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Developmental Delays at Arrival, Early Intervention Enrollment, and Adopted Chinese Girls’ Academic Performance and Internalizing Problems in Adolescence a
Tony Xing Tan a
University of South Florida Published online: 11 Jun 2014.
To cite this article: Tony Xing Tan (2014) Developmental Delays at Arrival, Early Intervention Enrollment, and Adopted Chinese Girls’ Academic Performance and Internalizing Problems in Adolescence, The Journal of Genetic Psychology: Research and Theory on Human Development, 175:4, 318-331, DOI: 10.1080/00221325.2014.913547 To link to this article: http://dx.doi.org/10.1080/00221325.2014.913547
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THE JOURNAL OF GENETIC PSYCHOLOGY, 175(4), 318–331, 2014 C Taylor & Francis Group, LLC Copyright ISSN: 0022-1325 print / 1940-0896 online DOI: 10.1080/00221325.2014.913547
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Developmental Delays at Arrival, Early Intervention Enrollment, and Adopted Chinese Girls’ Academic Performance and Internalizing Problems in Adolescence Tony Xing Tan University of South Florida
ABSTRACT. The author investigated the extent of developmental delays in girls adopted from China, their subsequent early intervention (EI) enrollment, and how the delays and EI were related to their academic performance and internalizing problems in adolescence. The sample included 180 adolescent girls (M = 13.4 years, SD = 2.0 years) who were adopted at 3–23.5 months (M = 11.5 months, SD = 3.7 months). Data on the adopted Chinese girls’ delays at arrival and EI enrollment in physical therapy (PT) and speech–language therapy (SLT) were collected from the adoptive mothers at the Baseline; data on the adopted Chinese girls’ present academic performance and internalizing problems were collected from the adoptive mothers and adopted girls at Wave 4 six years later. Data analyses revealed that 55% of the adoptees had moderate-to-severe delays when first arrived at the adoptive homes. Motor delays significantly increased the odds for PT (odds ratio [OR] = 3.98, 95% CI [2.18, 7.82], p < .001) and SLT (OR = 2.36, 95% CI [1.50–3.72, p < .001). Social-cognitive delays also significantly increased the odds for PT (OR = 1.90, 95% CI [1.36, 2.63], p < .001) and SLT (OR = 1.63, 95% CI [1.22, 2.17], p < .001). Motor delays were negatively associated with academic performance but positively associated with internalizing problems. General linear modeling showed that the adoptees who had developmental delays at arrival and subsequently enrolled in EI scored significantly lower on academic performance than their peers who had delays but did not enroll in EI, as well their peers who had no delays and did not enroll in EI. Implications of these findings are discussed. Keywords academic performance, adopted children, delays at adoption, early intervention, internalizing problems
Children under institutional care in developing countries often experience physical, socioemotional, and cognitive deprivation (see the review by Johnson, 2002). For them, being adopted into foreign families leads to an immediate end of their exposure to the institutional environment. Not surprisingly, upon arriving at the adoptive homes, delays in motor development, language development, and social-cognitive functioning are commonly observed in these children (e.g., Narad & Mason, 2004; Palacios, Rom´an, & Camacho, 2011; Park et al., 2011; Pomerleau et al., 2005). Received July 23, 2013; accepted March 31, 2014. Address correspondence to Tony Tan, EDU105, College of Education, University of South Florida, 4202 E. Fowler Avenue, Tampa, FL 33620, USA; [email protected] (e-mail).
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Early intervention has been considered a viable tool that can potentially help facilitate internationally adopted children’s developmental catch-up (Johnson & Dole, 1999). While representative statistics are not available, a survey by Bruder, Dunst, and Mogro-Wilson (2009) of 318 adoptive families with children adopted from China showed that only 37% of the families received Part C early intervention and 32% exhibited developmental concerns but the adoptive parents chose not to utilize early intervention. There is no research on the role of early intervention on internationally adopted children’s long-term outcomes. Contrary to the lack of research on the role of postadoption early intervention on adopted children’s development, there is a large body of literature on the long-term impact of early institutionalization. Converging evidence shows that the vast majority of internationally adopted children experience a massive postadoption catch-up (van IJzendoorn, Bakermans-Kranenburg, & Juffer, 2007; van IJzendoorn & Juffer, 2006). However, there is also evidence that preadoption adversity can have a persistent and negative influence on children’s development many years after adoption. Adoptees with serious and prolonged preadoption deprivation have been shown to have social and cognitive delays or impairment well into adolescence and adulthood (e.g., Audet & Le Mare, 2011; van der Vegt, van der Ende, Ferdinand, Verhulst, & Tiemeier, 2009). For those whose deprivation was less prolonged and less severe, the literature is mixed. Some studies have documented that as international adoptees reached adolescence, their adjustment outcomes were no longer attributable to preadoption adversity. For instance, when Dutch international adoptees reached 14–17 years of age, their preadoption adversity in the forms of neglect or abuse and multiple placements no longer predicted their behavior problems (Verhulst & Versluis-den Bieman, 1995). Other studies have shown that among children adopted from China, preadoption adversity was less prolonged and less serious but it continued to negatively affect adopted children’s development during childhood. For instance, developmental delays around the time of adoption were still a risk factor for adjustment several years after adoption (Cohen, Lojkasek, Pugliese, Zadeh, & Kiefer, 2008; Tan, Marfo, & Dedrick, 2010). In a recent study Gagnon-Oosterwaal et al. (2012) found that the adoptees’ weight and height ratio at the time of adoption (a reflection of the adopted children’s nutritional status) predicted more self-reported behavior problems at age seven. In sum, there is now extensive knowledge on the potential detriment of early institutionalization on children’s postadoption long-term development. The adoption research literature, however, is severely lacking on the extent to which early intervention has been utilized among the population of internationally adopted children. Consequently little is known regarding the role of early intervention in internationally adopted children’s long-term outcomes. By design, early intervention serves as an additional support that at-risk young children may need in order to meet their developmental demands. Thus, it would be reasonable to expect children who received early intervention to outperform children of similar characteristics but did not receive early intervention. Within the adoptive context, however, this concept is more complex. Specifically, adoption itself has been considered a form of highly effective early intervention that often leads to massive developmental catch-up (van IJzendoorn & Juffer, 2006). Hypothetically, while early intervention might be beneficial for at-risk children, when placed within the adoptive context it might also be a potential source of stress that might interrupt the emerging parent-child relationship development. Thus, the extent to which participating in early intervention may (or may not) benefit the adopted
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children is worth investigating. In the present study, the author aimed to address three questions with a sample of adolescent girls who were adopted in infancy from China: Research Question 1: To what extent was early intervention utilized among Chinese children who were adopted in infancy?
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Research Question 2: How might developmental delays at the time of arriving at the adoptive homes be related to early intervention enrollment? Research Question 3: How were the adopted Chinese children’s present academic performance and behavioral adjustment related to their delays at arrival and early interventions?
METHOD Sample The sample for this analysis was drawn from an ongoing longitudinal study on children adopted from China. Presently four waves of data with two-year intervals have been collected. In the first three waves of the study, the adoptees did not directly provide data. In the fourth (present) wave, an email was first sent to parents who had previously participated in the study to inform them about the present phase of the study. The parents were instructed to respond with basic information about number of children they had and each child’s age. For families with children who were about 11 years old or older (about 420 in total), the parents were asked to indicate if they would like a child survey be prepared for their children. For 385 (about 92%) children, the adoptive parents said yes. A survey link for each of the 385 children was created and sent to the parent, along with a request for the parent to pass the link along to the child. It is unknown how many links were actually passed along to the children. The survey would take a child approximately 45–60 min to complete. Overall, 235 adoptees completed the surveys (about 61% response rate). They were adopted from 109 different orphanages in 19 Chinese provinces and municipalities. Consistent with the demographics of children adopted from China, 95.7% (n = 225) adoptees were girls and 4.3% (n = 10) were boys. At the time of Wave 4 data collection, they were 13.6 years old on average (SD = 2.1 years). Overall, 97.4% of the children were raised in families in which one or both parents were White and only 2.6% (six girls) were in families where both parents were of Asian descent. The adoptees were from 185 adoptive families (65.4% were headed by two parents). The adoptive mothers’ average age was 54 years old (SD = 5.5 years). Nearly 60% of the adoptive mothers had at least a master’s degree, and nearly half of the families reported an annual income of $90,000 to more than $150,000.
Selection Criteria for Children in the Present Analysis Because the 10 boys were adopted through special needs programs, they were excluded from data analysis to focus on the adopted Chinese girls. Additionally, there were 32 girls who were adopted
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after their second birthdays. They were excluded to focus on children whose institutionalization took place in infancy and to ensure their eligibility for early intervention. Finally, there were 13 girls whose parents could not recall their developmental delay status upon arrival. They were also excluded from the analysis. As a result, 180 girls remained for the present data analysis. They were all attending secondary schools at Wave 4 of the study. Their average age at adoption was 11.5 months (SD = 3.7 months). These girls were 13.4 years on average (SD = 2.0 years) and had lived in the adoptive homes for an average of 12.5 years (SD = 2.1 years). They were not different from the excluded children on adoptive family characteristics.
