of ADHD and differences in cognitive impairment,
comorbid behavior problems and some discrepancies in
symptomatology have been noted (Heptinstall and Taylor
2002). However, in our institution-reared (IR) sample at age
6 there was a fairly even distribution of deprivation-related
I/O across boys and girls (Kreppner et al. 2001). One pos-
sible reason for this is that early institutional deprivation is a
particularly potent risk factor for female I/O that combines
with other risks in a way that pushes certain girls over their
risk threshold for the expression of the condition.
Conduct problems Nondeprivation-related I/O and conduct
problems often co-occur. Studies of clinic and population-
derived samples of children and adolescents have found a
high rate of ADHD cases comorbid with conduct disorder
(CD) or oppositional defiant disorder (ODD): in the region
of 4090% (Jensen et al. 1997). This pattern of comorbidity
is a c ommon and pervasive long-term adverse outcome
with strong homotypic continuity over time (Willcutt et al.
1999; Burke et al. 2005). Although it has been suggested
that ADHD comorbid with CD may share a common set of
genetic risk factors and may represent a genetically more
severe type of ADHD, research has supported the distinction
of these two domains of dysfunction (Thapar et al. 2001).
Developmental studies have suggested that the presence of
early ADHD predicts the occurrence of ODD and subse-
quent CD, but ODD does not predict the later emergence of
ADHD (Burke et al. 2005; Taylor et al. 1996). In addition
to genetic influences, it is plausible that the similar set of
environmental risk factors such as pre- and perinatal ad-
versity, and psychosocial/family risk, associated with both
ADHD and conduct/oppositional problems could help to
account for the progression from one condition to the other
(Thapar et al. 2006). The findings from the ERA study
suggested that at age 6 and age 11 conduct problems were
not a specific outcome of the deprivation experience (i.e.,
related to dose of deprivation) (Colvert et al. in press) but
the relation to I/O in deprived samples has not been
investigated. There has been mixed evidence from other
samples of post institutionalized children in relation to
whether increases in levels of conduct and oppositional
problems are observed (Gunnar and van Dulmen 2007).
Low IQ The negative association between IQ and non-
deprivation-related I/O symptoms has been consistently
reported. There is typically a correlation of around 0.3 be-
tween ADHD symptom scores or diagnosis and IQ (Kuntsi
et al. 2004) representing a deficit of between 9 and 13 IQ
points (Rucklidge and Tannock 2001; Crosbie and Schachar
2001) compared with normal controls. The nature of this
association is open to several interpretations (see Goodman
et al. 1995). Goodman et al. theorized that hyperactive be-
havior may interfere with learning success or performance
on IQ tests or perhaps that low IQ increases the risk for
hyperactivity via its association with reduced self esteem.
Low IQ and I/O could also be markers of some common
underlying risk factor or factors such as variations in brain
development, individual genetic makeup or shared environ-
mental adversity (Goodman et al. 1995;Kuntsietal.2004).
Executive dysfunction The dominant model of the psy-
chopathophysiology of ADHD has focused on the role of
executive dysfunctions involving multifaceted deficits in neu-
rocognitive processes, such as working memory, response
inhibition and interference control, which maintain and man-
age appropriate information and problem solving sets in order
to achieve a future cognitive goal (Castellanos et al. 2006). A
recent meta-analysis by Willcutt et al. (2005)demonstrated
significant case-control differences, with medium effect sizes
(d=0.40.6) in several key domains: response inhibition,
vigilance, spatial working memory and some planning tasks,
which were independent of IQ, academic attainment or
comorbid disorders.
Our third aim was more exploratory and related to one
of the most obvious areas where deprivation and non-
deprivation-related I/O might differ: the association with
reactive attachment disorder of the disinhibited subtype, a
common outcome in studies of institutionalized children
(Zeanah et al. 2005; Chisholm 1998; Rutter et al. 2007a;
Roy et al. 2004). This consisted of an unusual pattern of
disinhibited approach to strangers and was noted by parents
and observed by study investigators. Study of the relation-
ship between I/O and attachment in non-institutionalized
J Abnorm Child Psychol (2008) 36:385398 387387
samples has been limited. However, attachment theory holds
that a secure and responsive early parent child relationship
is an integral part of the d evelopment of effective self-
regulation in the child and self-regulation is linked to im-
pulse control, perseverance and inhibition, which make up
important features of the nondeprivation-related I/O and
ADHD phenotype. Most studies have focused on insecure
attachment with parents, rather than disinhibition with
strangers, and are mainly based on small clinical case studies
(Stiefel 1997; Clarke et al. 2002). Nevertheless, in com-
bination with the striking pattern of disinhibited attachment
observed in our sample and pattern of overlap noted by
Kreppner et al. (2001 ), these studies highlight this as an
important area of investigation when considering the phe-
notypic characteristics of I/O in adolescence.
The aim of the current paper was to explore deprivation-
related I/O in early adolescence by asking the following
questions:
1. Does the risk for I/O associated with severe early insti-
tutional deprivation persist to age 11 years?
2. Is there individual continuity in I/O behavior?
3. Is deprivation-related I/O phenotypically similar to
ADHD/hyperactivity in terms of:
a. The gender imbalance in prevalence rates?
b. The comorbidity and developmental association with
conduct problems?
c. The association with low IQ?
d. The association with executive function?
4. Is there overlap between I/O and disinhibited attachment?
Materials and Methods
Sample
The sample of 165 Romanian children adopted before the
age of 43 months was drawn from 324 children adopted into
UK families between February 1990 and September 1992.
The adoptive parents did not always know the ethnicity of
the children they adopted so the collection of systematic data
on ethnicity was not possible. However, in Romania as a
whole the population is over 90% Romanian, defined by a
common language, and includes a substantial minority of
Roma people (estimates vary between 510% of the pop-
ulation) and also people from neighbouring countries e.g.
Hungary and Russia. At the time of entry to the UK only a
small minority of children possessed even the most basic
language skills. Of the children aged 18 months or over (the
age by which in a normal population the vast majority of
children would be attempting to reproduce words) only 13
out of 57 were using 3 recognizable words and none had
even minimal fluency in spoken Romanian language, despite
the age range of the children reaching 3 1/2years. Language
development throughout the sample was tested at age 6
and all assessments were carried out in English (Croft
et al. 2007).
