Post-institutionalized Research Articles

Hyper- and hypo-cortisol functioning in post-institutionalized adolescents: The role of severity of neglect and context

Understanding the developmental timing of stress exposure may help inform mechanisms underlying how stress “gets under the skin” and influences the stress response system, including the HPA axis and its end-product cortisol. Early adversity may be particularly detrimental; however, it is difficult to disentangle the timing of adversity from its cumulative burden because there is typically high continuity between early and later adversity. Moreover, context and the different stressors inherent in various contexts may interact with stress exposure to influence psychophysiological functioning. To address this issue, we examined adolescents who had been reared in institutions and suffered neglect or social deprivation ranging from approximately six months to several years of life prior to adoption into U.S. homes. We focused on the stress hormone cortisol because it can reflect continued regulatory problems in youth, even years after youth transition to typical homes. We examined cortisol morning levels and diurnal rhythms across multiple contexts (home, school, lab) on 5 separate days in 41 post-institutionalized youth and 78 comparison youth. Employing hierarchical linear modeling, we found that when assessed in the lab, post-institutionalized (PI) youth displayed lower morning cortisol levels and flatter diurnal slopes than the control youth. Yet at home, PI youth displayed higher morning cortisol levels than the control youth. In addition to group effects, we also examined severity of early adversity and found that PI kids who had endured the most severe early adversity displayed lower home cortisol levels than controls. No significant predictors of diurnal cortisol on school days were identified. These data fit with the notion that the HPA axis is impacted by early adversity, even years after adoption, and with emerging theories that postulate that stress physiology calibrates within youth to help them adapt to their context. In the case of severe early adversity, the cost of such adaptation may not be desirable. It also highlights the important role of context when assessing HPA axis activity, particularly in post-institutionalized youth.

Risk taking, decision-making, and brain volume in youth adopted internationally from institutional care

Early life stress in the form of early institutional care has been shown to have wide-ranging impacts on the biological and behavioral development of young children. Studies of brain structure using magnetic resonance imaging have reported decreased prefrontal volumes, and a large literature has detailed decreased executive function (EF) in post-institutionalized (PI) youth. Little is known about how these findings relate to decision-making, particularly in PI youth entering adolescence—a period often characterized by social transition and increased reliance upon EF skills and the still-maturing prefrontal regions that support them. As decision-making in risky situations can be an especially important milestone in early adolescence, a clearer knowledge of the relationship between risky decision making and prefrontal structures in post-institutionalized youth is needed. The youth version of the Balloon Analogue Risk Task and a two-deck variant of the Iowa Gambling Task were used to assess risky decision-making in post-institutionalized youth and a community control group (N = 74, PI = 44, Non-adopted = 30; mean age = 12.93). Participants also completed a structural MRI scan for the assessment of group differences in brain structure. We hypothesized that participants adopted from institutions would display poorer performance on risky-decision making tasks and smaller brain volumes compared to non-adopted youth. Results indicated that later-adopted participants made fewer risky decisions than those experiencing shorter periods of deprivation or no institutional rearing. Further, decreased prefrontal volumes were observed in later-adopted youth and were significantly associated with task performance. Our results suggest that changes in risky-decision making behavior and brain structure are associated with the duration of early institutional care.

Peer Problems Among Postinstitutionalized, Internationally Adopted Children: Relations to Hypocortisolism, Parenting Quality, and ADHD Symptoms.

Seventy-eight postinstitutionalized (PI) children adopted at ages 17-36months were assessed 2, 8, 16, and 24months postadoption on measures of cortisol and parenting quality, and compared to same-aged children adopted from foster care (FC, n=45) and nonadopted children (NA, n=45). In kindergarten (Mage =6.0years), teachers, parents, and trained observers completed measures of peer relationships and attention deficit hyperactivity disorder (ADHD) symptoms. PI children had more peer problems and ADHD symptoms according to teachers and observers than NA children with FC children in between, whereas both PI and FC children were at significantly greater risk of hypocortisolism (i.e., blunted cortisol diurnal rhythm and reactivity). Hypocortisolism and ADHD symptoms mediated the association between preadoption adversity and peer difficulties. Higher postadoption parenting quality was protective.

