Caregiver ratings of executive functions among foster children in middle childhood: Associations with early adversity and school adjustment
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
References (72)
- et al.
Mental health need and access to mental health services by youths involved with child welfare: A national survey
Journal of the American Academy of Child & Adolescent Psychiatry
(2004) - et al.
The unique impact of out-of-home placement and the mediating effects of child maltreatment and homelessness on early school success
Children and Youth Services Review
(2007) - et al.
Longitudinal study of self-regulation, positive parenting, and adjustment problems among physically abused children
Child Abuse and Neglect
(2012) - et al.
Cognitive flexibility and theory of mind outcomes among foster children: Preschool follow-up results of a randomized clinical trial
Journal of Adolescent Health
(2012) - et al.
The brain on stress: Vulnerability and plasticity of the prefrontal cortex over the life course
Neuron
(2013) - et al.
Neglect as a violation of species-expectant experience: Neurodevelopmental consequences
Biological Psychiatry
(2017) - et al.
How do different aspects of self-regulation predict successful adaptation to school?
Journal of Experimental Child Psychology
(2012) - et al.
Children’s executive function in a CPS-involved sample: Effects of cumulative adversity and specific types of adversity
Children and Youth Services Review
(2016) - et al.
Adverse childhood experiences among children placed in and adopted from foster care: Evidence from a nationally representative survey
Child Abuse and Neglect
(2017) - et al.
Twenty years of foster care in Spain: Profiles, patterns and outcomes
Children and Youth Services Review
(2009)
Validity of the executive function theory of attention-deficit/hyperactivity disorder: A meta-analytic review
Biological Psychiatry
Predicting impairment in major life activities and occupational functioning in hyperactive children as adults: Self-reported executive function (EF) deficits versus EF tests
Developmental Neuropsychology
Defining child maltreatment: The interface between policy and research
Caregiver substance abuse among maltreated children placed in out-of-home care
Child Welfare
School readiness and self-regulation: A developmental psychobiological approach
Annual Review of Psychology
Relating effortful control, executive function, and false belief understanding to emerging math and literacy ability in kindergarten
Child Development
A bidirectional model of executive functions and self-regulation
Statistical power analysis for the behavioral sciences
How to deal with missing data. Conceptual overview and details for implementing two modern methods
Interventions shown to aid executive function development in children 4 to 12 years old
Science
Annual research review: Embracing not erasing contextual variability in children’s behavior - theory and utility in the selection and use of methods and informants in developmental psychopathology
Journal of Child Psychology and Psychiatry, and Allied Disciplines
Interventions for foster parents: Implications for developmental theory
Development and Psychopathology
The development of children ages 6 to 14
Future of Children
Caregiver ratings and performance-based indices of executive function among preschoolers with and without maltreatment experience
Child Neuropsychology
The combined effects of prenatal drug exposure and early adversity on neurobehavioral disinhibition in childhood and adolescence
Development and Psychopathology
A developmental psychopathology perspective on foster care research
Executive function in preschoolers: A review using an integrative framework
Psychological Bulletin
Cognitive development and culture
Behavior rating inventory of executive function
Child Neuropsychology
Executive function in the real world: BRIEF lessons from mark Ylvisaker
The Journal of Head Trauma Rehabilitation
Executive function deficits in children with fetal alcohol spectrum disorders (FASD) measured using the Cambridge Neuropsychological Tests Automated Battery (CANTAB)
Journal of Child Psychology and Psychiatry, and Allied Disciplines
Children with behaviour problems: The influence of social competence and social relations on problem stability, school achievement and peer acceptance across the first six years of school
Infant and Child Development
Polyvictimization and externalizing symptoms in foster care children: The moderating role of executive function
Journal of Trauma & Dissociation
Associations between early life adversity and executive function in children adopted internationally from orphanages
Proceedings of the National Academy of Sciences
Changes and challenges in 20 years of research into the development of executive functions
Infant and Child Development
I. Children in institutional care: Delayed development and resilience
Monographs of the Society for Research in Child Development
Cited by (11)
Resilience among children in foster care: Variability in adaptive functioning and associated factors
2024, Children and Youth Services ReviewAn executive function training programme to promote behavioural and emotional control of children and adolescents in foster care in Spain
2022, Trends in Neuroscience and EducationCitation Excerpt :Although seemingly contradictory, the fact that the minors reported more emotion regulation problems might indicate that the intervention helped them identify their own emotions and thus recognise the difficulties that the regulation of these emotions implies. Given the adverse situations these minors often have to face [11], it is also worth noting that the minors in this study reported having fewer post-traumatic symptoms, that could entail a threat to their physical or psychological integrity. This finding is particularly relevant since it appears that stressful situations have a negative impact on the perceived psychological well-being of adolescents, and the greater the number of critical changes they experience (e.g. the number of care homes or school changes the minor has been through), the more the perceived life satisfaction decreases [45].
Relationships between Depression and Executive Functioning in Adolescents: The Moderating Role of Unpredictable Home Environment
2022, Journal of Child and Family StudiesSpecific Educational Support Needs of Children in Non-Kinship Foster Care
2022, Revista Espanola de Orientacion y Psicopedagogia