The sample was balanced for gender, selected at random
from within two age bands (<6 months; 6 to <24 months)
and stratified according to age at entry to the UK ; all the
families of the children of 24 months of age were selected,
as there were fewer children in this age band. Of the 165
children in the Romanian sample, 144 were raised, usually
from soon after birth, in the extremely depriving conditions
of the state institutions. The remaining 21 Romanian chil-
dren were adopted from family settings and their ages at
adoption were spread throughout the 3 main ages bands.
This group of non-institutionalized children provided a use-
ful comparison in that they experienced the general hardsh ip
and poverty suffered by underprivileged Romanian families
at the time but they were not subject to the experience of
institutional rearing and its associated risks.
A comparison sample of 52 within country (UK) adoptees
aged below 6 months when adopted was selected and
obtained through voluntary and local authority adoption
agencies. The comparison sample was chosen in order to
control for the experience of adoption and of being brought
up, post adoption, in an above average rearing environment,
but to vary in terms of the experience of early severe psy-
chological and nutritional deprivation. For a more compre-
hensive description of the sample, including sampling and
assessment strategy, post adoption environment and the
physical and developmental condition of the children at the
time of adoption, see OConnor et al. (2000).
For 210 of the 217 (97%) children in the study data on
I/O at age 11 had been collected from either parent (n=199,
92%) or teacher (n=188, 87%) reports. The seven children
with missing data were all from the Romanian sample and
were split evenly across the 3 main age bands (<6: n=2; 6
to <24: n=2; 24: n=3) with slightly more girl s than boys
with data missing (girls: n=5; boys: n=2).
Measures
The full sample was assessed at ages 6 and 11 years using a
combination of standardized tests, standardized investigator-
based interviews, qualitative interviews, questionnaires and
observations. In-depth interviews were carried out with adop-
tive parents and questionnaires on childrens behavior were
completed by parents and teachers.
Behavioral assessment of I/O and conduct problems The
Revised Rutter Parent and Teacher Scales for school-age
children (Elander and Rutter 1996) with supplementary ques-
388 J Abnorm Child Psychol (2008) 36:385398
tions from Behar and Stringfield (Behar 1977;Hoggetal.
1997) were administered at ages 6 and 11years. The ques-
tionnaires were completed at both assessment time-points
by mothers, fathers and teachers. At the age 11 time-point
the questionnaires were completed by each childsprimary
school main class teacher, i.e. before they moved to second-
ary education. The scales comprised sets of items describing
different behaviors; each item, or statement, is scored on a
scale of 02: 0 for doesntapply, 1 for applies somewhat,2
for certainly applies. The individual items used to assess
these domains are listed in Appendix.
Parent and teacher composite scores were created for
both the I/O and conduct problems subscales. A combined
parent score was calculated by taking the mean mother and
mean father scores across the questionnaire items and then
calculating an average of the two. In order to maximize the
sample size, children who had obtained ratings from only
one parent were also included. The correlation between
mother and father reports of I/O behaviors on the Rutter
Scales was high, with medium to high effect sizes found
(Age 6: r (175)=0.74; p<0.001; r
2
=0.54. Age 11: r(174)=
0.78; p<0.001; r
2
=0.61). Teacher scores were calculated by
taking the mean score across the items for each behavioral
domain.
In order to examine markedly abnormal behavior and to
compare with prevalence rates in the population, cut-offs
were calculated by transforming the continuous outcome
measure of I/O into categorical data. There were no estab-
lished cut-off criteria for the Rutter subscales and therefore
the following strategy was developed based on the pro-
cedure used for assessing behavior rated on the Strengths
and Difficulties Questionnaire (SDQ; Goodman 1997). This
also allowed us to compare rates of problem behavior with
those from a population sample using normative data on the
SDQ. The SDQ comprises sets of behavioral description
items based largely on the Rutter Scales that are scored on a
similar 3 point scale: 0 for not true, 1 for somewhat true
and 2 for certainly true (see Appendix). As reported by
Goodman (1997), the Rutter Scales and the SDQ are very
highly correlated, r(346)=0.88, 0.88, 0.82 and r(185)=
0.92, 0.91, 0.90 in terms of total difficulties, hyperactivity
and conduct problems scales according to parent and
teacher ratings, respectively. The equivalence of the two
scales in terms of correlation, behavior scale items and rat-
ing structure justified the application of a cut-off from one
scale being applied to the other.
The cut-off was calculated for the Rutter Scales accord-
ing to the procedure for determining behavior in the abnor-
mal range as outlined on the official SDQ-info website
(Youth in Mind, http://www.sdqinfo.com/ScoreSheets/e1.
pdf; Goodman 1997). For the hyperactivity subscale on the
SDQ a score of 7 or above on the summed composite (score
of 0, 1 or 2 per item on a five question subscale; making a
possible total score of 10) was considered in the abnormal
range. The abnormal cut-off was transformed for the Rutter
Scales by taking the lower limit of the abnormal banding on
the SDQ and dividing by the number of items on the SDQ
hyperactivity scale to obtain an average score per item, at or
above which would be considered abnormal: 7 (lower
limit)÷5 (items)=1.4. This cut-off was then applied to the
mean scores of parents and teachers on the Rutter Scales.
For the analyses of the patterns of association between
deprivation-related I/O in the Romanian-IR risk sample
aged 642months at adoption and the various phenotypic
features the subsample was split according to their level of
I/O impairment. There were three I/O impairment groups:
firstly, those children who were below cut-off according to
both parents and teacher were classed as being in the
normal range; secondly, the children rated as above cut-
off according to parents or teachers were classified as hav-
ing situational I/O; lastly, those children rated above cut-off
according to both parents and teachers were designated as
pervasive. To address questions about continuity of I/O
impairment or normality the situational and pervasive I/O
categories were collapsed to create a dichotomous split
between those in the abnormal range according to parent
and/or teacher and those in the normal range according to
both informants.
To compare prevalence rates in early adolescence of
abnormal I/O behavior in the Romanian IR risk sample
according to gender with the discrepancy seen in ADHD in
the population it was necessary to restrict the analysis to
those who showed I/O impairment according to parent and/
or teacher reports at age 6 and age 11, as ADHD diagnostic
criteria require an onset before the age of 7years. This,
however, did restrict the sample size as individuals had to
have data at all four data-points in order to be included in
this analysis (parent and teacher report at 6 and 11years).
