Impact case study database

i. Changing our understanding of attachment and attachment disorders in children with histories of severe early deprivation and informing new treatment approaches: ERA’s findings provided “ crucial evidence to underpin the re-classification of attachment disorders in the 5^th edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5; APA, 2013) which is a manual for assessment and diagnosis of mental disorders used internationally by experts in all areas of mental health” [ 5.1]. ERA’s work has since been central to the new diagnostic classifications of early childhood disorders (DC:0-5; ZERO TO THREE, 2016, see [ 5.1]), which complements the DSM-5, and the NICE guidelines (2015) on ‘Attachment in children and young people who are adopted from care, in care, or at risk of going into care’ [ 5.2]. Specifically, ERA has provided evidence to enhance knowledge in this area as corroborated by Professor Charles Zeanah who states ERA has “ contributed to a real shift in our understanding that variations in attachment security and insecurity are distinct from reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED)” [ 5.1] . This is also referenced in the NICE guidelines [ 5.2] with explicit reference to [ 3.4]: “ *A significant body of research has investigated the causes of variations in the attachment patterns shown by infants and young children. The evidence is quite clear that the causal factors giving rise to security versus insecurity are distinct from those influencing the development of attachment disorders (Rutter et al., 2009).*” [ 5.2, p.21]. Zeanah adds “ *these are quite crucial distinctions that clinicians must appreciate.*” [ 5.1]. In addition, the ‘American Academy of Child and Adolescent Psychiatry’s Practice parameters for the assessment and treatment of children and adolescents with reactive attachment disorder and disinhibited social engagement disorder’, co-authored by Zeanah [ 5.3] “ relies in part on ERA’s findings” as it is currently “ the only data available for DSED presentation in young adulthood and the longest longitudinal study of disinhibited social behavior conducted to date” [ 5.1]. Dr John Simmonds, Director of Policy, Research and Development at CoramBAAF, Britain’s leading membership organisation of agencies and professionals involved in supporting children separated from their birth parents emphasises that “The work of ERA has led to enhanced understanding and interventions of children with complex histories of deprivation and neglect. The research has informed a change in classification of these behaviours, documented in NICE guidance which has been crucial to developing changes to legislation that include improved assessment, treatment, support approaches, service provision and ultimately better outcomes for families.” [ 5.4].

ii. Influencing campaigns to end institutional care for children world-wide: Over the last 10 years, the number of children worldwide living in residential care has substantially reduced from an estimated 8 million to 2.7 million (Petrowski, et al. 2017). ERA findings have played an important role in forming a wider body of evidence that has contributed to global progress to better the lives of children without parental care.

Evidence from eight ERA scientific papers authored by Southampton researchers was included in the highly influential Berens and Nelson review 2015 [ 5.5] in which the ERA study is explicitly mentioned (i.e. six times) to evidence the developmental sequelae associated with institutional care: “The ERA Study published detailed results through to 17 years of age on the developmental outcomes [ …] with analysis indicating persistent developmental deficits associated with institutional care experienced past 6 months of age” (p.391), or “… decreased head circumference among neglected children could arise from an excess of neural pruning in response to under-stimulation. Supporting this contention, the ERA study noted that duration of deprivation longer than 6 months [ …] was associated with smaller head circumference independent of nutritional status” (p.391-392). The Berens and Nelson review, informed by the ERA, was used to underpin key recommendations [ 5.6a] for the 2019 United Nation General Assembly (UNGA) Resolution on the Rights of the Child put forward by the Better Care Network (BCN), an international network of organisations and agencies committed to supporting children without adequate family care around the world, which promotes collaboration, research and information sharing, and advocates for changes to national and international policies to improve alternative care provision. In their key recommendations to the UNGA, the BCN emphasised the need to put an end to child institutionalization by highlighting the harm it does to children’s development. Specifically, BCN key recommendation 4a states “Recognize the harm of institutionalization and institutional care to children’s growth and development across domains and throughout the life-course…” (p.4). The evidence cited for this key recommendation is the Berens and Nelson review which explicitly reports the findings from our ERA study. The Resolution on the Rights of the Child was formally adopted by the UNGA on 18^th December 2019, including the recommendation and commitment to put an end to child institutionalization [ 5.7].

