Are There Biological Programming Effects for Psychological Development? Findings From a Study of Romanian Adoptees

Outcomes of children adopted from Eastern Europe

Behavioral problems are frequent among post-institutionalized Eastern European adoptees. However, risk factors related to outcomes have not been fully delineated. We evaluated 50 Eastern European adoptees, age 8—10 years, with their adoptive families for more than five years. Cognitive and behavioral outcomes and parenting stress were evaluated in relation to pre-adoptive risk factors, including arrival age, growth, and facial phenotype related to prenatal alcohol exposure. At follow-up, IQ and achievement scores were ≥ average in most children (≥74%). Behavioral and school problems were common (externalizing 44%, internalizing 18%, behavioral symptoms 50%, attention deficit hyperactivity disorder (ADHD) 46%, learning disabilities 40%, mental health disorders 28%); 38% had multiple problems. Behavioral problems correlated inversely with IQ. Parent stress was high and correlated with child externalizing behaviors and inversely to child full scale IQ. Children with “severe behavioral disturbances” (24%) were more likely to have had smaller head circumferences at arrival. Child's age at adoption related inversely to parent stress, possibly due to the longer duration of time that children resided with their families. “High/intermediate risk” phenotypic facial scores for prenatal alcohol exposure (58%) correlated with head circumference z scores at arrival and follow-up. Otherwise, arrival age, growth, and facial phenotype did not correlate with these specific outcome measures.

Early childhood stress is associated with elevated antibody levels to herpes simplex virus type 1

It is well known that children need solicitous parenting and a nurturing rearing environment to ensure their normal behavioral development. Early adversity often negatively impacts emotional and mental well-being, but it is less clearly established how much the maturation and regulation of physiological systems is also compromised. The following research investigated the effect of 2 different types of adverse childhood experiences, early deprivation through institutionalization and physical abuse, on a previously unexplored outcome: the containment of herpes simplex virus (HSV). The presence of HSV-specific antibody in salivary specimens was determined in 155 adolescents, including 41 postinstitutionalized, 34 physically-abused, and 80 demographically-similar control youth. Across 4 school and home days, HSV antibody was higher in both postinstitutionalized and physically-abused adolescents when compared with control participants. Because the prevalence of HSV infection was similar across the groups, the elevated antibody was likely indicative of viral recrudescence from latency. Total secretory Ig-A secretion was associated with HSV, but did not account for the group differences in HSV-specific antibody. These findings are likely caused by a failure of cellular immune processes to limit viral reactivation, indicating a persistent effect of early rearing on immune functioning. The fact that antibody profiles were still altered years after adoption into a more benevolent setting with supportive families suggests these results were not caused by contemporaneous factors, but rather reflect a lingering influence of earlier life experiences.

Risk and resilience: early manipulation of macaque social experience and persistent behavioral and neurophysiological outcomes

OBJECTIVE

To review the contributions of research on nonhuman primates, specifically macaque monkeys, to the understanding of early social stress and its effects on behavior and neurophysiology.

METHOD

Review and synthesis of two bodies of work on macaque monkeys and early social manipulation: peer rearing and variable foraging demands. The literature was searched with Medline using key terms macaque, variable foraging, and peer rearing. The reference lists of these articles were also used to generate potential studies for review.

RESULTS

Nonhuman primate macaques show similarities to humans in their social development and functioning. Peer rearing of young macaques and rearing of young macaques with mothers experiencing variable foraging conditions both result in increased anxious, impulsive, and aggressive temperament and behavior; more reactive stress physiology; altered neurotransmitter functioning; and immune and metabolic changes. Functional variants of specific genes that code for neuromodulators are mediators of these effects.

CONCLUSIONS

Disrupted social relations during macaque rearing contribute to the risk for developing emotional and neurophysiological disturbance. In the face of such disruption, certain genotypes contribute to resilience. This can be alternately stated that, for animals of high-risk genotypes, resilience is conferred by quality relationships during rearing. This interaction of genetics with early social environment also applies to child mental health, implicating biological mediators identified in macaques as contributing to more complex outcomes in humans.

Non-human primates: model animals for developmental psychopathology

Non-human primates have been used to model psychiatric disease for several decades. The success of this paradigm has issued from comparable cognitive skills, brain morphology, and social complexity in adult monkeys and humans. Recently, interest in biological psychiatry has focused on similar brain, social, and emotional developmental processes in monkeys. In part, this is related to evidence that early postnatal experiences in human development may have profound implications for subsequent mental health. Non-human primate studies of postnatal phenomenon have generally fallen into three basic categories: experiential manipulation (largely manipulations of rearing), pharmacological manipulation (eg drug-induced psychosis), and anatomical localization (defined by strategic surgical damage). Although these efforts have been very informative each of them has certain limitations. In this review we highlight general findings from the non-human primate postnatal developmental literature and their implications for primate models in psychiatry. We argue that primates are uniquely capable of uncovering interactions between genes, environmental challenges, and development resulting in altered risk for psychopathology.