Measures Data for this analysis were collected from the adoptive mothers and the adopted Chinese girls separately. In addition to demographic data (e.g., the child’s age at the time of adoption), the adoptive mother provided data in the following areas at the beginning of the longitudinal study (i.e., baseline at Wave 1).
Developmental delays at arrival Because it is a standard practice for internationally adopted children to receive comprehensive medical and developmental evaluations upon arrival in the adoptive country, all children in the present analysis received evaluations. The adoptive mothers reported their children’s postadoption evaluation conclusions. Although some parents also provided supporting documents such as pediatricians’ notes, the participants were not asked to substantiate their reports. Instead, three steps were used in gathering data on the children’s developmental delays. Step 1: The parents were asked to indicate if their children were first evaluated by professionals (yes or no) upon returning from China. Step 2: If the answer was yes, they were then asked to report how many weeks after the child’s arrival the initial evaluation took place. Step 3: Parents were asked to report the evaluation conclusions in the children’s different developmental domains: gross motor, fine motor, language, social skills, emotional understanding, and cognitive skills (too young to tell = 0, no/minor delay = 0, moderate delay = 1, severe delay = 2).
As severe delays were not prevalent in the sample, moderate delays and severe delays were collapsed into a moderate-to-severe delay category (too young to tell/no/minor delay = 0, moderate/severe delay = 1). The evaluations typically took place within the first week of arriving home, which corresponded to about 3–4 weeks after adoption because it took about 2–3 weeks to obtain paperwork for the child to leave China. As rapid developmental catch-up tends to happen during the earliest periods of adoption (Palacios et al., 2011), it is quite possible that the children had made some gains in their development during the weeks since adoption. The results, thus, reflected the children’s conditions at about one month after being removed from the institutions.
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Factor analysis with a Promax rotation showed that the six items formed two factors: motor delays (two items: gross motor and fine motor delay; Cronbach’s α = .77) and social-cognitive delays (four items: delays in language, social skills, emotional understanding and cognitive skills; Cronbach’s α = .83). In data analysis, the sum of each factor was used to reflect motor delays and social-cognitive delays.
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Early intervention enrollment At baseline (Wave 1 in 2005), the adoptive mothers responded to questions on whether their children had received early interventions in physical therapy (PT; yes or no) and speech–language therapy (SLT; yes or no) from state or local agencies. For those who received either therapy, the adoptive mothers were asked to report the duration of the intervention in months. Six years later (Wave 4, 2011), both adoptive mothers and adoptees independently provided data in the following two areas. The adopted children completed the surveys at about 1–2 weeks after the adoptive mothers did.
Academic performance A 5-item academic functioning subscale adapted from the Social Skills Rating System–Teacher Report (SSRS; Gresham & Elliott, 1990) was used to gather the adoptee’s self-report on their overall academic performance, performance in math, performance in English or reading, achievement motivation, and intellectual ability, as compared to other classmates on a 5-point Likert-scale ranging from 1 (lower than most students) to 5 (higher than most students). The internal consistency was high (α = .86). The adoptive mothers were asked to independently rate their children’s performance in the same five areas and to explain the basis for their ratings. The internal consistency was also high (α = .91). Overall, report cards and parent–teacher conferences were the major bases for parental ratings. In the present analysis, the average scores from self-ratings and parent ratings were used.
Internalizing problems The adopted Chinese girls were asked to respond to items that form the internalizing problem scale (31 items) of the Child Behavior Checklist–Youth Self-Report (CBCL-YSR; Achenbach & Rescorla, 2001). This was the first time that the adoptees directly contributed data since the beginning of the ongoing longitudinal study. The internal consistency was high (α = .87). The adoptive mothers completed the CBCL–Parent Report (CBCL-PR; Achenbach & Rescorla, 2001). The internalizing problems (32 items) were used for analysis. The internal consistency was also high (α = .84). The items on the CBCL-YSR internalizing scale and the items on the CBCL-PR internalizing scale were nearly identical expect one item. The reason that only internalizing problems were assessed was because (a) earlier data from adoptive parents showed that the adopted Chinese girls had few externalizing problems (Tan, 2011), (b) developmentally internalizing problems were frequently associated with girls’ adjustment during adolescence
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(Rescorla et al., 2007). In the analysis, standardized scores (t-test scores) were used to facilitate the interpretability of the results. RESULTS
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Research Question 1. To What Extent Was Early Intervention Utilized Among Chinese Children Who Were Adopted in Infancy? Among the 180 adopted Chinese girls, 99 (55%) had delays in at least one area of their development at the time of arrival. Of the 99 children with delays, 37 (37.4%) received early intervention (EI) in the form of PT or SLT. However, the other 62 girls (62.3%) had delays but did not enroll in EI. Additionally, 11 (6.1%) of the 180 girls had no delays but received EI. The details were summarized in Table 1. For those who enrolled in EI, the average length of PT was 8.4 months (SD = 8.4 months) and the average length of SLT was 15.7 months (SD = 12.8 months) at the time of data collection. For children who received PT (n = 26), length of the service was not correlated with the extent of motor delays at arrival (r = .01, p = .98) or social-cognitive delays at arrival (r = .22, TABLE 1 Summary of Adolescent Adopted Chinese Girls’ History of Delays at Arrival and Physical and Speech–Language Therapy Physical therapy Yes Delays at arrival Delays in gross motor skills Yes (n = 88) No (n = 92) Delays in fine motor skills Yes (n = 52) No (n = 128) Delays in language Yes (n = 40) No (n = 140) Delays in social skills Yes (n = 24) No (n = 156) Delays in emotional understanding Yes (n = 23) No (n = 157) Delays in cognitive skills Yes (n = 22) No (n = 158) ∗p
n
Speech/language therapy
No %
n
Yes %
χ2
n
No %
n
%
χ2
22 4
25.0 4.4
66 88
75.0 95.6
15.52∗∗∗
27 10
30.7 10.9
61 82
69.3 89.1
10.81∗∗∗
18 8
34.6 6.3
34 120
65.4 93.7
24.08∗∗∗
20 17
38.5 13.3
32 111
61.5 86.7
14.36∗∗∗
11 15
27.5 10.7
29 125
72.5 89.3
7.09∗∗
15 22
35.5 15.7
25 118
62.5 84.3
9.04∗∗
9 17
40.9 10.9
15 139
62.5 89.1
11.91∗∗∗
10 27
41.7 17.3
14 129
58.3 82.7
7.56∗∗∗
8 18
34.7 11.5
15 139
65.2 88.5
8.83∗∗
9 14
39.1 60.9
14 129
60.9 82.2
5.57∗
9 17
40.9 10.8
13 141
59.1 89.2
14.20∗∗∗
13 24
59.1 15.2
9 134
40.9 84.8)
22.79∗∗∗
< .05. ∗∗ p < .01. ∗∗∗ p < .001.
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p = .29). Similarly, for children who received SLT (n = 37), length of the service was not correlated with the extent of motor delays at arrival (r = .09, p = .60) or social-cognitive delays (r = –.05, p = .78).
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Research Question 2. How Might Developmental Delays at the Time of Arriving at the Adoptive Homes Be Related to Early Intervention Enrollment? The adoptees were 3–23.5 months (M = 11.5 months, SD = 3.7 months) at the time of adoption. Age at adoption was not correlated with motor delays at arrival (r = .03, p = .69) but it was correlated with social-cognitive delays at arrival (r = .22, p < .01). Motor delays and socialcognitive delays were moderately correlated (r = .51, p < .001). Logistic regression analysis showed that controlling for age at adoption, the adoptive mother’s age, education level and household income, motor delays at arrival significantly increased the odds for PT (odds ratio [OR] = 3.98, 95% CI [2.18, 7.28], p < .001) and SLT (OR = 2.36, 95% CI [1.50–3.72, p < .001). Similarly, social-cognitive delays at arrival also significantly PT increased the odds for PT (OR = 1.90, 95% CI [1.36, 2.63], p < .001) and SLT (OR = 1.63, 95% CI [1.22, 2.17], p < .001). The adoptees’ age at adoption, adoptive mother’s age, education level, and household income, however, were not associated with either PT or SLT. These results suggest that enrollment in EI was largely driven by the adoptees’ delays at arrival.
