APPLIED NEUROPSYCHOLOGY: CHILD

http://dx.doi.org/10.1080/21622965.2016.1182433

Structural language, pragmatic communication, behavior, and social

competence in children adopted internationally: A pilot study
Christine L. Petranovicha, Nicolay Chertkoff Walzb, Mary Allen Staatc, Chung-Yiu Peter Chiud, and Shari L. Wadee
a
Department of Psychiatry and Behavioral Sciences, The University of New Mexico Health Sciences Center, Albuquerque, New Mexico, USA;
b
Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital Medical Center, Cincinnati, Ohio, USA; cDivision of
Infectious Disease, Cincinnati Children’s Hospital Medical Center, The University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA;
d
Department of Psychology, The University of Cincinnati, Cincinnati, Ohio, USA; eDivision of Physical Medicine and Rehabilitation, Cincinnati
Children’s Hospital Medical Center, The University of Cincinnati, College of Medicine, Cincinnati, Ohio, USA

ABSTRACT KEYWORDS
The objectives of this study were to examine the association of structural language and pragmatic Communicative
communication with behavior problems and social competence in girls adopted internationally. disorders-speech;
Participants included girls between 6–12 years of age who were internationally adopted from international adoption;
social competence
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China (n ¼ 32) and Eastern-Europe (n ¼ 25) and a control group of never-adopted girls (n ¼ 25).
Children completed the Wechsler Abbreviated Scale of Intelligence. Parents completed the Child
Communication Checklist- second edition, the Child Behavior Checklist, and the Home and
Community Social Behavior Scales. Compared to the controls, parents in the Eastern European
group reported more problems with social competence, externalizing behaviors, structural
language, and pragmatic communication. The Chinese group evidenced more internalizing
problems. Using generalized linear regression, interaction terms were examined to determine if the
associations of pragmatic communication and structural language with behavior problems and
social competence varied across groups. Controlling for general intellectual functioning, poorer
pragmatic communication was associated with more externalizing problems and poorer social
competence. In the Chinese group, poorer pragmatic communication was associated with more
internalizing problems. Post-adoption weaknesses in pragmatic communication are associated
with behavior problems and social competence. Internationally adopted children may benefit from
interventions that target pragmatic communication.

Introduction Poorer pragmatic language has also been was associated

with more externalizing behavior problems in typically
Recent theories from the field of social neuroscience
developing children (Ketelaars, Cuperus, Jansonius, &
have posited that language and communication skills
Verhoeven, 2010) and greater impulsivity in children
may be central to social and behavioral adjustment in
with attention deficit/hyperactivity disorder (Geurts &
children. Pragmatic communication, or the ability to
Embrechts, 2008). Beauchamp and Anderson (2010)
understand social elements of language and to adjust
more broadly considered the role of language and pos-
communication strategies in response to situational
ited that pragmatic communication and expressive and
demands (Yeates et al., 2007), has been primarily asso-
receptive abilities are relevant to social functioning in
ciated with right frontal lobe functioning (Ferstl,
children. According to the authors, language is the basis
Neumann, Bogler, & von Cramon, 2008; Martin &
for processing thoughts, intentions, and social infor-
McDonald, 2003) with limited evidence suggesting
mation. Expressive and receptive language skills allow
involvement of the right posterior and temporal areas
for efficient expression and comprehension of infor-
(Johns, Tooley, & Traxler, 2008). In typically developing
mation that is exchanged in social interactions. In typi-
children (Leonard, Milich, & Lorch, 2011) and those
cally developing children, weaknesses in structural
with clinical disorders, including specific language
language may result in an impaired ability to effectively
impairment (Brinton & Fujiki, 1999) and autism spec-
communicate with others and to implement effective
trum disorder (Volden, Coolican, Garon, White, & Bry-
behavioral solutions (Ayduk, Rodriguez, Mischel,
son, 2009), poorer pragmatic communication has been
Shoda, & Wright, 2007). In children with speech/
associated with more problems with social competence.
language impairment, poorer expressive and receptive

