The Clinical Neuropsychologist, 2015

Vol. 29, No. 5, 639–655, http://dx.doi.org/10.1080/13854046.2015.1070205

Intelligence, Attention, and Behavioral Outcomes in

Internationally Adopted Girls with a History of
Institutionalization

Christine L. Petranovich1,2, Nicolay Chertkoff Walz3,

Mary Allen Staat4,5, Chung-Yiu Peter Chiu1, and
Shari L. Wade2,5
1
Department of Psychology, The University of Cincinnati, Cincinnati, OH, USA
2
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Division of Physical Medicine and Rehabilitation, Cincinnati Children’s Hospital Medical

Center, Cincinnati, OH, USA
3
Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children’s Hospital
Medical Center, Cincinnati, OH, USA
4
Division of Infectious Disease, Cincinnati Children’s Hospital Medical Center, Cincinnati, OH,
USA
5
University of Cincinnati, College of Medicine, Cincinnati, OH, USA

Objective: The aim of this study was to investigate the association of neurocognitive functioning
with internalizing and externalizing problems and school and social competence in children
adopted internationally. Method: Participants included girls between the ages of 6–12 years who
were internationally adopted from China (n = 32) or Eastern Europe (n = 25) and a control
group of never-adopted girls (n = 25). Children completed the Vocabulary and Matrix Reasoning
subtests from the Wechsler Abbreviated Scale of Intelligence and the Score! and Sky Search
subtests from the Test of Everyday Attention for Children. Parents completed the Child Behavior
Checklist and the Home and Community Social Behavior Scales. Results: Compared to the con-
trols, the Eastern European group evidenced significantly more problems with externalizing
behaviors and school and social competence and poorer performance on measures of verbal
intelligence, perceptual reasoning, and auditory attention. More internalizing problems were
reported in the Chinese group compared to the controls. Using generalized linear regression,
interaction terms were examined to determine whether the associations of neurocognitive func-
tioning with behavior varied across groups. Eastern European group status was associated with
more externalizing problems and poorer school and social competence, irrespective of neu-
rocognitive test performance. In the Chinese group, poorer auditory attention was associated
with more problems with social competence. Conclusions: Neurocognitive functioning may be
related to behavior in children adopted internationally. Knowledge about neurocognitive
functioning may further our understanding of the impact of early institutionalization on post-
adoption behavior.

Keywords: Attention; Social competence; Childhood behavior problems.

Children adopted internationally are often exposed to a range of adverse early

experiences, including in utero substance exposure, malnutrition, neglect, and abuse
(O’Connor et al., 2003), lack of individualized care and attention (Gunnar, Bruce, &
Grotevant, 2000), and few opportunities to engage in activities that facilitate cognitive

Address correspondence to: Christine L. Petranovich, M.A., Department of Psychology, University of

Cincinnati, 1 Edwards Center, ML 0376 Cincinnati, OH, 45221, USA. E-mail: karvercl@mail.uc.edu
(Received 6 March 2015; accepted 2 July 2015)

© 2015 Taylor & Francis

 640 CHRISTINE L. PETRANOVICH ET AL.

development (Johnson, 2002), which may contribute to post-adoption problems with

behavior and social functioning (Gunnar et al., 2007). Results of a meta-analysis that
included children internationally adopted from multiple areas, including Eastern Europe
and Asia, indicated significantly more internalizing and externalizing problems com-
pared to never-adopted peers in the destination country (Juffer & van IJzendoorn,
2005). In a sample of children internationally adopted from China, most were in the
non-clinical range on a parent-report measure of behavior. There was, however, substan-
tial variability, particularly with regard to hyperactivity, aggression, and withdrawal
(Rojewski, Shapiro, & Shapiro, 2000). Problems with social competence, including
difficulties forming relationships with peers, have also been documented in school-aged
children adopted internationally from Eastern Europe (Colvert et al., 2008; Gunnar at
et al., 2007), Asia (predominately China and South Korea), and South America (Gunnar
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et al., 2007). Using parent-report and observational measures to examine social func-
tioning in children internationally adopted from Eastern Europe and Asia (predomi-
nately China and South Korea), Bruce, Tarullo, and Gunnar (2009) reported
disinhibited social behavior, atypical lack of social reserve, and indiscriminate
friendliness. With respect to school competence, results of a meta-analysis that included
children adopted from multiple areas indicated significant problems with school
performance compared to never-adopted peers in the destination country (van
IJzendoorn, Juffer, & Poelhuis, 2005). Dalen (2002) similarly documented poorer school
competence in children between the ages of 11–16 who were internationally adopted
from Columbia and Korea compared to never-adopted peers in the destination country.
It has been reported that Eastern European adoptees often experience more behav-
ioral and social difficulties compared to children adopted from other areas (Gunnar
et al., 2007). This may be related to greater pre-adoption adversity, including increased
risk of in utero substance exposure (Gunnar et al., 2007) and genetic factors that may
place the child at elevated risk for mental health disorders (Stevens et al., 2008).
Relative to children placed in institutionalized care in other areas, those adopted from
Eastern European institutions may have been exposed to particularly poor conditions,
including malnutrition, neglect, and lack of consistent and responsive caregivers
(Groark, Muhamedrahimov, Palmov, Nikiforova, & McCall, 2005). As an additional
consideration, motivation to place a child for adoption may have differed by area of ori-
gin in recent years. Many Eastern European families may have selected adoption
because of stressors that would have made child rearing difficult (e.g., fewer financial
resources, mental health issues in the biological family) while many Chinese families
may have chosen adoption because of governmental policies (e.g., China’s One-Child
Policy).
General cognitive ability is an area of identified weakness in children adopted
internationally. Children adopted internationally from multiple areas, including Eastern
Europe and Asia (predominately China and Korea), often underperform never-adopted
peers in the destination country (Bruce et al., 2009; van IJendoorn & Juffer, 2006;
Loman et al., 2009) and children internationally adopted from foster care (Loman et al.,
2009). In a study that examined cognitive development through 54 months of age in a
sample of Romanian children, those who remained in long-term institutionalized care
exhibited significantly poorer general cognitive ability compared to the control group of
never-adopted Romanian peers without a history of institutionalization and Romanian
 INTELLIGENCE, ATTENTION, AND BEHAVIORAL OUTCOMES 641