An implicit enumeration method for an exact test of weighted kappa

The kappa coefficient is one of the most widely used measures for evaluating the agreement between two raters asked to assign N objects to one of K nominal categories. Weighted versions of kappa enable partial credit to be awarded for near agreement, most notably in the case of ordinal categories. An exact significance test for weighted kappa can be conducted by enumerating all rater agreement tables with the same fixed marginal frequencies as the observed table, and accumulating the probabilities for all tables that produce a weighted kappa index that is greater than or equal to the observed measure. Unfortunately, complete enumeration of all tables is computationally unwieldy for modest values of N and K. We present an implicit enumeration algorithm for conducting an exact test of weighted kappa, which can be applied to tables of non-trivial size. The algorithm is particularly efficient for 'good' to 'excellent' values of weighted kappa that typically have very small p-values. Therefore, our method is beneficial for situations where resampling tests are of limited value because the number of trials needed to estimate the p-value tends to be large.

Is sub-nutrition necessary for a poor outcome following early institutional deprivation?

Institutional deprivation is multifaceted and includes adverse psychosocial and nutrition-related components. In this study we partitioned these risks in relation to cognitive impairment and mental ill health, and explored the mediating role of reduced head/brain size. There were 138 participants (61 males, 77 females) in the study. Participants were Romanian adoptees who had experienced at least 2 weeks of early institutional deprivation. The sample was stratified on the basis of duration of deprivation (high risk >6 mo in institutions) and sub-nutrition (i.e. 1.5 SD below UK age-related norms for weight at UK entry). UK children adopted before 6 months of age and a group of non-institutionally deprived Romanian children constituted the comparison groups. Duration of deprivation was associated with smaller head circumference, lowered IQ, and increased mental heath problems, independently of effects found for sub-nutrition on head circumference and IQ. The mediating role of head circumference was limited to either sub-nourished (IQ) or non-sub-nourished (inattention/overactivity and disinhibited attachment) subgroups. Many negative effects of early deprivation, including stunted brain growth, occur without sub-nutrition: psychosocial deprivation plays a major role in neurodevelopmental effects of deprivation. Further studies of functional and structural neuroanatomy following institutional deprivation are required to delineate the role of brain development in its effects.

Duration of early maternal separation and prediction of schizotypal symptoms from early adolescence to midlife

Early childhood experiences influence the capacity for healthy social and emotional development. The present study uses longitudinal data to determine whether early maternal separation predicted the subsequent development of schizotypal personality disorder (SPD) symptoms assessed repeatedly from early adolescence over the following 20 years. Within this community sample (N=766), multilevel linear regression analyses revealed the duration of separation from mother in the first 2 years of life predicted elevated SPD symptoms. This relationship was specific to children with mother-reported early angry emotional behavior. These results provide support for the role of early childhood psychosocial risk factors in the development of subsequent schizophrenia spectrum symptoms in emotionally vulnerable children.

Children adopted from China: a prospective study of their growth and development

BACKGROUND

China has become a lead country for international adoption because of the relatively young age of the children and reported positive conditions of the orphanages. This study examined the process and outcome of growth and development of children adopted from China over their first two years with their adoptive families.

METHOD

Seventy infant girls adopted from China at 8 to 21 months of age (Mean age = 13 months) were examined on arrival in Canada and 6, 12, and 24 months later. Comparisons were made with non-adopted Canadian girls of similar age and from a similar family background as adoptive parents on indices of growth and standardized measures of mental, psychomotor, and language development.

RESULTS

At arrival, children adopted from China were smaller physically and exhibited developmental delays compared to current peers. Children adopted from China were functioning in the average range on physical and developmental measures within the first 6 months following adoption. However, they were not performing as well as current peers until the end of their second year after adoption. Even then, there was developmental variation in relation to comparison children and continuation of relatively smaller size with respect to height, weight, and head circumference. Physical measurement was related to outcomes at various points on all developmental measures.

CONCLUSIONS

Deprivation in experience in the first year of life has more long-lasting effects on physical growth than on mental development. The variable most consistently related to development was height-to-age ratio. As a measure of nutritional status, the findings reinforce the critical importance of early nutrition.

Psychobiology of childhood maltreatment: effects of allostatic load?

OBJECTIVE: Facing an adverse physical or psychosocial situation, an individual is forced to adapt in order to survive. Allostasis is the term used to refer to adapting processes used to maintain the stability of an organism through active processes. When allostatic response is excessive or inefficient, the organism develops an allostatic load. The cascade of molecular and neurobiological effects associated with childhood abuse and neglect could be an example of allostatic response that could precipitate allostatic load in organism still vulnerable during its development. This article reviews the psychobiological consequences related to childhood abuse and neglect. METHOD: A selective review with a systematic procedure was performed to investigate studies showing explicit association between childhood maltreatment and psychobiological/neurobiological consequences. We searched electronic database MedLine-PubMed to identify English-language articles from 1990 to 2007. RESULTS: From 115 articles we selected 55 studies from MedLine and 30 from their reference lists, in a total of 85 articles (JCR IF range: 1-31.4; median: 5.88). Only 29 studies showed direct and explicit association between them. CONCLUSION: Structural consequences of childhood maltreatment include disruptive development of corpus callosum, left neocortex, hippocampus, and amygdale; functional consequences include increased electrical irritability in limbic areas, frontal lobe dysfunctions and reduced functional activity of the cerebellar vermis; and neurohumoral consequences include the reprogramming activity of hypothalamo-pituitary-adrenal (HPA) axis and subsequently the stress response.