CONTACT Christine L. Petranovich, Ph.D cpetranovich@salud.unm.edu The University of New Mexico Health Sciences Center MSC 09 5030,
1 University of New Mexico, Albuquerque, NM 87131, USA.
© 2016 Taylor & Francis
 2 C. L. PETRANOVICH ET AL.
language has been associated with problems with social
assertiveness, more internalizing problems, and poorer
self-control (McCabe & Meller, 2004).
Internationally adopted children with a history of
early life institutionalization often have had experiences
that place them at risk for negative cognitive, beha-
vioral, and social outcomes. These risk factors may
include in-utero substance exposure, poor prenatal
and perinatal healthcare services, malnutrition, neglect,
abuse (McGuinness & Pallansch, 2000; O’Connor et al.,
2003), lack of individualized care and attention (Gunnar
et al., 2000), and few opportunities to engage in
activities that facilitate cognitive and social development
(Johnson, 2002). Potentially related to these negative
early experiences, many internationally adopted chil-
dren evidence a variety of neurobiological consequences
compared to never- institutionalized children. This
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includes abnormal patterns of connectivity in the fron-
tostriatal projections (Behen et al., 2009) and decreased
metabolism in the amygdala, hippocampus, orbital
frontal gyrus, and infralimbic prefrontal cortex
(Chugani et al., 2001). Atypical neurodevelopment
may have long-term consequences, including a general
lag in development compared to children without a
history of institutionalization (Pollak et al., 2010) and
problems with behavioral and emotional regulation
(Anderson, Damasio, Tranel, & Damasio, 2000) and
social functioning (Stuss & Alexander, 2000). Consistent
with this, results of a meta-analysis that included
adoptees from multiple areas, including Eastern Europe
and Asia, indicated significantly more internalizing and
externalizing problems compared to never-adopted
peers in the destination country (Juffer & van
IJzendoorn, 2005). In a sample of children inter-
nationally adopted from China, most were in the
nonclinical range on a parent-report measure of
behavior. There was, however, substantial variability,
particularly with regard to hyperactivity, aggression,
and withdrawal (Rojewki, Shapiro, & Shapiro, 2000).
Problems with social competence, including difficulties
forming relationships with peers, have also been docu-
mented in school-aged children adopted internationally
from Eastern Europe (Colvert et al., 2008; Gunnar, Van
Dulmen, & The International Adoption Project Team,
2007), Asia, and South America (Gunnar et al., 2007).
Using parent-report and observational measures in a
sample of children that were internationally adopted
from Eastern Europe and Asia, Bruce, Tarullo, and
Gunnar (2009) reported disinhibited social behavior
and atypical lack of social reserve.
Prior research has identified factors that influence
post-adoption functioning. Children adopted from
Eastern Europe may be particularly vulnerable to
negative outcomes, including internalizing and externa-
lizing behavior problems (Pomerleau et al., 2005).
Greater risk in Eastern European adoptees is thought
to be related to numerous factors, including increased
risk of in-utero substance exposure (Gunnar et al.,
2007), genetic factors that may place the child at elev-
ated risk for mental health disorders (Stevens et al.,
2009), and the potential for early life trauma, including
exposure to war, a lack of social welfare in their country
of origin, and particularly poor conditions in the insti-
tutionalized setting, including malnutrition, neglect,
and lack of consistent caregivers (Gunnar, Morrison,
Chisholm, & Schuder, 2001). Older age at adoption,
which is thought to represent longer duration of institu-
tionalization and less time in the adopted family, has
been associated with more problems with behavior
(Gunnar et al., 2001; Merz & McCall, 2010), social com-
petence (Merz & McCall, 2010), and language (Glennen
& Masters, 2002; Jacobs, Miller, & Tirella, 2010). Finally,
gender differences have been reported. Compared to
girls, internationally adopted boys may have more prob-
lems with behavior, including hyperactivity (Stevens
et al., 2008) and aggression (Groza, Ryan, & Cash,
2003). Other lines of research have not found gender
differences (Abrines et al., 2012; Hanson et al., 2013;
Jacobs et al., 2010; Merz & McCall, 2011).
For many children adopted internationally, they are
exposed to one culture and language in early life and,
upon adoption, are expected to enter a new culture
and acquire a second language. This atypical develop-
mental course may make language and communication
particularly relevant to post-adoption psychosocial
functioning (Glennen & Masters, 2002). The results of
a meta-analysis indicated that internationally adopted
children evidence weaker overall language compared
to peers in the destination country and normative data,
although there was notable variability (Scott, Roberts, &
Glennen, 2011). Findings from other lines of research
indicated weaknesses in receptive and expressive language
compared to never-adopted peers in the destination
country (Helder, Behen, Wilson, Muzik, & Chugani,
2014; Loman, Wiik, Frenn, Pollak, & Gunnar, 2009)
and children internationally adopted from foster care
(Loman et al., 2009). Using the Child Communication
Checklist- second edition, parent-reported pragmatic
communication was significantly weaker than structural
language in a sample of children that were internationally
adopted from Eastern Europe (Glennen & Bright, 2005).
Although prior research has documented problems
with language, behavior, and social competence in chil-
dren adopted internationally, few studies have examined
associations among these areas of functioning. In a sam-
ple of internationally adopted children with and without