peers with a history of institutionalization that were subsequently adopted internation-

ally. The internationally adopted group had poorer abilities than the control group, sug-
gesting that although children adopted internationally fare better than peers who remain
in institutionalized care, performance is lower than same-culture peers without a history
of institutionalization (Nelson et al., 2007).
In typically developing children, general cognitive ability, particularly verbal
intelligence, has been associated with behavior (Ayduk, Rodriguez, Mischel, Shoda, &
Wright, 2007; McEachern & Snyder, 2012). However, few studies have examined this
relationship in children adopted internationally and the results were somewhat mixed.
In a sample of school-aged children who were internationally adopted from Eastern
Europe, general cognitive ability was inversely correlated with parent-reported exter-
nalizing problems (Miller, Chan, Tirella, & Perrin, 2009). Dalen (2002) reported that
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lower verbal intelligence was associated with poorer school competence in children
between the ages of 11–16 who were internationally adopted from Columbia and
Korea. In contrast, results of a meta-analysis indicated that general cognitive ability did
not account for differences in school competence compared to never-adopted peers in
the destination country (van IJzendoorn et al., 2005).
Attention is another area of weakness in children adopted internationally.
Parent-reported problems with attention have been documented in children adopted
from Eastern Europe (Gunnar et al., 2007; Miller, Chan, Tirella, & Perrin, 2009; Rutter,
Kreppner, & O’Connor, 2001) and Asia, predominately China and South Korea
(Gunnar et al., 2007). In a sample of eight-year old Romanian children, performance on
a measure of visual attention and inhibition was poorer in Romanian children who
remained in institutionalized care compared to children raised in Romanian foster care
and Romanian peers without a history of institutionalization (McDermott, Westerlund,
Zeanah, Nelson, & Fox, 2012). Other lines of research have found that school-aged
children adopted from Eastern Europe (Behen et al., 2009; Chugani et al., 2001; Loman
et al., 2013; Pollak et al., 2010) and Asia, predominately China and Korea (Loman
et al., 2013; Pollak et al., 2010), evidenced poorer visual sustained attention compared
to never-adopted peers in the destination country.
It has been posited that post-adoption difficulties with attention would be
expected to negatively impact behavior, particularly in environments that place high
demands on attention, such as school (McDermott et al., 2012). In support, Dalen
(2002) reported that problems with school competence were more severe in internation-
ally adopted children with more parent-reported symptoms of Attention Deficit/
Hyperactivity Disorder. Using neuropsychological measures, Bruce and colleagues
(2009) reported more disinhibited social behavior in children adopted internationally
compared to never-institutionalized controls. Duration of institutionalization predicted
parent-reported social functioning, although this relationship became non-significant
after controlling for visual attention. While these findings provide limited evidence to
suggest that attention and behavior are related in children adopted internationally, there
are no studies that have examined the associations of neurocognitive functioning with a
wide range of behavioral outcomes.
This study aimed to examine the relationship of neurocognitive functioning
(verbal intelligence, perceptual reasoning, and visual and auditory attention) with inter-
nalizing and externalizing problems and social and school competence in children
adopted internationally. We further aimed to determine whether the associations of
 642 CHRISTINE L. PETRANOVICH ET AL.

neurocognitive factors and behavior varied across groups. It was hypothesized that
compared to never-adopted controls, children adopted internationally would evidence
poorer performance on neurocognitive measures and more parent-reported internalizing
and externalizing problems and poorer school and social competence. It was also
expected that poorer performance on neurocognitive measures would be associated with
more internalizing and externalizing problems and poorer school and social
competence.