Research Question 3. How Were the Adopted Children’s Present Academic Performance and Behavioral Adjustment Related to Their Delays at Arrival and Early Interventions? The adopted Chinese girls’ academic performance was well within normal range: The adopted Chinese girls’ self-report showed an average of 4.05 (SD = 0.77; range = 1.6–5.0; 4 = higher than average), which was significantly lower than the average of 4.25 (SD = 0.80; range = 1.2–5.0) as reported by the adoptive mothers, paired t(176) = 4.75, p < .001. The mother–daughter agreement was strong (r = .74, p < .001) on academic performance. The adoptees’ internalizing problems were also within normal range: The adopted Chinese girls self-reported an average of 48.49 (SD = 9.77; range = 27.00–80.00), which was nearly significantly higher than the average of 46.88 (SD = 9.03; range = 33.00–71.00) as reported by the adoptive mothers, paired t(175) = 1.97, p = .051. The mother–daughter agreement was moderate (r = .46, p < .001). The adoptees’ self-reported internalizing problems and academic performance was modestly and negatively correlated (r = −.19, p < .01). The adoptive mother-reported internalizing problems and academic performance were also modestly and negatively correlated (r = −.18, p < .01). Table 2 summarizes the correlation analysis between developmental delays at arrival at about 11 months old and the adoptees’ present adjustment outcomes at about 13 years of age. Overall, greater motor delays at the time of arriving at the adoptive homes were significantly correlated with lower academic performance and more internalizing problems. Social-cognitive delays were only marginally correlated with self-reported internalizing problems (r = .15, p = .051) but not with other outcomes. The adopted Chinese girl’s age was positively correlated with self-reported
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TABLE 2 Correlation Coefficients Between Present Adjustment and Delays at Arrival, Child and Family Demographics
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Academic performance Self-report
Mother report
Self-report
−.18∗ −.03 −.04 −.02 0 −.10 −.03
−.16∗ −.06 −.10 −.06 −.14† −.03 −.06
.19∗ .09 .01 −.03 −.11 .10 .09
.22∗∗ .15† .03 .19∗ −.03 .11 −.02
Motor delays Social-cognitive delays Age at adoption Child’s present age Mother’s age Mother’s education level Household income †p
Internalizing problems
Mother report
< .10. ∗ p < .05. ∗∗ p < .01.
internalizing problems (r = .19, p < .05). No other variables were significantly correlated with the adoptees’ academic performance and internalizing problems. Table 3 summarizes the results from comparing the adoptees who participated in early intervention with those who did not on academic performance and internalizing problems. Those who received SLT scored lower than those who did not on self-reported and mother-reported academic performance. Finally, general linear modeling (GLM) was performed to better differentiate how status of developmental delays and early intervention was related to the adoptee’s academic performance and internalizing problems. The adoptees were divided into four groups based on their delay status (yes or no) and early intervention enrollment status (yes or no): Group 1: adoptees had no delays at arrival and received no EI (n = 70; 38.9%), Group 2: adoptees had no delays at arrival but received EI (n = 11; 6.1%), Group 3: adoptees had delays at arrival but received no EI (n = 62; 34.4%), and finally Group 4: adoptees had delays at arrival and received EI (n = 37; 20.6%). Note that a child’s developmental delay status was determined by whether there was TABLE 3 Comparing Academic Performance and Internalizing Problems Between Adolescent Chinese Adoptees With and Without History of Early Intervention Academic performance Mother report Early intervention
t(176)
Physical therapy Yes No Speech–language therapy Yes No
0.76
∗∗∗ p
< .001.
3.81∗∗∗
Internalizing problems
Self-report
M
SD
4.14 4.27
0.78 0.81
t(176)
Mother report
M
SD
3.86 4.08
0.83 0.75
1.41
3.82 4.37
1.00 0.70
3.46∗∗∗
t(176)
M
SD
46.96 46.87
9.57 8.97
0.05
0.97 0.68
M
SD
49.46 49.34
9.64 9.81
0.52
0.54 3.67 4.15
Self-report t(176)
1.54 47.59 10.02 46.70 8.78
50.72 10.91 47.92 9.4
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TABLE 4 Adjusted Means and 95% Confidence Intervals of Academic Performance and Internalizing Problems by Status of Delays and Early Interventions From General Linear Modeling Academic performance Mother report
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Delay and EI status Group 1 (n = 70): delays = no, EI = no Group 2 (n = 11): delays = no, EI = yes Group 3 (n = 62): delays = yes, EI = no Group 4 (n = 37): delays = yes, EI = yes
M
95% CI
4.46b [4.27, 4.65]
Internalizing problems
Self-report M 4.14b
95% CI
Mother report M
95% CI
Self-report M
95% CI
[3.96, 4.32] 44.85a
[42.71, 46.98]
47.25b [45.03, 49.48]
4.26ab [3.79, 4.72] 4.01ab [3.56, 4.45] 44.55a
[39.26, 49.83]
41.26b [35.44, 47.08]
4.29b [4.08, 4.49]
4.17b
[3.98, 4.36] 48.51a
[46.23, 50.80] 48.69ab [46.30, 51.07]
3.84a [3.58, 4.10]
3.72a
[3.48, 3.97] 49.00a
[46.09, 51.91]
52.62a [49.52, 55.71]
Note. All means were adjusted for age at adoption, age, adoptive mother’s age, education level, and household income. For delays, no = child had no delays at arrival; yes = child had one or more delays at arrival; For early intervention (EI), no = child did not receive early intervention; yes = child received early intervention. Values with overlapping superscript letters were not significantly different. ∗ p < .05. ∗∗ p < .01.
delay in any of the six areas at the time of arrival. A child’s early interventional enrollment status was determined by whether the child received PT or SLT. Group 3 scored significantly lower than Group 4 on motor delays (M = 1.26, SD = 0.70 vs. M = 1.68, SD = 0.53), t(97) = 3.13, p < .01, as well as on social-cognitive delays (M = 0.85, SD = 1.23 vs. M = 1.51, SD = 1.52), t(97) = 2.35, p < .05. These results suggest that severity of delays at arrival served as a main driving force for EI enrollment. In performing the GLM analysis to determine if the four groups differed in academic performance and internalizing problem scores, the adoptees’ age at adoption, present age and the adoptive mother’s age, educational level, and the adoptive family’s income were included as covariates. No interaction term was included because preliminary analysis showed no significant interaction between delay status and EI. Bonferroni correction was applied for the purpose of multiple comparisons. Additionally, a 95% confidence interval was requested for the predicted means. The Bonferroni adjusted means and 95% confidence intervals for the adoptees’ academic performance scores and internalizing problem scores are summarized in Table 4. For both self-reported and mother-reported academic performance, the girls in Group 4 scored significantly lower than those in Group 1 and those in Group 3, but did not score statistically differently from those in Group 2. In other words, the group who had delays at arrival and then received early intervention scored the lowest on academic performance. For mother-reported internalizing problems, there was no group difference in the adoptive mother’s report. For self-reported internalizing problems, however, the girls in Group 4 scored significantly higher than their peers in Group 1 and those in Group 2. There was no statistical difference between children in Group 4 and Group 3. In other words, the group that had delays and then received early intervention had the highest average internalizing problem score, per the adoptees’ self-report.
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DISCUSSION In this study the author investigated the roles of developmental delays at the time of arrival and postadoption early intervention enrollment in a sample of adopted Chinese adolescents’ present academic performance and behavioral adjustment. To address the scarcity of studies that utilize data from adoptees, data from a sample of teenage Chinese adoptees, in addition to the adoptive mothers, were collected in the present study. Before delving deeper into discussing the findings, it should be emphasized that children adopted from China are mostly girls under 2 years of age at the time of adoption (U.S. Department of State, 2013). Most children became available for adoption not due to their special needs but due to their gender. As most of them lived in Children’s Welfare Institutes before adoption (Hague Conference on Private International Law, 2010), developmental delays were rather prevalent in newly adopted Chinese children (Miller & Hendrie, 2000). Their postadoption adjustment has been shown to be favorable (e.g., Dalen & Rygvold, 2006; Tan & Marfo, 2006), although more severe preadoption adversity has been associated with poorer postadoption behavioral adjustment in preschool years (Tan et al., 2011). The present study showed that developmental delays were common at the time of arriving at the adoptive homes (55% of the children had delays). Although delays at arrival significantly increased the odds for early intervention, further analysis showed that it was the subsample of girls (37.4% of the 99 children with delays) who had more serious delays that actually utilized early intervention. Similarly low rate of early intervention utilization among adoptive families with Chinese children has also been reported by Bruder et al. (2009). Because most of the adoptive families had high socioeconomic status (SES) and were likely keen on promoting their children’s developmental catch-up, it was a surprise that early intervention seemed under-utilized by these families. I offer three speculations about the low rate of EI enrollment. First, these children were ≤ 24 months at the time of adoption, which is typically within the sensitive period of attachment formation. As such, some adoptive parents might avoid participating in early intervention so as to focus on mother–child bonding. Second, it was speculated by Bruder et al. (2009) that parents were aware that developmental catch up (usually without early intervention) took place quickly and naturally when the underlying contributors of delays (i.e., institutional care) were removed. In other words, the adoption itself functioned as a form of highly effective intervention. Indeed existing research suggests that massive catch-up was very common during the first one or two years after adoption (e.g., Palacios et al., 2011). This might be particularly the case for those children’s whose delays were not as serious (i.e., the ones in Group 3 of the present study). Third, in deciding whether to utilize early intervention, adoptive parents may assess its cost and benefit. If parents believed that the benefit of having exclusive interactions with their children to facilitate a smoother transition into the family was outweighed by their concerns about their children’s delays, the parents would likely choose to use early intervention. In this case, children who enrolled in early intervention would likely be a subgroup of adoptees with more severe developmental delays. Data from this study supported this speculation. Among the adopted Chinese girls with motor delays and social-cognitive delays at arrival, early intervention enrollment primarily happened to those with more serious delays.