ADHD Symptoms in Post-Institutionalized Children Are Partially Mediated by Altered Frontal EEG Asymmetry.

Individual differences in the propensity for left versus right frontal electroencephalogram (EEG) asymmetry may underlie differences in approach/withdrawal tendencies and mental health deficits. Growing evidence suggests that early life adversity may shape brain development and contribute to the emergence of mental health problems. The present study examined frontal EEG asymmetry (FEA) following the transition to family care in children adopted internationally from institutional care settings between 15 and 36months of age (N=82; 46 female, 36 male). Two comparison groups were included: an international adoption control consisting of children adopted from foster care with little to no institutional deprivation (N=45; 17 female, 28 male) and a post-adoption condition control consisting of children reared in birth families of the same education and income as the adoptive families (N=48; 23 female, 25 male). Consistent with evidence of greater approach and impulsivity-related behavior problems in post-institutionalized (PI) children, PI status was associated with greater left FEA than found in the other two groups. In addition, left FEA served as a mediator between institutionalization and age 5 ADHD symptoms for girls. Age at adoption and other preadoption factors were examined with results suggesting that earlier adoption into a supportive family resulted in a more typical pattern of brain functioning. Findings support the idea that the capacity of brain activity to evidence typical functioning following perturbation may differ in relation to the timing of intervention and suggest that the earlier the intervention of adoption, the better.

The course of early disinhibited social engagement among post-institutionalized adopted children.

Approximately 20% of post-institutionalized (PI) children exhibit disinhibited social engagement (DSE) or the propensity to approach and engage strangers. There is little longitudinal research examining changes in DSE after adoption, or methods of identifying children with persistent behaviors. DSE was assessed observationally four times during the first 2years postadoption in PI children 16-36months at adoption (n=68) relative to same-age nonadopted children (n=52). At age 5, a validated interview determined which PI children met criteria for Disinhibited Social Engagement Disorder (DSED). DSE trajectories initially increased and then stabilized. PIs had higher DSE levels initially and a steeper increase rate than NAs. When separated into physical and nonphysical DSE components, group differences arose in initial physical DSE and the rate of change of nonphysical DSE. DSE rate of increase predicted DSED diagnosis, as did longer institutional duration and poorer institutional care. The rate of increase in DSE postadoption, rather than the level observed at adoption, is predictive of disordered social engagement by age 5years.

To trust or not to trust: social decision-making in post-institutionalized, internationally adopted youth.

Chronic parental maltreatment has been associated with lower levels of interpersonal trust, and depriving environments have been shown to predict short-sighted, risk-averse decision-making. The present study examined whether a circumscribed period of adverse care occurring only early in life was associated with biases in trust behavior. Fifty-three post-institutionalized (PI) youth, adopted internationally on average by 1year of age, and 33 never-institutionalized, non-adopted youth (Mage =12.9years) played a trust game. Participants decided whether or not to share coins with a different anonymous peer in each trial with the potential to receive a larger number of coins in return. Trials were presented in blocks that varied in the degree to which the peers behaved in a trustworthy (reciprocal) or untrustworthy (non-reciprocal) manner. A comparison condition consisted of a computerized lottery with the same choices and probabilistic risk as the peer trials. Non-adopted comparison youth showed a tendency to share more with peers than to invest in the lottery and tended to maintain their level of sharing across trials despite experiencing trials in which peers failed to reciprocate. In contrast, PI children, particularly those who were adopted over 1year of age, shared less with peers than they invested in the lottery and quickly adapted their sharing behavior to peers' responses. These results suggest that PI youth were more mistrusting, more sensitive to both defection and reciprocation, and potentially more accurate in their trusting decisions than comparison youth. Results support the presence of a sensitive period for the development of trust in others, whereby conditions early in life may set long-term biases in decision-making.

Emotion understanding, parent mental state language, and behavior problems in internationally adopted children.