METHODS
Participants
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This study included a sample of girls that were adopted from Eastern Europe or
China and a comparison group of never-adopted, American-born controls. Females
from China and Eastern Europe were selected because these groups represented the
largest sources of children adopted internationally locally, nationally, and worldwide
during the study period (Juffer & van IJzendoorn, 2005). For all participants, eligibility
criteria included being between the ages of 6–12 years at the time of recruitment.
Exclusionary criteria included the presence of significant developmental delay or intel-
lectual disability (e.g., diagnosis of Intellectual Disability or IQ < 70). For adoptees,
additional inclusionary criteria included being between 6 and 48 months of age at
adoption and having spent at least six months in institutionalized care (e.g., orphanages,
baby homes, or hospitals). The latter was included to ensure that all children
experienced early institutionalization.
Demographic information is reported in Table 1. Groups were well matched for
age, family income, and primary caregiver education (all p > .45). The Eastern Euro-
pean group was older (in months) at the time of adoption compared to the Chinese
group (p = .005). Six (18.7%) children in the Chinese group and 12 (48.0%) in the
Eastern European had a history of school-based remedial services, compared to zero
controls. History of remediation was significantly higher in the Eastern European com-
pared to the Chinese group (χ2 = 5.55, p = .01) and the controls (χ2 = 15.78, p < .001)
and in the Chinese group compared to the controls (χ2 = 5.23, p = .02). None of the
Chinese adoptees or controls reported a history of grade retention, compared to three
(12.0%) in the Eastern European group (Eastern European versus Chinese group;
χ2 = 4.05, p = .04). One parent in the Chinese group (3.1%), four in the Eastern
European (16.0%), and one in the control group (4.0%) reported that their child had been
diagnosed with Attention Deficit/Hyperactivity Disorder (ADHD). Of these participants,
zero in the Chinese group, three in the Eastern European, and one control reported being
prescribed medication for the treatment of ADHD. The proportion of children with
diagnosed ADHD and prescription use did not differ between groups (p > .05).

Procedure
The study was approved by the Institutional Review Board at the study site.
Potentially eligible international adoptees were identified from records maintained by an
international adoption center at a medical center located in the Midwestern United States.
Control participants were recruited by word of mouth. Potentially eligible children were
 INTELLIGENCE, ATTENTION, AND BEHAVIORAL OUTCOMES 643

Table 1. Sample demographic characteristics, Mean (SD), [range]

Control Eastern European Chinese

N 25 25 32
Age at testing in years 8.89 (1.64) 8.60 (1.17) 8.44 (1.23)
[6.6–12.5] [7.0–12.0] [6.1–12.0]
Age at adoption in monthsc – 23.70 (10.38) 16.64 (6.84)
[8–42] [9–33]
Time since adoption in – 78.74 (19.91) 84.76 (15.71)
months [43–136] [55–128]
Two-parent household % (N) 100% (25) 88% (22) 84% (27)
Number of siblings 2.28 (1.72) 1.36 (1.15) 1.90 (2.68)
[0–7] [0–4] [0–15]
Primary caregiver education High school or High school or High school or
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GED = 4.0% GED = 8.0% GED = 6.2%

Some college = 16.0% Some college = 16.0% Some college = 6.2%
4-year degree = 16.0% 4-year degree = 36.0% 4-year degree = 46.9%
Graduate/professional Graduate/professional Graduate/professional
degree = 64.0% degree = 40.0% degree = 40.7%
Family income $30–$59,000 = 4.0% $30–$59,000 = 4.0% $30–$59,000 = 9.4%
$60–$79,000 = 4.0% $60–$79,000 = 8.0% $60–$79,000 = 18.7%
$80–$99,000 = 24.0% $80–$99,000 = 20.0% $80–$99,000 = 12.5%
>$100,000 = 68.0% >$100,000 = 68.0% >$100,000 = 59.4%
History of remedial school 0 (0%) 12 (48.0%) 6 (18.7%)
services N (%)a,b,c
History of grade retention N 0 (0%) 3 (12.0%) 0 (0%)
(%)c
WASI IQa,b,c 119.20 (13.44) 94.08 (13.34) 106.87 (13.28)
[97–142] [73–128] [83–133]
a
Significant difference between Control and Eastern European.
b
Significant difference between control and Chinese.
c
significant difference between Eastern European and Chinese.
Notes: GED = General Equivalency Diploma (GED); WASI = Wechsler Abbreviated Scale of Intelligence.

contacted by phone, mail, or email. Interested families were screened to ensure

that all eligibility requirements were met. At a study visit that was conducted at the
medical center, parents provided demographic information and completed standardized
behavioral ratings. Children were administered neurocognitive measures that assessed
verbal intelligence, perceptual reasoning, and auditory and visual attention. Total
participation time was approximately 1.5 h, and families were compensated for time and
travel.
Children were administered the Vocabulary and Matrix Reasoning subtests from
the Wechsler Abbreviated Scale of Intelligence (WASI; Psychological Corporation,
1999). Validation studies of the WASI have reported that these subtests provide reliable
estimates of the Verbal Intelligence and Perceptual Reasoning indices from the Wech-
sler Intelligence Scale for Children-III (Psychological Corporation, 1999). In a pediatric
sample, reliability was acceptable and ranged from .93 to .96 (Jeyakumar, Warriner,
Raval, & Ahmad, 2004). For this study, age-adjusted T scores were reported.
Children were also administered the Sky Search and Score! subtests from the Test
of Everyday Attention for Children (TEA-Ch; Manly, Robertson, Anderson, &
Nimmo-Smith, 1999). Sky Search assessed visual attention by requiring the examinee to
 644 CHRISTINE L. PETRANOVICH ET AL.

