Caregiver ratings of executive functions among foster children in middle childhood: Associations with early adversity and school adjustment

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Highlights

  • The foster children presented executive function difficulties in most areas, especially in behavioral regulation.

  • 22% of the foster children presented executive functions difficulties of clinical significance.

  • Prenatal substance exposure was associated with a poorer capacity to plan and organize.

  • Difficulties in inhibitory control, shift, and working memory were related to poorer school adjustment.

  • Interventions aimed at enhancing executive functions could be useful for improving foster children's adaptation.

Abstract

Children in foster care often present difficulties related to executive functions, such as poor school adjustment and impulsivity. Despite their importance, few studies have analyzed executive functions in foster children, especially beyond preschool age. This study sought to analyze the executive functions of a sample of 43 Spanish foster children aged between five and nine years (M = 7.51, SD = 1.29), using a caregiver-reported questionnaire. We also explored the relationship between executive functions, early adversity variables, and teacher-reported school adjustment. Results indicate that participants experienced more executive function-related difficulties than the measure's standardization sample in almost all areas, particularly in behavioral regulation, although they were found to have age-appropriate executive function levels in some areas, such as monitoring and organization of materials. Prenatal substance exposure was associated with poorer planning/organization skills, whereas other early adversity variables showed no statistically significant associations with executive functions. A higher level of difficulty in inhibitory control and other areas were associated with poorer school adjustment as reported by teachers. The results of our study point to an important presence of executive function difficulties in foster children in middle childhood, a finding which highlights the need for early intervention efforts targeting these skills among this population.

Introduction

Family foster care is the preferred alternative care measure for children who must be removed from their birth family due to neglect or abuse, as it provides them with a family context conducive to their development (United Nations General Assembly, 2010). In Spain, residential care has traditionally been the predominant alternative care option, and it was only at the turn of the new millennium that foster care placements began to increase (Palacios & Amorós, 2006). According to Spanish child welfare statistics, 58% of all children in care in the country are placed in foster families (Observatorio de la infancia, 2017; to know more about foster care practices in Spain, see the excellent review of del Valle, López, Montserrat, & Bravo, 2009).

Developing a foster care system which meets the needs of both children and families can be challenging, given that foster children are at risk for several difficulties, especially impulsivity, externalizing behaviors, and poor school adjustment (Burns et al., 2004; Fantuzzo & Perlman, 2007; Salas, Fuentes, Bernedo, & García-Martín, 2016). Deficits in executive functions (EFs), the cognitive skills that sustain self-regulation, may be at the core of these problems (Blair & Ursache, 2011; Willcutt, Doyle, Nigg, Faraone, & Pennington, 2005). Associations have consistently been found between EF deficits and exposure to adverse childhood events (which are common among this population), such as neglect, family violence, and prenatal substance exposure, among others (Fisher, Leve, Delker, Roos, & Cooper, 2016; McEwen & Morrison, 2013; McLaughlin, Sheridan, & Nelson, 2017; Pears & Fisher, 2005; Sheridan, Peverill, Finn, & McLaughlin, 2017).

Given the role of EFs as antecedents of adaptation and adjustment and the risk factors for EF development to which foster children are exposed, it would appear useful to analyze this area and related factors among that population. Since EFs are responsive to intervention, the knowledge gained may serve to guide targeted intervention efforts aimed at promoting foster children's adaptation and preventing further difficulties (Dozier, Albus, Fisher, & Sepulveda, 2002; McDermott et al., 2013).

Following this rationale, the present study analyzes the EFs of a sample of Spanish foster children in middle childhood, as well as the association between EFs and related predictor (early adversity) and outcome (school adjustment) variables.

EFs are higher-order cognitive processes essential for goal-oriented behavior and the self-regulation of attention, emotion, and behavior. They include several components, typically inhibitory control (being able to inhibit predominant responses to respond to situational demands), working memory (holding relevant information in mind and working with it), and cognitive flexibility (managing to change one's perspective about something; Blair & Ursache, 2011; Hughes, 2011).