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Turning to the findings on the adoptees’ academic performance and internalizing problems in relation to their delays and early intervention. The group of adopted girls who had delays at arrival and subsequently received early intervention (Group 4) scored lower on self-reported and mother-reported academic performance than their peer group who also had delays but did not receive early intervention (Group 3), as well as those who had no delays and received no intervention (Group 1). In terms of internalizing problems, the adopted girls in Group 4 scored higher in self-report than their peers in Group 1. No other differences were observed. Because by design early intervention is to facilitate catch-up in children with developmental delays, it is somewhat counterintuitive that those who received early intervention still scored lower than their peers in academic performance and higher in self-reported internalizing problems. To understand this finding, it is important to be reminded that children in Group 4 were significantly more delayed than their peers in Group 3. The severity of delays that children in Group 4 experienced might have some impact on their executive functioning and development in general, which would likely present a risk for learning and emotional regulation. This speculation is supported by research that has linked preadoption adversity to impairment in adopted children’s executive functioning later on (e.g., Hostinar, Stellern, Schaefer, Carlson, & Gunnar, 2012) and development in general (see the review by Frank, Klass, Earls, & Eisenberg, 1996). It is possible that early intervention might have benefited the children in Group 4 but not to the extent in which they were comparable to those who did not receive the therapy. In other words, if these children had not received early intervention, they would have fared even more poorly. It is also possible that the children who received early intervention might have had constitutional challenges that were not directly related to institutionalization. For instance, some of these children might have had developmental issues (e.g., premature birth) at the time of entering the orphanage, which would further complicate the children’s postadoption development. From an environmental stress perspective (Cairney, Rigoli, & Piek, 2013), children with significant motor delays may be more likely to experience negative personal and interpersonal stressors, which in turn contribute to a higher risk for internalizing symptoms in the short and long term. In other words, it is not necessarily motor delays per se but rather it is the stress that stemmed from such delays that has contributed to the elevated internalizing problems. From the perspective of behavioral continuity (Rutter & Rutter, 1993), it is possible that the Chinese adoptees’ who had delays and were going through early interventions (i.e., Group 4) experienced a higher amount of stress during the periods of preadoption institutionalization and possibly postadoption adjustment. The stress then contributed to more internalizing problems. These problems continued to be part of these children’s behavioral patterns. Thus, the observed correlation might have reflected continuity in the adopted children’s internalizing problems over time. Finally, the contributing factors to young children’s gross motor skill development may also help explain why serious motor delays might have negative long-term implications in learning and behavioral development. According to Adolph (1997), gross motor development starts in infancy with the major redistribution of body fat from upper body to lower body while the development of fine motor skills requires small muscle movements in coordination with the eyes (Rule & Stewart, 2002). Nutrition plays a key role in the development of muscle masses in children. Because gross motor development in children involves the development of the abilities to move large muscles (e.g., limbs) or the whole body (e.g., walking), adequate strength in large muscles
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is thus needed in order to accomplish these tasks. Malnutrition, therefore, can significantly compromise this process and limit the development of muscle masses. Lack of physical activities (e.g., play with toys or other children, interacting with adults) can further compromise children’s gross motor and fine motor development, as well as cognitive development. Children living in institutions often experience a combination of malnutrition and lack of opportunities to play. Thus, for institutionalized children, motor delays might signal the cumulative effect of inadequate nutrition and limited social-cognitive stimulation. Consequently, serious delays resulted from such adversity may jeopardize the adoptees’ social-cognitive development and place a heavier demand on their postadoption catch-up. These factors may be an underlying contributor of later elevated risk for learning and internalizing problems in the adopted Chinese girls. Of course these speculations must be carefully evaluated with studies that are designed to determine the underlying causes of motor delays as well as the social-emotional developmental trajectories of children who are recovering from those delays. Taken together, the findings from this study provide evidence that for children with more serious delays at the time of arriving at the adoptive home, even after early intervention they were still at a higher risk for poorer academic performance in adolescence. The robustness of the finding was further buttressed by the fact that data on the girls’ developmental status at arrival and present adjustment were collected six years apart. Additionally, two sources of data (i.e., from adoptive mothers and adoptees themselves respectively) were collected to reflect the adopted Chinese girls’ present outcomes. Because most children adopted from China usually did not experience very severe adversity, it is conceivable that when children were exposed to more severe and global adversity (e.g., children who were adopted from very deprived orphanages), the long-term harm may be more severe in magnitude. Nonetheless, caution is warranted in interpreting the results from this study due to several limitations. Specifically, this study only included nonrandomly sampled adopted Chinese girls in data analysis. Thus, the findings might not be generalizable, especially to adopted boys. The other limitation of this study is that data on developmental delays at arrival was not gathered directly from the clinics that conducted the evaluations. Instead, retrospective report was obtained from the adoptive mothers on the children’s professional evaluation results. This methodology was similar to the 2007–2008 National Survey of Adoptive Parents in assessing preadoption adversity (Bramlett et al., 2010). This approach has limitation but it also reflected an improvement from previous research that relied on certainty that adoptive parents felt about preadoption abuse or neglect (e.g., Verhulst & Versluis-den Bieman, 1995), more systematic assessment (e.g., requiring pediatricians or other professionals to fill out a preprepared questionnaire by researchers) would strengthen the validity of the early adversity indicators used in this study. Finally, no detailed data on early intervention were collected as it was beyond the scope of the study. It is thus not clear which aspects of the early intervention services that might have contributed to the observed outcomes in the present study. More detailed research on early intervention and internationally adopted children’s development is urgently needed.
Implications Findings from this study suggest that it is important to further establish protocols to evaluate and document the benefit of early intervention so that eligible adoptive families with children from
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foreign countries can better utilize this service. Given that the findings suggest that the adoptees’ academic performance and internalizing problems were correlated with their motor delays at the time of arriving at the adoptive homes about 12 years earlier, parents and professionals should be particularly cognizant about the potential long-term risks of early institutionalization.
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AUTHOR NOTE Tony Xing Tan is an associate professor in the College of Education at the University of South Florida in Tampa, Florida. He studies the development of children adopted from China.
REFERENCES Achenbach, T. M., & Rescorla, L. A. (2001). The manual for the ASEBA school-age forms & profiles. Burlington, VT: University of Vermont, Research Center for Children, Youth, & Families. Adolph, K. E. (1997). Learning in the development of infant locomotion. Monographs of the Society for Research in Child Development, 62(3), Serial No. 251. Audet, K., & Le Mare, L. (2011). Mitigating effects of the adoptive caregiving environment on inattention/overactivity in children adopted from Romanian orphanages. International Journal of Behavioral Development, 35, 107–115. Bramlett, M. D., Foster, E. B., Frasier, A. M., Satorius, J., Skalland, B. J., Nysse-Carris, K. L., . . . Chowdhury, S. R. (2010). Design and operation of the National Survey of Adoptive Parents, 2007. Vital and Health Statistics (Series 1), 50. Bruder, M. B., Dunst, C. J., & Mogro-Wilson, C. (2009). Child factors associated with enrollment in Part C early intervention among children adopted from China. Journal of Early Intervention, 32, 54–67. Cairney, J., Rigoli, D., & Piek, J. (2013). Developmental coordination disorder and internalizing problems in children: The environmental stress hypothesis elaborated. Developmental Review, 33, 224–238. Cohen, N. J., Lojkasek, M., Pugliese, M., Zadeh, Z. Y., & Kiefer, H. (2008). Children adopted from China: a prospective study of their growth and development. Journal of Child Psychology and Psychiatry, 49, 458–468. Dalen, M., & Rygvold, A. L. (2006). Educational achievement in adopted Children from China. Adoption Quarterly, 9, 45–58. Frank, D. A., Klass, P. E., Earls, F., & Eisenberg, L. (1996). Infants and young children in orphanages: One view from pediatrics and child psychiatry. Pediatrics, 97, 569–578. Gagnon-Oosterwaal, N., Cossette, L., Smolla, N., Pomerleau, A., Malcuit, G., Chicoine, J., . . . Berthiaume, C. (2012). Pre-adoption adversity and self-reported behavior problems in 7 year-old international adoptees. Child Psychiatry and Human Development, 43, 648–666. Gresham, F. M., & Elliott, S. N. (1990). Social skills rating system: Manual. Circle Pines, MN: American Guidance Service. Hague Conference on Private International Law. (2010). Annual adoption statistics from China. Retrieved from http:// www.hcch.net/upload/wop/adop2010pd05 cn.pdf Hostinar, C. E., Stellern, S. A., Schaefer, C., Carlson, S. M., & Gunnar, M. R. (2012). Associations between early life adversity and executive function in children adopted internationally from orphanages. PNAS Proceedings of the National Academy of Sciences of the United States of America, 109, 17208–17212. Johnson, D. E. (2002). Adoption and the effect on children’s development. Early Human Development, 68, 39–54. Johnson, D. E., & Dole, K. (1999). International adoptions: Implications for early intervention. Infants and Young Children, 11, 34–45. Miller, L. C., & Hendrie, N. W. (2000). Health of children adopted from China. Pediatrics, 105(6), E76. Narad, C., & Mason, P. W. (2004). International adoptions: Myths and realities. Pediatric Nursing, 30, 483–487. Palacios, J., Rom´an, M., & Camacho, C. (2011). Growth and development in internationally adopted children: Extent and timing of recovery after early adversity. Child: Care, Health and Development, 37, 282–288.