Sensitive, stimulating caregiving predicts cognitive and behavioral resilience in neurodevelopmentally at-risk infants

Although neurodevelopmental impairment is a risk factor for poor cognitive and behavioral outcomes, associations between early and later functioning are only moderate in magnitude, and it is likely that other factors intervene to modify this trajectory. The current study tested the hypothesis that sensitive, stimulating caregiving would promote positive behavioral and cognitive outcomes among children who were at risk based on the results of a neurodevelopmental screener and a temperament inventory. The sample comprised 1,720 infants and toddlers from the National Survey of Child and Adolescent Well-Being, a longitudinal study of children who were involved with child welfare services. Children were first assessed between 3 and 24 months of age and subsequently 18 months later. Children who experienced improvements in the amount of sensitive, stimulating caregiving they received had positive cognitive and behavioral outcomes 18 months later, despite early levels of neurodevelopmental risk. The association between changes in caregiving quality and changes in children's functioning was stronger for children who were removed from the care of their biological parents before the follow-up assessment than for children who remained in the care of biological parents, suggesting a causal role for caregiving quality on children's outcomes.

Effects of early intervention on EEG power and coherence in previously institutionalized children in Romania

Two groups of Romanian children were compared on spectral power and coherence in the electroencephalogram (EEG) in early childhood. One group consisted of previously institutionalized children who had been randomly assigned to a foster care intervention at a mean age of 23 months. The second group had been randomized to remain in institutional care. Because of a policy of noninterference, a number of these children also experienced placement into alternative family care environments. There were minimal group differences between the foster care and institutionalized groups in EEG power and coherence across all measured frequency bands at 42 months of age. However, age at foster care placement within the foster care group was correlated with certain measures of EEG power and coherence. Earlier age at foster care placement was associated with increased alpha power and decreased short-distance EEG coherence. Further analyses separating age at placement from duration of intervention suggest that this effect may be more robust for EEG coherence than EEG band power. Supplementary analyses examined whether the EEG measures mediated changes in intellectual abilities within the foster care children, but no clear evidence of mediation was observed.

Inattention/overactivity following early severe institutional deprivation: presentation and associations in early adolescence

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.

Language acquisition with limited input: Romanian institution and foster care

PURPOSE

To provide the first detailed information about native language abilities of children who are or had been institutionalized.

METHOD

The language of ten 30-month-old children raised in Romanian orphanages was compared with that of 30 chronological-age-matched peers: 10 children who had moved recently from orphanages to foster care, 10 children in foster families for at least 1 year, and 10 children raised in their biological families. Ten language measures were obtained from communication during play and from parent/caregiver report.

RESULTS

Children who were institutionalized and children in foster care for a brief time showed substantial language delays, with some of these children not yet producing intelligible words. Children in foster care for at least 1 year approximated the expressive output and receptive language of children who had never been institutionalized; however, they showed lower expressive grammatical abilities. Within the group of children who were institutionalized, the presence of a preferred caregiver and a measure of development, greater height, were associated with greater language output. Although children in orphanages produced fewer complex forms than children in biological families, there were no systematic qualitative differences in language structure across groups.

CONCLUSION

Foster care facilitated language growth after substantial language delays associated with institutionalization.

Plasticity of growth in height, weight, and head circumference: meta-analytic evidence of massive catch-up after international adoption

Are serious growth delays caused by malnutrition and neglect permanent or reversible? The effects of institutionalization and international adoption on children's physical growth are estimated with meta-analysis. Studies with sufficient data to compute differences between adoptees and the reference population (33 papers with 122 study outcomes) were collected through Web of Science, ERIC (Education Resource Information Center), PsycINFO (Psychological Literature), and Medline (U.S. National Library of Medicine) (1956-2006). The influence of pre- and postadoption care on height, weight, and head circumference was tested. Effect sizes (d) and confidence intervals (CIs) around the point estimate for the growth lag indices were computed. The more time spent in institutional care, the more the children lagged behind in physical growth (d = 1.71, 95% CI: 0.82-2.60, n = 893). At adoptive placement, the children showed large delays in height, weight, and head circumference (d = -2.39 to -2.60; n = 1331-3753). Although after adoption, they showed almost complete catch-up of height (d = -0.57, 95% CI: -0.87 to -0.27, n = 3437 adoptees) and weight (d = -0.72, 95% CI: -1.04 to -0,39, n = 3259 adoptees), catch-up of head circumference seemed slower and remained incomplete (d = -1.56, 95% CI: -2.27 to -0.85, n = 527). Later age at arrival was related to less complete catch-up of height and weight. International adoption leads to substantial catch-up of height and weight but not of head circumference, demonstrating differential plasticity of children's physical growth.

Recent advances in the theories of and interventions with attachment disorders

PURPOSE OF REVIEW

The present review examines the available literature to consider recent advances in the theories of, and interventions with, disorders of attachment. We discuss the existing evidence to argue that the conceptualization of attachment disorders remains problematic despite their clinical significance.

RECENT FINDINGS

Research into clinical disorders of attachment is limited, but there is some recent evidence that a standardized approach to diagnosis may improve identification. The current classificatory systems do not accommodate all clinical presentations and proposed broader approaches have greater clinical utility. A recent review of interventions for attachment disordered children confirms that 'coercive' interventions have no empirical support and are not biased on coherent principles of attachment theory.