language impairment, Helder et al. (2014) found more
parent-reported problems with hyperactivity and impul-
sivity compared to never-adopted controls. These
problems were not associated with performance on
measures of expressive or receptive language. It is
notable that this study did not include an assessment
of pragmatic communication. Additional research is
needed to examine the relationships of pragmatic com-
munication and structural language with behavior and
social competence.
This study aimed to investigate the associations of
structural language and pragmatic communication with
behavior problems and social competence in post-insti-
tutionalized children who were internationally adopted
from China or Eastern Europe. We further aimed to
determine if these relationships varied across groups.
It was hypothesized that the internationally adopted
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groups would evidence poorer structural language and
pragmatic communication and more problems with
behavior and social competence compared to a group
of never-adopted controls. It was also expected that
pragmatic communication would be more strongly
associated with behavior problems and social com-
petence than would structural language. Finally, it was
hypothesized that older age at adoption and Eastern
European area of origin would be associated with more
problems with behavior and social competence.
Methods
Procedure
This study was approved by the Institutional Review
Board at the study site. Potential participants were
identified from records maintained by an international
adoption center at a medical center in the Midwestern
United States. Never-adopted, never-institutionalized
control participants were recruited by word of mouth,
including a hospital wide email and recommendations
from enrolled participants. This recruitment strategy
was utilized in effort to recruit a group of never-adopted
peers that were raised in similarly enriched family envir-
onments. At a study visit that was at the medical center,
informed consent was obtained. Parents provided
demographic information and completed standardized
rating forms. Children were administered a measure
of general intellectual functioning. Families were com-
pensated for time and travel.
Participants
Consistent with other studies of international adoption,
participants included children that were adopted
APPLIED NEUROPSYCHOLOGY: CHILD 3
from Eastern Europe (Glennen & Bright, 2005; Gunnar
et al., 2007; Loman et al., 2013) and China (Loman et al.,
2013; Rojewki et al., 2000; Tarullo, Gavin, & Gunnar,
2011) and a comparison group of demographically-
matched, never-adopted controls in the country
of destination (Bruce et al., 2009; Tarullo, Gavin, &
Gunnar, 2011; Tottenham et al., 2010). The children
that participated in this study were selected to represent
higher functioning international adoptees. Therefore,
exclusionary criteria for both groups included a history
of significant developmental disability, such as intellec-
tual disability. As previously noted, prior studies have
found gender differences in post-adoption behavior
(Groza et al., 2003; Stevens et al., 2008). During the
study period (December 2007–April 2014), female
children from Eastern Europe and China accounted
for the majority of children adopted internationally
locally, nationally, and worldwide (Juffer & van
Ijzendoorn, 2005). Therefore, only girls between 6–12
years of age were included in an effort to reduce
heterogeneity within the sample. For internationally
adopted children, additional eligibility criteria included
being between 7–48 months of age at adoption and
having spent at least 6 months in pre-adoption institu-
tionalize care (e.g., orphanage, baby home, or hospital).
These criteria were included to assure that the inter-
nationally adopted children had a history of early life
institutionalization.
Participant demographic information is reported in
Table 1. Groups were well-matched for age, family
income, and primary caregiver education. The Eastern
European group was older (in months) at the time of
adoption compared to the Chinese group (p ¼ .005).
Information about history of in-utero substance
exposure was inconsistently available. Five parents
(20.0%) in the Eastern European group reported a
known or suspected history of in-utero exposure to sub-
stances. No parents in the Chinese and control groups
referenced a history of in-utero substance exposure.
With respect to language development, the mean age
(in months) at which the child spoke her first words was
17.33 (5.85) in the Chinese group and 24.93 (11.12) in
the Eastern European group. The Chinese (p ¼ .02)
and the Eastern European (p < .001) groups were sig-
nificantly delayed compared to controls (12.59 [3.30]
months). Sixteen children (50.0%) in the Chinese
group, 14 (56.0%) in the Eastern European group,
and zero controls had a history of speech/ language
therapy. Proportions were higher in the Chinese
(χ2 ¼ 17.378, p < .001) and the Eastern European
(χ2 ¼ 19.44, p < .001) groups relative to the controls.
Six children (18.7%) in the Chinese group, seven
(28.0%) in the Eastern European group, and zero
 4 C. L. PETRANOVICH ET AL.

Table 1. Demographic characteristics and neurobehavioral test data.

Control Eastern European Chinese
Mean (SD) Mean (SD) Mean (SD)
N 25 25 32
Age at testing in years 8.89 (1.64) 8.60 (1.17) 8.44 (1.23)
Age at adoption in monthsc – 23.70 (10.38) 16.64 (6.84)
Primary caregiver education High school or GED ¼ 4.0% High school or GED ¼ 8.0% High school or GED ¼ 6.2%
Some college ¼ 16.0% Some college ¼ 16.0% Some college ¼ 6.2%
4-year degree ¼ 16.0% 4-year degree ¼ 36.0% 4-year degree ¼ 46.9%
Graduate/professional Graduate/professional Graduate/professional
degree ¼ 64.0% degree ¼ 40.0% degree ¼ 40.7%
Family income $30–$59,000 ¼ 4.0% $30–$59,000 ¼ 4.0% $30–$59,000 ¼ 9.4%
$60–$79,000 ¼ 4.0% $60–$79,000 ¼ 8.0% $60–$79,000 ¼ 18.7%
$80–$99,000 ¼ 24.0% $80–$99,000 ¼ 20.0% $80–$99,000 ¼ 12.5%
>$100,000 ¼ 68.0% >$100,000 ¼ 68.0% >$100,000 ¼ 59.4%
HCSBS Social competencea 58.52 (6.26) 50.48 (8.80) 55.68 (8.45)
CBCL Externalizinga,c 45.44 (8.20) 54.40 (10.72) 47.43 (10.28)
CBCL Internalizingb 43.96 (7.72) 48.68 (9.22) 51.53 (11.24)
CCC-2 Structural languagea,b,c 11.35 (1.31) 8.19 (3.02) 9.67 (2.24)
CCC-2 Pragmatic communicationa,b 11.98 (1.45) 9.63 (2.40) 10.50 (1.91)
WASI IQa,b,c 119.20 (13.44) 94.08 (13.34) 106.87 (13.28)
Note. Group comparisons are Bonferroni corrected and control for family income logarithm. CBCL and HCSBS subscales are reported as age-adjusted T scores;
CCC-2 Composites are reported as age-adjusted scaled scores. asignificant difference between control and Eastern European; bsignificant difference between
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control and Chinese; csignificant difference between Eastern European and Chinese.

