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Abstract

This study focuses on the association between language skills and core cognitive processes relative to the duration of institutionalization in children adopted from orphanages abroad. Participants in the adoptive group (n = 46) had arrived in the United States between the ages of 2 and 84 months (mean = 24 months), and had been living in the United States for 1–9 years. Drawing on both experimental and standardized assessments, language skills of the international adoptees differed as a function of length of time spent in an institution and from those of 24 nonadopted controls. Top-down cognitive assessments including measures of explicit memory and cognitive control differed between adopted and nonadopted children, yet differences between groups in bottom-up implicit learning processes were unremarkable. Based on the present findings, we propose a speculative model linking language and cognitive changes to underlying neural circuitry alterations that reflect the impact of chronic stress, due to adoptees' experience of noncontingent, nonindividualized caregiving. Thus, the present study provides support for a relationship between domain-general cognitive processes and language acquisition, and describes a potential mechanism by which language skills are affected by institutionalization.
International adoption: Language and cognitive changes
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Language and cognitive outcomes in internationally adopted children
Inge-Marie Eigsti1, Carol Weitzman2, Jillian Schuh1, Ashley de Marchena1 and B.J. Casey3
1Department of Psychology, University of Connecticut
2Yale University School of Medicine
3Sackler Institute for Developmental Psychobiology, Weill Cornell Medical College
RUNNING HEAD: International adoption: Language and cognitive changes
Author note
Correspondence should be addressed to Inge-Marie Eigsti, Ph.D., University of Connecticut; 406
Babbidge Road, Unit 1020; Storrs, CT 06269; inge-marie.eigsti@uconn.edu. Voice: (860) 486-
6021. Fax: (860) 486-2760
Acknowledgements: This research was supported by a grant from the University of Connecticut
Research Foundation and by NIMH R01 MH73175 (to BJC). We are grateful to the families and
children that generously shared their time. We also thank Seth Pollak, Dan Mossler, Preston
Britner, and several anonymous reviewers for helpful comments and discussion, and to Tuhina
Joseph for her contributions.
International adoption: Language and cognitive changes
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Language and cognitive outcomes in internationally adopted children
Abstract (191 words)
This study focuses on the association between language skills and core cognitive processes
relative to the duration of institutionalization, in children adopted from orphanages abroad.
Participants in the adoptive group (n = 46) had arrived in the U.S. between the ages of two and
84 months (mean of 24 months), and had been living in the U.S. for one to nine years. Drawing
on both experimental and standardized assessments, language skills of the international adoptees
differed as a function of length of time spent in an institution and from those of 24 non-adopted
controls. Top-down cognitive assessments including measures of explicit memory and cognitive
control differed between adopted and non-adopted children, yet differences between groups in
bottom-up implicit learning processes were unremarkable. Based on the present findings, we
propose a speculative model linking language and cognitive changes to underlying neural
circuitry alterations that reflect the impact of chronic stress, due to adoptees’ experience of
noncontingent, nonindividualized caregiving. Thus, the present study provides support for a
relationship between domain-general cognitive processes and language acquisition, and describes
a potential mechanism by which language skills are affected by institutionalization.
Keywords: International adoption, cognition, learning, language, stress, brain development.
International adoption: Language and cognitive changes
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Language and cognitive outcomes in internationally adopted children
Language acquisition is a process characterized by remarkable consistency. The
significant homogeneity of the order and timing of language milestones (e.g., Brown, 1973),
however, provide a challenge to researchers who are interested in individual differences in
language development. Researchers have demonstrated significant variability in the timing of
production of syntactic structures in the case of late language learners (Johnson & Newport,
1989) and of child maltreatment (Eigsti & Cicchetti, 2004), among others. The current study was
motivated by this previous work to examine language-specific effects of early deprivation in the
caregiving environment after adoption into a more stable setting, because such perturbations
could reveal some of the causal mechanisms underlying differences in the language acquisition
process. Models of typical developmental processes are strengthened when they are grounded in,
and accommodate, cases of atypical development. International adoption presents a unique
situation in which early adversity, linked to changes in stress-regulating systems, is followed by
a sharp discontinuity of experience (e.g., Croft et al., 2007; Rutter, 2007); as such, this
population may open a window into the cognitive “building blocks” of language acquisition. In
the current study, we examine subtle differences in language abilities in children adopted to the
U.S. from international institutions, and probe for relationships between these language abilities
and domain-general differences in implicit learning, explicit memory and cognitive control. We
hypothesize that the neural effects of institutionalization-related stress provide a mechanism
linking these domain-general cognitive processes to language abilities.
Why international adoption? The population of international adoptees is growing. In
2008 (fiscal year), 17,438 visas were issued by the State Department of the United States for
International adoption: Language and cognitive changes
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international child adoptees (U.S. Department of State, 2009). There is a large and rapidly-
growing literature describing short- and long-term outcomes in post-institutionalized children
that illustrates the multi-system effects of institutionalization on child development. Physical
changes are most readily apparent; children adopted from countries within Eastern Europe
experience one month of growth delay for every five months of institutionalization (Johnson,
2000); furthermore, one of five adoptees has major medical problems, and most have delays in
gross motor (65-70%) and fine motor (50-82%) skills, smaller head sizes (70%), socio-emotional
delays (53%), and language delays (59%) when assessed shortly after adoption (Albers et al.,
1997). While adoptees from China may have somewhat better outcomes, they still exhibit delays
in growth, motor skills, and speech and language skills (Cohen et al., 2008) and often show
persistent emotion regulation problems (Tottenham et al., 2009, 2010).
Physical challenges often resolve within the first few years after adoption (Van
IJzendoorn et al., 2007). However, many formerly-institutionalized children experience longer-
lasting cognitive and behavior problems (van der Vegt et al., 2009; Verhulst et al., 1990a),
particularly when adopted after 24 months (Gunnar et al., 2007). One consistent behavioral
outcome has been higher rates of disorganized attachment in adoptees that seem to be related to
the duration of deprivation (O'Connor & Rutter, 2000). In one study, a large proportion (36%) of
post-institutionalized children exhibited disorganized attachment relationships (compared to 15%
in comparable normative samples; van Londen et al., 2007). The results across a variety of
studies have suggested a dose-response function, with more problems seen in children who spent
longer periods in institutions (Gunnar, 2001).
Findings remain controversial, however with several studies indicating that international
adoptees exhibit no more behavior problems than nonadopted children (Brand & Brinich, 1999;
International adoption: Language and cognitive changes
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Kim et al., 1999). Similarly, an epidemiological study (Verhulst et al., 1990a) found better
functional skills in some social domains for an adopted group. In a study of cognitive
development, a sample of 70 early-adopted (at age 5.5 months) children assessed at age 13.7
months was at expected chronological age norms for psychomotor and mental development
indices (van Londen et al., 2007).
Language and international adoption
In the context of language abilities, the reported findings in studies of language
achievement for international adoptees are highly variable. A number of studies have found
evidence that language skills are essentially intact after several years in an English-speaking
home. For example, Geren and colleagues find evidence of rapid acquisition and similar patterns
of vocabulary acquisition in a young sample of adoptees from China (Geren et al., 2005). Based
on parent report, one study found that structural and semantic aspects of language were intact,
with some evidence of weakness in pragmatic language skills (Glennen & Bright, 2005).
Multiple studies have detected no difference in language skills as a function of age of adoption in
international adoptees from orphanages alone (Glennen, 2007; Krakow et al., 2005) and
orphanages and foster homes (Pollock, 2005).
In contrast, several groups have suggested that at least some subsets of international
adoptees may exhibit ongoing language difficulties. Children adopted prior to 12 months appear
less likely to have later delays, whereas two studies using direct observation and assessment
found that children adopted after the 12-month point show language delays in proportion to the
length of time spent in institutions (Glennen & Masters, 2002; Miller & Hendrie, 2000). Another
study of a group of children adopted from Romania, compared to a group of within-country
(U.K.) adoptees, found an important threshold at eighteen months, such that children adopted
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after that age who showed early expressive language delays continued to experience language
deficits at six and eleven years (Croft et al., 2007). However, for children who spent up to 42
months in institutions, and who had speech sounds at the time of arrival, there was no
relationship between duration of institutionalization and language and cognitive skills. In
general, children with early delays (at age one) continue to be delayed at later ages (e.g., two
years, Glennen, 2007). Language skills are associated with age of adoption, with particularly
important cutoffs at 12 or 18 months. This set of studies suggests that expressive language, and
syntax in particular, may be more vulnerable to disruption, at least in the short term, than
language comprehension (Windsor et al., 2007).