This applies also to the analyses of continuity and pheno-
typic features described above. Moreover, gender discrep-
ancy was investigated by comparing prevalence rates in
the Romanian IR risk sample with those found in the nor-
mal population. Normative data from a large representative
British survey of chil d and adoles cent mental health, which
used the SDQ questionnaire, was exploited (Department of
Health & Office for National Statistics: Meltzer et al. 2000
).
The sample included 10,438 individuals aged between 5 and
15 years. Complete SDQ information was obtained from
10,298 parents (99% of sample), 8,208 teachers (79% of
sample) and 4,228 1115 year olds (93% of this age band)
(Youth in Mind, http://www.sdqinfo.com/bb1.html).
Assessment of cognitive and executive function Cognitive
functioning was assessed using a short form of the Wechsler
J Abnorm Child Psychol (2008) 36:385398 389389
Intelligence Scales for Children (WISC III
UK
; Wechsler
1992). Four subscales of the WISC were included in the
battery: two measuring verbal abilities vocabulary and
similarities; and two measuring performance abilities block
design and object assembly. These four subtests were se-
lected to provide a good estimate of full scale IQ (reliability
coefficient=0.94, Sattler 2002) and were prorated to form a
full scale IQ score. There were three Romanian IR children
who have been excluded from the analysis of association
between I/O, IQ and executive function as the severity of
their cognitive impairment was of such a degree that these
aspects of the assessment battery were not suitable and
therefore not administered (Beckett et al. 2006).
The concept of executive function covers a broad range of
cognitive proces ses. In this study two aspects of executive
functioning at age 11 were tested: interference/inhibitory
control and verbal working memory. The measures used to
assess these abilities were the Stroop ColorWord Interfer-
ence Test (Stroop 1935) and the backwards digit span sub-
test on the WISC III
uk
(Wechsler 1992). The Stroop task
assesses the speed and accuracy with which parti cipants can
name the contrastive color of the ink in which color words
are written (e.g. the words red, green and blue could be
written in blue, yellow and red ink, respectively). The task
is designed to assess interference control, since the default
response to seeing words on a card is to read the words
rather than to name the color of the ink, and this response
must be inhibited to complete the task correctly. The task
was administered twice: firstly, the child was required to
read the words on the card and ignore the color of the ink
and, secondly, they had to name the color of the ink and
ignore the wor ds themselv es (the inhibitory stage of the
task). For both trials the number of errors committed was
recorded and analyses used the total number of errors on
the first trial subtracted from the total error s on the second
trial as the dependent measure. The backwards digit span
subtest of the WIS C was used as a test of verbal working
memory. Participants repeated a series of digits in the
reverse order to which they were orally presented. The
score used in the current paper is the total raw score of
successfully completed trials.
Assessment of disinhibited attachment This was measured
using questions included in the interviews carried out with
parents when the children were aged 11 years concerning
essential components of disinhibited attachment behaviour:
wandering off; too friendly with strangers/lack of differen-
tiation; and physi cal contact/lack of understanding social
boundaries/personal space (see Rutter et al. 2007a). These
items were scored on a three point scale: 0 for no abnormality,
1forprobable problem and 2 for marked problem.Anover-
all score ranging from 0 to 6 was calculated by summing
across the three items.
Results
Does the Risk for I/O Associated with Institutional
Deprivation Persist to Age 11Years?
Kreppner et al. (2001) reported that prolonged duration of
institutional deprivation constituted a significant risk factor
for I/O at age 6. In order to establish whether, firstly, insti-
tutional deprivation continued to be a significant risk for
I/O into early adolescence and, secondly, whether the dose
response association between duration of deprivation and
level of impairment conti nued to show a linear-like pattern,
a within sample comparison of the mean levels of I/O be-
havior at 11 years was carried out across informants and
adoptee groups. Table 1 presents the means, standard devia-
tions and percentages in the abnormal range for I/O across
sample group (IR group split according to age at entry to
UK), gender and informant.
Analysis of variance was used to compare the UK com-
parison, Romanian IR (pooled <6, 6 to <24 and 24 month
groups) and Romanian non-IR. There was a significant
difference in I/O at age 11 according to both parent (F(2,
196)=4.90; p<0.01) and teacher reports (F(2, 185)=6.68;
p<0.01). Post hoc comparisons (Tukeys test) found sig-
nificantly higher levels of I/O in the Romanian IR sample
(parent: M=0.70, SD=0.62; teacher: M=0.73, SD=0.61)
when compared with the UK comparison group (parent:
M=0.43, SD=0.48; teacher: M=0.38, SD=0.58: parent:
p<0.05; teacher: p<0.01). There was no appreciable differ-
ence between the UK comparison group and the Romanian
non-IR group (parent: p=0.996; teacher: p=0.87).
Effect of duration of deprivation Sizeable and significant
differences in both the levels of I/O and the percentage in
the abnormal range were found between those children who
had experienced at least 6 months_ institutional care and
those who had either experienced less than 6 months_ or no
institutional care in Romania, or were adopted from within
the UK. Overall, analysis of variance showed a highly sig-
nificant difference in mean levels of I/O at age 11 across
adoptee groups, as reported by both parents and teache rs.
A highly significant association was also found between
adoptee group status and rates of I/O abnormality according
to parent reports using a chi square test (see Table 1). Post
hoc Tukeys tests found no difference in the level of I/O be-
tween the two late placed IR groups (6 to <24 and 24 months)
or among the IR <6 month, the non-IR and the UK adoptee
groups. The IR group aged 6 to <24 months was rated by
parents and teachers as having significantly higher I/O scores
than the IR <6 month, non-IR and the within-UK subsamples
(parent: p<0.05; p<0.05; p<0.01; teacher: p<0.01; p<0.05;
p<0.001 for the three groups, respectively). I/O in the IR
24 month group was significantly higher than the within-UK
390 J Abnorm Child Psychol (2008) 36:385398
sample according to teacher rating (p<0.05) but not parent
( p=0.07). When the non-IR group was excluded from the
analysis the difference became significant ( p<0.05). When
the two later placed adoptee groups were pooled and com-
pared with the Rom IR <6 months group a t test showed
there was a statistically significant difference between the
groups by both reporters (parent: t(129)=2.77; p<0.01;
teacher: t(117)=3.46; p<0.01). The two later placed IR
adoptee groups were then combined and compared with a
pooled subsample consisting of the three low risk groups:
non-IR, within-UK and IR <6 months. T tests showed that
the level of I/O in the combined >6 months IR group was
significantly higher than that in the low risk subsample
(parent: t(197)=4.33; p <0.001; teacher: t(186)=5. 13;
p<0.001).This pattern of results suggested a stepwise pat-
tern of association between duration of deprivation and
I/O at 11 years of age.