controls were receiving speech/ language therapy at the
time of study participation. This was greater in the
Chinese (χ2 ¼ 18.06, p < .001) and the Eastern European
(χ2 ¼ 18.43, p < .001) groups compared to the controls.
Measures
Consistent with other studies of international adoption
(Olsavsky et al., 2013; Tottenham et al., 2010), children
completed the two subtest estimate of intelligence
that is obtained from the Vocabulary and Matrix
Reasoning subtests from the Wechsler Abbreviated
Scale of Intelligence (WASI; Wechsler, 1999).
Validation studies have reported that the WASI pro-
vides a reliable estimate of the full scale intelligence
quotient from the Wechsler Intelligence Scale for
Children-III (Weschler, 1999).
Parents completed the Children’s Communication
Checklist- second edition (CCC-2; Norbury, Nash,
Baird, & Bishop, 2004), a parent-report measure of
structural language and pragmatic communication. By
providing an assessment of pragmatic communication
in everyday occurring behavior, standardized question-
naires may be more ecologically valid than perfor-
mance-based assessments. In support, it has been
reported that pragmatic communication in children
with autism spectrum disorder is often better when
assessed using performance-based measures than it is
in real-world social situations (Volden et al., 2009).
The CCC-2 has high levels of inter-rater reliability
and consistency (Norbury et al., 2004). It has been used
to in studies of international adoption (Glennen &
Bright, 2005) and in pediatric clinical populations,
including autism spectrum disorder and specific
language impairment (Geurts & Embrechts, 2008). This
measure includes six subscales assessing pragmatic
communication in the areas of initiation, stereotyped
language, use of context, non-verbal communication,
communication in social relations, and interests. Con-
sistent with prior research (Bishop, 1998), a Pragmatic
Communication composite was calculated by averaging
the scores on these subscales. The CCC-2 also includes
four subscales that assess structural language in the
areas of speech, syntax, semantics, and coherence. We
calculated an average of these subscales to create a
Structural Language composite. For both composite
measures, lower scores indicate more poorly developed
abilities.
Parents also completed the Child Behavior Checklist
(CBCL), a standardized rating of child behavior that is
widely used in both clinical and research settings
(Achenbach & Rescorla, 2001). This study used the
Internalizing and Externalizing Problems subscales to
assess functioning in these domains. The CBCL has high
test-retest reliability and criterion validity and has been
shown to be sensitive to childhood behavior problems
(Achenbach & Rescorla, 2001). Higher scores represent
more behavior problems.
Finally, parents completed the Home and Com-
munity Social Behavior Scale (HCSBS; Merrell &
Caldarella, 2002). This study utilized the Social Com-
petence subscale as a measure of social functioning in
the areas of peer relations, self-management, and com-
pliance. The HCSBS has been normed for children ages
5 to 18 years old. It has demonstrated satisfactory
reliability and validity (Lund & Merrell, 2001; Merrell
& Boelter, 2001; Merrell, Streeter, & Boelter, 2001).
Lower scores represent poorer social competence.