find matching objects in a picture and circle them quickly. After doing so, the examinee
completed a simplified motor speed version of the task. For Sky Search, we used
the attention score as the primary measure of performance. The attention score is
calculated by subtracting the motor task from the attention task, thus allowing for
assessment of attention that was free from the impact of motor speed. The Score!
subtest assessed auditory attention by requiring the examinee to count tones that were
presented at irregular intervals. For this subtest, the total accuracy score was used as the
primary measure of performance. The TEA-Ch has been shown to be valid for the
assessment of attention in children with acceptable levels of reliability (.90 for Sky
Search and .64 for Score!; Manly et al., 2001). For this study, age-adjusted scaled scores
were reported.
Parents completed the Child Behavior Checklist (CBCL; Achenbach & Rescorla,
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2001), a parent rating of child behavior problems that is widely used in clinical and
research settings. For this study, we used the Internalizing and Externalizing Problems and
School Competence subscales to assess functioning in these domains. For the Internalizing
and Externalizing subscales, higher scores represent more problems. For the School
Competence subscale, lower scores represent poorer competence. Prior research has
demonstrated that the Internalizing, Externalizing, and School Competence subscales are
sensitive to problems in these areas with moderate long-term stability (Biederman et al.,
2001), high test-retest reliability (Achenbach & Rescorla, 2001), and acceptable reliability
(.77; Dutra, Campbell, & Westen, 2004). Scores are reported as age-adjusted T scores.
Parents also completed the Home and Community Social Behavior Scale
(HCSBS; Merrell & Caldarella, 2002). For this study, we used the Social Competence
subscale as a measure of social functioning in everyday occurring situations. On this
measure, lower scores represent poorer competence. The HCSBS has demonstrated
satisfactory validity and acceptable reliability (ranging from .94 to .98; Merrell &
Boelter, 2001). Scores are reported as age-adjusted T scores.

Statistical approach
Univariate statistics were used to examine the distribution of the data and to test
for normality. Means and standard deviations for demographic variables and neu-
rocognitive and behavioral measures were reported. Pearson’s correlations were used to
test the bivariate relationships. Analysis of co-variance, Bonferroni corrected, was used
to compare the groups (Eastern European, Chinese, controls) on neurocognitive and
parent-report measures. Given research suggesting that socioeconomic status influences
access to mental health services and performance on neurocognitive tests (Snell-Johns,
Mendez, & Smith, 2004), family income was used as a covariate. Cohen’s d was
reported as a measure of effect size (d = .20 indicating small effect size, .50 indicating
medium, .80 indicating large; see Cohen, 1988).
Given the demonstrated heterogeneity of post-adoption outcomes in children
adopted internationally (Colvert et al., 2008; Tottenham et al., 2010), group means may
not be sensitive to between-subjects variation and may fail to indicate if group
differences are clinically meaningful. Therefore, we also reported the proportion of par-
ticipants in each group that evidenced clinically significant elevations on parent-report
measures of behavior and social and school competence. A T score greater than or
 INTELLIGENCE, ATTENTION, AND BEHAVIORAL OUTCOMES 645

equal to 63 on the CBCL Internalizing and Externalizing Problems subscales and less
than or equal to 35 on the CBCL School Competence and HCSBS Social Competence
subscales was used to determine clinical significance. We also reported the proportion
of participants that evidenced scores that were in the borderline impaired/mildly
impaired range or below on neurocognitive measures (i.e., ≤37 for T scores or <6 for
scaled scores). Chi-square analyses were used to compare group differences in eleva-
tions on parent-report measures and rates of impairment on neurocognitive measures.
Using contrast terms for group (Chinese, Eastern European, or controls), general-
ized linear regression was used to examine the main effects of group, WASI Vocabu-
lary, WASI Matrix Reasoning, TEA-Ch Sky Search Attention, and TEA-Ch Score!
Accuracy on CBCL Internalizing and Externalizing Problems and School Competence
and HCSBS Social Competence. Group × neurocognitive interaction terms were
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included to determine whether the associations of neurocognitive functioning with

behavior differed by group. Using manual backwards elimination, non-significant
interactions were eliminated and the models were re-estimated before eliminating non-
significant main effects (p > .05). Main effects of group and family income were
retained even if non-significant. Use of manual backwards elimination has been sug-
gested to increase the numerical stability and generalizability of results (Hegewald,
Pfahlberg, & Uter, 2003). For significant interactions, we reported estimated marginal
means, co-varying for the factors that were included in the final estimation of the
models. R2 was reported as a measure of effect size (R2 = .10 indicating small effect
size, .30 indicating medium, .50 indicating large; see Cohen, 1992).
Because the Eastern European and Chinese groups significantly differed in age at
adoption in months, we conducted an analysis that included only the internationally
adopted groups in which we re-calculated the final estimations of all models, controlling
for age at adoption.