EFs and related constructs measured in childhood predict an impressive range of later outcomes, including health, substance use, and criminal behavior (Moffitt et al., 2011; Ogilvie James, Stewart, Chan, & Shum, 2011). EFs also play a key role in school adjustment; they are necessary both for adapting to the changing rules and demands of the school environment (including successfully interacting with peers and teachers) and for the cognitive tasks involved in subjects like mathematics and literacy (Blair & Raver, 2015; Blair & Razza, 2007; McClelland et al., 2007; Neuenschwander, Röthlisberger, Cimeli, & Roebers, 2012).

Researchers have traditionally measured EFs in childhood with child-adapted laboratory tasks such as the Day-Night task, the Dimensional Change Card Sort, recall tasks, or computerized batteries (Garon, Bryson, & Smith, 2008; Hughes, 2011; Luciana & Nelson, 2002). Parent or teacher ratings of EFs have also been developed, with limited convergence with laboratory tasks but enhanced ecological validity given that they measure the application of EFs in daily activities at home and at school (Gioia, Kenworthy, & Isquith, 2010; Thorell, Veleiro, Siu, & Mohammadi, 2013). The consensus is that laboratory tasks and adult ratings of EFs measure different aspect of the same underlying construct, and previous research has shown that scores from both types of assessments can predict independent variance in ADHD symptoms or academic achievement (Gioia et al., 2010; Thorell et al., 2013; Toplak, West, & Stanovich, 2013).

Regarding EFs development, they start developing in infancy, show a marked improvement in the preschool years and continue to improve gradually throughout late childhood and adolescence (Hughes, 2011). The brain area which predominantly sustains EFs, the prefrontal cortex, shows a protracted development till late adolescence and is highly dependent on early experiences for its optimal development. If those early experiences are marked by adversity, deprivation of adequate stimulation, and continued stress, EFs and the capacity to self-regulate can be seriously hampered (McEwen & Morrison, 2013; McLaughlin et al., 2017).

Most children in foster care have been exposed to at least some early adverse experiences that are detrimental to EF development (Fisher et al., 2016). The following is a brief summary of the most important ones.

Prenatal exposure to drugs or alcohol is a proven risk factor for several conditions, including developmental delays in different areas and disrupted brain development. It seems that most substances, including cocaine, alcohol, and nicotine, strongly impact the development of the prefrontal cortex in prenatally exposed children, resulting in neurodevelopmental consequences such as attention and impulsivity problems and general EF impairment (Fisher et al., 2011; Green et al., 2009; Thompson, Levitt, & Stanwood, 2009). Despite the high prevalence of substance abuse problems among the birth parents of children in foster care (Besinger, Garland, Litrownik, & Landsverk, 1999; López, Montserrat, del Valle, & Bravo, 2010), few studies in the foster care literature have taken this factor into consideration, particularly in relation to EFs.

Child maltreatment predicts all kinds of negative outcomes, as well as general difficulties in self-regulation and EFs (Kim-Spoon, Haskett, Longo, & Nice, 2012; Rogosch, Cicchetti, & Aber, 1995). Although there is some empirical evidence pointing to a differential effect of different types of maltreatment (Sheridan et al., 2017), several studies have shown that cumulative exposure to multiple types of maltreatment (neglect, physical abuse, or emotional maltreatment) also predicts EFs and emotion regulation difficulties in children in preschool-age and middle childhood (Fay-Stammbach & Hawes, 2018; Kim & Cicchetti, 2009). These effects are likely due to the cumulative damage done by continued stressful experiences and the associated allostatic load on key brain areas for EFs (McEwen & Morrison, 2013).

Another known risk factor for EF development is institutional care. This kind of adversity entails a special type of structural neglect in which children are cared for by rotating caregivers and are deprived of continuous, stimulating interactions (van IJzendoorn et al., 2011). One of the most solid research findings with post-institutionalized adopted children is their long-term deficits in EFs, which are related to the length of institutionalization (Hostinar, Stellern, Schaefer, Carlson, & Gunnar, 2012; McDermott et al., 2013; Merz & McCall, 2011; Peñarrubia, 2015).