SUMMARY

Clinical interest in identification and treatment of attachment disorders has remained high. This is despite continuing confusion regarding terminology, phenomenology and diagnosis. The lack of agreed definition and conceptualization of these conditions is reflected in disparate approaches to intervention and limited empirical data. Interventions have little demonstrated benefit and some potential risk.

The International Adoption Project: population-based surveillance of Minnesota parents who adopted children internationally

OBJECTIVES

To conduct the first population-based surveillance in the United States of parents who adopted children from countries outside of the United States.

METHODS

A 556-item survey was mailed to 2,977 parents who finalized an international adoption in Minnesota between January 1990 and December 1998; 1,834 (62%) parents returned a survey.

RESULTS

Eighty-eight percent of the parents reported transracial adoptions (97% of the parents were white); 57% of the adopted children were Asian; 60% were female; and on average, the children were 18 months-old at the time of placement. Only 15% of the parents reported household annual incomes less than $50,000 and 71% reported they had college educations. Sixty-one percent traveled to their child's country of birth prior to the adoption. Almost three-quarters involved their children in experiences related to their birth countries and 98% would recommend international adoption. Three-quarters of the parents believe that parental leave was an issue for them as they adopted.

CONCLUSIONS

This is the first population-based survey of U.S. parents who have adopted internationally. The adoptive parents were socioeconomically different than birth parents in Minnesota and their families are most likely to be transracial. Because international adoption has become more prevalent, it is important to understand the strengths and needs of families that are created through this unique form of migration.

Physical abuse and neglect of children

Child maltreatment includes physical abuse and neglect, and happens in all countries and cultures. Child maltreatment usually results from interactions between several risk factors (such as parental depression, stress, and social isolation). Physicians can incorporate methods to screen for risk factors into their usual appointments with the family. Detection of physical abuse is dependent on the doctor's ability to recognise suspicious injuries, such as bruising, bite marks, burns, bone fractures, or trauma to the head or abdomen. Neglect is the most common form of child maltreatment in the USA. It can be caused by insufficient parental knowledge; intentional negligence is rare. Suspected cases of child abuse should be well documented and reported to the appropriate public agency which should assess the situation and help to protect the child.

Maternal isolation alters the expression of neural proteins during development: 'Stroking' stimulation reverses these effects

Rat pups reared apart from their siblings, mother, and nest environment in the 'pup-in-a-cup' regime show many alterations in behavior reminiscent of the Institutional Inattention/Overactivity Syndrome that characterizes children whose first few months are spent in institutions. In this report, we compare mother-reared (MR) and artificially reared (AR) male rats in concentrations and distributions of brain proteins that are involved in normal brain development. When assessed during the juvenile period and in adulthood, AR animals showed elevations in Neu-N (a neuronal marker) and in S-100 (an astrocyte marker) but reductions in synaptophysin (synapse protein), N-CAM (cell-adhesion molecule), GAP-43 (axon elongation protein), and BDNF (brain derived neurotrophic factor) in comparison to MR controls in many brain sites involved in attention, impulsivity, activity, and social behavior. Daily 'licking-like' stimulation provided to AR animals (AR-MAX) throughout early development that reverses many of the behavioral deficits, also reverses many of the isolation effects on brain proteins. Study 2 showed that elevations in the number of neurons in combination with decreases in functionality are associated with a reduction in neuronal pruning and apoptosis during the very early post-partum period in AR animals and their reversal through daily 'licking-like' stimulation.

Behavioral and physiological effects of an infant-neglect manipulation in a bi-parental, twinning primate: impact is dependent on familial factors

Experimental animal studies and epidemiological and clinical human studies demonstrate that atypical infant-caregiving can exert short- and long-term effects on offspring phenotype, including increased long-term risk of affective disorders. Whilst the early environment is therefore a major determinant of behavioral, physiological and neurobiological phenotypes, the effects of early adversity exhibit individual variation, presumably due to differences in environment-genotype interactions. Twin studies provide a powerful model with which to study such interactions. However, human twin studies rarely include analysis of genotype-environment interactions or of individuals exposed to extreme environments, and rat studies have rarely attempted to utilize littermates (i.e. dizygotic twins) to investigate environment-genotype interactions. Here, we report on the effects of repeated deprivation of caregiving in the common marmoset, a primate that exhibits dizygotic twinning and bi-parental care. Breeding pairs each contributed early deprived (ED) twins and control (CON) twins, thereby allowing for the study of effects of ED, parentage and ED-parentage interaction. Significant ED x parentage interaction effects were obtained for basal urinary, plasma and cerebrospinal-fluid cortisol titers (infancy-adolescence), and basal levels of social and maintenance behaviors (juveniles); basal urinary cortisol titers during a 2-week period of repeated psychosocial challenge (juveniles), and social and exploratory behavior during psychosocial challenge (juveniles). Significant main effects of ED were obtained for: basal levels of time spent in contact with parents (ED>CON; juveniles) and in locomotor activity (ED<CON; adolescents); basal and psychosocial-stress-related systolic blood pressure (ED>CON; juveniles); time spent in locomotor activity (ED<CON), contact calling (ED<CON) and exploring novelty (ED>CON) during psychosocial challenge (juveniles). This study provides evidence for long-term effects of early environment on bio-behavioral traits and states in marmosets specifically, and the importance of including parental factors in developmental studies in mammals generally.