In assessing language delays, some data suggest that while there is significant early
language catch-up, delays may become salient again when children reach school age and must
use their language to accomplish more complex academic and cognitive goals (Saetersdal &
Dalen, 1991). For example, Glennen and Bright (2005) collected parent and teacher surveys for a
group of six- to nine-year-old children adopted from Eastern Europe. Results indicated that 17%
were receiving special education services, and fully 54% had psychiatric diagnoses (most
commonly, ADHD). Further, their current social skills were predicted by expressive vocabulary
measured at age two to three years. In contrast, Scott, Roberts and Krakow (2008) studied a
group of 24 children ages seven to eight adopted from China using performance on standardized
tasks and a spontaneous story narration. Most children were average or above average relative to
test norms; two of the children (8%) were in the clinical range on these measures.
Problems with language are likely to have a cascade of effects on academic and
socioemotional functioning (Lyon et al., 1997); a number of studies of non-adopted children with
early unremediated language deficits suggest that a significant proportion (65%) go on to
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develop reading impairments (Snowling et al., 2000). International adoptees are more likely to
receive intervention and preventive services, and studies suggest that a majority will catch up
completely, but that a subgroup will continue to exhibit significant delays (Roberts et al., 2005;
Scott et al., 2008). For example, in the Roberts et al. (2005) study of Chinese adoptees, 94% of
the adoptees were within or above the average range; 6% scored more than 1.25 SDs below the
mean for standardized language assessments, a figure which approximates the prevalence (2.5-
4%) of language delays in a similar non-adopted Cantonese-speaking population (Wong et al.,
1992).
Children nurtured in initially difficult circumstances show remarkable plasticity.
Longitudinal studies have demonstrated that some children, typically those with the most
impairment at the outset, continue to show developmental improvements even a decade after
adoption (Beckett et al., 2006). Age of adoption (or the related variable, duration of
institutionalization) has generally been found to be an important contributor to later outcomes,
with early-adopted children (those who spent shorter periods in institutional care) faring better
than their later-adopted peers (Croft, et al., 2007; Gunnar, et al., 2007; McGuinness, et al., 2000;
Rutter, 1998; Tottenham et al., in press; Verhulst, et al., 1990b). Preadoptive conditions are also
important for long-term outcomes (including self esteem and psychological health; Andresen,
1992; Cederblad, et al., 1999); differences in results may reflect differences in the typical
standards of care across countries of origin.
The wide variability of outcomes for international adoptees is secondary, in part, to
methodological differences. In some studies, language is assessed via parent report, which may
introduce a bias based on parent expectations; other studies rely on standardized verbal IQ scales
(e.g., Roy et al., 2000); these global scores, which aggregate performance across a variety of
International adoption: Language and cognitive changes
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low-level cognitive processes, may impact our ability to detect more subtle impairments.
Furthermore, some studies recruit a comparison sample; others compare adoptees to standardized
test norms. This may be a particularly important methodological point. International adoptees are
typically adopted into resource-rich homes, by families with a relatively high standard of living
(socioeconomic status, or SES, which is calculated on the basis of family education, occupation,
and income). Studies from the typical language acquisition literature have consistently
demonstrated a marked effect of SES on language acquisition, with higher-SES children showing
richer vocabularies and more complex syntax at relatively earlier ages (Hart & Risley, 1995;
Hoff-Ginsberg, 1991, 1998). As such, comparing performance of adoptees to standardized test
norms may be informative about clinically-relevant outcomes, but risks missing subtle
differences in developmental attainment.
Potential physiological and psychological stress of orphanage rearing. There are many
diverse influences on outcomes in international adoptees, including (but not limited to) chronic
untreated middle ear infections and other immune system mechanisms (Coe & Laudenslager,
2007; Shirtcliff et al., 2009), exposure to environmental contaminants (Johnson, 2000), and lack
of social experience (Gunnar et al., 2000). It is well-established that institutionalization is
characterized by nonindividualized and non-contingent caregiving. Altogether, a growing body
of research indicates that the experience of institutionalization leads to alterations in the
development and activity of glucocorticoid-related stress hormones via a complex and possibly
synergistic set of influences (Gunnar et al., 2001). Glucocorticoids are regulated via the
hypothalamic-pituitary-adrenal (HPA) axis. Institutionalization has been found to impact the
biological systems involved in stress responses (including glucocorticoid levels; Kertes, Gunnar,
Madsen & Long, 2008; and see Gunnar & Quevedo, 2007). For example, studies of international
International adoption: Language and cognitive changes
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adoptees have found an association between duration of institutionalization and dysregulation of
glucocorticoids in children with a history of IA (Wismer Fries et al., 2008), with the degree of
deprivation in the institutions influencing corticoid levels, potentially reflecting changes in the
regulation of glucocorticoid receptor gene expression (Kertes et al., 2008). For a more in-depth
discussion of long-term impact on glucocorticoid functioning in humans as a function of early
deprivation, the reader is referred to Kertes et al., 2008.
Animal models (e.g., Meaney et al., 2007) and human neuroimaging experiments provide
complementary insights as to how the psychosocial stress of early adverse rearing and
environmental demands can induce long-lasting behavioral and neuroanatomical impairments (as
reviewed in Marshall & Kenney, 2009). Although emphasis has been placed on hippocampal-
dependent learning systems (Kirschbaum, 1996; Liu et al., 2000; Luine et al., 1996; Lupien,
1997; Monk & CA, 2002; Newcomer & Richards, 1999; Sandi, 1997; Wolkowitz et al., 1990),
the prefrontal cortex has been a recent focus of inquiry as well (Arnsten & Goldman-Rakic,
1998; Liston et al., 2006, 2009). Both systems are essential in higher order cognitive processes
and implicated in language acquisition and competency.
Frontohippocampal brain circuits, including the hippocampus and amygdala, are highly
sensitive to chronic stress (Arnsten & Goldman-Rakic, 1998; Liston et al., 2006, 2009;
Tottenham et al., 2010); these circuits are central to learning and memory functioning (Teyler &
DiScenna, 1987). The hippocampus is critically involved in learning and memory; relevant for
the present study, numerous studies have suggested that phonological memory abilities are
strongly related to later vocabulary skills (Adams & Gathercole, 2000; Hanten & Martin, 2001),
both over the course of development (Rodrigues & Befi-Lopes, 2009) and across various
disorders (Archibald & Gathercole, 2006; Gathercole et al., 2006). Some researchers have
International adoption: Language and cognitive changes
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proposed specific links between explicit memory processes and the acquisition of vocabulary, or
the lexicon (Ullman, 2001). Collectively, these data raise the possibility that the stressful
experience of institutionalization impacts the integrity and functioning of the hippocampal
explicit memory system, which in turn could impact some aspects of language development; this
proposal is outlined in Figure 1.
Chronic stress also appears to impact on another brain region, that of prefrontal cortex.
Animal models suggest that early maternal deprivation can lead to changes in prefrontal cortex
(Dent et al., 2000), and cognitive control has been shown to be particularly sensitive to the
influences of stress in rodents (Liston et al., 2006, 2009) and primates (Arnsten & Goldman-
Rakic, 1998). Consistent with these animal studies, a PET study of 10 Romanian adoptees found
decreased metabolism in prefrontal cortex, as well as orbital frontal gyrus, lateral temporal
cortex, bilateral hippocampus, amygdala and brainstem (Chugani et al., 2001). Among other
processes, prefrontal cortex is important in cognitive control, the ability to suppress attention and
responses to irrelevant information, particularly highly salient stimuli (Allport, 1987). Research
has linked the executive process of cognitive control to sentence comprehension in both adults
(Novick et al., 2005) and children (Choi & Trueswell, in press). Cognitive control may play a
role in language acquisition as well as comprehension, as demonstrated in studies of infant
speech perception (Conboy et al., 2008) and bilingualism (Carlson & Meltzoff, 2008).
Model of orphanage effects on language and cognitive development. The approach of
studying internationally adopted children permits us to gain traction on several important
theoretical issues. There has been extensive work linking domain-general cognitive mechanisms
to later language acquisition. For example, studies from the typical language acquisition
literature have examined relationships between early perceptual abilities and later word learning
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(Kuhl, 2008; Yeung & Werker, 2009) and vocabulary acquisition and later syntactic skills
(Hudson & Eigsti, 2003). Other research has examined statistical regularities that appear be
accessible to language learners. This latter line of work provides an important control for the
relationship between institutionalization-related stress and its impact on cognitive processes.
Specifically, a number of studies have suggested that language learners are sensitive to the
regularities of language structure (e.g., Maye et al., 2002; Saffran et al., 1996; Saffran et al.,
1999) and that the ability to implicitly learn these regularities may be important in language
acquisition, as demonstrated by a series of studies of children with specific language impairment,
or SLI, who require significantly more exposure to the implicit regularities of language structure
before they show any evidence of learning (Evans, Saffran & Robe, 2009). Implicit learning is
related to a network of brain areas, including the caudate nucleus; this region appears relatively
insensitive to the effects of chronic stress. Thus, while implicit learning is important for language
acquisition, it is not expected to be especially influenced by the experience of
institutionalization; again, Figure 1 lays out this model.