Less is known about the effects of less depriving residential care settings on EF development. Residential care facilities in countries with developed child welfare systems, as those in Spain, are much less depriving that the institutions where internationally adopted children spent their early years. Furthermore, unlike with most post-institutionalized adoptees, children in the Spanish child protection system enter residential care not as babies, but rather after years of family preservation services or multiple disruptions from care (López & Del Valle, 2015). To the best of our knowledge, the only study that has analyzed the EFs of pre-adolescent children in Spanish residential care centers found that they presented more problems than community controls in certain EFs, such as working memory and planning (Peñarrubia, 2015).

Another type of adversity experienced by children in alternative care is placement instability, with the frequent transitions between caregivers that this implies. A higher number of placement transitions has been associated with general EF deficits in a large sample of preschool-aged children within the child protection services (Roos, Kim, Schnabler, & Fisher, 2016), as well as with difficulties in inhibitory control in two samples of preschool-aged children in foster care (Pears, Bruce, Fisher, & Kim, 2010) and adopted from care (Lewis, Dozier, Ackerman, & Sepulveda-Kozakowski, 2007).

In recent years there has been a very active stream of research on the EFs of internationally-adopted children coming from depriving institutions, especially from Eastern Europe. This line of research has provided remarkable insights into the effects of early severe deprivation on EF development, as outlined above (e.g., Hostinar et al., 2012; McDermott et al., 2013; Merz & McCall, 2011; Peñarrubia, 2015).

However, much less research has been carried out on the EFs of children in family foster care. Although both populations have suffered early adversity, post-institutionalized adoptees and foster children in Western societies differ in significant ways: children in foster care typically have not been exposed to the gross deprivation characteristic of institutions, although they may have suffered more active maltreatment (e.g., physical abuse, domestic violence) and for a longer time (Pears & Fisher, 2005; Wretham & Woolgar, 2017).

Most studies analyzing EFs among foster children are evaluations stemming from two intervention programs carried out in the USA with preschool-aged children in foster care. Based on instruments such as a child-adapted Stroop task and neuropsychological batteries, the results revealed that foster children performed worse than community controls in different areas, including cognitive flexibility and inhibitory control (Horn, Roos, Beauchamp, Flannery, & Fisher, 2017; Lewis-Morrarty, Dozier, Bernard, Terracciano, & Moore, 2012; Lind, Raby, Caron, Roben, & Dozier, 2017; Pears, Fisher, Bruce, Kim, & Yoerger, 2010). In one of these studies, EF performance was found to predict both academic and social-emotional competence at school, as reported by teachers (Pears, Fisher, et al., 2010).

Another study with children adopted from foster care in the UK also showed deficits in EFs as compared with the measures' standardization samples. Interestingly, this study involved children in middle childhood and used both performance measures of EFs and a caregiver-reported questionnaire, which provides a different yet complementary assessment of EFs (Wretham & Woolgar, 2017).

Caregiver ratings of EFs add a useful point of view especially with foster children for several reasons. Reports of phenomenology, i.e. how the impairment manifests in daily activities, are especially useful when the impairment in that area is relevant, as in foster children's EFs (Dirks, De Los Reyes, Briggs-Gowan, Cella, & Wakschlag, 2012). Children's difficulties in daily activities due to EF deficits represent one of the major challenges to foster carers (Octoman, McLean, & Sleep, 2014), and ratings are more likely to reflect those EF difficulties as manifested in daily activities than laboratory tests (Barkley & Fischer, 2011). Although caregiver ratings are certainly more vulnerable to informant biases and validity concerns, foster carers have been found to be reliable informants on the foster children under their care (Tarren-Sweeny, Hazell, & Carr, 2004), and caregiver-ratings of EFs have been used before with post-institutionalized and maltreated children of various ages demonstrating concurrent and construct validity with academic adjustment, early adversity exposure, or some EF performance-based measures (Fay-Stammbach & Hawes, 2018; Kim-Spoon et al., 2012; Merz & McCall, 2011).

The findings in relation to early adversity and EFs tend to be inconsistent. As mentioned above, while some studies reviewed above with preschool aged-children have found that factors such as number of placements predict poorer EFs (Pears, Bruce, et al., 2010), others report negative findings (e.g., no link between polyvictimization and EFs performance; Horn et al., 2017) or even paradoxical ones (e.g., more maltreatment types associated with better EFs; Pears & Fisher, 2005). According to some authors, this is likely due to methodological difficulties for measuring early adversity variables and/or to the fact of analyzing high-risk samples, in which almost all participants have been exposed to diverse types of adverse events (Roos et al., 2016).