Predicting language outcomes for internationally adopted children

PURPOSE

Language and speech are difficult to assess in newly arrived internationally adopted children. The purpose of this study was to determine if assessments completed when toddlers were first adopted could predict language outcomes at age 2. Local norms were used to develop early intervention guidelines that were evaluated against age 2 outcomes. Patterns of language emergence were also analyzed.

METHOD

Twenty-seven children between 11 and 23 months of age adopted from Eastern Europe were followed from adoption through the 1st year home. Results from initial assessments using the Communication and Symbolic Behavior Scales-Developmental Profile (CSBS-DP; A. Wetherby & B. Prizant, 2002) and MacArthur Communicative Development Inventory-Words and Gestures (MCDI-WG; L. Fenson et al., 1993) were compared against speech and language outcomes 1 year later when the children were 2 years of age.

RESULTS

By age 2, receptive language and articulation were developing well; expressive language was still emerging. Initial assessment using the CSBS-DP Behavior Sample and MCDI-WG Words Understood Developmental Quotient predicted age 2 language outcomes. Early intervention guidelines based on these 2 measures had strong positive and negative likelihood ratios (LR) when using age 2 outcomes as the criteria (LR+ = 21.00; LR- = .00). Six of the 27 children (22%) had slow language development in comparison to their peers.

CONCLUSION

Newly adopted children with delays on prelinguistic and vocabulary comprehension measures were highly likely to have slow language development at age 2. Initial assessments of these abilities should be used to make early intervention decisions.

Amygdala gene expression correlates of social behavior in monkeys experiencing maternal separation

Children exposed to early parental loss from death or separation carry a greater risk for developing future psychiatric illnesses, such as major depression and anxiety. Monkeys experiencing maternal separation at 1 week of age show fewer social behaviors and an increase in self-comforting behaviors (e.g., thumb sucking) over development, whereas in contrast, monkeys experiencing maternal separation at 1 month of age show increased seeking of social comfort later in life. We sought to identify neural systems that may underlie these stress-induced behavioral changes by examining changes in mRNA content in amygdala tissue collected from 1 week separated, 1 month separated, and maternally reared infants at 3 months of age. mRNA from the right medial temporal lobe, primarily the amygdala, was analyzed using Affymetrix U133A 2.0 arrays. One gene, guanylate cyclase 1 alpha 3 (GUCY1A3), showed differential expression between the 1 week and maternally reared groups and the 1 week and 1 month groups; these changes were confirmed by in situ hybridization. The expression of this gene was positively correlated with acute social-comforting behavior (r = 0.923; p = 0.001) and longer-term close social behavior (r = 0.708; p = 0.015) and negatively correlated with self-comforting behaviors (r = -0.88; p < 0.001). Additional in situ hybridization studies of GUCY1A3 in normal monkeys showed that this gene is expressed at adult levels by 1 week of age and that its expression is greater in the amygdala than all other brain areas examined. We conclude that GUCY1A3 may contribute to the altered behavioral phenotypes that are differentially displayed depending on the age at which macaque infants experience an early-life stress.

Behavior problems in postinstitutionalized internationally adopted children

Using the Child Behavior Checklist (CBCL), the rate and type of behavior problems associated with being reared in an institution prior to adoption were examined in 1,948, 4- through 18-year-old internationally adopted children, 899 of whom had experienced prolonged institutional care prior to adoption. The children's adoptions were decreed between 1990 and 1998 in Minnesota. Binomial logistic regression analyses revealed that early institutional rearing was associated with increased rates of attention and social problems, but not problems in either the internalizing or externalizing domains. Independent of institutional history, children who were adopted >or=24 months had higher rates of behavior problems across many CBCL scales, including internalizing and externalizing problems. In general, time in the adoptive home, which also reflected age at testing, was positively associated with rates of problem behavior. Thus, there was little evidence that the likelihood of behavior problems wane with time postadoption. Finally, children adopted from Russia/Eastern Europe appeared at greater risk of developing behavior problems in several domains compared to children adopted from other areas of the world.

Strategies to avoid the loss of developmental potential in more than 200 million children in the developing world

This paper is the third in the Child Development Series. The first paper showed that more than 200 million children under 5 years of age in developing countries do not reach their developmental potential. The second paper identified four well-documented risks: stunting, iodine deficiency, iron deficiency anaemia, and inadequate cognitive stimulation, plus four potential risks based on epidemiological evidence: maternal depression, violence exposure, environmental contamination, and malaria. This paper assesses strategies to promote child development and to prevent or ameliorate the loss of developmental potential. The most effective early child development programmes provide direct learning experiences to children and families, are targeted toward younger and disadvantaged children, are of longer duration, high quality, and high intensity, and are integrated with family support, health, nutrition, or educational systems and services. Despite convincing evidence, programme coverage is low. To achieve the Millennium Development Goals of reducing poverty and ensuring primary school completion for both girls and boys, governments and civil society should consider expanding high quality, cost-effective early child development programmes.