Statistical approach
Univariate statistics were used to examine the distri-
bution of the data and to test for normality. Means
and standard deviations for demographic variables
and measures of structural language, pragmatic com-
munication, externalizing and internalizing behavior,
and social competence were reported. Pearson’s
correlations were used to test the bivariate relation-
ships between predictors and outcome variables.
Analysis of co-variance (ANCOVA), Bonferroni
corrected, was used for group comparisons (Eastern
European, Chinese, or controls). Because socioeco-
nomic status influences access to healthcare and
mental health services (Snells-Johns, Mendez, &
Smith, 2004), family income was used as a covariate.
For mean comparisons, Cohen’s d was reported as a
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measure of effect size (d ¼ .20 indicating small effect
size, .50 indicating medium, .80 indicating large;
Cohen, 1988).
Using contrast terms for group (Chinese, Eastern
European, or controls), generalized linear regression
was used to examine the main effects of CCC-2
Structural Language and Pragmatic Communication
on CBCL Internalizing and Externalizing Problems
and HCSBS Social Competence. Group and family
income were included as covariates. WASI was included
as a control variable in order to determine if structural
language and pragmatic communication were associa-
ted with behavior problems and social competence
beyond the effects of estimated general intellectual
functioning. Group � CCC-2 interaction terms were
included to determine if these associations differed by
group. For each model, Variance Inflation Factor
(VIF) and tolerance were calculated to assess for
multicollinearity among main effects. Using manual
backwards elimination, non-significant interactions
were eliminated. The models were re-estimated and
non-significant main effects were eliminated (p > .05).
Group, family income, and WASI were retained even
if non-significant. For significant interactions, we
reported estimated marginal means, co-varying for the
factors that were included in the final estimations of
the models. For the final estimations, R2 was reported
as a measure of effect size (R2 ¼ .10 indicating small
effect size, .30 indicating medium, .50 indicating large;
Cohen, 1992).
We also conducted an analysis that included only
the internationally adopted groups in which age at
adoption was introduced to the final estimations. This
allowed for examination of the specific effects of area
of origin (Eastern European or Chinese) and age at
adoption.
APPLIED NEUROPSYCHOLOGY: CHILD 5
Results
Distributions and bivariate relationships
The following variables were normally distributed:
CBCL Externalizing and Internalizing Problems,
HCSBS Social Competence, WASI IQ, age at adoption,
and the CCC-2 Pragmatic Communication and Struc-
tural Language. Family income (skew ¼ 1.04) was
slightly negatively skewed. For family income, the logar-
ithm was used in the generalized linear regression
models.
Correlations among outcome measures ranged from
.30 (CBCL Internalizing and HCSBS Social Com-
petence) to .56 (CBCL Externalizing and HCSBS
Social Competence). The correlation of CCC-2 Prag-
matic Communication and Structural Language was
.80. Relationships of outcomes measures with the
CCC-2 composites ranged from .30 (CBCL Internaliz-
ing and CCC-2 Structural Language) to .67 (HCSBS
Social Competence and CCC-2 Pragmatic
Communication).
Mean comparisons
Means, standard deviations, and ranges are reported in
Table 1. ANOVA, Bonferroni corrected and controlling
for family income, indicated significant differences on
CBCL Externalizing, F(82), ¼ 5.91, p ¼ .004. Post-hoc
comparisons revealed more problems in the Eastern
European group relative to the Chinese group (p ¼ .02,
d ¼ .66) and the controls (p ¼ .007, d ¼ .93). With
respect to CBCL Internalizing, F(82) ¼ 3.81, p ¼ .02,
the Chinese group evidenced more problems than the
controls (p ¼ .02, d ¼ .78). On HCSBS Social Com-
petence, F(82) ¼ 6.82, p ¼ .002, parents in the Eastern
European group reported more problems compared to
the controls (p ¼ .001, d ¼ 1.52). The difference between
the Eastern European and the Chinese groups trended
toward significant (p ¼ .06; d ¼ .60)
Groups also significantly differed on the WASI,
F(82) ¼ 22.83, p < .001. The Eastern European (p < .001,
d ¼ 1.87) and the Chinese (p ¼ .005, d ¼ 0.92) groups
had lower scores than the controls. The Eastern
European also underperformed the Chinese group
(p ¼ .001, d ¼ 0.96).
On the CCC-2, groups significantly differed on
the Pragmatic Communication composite, F ¼ 8.92,
p < .001. Compared to the controls, scores were lower
in the Eastern European (p < .001, d ¼ 1.18) and the
Chinese groups (p ¼ .02, d ¼ .87). On the Structural
Language composite, F(82) ¼ 11.57, p < .001, the
Eastern European group (p � .001, d ¼ 1.35) and the
 6 C. L. PETRANOVICH ET AL.

Table 2. Correlation coefficients among factors.

Income WASI IQ CCC-2 structural CCC-2 pragmatic CBCL external CBCL internal HCSBS social
Income – .24 .12 .15 .16 .18 .14
WASI IQ – – .55 .53 .37 .22 .38
CCC-2 Structural – – – .80 .49 .30 .53
CCC-2 Pragmatic – – – – .66 .44 .67
CBCL External – – – – – .45 .56
CBCL Internal – – – – – – .30

Chinese group (p ¼ .03, d ¼ 0.91) had lower scores com-
pared to the controls. The Eastern European group was
also lower than the Chinese group (p ¼ .04, d ¼ 0.55).
Association of CCC-2 with behavior problems and
social competence
For all models, VIF and tolerance values were within the
acceptable range (i.e., tolerance > 0.1 and VIF � 10; see
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of origin, and older age at adoption were associated with
more externalizing problems.
With CBCL Internalizing Problems as the dependent
measure, there was a significant group � CCC-2
Pragmatic Communication interaction (R2 ¼ .30). See
Table 2. Post-hoc analysis of the estimated marginal
means indicated that within the Chinese group, lower
CCC-2 Pragmatic Communication was associated
with higher ratings on CBCL Internalizing Problems