The findings strongly suggested that the two later placed
IR groups are at a significantly increased risk for elevated
levels of I/O behavior in early adolescence but that no addi-
tional risk is added as one moves to the group with more
than 24 months deprivation. Therefore, the subsequent anal-
ysis of continuity and phenotypic distinctiveness of I/O are
focused on a merged risk sample of the IR 6 to <24 and 24
groups. Moreover, because the level of I/O in the non-IR
group was similar to that reported in the within-UK group
and the Romanian IR <6 month groups, the non-IR sub-
sample, whose age at adoption is spread over the total range,
has been excluded from the following analyses.
Is There Individual Continuity in I/O Behavior?
Overall mean scores remained fairly constant in the IR risk
sample (aged 642 months at adoption) across time-points
according to both parent and teacher reports (parent: age 6
M=0.88, age 11 M=0.80; teacher: age 6 M=1.00, age 11
M=0.85). In order to get an overall picture of continuity, or
persistence, in I/O behavior in the later placed Romanian
adoptee group, correlations across the two time-points were
performed. There were highly significant correlations, accord-
ing to both informants, between I/O at ages 6 and 11 years
(parent report: r=0.67; p<0.001; teacher report: r=0.43;
p<0.001). This was explored further using a categorical
approach (see Materials and Methods). Figure 1 illustrates
the moderate to strong individual continuity in I/O behavior
between ages 6 and 11 years for reports of normality and
impairment. Four-fifths of the children in the normal range
for I/O at age 6 remained below cut-off at age 11 according
to both parents and teachers. There was also moderate con-
tinuity in persistence of impairment with over half the chil-
dren above cut-off according to parent and/or teacher at age
6 persisting to age 11. A similar pattern of results was found
when parent and teacher reports were considered separately,
although the drop off from 611 was largely owing to lower
Table 1 I/O at age 11: mean scores, standard deviations and percentages in abnormal range
I/O mean scores (SD) I/O % in abnormal range (n)
Adoptee groups Parent Teacher Parent Teacher
UK comparison Both sexes 0.43 (0.48) 0.38 (0.58) 6% (3) 8% (4)
n=48 (parent) Male 0.51 (0.51) 0.52 (0.66) 6% (2) 12% (4)
n=50 (teacher) Female 0.28 (0.40) 0.13 (0.22) 6% (1) 0% (0)
Romanian non IR Both sexes 0.42 (0.49) 0.46 (0.52) 5% (1) 11% (2)
n=20 (parent) Male 0.41 (0.37) 0.41 (0.52) 0% (0) 9% (1)
n=19 (teacher) Female 0.43 (0.63) 0.54 (0.55) 11% (1) 13% (1)
Romanian IR <6 months Both sexes 0.49 (0.49) 0.44 (0.47) 5% (2) 6% (2)
n=42 (parent) Male 0.55 (0.53) 0.54 (0.48) 9% (2) 6% (1)
n=35 (teacher) Female 0.42 (0.44) 0.35 (0.47) 0% (0) 6% (1)
Romanian IR 6 <24 months Both sexes 0.84 (0.64) 0.92 (0.65) 25% (12) 25% (11)
n=49 (parent) Male 0.89 (0.69) 1.08 (0.68) 32% (7) 33% (6)
n=44 (teacher) Female 0.80 (0.60) 0.81 (0.61) 19% (5) 19% (5)
Romanian IR 24 42 months Both sexes 0.75 (0.67) 0.77 (0.59) 23% (9) 13% (5)
n=40 (parent) Male 0.88 (0.77) 0.80 (0.60) 36% (5) 13% (2)
n=40 (teacher) Female 0.69 (0.62) 0.75 (0.60) 15% (4) 12% (3)
ANOVA (means); chi square
(percentages)
Both sexes F(4,194)=4.83** F(4,183)=6.98*** χ
2
(4)=13.93** χ
2
(4)=8.58; p=0.07
Male F(4,96)=2.50* F(4,89)=3.39* χ
2
(4)=13.39** χ
2
(4)=6.44
Female F(4,93)=3.03* F(4,89)=5.95*** χ
2
(4)=4.82 χ
2
(4)=4.61
*p<0.05. **p<0.01. ***p<0.001
J Abnorm Child Psychol (2008) 36:385398 391391
I/O ratings from teachers at age 11, especially for girls.
Eleven out of the 13 offset cases were female.
Is Deprivation-related I/O Phenotypically Similar to ADHD/
Hyperactivity in Terms of Its Association with Gender,
Conduct Problems, IQ and Executive Function?
Table 2 sets out the associations between I/O in the IR risk
subsample and conduct problems, intellectual and executive
functioning, disinhibited attachment and gender.
Gender Rates of both male and female persistent, early onset
I/O were elevated when compared with population figures
(see Fig. 2). We can also see that sex differences emerged in
the Romanian sample in early adolescence. The sex ratio
was 1:1.6 , with boys having higher symptom levels. The
picture was very similar when parent and teacher reports at
age 11 were analyzed separately (ratio for parent report:
1:2; teacher report: 1:1.5).
I/O and comorbidity with conduct problems Analysis of
variance tests found there was a highly significant difference
in the conduct scores across children in the normal, situa-
tional and pervasive I/O groups according to both parent and
teacher reports (parent: F(2,76)=20.12; p<0.001; teacher:
F(2,76)=36.59; p<0.001). Figures 3a and 3b show highly
significant correlations ( p<0.001) between concurrent I/O
and conduct problems, suggesting a strong contemporane-
ous association (parent report r=0.33; r=0.63; teacher re-
port r=0.64; r=0.68, for ages 6 and 11, respectively).
Developmental pathways from I/O and conduct pr oblems Mul-
tiple regression was used to examine the indepe ndent
contribution of conduct problems and I/O at 6 years to
each domain at 11 years. According to parent reports, both
I/O (β=0.23; p<0.01) and conduct problems (β=0.58; p<
0.001) at age 6 made an independent contribution to conduct
variation at age 11. Conduct problems at age 6 also
contributed to I/O variation at age 11 with a significant,
but weak, association (β=0.15; p<0.05). Teacher data
demonstrated no such associations.