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Park, H., Bothe, D., Holsinger, E., Kirchner, H. L., Olness, K., & Mandalakas, A. (2011). The impact of nutritional status and longitudinal recovery of motor and cognitive milestones in internationally adopted children. International Journal of Environmental Research and Public Health, 8, 105–116. Pomerleau, A., Malcuit, G., Chicoine, J., S´eguin, R., Belhumeur, C., Germain, P., . . . J´eliu, G. (2005). Health status, cognitive and motor development of young children adopted from China, East Asia, and Russia across the first 6 months after adoption. International Journal of Behavioral Development, 29, 445–457. Rescorla, L., Achenbach, T., Ivanova, M. Y., Dumenci, L., Almqvist, F., Bilenberg, N., . . . Verhulst, F. (2007). Behavioral and emotional problems reported by parents of children ages 6 to 16 in 31 societies. Journal of Emotional and Behavioral Disorders, 15, 130–142. Rule, A. C., & Stewart, R. A. (2002). Effects of practical life materials on kindergartners’ fine motor skills. Early Childhood Education Journal, 30, 9–13. Rutter, M., & Rutter, M. (1993). Developing Minds: Challenge and Continuity across the Life Span. New York. NY. Basic Books. Tan, T. X. (2011). Two-year follow-up of girls adopted from China: Continuity and change in behavioural adjustment. Child and Adolescent Mental Health, 16, 14–21. Tan, T. X., & Marfo, K. (2006). Parental ratings of behavioral adjustment in two samples of adopted Chinese girls: Age-related versus socio-emotional correlates and predictors. Journal of Applied Developmental Psychology, 27, 14–30. Tan, T. X., Marfo, K., & Dedrick, R. F. (2010). Early developmental and psychosocial risks and longitudinal behavioral adjustment: Outcomes for preschool-age girls adopted from China. Journal of Applied Developmental Psychology, 31, 306–314. U.S. Department of State. (2013). Intercountry adoption: Statistics. Retrieved from http://adoption.state.gov/about us/ statistics.php Van der Ende, J., & Verhulst, F. C. (2005). Informant, gender and age differences in ratings of adolescent problem behavior. European Child and Adolescent Psychiatry, 14, 117–126. Van der Vegt, E. J. M., van der Ende, J., Ferdinand, R. F., Verhulst, F. C., & Tiemeier, H. (2009). Early childhood adversities and trajectories of psychiatric problems in adoptees: Evidence for long lasting effects. Journal of Abnormal Child Psychology, 37, 239–249. Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., & Juffer, F. (2007). Plasticity of growth in height, weight, and head circumference: Meta-analytic evidence of massive catch-up after international adoption. Journal of Developmental and Behavioral Pediatrics, 28, 334–343. Van IJzendoorn, M. H., & Juffer, F. (2006). The Emanuel Miller Memorial Lecture 2006: Adoption as intervention. Meta-analytic evidence for massive catch-up and plasticity in physical, socio-emotional, and cognitive development. Journal of Child Psychology and Psychiatry, 47, 1228–1245. Verhulst, F. C., & Versluis-den Bieman, H. J. M. (1995). Developmental course of problem behaviors in adolescent adoptees. Journal of the American Academy of Child and Adolescent Psychiatry, 34, 151–159.
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Developmental Delays at Arrival, Early Intervention Enrollment, and Adopted Chinese Girls’ Academic Performance and Internalizing Problems in Adolescence a
Tony Xing Tan a
University of South Florida Published online: 11 Jun 2014.
To cite this article: Tony Xing Tan (2014) Developmental Delays at Arrival, Early Intervention Enrollment, and Adopted Chinese Girls’ Academic Performance and Internalizing Problems in Adolescence, The Journal of Genetic Psychology: Research and Theory on Human Development, 175:4, 318-331, DOI: 10.1080/00221325.2014.913547 To link to this article: http://dx.doi.org/10.1080/00221325.2014.913547
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Developmental Delays at Arrival, Early Intervention Enrollment, and Adopted Chinese Girls’ Academic Performance and Internalizing Problems in Adolescence Tony Xing Tan University of South Florida
ABSTRACT. The author investigated the extent of developmental delays in girls adopted from China, their subsequent early intervention (EI) enrollment, and how the delays and EI were related to their academic performance and internalizing problems in adolescence. The sample included 180 adolescent girls (M = 13.4 years, SD = 2.0 years) who were adopted at 3–23.5 months (M = 11.5 months, SD = 3.7 months). Data on the adopted Chinese girls’ delays at arrival and EI enrollment in physical therapy (PT) and speech–language therapy (SLT) were collected from the adoptive mothers at the Baseline; data on the adopted Chinese girls’ present academic performance and internalizing problems were collected from the adoptive mothers and adopted girls at Wave 4 six years later. Data analyses revealed that 55% of the adoptees had moderate-to-severe delays when first arrived at the adoptive homes. Motor delays significantly increased the odds for PT (odds ratio [OR] = 3.98, 95% CI [2.18, 7.82], p < .001) and SLT (OR = 2.36, 95% CI [1.50–3.72, p < .001). Social-cognitive delays also significantly increased the odds for PT (OR = 1.90, 95% CI [1.36, 2.63], p < .001) and SLT (OR = 1.63, 95% CI [1.22, 2.17], p < .001). Motor delays were negatively associated with academic performance but positively associated with internalizing problems. General linear modeling showed that the adoptees who had developmental delays at arrival and subsequently enrolled in EI scored significantly lower on academic performance than their peers who had delays but did not enroll in EI, as well their peers who had no delays and did not enroll in EI. Implications of these findings are discussed. Keywords academic performance, adopted children, delays at adoption, early intervention, internalizing problems
Children under institutional care in developing countries often experience physical, socioemotional, and cognitive deprivation (see the review by Johnson, 2002). For them, being adopted into foreign families leads to an immediate end of their exposure to the institutional environment. Not surprisingly, upon arriving at the adoptive homes, delays in motor development, language development, and social-cognitive functioning are commonly observed in these children (e.g., Narad & Mason, 2004; Palacios, Rom´an, & Camacho, 2011; Park et al., 2011; Pomerleau et al., 2005). Received July 23, 2013; accepted March 31, 2014. Address correspondence to Tony Tan, EDU105, College of Education, University of South Florida, 4202 E. Fowler Avenue, Tampa, FL 33620, USA; [email protected] (e-mail).
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Early intervention has been considered a viable tool that can potentially help facilitate internationally adopted children’s developmental catch-up (Johnson & Dole, 1999). While representative statistics are not available, a survey by Bruder, Dunst, and Mogro-Wilson (2009) of 318 adoptive families with children adopted from China showed that only 37% of the families received Part C early intervention and 32% exhibited developmental concerns but the adoptive parents chose not to utilize early intervention. There is no research on the role of early intervention on internationally adopted children’s long-term outcomes. Contrary to the lack of research on the role of postadoption early intervention on adopted children’s development, there is a large body of literature on the long-term impact of early institutionalization. Converging evidence shows that the vast majority of internationally adopted children experience a massive postadoption catch-up (van IJzendoorn, Bakermans-Kranenburg, & Juffer, 2007; van IJzendoorn & Juffer, 2006). However, there is also evidence that preadoption adversity can have a persistent and negative influence on children’s development many years after adoption. Adoptees with serious and prolonged preadoption deprivation have been shown to have social and cognitive delays or impairment well into adolescence and adulthood (e.g., Audet & Le Mare, 2011; van der Vegt, van der Ende, Ferdinand, Verhulst, & Tiemeier, 2009). For those whose deprivation was less prolonged and less severe, the literature is mixed. Some studies have documented that as international adoptees reached adolescence, their adjustment outcomes were no longer attributable to preadoption adversity. For instance, when Dutch international adoptees reached 14–17 years of age, their preadoption adversity in the forms of neglect or abuse and multiple placements no longer predicted their behavior problems (Verhulst & Versluis-den Bieman, 1995). Other studies have shown that among children adopted from China, preadoption adversity was less prolonged and less serious but it continued to negatively affect adopted children’s development during childhood. For instance, developmental delays around the time of adoption were still a risk factor for adjustment several years after adoption (Cohen, Lojkasek, Pugliese, Zadeh, & Kiefer, 2008; Tan, Marfo, & Dedrick, 2010). In a recent study Gagnon-Oosterwaal et al. (2012) found that the adoptees’ weight and height ratio at the time of adoption (a reflection of the adopted children’s nutritional status) predicted more self-reported behavior problems at age seven. In sum, there is now extensive knowledge on the potential detriment of early institutionalization on children’s postadoption long-term development. The adoption research literature, however, is severely lacking on the extent to which early intervention has been utilized among the population of internationally adopted children. Consequently little is known regarding the role of early intervention in internationally adopted children’s long-term outcomes. By design, early intervention serves as an additional support that at-risk young children may need in order to meet their developmental demands. Thus, it would be reasonable to expect children who received early intervention to outperform children of similar characteristics but did not receive early intervention. Within the adoptive context, however, this concept is more complex. Specifically, adoption itself has been considered a form of highly effective early intervention that often leads to massive developmental catch-up (van IJzendoorn & Juffer, 2006). Hypothetically, while early intervention might be beneficial for at-risk children, when placed within the adoptive context it might also be a potential source of stress that might interrupt the emerging parent-child relationship development. Thus, the extent to which participating in early intervention may (or may not) benefit the adopted
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children is worth investigating. In the present study, the author aimed to address three questions with a sample of adolescent girls who were adopted in infancy from China: Research Question 1: To what extent was early intervention utilized among Chinese children who were adopted in infancy?