Two additional campaigns, informed by ERA’s work, also targeted the same UNGA Resolution on the Rights of the Child: i) LUMOS, a UK and US foundation created by author J.K. Rowling actively campaigns for ending institutionalisation of children across the world. ERA research [ 3.1] informs Lumos’s recent report (2019) ‘A Goal Within Reach: Ending the institutionalization of children to ensure that no one is left behind’ [ 5.8]; ii) UNICEF’s (2015) Making Decisions For The Better Care of Children: The role of gatekeeping and strengthening the family-based care and reforming alternative care systems [ 5.9] discusses and references findings from the ERA study including reference to [ 3.3]. Moreover, ERA’s recent findings [ 3.1, 3.5] continue to inform the BCN via inclusion in their recommended evidence library [ 5.6b] .

In June 2020, The Lancet Group Commission on institutionalisation and deinstitutionalisation of children launched, which ‘advocates global reform of the care of separated children’. The Chair, Professor Sonuga-Barke, PI of ERA’s young adult assessment phases, is senior author of the Commission’s systematic and integrative review of evidence regarding effects of institutionalization on development [ 5.10]. This review extensively references the work by the ERA study team and explicitly discusses its findings [ 3.1] “ The clearest example of the relationship between duration of deprivation and the scale of post institutional recovery comes from the English and Romanian Adoptees study. In this study, even after 20 years in adoptive homes, children who had extended institutional care showed significantly elevated prevalence of autism spectrum disorder, attention-deficits hyperactivity disorder, and disinhibited social engagement symptoms. Children exposed to shorter durations of institutional care were largely indistinguishable from the non-deprived adoptive control group. This difference between children exposed to extended or short periods of institutional care was already established by the age of 6 years.” (p.714).

iii. Impact in Education: The ERA study has become one of the most influential studies in developmental psychology and child psychiatry over the last 10 years, cited many thousands of times in the scientific literature. The most recent version of the AQA A level psychology syllabus, revised in 2015, specifically requires students to learn about Romanian orphan studies as an example of the effects of institutional care. [ 5.11a, b]. Over 60,000 pupils were registered in 2020 for A-level Psychology in the UK, about 80% of which study the AQA curriculum [ 5.11a]. In 2016 the ERA team was invited to share their findings in the UK’s leading Psychology Review Magazine for A-level students [ 5.12]. This Magazine has approximately 3000 subscriptions in the UK and internationally (as international schools often follow the AQA exam), including students, teachers, and libraries. Our ERA article is re-published by Hodder Education as part of a new resource called ‘Psychology Review: Exam Skills and Practice’, which combines new revision material and practice questions whilst incorporating past Psychology Review magazine articles. The re-publication of ERA’s original article for this new resource underscores ERA’s critical relevance to the teaching and learning of A-level Psychology with a three years sales projection of 7,750 [ 5.11b]. Cara Flanagan, Senior Editor of Psychology Review states: “ As the findings of the English and Romanian Adoption Study have been so influential in informing our understanding of the long-term effects of early institutional deprivation on human development, Psychology Review was keen for the ERA team to share their most recent findings with our readership to provide a clear and up-to-date account of their results and conclusions. Their study is a model of good research as it has enabled controlled investigation of so many different aspects of child development.” [ 5.11a]. ERA’s importance in the field of developmental psychology is further reflected in its inclusion as a case study in many higher education-level course textbooks nationally and internationally [ 5.13a & b].

iv. Media coverage of Southampton’s research on the long-term impact of early life adverse experiences: ERA’s most recent young adult findings [ 3.1, 3.5] have been widely discussed in national and international news and social media [ 5.14]. According to Altmetric data [see 5.15], both [ 3.1]’s and [ 3.5]’s attention scores places them in the top 5% of all research outputs scored by Altmetric, and both are in the top 1% of outputs of the same age. Almetric data for our publication in the Lancet [ 3.1] records >400 tweets by >370 tweeters with an upper bound of >1.5 million followers. The PNAS publication [ 3.5] has >300 tweets with an upper bound of over 750,000 followers. Our publications [ 3.1, 3.5] were reported in several national and international public media outlets [ see 5.14] including BBC articles on adopted Romanian children ‘still suffering in adulthood’ (Feb 2017), and ‘Neglected children end up with ‘smaller brains’ (Jan 2020). Further media coverage appeared in Deutschlandfunk (Jan 2020), and in Mental Elf’s blog (Feb 2017) ‘Early life deprivation, neurodevelopment, mental health and resilience: ERA study’. Both ERA articles are also discussed in the German Ärzteblatt, the official journal of Germany’s leading medical bodies, the German Medical Association and the National Association of Statutory Health Insurance Physicians.