Internationally adopted postinstitutionalized (PI) children are at risk for lower levels of emotion understanding. This study examined how postadoption parenting influences emotion understanding and whether lower levels of emotion understanding are associated with behavior problems. Emotion understanding and parent mental state language were assessed in 3-year-old internationally adopted PI children (N = 25), and comparison groups of children internationally adopted from foster care (N = 25) and nonadopted (NA) children (N = 36). At 5.5-year follow-up, PI children had lower levels of emotion understanding than NA children, a group difference not explained by language. In the total sample, parent mental state language at age 3 years predicted 5.5-year emotion understanding after controlling for child language ability. The association of parent mental state language and 5.5-year emotion understanding was moderated by adoption status, such that parent mental state language predicted 5.5-year emotion understanding for the internationally adopted children, but not for the NA children. While postadoption experience does not erase negative effects of early deprivation on emotion understanding, results suggest that parents can promote emotion understanding development through mental state talk. At 5.5 years, PI children had more internalizing and externalizing problems than NA children, and these behavioral problems related to lower levels of emotion understanding.

Early social deprivation and the social buffering of cortisol stress responses in late childhood: An experimental study.

The goal of the present study was to investigate the role of early social deprivation in shaping the effectiveness of parent support to alleviate hypothalamic-pituitary-adrenal (HPA)-axis-stress responses of children (ages 8.9-11, M = 9.83 years, SD = .55). The sample was equally divided between children who had been adopted internationally from orphanage care by age 5 (n = 40) and an age- and gender-matched group of nonadopted (NA) children (n = 40). On average, internationally adopted children were invited to the laboratory 7.6 years postadoption (SD = 1.45). We experimentally manipulated the provision of parent support during the 5-min speech preparation period before a modified Trier Social Stress Test (TSST) and examined its effect on levels of salivary cortisol secreted in response to this laboratory stressor. All participants were randomly assigned to receive support from their parent or a stranger. Analyses revealed a significant interaction of support condition and group such that parent support significantly dampened the cortisol-stress response in NA children compared with support from a stranger, whereas the cortisol response curves of postinstitutionalized (PI) children did not differ between the parent- and stranger-support conditions. Cortisol reactivity for PI children in both conditions was lower than that of NA children in the stranger-support condition. Social deprivation during the first few years of life may shape neurobehavioral development in ways that reduce selective responses to caregivers versus strangers.

Psychosocial Differences in Post-Institutionalized, Internationally Adopted Children and Other Groups of Children Referred for Clinical Services

Thousands of children are adopted into the United States each year, many of whom have spent a significant portion of their pre adoptive lives in an institutional setting. Post-institutionalized (PI) children adopted into the United States are often referred for mental health services at higher rates than other groups of children. There is a lack of research examining differences in clinically referred PI children and other groups. The purpose of this study was to address this gap in knowledge. Results from multiple analysis of covariance and follow-up pairwise contrast analyses found significant differences only between PI and domestic adoptees (DA). Specifically, DA exhibited poorer functioning in the areas of attention problems and social problems. Mean scores were above the 85th percentile for all indicators for all groups, indicating the severity of psychosocial problems for the sampled group of clinical referrals. More research is needed that compares the psychosocial problems of PI children to other adopted youth.

Social Skills in Children Adopted From Socially-Emotionally Depriving Institutions

ABSTRACTThis study assessed social skills in post-institutionalized (PI) children with respect to age at adoption, age at assessment, and gender. Parent ratings of social skills (Social Skills Rating System) and behavior problems (Child Behavior Checklist) were obtained for 214 children and 127 adolescents who were adopted from socially-emotionally depriving Russian institutions. Results showed that children adopted before 18 months of age have better social skills than those adopted after this age; those assessed in childhood demonstrate better social skills than those assessed in adolescence. PI females, especially later-adopted adolescents, have particularly poor social skills. Children with poor social skills tend to have higher rates of behavior problems.

Peer victimization and internalizing symptoms among post-institutionalized, internationally adopted youth.