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Research Question 2: How might developmental delays at the time of arriving at the adoptive homes be related to early intervention enrollment? Research Question 3: How were the adopted Chinese children’s present academic performance and behavioral adjustment related to their delays at arrival and early interventions?
METHOD Sample The sample for this analysis was drawn from an ongoing longitudinal study on children adopted from China. Presently four waves of data with two-year intervals have been collected. In the first three waves of the study, the adoptees did not directly provide data. In the fourth (present) wave, an email was first sent to parents who had previously participated in the study to inform them about the present phase of the study. The parents were instructed to respond with basic information about number of children they had and each child’s age. For families with children who were about 11 years old or older (about 420 in total), the parents were asked to indicate if they would like a child survey be prepared for their children. For 385 (about 92%) children, the adoptive parents said yes. A survey link for each of the 385 children was created and sent to the parent, along with a request for the parent to pass the link along to the child. It is unknown how many links were actually passed along to the children. The survey would take a child approximately 45–60 min to complete. Overall, 235 adoptees completed the surveys (about 61% response rate). They were adopted from 109 different orphanages in 19 Chinese provinces and municipalities. Consistent with the demographics of children adopted from China, 95.7% (n = 225) adoptees were girls and 4.3% (n = 10) were boys. At the time of Wave 4 data collection, they were 13.6 years old on average (SD = 2.1 years). Overall, 97.4% of the children were raised in families in which one or both parents were White and only 2.6% (six girls) were in families where both parents were of Asian descent. The adoptees were from 185 adoptive families (65.4% were headed by two parents). The adoptive mothers’ average age was 54 years old (SD = 5.5 years). Nearly 60% of the adoptive mothers had at least a master’s degree, and nearly half of the families reported an annual income of $90,000 to more than $150,000.
Selection Criteria for Children in the Present Analysis Because the 10 boys were adopted through special needs programs, they were excluded from data analysis to focus on the adopted Chinese girls. Additionally, there were 32 girls who were adopted
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after their second birthdays. They were excluded to focus on children whose institutionalization took place in infancy and to ensure their eligibility for early intervention. Finally, there were 13 girls whose parents could not recall their developmental delay status upon arrival. They were also excluded from the analysis. As a result, 180 girls remained for the present data analysis. They were all attending secondary schools at Wave 4 of the study. Their average age at adoption was 11.5 months (SD = 3.7 months). These girls were 13.4 years on average (SD = 2.0 years) and had lived in the adoptive homes for an average of 12.5 years (SD = 2.1 years). They were not different from the excluded children on adoptive family characteristics.
Measures Data for this analysis were collected from the adoptive mothers and the adopted Chinese girls separately. In addition to demographic data (e.g., the child’s age at the time of adoption), the adoptive mother provided data in the following areas at the beginning of the longitudinal study (i.e., baseline at Wave 1).
Developmental delays at arrival Because it is a standard practice for internationally adopted children to receive comprehensive medical and developmental evaluations upon arrival in the adoptive country, all children in the present analysis received evaluations. The adoptive mothers reported their children’s postadoption evaluation conclusions. Although some parents also provided supporting documents such as pediatricians’ notes, the participants were not asked to substantiate their reports. Instead, three steps were used in gathering data on the children’s developmental delays. Step 1: The parents were asked to indicate if their children were first evaluated by professionals (yes or no) upon returning from China. Step 2: If the answer was yes, they were then asked to report how many weeks after the child’s arrival the initial evaluation took place. Step 3: Parents were asked to report the evaluation conclusions in the children’s different developmental domains: gross motor, fine motor, language, social skills, emotional understanding, and cognitive skills (too young to tell = 0, no/minor delay = 0, moderate delay = 1, severe delay = 2).
As severe delays were not prevalent in the sample, moderate delays and severe delays were collapsed into a moderate-to-severe delay category (too young to tell/no/minor delay = 0, moderate/severe delay = 1). The evaluations typically took place within the first week of arriving home, which corresponded to about 3–4 weeks after adoption because it took about 2–3 weeks to obtain paperwork for the child to leave China. As rapid developmental catch-up tends to happen during the earliest periods of adoption (Palacios et al., 2011), it is quite possible that the children had made some gains in their development during the weeks since adoption. The results, thus, reflected the children’s conditions at about one month after being removed from the institutions.
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Factor analysis with a Promax rotation showed that the six items formed two factors: motor delays (two items: gross motor and fine motor delay; Cronbach’s α = .77) and social-cognitive delays (four items: delays in language, social skills, emotional understanding and cognitive skills; Cronbach’s α = .83). In data analysis, the sum of each factor was used to reflect motor delays and social-cognitive delays.
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Early intervention enrollment At baseline (Wave 1 in 2005), the adoptive mothers responded to questions on whether their children had received early interventions in physical therapy (PT; yes or no) and speech–language therapy (SLT; yes or no) from state or local agencies. For those who received either therapy, the adoptive mothers were asked to report the duration of the intervention in months. Six years later (Wave 4, 2011), both adoptive mothers and adoptees independently provided data in the following two areas. The adopted children completed the surveys at about 1–2 weeks after the adoptive mothers did.
Academic performance A 5-item academic functioning subscale adapted from the Social Skills Rating System–Teacher Report (SSRS; Gresham & Elliott, 1990) was used to gather the adoptee’s self-report on their overall academic performance, performance in math, performance in English or reading, achievement motivation, and intellectual ability, as compared to other classmates on a 5-point Likert-scale ranging from 1 (lower than most students) to 5 (higher than most students). The internal consistency was high (α = .86). The adoptive mothers were asked to independently rate their children’s performance in the same five areas and to explain the basis for their ratings. The internal consistency was also high (α = .91). Overall, report cards and parent–teacher conferences were the major bases for parental ratings. In the present analysis, the average scores from self-ratings and parent ratings were used.
Internalizing problems The adopted Chinese girls were asked to respond to items that form the internalizing problem scale (31 items) of the Child Behavior Checklist–Youth Self-Report (CBCL-YSR; Achenbach & Rescorla, 2001). This was the first time that the adoptees directly contributed data since the beginning of the ongoing longitudinal study. The internal consistency was high (α = .87). The adoptive mothers completed the CBCL–Parent Report (CBCL-PR; Achenbach & Rescorla, 2001). The internalizing problems (32 items) were used for analysis. The internal consistency was also high (α = .84). The items on the CBCL-YSR internalizing scale and the items on the CBCL-PR internalizing scale were nearly identical expect one item. The reason that only internalizing problems were assessed was because (a) earlier data from adoptive parents showed that the adopted Chinese girls had few externalizing problems (Tan, 2011), (b) developmentally internalizing problems were frequently associated with girls’ adjustment during adolescence
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(Rescorla et al., 2007). In the analysis, standardized scores (t-test scores) were used to facilitate the interpretability of the results. RESULTS
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Research Question 1. To What Extent Was Early Intervention Utilized Among Chinese Children Who Were Adopted in Infancy? Among the 180 adopted Chinese girls, 99 (55%) had delays in at least one area of their development at the time of arrival. Of the 99 children with delays, 37 (37.4%) received early intervention (EI) in the form of PT or SLT. However, the other 62 girls (62.3%) had delays but did not enroll in EI. Additionally, 11 (6.1%) of the 180 girls had no delays but received EI. The details were summarized in Table 1. For those who enrolled in EI, the average length of PT was 8.4 months (SD = 8.4 months) and the average length of SLT was 15.7 months (SD = 12.8 months) at the time of data collection. For children who received PT (n = 26), length of the service was not correlated with the extent of motor delays at arrival (r = .01, p = .98) or social-cognitive delays at arrival (r = .22, TABLE 1 Summary of Adolescent Adopted Chinese Girls’ History of Delays at Arrival and Physical and Speech–Language Therapy Physical therapy Yes Delays at arrival Delays in gross motor skills Yes (n = 88) No (n = 92) Delays in fine motor skills Yes (n = 52) No (n = 128) Delays in language Yes (n = 40) No (n = 140) Delays in social skills Yes (n = 24) No (n = 156) Delays in emotional understanding Yes (n = 23) No (n = 157) Delays in cognitive skills Yes (n = 22) No (n = 158) ∗p
n
Speech/language therapy
No %
n
Yes %
χ2
n
No %
n
%
χ2
22 4
25.0 4.4
66 88
75.0 95.6
15.52∗∗∗
27 10
30.7 10.9
61 82
69.3 89.1
10.81∗∗∗
18 8
34.6 6.3
34 120
65.4 93.7
24.08∗∗∗
20 17
38.5 13.3
32 111
61.5 86.7
14.36∗∗∗
11 15
27.5 10.7
29 125
72.5 89.3
7.09∗∗
15 22
35.5 15.7
25 118
62.5 84.3
9.04∗∗
9 17
40.9 10.9
15 139
62.5 89.1
11.91∗∗∗
10 27
41.7 17.3
14 129
58.3 82.7
7.56∗∗∗
8 18
34.7 11.5
15 139
65.2 88.5
8.83∗∗
9 14
39.1 60.9
14 129
60.9 82.2
5.57∗
9 17
40.9 10.8
13 141
59.1 89.2
14.20∗∗∗
13 24
59.1 15.2
9 134
40.9 84.8)
22.79∗∗∗
< .05. ∗∗ p < .01. ∗∗∗ p < .001.