The present study addresses several issues. First, given the conflicting findings in the
literature, we examine the language-specific effects of the institutionalization experience in a
group of school-age children. Whereas several studies find language delays and deficits, others
have found age-appropriate abilities. The current study directly assesses language skills, in a
sample of adopted children and SES-matched non-adopted controls, to gain further perspective
on language outcomes in middle childhood. A better understanding of the impact of
institutionalization on language, after the children have acquired the new language, is relevant
for helping to identify and remediate areas of likely challenge for this population of children. We
predict that the children with the longest durations of institutionalization will show impairments
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in language abilities, even when taking into account the length of time that they have been
exposed to English.
Thus far, it has been difficult to pinpoint the mechanism underlying subtle but long-term
language delays. A study of adoptees who, by virtue of their early life experiences, vary
significantly in their cognitive abilities, may illuminate links between language acquisition and
domain-general cognitive processes. Findings may reveal associations between processes that are
typically confounded in maturation; because international adoptees may exhibit a specific pattern
of cognitive deficits, associations across systems are more likely to emerge. We proposed a
mechanism subserving these cognitive changes: specifically, we hypothesize that exposure to
chronic stress, operationalized as the duration of institutionalization, has specific neural effects
on cognitive processes that are involved in language acquisition.
The present study was designed to test a model, shown in Figure 1, linking specific low-
level cognitive processes to language skills. Cognitive processes were identified as 1) critical in
language acquisition (explicit memory, cognitive control, and implicit learning) and 2) linked to
brain circuits that are either highly sensitive to chronic stress (hippocampus and prefrontal
cortex) or as relatively stress-insensitive (dorsal striatum; note that ventral striatum may be
sensitive to stress due to projections from amygdala to that region). Participants completed a
battery of standardized and experimental tasks that assessed language skills as well as explicit
memory, cognitive control, and implicit learning. We also assessed nonverbal IQ to account for
domain-general developmental delays. The longer-institutionalized participants were predicted to
perform worse on explicit memory and cognitive control measures, with no predicted differences
for implicit learning tasks. All three cognitive processes were predicted to relate to language
abilities, which were in turn expected to differ in adoptees relative to non-adopted children.
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Nonverbal IQ was also explored, to probe for generalized developmental delays. In summary, the
goal of the present work was to assess the long-term effects of institutionalization on language
acquisition, as well as effects on distal (i.e., those not directly involving language) cognitive
processes.
Methods
Participants. Seventy children (44 males and 34 females) between the ages of 4 and 13
participated in the study (mean age = 8 years, 6 months, SD = 2 years, 4 months; range = 48 –
158 months); see Table 1. Participants with a history of international adoption were recruited
from a clinical database at the Yale International Adoption Clinic (n = 579) and through word of
mouth (n = 14); potential participants had to have lived in the U.S. for a minimum of one year.
Of the 110 in the clinic database that were contacted by phone and eligible, 59 children
participated (49%). Participants were excluded if there was an existing diagnosis of fetal alcohol
syndrome as determined by a developmental pediatrician (Dr. Weitzman; n = 5) or a history of
international foster family care, but not orphanage life (n = 8), leaving a final sample of 46
adoptees. A comparison sample of 24 non-adopted children was recruited through word of
mouth, and via referrals from adopted participants. Children were included as controls if they
met age criteria and had experienced no reported disruptions in caregiving (e.g., death of a
parent). Consent and assent were obtained prior to testing, and procedures followed all
applicable human subjects guidelines.
The adopted sample was divided into three groups based on the length of time each child
spent in an orphanage; note that duration of institutionalization correlated highly (r = .65, p <
.001) with age of adoption. The correlation was not perfect, as some children were given up for
adoption at birth (n = 27) and others were given up at a later period (n = 19), ranging from as
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young as one month to as old as 48 months, M(SD) = 8.0 (13.1). Sample grouping was designed
to permit the evaluation of specific timepoints that have been found in previous studies to
demarcate important differences in developmental outcomes.
The four groups (1-12 months, 13-24 months, and 25+ months in orphanage care, and
non-adopted controls) were matched on a number of variables, as shown in Table 1: current
chronological age, F(3, 66) = .87, p = .46,
η
2p = . 0.04; gender,
χ
2 (3, n = 70) = 7.23, p = .07, and
socioeconomic status (SES, Hollingshead, 1975), F(3, 66) = .486, p = .69,
η
2p = . 0.02. The
similarity in SES across groups, including non-adopted controls, is particularly important, given
the likelihood that international adoptees will be adopted by higher-SES families (Gauthier &
Genessee, 2007). In addition, the adopted groups did not differ in how long they had spent with
their adoptive families (“Time since adoption” in Table 1), F(2, 43) = 1.16, p = .32,
η
2p = .05,
and the relationship between the length of time spent in an institution and time spent in the U.S.
was not correlated, r(46) = -.16, p = .30. This is particularly important given findings from the
animal literature that indicate some reversibility of the effects of maternal deprivation in early
life on cognitive functioning in adulthood (Bredy, Humpartzoomian, Cain & Meaney, 2003).
Participants had, on average, been in the U.S. for over five years; one participant had been
adopted 15 months prior to evaluation. A scatterplot showing length of time in adoptive family
as a function of age of adoption is shown in Figure 2. Groups were also matched on the age at
which their biological families gave them up for adoption, F(2, 43) = 0.36, p = .70,
η
2p = .02. As
expected, the three adopted groups differed significantly in age at time of adoption, such that the
children who spent a longer period in institutions were also older at the time of adoption.
Birth locations for the adopted participants were organized into four geographic regions:
Eastern Europe (Lithuania, Romania, Russia, Ukraine): Northeastern Asia (China, Korea): Latin
International adoption: Language and cognitive changes
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and South America (Peru, Columbia): Southeast Asia (Cambodia, Vietnam); data shown in Table
1. Across groups, there were no differences in country of origin,
χ
2 (6, n = 46) = 7.32, p = .29.
The participants spanned a wide age range (4-13 years). This variability was important in
allowing us to recruit children who varied in the length of time they were institutionalized, and
length of time spent in an adoptive home, which in turn revealed the effect of institutionalization
on low-level cognitive processes. Time spent in the adoptive home has been shown to exert
positive effects on development, and as such is likely to exert the opposite effects on
performance relative to time spent in an institution (Tottenham et al., 2009). As a control for this
factor, and to control for the amount of exposure that a child had to English, length of time spent
in an adoptive home was included as a covariate for all analyses. For non-adopted children,
chronological age (which also comprises duration of exposure to English) was entered in lieu of
time in adopted family1.
Procedure
Children and a parent (a father, in 3 cases) participated in a three- to four-hour
assessment, which took place at the Developmental Cognitive Neuroscience Lab at the
University of Connecticut. Parents completed several written questionnaires, and also
participated in interviews with a licensed clinical psychologist (Dr. Eigsti) or a graduate research
assistant with training in clinical assessment. Children completed a battery of measures with a
1 Note that because some children did not leave their biological families until up to 48 months
after birth, there is additional noise added to this analysis; for example, one child in the “1-12
months in orphanage group” was actually 2 ½ years old when placed in an institution. Many
published studies do not report data on the age at which their participants left their birth families;
only the age of adoption is reported, with the implication that the time prior to adoption was
entirely at an institution. Because the focus of this study was on identifying the role of the stress
of institutionalization and its effects on cognitive and language outcomes, we have chosen to
characterize the length of time that children spent in institutions, rather than the age at which
they were adopted to the U.S.
International adoption: Language and cognitive changes
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research assistant in an adjoining room. They were offered numerous breaks as needed. Upon
completion of the session, participants received financial compensation, and adoptive families
later received a written report documenting the child’s current cognitive and language
functioning. All participants, with the exception of two 4-year-old control and two 5-year-old
adopted children, were able to complete all measures within a single session; these latter
participants completed the remaining measures at a second session.
Adoptive history. Parents responded to questions about their children as part of a
structured interview. They were asked about the child’s birth history, the quality and
characteristics of the orphanage placement, the child’s developmental level (age, cognitive,
language, motor, and social skills) at the time of adoption, and the challenges the family faced
during the first six months after the child joined the family. Detailed data from this interview are
reported elsewhere (Eigsti et al., March, 2009) and are currently being prepared for publication.
To assess the parent-child attachment relationship at the time of the evaluation, we administered
the Disturbance of Attachment Inventory (DAI, Smyke et al., 2002) to parents of both adopted
and non-adopted participants. Questions probed for behaviors that characterize children with
dysregulated attachment, such as not seeking comfort preferentially from one’s caregiver, lack of
reticence with unfamiliar adults, or warily monitoring a caregiver’s mood. Items, which fell into
three mutually exclusive categories (inhibited insecure attachment; disinhibited insecure
attachment; and dysregulated use of caregiver as a secure base), were analyzed as a total score. A
subset (20%) of questionnaires were double-coded and reliability was high (> 95%).