I/O and IQ The IR 642 month group as a whole had de-
pressed IQ scores, with even the normal I/O subgroup scoring
on average nearly15 IQ points (1 standard deviation in
population norms) below the population mean of 100. There
was no significant difference in IQ among the three I/O groups
using analysis of variance testing (F(2,69)=0.52; p=0.59),
and there was no correlation between I/O mean scores and
WISC scores at age 11 (parent report: r=0.12; p=0.33;
teacher report: r=0.15; p=0.20).
I/O and executive dysfunction Interference control (Stroop
test) and working memory performance (backwards digit
Table 2 Pattern of associations at age 11 between I/O and conduct problems, IQ, executive function, disinhibited attachment and gender in the
Romanian sample aged 6 months or over at adoption
Phenotypic features: means (SD)
Conduct problems IQ Executive function Disinhibited
attachment
Gender
I/O impairment
groups
Parent report Teacher report WISC score Stroop task Digit span
backwards
Parent report Male Female
Normal range 0.32 (0.27) 0.22 (0.25) 86.83 (14.61) 10.80 (8.5) 4.82 (1.80) 0.94 (1.24) 58% 69%
n=51 n=51 n=46 n=44 n=45 n=51 n=18 n=33
Situational 0.73 (0.46) 0.65 (0.48) 83.95 (13.67) 14.65 (12.28) 3.74 (1.59) 1.90 (2.07) 26% 27%
n=21 n=21 n=20 n=17 n=19 n=21 n=8 n=13
Pervasive 1.01 (0.36) 1.2 (0.14) 81.50 (17.94) 21.20 (11.21) 4.00 (2.00) 3.71 (1.60) 16% 4%
n=7 n =7 n=6 n=5 n=6 n=7 n=5 n=2
ANOVA F(2,76)=
20.12**
F(2,76)=
36.59**
F(2,69)=0.52
p=0.59
F(2,63)=
3.05*
F(2,67)=2.75
p=0.07
F(2,76)=11.40**
*p=0.05. **p<0.001
Below abnormal
cut-off n = 42
At 11 years:
At 6 years:
Below abnormal
cut-off n = 46
Above abnormal
cut-off n = 23
Above abnormal
cut-off n =27
n=33 (79%)
n=13 (48%)
n=14 (52%)
n=9 (21%)
Fig. 1 Continuity and change in I/O for Romanian institution-reared
children aged 6 months or over at adoption
392 J Abnorm Child Psychol (2008) 36:385398
span) were significantly correlated with I/O according to
both parent and teacher reports: backwards digit span (parent
report: r=0.30; p<0.01; teacher report: r=0.34; p<0.01);
Stroop (parent report: r=0.28; p<0.05; teacher report; r=
0.47; p<0.001). Using ANOVA, a significant difference was
found among the three I/O severity groups (F(2,63)=3.05;
p<0.05) on Stroop task performance, with over a 10 point
difference in errors between those in the normal range for
I/O according to parents and teachers and those with perva-
sive I/O. The difference across the three I/O groups ap-
proached, but did not reach, significance for the digit span task
(F(2,67)=2.75; p=0.07), and was in the expected direction.
Disinhibited attachment An analysis of variance test found a
highly significant difference in levels of disinhibited attach-
ment across the I/O cut-off groups (F(2,76)=11.40; p<0.001).
Those with the highest I/O symptomatology were also rated
by their parents as having significantly higher disinhibited
behavior. Furthermore, there were highly significant bivariate
correlations between disinhibited attachment and both parent
and teacher reports of I/O (parent: r=0.46; p<0.001; teacher:
r=0.25; p<0.05). A partial correlation between I/O and
0
5
10
15
20
25
30
Romanian
sample
British norms
(parent report)
British norms
(teacher report)
Male
Female
%
Fig. 2 Percentages in abnormal range for I/O presented by gender in
the Romanian-IR sample age 6 months or over at adoption
R
2
=0.54:
F(2,124)=73.42;p<0.001
R
2
=0.47;
F(2,124)=55.97; p<0.001
=0.67; p<0.001
=0.15;p<0.05
=0.23;p<0.01
=0.58; p<0.001
Inattention/
overactivity
Age 6
Age 11
Conduct
problems
Inattention/
overactivity
Conduct
problems
r=0.33;
p<0.001
r=0.63;
p<0.001
R
2
=0.20
F(2,104)=12.86;p<0.001
R
2
=0.10;
F(2,104)=6.06; p<0.01
=0.40; p<0.001
=0.07;p=0.50
=0.10;p=0.39
=0.25; p<0.05
Inattention/
overactivity
Age 6
Age 11
Conduct
problems
Inattention/
overactivity
Conduct
problems
r=0.64;
p<0.001
r=0.68;
p<0.001
Prediction of
conduct problems
Prediction of I/O
Concurrent I/O and
CP correlation
b Teacher report a Parent report
β
β
β
β
β
β
β
β
Fig. 3 Regression and correlation model of I/O and conduct problems in Romanian-IR sample
J Abnorm Child Psychol (2008) 36:385398 393393
disinhibited attachment was also highly significant (r=0.47;
p<0.001) after controlling for the shared association with
duration of deprivation. This raises the question of whether
I/O, conduct problems and disinhibited attachment within
this sample are overlapping but distinct constructs or differ-
ent elements of the same underlying construct. To investigate
this we carried out an exploratory factor analysis using the
I/O, conduct problem and disinhibited attachment assessment
items. The outcome measures seemed to distinguish the three
domains as separate dissociable factors. The I/O items loaded
together, along with one of the disinhibited attachment items:
wandering off. This factor accounted for 43% of the variance.
The other two disinhibited attachment items: too friendly with
strangers/lack of differentiation and physical contact/lack of
understanding socia l boundaries/personal space loaded
together and accounted for a further 8% of the variance.
The conduct items loaded on two additional factors, largely
divergent according to whether the items tapped aggressive
(e.g. bullies other children) or non aggressive (e.g. often tells
lies) aspects of conduct disturbance and accounted for 12%
and 9% of the variance, respectively.
Discussion
The current results help to identify a number of important
characteristics of I/O as an early adolescent outcome of
severe institutional deprivation.