RESULTS
Distributions and bivariate relationships
The following variables were normally distributed: TEA-Ch Sky Search Atten-
tion, TEA-Ch Score! Total Accuracy, WASI Vocabulary and Matrix Reasoning subtest,
CBCL Externalizing and Internalizing Problems and School Competence subscales, and
HCSBS Social Competence. Family income was found to be slightly negatively skewed
(skew = −1.04).
Pearson’s correlations are reported in Table 2. Relationships among the parent-re-
port measures ranged from −.30 (CBCL Internalizing Problems and HCSBS Social
Competence) to −.56 (CBCL Externalizing Behavior Problems and HCSBS Social
Competence). Among neurocognitive factors, correlations ranged from .14 (TEA-Ch
Sky Search Attention Score and WASI Vocabulary) to .40 (WASI Matrix Reasoning
and WASI Vocabulary). Correlations of parent-report measures with neurocognitive
measures ranged from −.004 (TEA-Ch Sky Search Attention and CBCL Internalizing
Problems) to .35 (WASI Vocabulary and HCSBS Social Competence).
To address the issue of whether measures of intelligence and attention predicted
behavior based on a common latent factor, partial correlations between the behavioral
measures and the Matrix Reasoning and Vocabulary subtests, controlling for TEA-Ch
 646 CHRISTINE L. PETRANOVICH ET AL.

Table 2. Bivariate correlations among neurocognitive factors and behavioral measures

TEA-Ch
Sky TEA-Ch WASI WASI CBCL CBCL CBCL HCSBS
Income Search Score! Vocabulary Matrix External Internal School Social

Income – −.07 −.13 .17 .22* −.18 −.21 −.007 −.12

TEA-Ch Sky – – .36** .14 .31** .10 −.004 .19 −.09
Search
TEA-Ch Score! – – – .32** .26* −.19 −.02 .35** .16
WASI Vocab – – – – .40** −.30** −.16 .50** .46**
WASI Matrix – – – – – −.33** −.20 .55** .19
CBCL External – – – – – – .45** −.49** −.56**
CBCL Internal – – – – – – – −.34** −.30**
CBCL School – – – – – – – – .52**
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Notes: *Correlation significant at .05 level.

**Correlation significant at .001 level.
WASI = Wechsler Abbreviated Scale of Intelligence; TEA-Ch = Test of Everyday Attention for Children;
CBCL = Child Behavior Checklist; HCSBC = Home and Community Social Behavior Scale.

Sky Search and Score!, were calculated. Partial correlations between the behavioral
measures and the TEA-CH Sky Search and Score! subtests, controlling for WASI
Vocabulary and Matrix Reasoning, were also calculated. The pattern of the partial
correlations was generally consistent with that of the bivariate correlations (all
correlation coefficients changed less than .06), providing support for consideration of
intelligence and attention as separate predictors of behavior.

Mean comparisons
Means, standard deviation, ranges of scores, and impairment rates are reported in
Table 3. On CBCL Externalizing, the Eastern European group reported more problems
compared to the Chinese group (mean difference = 7.24, p = .02, d = .66) and the con-
trols (mean difference = 8.70, p = .007, d = .93). Rates of clinically significant problems
were higher in the Eastern European compared to the Chinese groups (χ2 = 4.24,
p = .03). Compared to the controls, the Chinese group evidenced more problems on
CBCL Internalizing (mean difference = 7.07, p = .02, d = .78) and a higher rate of clini-
cally significant problems (χ2 = 5.23, p = .02). On CBCL School Competence, the
Eastern European group reported poorer competence compared to the controls (mean
difference = 12.14, p < .001, d = 1.62) and the Chinese group (mean difference = 9.16,
p < .001, d = −1.17). The Eastern European group had a higher rate of impairment
compared to the Chinese group (χ2 = 14.10, p < .001) and the controls (χ2 = 14.10,
p < .001). The Eastern European group reported poorer competence on HCSBS Social
Competence compared to the controls (mean difference = 8.19, p = .001, d = 1.52).
Groups did not significantly differ in rates of impairment.
Considering WASI Vocabulary, the Eastern European group underperformed the
controls (mean difference = 16.10, p < .001, d = 1.68) and the Chinese group (mean
difference = 6.32, p = .001, d = .91). The Chinese group underperformed the controls
(mean difference = 6.32, p = .05, d = .70). Rates of impairment were higher in the
 INTELLIGENCE, ATTENTION, AND BEHAVIORAL OUTCOMES 647

Table 3. Neurobehavioral data and impairment rates

Control Eastern European Chinese

b
CBCL Internalizing Mean (SD) 43.96 (7.72) 48.68 (9.22) 51.53 (11.24)
Problems (T score) Range 33–62 33–73 33–76
N (% impaired)b 0 (.0%) 1 (4.0%) 6 (18.7%)
CBCL Externalizing Mean (SD)a,c 45.44 (8.20) 54.40 (10.72) 47.43 (10.28)
Problems (T score) Range 34–64 34–81 34.70
N (% impaired)c 1 (4.0%) 5 (20.0%) 1 (3.1%)
CBCL School Competence Mean (SD)a,c 51.00 (5.18) 38.88 (10.04) 48.06 (6.76)
(T score) Range 38–55 26–55 32–55
N (% impaired)a,c 0 (.0%) 11 (44.0%) 1 (3.1%)
HCSBS Social Competence Mean (SD)a 58.52 (6.26) 50.48 (8.80) 55.68 (8.45)
(T score) Range 46–67 31–64 36–72
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N (% impaired) 0 (.0%) 2 (8.0%) 0 (.0%)