Language Assessment
Language. To assess language skills, children completed core subtests of the Clinical
Evaluation of Language Fundamentals – 4 (CELF, Semel et al., 2003). The CELF evaluates a
International adoption: Language and cognitive changes
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student’s general language ability. Participants completed tasks assessing their ability to interpret
spoken directions of increasing length and complexity (Concepts and Following Directions),
listen to and repeat sentences of increasing length and complexity (Recalling Sentences),
formulate spoken sentences of increasing length and complexity using words and pictures
provided by the examiner (Formulated Sentences), and understand and express relationships
between words that are related by semantic class features (Word Classes).
There were four 4-year-old participants who completed the six subtests of the preschool
form of the CELF (CELF-P; Semel et al., 2004). For the CELF-P, children completed six
subtests asking them to interpret spoken sentences of increasing length and complexity (Sentence
Structure), to follow directions using concepts containing logical operations (Linguistic
Concepts), to demonstrate knowledge about dimension, location, quantity, and equality by
pointing to a picture that best identifies a concept (Basic Concepts), to imitate orally presented
sentences (Recalling Sentences in Context), to name common concepts (Formulating Labels),
and to demonstrate knowledge of morphological rules in a sentence-completion task (Word
Structure). For all participants, the Core Language scaled score was considered as an estimate of
current language functioning, as this measure comprises both receptive and productive
vocabulary, morphology, and syntactic language abilities.
Vocabulary, or lexical skill, is the language domain that was hypothesized to be most
associated with explicit memory skills (e.g., Gathercole et al., 1997). The Peabody Picture
Vocabulary Test – 3 (PPVT-3; Dunn & Dunn, 1997) was used to assess receptive vocabulary
skills.
Domain-General Cognitive Assessments
Explicit memory was assessed with the California Verbal Learning Test-Children's
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Version (CVLT; Delis et al., 1994). In this well-studied list-learning task, children hear a list of
15 common words that fall into one of three categories (clothing, fruit or toys) and are asked to
recall as many words as possible. After repeating the list over five trials, the child hears and
repeats back a new distraction list; this is followed by free recall of the original list. After a 20-
minute delay, the list is recalled from memory, followed by a recognition memory test. Children
did not complete the cued recall short delay task, which does not appear to account for additional
variance in performance (O'Jile et al., 2005). List memory on the first trial following the
interference list and for the 20-minute delay list comprised the explicit memory variables.
Cognitive control, defined as sustained attention and susceptibility to competing
information, was also hypothesized to reflect early stress experiences via their impact on
prefrontal cortical area. Cognitive control was assessed with an experimental as well as a
standardized measure. First, children completed an experimental go/nogo task that has been
shown to be sensitive to subtle but enduring individual differences (e.g., Eigsti et al., 2006). In
the go/nogo task, the child’s task was to press a button (“go”) in response to frequent (75%)
visually-presented targets (Pokemon cartoon characters), but to avoid responding (“nogo”) to an
infrequent (25%) nontarget (a distinctive Pokemon character). Performance was evaluated with
d-prime (d'), a measure of response sensitivity which includes both misses and false alarms, and
including RT as a covariate to control for speed-accuracy tradeoffs. The NEPSY Auditory
Attention task, which demands sustained attention, response inhibition, and goal maintenance,
provided a second cognitive control task. In this task, children followed recorded instructions to
place colored shapes into a box; after several minutes, the task undergoes a shift, such that when
they hear instructions about one color, they must respond with a different color. This task
assesses both sustained attention as well as inhibitory control.
International adoption: Language and cognitive changes
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Implicit learning. Finally, implicit learning abilities have been proposed as particularly
relevant for syntactic development (e.g., Ullman, 2001). However, implicit learning is associated
with brain structures (e.g., caudate nucleus) hypothesized to be less impacted by
institutionalization-related stress. Implicit learning was assessed in an experimental serial
reaction time (SRT) task. Children were presented with a cartoon stimulus that appeared in one
of four boxes; a 10-item Nissen-Bullmer sequence governed the location in which the stimulus
appeared. Trials were presented in blocks of 100, where the second, third, and fifth blocks used
the fixed sequence, and (to control for simple motor learning) the first and fourth used a
pseudorandom order. Responses were collected via touch-screen, and differences in RT between
the fourth and fifth blocks (controlling for age and accuracy) provided the dependent measure.
Nonverbal IQ. The relationship between explicit memory and language functioning could
potentially be moderated by domain-general IQ skills; for example, the experience of
institutionalization could lead to generalized delay or impairment. To provide an estimate of IQ
independent of memory and language abilities, and thus to address the specificity of the
hypothesized relationship between explicit memory and language skills, children completed the
Object Series/Matrices subtest of the Stanford-Binet – 5th Edition (SB-5, Roid, 2003). This task
asks children to choose the best option to complete a series of objects, and depends on non-
verbal responses.
Results
Preliminary analyses. Prior to all inferential statistics, dependent variables were
examined for deviations from normality and sphericity. All of the dependent variables were
distributed normally. Effect sizes were calculated with partial eta squared (
η
2p), which describes
International adoption: Language and cognitive changes
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the percentage of the variance (effect + error) in the comparison accounted for by the relevant
variable.
Previous studies of internationally-adopted children suggest an association between
duration (in months) of institutionalization and the severity of problems in a variety of domains,
particularly for children adopted after age 12 months, suggesting the presence of ceiling effects
or other attenuating variables in earlier-adopted children (Beckett et al., 2006; Rutter &
O'Connor, 2004). To address the possibility of a developmental shift in vulnerability occurring at
the 12-month point, as well as to examine the role of the duration of the stressful
institutionalization experience, we analyzed our data using two complementary strategies. First,
we examined possible group differences among children who spent only 1-12 months in
orphanage care, compared with children who spent 13-24, or 25-plus months in orphanage care;
non-adopted children formed the fourth group for comparison. Planned comparisons were
analyzed as MANCOVAs of the dependent variables, with months in the U.S. as a covariate.
Second, correlational analyses and hierarchical regression were used to examine the extent to
which duration of institutionalization accounted for variance in the data. Correlations from 0.5 –
1.0 are described as strong; 0.3 – 0.5 as moderate; and 0.1 – 0.3 as weak.
Some task data were missing due to experimenter error or equipment problems; missing
data included DAI scores (n = 2 adopted group, n = 5 comparison group), CELF Core Language
scores, due to missing subtest scores (n = 3, n = 2, respectively), PPVT (n = 4, adopted group),
NEPSY (n = 4, n = 1), Go/Nogo task (n = 8, n = 1), and implicit learning (n = 6, n = 2). Missing
data were distributed equally between adopted and control groups,
χ
2 (4, n = 70) = 7.08, p = .13.
In addition, 4 participants did not receive NEPSY scaled scores, because their age (4 years)
precluded scoring relative to standardized norms. Analyses included all available data.
International adoption: Language and cognitive changes
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Institutionalization and attachment. While physiological markers of stress were not
available, parents completed an interview that reported the presence of child behaviors
suggesting disorganized or insecure attachment relationships to caregivers. These data indicated
that there was a significant difference, across all groups, for the number of current
disorganized/insecure attachment behaviors at the time of evaluation, controlling for time (in
months) spent with the adoptive family, F(1, 39) = 4.94, p = .004,
η
2p = .21. Data, shown in
Table 2, indicated that 21% of the variance in disorganized or insecure attachment behaviors was
accounted for by grouping of how long children had spent in an orphanage. Furthermore, for
adoptees only, duration of institutionalization was significantly and moderately correlated with
disorganized/insecure attachment behaviors, controlling for time spent with the adoptive family,
r(40) = .441, p = .003. These data were consistent with the hypothesis that the institutionalization
experience was noncontingent, leading to dysregulation of behavior and potential stress
dysregulation, as it led to more behaviors indicating insecure or disordered attachments for the
adopted group.
Language and Cognitive Measures
Language assessment. A primary goal of this study was to examine the long-term effects
of institutionalization on language, after children had spent a significant period in an English
language environment (greater than 12 months; 74 months on average across groups).
Participants completed the CELF, which assesses language knowledge across several language
domains. Findings indicated that the adopted group scores were at the mean for the
standardization sample (M = 95.7, SD = 15.9), but significantly lower (22 points, more than 1 SD
in difference) than the comparison sample (M = 118.4, SD = 11.8), controlling for time in the
U.S., F(1, 62) = 19.13, p < .001,
η
2p = .24. The effect size indicated that 24% of the variance in
International adoption: Language and cognitive changes
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CELF Core Language scores was accounted for by adoption group status. Results are presented
in Table 2.
The mean for CELF Core Language scores is set at 100, with a standard deviation of 15.