First, deprivation-related I/O persisted into early adoles-
cence. However, high levels of I/O at 6 years only mod-
erately predicted similarly high levels at 11 years. In general
the findings support developmental continuity, in this as in
other outcomes (Kreppner et al. 2007), evident in large dif-
ferences between adoptee groups and high correlation in
impairment from age 6 to 11. This persistence, despite the
radical change in social environment following adoption,
makes it highly unlikely that the effects are the result of a
behavioral reaction to the poor conditions of the early envi-
ronment, the influence of which one would expect to de-
crease with duration of time spent in good environments.
Rather this is perhaps suggestive of some form of intra-
organismic or fundamental neurobiological alteration. Rutter
and OConnor ( 2004) hyp ot hesi ze d that persi s ten t prob-
lems, such as I/O, following exposure to early severe adverse
events, were the result of experience-adaptive biological pro-
gramming, whereby the brain adapts to certain experiences
during a critical period to optimize the specific conditions of
that environment. This lends itself to the proposition that an
alternative neuro-developmental pathway is initiated during
an early critical period that is adapted to the stressful rearing
environment (Teicher et al. 2003), a model that may hold
some relevance for the persistent adverse effects presented
above. Animal models support the existence of long lasting
effects of early stress on brain development and on later
psychological and behavioral functioning, including altered
structure and function (e.g. HPA axis and associated brain
structures) and neuro-chemical processes as it affects the
processes of neurogenesis, synaptic overproduction and
pruning and myelination (Teicher et al. 2003; McEwan
1999). One such model suggests that antenatal exposure to
glucocorticoids (due to maternal stress or administration of a
synthetic analogue during pregnancy) has long term effects
on the HPA axis development and functioning of offspring
and impacts on later locomotor activity in animals and
ADHD-type behaviours in humans (Kapoor et al. 2007).
Recent MRI work on a subsample of ERA participants is
consistent with this model. Future research is needed to
focus on the role of stress reactivity following early
deprivation in developmental outcomes such as I/O.
Second, and in contrast to the findings at age 6, the
doseresponse relationship between I/O and duration of
deprivation was marked by a clear step-like increase in risk
at around 6 months of institutional deprivation consistent
with a threshold model of early-deprivation-related risk.
This is again consistent with accounts in which early ad-
verse events need to occur within a critical developmental
window for negative outcomes to follow (Bruer 2001). Due
to the inevitable confound between age and duration of
deprivation in the ERA study these models cannot be tested
definitively using the current data. How ever, this finding
does help to disentangle the notion of whether institutional
rearing may in fact be a marker for some underlying genetic
predisposition for problem behaviors such as I/O and also
explore the potential confounding effect of prenatal risk
factors on the prevalence of I/O in this sample. It is possible
that parental ADHD or prenatal risk factors, such as low
birth weight, maternal smoking or alcohol use during
pregnancy or premature birth, known to be associated with
ADHD in the general population, may have had some
impact on the elevated levels and rates of I/O found in our
sample. If selection into institutions reflected such a pre-
disposition or if prenatal risk factors were driving the asso-
ciation between institutional depri vation and I/O then the
increased risk for I/O shoul d be spread across the adoptee
age groups, and not just for those who experienced over
6 months _ deprivation. Moreover, if in fact it was the dose
of deprivation that was the marker for genetic or prenatal
risk then it follows that those chil dren who experienced an
extended period of deprivati on would have greater genetic
liability or prenatal adversity than earlier adopted children.
One reason why it is unlikely that those children who were
adopted at an older age would be differentially affected by
such risk facto rs is that the ERA children could not be
adopted until the fall of the Ceaus$escu regime, thereby
largely avoidin g the possibility that the children who
394 J Abnorm Child Psychol (2008) 36:385398
resided longer in the institutions comprised those who had
not been adopted sooner, possibly due to developmental or
behavioral problems (which could be influenced by genetic
makeup or prenatal adversity). However, such processes
cannot be definitively tested and the potential influence of
genetic predisposition and prenatal risk are important
limitations to the current study.
There are also several other potentially confounding fac-
tors that warrant mention here but are unfortunately outside
the scope of the current paper and have been addressed in
other papers by the ERA study. Factors such as differences
in quality of care between individual children and between
inst itutions (Castle et al. 1999), physical health status
(Beckett et al. 2003) and post institution rearing environ-
ment may all potentially have had some impact on
persistence and prevalence of I/O impairment. However, it
is worth noting that the quality of care in the institutions
ranged from poor to abysmal and that the post adoption
rearing environments have not been found to mediate the
impact of institutional deprivation on other areas of
impairment, although this may be due to a lack of variation
in range (see Colvert et al. in press; Kreppner et al. 2007).
Our third main finding is that by 11 years deprivation-
related I/O impairment was more common in boys than
girls, as is the case in nondeprivation-related I/O, with a
similar gender discrepancy in prevalence rates to that seen
in clinical and epidemiological populations. This was a
different picture from that at age 6 where roughly equal
numbers of boys and girls exhibited I/O difficulties. This
shift in the sex ratio may reflect a development al process
whereby more general risk factors for I/O other than those
specifically related to deprivation come into play as one
moves further away in time from the institutional exposure.
Fourth, deprivation-related I/O was associated with con-
duct problems. However, we need to be cautious about
drawing a direct comparison between deprivation and non-
deprivation-related I/O in this regard, because in non-
deprived samples most evidence supports the model that
I/O is a developmental precursor for conduct problems
rather than the other way around (Burke et al. 2005). The
current analysis suggest a more complicated reciprocal pat-
tern with parent data showing both I/O leading to conduct
problems and conduct problems leading to I/O. Addition-
ally, teacher data does not support a developmental path-
way from early I/O to later conduct problems at all. This
lack of effect in teacher reports may be due to the fact that
different raters are reporting at different ages. Individual
teachers may have different tolerances to what they see as
problematic behaviour in the classroom, especially at the
different developmental stages. Parent reports are far more
consistent over time. Furthermore, these mixed findings
may be due in part to the behaviors being rated on ques-
tionnaire scales that are very good at picking up behavioral
problems in general but are perhaps less proficient at pick-
ing up the development o f multiple domains, particularly
highly correlated ones. Fifth, I/O was associated with defi-
cient executive functioning, at least as measured by the
Stroop test of interference control, despite no association
with IQ. This associ ation was also reflected in the corre-
lation between I/O and both our measures of executive
functioning. However, the use of a risk subsample with
depressed IQ scores overall suggests that the lack of effect
of I/O status could be largely due to the overriding in-
fluence of duration of deprivation on IQ scores. Although
one must be cautious about over-interpreting the finding of
impaired executive function in relation to I/O, as it is based
on only two tests, it does provide the first evidence that I/O
in institutionally deprived samples bears the hallmark exec-
utive dysfunction found in ADHD and that it may also
share elements of its psychopathophysiology (Willcutt et al.