Freund & Littell, 2000). (p ¼ .01). See Figure 1. In the analysis that included only
With CBCL Externalizing Problems as the dependent the internationally adopted groups, the group � CCC-2
measure, there was a significant main effect of CCC-2 Pragmatic Communication interaction was non-signifi-
Pragmatic Communication (R2 ¼ .46). See Table 2. cant (p ¼ .13). There was a significant main effect of
Lower CCC-2 Pragmatic Communication (poorer CCC-2 Pragmatic Communication (R2 ¼ .30). Lower
abilities) was associated with higher scores on CBCL CCC-2 Pragmatic Communication was associated with
Externalizing Problems (more problems). See Table 3. higher CBCL Internalizing Problems.
In the analysis that included only the internationally Considering HCSBS Social Competence as the
adopted groups, there were significant main effects of dependent measure, there were significant main effects
CCC-2 Pragmatic Communication, area of origin, and of family income and CCC-2 Pragmatic Communi-
age at adoption (R2 ¼ .52). See Table 4. Lower CCC-2 cation (R2 ¼ .53). See Table 2. Lower CCC-2 Pragmatic
Pragmatic Communication, Eastern European country Communication and higher family income was associa-
ted with lower HCSBS Social Competence scores
(poorer competence). In the analysis within the
Table 3. Regression analysis examining the association of area
of origin and age at adoption.
Table 4. Trimmed regression models examining the association
Variable b SE Std b t p
of CCC-2 composites with behavior problems and social
CBCL Externalizing behaviors competence.
Area of origin 7.26 2.61 .33 2.78 .008*
Family income 7.12 3.67 .20 1.93 .058 Variable b SE Std b t p
WASI IQ .01 .09 .02 .20 .830 CBCL Externalizing behaviors
CCC-2 Pragmatic 3.10 .55 .61 5.59 <.001** Group 1.75 1.09 .14 1.60 .11
communication Family income 2.36 2.94 .06 .80 .42
Age at adoption .33 .13 .28 2.47 .010* WASI IQ .02 .06 .04 .39 .69
2
R .52** CCC-2 Pragmatic 3.26 .48 .67 6.75 <.001**
CBCL Internalizing behaviors communication
Area of origin 20.88 12.63 1.00 1.65 .100 R2 .46**
Family income 4.03 4.28 .12 .94 .350 CBCL Internalizing behaviors
WASI IQ .12 .10 .18 1.22 .220 Group 19.66 7.66 1.63 2.56 .01*
CCC-2 Pragmatic 5.43 1.96 1.12 2.76 .008* Family income 3.80 3.28 .11 1.16 .25
communication WASI IQ .03 .07 .05 .45 .64
Group � Pragmatic 1.81 1.19 .97 1.52 .130 CCC-2 Pragmatic 4.76 1.34 1.01 3.53 .001*
communication communication
Age at adoption .09 .16 .08 .61 .540 Group � Pragmatic 1.52 .67 1.70 2.26 .02*
R2 .30* communication
HCSBS Social competence R2 .30**
Area of origin 3.40 2.07 .19 1.64 .100 HCSBS Social competence
Family income 4.09 2.92 .14 1.40 .160 Group .59 .83 .05 .71 .470
WASI IQ .02 .07 .03 .31 .750 Family income 7.65 2.24 .27 3.40 .001*
CCC-2 Pragmatic 2.72 .44 .66 6.17 <.001** WASI IQ .05 .04 .10 1.08 .280
communication CCC-2 Pragmatic 2.69 .36 .68 7.32 <.001**
Age at adoption .15 .10 .16 1.44 .150 communication
R2 .54** R2 .53**
Note. To correct for skew, the logarithm for family income was used. Note. To correct for skew, the logarithm for family income was used.