WASI Vocabulary (T score) Mean (SD)a,c 61.16 (9.04) 44.92 (10.25) 54.34 (10.37)
Range 44–79 27–72 30–73
N (% impaired)a 0 (.0%) 6 (24.0%) 2 (6.25%)
WASI Matrix Reasoning Mean (SD)a,c 60.20 (9.46) 47.28 (10.83) 53.37 (9.69)
(T score) Range 33–70 30–67 33–70
N (% impaired) 1 (4.0%) 4 (16.0%) 1 (3.1%)
TEA-Ch Sky Search Mean (SD) 9.16 (2.44) 7.08 (3.77) 8.03 (3.28)
Attention Score Range 4–13 1–15 2–18
(Scaled score) N (% impaired) 2 (8.0%) 7 (28.0%) 6 (18.7%)
TEA-Ch Score! Mean (SD)a,c 10.16 (2.93) 7.16 (3.67) 9.50 (2.99)
(Scaled score) Range 5–15 2–14 3–15
N (% impaired)a,c 1 (4.0%) 9 (36.0%) 3 (9.3%)
a
Significant difference between Control and Eastern European.
b
Significant difference between control and Chinese.
c
Significant difference between Eastern European and Chinese.
Notes: Mean group comparisons were Bonferroni corrected and controlled for family income; clinical
elevation for CBCL Internalizing and Externalizing subscales defined by T score ≥ 63; for CBCL School
Competence and HCSBS Social Competence T ≤ 35; for WASI subtests, T-score ≤37; for TEA-Ch subtests,
scaled score <6. WASI = Wechsler Abbreviated Scale of Intelligence; TEA-Ch = Test of Everyday Attention
for Children; CBCL = Child Behavior Checklist; HCSBC = Home and Community Social Behavior Scale.

Eastern European groups compared to the controls (χ2 = 6.81, p = .009). On WASI
Matrix Reasoning, the Eastern European group underperformed the controls (mean dif-
ference = 12.62, p < .001, d = 1.27) and the Chinese group (mean difference = 6.43,
p = .04, d = .59). On TEA-Ch Score!, the Eastern European group underperformed the
Chinese group (mean difference = 2.70, p = .02; d = .69) and the controls (mean differ-
ence = 3.06, p = .003; d = .90). Impairment rates were higher in the Eastern European
group compared to the controls (χ2 = 8.00, p = .005) and the Chinese group (χ2 = 5.98,
p = .01).

Relationship of neurocognitive and behavioral measures

With CBCL Externalizing as the dependent measure, there was a significant
interaction of group and TEA-Ch Sky Search Attention. Post hoc tests revealed that
TEA-Ch Sky Search was associated with CBCL Externalizing within the control group
(p = .02). Higher TEA-Ch Sky Search was associated with higher CBCL Externalizing
 648 CHRISTINE L. PETRANOVICH ET AL.
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CBCL School Competence

60

55

50

45

40

35

30
Control, higher Control, lower Sky Eastern Euorpean, Eastern European, Chinese, higher Chinese, lower
Sky Search Search higher Sky Search lower Sky Search Sky Search Sky Search

Figure 1. Estimated marginal means for significant interactions.

Note: Higher denotes scores that are above the group mean; lower denotes scores that are below
the group mean.
CBCL = Child Behavior Checklist; HCSBC = Home and Community Social Behavior Scale.
 INTELLIGENCE, ATTENTION, AND BEHAVIORAL OUTCOMES 649

Table 4. Trimmed linear regression models examining the association of neurocognitive and behavioral
measures

Variable β SE Std β t p

CBCL externalizing problems

Group 11.24 4.05 .90 2.77 .007*
Family income −.38 .45 −.09 −.84 .40
TEA-Ch Score! −.83 .34 −.26 −2.41 .01*
TEA-Ch Sky Search 3.22 .88 1.00 3.64 .001**
WASI Matrix Reasoning −.29 .11 −.30 −2.68 .009*
Group × Sky Search −1.28 .44 −1.25 −2.88 .005*
R2 .28**
CBCL Internalizing Problems
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Group −3.50 1.27 −.29 −2.74 .008*

Family income −.72 .43 −.17 −1.65 .10
R2 .12*
CBCL School Competence
Group −6.66 2.98 −.64 −2.23 .02*
Family income −.65 .33 −.18 −1.98 .051
WASI Matrix Reasoning .33 .08 .41 3.99 <.001**
WASI Vocabulary .29 .07 .38 3.90 <.001**
TEA-Ch Sky Search −1.22 .64 −.45 −1.91 .059
Group × Sky Search .69 .32 .81 2.13 .03*
R2 .44**
HCSBS Social Competence
Group −6.75 3.41 −.66 −1.97 .052
Family income −.81 .34 −.23 −2.35 .02*
WASI Vocabulary .36 .07 .50 4.78 <.001**
TEA-Ch Score! −1.48 .69 −.59 −2.13 .03*
Group × Score! .72 .33 .94 2.18 .03*
R2 .30**

Notes: Group = China, Eastern Europe, or control.