2005). Studies with larger batteries of meas ures that in-
vestigate the functional neuro-anatomy of execut ive dys-
function in deprivation-related I/O are warranted. One key
question is whether functional alterations in the fronto
striatal circuits implicated in executive dysfunction in ADHD
are also the basis for impairment in deprived samples, or are
alterations in brain circuits more typically regarded as stress
targets (hippocampus, amygdala etc) the main locus for
impairment.
Sixth, despite being dissociable constructs there was an
overlap between I/O and disinhibited attachment, as has
been identified in other institution reared samples (Roy et al.
2004). This overlap was not accounted for by the shared
association with duration of deprivation. On the face of it
this seems like a distinctive feature of deprivatio n-related
I/O. At present, however, there is insufficient evidence from
non-deprived samples to assess whether disinhibited attach-
ment of the sort displayed by the deprived children in the
current sample might also be present as an important clin-
ical feature in at least a subsample of ADHD cases.
In summary, the evidence suggests that I/O is a fairly
stable domain of impairment for this group of children and
the risk for I/O continues to be associated with institutional
deprivation into early adolescence. This highlights the long
lasting effects of the childrens early adverse experience
and institutional rearing. Furthermore, our analyses suggest
that deprivation-related I/O shares a number of the features
of I/O in non-deprived samples despite its different etiology
and putative developmental mechanisms. This begs the
question as to whether institutional deprivation should be
seen as one (uncommon) route into a common disorder
(ADHD) or whether deprivation-related I/O should be
seen as a qualitatively different clinical phenotype with a
distinct pathophysiology. One strategy for addressing this
question scientifically involves hypothesizing a plausible,
neuro-biological mechanism by which early institutional
J Abnorm Child Psychol (2008) 36:385398 395395
deprivation might lead to ADHD in its normal clinical
expression. One such mechanism, although speculative at
this stage, relates to the long term negative down-stream
effects on neuro-transmitter branches (e.g. dopamine and
norepinephrine systems; Pani et al. 2000) and brain circuits
(e.g. dorsal striatum, pre-frontal cortex) implicated in the
patho-physiology of ADHD (Sanchez et al. 2001) of early
stress-related dysregulations of the hypothalamic-pituitary
adrenal axis (Kaufman and Cha rney 2001). If this were the
operative pathway then one would predict that I/O would
be a persistent domain of impairment and would share
many similarities with ADHD at the pathophysiological
level because of the involvement of common dopamine
modulated brain networks. The current data go a small way
to supporting this type of account but much more research into
the genetics and pathophysiology of deprivation-related I/O is
required before a definitive answer can be given.
Acknowledgements We are most grateful to all the families who have
generously given their time to participating in this study, and whose
comments and suggestions have been very helpful in relation to the
interpretation of findings. The data collection phase of the study was
supported by grants from the Helmut Horten Foundation and the UK
Department of Health. Ongoing support is provided by grants from the
Department of Health, the Nuffield Foundation and the Jacobs Foun-
dation. 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.
Table 3 Items used to assess I/O and conduct difficulties: the Revised Rutter Parent and Teacher Scales for School-age Children (Hogg et al.
1997) and the Strengths and Difficulties Questionnaire (SDQ; Goodman 1999)
Mother and father items Teacher items
Rutter Scales SDQ Rutter Scales SDQ
Inattention/
overactivity
score
Very restless, has difficulty
staying seated for long
Restless, overactive, cannot stay
still for long
Very restless, has difficulty
staying seated for long
Restless, overactive, cannot
stay still for long
Squirmy, fidgety child Constantly fidgeting or squirming Squirmy, fidgety child Constantly fidgeting or
squirming
Inattentive, easily distracted Easily distracted, concentration
wanders
Inattentive, easily distracted Easily distracted,
concentration wanders
Cannot settle to anything for
more than a few moments
Sees tasks through to the end,
good attention span (coding
reversed)
Cannot settle to anything for
more than a few moments
Sees tasks through to the end,
good attention span (coding
reversed)
Thinks things out before acting
(coding reversed)
Fails to finish things started
short attention span
Thinks things out before
acting (coding reversed)
Excessive demands for
teachers attention
Conduct
difficulties
score
Frequently fights or is
extremely quarrelsome with
other children
Often fights with other children
or bullies them
Frequently fights or is
extremely quarrelsome
with other children
Often fights with other
children or bullies them
Has stolen things on more than
one occasion in the past
12 months
Steals from home, school
or elsewhere
Has stolen things on one or
more occasions in the past
12 months
Steals from home, school
or elsewhere
Is often disobedient Generally obedient, usually does
what adults request (coding
reversed)
Is often disobedient Generally obedient, usually
does what adults request
(coding reversed)
Often tells lies Often lies or cheats Often tells lies Often lies or cheats
Kicks or bites other children Often has temper tantrums
or hot tempers
Often destroys or damages
own or others property
Often has temper tantrums
or hot tempers
Blames others for things Kicks, bites other children
Bullies other children Blames others for things
Inconsiderate of others Bullies other children
Inconsiderate of others
Disturbs other children
Appendix
396 J Abnorm Child Psychol (2008) 36:385398
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398 J Abnorm Child Psychol (2008) 36:385398
    • "The amount depends on the income of the parents, and is currently up to 1,900 USD per year on average (more in the younger years and gradually less as the children age). In contrast, the RIA with the strongest predictive ability in the present study was placement in out-of-home care, a finding , which is in accordance with previous studies suggesting a strong association between early institutionalization and ADHD [36][37][38][39]. Despite the fact that our results show that there are substantial differences in the predictive ability of the various RIA, the maintained dose-response relationship across the leave-one-out Table 2. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Attention-deficit/hyperactivity disorder (ADHD) is a prevalent neurodevelopmental disorder with early onset. ADHD is associated with significant morbidity and mortality, partly due to delayed diagnosis. Identification of children at high risk for developing ADHD could lead to earlier diagnosis and potentially change the negative trajectory of the illness for the better. Since early psychosocial adversity is considered to be a likely etiological risk factor for ADHD, markers of this construct may be useful for early identification of children at high risk. Therefore, we sought to investigate whether Rutter's indicators of adversity (low social class, severe marital discord, large family size, paternal criminality, maternal mental disorder, and placement in out-of-home care) assessed in infancy could serve as early predictors for the development of ADHD. Methods and findings: Using data from the Danish nationwide population-based registers, we established a cohort consisting of all 994,407 children born in Denmark between January 1st 1993 and December 31st 2011 and extracted dichotomous values for the six Rutter's indicators of adversity at age 0-12 months (infancy) for each cohort member. The cohort members were followed from their second birthday and the association between the sum of Rutter's indicators of adversity (RIA-score) in infancy and subsequent development of ADHD was estimated by means of Cox regression. Also, the number needed to screen (NNS) to detect one case of ADHD based on the RIA-scores in infancy was calculated. During follow-up (9.6 million person-years), 15,857 males and 5,663 females from the cohort developed ADHD. For both males and females, there was a marked dose-response relationship between RIA-scores assessed in infancy and the risk for developing ADHD. The hazard ratios for ADHD were 11.0 (95%CI: 8.2-14.7) and 11.4 (95%CI: 7.1-18.3) respectively, for males and females with RIA-scores of 5-6, compared to males and females with RIA-scores of 0. Among males with RIA-scores of 5-6, 37.6% (95%CI: 27.0-50.7) had been diagnosed with ADHD prior to the age of 20, corresponding to a NNS of 3.0 (95%CI: 2.2-4.0). Conclusions: Rutter's indicators of adversity assessed in infancy strongly predicted ADHD. This knowledge may be important for early identification of ADHD.
    Article · Jun 2016
    • "In fact, those individuals in the institutions for less than 6 months were in many ways indistinguishable from typically developing peers (Kreppner et al., 2007). Many adoptees also displayed clinically elevated levels of ADHD symptoms at all follow-ups – again showing the characteristic step-wise increase with duration of deprivation (Kreppner, O'Connor, Rutter, & the ERA Team, 2001; Stevens et al., 2008). At age 15 years, individuals who experienced more than 6-month deprivation were four times more likely to meet DSM-IV diagnostic criteria for ADHD than those with less than 6-month deprivation (16% vs. 4%) (Stevens et al., 2009). "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Early-life institutional deprivation is associated with attention-deficit/hyperactivity disorder (ADHD) later in childhood and adolescence. In this article, we examine, for the first time, the persistence of deprivation-related ADHD into young adulthood in a sample of individuals adopted as young children by UK families after periods in extremely depriving Romanian orphanages. Methods: We estimated rates of ADHD at age 15 years and in young adulthood (ages 22-25 years) in individuals at low (LoDep; nondeprived UK adoptees and Romanian adoptees with less than 6-month institutional exposure) and high deprivation-related risk (HiDep; Romanian adoptees with more than 6-month exposure). Estimates were based on parent report using DSM-5 childhood symptom and impairment criteria. At age 15, data were available for 108 LoDep and 86 HiDep cases, while in young adulthood, the numbers were 83 and 60, respectively. Data on education and employment status, IQ, co-occurring symptoms of young adult disinhibited social engagement (DSE), autism spectrum disorder (ASD), cognitive impairment, conduct disorder (CD), callous-unemotional (CU) traits, anxiety, depression and quality of life (QoL) were also collected. Results: ADHD rates in the LoDep group were similar to the general population in adolescence (5.6%) and adulthood (3.8%). HiDep individuals were, respectively, nearly four (19%) and over seven (29.3%) times more likely to meet criteria, than LoDep. Nine 'onset' young adult cases emerged, but these had a prior childhood history of elevated ADHD behaviours at ages 6, 11 and 15 years. Young adult ADHD was equally common in males and females, was predominantly inattentive in presentation and co-occurred with high levels of ASD, DSE and CU features. ADHD was associated with high unemployment and low educational attainment. Conclusion: We provide the first evidence of a strong persistence into adulthood of a distinctively complex and impairing deprivation-related variant of ADHD. Our results confirm the powerful association of early experience with later development in a way that suggests a role for deep-seated alterations to brain structure and function.
    Article · Jun 2016 · Psychological Medicine
    • "The association between institutionalization and symptoms of ADHD observed here are consistent with results from a number of other studies (e.g. Kreppner et al. 2001; Stevens et al. 2008; Wiik et al. 2011), as well as our own work in the BEIP when the children were assessed at earlier ages (Zeanah et al. 2009). Elevated ADHD symptomatology associated with early institutionalization is likely to result from deficits in neurodevelopmental processes. "
    [Show abstract] [Hide abstract] ABSTRACT: Background: Young children raised in institutions are exposed to extreme psychosocial deprivation that is associated with elevated risk for psychopathology and other adverse developmental outcomes. The prevalence of attention deficit hyperactivity disorder (ADHD) is particularly high in previously institutionalized children, yet the mechanisms underlying this association are poorly understood. We investigated whether deficits in executive functioning (EF) explain the link between institutionalization and ADHD. Method: A sample of 136 children (aged 6-30 months) was recruited from institutions in Bucharest, Romania, and 72 never institutionalized community children matched for age and gender were recruited through general practitioners' offices. At 8 years of age, children's performance on a number of EF components (working memory, response inhibition and planning) was evaluated. Teachers completed the Health and Behavior Questionnaire, which assesses two core features of ADHD, inattention and impulsivity. Results: Children with history of institutionalization had higher inattention and impulsivity than community controls, and exhibited worse performance on working memory, response inhibition and planning tasks. Lower performances on working memory and response inhibition, but not planning, partially mediated the association between early institutionalization and inattention and impulsivity symptom scales at age 8 years. Conclusions: Institutionalization was associated with decreased EF performance and increased ADHD symptoms. Deficits in working memory and response inhibition were specific mechanisms leading to ADHD in previously institutionalized children. These findings suggest that interventions that foster the development of EF might reduce risk for psychiatric problems in children exposed to early deprivation.
    Full-text · Article · Oct 2015
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