In the present study, impairment in functioning was defined at 1.5 SD below the mean, and
participants were assessed as falling in the average, impaired, or above average range. Data are
shown in Table 2, and indicate that none of the comparison participants were in the impaired
range, and 33% were in the above-average range. In contrast, for the adopted participants, the
scores of 15-35% fell in the impaired range, depending on the group. Furthermore, performance
on the CELF in the adoptive group was associated with the duration of institutionalization,
controlling for time spent with an adoptive family, r(40) = -.305, p = .049, a correlation in the
moderate range. The longer a child spent institutionalized, the lower his or her scores were likely
to be, even taking into account the length of a child’s experience in an English-speaking
environment.
For the Core Language scores, effect sizes were large, suggesting that an important
proportion of the variance in scores was accounted for by group status. We highlight the finding
that the adoptive group scores were generally in the average range, indicating a lack of long-term
impairments in language for most participants. However, the notion of “average” is relative to
the tests’ standardization samples. The adoptive participants were generally of high SES status
(M = 56 in all groups), a factor which is robustly correlated with better performance on language
tasks in large studies of typically-developing children (Hart & Risley, 1995; Hoff-Ginsberg,
1998). Data from the comparison group are consistent with this finding, with an average score on
the CELF Core Language measure in the high average range (M = 118). In this regard, when
participants are high in SES, performance relative to an SES-matched group may be more
International adoption: Language and cognitive changes
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informative than the performance of adoptees relative to test norms, as it permits us to more
accurately assess the impact of the institutionalization experience on language skills.
Receptive vocabulary was assessed using the PPVT-3. Findings, shown in Table 2,
showed a clear impact of institutionalization, with significant group differences between
adoptees and the comparison group, controlling for duration of exposure to English, F(1, 63) =
20.16, p < .001,
η
2p = .24, with each group of adoptees scoring significantly lower than the
comparison group, all p’s < .01. However, the correlation between institutionalization and
PPVT-3 scores did not reach significance, r(39) = -.29, p = .07. The PPVT-3 has a mean of 100
and a SD of 15; none of the participants scored in the clinical range. Fifty percent of the
comparison group scored in the above-average range, whereas between 0 and 10% of adoptees
scored in that range. The PPVT-3 data suggest that institutionalization had more limited effects
on vocabulary, or that receptive vocabulary is more easily “ameliorated” by time spent with an
adoptive family.
Explicit memory. Declarative memory has been linked in many prior studies to language
skills, particularly to vocabulary development, because of the need for the phonological form of
a word to be encoded in short-term memory (e.g., Gathercole et al., 1997). If institutionalization
is associated with language deficits, explicit (i.e., declarative) memory is very likely to be
implicated. Results from the CVLT showed a significant main effect of institutionalization on
memory, controlling for time in the U.S; data are presented in Table 3. There was a significant
group difference in number of items recalled (no delay), F(3, 63) = 3.69, p = .02,
η
2p = .16, with
adopted participants recalling fewer items. Similarly, adoptees recalled significantly fewer items
after a 20-min delay, F(3, 63) = 2.91, p = .04,
η
2p = .12. Furthermore, institutionalization was
significantly and weakly correlated with number of items recalled after a delay, controlling for
International adoption: Language and cognitive changes
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time in the U.S., r(41) = -.26, p = .04. There was no correlation between duration and items
recalled with no delay, r(41) = -.18, p = .12. The findings were consistent with a significant
association between duration of institutionalization and memory abilities. Furthermore,
vocabulary (PPVT-3) scores were moderately correlated with CVLT recall after a delay, r(41) =
.473, p =.002, in adoptive participants, but unassociated in the comparison group, r(24) = .07, p
= .76; correlational data are shown in Table 4.
To assess memory on items recalled with no delay, the CVLT uses a T-score, with a
mean of 50 and an SD of 10. On this measure, the adopted participants had a mean score of 42.5,
significantly lower than the mean of 51.7 for the comparison group, but still within the average
range. The adoptees had a total of 12 participants (27%) with scores more than one SD below the
mean; the comparison group had two participants (9%) with scores in that range. To assess
performance on number of items recalled after a 20-minute delay, the CVLT uses z-scores, with
a mean of zero and an SD of one. On this measure, the adopted participants had a mean score of -
.768, significantly lower than the mean of +.313 for the comparison group, but still within the
average range. However, the adoptees had a total of 19 participants (37%) with scores that were
more than one SD below the mean; in comparison, the comparison group had just two
participants (8%) with scores in the below-average range.
On average, explicit memory skills for adoptees were in the low end of the average range,
with few participants in the above-average range, but a significant proportion of the adopted
group showed impairments that were clinically significant. Few of the adopted participants (and
only ones from the 1-12 mos. group) were in the above-average range.
Cognitive control. Cognitive control refers to the active maintenance of goals and the
means to achieve them. For example, someone raised in the U.S. has a bias to look to the left
International adoption: Language and cognitive changes
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when crossing the street, to avoid oncoming traffic; when visiting a country where traffic flows
in the opposite direction, this highly-overlearned bias must be actively overridden. Two
assessments of cognitive control were included: a go/nogo task and the NEPSY Auditory
Attention task. Findings from the Go/nogo task showed an significant main effect of group,
controlling for RT and time spent in the U.S., F(1, 57) = 5.09, p = .03,
η
2p = .08, such that the
comparison group had significantly higher (more accurate) d' scores than adoptees (5.21 (SD =
2.22) vs. 2.94 (SD = 1.86) , respectively); refer to Table 3. The relationship between d' and
duration of institutionalization was in the moderate range and approached significance,
controlling for time in the U.S. and RT, r(34) = .32, p = .05. These data suggest that the adopted
group as a whole was less able to inhibit inappropriate responses, and that task differences were
sensitive to duration of institutionalization.
In the Auditory Attention task, adopted participants had significantly lower scaled scores
than the comparison group, F(1, 58) = 4.05, p = .049,
η
2p = .07; see Table 3. Duration of
institutionalization and sustained attention showed a trend towards a weak correlation, r(36) = -
.30, p = .07, indicating that later-adopted participants were less able to stay on task and inhibit
attention to irrelevant information. All but one adopted participant scored in the average range,
suggesting that effects of institutionalization were subtle and did not lead to significant
impairment. Taken together, data from the Go/nogo and Auditory Attention measures suggest
significant group differences in cognitive control; however, performance was only weakly
associated with institutionalization, indicating that these differences were small.
Implicit learning. Implicit learning has been closely related to language acquisition in
some theoretical accounts due to its role in learning about bottom-up statistical regularities that
lie at the core of rudimentary language processes. In contrast to explicit memory and cognitive
International adoption: Language and cognitive changes
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control, however, the neural substrates of implicit learning (e.g., dorsal striatum) are not thought
to be as sensitive to the effects of psychological stressors (Tottenham et al., 2009). If so, implicit
learning should show limited or no effects of institutionalization. To test this possibility,
participants completed an implicit learning (serial reaction time, or SRT) task. In the implicit
SRT task, learning was assessed via the change in reaction time between blocks two, three, and
five, all of which consisted of sequenced items. There was evidence of learning, in that there was
a significant main effect of Block for reaction time (RT) in a repeated-measures ANOVA
controlling for age, F(2, 110) = 4.84, p = .01,
η
2p = .08, with RT decreasing across the three
blocks (significant linear effect, F(1, 55) = 5.89, p = .02,
η
2p = .10). However, adoption status
was not a significant group difference, F(2, 114) = 1.22, p = .30. Similarly, a one-way ANOVA
comparison of adopted and non-adopted participants revealed a lack of group differences in SRT
performance, for the difference between the two final structured and random blocks, F(1, 57) =
1.21, p = .28,
η
2p = .02. Months of institutionalization was uncorrelated with SRT task
performance (difference between two final blocks), r(35) = .03, p = .86. Data are presented in
Table 3. The data indicate that institutionalization had relatively little impact on implicit
learning; adopted participants were just as able as the comparison group to learn an embedded
pattern.
Intellectual functioning. It is possible that the association between language, cognitive
abilities, and institutionalization, could be mediated largely by IQ – that is, the
institutionalization experience could depress cognitive functioning in a domain-general fashion.
Participants completed a subtest of the Stanford-Binet – 5th Edition, the Object Series task. This
task, which is the primary nonverbal subtest, asks children to choose the best option to complete
a series of objects. Results indicated that the adopted participants as a group scored as highly as
International adoption: Language and cognitive changes
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the comparison group, F(1, 67) = 2.04, p = .16,
η
2p = .03; refer to Table 2. Duration of
institutionalization did not correlate with IQ scores, r(43) = .02, p = .88. These data suggest no
particular association between institutionalization and domain-general cognitive abilities. It does
not appear that longer-institutionalized children showed a generalized decrement in cognitive
ability.