Developmental potential in the first 5 years for children in developing countries

Many children younger than 5 years in developing countries are exposed to multiple risks, including poverty, malnutrition, poor health, and unstimulating home environments, which detrimentally affect their cognitive, motor, and social-emotional development. There are few national statistics on the development of young children in developing countries. We therefore identified two factors with available worldwide data--the prevalence of early childhood stunting and the number of people living in absolute poverty--to use as indicators of poor development. We show that both indicators are closely associated with poor cognitive and educational performance in children and use them to estimate that over 200 million children under 5 years are not fulfilling their developmental potential. Most of these children live in south Asia and sub-Saharan Africa. These disadvantaged children are likely to do poorly in school and subsequently have low incomes, high fertility, and provide poor care for their children, thus contributing to the intergenerational transmission of poverty.

Early adolescent outcomes for institutionally-deprived and non-deprived adoptees. I: disinhibited attachment

BACKGROUND

Disinhibited attachment is an important sequel of an institutional rearing, but questions remain regarding its measurement, its persistence, the specificity of the association with institutional rearing and on whether or not it constitutes a meaningful disorder.

METHOD

Children initially reared in profoundly depriving institutions in Romania and subsequently adopted into UK families were compared with respect to findings at 11 years with children who had not experienced institutional deprivation and who had been adopted within the UK before the age of 6 months. Measures included parental reports, a Strange Situation procedure modified for use in the home and systematic standardised investigator ratings of the children's behaviour.

RESULTS

Disinhibited attachment, as reported by parents, showed a high degree of persistence from 6 to 11, but also a reduction over time in its frequency. Investigator ratings validated the parental reports but suggested that much of the fall in rate of disinhibited attachment was a function of the parental measure being less developmentally appropriate at 11 than it had been at 6. Disinhibited attachment was strongly associated with institutional rearing but there was not a significant increase in relation to duration of institutional deprivation beyond the age of 6 months. Mild, but not marked, disinhibited attachment was quite frequent in non-institutionalised adopted children but both the course and correlates indicated that its meaning was probably quite different. In the institution-reared children, disinhibited attachment was associated with a marked increase in service usage and associations with other forms of psychopathology.

CONCLUSIONS

Disinhibited attachment constitutes a valid, and handicapping, clinical pattern that is strongly associated with an institutional rearing.

The Emanuel Miller Memorial Lecture 2006: adoption as intervention. Meta-analytic evidence for massive catch-up and plasticity in physical, socio-emotional, and cognitive development

BACKGROUND

Adopted children have been said to be difficult children, scarred by their past experiences in maltreating families or neglecting orphanages, or by genetic or pre- and perinatal problems. Is (domestic or international) adoption an effective intervention in the developmental domains of physical growth, attachment security, cognitive development and school achievement, self-esteem, and behaviour problems?

METHOD

Through a series of meta-analyses on more than 270 studies that include more than 230,000 adopted and non-adopted children and their parents an adoption catch-up model was tested.

RESULTS

Although catch-up with current peers was incomplete in some developmental domains (in particular, physical growth and attachment), adopted children largely outperformed their peers left behind. Adoptions before 12 months of age were associated with more complete catch-up than later adoptions for height, attachment, and school achievement. International adoptions did not lead to lower rates of catch-up than domestic adoptions in most developmental domains.

CONCLUSIONS

It is concluded that adoption is an effective intervention leading to massive catch-up. Domestic and international adoptions can be justified on ethical grounds if no other solutions are available. Humans are adapted to adopt, and adoption demonstrates the plasticity of child development.

Translating research findings on early experience to prevention: animal and human evidence on early attachment relationships

Recent studies provide a wealth of findings on the mechanisms by which early stress exposure, particularly within the early child-parent attachment relationship, may influence long-term adaptation. Translating these findings to clinical practice and social policy is now underway. In this review, some key considerations in this translational task are examined, specifically, the conceptual bases underlying the research designs, the putative mechanisms involved, and the degree to which currently available findings might shape interventions. Although the primary focus is on depression, a broader range of phenotypes associated with poor early caregiving environments is also considered.

Communal nesting, an early social enrichment, increases the adult anxiety-like response and shapes the role of social context in modulating the emotional behavior

Early experiences affect brain function and behavior at adulthood. Being reared in a communal nest (CN), consisting in a single nest where three mothers keep their pups together and share care-giving behavior from birth to weaning (postnatal day 25), provides a highly stimulating social environment to the developing pup. CN characterizes the natural ecological niche of many rodent species including the mouse. Here we show that, at adulthood, compared to mice reared in standard laboratory conditions (SN), CN reared mice displayed increased anxiety-like behavior, performing more thigmotaxis in the open field and spending less time in the open arms of the plus-maze. Furthermore, we showed that social context (being alone or with a familiar conspecific in the test apparatus) affects the emotional response in both the plus-maze and open field test and that the relevance of social context changes according to the early social experiences. In particular, CN mice display higher levels of anxiety-like behavior, compared to SN mice, only when alone but not in the presence of a familiar conspecific. Overall, in line with previous findings, the present study suggests that CN mice have a more elaborate social and emotional behavior compared to SN mice and thus may be more appropriate to investigate socio-emotional impairments, in particular in the case of mouse models of neurodevelopmental disorders, such as autism, or anxiety and mood disorders.