Early institutional or orphanage rearing, typically characterized by profound psychosocial deprivation, has been associated with adjustment difficulties that may persist long after adoption (for a review, see Gunnar 2001). In particular, post-institutionalized (PI) youth, especially those having experienced longer durations of adverse care, are more likely to show deficits in social cognition (e.g., Theory of Mind, Colvert et al. 2008b; Tarullo et al. 2007; emotion processing, Parker and Nelson 2005; Wismer Fries and Pollak 2004). These difficulties in recognizing and understanding others’ thoughts and feelings are likely to hinder PI youths’ ability to navigate social interactions with peers, which become increasingly complex in adolescence (Steinberg and Morris 2001). As such, PI youth may become targets of peers’ rebuffs and abuse, common sequelae of social cognitive deficits in normative samples (e.g., Kaukiainen et al. 2002). Indeed, early institutional deprivation has been linked to elevated social problems in broad-based functional assessments (Groze and Ileana 1996; Gunnar et al. 2007; Hawk and McCall 2011), and several studies have described lower peer acceptance and difficulties forming and maintaining intimate friendships years after adoption (e.g., Hodges and Tizard 1989; Tizard and Hodges 1978). Little research to date has examined distinct aspects of peer relations in PI populations. Often, numerous aspects of peer problems such as peer acceptance, isolation, and verbal and physical bullying have been combined into one scale for analysis (e.g., Rutter et al. 2001). Furthermore, because the focus has often been on youths’ behavior (e.g., is she aggressive?) and not treatment by peers (e.g., is she victimized?), our understanding of PI children and adolescents’ peer relations is somewhat one-sided. In one exception, Raaska et al. (2012) assessed self-reported experiences of bullying in 9- to 15-year-old internationally adopted youth, some of whom had experienced institutional care prior to adoption. Compared to youth raised in their natal families, younger adoptees were more likely to be victimized, while older adoptees were less likely to bully others. In turn, rejection and victimization by peers may promote emotional difficulties in PI children and adolescents. In normative samples, peer maltreatment has been associated with increases in internalizing symptoms (e.g., depression, loneliness; for a review, see Hawker and Boulton 2000). However, the relationship between peer victimization and emotional problems has not been examined in PI youth, despite research documenting heightened levels of internalizing problems in this population in adolescence (Colvert et al. 2008a; Tieman et al. 2005). Thus, the present study examined multiple aspects of peer relationships, including peer aggression, victimization and rejection, in PI youth adopted as infants or young children compared to youth who were raised in their families of origin. This comparison group was selected to allow for an approximate match to PI participants on the basis of parent education and family socio-economic status. In addition to measuring overt forms of victimization, we also measured relational victimization (e.g., exclusion, friendship manipulation; Crick and Grotpeter 1995), as research has shown that it makes unique contributions to psychosocial adjustment (Crick and Grotpeter 1996). We expected that PI youth, particularly those having experienced longer durations of institutional care, would experience lower peer acceptance and more peer victimization. We also hypothesized that these experiences would mediate the relation between early institutional care status and internalizing symptoms. Given mixed findings regarding overt aggression in PI youth (e.g., Merz and McCall 2010; Gunnar et al. 2007), and the lack of information about relational aggression, we did not make strong predictions about whether these behaviors would be elevated. We also examined differences in prosocial behavior and social withdrawal, because these behaviors are important predictors of social adjustment (e.g., Boivin et al. 1995; Crick 1996). Based on studies of domestic and international adoptees, we hypothesized that being older at adoption (i.e., 12 months or older) would be associated with more negative outcomes (for a review, see Zeanah et al. 2011). Finally, we explored whether gender moderated the associations between early institutional care and peer functioning. Some studies of PI children have reported more adverse effects for boys compared to girls, for instance, with respect to behavior problems and peer victimization (Bos et al. 2011; Raaska et al. 2012), though others find no gender interactions (Gunnar et al. 2007; Juffer and Van IJzendoorn 2005). Given these mixed findings, we explored but did not make directional predictions for gender effects.

Disinhibited social engagement in postinstitutionalized children: Differentiating normal from atypical behavior

The most commonly reported socially aberrant behavior in postinstitutionalized (PI) children is disinhibited social engagement (DSE; also known as indiscriminate friendliness). There is no gold standard for measurement of this phenomenon nor agreement on how to differentiate it from normative behavior. We adopted a developmental psychopathology approach (Cicchetti, 1984) to study this phenomenon by comparing it to normative social development and by studying its patterns over time in 50 newly adopted PI children (16-36 months at adoption) compared with 41 children adopted early from foster care overseas and 47 nonadopted (NA) controls. Using coded behavioral observations of the child's interaction with an unfamiliar adult, atypical behaviors were differentiated from normative behaviors. Principal components analysis identified two dimensions of social disinhibition. The nonphysical social dimension (e.g., initiations, proximity) showed wide variation in NA children and is therefore considered a typical form of sociability. Displays of physical contact and intimacy were rare in NA children, suggesting that they represent an atypical pattern of behavior. Both adopted groups demonstrated more physical DSE behavior than NA children. There were no group differences on the nonphysical factor, and it increased over time in all groups. Implications for understanding the etiology of DSE and future directions are discussed.