Figure 1. Estimated marginal means for significant group � CCC-2 pragmatic communication interaction with CBCL Internalizing as
the dependent measure.
internationally adopted groups, there was a significant
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main effect of CCC-2 Pragmatic Communication
(R2 ¼ .54). See Table 4. Lower CCC-2 Pragmatic Com-
munication remained associated with lower ratings of
social competence.
Discussion
This study examined the relationships of structural lan-
guage and pragmatic communication with behavior
problems and social competence in children adopted
internationally from China and Eastern Europe relative
to a group of never-adopted controls. Consistent with
study hypotheses, the internationally adopted groups
evidenced more problems relative to the controls. Par-
ents in the Chinese group reported more internalizing
problems and poorer structural language and pragmatic
communication compared to the controls. Parents in
Eastern European group reported more externalizing
problems compared to both the Chinese and the control
groups and poor social competence and pragmatic com-
munication relative to the controls. This is in line with
previous research suggesting that children adopted
internationally often experience difficulties with prag-
matic communication (Glennen & Bright, 2005; Loman
et al., 2009; Scott, Roberts, & Glennen, 2011) and that
Eastern European adoptees may be particularly vulner-
able to negative post-adoption outcomes (Gunnar et al.,
2001). Weaknesses in pragmatic communication, exter-
nalizing behaviors, and social competence, which were
most prominent in the Eastern European group, may
be related to numerous factors. Many children adopted
internationally evidence lags in cognitive and social
development relative to never-adopted peers that were
raised in similar environments (Pollak et al., 2010). In
children adopted from Eastern Europe, developmental
lags may be related to multiple factors, including higher
APPLIED NEUROPSYCHOLOGY: CHILD 7
risk of in-utero substance exposure (Gunnar et al.,
2007), genetic factors that may place the child at
elevated risk for mental health disorders (Stevens
et al., 2009), possible exposure to war and a lack of
social welfare in their country of origin, and the
potential for particularly poor conditions in the
institutionalized setting (Gunnar et al., 2001). These
pre-adoption factors may lead to alterations in neural
development that are particularly prominent in the
frontal areas (Behen et al., 2009; Chugani et al., 2001).
Atypical neural development may contribute to
problems with pragmatic communication (Martin &
McDonald, 2003), behavioral and emotional regulation
(Anderson et al., 2000), and social functioning (Stuss
& Alexander, 2000). Finally, internationally adopted
children are often exposed to one culture and language
in early life and, upon adoption, are expected to enter a
new culture and acquire a second language. This atypi-
cal developmental course may further contribute to the
weaknesses in pragmatic communication, behavior, and
social competence that were documented by this study.
Overall, there are a multitude of pre-adoption factors
that contribute to post-adoption outcomes. However,
given the nature of international adoption, knowledge
of pre-adoption adversity and early history is often
unavailable. This lack of information limits our ability
to identify the specific range of factors that influence
post-adoption outcomes.
Consistent with theories from the social neuroscience
literature (Beauchamp & Anderson, 2010; Yeates et al.,
2007), our findings support the hypothesized relation-
ship of pragmatic communication with behavior prob-
lems and social competence. Controlling for general
intellectual functioning, poorer pragmatic language
was associated with more externalizing problems and
poorer social competence. These associations did not
vary by group, suggesting that these relationships
 8 C. L. PETRANOVICH ET AL.
existed in both the control and the internationally
adopted groups. Consistent with studies that have
reported more internalizing problems in children inter-
nationally adopted from China (Rojewki et al., 2000),
parents the Chinese group reported more internalizing
behaviors than the controls. Within this group, poorer
pragmatic communication was associated with more
internalizing problems. This is in line with other studies
that have reported associations of pragmatic language
and internalizing problems in typically developing chil-
dren (Ketelaars et al., 2010) and children with speech-
language impairment (Gallagher, 1999). In explaining
this relationship, pragmatic communication weaknesses
may result in emotional problems that result from an
inability to use communication to form social bonds
(Hyter, Rogers-Atkinson, Self, Simmons, & Jantz,
2001). Alternatively, it may be that emotional problems
Downloaded by [University of Cambridge] at 23:38 13 June 2016
result in fewer social opportunities, which may contrib-
ute to weaknesses in pragmatic communication.
The internationally adopted groups reported more
problems with structural language compared to the
controls. However, the findings of this study failed to
identify an association of structural language with
behavior problems or social competence. This is con-
sistent with research in typically developing children
that suggested that pragmatic communication is more
salient than structural language when considering
behavior problems (Ketelaars et al., 2010). As suggested
by Ketelaars et al., structural language problems
may often be identified and remediated in early child-
hood. Weaknesses in pragmatic communication may
be less likely to be identified and may therefore go
unaddressed, potentially resulting in a greater impact
on long-term behavior and social functioning.
Also consistent with study hypotheses, Eastern
Europe as the area of origin and older age at adoption
were associated with more externalizing problems. As
previously noted, other studies have reported delays in
frontal lobe development in internationally adopted
children, which may be expected to negatively impact
executive functioning (Behen et al., 2009; Hanson
et al., 2013). Externalizing problems may be closely
related to executive functioning, particularly behavioral
regulation (Anderson et al., 2000). Delays in frontal lobe
development, potentially resulting in behavioral dysre-
gulation and externalizing behaviors, may be parti-
cularly prominent in Eastern Europe adoptees and
those with longer duration of institutionalization. In
contrast to study hypotheses, area of origin and age at
adoption were not significantly associated with interna-
lizing problems or social competence. This is in line
with other lines of research that similarly reported
non-significant findings with respect to age at adoption
(Abrines et al., 2012; Hanson et al., 2013; Jacobs et al.,
2010; Merz & McCall, 2011).
In children adopted internationally, it is often diffi-
cult to distinguish problems that are associated with
English as a second language from more fundamental
weaknesses in structural language and pragmatic com-
munication (Welsh, Viana, Petrill, & Mathias, 2007).
This study is therefore limited by having not assessed
English language proficiency. However, there is avail-
able information that may speak to English language
experience. All parents reported that English is the
child’s primary language. The average number of
months since adoption was 84.76 in the Chinese group
(range 55–128 months) and 78.74 months in the Eastern
European group (range 43–136 months). In a study of
bilingual English-learning children, it was reported that
it takes an average of 3.31 years to achieve performance
on English language tests that is similar to that of native
English speakers (McSwan & Pray, 2005). In a separate
study, children that were internationally adopted as
infants and toddlers demonstrated language abilities
that were similar to English based norms by 36–40
months of age (Glennen & Masters, 2002). In view of
these findings, participants in this study may be
expected to have English language proficiency that is
similar to that of native English speakers and
English-based norms.
As noted above, the population of children adopted
internationally is heterogeneous because of the numer-
ous factors that often vary, including genetic risks, poor
maternal health, in-utero exposure to teratogens, quality
of pre-adoptive medical care, pre-adoptive abuse,
neglect, and duration of institutionalization (Colvert
et al., 2008; Tottenham et al., 2010). From a research
perspective, heterogeneity poses difficulty when making
comparisons between groups of internationally adopted
children and when selecting a control group (Colvert
et al., 2008). The advantage of the never-adopted con-
trol group is that it offers a comparison relative to peers
that were raised in similarly enriched family environ-
ments. Its use is limited because it is not possible to
ascertain the role of institutionalization itself and the
proportion of observable differences that may be
attributable to cultural and family-level factors.
Additionally, as also noted above, we are unable to
account for adoption-related risk factors, including
trauma, degree of deprivation and lack of social welfare
in the country of origin, which would be expected to
impact the severity of post-adoption problems. We are
also unable to account for pre-existing developmental
and/or medical problems, which may have contributed
to the biological family’s decision to place the child up
for adoption. This study is therefore limited by its