Cross-domain correlational analysis. A final question remains: What are the associations
between language skills, on the one hand, and lower-level cognitive processes including explicit
memory, cognitive control and implicit learning, on the other? Correlational analyses were used
to address this issue, with data split by group (adoptees versus the comparison group); these data
are shown in Table 4. Findings indicated that, in adoptees, CELF Core language scores were
significantly associated with CVLT declarative memory (e.g., list memory) over a 20-minute
delay, r = .35, p = .02, and with cognitive control as assessed in the Auditory Attention, r = .34,
p = .04, and go/nogo, r = .54, p = .001, tasks. Correlations were all in the moderate or strong
range. In contrast, there was no association between core language scores and implicit learning
(calculated as change in RT in the final sequenced and final random blocks22; r = -.082, p = .63)
or Nonverbal IQ, r = .22, p = .15. The comparison participants, in contrast, showed no significant
relationships among domains. None of the correlations for the adopted versus comparison groups
differed significantly, all z’s < 2.1, all p’s > .10.
Discussion
The present study was designed to illuminate links between language and cognitive
processes, by directly assessing these processes in a large sample of 46 internationally-adopted
2 A standard approach for analysis for SRT task data is to calculate the change in RT between
final random and the final sequenced blocks. In the present dataset, that variable was highly
skewed; to make the data appropriate for parametic analyses, a square root transformation was
applied.
International adoption: Language and cognitive changes
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children compared to 24 non-adopted, socioeconomically-matched typically developing children,
ages 4-13 years. One primary goal was to shed light on language abilities in internationally-
adopted children, addressing the conflicting findings in the literature. A second goal was to
determine which top-down and bottom-up cognitive processes implicated in language abilities
may be least and most affected by prior institutionalization, and examine the linkage between
these processes and any language deficits. Finally, drawing on the study findings, the present
study outlines a candidate mechanism by which early postnatal stress leads to these effects by
linking institutionalization to changes in brain structures that drive cognitive processes.
Consistent with some findings in the literature, results from the present study indicated
that adoptees continue to lag behind their non-adopted peers on standardized language
assessments. Although most adopted participants scored in the average range, their language
skills as assessed with the CELF were lower than those of the matched comparison group; in
total, 19% of the adoptees (and none of the comparison group) scored more than 1.5 SD below
the mean, indicating a clinically significant delay. Receptive vocabulary, measured with the
PPVT, was also significantly lower in adoptees than in the comparison group (M = 103.3 and
123.0, respectively), but none of the participants scored 1.5 SD below the mean. Scores for the
language measures were significantly and moderately associated with the duration of
institutionalization. Thus, standardized language assessments indicated that on average, adopted
participants were performing in the average range, but that one out of five adoptees exhibited
clinically significant delays on the CELF. It is notable that, with a few exceptions, none of the
children in the adopted group was receiving services through the schools to address speech-
language delay.
The contradiction between this findings and previous studies suggesting catch-up (Geren
International adoption: Language and cognitive changes
Page 29
et al., 2005; Krakow et al., 2005) may reflect the heterogeneous nature of the sample in the
current study, which was drawn from a variety of countries; the Geren et al. and Krakow et al.
samples, in contrast, consisted entirely of children adopted from China. It may be the case that
conditions in Chinese institutions are associated with better long-term outcomes. Another
possibility is that the present study is based on the comparison of the adopted participants to a
comparison sample, rather than test norms. Our comparison group was also matched for current
socioeconomic status (SES), which is particularly important given the typically higher SES of
adoptive families (Gauthier & Genessee, 2007). Finally, reports in the literature vary
dramatically in the kind of language data collected (direct assessment with standardized or
spontaneous language tasks versus parent report) and the age of children collected. The present
data, which are drawn from a relatively older school-age population and include direct
standardized assessments, could be interpreted as showing somewhat negative long-term impacts
of institutionalization on language development for the group, with tremendous individual
variability (with approximately four-fifths of participants at the average level for their age, but
one-fifth of children continuing to show clinically-significant delays).
The present study found that institutionalization was associated with performance on
multiple measures of explicit memory, including immediate recall of word lists and recall after a
20-minute delay, in an explicit memory task (the CVLT). Specifically, adoptees had significantly
lower scores than the non-adopted children, with 39% of adoptees performing at 1.5 SD below
the mean, in the clinically-significant range. Previous work has established close links between
short-term memory capacity and word learning (Gathercole et al., 1997); given this finding, one
would predict that adoptees would know significantly fewer words (e.g., would have smaller
vocabularies). Our data (shown in Table 4) are consistent with this prediction, and the significant
International adoption: Language and cognitive changes
Page 30
association between language and memory performance in adoptees further supports the links
between these processes in language acquisition.
In addition to group differences in CELF Core language and memory scores, data from
two cognitive control tasks (Go/nogo and NEPSY Auditory Attention) showed that, as a group,
the adopted children were less able to regulate attention and actions, consistent with early
adversity leading to dysregulation of the development of prefrontal cortical structures or
connectivity. Furthermore, the extent to which individual adopted children experienced these
difficulties was weakly associated with the duration of their institutionalization experience.
However, this association was only a trend once length of time they had spent in the U.S. was
controlled. This task in part relies on regions of the striatum (frontostriatal circuitry), a region not
expected to exhibit significant vulnerability to stress, which may explain the lack of robust
effects (Durston et al., 2002; Vaidya et al., 1998). Nonetheless, this finding is consistent with
dampening of prefrontal activity and connections with psychological stress in humans and
animals (Liston et al., 2006, 2009). The same frontostriatal circuitry has also been implicated in
word generation tasks (Tremblay & Gracco, 2006); as such, future studies of international
adoption could employ word generation and word fluency paradigms to assess language-specific
aspects of prefrontal functioning.
The final experimental assessment examined implicit learning, which has been proposed
to be critical for syntactic development (Ullman, 2001). Participants were able to learn the
sequence embedded in the location of targets, as shown in an overall decrement in reaction time
to sequenced stimuli across blocks of an experimental SRT task. There were no group-specific
differences in RT, and no relationship between length of institutionalization and learning within
this task. These findings suggest no association between institutionalization and bottom-up
International adoption: Language and cognitive changes
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implicit learning; such a finding is consistent with recent reports of no abnormalities in neural
systems underlying this type of statistical learning (e.g. structure or function of dorsal striatum)
in previously institutionalized children (Tottenham et al 2009, 2010).
The current data are consistent with a hypothesized model linking language outcomes to
lower-level cognitive processes, which are in turn impacted by the stress associated with
institutionalization. Future work will draw on a different form of implicit learning, known as
spatial context learning, associated with activity in medial temporal circuits, with the prediction
of a relationship between institutionalization and learning in such tasks (reflecting the impact of
early stress on such brain circuits).
Consistent with some previous indications that general cognitive ability does not
specifically correlate with the duration of institutionalization (at least in children ages 6-42
months, Croft et al., 2007b), the current data exhibited no relationship between non-verbal IQ
and duration; moreover, the adopted participants did not differ from the comparison group in
NVIQ scores. In contrast, some groups have found a significant relationship between cognitive
ability and duration of orphanage care and relatively limited evidence of “catch-up” (Nelson et
al., 2007; O'Connor et al., 2000), for children reared in situations of severe deprivation. One
potentially relevant influence is the effect of age of placement into a family on IQ. Because a
greater proportion of our participants (n = 25, or 54%) were placed by age 12 months (in contrast
to, e.g., Nelson et al.’s 2007 Bucharest sample, of which n =14, or 23%, were placed by age 18
months), the current data are likely to reflect the more positive outcomes in IQ associated with
earlier removal from institutionalization.
The approach of studying internationally adopted children permits us to gain traction on
several questions. First, addressing multiple conflicting prior findings in the literature, the
International adoption: Language and cognitive changes
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present data, which rely on direct language assessments of adoptees compared to a sample of
SES-matched children, show subtle but enduring language deficits in the adopted group. While
fully 80% of adopted participants scored within or above the average range across language
subtests, the remaining 20% were in the clinically impaired range, suggesting that a large
subgroup continues to struggle with language. Such difficulties place adoptees at greater risk for
academic, psychological, and social problems. In addition, these results may be informative for
teachers and family members, who may be surprised to learn of enduring language delays in their
generally well-adapted, native-like child.
Going beyond the assessment of language skills, the present study provides evidence for
a specific link between language skills and specific cognitive processes, including explicit
memory and cognitive control, but not including implicit learning. Several limitations to the
present study, however, merit discussion. First, children adopted from other countries form a
group that is highly heterogeneous. The present study, and research in this field, must grapple
with controlling or accounting for variability in the quality of caregiving prior to adoption, first
language experience, early nutritional history, toxic exposures, and reasons for adoptive
placement. Adding to the variability is the fact that most of these factors may be unquantifiable.
One important generalization is that, even in the best institutions, children still experienced less-
individualized and less-contingent care.
An additional significant limitation is that our participants’ adoptive histories were based
exclusively on parent report, which in turn was based on institutional records of questionable
reliability. Adopted participants had experienced a variety of circumstances prior to adoption.