The ABC of demographic behaviour: how the interplays of alleles, brains, and contexts over the life course should shape research aimed at understanding population processes

This paper proposes core innovations in the strategy of research on demographic behaviour. One aim is a shift of attention away from events and towards a focus on dynamic processes and their interplay: away from a preoccupation with marriage and divorce, births, deaths, migrations, and household structure towards a broader perspective that takes account of partnership and intimacy, parenthood, potential and well-being, position in society and space, and personal ties. Another aim is a much closer engagement with genetics, neuroscience, psychology, and behavioural economics. A third aim is a strategy that pays more attention to pathways within the individual, to the processes entailed when the individual interacts with various contexts, and to progressions that involve the interplay of the pathways and processes through the life course. These shifts of emphasis, which have already begun to occur, require a systematic reassessment of priorities for research on demographic behaviour.

Do the Effects of Early Severe Deprivation on Cognition Persist Into Early Adolescence? Findings From the English and Romanian Adoptees Study

Cognitive outcomes at age 11 of 131 Romanian adoptees from institutions were compared with 50 U.K. adopted children. Key findings were of both continuity and change: (1) marked adverse effects persisted at age 11 for many of the children who were over 6 months on arrival; (2) there was some catch-up between ages 6 and 11 for the bottom 15%; (3) there was a decrease of 15 points for those over 6 months on arrival, but no differentiation within the 6-42-month range; (4) there was marked heterogeneity of outcome but this was not associated with the educational background of the adoptive families. The findings draw attention to the psychological as well as physical risks of institutional deprivation.

Institutional care: associations between inattention and early reading performance

BACKGROUND

Recent government papers have expressed concern about the poor educational attainment of 'looked after' children. Early reading development has been found to be significant in their subsequent academic achievement. The possibility that biosocial factors extraneous to their experiences in public care may underpin their low attainment has not been investigated to date.

METHODS

The reading ability of 19 primary school children, who had been raised in institutional care from an early age, were compared with 19 children, matched for age and sex, who were comparable in biological background and who had experienced uninterrupted family foster care. Both groups were compared with classroom controls using teacher questionnaires, interviews, systematic observations and cognitive testing.

RESULTS

Reading delay was more prevalent in the institutional group and as a group they had lower reading scores than the children reared in family foster care. Variation in IQ accounted for the lower reading scores of the family foster care group compared with their matched classroom controls. Inattention, found in a previous study to be much more evident in the institutional group, partially accounted for the group difference in reading scores, and was situationally specific to formal teacher-directed tasks. Differential effects of caregivers' interest in terms of help with homework were also found.

CONCLUSIONS

Early reading performance was associated with the experience of being raised 'in care' but was not an inevitable outcome. It was concluded that the type of substitute caregiving experienced affected reading performance. Institutional upbringing affected reading performance both directly and indirectly through the heightened levels of inattention associated with institutional care.

Measured Gene-Environment Interactions in Psychopathology: Concepts, Research Strategies, and Implications for Research, Intervention, and Public Understanding of Genetics

There is much curiosity about interactions between genes and environmental risk factors for psychopathology, but this interest is accompanied by uncertainty. This article aims to address this uncertainty. First, we explain what is and is not meant by gene-environment interaction. Second, we discuss reasons why such interactions were thought to be rare in psychopathology, and argue instead that they ought to be common. Third, we summarize emerging evidence about gene-environment interactions in mental disorders. Fourth, we argue that research on gene-environment interactions should be hypothesis driven, and we put forward strategies to guide future studies. Fifth, we describe potential benefits of studying measured gene-environment interactions for basic neuroscience, gene hunting, intervention, and public understanding of genetics. We suggest that information about nurture might be harnessed to make new discoveries about the nature of psychopathology.

Gene-environment interplay and psychopathology: multiple varieties but real effects

Gene-environment interplay is a general term that covers several divergent concepts with different meanings and different implications. In this review, we evaluate research evidence on four varieties of gene-environment interplay. First, we consider epigenetic mechanisms by which environmental influences alter the effects of genes. Second, we focus on variations in heritability according to environmental circumstances. Third, we discuss what is known about gene-environment correlations. Finally, we assess concepts and findings on the interaction between specific identified genes and specific measured environmental risks. In order to provide an understanding of what may be involved in gene-environment interplay, we begin our presentation with a brief historical review of prevailing views about the role of genetic and environmental factors in the causation of mental disorders, and we provide a simplified account of some of the key features of how genes 'work'.

Household income histories and child mental health trajectories

Although it is widely accepted that low household income is associated with worse child mental health, less is known about whether income histories, often differentiated into stable and dynamic components, also matter. Using longitudinal data from the Child Supplement of the National Longitudinal Study of Youth, comprising the repeated measures of children ages 4 to 14 from 1986 to 1998 inclusive, I estimate generalized linear mixed models to evaluate the influence of household income histories on child depression and antisocial behavior over time. Results indicate that, at initial interview, low household income is associated with higher levels of depression and antisocial behavior; subsequent improvements in household income reduce child mental health problems. Further, the effect of initial household income on the rate of change in child depression attenuates as children grow older, whereas for antisocial behavior the effect of initial household income becomes stronger over time. These findings highlight the importance of understanding the ways in which children are influenced by their families' income histories.