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p = .29). Similarly, for children who received SLT (n = 37), length of the service was not correlated with the extent of motor delays at arrival (r = .09, p = .60) or social-cognitive delays (r = –.05, p = .78).
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Research Question 2. How Might Developmental Delays at the Time of Arriving at the Adoptive Homes Be Related to Early Intervention Enrollment? The adoptees were 3–23.5 months (M = 11.5 months, SD = 3.7 months) at the time of adoption. Age at adoption was not correlated with motor delays at arrival (r = .03, p = .69) but it was correlated with social-cognitive delays at arrival (r = .22, p < .01). Motor delays and socialcognitive delays were moderately correlated (r = .51, p < .001). Logistic regression analysis showed that controlling for age at adoption, the adoptive mother’s age, education level and household income, motor delays at arrival significantly increased the odds for PT (odds ratio [OR] = 3.98, 95% CI [2.18, 7.28], p < .001) and SLT (OR = 2.36, 95% CI [1.50–3.72, p < .001). Similarly, social-cognitive delays at arrival also significantly PT increased the odds for PT (OR = 1.90, 95% CI [1.36, 2.63], p < .001) and SLT (OR = 1.63, 95% CI [1.22, 2.17], p < .001). The adoptees’ age at adoption, adoptive mother’s age, education level, and household income, however, were not associated with either PT or SLT. These results suggest that enrollment in EI was largely driven by the adoptees’ delays at arrival.
Research Question 3. How Were the Adopted Children’s Present Academic Performance and Behavioral Adjustment Related to Their Delays at Arrival and Early Interventions? The adopted Chinese girls’ academic performance was well within normal range: The adopted Chinese girls’ self-report showed an average of 4.05 (SD = 0.77; range = 1.6–5.0; 4 = higher than average), which was significantly lower than the average of 4.25 (SD = 0.80; range = 1.2–5.0) as reported by the adoptive mothers, paired t(176) = 4.75, p < .001. The mother–daughter agreement was strong (r = .74, p < .001) on academic performance. The adoptees’ internalizing problems were also within normal range: The adopted Chinese girls self-reported an average of 48.49 (SD = 9.77; range = 27.00–80.00), which was nearly significantly higher than the average of 46.88 (SD = 9.03; range = 33.00–71.00) as reported by the adoptive mothers, paired t(175) = 1.97, p = .051. The mother–daughter agreement was moderate (r = .46, p < .001). The adoptees’ self-reported internalizing problems and academic performance was modestly and negatively correlated (r = −.19, p < .01). The adoptive mother-reported internalizing problems and academic performance were also modestly and negatively correlated (r = −.18, p < .01). Table 2 summarizes the correlation analysis between developmental delays at arrival at about 11 months old and the adoptees’ present adjustment outcomes at about 13 years of age. Overall, greater motor delays at the time of arriving at the adoptive homes were significantly correlated with lower academic performance and more internalizing problems. Social-cognitive delays were only marginally correlated with self-reported internalizing problems (r = .15, p = .051) but not with other outcomes. The adopted Chinese girl’s age was positively correlated with self-reported
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TABLE 2 Correlation Coefficients Between Present Adjustment and Delays at Arrival, Child and Family Demographics
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Academic performance Self-report
Mother report
Self-report
−.18∗ −.03 −.04 −.02 0 −.10 −.03
−.16∗ −.06 −.10 −.06 −.14† −.03 −.06
.19∗ .09 .01 −.03 −.11 .10 .09
.22∗∗ .15† .03 .19∗ −.03 .11 −.02
Motor delays Social-cognitive delays Age at adoption Child’s present age Mother’s age Mother’s education level Household income †p
Internalizing problems
Mother report
< .10. ∗ p < .05. ∗∗ p < .01.
internalizing problems (r = .19, p < .05). No other variables were significantly correlated with the adoptees’ academic performance and internalizing problems. Table 3 summarizes the results from comparing the adoptees who participated in early intervention with those who did not on academic performance and internalizing problems. Those who received SLT scored lower than those who did not on self-reported and mother-reported academic performance. Finally, general linear modeling (GLM) was performed to better differentiate how status of developmental delays and early intervention was related to the adoptee’s academic performance and internalizing problems. The adoptees were divided into four groups based on their delay status (yes or no) and early intervention enrollment status (yes or no): Group 1: adoptees had no delays at arrival and received no EI (n = 70; 38.9%), Group 2: adoptees had no delays at arrival but received EI (n = 11; 6.1%), Group 3: adoptees had delays at arrival but received no EI (n = 62; 34.4%), and finally Group 4: adoptees had delays at arrival and received EI (n = 37; 20.6%). Note that a child’s developmental delay status was determined by whether there was TABLE 3 Comparing Academic Performance and Internalizing Problems Between Adolescent Chinese Adoptees With and Without History of Early Intervention Academic performance Mother report Early intervention
t(176)
Physical therapy Yes No Speech–language therapy Yes No
0.76
∗∗∗ p
< .001.
3.81∗∗∗
Internalizing problems
Self-report
M
SD
4.14 4.27
0.78 0.81
t(176)
Mother report
M
SD
3.86 4.08
0.83 0.75
1.41
3.82 4.37
1.00 0.70
3.46∗∗∗
t(176)
M
SD
46.96 46.87
9.57 8.97
0.05
0.97 0.68
M
SD
49.46 49.34
9.64 9.81
0.52
0.54 3.67 4.15
Self-report t(176)
1.54 47.59 10.02 46.70 8.78
50.72 10.91 47.92 9.4
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TABLE 4 Adjusted Means and 95% Confidence Intervals of Academic Performance and Internalizing Problems by Status of Delays and Early Interventions From General Linear Modeling Academic performance Mother report
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Delay and EI status Group 1 (n = 70): delays = no, EI = no Group 2 (n = 11): delays = no, EI = yes Group 3 (n = 62): delays = yes, EI = no Group 4 (n = 37): delays = yes, EI = yes
M
95% CI
4.46b [4.27, 4.65]
Internalizing problems
Self-report M 4.14b
95% CI
Mother report M
95% CI
Self-report M
95% CI
[3.96, 4.32] 44.85a
[42.71, 46.98]
47.25b [45.03, 49.48]
4.26ab [3.79, 4.72] 4.01ab [3.56, 4.45] 44.55a
[39.26, 49.83]
41.26b [35.44, 47.08]
4.29b [4.08, 4.49]
4.17b
[3.98, 4.36] 48.51a
[46.23, 50.80] 48.69ab [46.30, 51.07]
3.84a [3.58, 4.10]
3.72a
[3.48, 3.97] 49.00a
[46.09, 51.91]
52.62a [49.52, 55.71]
Note. All means were adjusted for age at adoption, age, adoptive mother’s age, education level, and household income. For delays, no = child had no delays at arrival; yes = child had one or more delays at arrival; For early intervention (EI), no = child did not receive early intervention; yes = child received early intervention. Values with overlapping superscript letters were not significantly different. ∗ p < .05. ∗∗ p < .01.
delay in any of the six areas at the time of arrival. A child’s early interventional enrollment status was determined by whether the child received PT or SLT. Group 3 scored significantly lower than Group 4 on motor delays (M = 1.26, SD = 0.70 vs. M = 1.68, SD = 0.53), t(97) = 3.13, p < .01, as well as on social-cognitive delays (M = 0.85, SD = 1.23 vs. M = 1.51, SD = 1.52), t(97) = 2.35, p < .05. These results suggest that severity of delays at arrival served as a main driving force for EI enrollment. In performing the GLM analysis to determine if the four groups differed in academic performance and internalizing problem scores, the adoptees’ age at adoption, present age and the adoptive mother’s age, educational level, and the adoptive family’s income were included as covariates. No interaction term was included because preliminary analysis showed no significant interaction between delay status and EI. Bonferroni correction was applied for the purpose of multiple comparisons. Additionally, a 95% confidence interval was requested for the predicted means. The Bonferroni adjusted means and 95% confidence intervals for the adoptees’ academic performance scores and internalizing problem scores are summarized in Table 4. For both self-reported and mother-reported academic performance, the girls in Group 4 scored significantly lower than those in Group 1 and those in Group 3, but did not score statistically differently from those in Group 2. In other words, the group who had delays at arrival and then received early intervention scored the lowest on academic performance. For mother-reported internalizing problems, there was no group difference in the adoptive mother’s report. For self-reported internalizing problems, however, the girls in Group 4 scored significantly higher than their peers in Group 1 and those in Group 2. There was no statistical difference between children in Group 4 and Group 3. In other words, the group that had delays and then received early intervention had the highest average internalizing problem score, per the adoptees’ self-report.