*p < .05.
**p < .001.
WASI = Wechsler Abbreviated Scale of Intelligence; TEA-Ch = Test of Everyday Attention for Children;
CBCL = Child Behavior Checklist; HCSBC = Home and Community Social Behavior Scale.

(more problems). Eastern European group status was associated with higher CBCL
Externalizing compared to the Chinese group and the controls. See Figure 1. In addition
to this interaction, there were significant main effects of TEA-Ch Score! and WASI
Matrix Reasoning (R2 = .28). See Table 4. Poorer neurocognitive test performance was
associated with higher CBCL Externalizing.
Considering CBCL Internalizing, there was a significant main effect of group
(R2 = .12). See Table 4. Chinese group status was associated with higher CBCL Inter-
nalizing (more problems). No other factors were significant.
With CBCL School Competence as the dependent measure, there was a significant
interaction of group and TEA-Ch Sky Search. Poorer TEA-Ch Sky Search performance
was associated with lower CBCL School Competence (poorer competence) within the
control group (p = .008). The association approached significance in the Chinese group
(p = .055). Eastern European group status was associated with poorer ratings of school
competence compared to the Chinese group and the controls. See Figure 1. In addition to
 650 CHRISTINE L. PETRANOVICH ET AL.

this interaction, there were significant main effects of WASI Matrix Reasoning and
Vocabulary (R2 = .44). See Table 4. Lower income and poorer neurocognitive test
performance were associated with poorer school competence.
Considering HCSBS Social Competence, there was a significant interaction of
group and TEA-Ch Score! Within the Chinese group, TEA-Ch Score! was associated
with HCSBS Social Competence (p = .004). Lower TEA-Ch Score! corresponded with
lower HCSBS Social Competence (poorer competence). Eastern European group status
was associated lower ratings of social competence. See Figure 1. There were also sig-
nificant main effects of family income and WASI Vocabulary (R2 = .30). See Table 4.
Higher income and poorer neurocognitive test performance were associated with lower
HCSBS Social Competence.
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The association of age at adoption

In the analysis that included only the internationally adopted groups, age at
adoption was a non-significant predictor for all dependent measures (all p > .11).

DISCUSSION
This study aimed to examine the relationship of neurocognitive functioning
(verbal intelligence, perceptual reasoning, and visual and auditory attention) with inter-
nalizing and externalizing problems and school and social competence in internationally
adopted children with a history of institutionalization. Consistent with study hypotheses,
the Eastern European group evidenced more problems with externalizing behaviors and
school and social competence and poorer performance on measures of verbal intelli-
gence, perceptual reasoning, and auditory attention compared to the control and the
Chinese groups. For many domains of functioning, the Eastern European group
included a significantly larger proportion of participants with clinically significant
behavioral issues and neurocognitive test performance that was in the borderline
impaired/mildly impaired range or below. These findings are consistent with prior stud-
ies that have reported that children adopted from Eastern Europe often experience more
post-adoption difficulties compared to peers in the destination country (Gunnar et al.,
2007; van IJendoorn & Juffer, 2006). Relative to the controls, the Chinese group
reported significantly more internalizing problems and higher rates of clinically signifi-
cant issues. This finding may be congruent with prior research that has reported more
internalizing problems, including withdrawal, in children adopted from China compared
to never-adopted peers in the destination country (Rojewski et al., 2000). However,
compared to United States norms, the rate of clinically significant internalizing prob-
lems was within the expected range in the Chinese group and lower than expected in
the control group (Achenbach & Rescorla, 2001). Lower than the expected rate of clini-
cally significant problems in the controls may have inflated the appearance of problems
in the Chinese group. When considering these findings, it is notable that higher family
socio-economic status has been associated with fewer childhood behavior problems
(Bradley & Corwyn, 2002). Because the participants in this study were of higher family
socio-economic status, fewer behavior problems relative to United States norms may be
expected.
 INTELLIGENCE, ATTENTION, AND BEHAVIORAL OUTCOMES 651