The emergence of attachment following early social deprivation

This study examined the formation and quality of attachment of 65 postinstitutionalized (PI) toddlers with their parents at 1-3 and 7-9 months postadoption compared to 52 nonadopted (NA) children. The formation of attachment relationships of PI children with adoptive parents occurred relatively quickly. Children exposed to greater preadoption adversity took longer to form an attachment to their adoptive parents, although by 7-9 months postadoption, nearly all (90%) of the children achieved the highest level on an attachment formation rating scale. PI children did not differ from NA children in attachment security, based either on the Attachment Q-Sort or Strange Situation categorical scoring. However, the PI children were more likely to be disorganized in their attachment patterns. Preadoption adversity was related to lower Q-sort security scores especially at the initial assessment 1-3 months postadoption. The results indicated that attachment formation and attachment quality in PI children are differentiable constructs with different precursors.

Early deprivation impairs the development of balance and bilateral coordination

This study examined balance and bilateral coordination skills in a sample of internationally adopted, post-institutionalized (PI) children. We compared the performance of these PI children to two age-matched groups. One was a group of children who were internationally adopted from foster care (FC). The second group consisted of non-adopted children being raised in their birth families, who served as controls (Control). Both PI and FC children scored lower than control children on balance, while PI children scored lower than both FC and control children on bilateral coordination. These results suggest that aspects of institutional rearing impact the development of bilateral coordination, while factors common to internationally adopted children other than institutionalization impact the development of balance. Region of birth (Asia, Latin/South America, Russia/Eastern Europe) did not moderate associations between institutional duration and bilateral coordination.

Inhibitory control and working memory in post-institutionalized children.

Inhibitory control and working memory were examined in post-institutionalized (PI) children adopted into United States families from Russian institutions. The PI sample originated from institutions that were less severely depriving than those represented in previous studies and approximated the level of psychosocial deprivation, which is characterized by adequate physical resources but a lack of consistent and responsive caregiving. PI children (N = 75; 29 male) ranged in age from 8-17years (M = 12.97; SD = 3.03) and were grouped according to whether they were adopted after 14months or before 9months. A non-adopted comparison group (N = 133; 65 male) ranged in age from 8-17years (M = 12.26; SD = 2.75). PI children adopted after 14months of age displayed poorer performance on the stop-signal and spatial span tasks relative to PI children adopted before 9months of age after controlling for age at assessment. The two PI groups did not differ in their performance on a spatial self-ordered search task. Older-adopted PI children also showed poorer spatial span task performance compared to non-adopted children, but younger-adopted PI children did not. Task performance was significantly associated with parent-rated hyperactive-impulsive behavior in everyday contexts. These findings suggest that exposure to prolonged early institutional deprivation may be linked with inhibitory control and working memory difficulties years after adoption.

Behavioral and EEG Correlates of Reduced Executive Functioning in Adolescents

Exposure to orphanage care or other deprived conditions represent a contributing risk factor in the development of ADHD behaviors. Upon leaving these contexts, the resting EEG patterns found in post-institutionalized (PI) children resemble the EEG profile of children with behavior problems, such as inattention, hyperactivity, and impulsivity. Specifically, this atypical pattern consists of increased theta power relative to other power spectra and decreased alpha power. This study examined if this pattern persists years after adoption and/or whether they were found only in PI youth who developed ADHD. PI and nonadopted (NA) children, between 11-15 year old, comprised the two groups in the study. Approximately half of the participants in each group were diagnosed with ADHD. Parent-reported executive function and attention problems differed by ADHD, but not by adoption classification (PI/NA). The PI youth and NA youth with ADHD exhibited the atypical EEG pattern related to early deprivation and ADHD-related deficits. In the PI youth only, concentrations in beta power and alpha power were positively and negatively associated with fewer executive functions.