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DISCUSSION In this study the author investigated the roles of developmental delays at the time of arrival and postadoption early intervention enrollment in a sample of adopted Chinese adolescents’ present academic performance and behavioral adjustment. To address the scarcity of studies that utilize data from adoptees, data from a sample of teenage Chinese adoptees, in addition to the adoptive mothers, were collected in the present study. Before delving deeper into discussing the findings, it should be emphasized that children adopted from China are mostly girls under 2 years of age at the time of adoption (U.S. Department of State, 2013). Most children became available for adoption not due to their special needs but due to their gender. As most of them lived in Children’s Welfare Institutes before adoption (Hague Conference on Private International Law, 2010), developmental delays were rather prevalent in newly adopted Chinese children (Miller & Hendrie, 2000). Their postadoption adjustment has been shown to be favorable (e.g., Dalen & Rygvold, 2006; Tan & Marfo, 2006), although more severe preadoption adversity has been associated with poorer postadoption behavioral adjustment in preschool years (Tan et al., 2011). The present study showed that developmental delays were common at the time of arriving at the adoptive homes (55% of the children had delays). Although delays at arrival significantly increased the odds for early intervention, further analysis showed that it was the subsample of girls (37.4% of the 99 children with delays) who had more serious delays that actually utilized early intervention. Similarly low rate of early intervention utilization among adoptive families with Chinese children has also been reported by Bruder et al. (2009). Because most of the adoptive families had high socioeconomic status (SES) and were likely keen on promoting their children’s developmental catch-up, it was a surprise that early intervention seemed under-utilized by these families. I offer three speculations about the low rate of EI enrollment. First, these children were ≤ 24 months at the time of adoption, which is typically within the sensitive period of attachment formation. As such, some adoptive parents might avoid participating in early intervention so as to focus on mother–child bonding. Second, it was speculated by Bruder et al. (2009) that parents were aware that developmental catch up (usually without early intervention) took place quickly and naturally when the underlying contributors of delays (i.e., institutional care) were removed. In other words, the adoption itself functioned as a form of highly effective intervention. Indeed existing research suggests that massive catch-up was very common during the first one or two years after adoption (e.g., Palacios et al., 2011). This might be particularly the case for those children’s whose delays were not as serious (i.e., the ones in Group 3 of the present study). Third, in deciding whether to utilize early intervention, adoptive parents may assess its cost and benefit. If parents believed that the benefit of having exclusive interactions with their children to facilitate a smoother transition into the family was outweighed by their concerns about their children’s delays, the parents would likely choose to use early intervention. In this case, children who enrolled in early intervention would likely be a subgroup of adoptees with more severe developmental delays. Data from this study supported this speculation. Among the adopted Chinese girls with motor delays and social-cognitive delays at arrival, early intervention enrollment primarily happened to those with more serious delays.
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Turning to the findings on the adoptees’ academic performance and internalizing problems in relation to their delays and early intervention. The group of adopted girls who had delays at arrival and subsequently received early intervention (Group 4) scored lower on self-reported and mother-reported academic performance than their peer group who also had delays but did not receive early intervention (Group 3), as well as those who had no delays and received no intervention (Group 1). In terms of internalizing problems, the adopted girls in Group 4 scored higher in self-report than their peers in Group 1. No other differences were observed. Because by design early intervention is to facilitate catch-up in children with developmental delays, it is somewhat counterintuitive that those who received early intervention still scored lower than their peers in academic performance and higher in self-reported internalizing problems. To understand this finding, it is important to be reminded that children in Group 4 were significantly more delayed than their peers in Group 3. The severity of delays that children in Group 4 experienced might have some impact on their executive functioning and development in general, which would likely present a risk for learning and emotional regulation. This speculation is supported by research that has linked preadoption adversity to impairment in adopted children’s executive functioning later on (e.g., Hostinar, Stellern, Schaefer, Carlson, & Gunnar, 2012) and development in general (see the review by Frank, Klass, Earls, & Eisenberg, 1996). It is possible that early intervention might have benefited the children in Group 4 but not to the extent in which they were comparable to those who did not receive the therapy. In other words, if these children had not received early intervention, they would have fared even more poorly. It is also possible that the children who received early intervention might have had constitutional challenges that were not directly related to institutionalization. For instance, some of these children might have had developmental issues (e.g., premature birth) at the time of entering the orphanage, which would further complicate the children’s postadoption development. From an environmental stress perspective (Cairney, Rigoli, & Piek, 2013), children with significant motor delays may be more likely to experience negative personal and interpersonal stressors, which in turn contribute to a higher risk for internalizing symptoms in the short and long term. In other words, it is not necessarily motor delays per se but rather it is the stress that stemmed from such delays that has contributed to the elevated internalizing problems. From the perspective of behavioral continuity (Rutter & Rutter, 1993), it is possible that the Chinese adoptees’ who had delays and were going through early interventions (i.e., Group 4) experienced a higher amount of stress during the periods of preadoption institutionalization and possibly postadoption adjustment. The stress then contributed to more internalizing problems. These problems continued to be part of these children’s behavioral patterns. Thus, the observed correlation might have reflected continuity in the adopted children’s internalizing problems over time. Finally, the contributing factors to young children’s gross motor skill development may also help explain why serious motor delays might have negative long-term implications in learning and behavioral development. According to Adolph (1997), gross motor development starts in infancy with the major redistribution of body fat from upper body to lower body while the development of fine motor skills requires small muscle movements in coordination with the eyes (Rule & Stewart, 2002). Nutrition plays a key role in the development of muscle masses in children. Because gross motor development in children involves the development of the abilities to move large muscles (e.g., limbs) or the whole body (e.g., walking), adequate strength in large muscles
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is thus needed in order to accomplish these tasks. Malnutrition, therefore, can significantly compromise this process and limit the development of muscle masses. Lack of physical activities (e.g., play with toys or other children, interacting with adults) can further compromise children’s gross motor and fine motor development, as well as cognitive development. Children living in institutions often experience a combination of malnutrition and lack of opportunities to play. Thus, for institutionalized children, motor delays might signal the cumulative effect of inadequate nutrition and limited social-cognitive stimulation. Consequently, serious delays resulted from such adversity may jeopardize the adoptees’ social-cognitive development and place a heavier demand on their postadoption catch-up. These factors may be an underlying contributor of later elevated risk for learning and internalizing problems in the adopted Chinese girls. Of course these speculations must be carefully evaluated with studies that are designed to determine the underlying causes of motor delays as well as the social-emotional developmental trajectories of children who are recovering from those delays. Taken together, the findings from this study provide evidence that for children with more serious delays at the time of arriving at the adoptive home, even after early intervention they were still at a higher risk for poorer academic performance in adolescence. The robustness of the finding was further buttressed by the fact that data on the girls’ developmental status at arrival and present adjustment were collected six years apart. Additionally, two sources of data (i.e., from adoptive mothers and adoptees themselves respectively) were collected to reflect the adopted Chinese girls’ present outcomes. Because most children adopted from China usually did not experience very severe adversity, it is conceivable that when children were exposed to more severe and global adversity (e.g., children who were adopted from very deprived orphanages), the long-term harm may be more severe in magnitude. Nonetheless, caution is warranted in interpreting the results from this study due to several limitations. Specifically, this study only included nonrandomly sampled adopted Chinese girls in data analysis. Thus, the findings might not be generalizable, especially to adopted boys. The other limitation of this study is that data on developmental delays at arrival was not gathered directly from the clinics that conducted the evaluations. Instead, retrospective report was obtained from the adoptive mothers on the children’s professional evaluation results. This methodology was similar to the 2007–2008 National Survey of Adoptive Parents in assessing preadoption adversity (Bramlett et al., 2010). This approach has limitation but it also reflected an improvement from previous research that relied on certainty that adoptive parents felt about preadoption abuse or neglect (e.g., Verhulst & Versluis-den Bieman, 1995), more systematic assessment (e.g., requiring pediatricians or other professionals to fill out a preprepared questionnaire by researchers) would strengthen the validity of the early adversity indicators used in this study. Finally, no detailed data on early intervention were collected as it was beyond the scope of the study. It is thus not clear which aspects of the early intervention services that might have contributed to the observed outcomes in the present study. More detailed research on early intervention and internationally adopted children’s development is urgently needed.
Implications Findings from this study suggest that it is important to further establish protocols to evaluate and document the benefit of early intervention so that eligible adoptive families with children from
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foreign countries can better utilize this service. Given that the findings suggest that the adoptees’ academic performance and internalizing problems were correlated with their motor delays at the time of arriving at the adoptive homes about 12 years earlier, parents and professionals should be particularly cognizant about the potential long-term risks of early institutionalization.
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AUTHOR NOTE Tony Xing Tan is an associate professor in the College of Education at the University of South Florida in Tampa, Florida. He studies the development of children adopted from China.
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