Some had been faced with significant deprivation of basic resources (food, medical care), others
had shared a small number of caregivers with a large set of children, and others reportedly had
International adoption: Language and cognitive changes
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experienced abusive maltreatment. These adversities tended to be shared across countries,
though the adoptees who were born in Eastern Europe and Northern Asia were housed with
significantly larger groups of children (average of one caregiver to six children, for the former,
and one to ten, for the latter) than children from Southeast Asia and South America (one
caregiver for two children, on average), a difference that was significant, F(3, 29) = 8.83, p <
.001,
η
2p = .50. The fact that the results were consistent with study hypotheses, in the face of this
variability, suggests a meaningful relationship between brain areas, cognitive functions, and
high-level outcomes such as language development. In addition, the variability of the sample
likely broadens the generalizability of findings.
Another study limitation that merits specific mention involves the cognitive abilities of
birth parents. Studies have long reported the relatively stable and heritable nature of IQ (e.g.,
Plomin et al., 1994); in this case, the (unknown) IQ of adoptees’ birth parents is likely to have a
significant influence on the abilities of their biological children. However, in a study that
compared adopted school-age orphans raised in institutions, to a similar group raised by relatives
in the same communities, the institutionalized group had higher IQ scores (Whetten et al., 2009).
This suggests that the adoptive family environment may mute the contribution of biological
parent IQ, making biological parent IQ less salient over time.
A final limitation that bears mentioning is that, in addition to the impact of stress,
language skills are certainly influenced by exposure to language; children in the international
adoption group in this study were, as a group, exposed to less language-specific stimulation and
social interaction, at least with adults. This influence is likely complementary to that of changes
in the stress system; unfortunately, deprivation of language input (as a function of duration of
institutionalization) is almost completely confounded with stress (as a function of duration of
International adoption: Language and cognitive changes
Page 34
institutionalization). Institutionalization was associated with changes in cognitive systems less
directly related to language input, including declarative memory and cognitive control,
suggesting that these effects may not be identical; however, language input was not directly
measured or addressed in the current study design.
Rather than a generalized effect of institutionalization on all cognitive functions, this
study suggests a more specific impact on the cognitive processes of explicit memory and
cognitive control. These data are consistent with findings of a relationship between chronic stress
and changes in hippocampal and prefrontal circuits, which are associated with these cognitive
processes. Both implicit learning and nonverbal IQ were essentially unaffected by
institutionalization; implicit learning is associated with a brain region (the striatum) which is
largely unaffected by stress. The data are consistent with the hypothesis that two processes
(explicit memory and cognitive control) that are associated with stress-sensitive brain regions
(hippocampus and prefrontal cortex) are affected by institutionalization; in contrast, implicit
learning is associated with a less-stress-sensitive region (striatum) and appears relatively
unaffected. Nonverbal IQ scores also suggest that stress does not negatively impact all cognitive
processes in a general fashion. To summarize, stress exerts a fairly specific set of influences on
brain development; these brain changes, in turn, entail a profile of intact and affected
neurocognitive processes, which is associated with a pattern of strengths and weaknesses in
international adoptees.
The data from international adoptees and non-adopted comparison children also show
clear links between domain-general cognitive processes of explicit memory and cognitive control
and language skills. Contrary to our hypotheses, language skills appeared uncorrelated with
implicit learning, which has been proposed to be central in the acquisition of syntax (Ullman,
International adoption: Language and cognitive changes
Page 35
2001). It is possible that, because our sample of participants did not vary greatly in their implicit
learning abilities, there was insufficient variability in scores and therefore insufficient power to
detect a correlation. Alternatively, it is possible that the non-verbal serial reaction time (SRT)
task used here is too dissimilar from the pattern-extraction necessary for language acquisition
(though cf. a study in which language delays in children with specific language impairment, or
SLI, were specifically associated with performance on a tone-based implicit learning task; Evans,
Saffran & Robe, 2009).
The findings offers a possible pathway by which disrupted early caregiving can lead to
long-term language abilities that, despite being in the average range, may nonetheless leave one-
fifth of internationally-adopted children lagging behind. These difficulties with language,
memory, and cognitive control are likely to have cascading effects on other academic and
socioemotional domains. In the present study, we propose a framework in which stress causes
neural changes which in turn lead to cognitive changes; these may help to illuminate the
cognitive foundations and brain bases of language acquisition, both in the case of international
adoption, and also in typical development.
International adoption: Language and cognitive changes
Page 36
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... The DMAP suggests that early deprivation is primarily associated with alterations in cognitive functioning that are not observed as consistently among those exposed to threat [4]. In support of this hypothesis, exposure to deprivation has been consistently linked to a range of cognitive and academic difficulties [88][89][90][91][92][93]. It has also been shown that early intervention can offset these cognitive difficulties through early removal from institutions and placement in high-quality family care settings [88,89,94,95]. ...
... In addition to impairments in general intellectual and academic abilities, deprivation has also been associated with reduced language skills [90,91,98,99]. In studies of typically-developing children, reduced language input from caregivers at 18 months is associated with lower pre-academic skills at age 4.5 years through a host of cognitive skills at age 3, including reduced language ability, inhibitory control, and ToM [100]. ...
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While initial findings suggested that children who are adopted (adoptees) perform less well academically, this result is not consistent across the literature. To explain these, often conflicting, results, researchers acquired a lagging view, in which adoptees need to “catch up” to their non-adopted peers. According to the lagging view, those adopted at a younger age have less catching up to do than those adopted when they are older. However, the lagging view does not account for the period in which adoptees and their new families adjust to one another. A period that we refer to as relational uncertainty. This is particularly relevant as data on adoptees’ academic performance is largely based on parent reports. The overarching goal of this study was to determine if parental perception of adoptees’ academic achievement changed over time, after accounting for the impact of age of adoption. Using a nationally representative dataset, we found that after accounting for age of adoption the length of time that children resided in their adoptive homes predicted parental perception of academic performance. Specifically, after accounting for age of adoption, parental perception of adoptees’ academic performance demonstrated early consistency followed by a significant decline. We also investigated if the relation, of those factors previously associated with parental perception of adoptees’ academic performance, remained after variance was accounted for by both age of adoption and children's length of stay in their adoptive homes. Several previous factors (where the child lived pre-adoption and the socioeconomic status of their adoptive household) and child characteristics (sex and the first language the child learned to speak) demonstrated a continued association. Results indicate the need for a paradigm shift in how we view parent reports of adoptees’ academic achievement, as well as the frequently reported factors surrounding adoptees’ academic performance. The implications for how to support adoptees’ academic achievement are discussed.
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Recent neurodevelopmental and evolutionary theories offer strong theoretical rationales and some empirical evidence to support the importance of specific dimensions of early adversity. However, studies have often been limited by omission of other adversity dimensions, singular outcomes, and short follow up durations. 1,420 participants in the community, Great Smoky Mountains Study, were assessed up to eight times between age 9 and 16 for four dimensions of early adversity: Threat, Material Deprivation, Unpredictability, and Loss (as well as a Cumulative Adversity measure). Participants were followed up to four times in adulthood (ages 19, 21, 25, and 30) to measure psychiatric disorders, substance disorder, and “real-world” functioning. Every childhood adversity dimension was associated with multiple adult psychiatric, substance, or functional outcomes when tested simultaneously in a multivariable analysis that accounted for other childhood adversities. There was evidence of differential impact of dimensions of adversity exposure on proximal outcomes (e.g., material deprivation and IQ) and even on distal outcomes (e.g., threat and emotional functioning). There were similar levels of prediction between the best set of individual adversity scales and a single cumulative adversity measure when considering distal outcomes. All dimensions of childhood adversity have lasting, pleiotropic effects, on adult health and functioning, but these dimensions may act via distinct proximal pathways.
Article
This book presents specific methods for the physical rehabilitation, mental health restoration, and academic remediation of post-institutionalized international adoptees. The focus of the book is on the neurological, psychological, and educational consequences of complex childhood trauma in the context of a fundamental change in the social situation of development of former orphanage residents. A discussion of after-adoption traumatic experiences includes a critique of certain “conventional” approaches to the treatment of mental health issues and different disabilities in international adoptees. Using his 30-year background in research and clinical practice, the author expertly describes and analyses a range of methodologies in order to provide an integrated and practical system of “scaffolding” and “compensation” for the successful rehabilitation and remediation of children with ongoing traumatic experiences. This is essential reading for researchers and practicing clinicians concerned with childhood trauma, remedial education, and issues of international adoption.
Book
This book presents specific methods for the physical rehabilitation, mental health restoration, and academic remediation of post-institutionalized international adoptees. The focus of the book is on the neurological, psychological, and educational consequences of complex childhood trauma in the context of a fundamental change in the social situation of development of former orphanage residents. A discussion of after-adoption traumatic experiences includes a critique of certain “conventional” approaches to the treatment of mental health issues and different disabilities in international adoptees. Using his 30-year background in research and clinical practice, the author expertly describes and analyses a range of methodologies in order to provide an integrated and practical system of “scaffolding” and “compensation” for the successful rehabilitation and remediation of children with ongoing traumatic experiences. This is essential reading for researchers and practicing clinicians concerned with childhood trauma, remedial education, and issues of international adoption.