The effect of early deprivation on executive attention in middle childhood

Children reared in deprived environments, such as institutions for the care of orphaned or abandoned children, are at increased risk for attention and behavior regulation difficulties. This study examined the neurobehavioral correlates of executive attention in post institutionalized (PI) children. The performance and event-related potentials (ERPs) of 10- and 11-year-old internationally adopted PI children on two executive attention tasks, go/no-go and Flanker, were compared with two groups: children internationally adopted early from foster care (PF) and nonadopted children (NA). Behavioral measures suggested problems with sustained attention, with PIs performing more poorly on go trials and not on no-go trials of the go/no-go and made more errors on both congruent and incongruent trials on the Flanker. ERPs suggested differences in inhibitory control and error monitoring, as PIs had smaller N2 amplitude on go/no-go and smaller error-related negativity on Flanker. This pattern of results raises questions regarding the nature of attention difficulties for PI children. The behavioral errors are not specific to executive attention and instead likely reflect difficulties in overall sustained attention. The ERP results are consistent with neural activity related to deficits in inhibitory control (N2) and error monitoring (error-related negativity). Questions emerge regarding the similarity of attention regulatory difficulties in PIs to those experienced by non-PI children with ADHD.

Iron Deficiency After Arrival is Associated with General Cognitive and Behavioral Impairment in Post-Institutionalized Children Adopted from Eastern Europe

To investigate the role of iron deficiency in general cognitive and behavioral development in post-institutionalized (PI) children during the early post-adoption period. PI children (N = 57) adopted from Eastern Europe or Central Asia (9-46 months of age) were seen at baseline around 1 month after arrival into the US and at follow-up 6 months later. Measures included anthropometry, iron status, the Toddler Behavior Assessment Questionnaire-R (TBAQ-R), the Mullen Scales of Early Learning, and examiner-rated behaviors during testing. 26 % were iron deficient at baseline; 18 % were iron deficient at follow-up. There was a trend for those with iron deficiency at baseline to be more fearful on the TBAQ-R. Those with iron deficiency at follow-up displayed more hyperactivity on both the TBAQ-R and the examiner-rated behaviors. Those with iron deficiency at follow-up were more likely to score below average on the Mullen Early Learning Composite (iron deficient: 80 %; good iron status: 32 %). The association between iron status at follow-up and the Mullen Early Learning Composite was mediated by inattention and hyperactivity behaviors during testing. Iron deficiency is associated with neurobehavioral alterations months after arrival, mediated by the effect on attention and activity levels. Iron status needs to be monitored at least through the first half-year post-adoption, particularly in children exhibiting rapid catch-up growth. Additionally, developmental evaluation is recommended in those with iron deficiency, even in children with good iron status at arrival.

Age at Adoption: A Measure of Time in the Orphanage or Child-Specific Factors?

This study examined the association between pre-adoption variables (e.g., time in orphanage, birth weight) and age at adoption in a sample of 169 children, aged 0–4 years, adopted from orphanages in St. Petersburg, Russian Federation. Time in orphanage was the best predictor of age at adoption. Later adoptees were also more likely to have spent time in a family prior to the orphanage and to have experienced abuse/neglect than earlier adoptees. These results suggest that age at adoption is most strongly related to time in the orphanage; however, family experience, especially abuse/neglect, should also be evaluated in post-institutionalized (PI) children.

Sentence comprehension in postinstitutionalized school-age children.

In this study, the authors investigated sentence comprehension and spatial working memory abilities in a sample of internationally adopted, postinstitutionalized (PI) children. The authors compared the performance of these PI children with that of an age-matched group of children living with their birth families. They hypothesized that PI children would perform below clinical threshold on tasks of sentence comprehension and that poor sentence comprehension would be associated with poor performance in working memory. Twenty-three PI children and 36 comparison children were administered sentence comprehension and spatial memory tasks from standardized assessments. Some oral sentence comprehension skills and the spatial working memory skills were weaker in the school-age PI children than in the age-matched comparison children. A mediational analysis demonstrated that poor spatial working memory performance partially explains the sentence comprehension differences between the 2 groups. These findings provide valuable information to better plan early intervention and special education for PI children.