Preadoption opportunities for pediatric providers

International adoption pairs the most vulnerable and high-risk pediatric population with the lowest risk parent group. International adoption also presents unique and rewarding challenges for primary care pediatricians. After receiving information from the medical reviewer, a parent must determine whether or not this child is "their child." The position of the medical reviewer is to provide the family with as much information as possible about the health status of the child by explaining the terminology in the report and assessing the photograph or videotape. It is also the reviewer's job to guide the parent's expectations of the adoption by explaining the inherent differences in the development of children in institutions. In the preadoption phase, we must remember that our ultimate goal is to aid in the permanent placement of a child with a family that has realistic expectations and is well prepared to aid that child to reach his or her fullest potential.

Children in adoptive families: overview and update

OBJECTIVE

To summarize the past 10 years of published research concerning the 2% of American children younger than 18 years old who are adoptees.

METHOD

Review recent literature on developmental influences, placement outcome, psychopathology, and treatment.

RESULTS

Adoption carries developmental opportunities and risks. Many adoptees have remarkably good outcomes, but some subgroups have difficulties. Traditional infant, international, and transracial adoptions may complicate adoptees' identity formation. Those placed after infancy may have developmental delays, attachment disturbances, and posttraumatic stress disorder. Useful interventions include preventive counseling to foster attachment, postadoption supports, focused groups for parents and adoptees, and psychotherapy.

CONCLUSIONS

Variables specific to adoption affect an adopted child's developmental trajectory. Externalizing, internalizing, attachment, and posttraumatic stress disorder symptoms may arise. Child and adolescent psychiatrists can assist both adoptive parents and children.

Long-term developmental, behavioral, and attachment outcomes after international adoption

Children adopted internationally and their families are a heterogeneous group. Internationally-adopted children have been reported to have a range of developmental and behavioral difficulties. The authors describe the current evidence documenting developmental outcomes for children and common behavioral and mental health concerns including attachment difficulties that may impact children and their families after international adoption. Pediatricians must be thoughtful to individualize the care of adoptive children and not make assumptions shortly after adoption. It is critical to avoid using "standard" parenting advice that may not apply to children who have experienced loss, deprivation, separation, and instability in their early lives. By listening to families, carefully evaluating children, and monitoring progress over time, pediatricians can avoid the pitfall of oversimplifying and underestimating the complexity and challenges that these families face. Instead, pediatric primary care providers can play a key role in maximizing the potential of an internationally adopted child and his or her family.

Prenatal anxiety predicts individual differences in cortisol in pre-adolescent children

BACKGROUND

Animal studies suggest that prenatal stress is associated with long-term disturbance in hypothalamic-pituitary-adrenal (HPA) axis function, but evidence in humans is lacking. This study examined the long-term association between prenatal anxiety and measures of diurnal cortisol at age 10 years.

METHODS

Measures of cortisol were collected at awakening, 30 min after awakening, and at 4 pm and 9 pm on 3 consecutive days in a sample of 10-year-olds (n = 74) from the Avon Longitudinal Study of Parents and Children, a prospective longitudinal cohort study of mothers and children on whom measures of anxiety and depression were collected in pregnancy and the postpartum period. Analyses examined the links between symptoms of prenatal anxiety and multiple indicators of cortisol, an index of HPA axis functioning.

RESULTS

Prenatal anxiety was significantly associated with individual differences in awakening and afternoon cortisol after accounting for obstetric and sociodemographic risk (partial correlations were .32 and .25, p < .05). The effect for awakening cortisol remained significant after controlling for multiple postnatal assessments of maternal anxiety and depression.

CONCLUSIONS

This study provides the first human evidence that prenatal anxiety might have lasting effects on HPA axis functioning in the child and that prenatal anxiety might constitute a mechanism for an increased vulnerability to psychopathology in children and adolescents.

Paternal depression in the postnatal period and child development: a prospective population study

BACKGROUND

Depression is common and frequently affects mothers and fathers of young children. Postnatal depression in mothers affects the quality of maternal care, and can lead to disturbances in their children's social, behavioural, cognitive, and physical development. However, the effect of depression in fathers during the early years of a child's life has received little attention.

METHODS

As part of a large, population-based study of childhood, we assessed the presence of depressive symptoms in mothers (n=13,351) and fathers (n=12,884) 8 weeks after the birth of their child with the Edinburgh postnatal depression scale (EPDS). Fathers were reassessed at 21 months. We identified any subsequent development of behavioural and emotional problems in their children (n=10,024) at age 3.5 years with maternal reports on the Rutter revised preschool scales.

FINDINGS

Information was available for 8431 fathers, 11,833 mothers, and 10,024 children. Depression in fathers during the postnatal period was associated with adverse emotional and behavioural outcomes in children aged 3.5 years (adjusted odds ratio 2.09, 95% CI 1.42-3.08), and an increased risk of conduct problems in boys (2.66, 1.67-4.25). These effects remained even after controlling for maternal postnatal depression and later paternal depression.

INTERPRETATION

Our findings indicate that paternal depression has a specific and persisting detrimental effect on their children's early behavioural and emotional development.