It was also hypothesized that poorer neurocognitive test performance would be

associated with more parent-reported internalizing and externalizing problems and poorer
school and social competence. In support, poorer auditory attention was associated with
more problems with social competence in the Chinese group. Although Eastern European
group status was associated with more externalizing problems and poorer school and
social competence, behavioral ratings were not associated with neurocognitive perfor-
mance. Considered together, these findings suggest that in internationally adopted chil-
dren, the relationship between neurocognitive functioning and behavior is variable and
may differ by area of origin. Rather than simply the experience of institutionalization
itself, it may be that it is the range of pre-adoption adversity that contributes to risk for
negative post-adoption outcomes. As noted above, pre-adoption adversity may include
genetic factors that place the child at elevated risk for mental health disorders (Stevens
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et al., 2008) and increased risk of in utero substance exposure, the latter of which has
been shown to be more prevalent in children adopted from Eastern Europe compared to
other common areas of origin (Gunnar et al., 2007). Prenatal alcohol exposure has been
linked to impairments in attention and behavior similar to those observed in the Eastern
European group in this study (Mattson, Lang, & Calarco, 2002). Also noted above, chil-
dren adopted from Eastern Europe may have experienced particularly poor conditions in
the institutionalized setting (Groark et al., 2005), which would be expected to impact
development and psychosocial functioning (Gunnar et al., 2000).
With respect to general cognitive ability, poorer perceptual reasoning was related to
more externalizing problems and poorer school competence. Lower verbal intelligence
was significantly associated with poorer school and social competence. This is consistent
with findings from studies of typically developing children that suggested that better
developed verbal intelligence is associated with fewer behavior problems (Ayduk et al.,
2007). In theorizing about the relationship of general cognitive ability and behavior, bet-
ter developed perceptual reasoning abilities may allow the child to use problem-solving
and reasoning skills to generate effective behavioral solutions. Better developed verbal
abilities may help the child to articulate feelings and organize their environment.
The internationally adopted children that participated in this study were born in
non-English speaking areas, an issue that may be relevant when considering the validity
of English-based neurocognitive measures. However, in a study of children adopted
internationally from Eastern Europe during infancy and toddlerhood, the majority evi-
denced the development of English language skills that was similar to that of non-
adopted peers in their destination country (Glennen & Masters, 2002). This finding may
suggest that the participants in this study would be expected to have English language
skills that are similar to that of the control group. As an additional consideration, the
measures that were used in this study are based on normative samples that are culturally
different from the internationally adopted groups. In view of these issues, it cannot be
concluded that differences in language and culture did not influence these findings.
Previous authors have noted the difficulty of selecting an appropriate group for
comparison with international adoptees. While some research has similarly used a never-
institutionalized, never-adopted control group (Behen et al., 2009; Bruce et al., 2009;
Pollak et al., 2010; Tottenham et al., 2010), other lines of research have used groups of
domestically adopted children (Colvert et al., 2008; Stevens et al., 2008) and
internationally adopted children without a history of institutionalization (Bruce et al.,
2009; Loman et al., 2013; Pollak et al., 2010). The advantage of using the never-adopted,
 652 CHRISTINE L. PETRANOVICH ET AL.

never-institutionalized group is that it offers a comparison relative to peers in the

destination country (i.e., children raised in similarly enriched family environments). Its
use is limited because it is not possible to ascertain the role of institutionalization and
early deprivation itself and the proportion of observable differences that may be
attributable to cultural (e.g., linguistic differences, cultural norms) and family level (e.g.,
parenting style, caregiver attachment) factors. Additionally, we are unable to account for
pre-adoption adversity, such as trauma and degree of deprivation, which would be
expected to impact the severity of post-adoption problems. Given the nature of interna-
tional adoption, inconsistent knowledge of pre-adoption experiences is a limitation that is
inherent to research within this population (Gunnar et al., 2000).
Sample size is key limitation. With a larger sample, this study would have had
greater statistical power to detect group differences and patterns that were documented
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in this sample. There may also be potential issues with regard to sample selection.
Although the exclusionary criterion was designed to exclude children with significant
developmental delays or intellectual disability, it is possible that parents of children
with greater current difficulties were more likely to agree to participate. As an addi-
tional limitation, behavior was assessed using only parent-report. A more comprehen-
sive assessment of behavior and social functioning would be obtained by using
structured interviews, observational measures, and standardized measures from multiple
raters, including teacher- and self-report. This study design is further limited by use of
a cross-sectional rather than a longitudinal design. Therefore, we can only document
functioning at a single time point and cannot make conclusions about the development
and maintenance of problems. Longitudinal studies may be especially important in view
of evidence suggesting that problems with psychosocial functioning emerge with time
and may become especially problematic in adolescence (Colvert et al., 2008). Finally,
this study only included girls in an effort to reduce heterogeneity within the sample.
However, boys adopted internationally may tend to experience more problems with
attention, hyperactivity (Stevens et al., 2008), and aggression (Groza, Ryan, & Cash,
2003) compared to girls. Patterns of findings may have been different if this study had
included both boys and girls. In view of these limitations, additional research is needed
that more comprehensively examines longitudinal neurocognitive functioning and
behavior following international adoption.
In conclusion, these results demonstrate that children adopted internationally may
experience weaknesses in verbal intelligence, perceptual reasoning, and visual and
auditory attention that may be associated with internalizing and externalizing problems
and school and social competence. These findings contribute to our understanding of
neurocognitive functioning, behavior, and social functioning in children with a history
of early life institutionalization, offering professionals greater insight into the needs of
this population. In view of these findings, children adopted internationally may benefit
from early intervention services that target neurocognitive weaknesses, thereby support-
ing post-adoption behavioral adjustment.

ACKNOWLEDGMENTS
The authors wish to acknowledge the International Adoption Center at Cincinnati
Children’s Hospital Medical Center for assistance with participant recruitment and
 INTELLIGENCE, ATTENTION, AND BEHAVIORAL OUTCOMES 653

financial support and Holly MacPherson, Karen Oberjohn, Jennifer Taylor, and Julia
Smith for assistance with participant recruitment and data collection.

DISCLOSURE STATEMENT
No potential conflict of interest was reported by the authors.

FUNDING
This work was supported by The University of Cincinnati, University Research Council
Interdisciplinary Grant.
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