In sum, the studies reviewed suggest that children in foster care in preschool-age do show deficits in EFs as measured by laboratory tasks. Although the results on early adversity and EFs are not completely consistent, certain aspects such as maltreatment, prenatal exposure to drugs, and, especially, caregiver changes, seem to be associated with worse EFs. However, studies on the EFs of foster children are still scarce. Most of them have focused on preschool-aged children from the USA, have used laboratory tests for measuring EFs, and do not include the most common types of adverse events at the same time but only some of them.

It is important to analyze the EFs of children in foster care in different Western societies to ascertain whether (as would be expected given their early adverse experiences and difficulties in areas related to EFs) they present EF difficulties that could be targeted by interventions. Furthermore, we know very little about EFs in this population in developmental stages other than the preschool period, such as middle childhood for instance, during which EFs continue to develop and new challenges appear (e.g., more demanding school tasks and the need to integrate in peer groups; Eccles, 1999; Hughes, 2011). The inclusion of different types of adverse events that negatively affect EF development could shed light on which factors are most closely associated with EF difficulties, considering the common co-occurrence of risk factors in this population (Turney & Wildeman, 2017). The use of caregiver-reported assessments of EFs may enhance our understanding of how the EF difficulties demonstrated in previous studies with performance-based measures manifest in daily life and activities, a highly valuable piece of information for intervention and support purposes.

Following these gaps in the literature, the primary goal of our study was to analyze the EFs of Spanish children in foster care aged between five and nine. Our secondary goal was to explore the association between EFs and other related variables.

In specific terms, the study had three aims: 1) to analyze caregiver-reported EFs in a sample of foster children in comparison with a standardization sample of low-risk children; 2) to explore the associations between relevant early adversity variables (prenatal substance exposure, maltreatment, residential care placement, and frequent caregiver transitions) and EFs after controlling for relevant covariates; and 3) to examine correlations between EFs and teacher-reported school adjustment.

Based on previous findings, we hypothesized that foster children would present more EF difficulties than the standardization sample of low-risk children. The analyses of early adversity and EFs were largely exploratory, although given previous findings, we expected prenatal substance exposure, frequent caregiver transitions, and maltreatment to be associated with more EF difficulties. We also hypothesized that poorer EFs would correlate with worse school adjustment.

Section snippets

Participants

The final sample for this study comprised 43 foster children (18 boys, 41.9%) aged between five and nine years at assessment (M = 90.16 months, SD = 15.59), placed in 40 foster families. Their age of entry into care ranged from zero to 93 months (M = 46.19, SD = 24.84) and they had all been between five and 106 months in their current foster placement (M = 28.72, SD = 25.48). All participants except two had lived with their biological family prior to their entry into care from two to 93 months (

Description of EFs in foster children

Table 1 shows foster children's mean T scores on the different BRIEF scales. Their mean scores were higher (indicating more EF difficulties) than the standardization community sample's mean of 50 in the global executive composite, the behavioral regulation index and the metacognition index, as well as on the inhibit, shift, initiate, working memory, and plan/organize subscales.

Large effect sizes in the means comparisons were found in the initiate, working memory and, especially, the shift

Discussion

Our primary goal in this study was to analyze the EFs of Spanish foster children aged between five and nine years, as reported by caregivers. We also sought to explore the associations between EFs and other related elements, namely early adversity and school adjustment.

As expected, the foster children in our sample were found to have more EF difficulties in everyday behavior than the controls (community children in the standardization sample), especially in relation to behavioral regulation.

Declaration of Competing Interest

None.

Acknowledgements

This study forms part of a broader project entitled “Foster care as a challenge for the Child Protection System”, carried out in collaboration with the Andalusian Regional Government and the foster care agencies “Márgenes y Vínculos” and “Aproni”. We thank the foster families, children, caseworkers and teachers who have altruistically participated in this study. We also thank Simon Kinch for his assistance in reviewing the English language usage. This research did not receive any specific grant

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