inability to identify the specific pre-adoption factors
that contribute to post-adoption problems with beha-
vior and social competence. Inconsistent knowledge of
pre-adoption adversity and early history is a limitation
that is inherent to this population.
There may also be characteristics of the adoptive
family that impact post-adoption child outcomes. For
example, Hellerstedt et al. (2008) reported that the
majority of parents that adopted internationally ident-
ified as white/ Caucasian. Depending on the race of
the child and the adopting family, the child may or
may not appear to be of the same race as his or her
adopted family. The desire to have a child that appears
racially similar or dissimilar may be a relevant consider-
ation when families are deciding from where to adopt a
child. In a separate study, Lee et al. (2006) described
attitudes about cultural socialization and race in parents
Downloaded by [University of Cambridge] at 23:38 13 June 2016
of internationally adopted children, including those
adopted from Eastern Europe and Asia. Across coun-
tries of origin, higher value on cultural socialization to
the child’s country of origin was associated with greater
help seeking behavior, such as speaking with a teacher
about issues that their child is experiencing. Taken
together, these findings highlight family characteristics
that may influence post-adoption outcomes. Additional
research is needed that more comprehensively examines
the impact of family-related factors, such as parenting
style, cultural values, and quality of life, on behavior
and social competence.
When considering these findings, sample size is a
key limitation. With a larger sample, this study may
have been able to detect patterns that were not observ-
able in this sample. Consistent with other lines of
research (e.g., Glennen & Bright, 2005; Gunnar et al.,
2007; Loman et al., 2013), this study grouped together
children that were adopted from Eastern Europe. This
was done because there are pre-adoption risk factors
that are common to children that were adopted from
institutions in this region (Gunnar et al., 2001;
Pomerleau et al., 2005). However, Eastern Europe is
a large geographical area that includes many diverse
countries and cultures. There may be variability
among Eastern European adoptees that was not cap-
tured by this study. As an additional limitation, the
children that participated in this study were selected
to represent higher functioning international adoptees
(e.g., those without a history of intellectual disability
or significant developmental delays). As a result, this
sample may not be representative of the larger popu-
lation of internationally adopted children. This study
is further limited by having assessed behavior prob-
lems and social competence using only parent-report.
Reliance on a single rater may inflate variance among
APPLIED NEUROPSYCHOLOGY: CHILD 9
measures, which may be related to rater bias
(Holmbeck, Li, Schurman, Friedman, & Coakley,
2002). A more comprehensive assessment of behavior
problems and social functioning would be obtained
by using observational measures and standardized
measures from multiple raters, including teacher-
and self-report. This study assessed structural language
and pragmatic communication by parent report. As
noted above, this method may have the advantage of
offering information about abilities as they present in
everyday occurring situations, which may be parti-
cularly important in view of findings indicating that
pragmatic communication may be better on
performance-based measures than in real-world social
situations (Volden et al., 2009). However, a more
comprehensive assessment of structural language
and pragmatic communication would be obtained by
using multiple methods, including standardized ques-
tionnaires from multiple raters and observational
and performance-based measures. As an additional
consideration, this study used a cross-sectional
design. Therefore, we can only document functioning
at a single time point and cannot make conclusions
about development and long-term maintenance of
problems. Finally, only girls were included in this
sample in an effort to reduce heterogeneity. Other
authors have found that internationally adopted boys
have more behavior problems than girls (Groza
et al., 2003; Stevens et al., 2008). Patterns of findings
may have been different if this study had included boys
and girls.
These findings further our knowledge about factors
that are associated with behavior problems and social
functioning in internationally adopted children with a
history of institutionalization. This study has the
advantage of using a comparison group of peers without
a history of institutionalization that was well-matched
on key post-adoption demographic variables. As an
additional strength, this study controlled for general
intellectual functioning, thereby demonstrating that
pragmatic communication is associated with behavior
problems and social competence above that accounted
for by intellectual ability. In view of these findings, there
is a need for longitudinal research that uses multiple
assessment methods to better understand the inter-
relationship of pragmatic communication, behavior
problems, and social functioning over time. Future
investigations may also seek to develop interventions
that are tailored to meet the specific needs of inter-
nationally adopted children and their families. This
may include programs that target weaknesses in
pragmatic communication and support post-adoption
behavioral and social adjustment.
 10 C. L. PETRANOVICH ET AL.
Acknowledgments
The authors wish to acknowledge the International Adoption
Center at Cincinnati Children’s Hospital Medical Center for
assistance with participant recruitment and financial support.
We also wish to acknowledge Holly MacPherson, Karen
Oberjohn, Jennifer Taylor, and Julia Smith for assistance with
participant recruitment, data collection, and data entry.
Funding
Funding was provided by the University of Cincinnati, Uni-
versity Research Council Interdisciplinary Grant. The authors
have no conflicts of interest to disclose.
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