Article
Importance Many studies have demonstrated an association between early-life adversity (ELA) and executive functioning in children and adolescents. However, the aggregate magnitude of this association is unknown in the context of threat and deprivation types of adversity and various executive functioning domains. Objective To test the hypothesis that experiences of deprivation are more strongly associated with reduced executive functioning compared with experiences of threat during childhood and adolescence. Data Sources Embase, ERIC, MEDLINE, and PsycInfo databases were searched from inception to December 31, 2020. Both forward and reverse snowball citation searches were performed to identify additional articles. Study Selection Articles were selected for inclusion if they (1) had a child and/or adolescent sample, (2) included measures of ELA, (3) measured executive functioning, (4) evaluated the association between adversity and executive functioning, (5) were published in a peer-reviewed journal, and (6) were published in the English language. No temporal or geographic limits were set. A 2-reviewer, blinded screening process was conducted. Data Extraction and Synthesis PRISMA guidelines were used to guide data extraction and article diagnostics (for heterogeneity, small study bias, and p-hacking). Article quality was assessed, and data extraction was performed by multiple independent observers. A 3-level meta-analytic model with a restricted maximum likelihood method was used. Moderator analyses were conducted to explore heterogeneity. Main Outcomes and Measures Primary outcomes included measures of the 3 domains of executive functioning: cognitive flexibility, inhibitory control, and working memory. Results A total of 91 articles were included, representing 82 unique cohorts and 31 188 unique individuals. Deprivation, compared with threat, was associated with significantly lower inhibitory control (F1,90 = 5.69; P = .02) and working memory (F1,54 = 5.78; P = .02). No significant difference was observed for cognitive flexibility (F1,36 = 2.38; P = .12). The pooled effect size of the association of inhibitory control with deprivation was stronger (Hedges g = −0.43; 95% CI, −0.57 to −0.29) compared with threat (Hedges g = −0.27; 95% CI, −0.46 to −0.08). The pooled effect size of the association of working memory with deprivation was stronger (Hedges g = −0.54; 95% CI, −0.75 to −0.33) compared with threat (Hedges g = −0.28; 95% CI, −0.51 to −0.05). Conclusions and Relevance Experiences of both threat and deprivation in childhood and adolescence were associated with reduced executive functioning, but the association was stronger for exposure to deprivation. Efforts to address the consequences of ELA for development should consider the associations between specific dimensions of adversity and specific developmental outcomes.
Article
Purpose : Children adopted from Eastern Europe were assessed at ages 6 to 7 years and results were compared to the same children when they were 8 years. Patterns of relative strengths and weaknesses in language, verbal memory and literacy were analyzed. Variables that predicted reading and writing were determined. Method : Children adopted from Eastern Europe between 1;0 and 4;11 years of age were assessed at ages 6 to 7 years and age 8 years on a variety of tests that measured language, verbal memory and literacy. Results were compared across ages, and language, verbal memory and literacy domains. Results : Group means for all measures fell within the average range at both ages. The children's scores were not significantly different from test norms except for measures of rapid naming and number repetition. However, a larger than expected percentage of children scored -1SD below the mean on decontextualized measures of verbal working memory and reading fluency. At age 8 years 24% of children received speech language therapy services and 26% had repeated a grade level. Vocabulary, expressive syntax, verbal short-term memory and writing were areas of relative strength. Higher level vocabulary knowledge was strongly correlated with all literacy measures. Conclusion : As a group, Eastern European adoptees scored average on measures of language and literacy at 6 or 7 years and again at age 8 years. However, 26% of the children had repeated a grade and 24% were still receiving speech and language services. Vocabulary was an area of strength reflecting the children's enriched adopted home environments. In-depth knowledge of vocabulary was the best predictor of reading and writing. Some aspects of working memory were a strength but others were not. Rapid naming was also a weakness.
Article
The aim of this systematic review was to provide insight in inhibitory control (prepotent response inhibition and interference control) in trauma-exposed youth from a developmental perspective and exploring the effects of prolonged stress. A systematic search was conducted, resulting in 1722 abstracts. Of those, 33 studies met inclusion criteria. Twelve studies measured prepotent response inhibition (Go/no-go and Stop-signal task), 20 studies measured interference control (Flanker and Stroop task), and one measured both. Some studies indeed found evidence for prolonged trauma exposure impeding both subcomponents of inhibitory control, although others did not. At a later age, inhibitory control problems on task performance seem to disappear. However, distinct patterns of brain activity may suggest that those individuals employ compensation strategies. Together, the findings may suggest that non-specific inhibitory control problems occur after prolonged trauma exposure, with older youth possibly employing compensation strategies on the tasks. Future studies may provide a clearer picture of the compensation strategies and the circumstances in which they become visible.
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Six and a half years after adoption, 6-to 12-year-old children reared in Romanian orphanages for more than 8 months in their first years of life (RO, n = 18) had higher cortisol levels over the daytime hours than did early adopted (EA, ≤ 4 months of age, n = 15) and Canadian born (CB, n = 27) children. The effect was marked, with 22% of the RO children exhibiting cortisol levels averaged over the day that exceeded the mean plus 2 SD of the EA and CB levels. Furthermore, the longer beyond 8 months that the RO children remained institutionalized the higher their cortisol levels. Cortisol levels for EA children did not differ in any respect from those of CB comparison children. This latter finding reduces but does not eliminate concerns that the results could be due to prenatal effects or birth family characteristics associated with orphanage placement. Neither age at cortisol sampling nor low IQ measured earlier appeared to explain the findings. Because the conditions in Romanian orphanages at the time these children were adopted were characterized by multiple risk factors, including gross privation of basic needs and exposure to infectious agents, the factor(s) that produced the increase in cortisol production cannot be determined. Nor could we determine whether these results reflected effects on the limbic–hypothalamic–pituitary– adrenal axis directly or were mediated by differences in parent–child interactions or family stress occasion by behavioral problems associated with prolonged orphanage care in this sample.
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In the November 2002 issue of AJLSP , the article, "Typical and Atypical Language Development in Infants and Toddlers Adopted From Eastern Europe," by Sharon Glennen and M. Gay Masters, contained errors in Table 3 (p. 105). Under the heading Expressive Vocabulary , the +/– SD values for ages 22–24 months should have been 8.6–126.66 and the values for ages 25–27 months should have been 12.25–110.93 . We regret any inconvenience or confusion that this misprint may have caused.
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Longitudinal language development data were collected on 130 infants and toddlers adopted from Eastern Europe. The children were followed by means of parent surveys from the age at adoption up through age 36–40 months. The surveys collected data on expressive vocabulary growth, mean length of the three longest utterances, and development of four bound grammatical morphemes. Additional language data were collected using a modified version of the Rossetti Infant-Toddler Language Scale (1990). A multivariate factor analysis found no significant correlation between preadoption medical and developmental risk factors and eventual language development outcomes. The majority of children acquired English using the same developmental trajectories as nonadopted peers. By age 36–40 months, children adopted at younger ages had fully caught up to English language norms. Children adopted at older ages lagged behind, with the length of delay related to age at adoption. On the basis of these data, clinical guidelines are provided for assessing and treating speech and language disorders in internationally adopted children.
Article
Context. —Children born in the countries of the former Soviet Union and Eastern Europe are now a main source of international adoptions in the United States, but often little information is available about these children prior to adoption.Objective. —To analyze the preadoptive medical reports of children adopted from Eastern Europe and the former Soviet Union and to compare these reports with their evaluations after arrival in the United States.Design. —Case series.Subjects and Setting. —A total of 56 children adopted from Eastern Europe and the former Soviet Union were evaluated in 2 international adoption clinics. Preadoptive medical records were available for 47 of these children.Results. —There were 43 (91%) of 47 medical reports available from the children's birth countries that included multiple unfamiliar neurologic diagnoses. Evaluations in the International Adoption Clinics frequently revealed growth delays (z score -le-1 for weight in 44% of children, height in 68%, and head circumference in 43%). Children had 1 month of linear growth lag for every 5 months in an orphanage (r=-0.48, P<.001). Developmental delays were also common (gross motor delays in 70% of children, fine motor in 82%, language in 59%, and socialemotional in 53%). While serious medical problems were found or corroborated in 11 (20%) of the 56 children evaluated in our clinics, neurologic diagnoses cited in preadoptive medical reports were not confirmed.Conclusions. —Preadoptive medical records from these international adoptees included multiple diagnoses suggesting severe neurologic impairment. Although these diagnoses were not confirmed when the children were evaluated in the United States, substantial growth and developmental delays were identified.