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Cited by 66Attention Deficit Hyperactivity DisorderChild Welfare and AdoptionChild Abuse and Trauma

Disruptions of working memory and inhibition mediate the association between exposure to institutionalization and symptoms of attention deficit hyperactivity disorder

Open access
Tibu, F., Sheridan, M. A., McLaughlin, K. A., Nelson, C. A., Fox, N. A., Zeanah, C. H.·2016·Psychological Medicine
DOI 10.1017/s0033291715002020PMC PMC4739820
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Abstract

Background: Young children raised in institutions are exposed to extreme psychosocial deprivation that is associated with elevated risk for psychopathology and other adverse developmental outcomes. The prevalence of attention deficit hyperactivity disorder (ADHD) is particularly high in previously institutionalized children, yet the mechanisms underlying this association are poorly understood. We investigated whether deficits in executive functioning (EF) explain the link between institutionalization and ADHD. Method: A sample of 136 children (aged 6–30 months) was recruited from institutions in Bucharest, Romania, and 72 never institutionalized community children matched for age and gender were recruited through general practitioners’ offices. At 8 years of age, children's performance on a number of EF components (working memory, response inhibition and planning) was evaluated. Teachers completed the Health and Behavior Questionnaire, which assesses two core features of ADHD, inattention and impulsivity. Results: Children with history of institutionalization had higher inattention and impulsivity than community controls, and exhibited worse performance on working memory, response inhibition and planning tasks. Lower performances on working memory and response inhibition, but not planning, partially mediated the association between early institutionalization and inattention and impulsivity symptom scales at age 8 years. Conclusions: Institutionalization was associated with decreased EF performance and increased ADHD symptoms. Deficits in working memory and response inhibition were specific mechanisms leading to ADHD in previously institutionalized children. These findings suggest that interventions that foster the development of EF might reduce risk for psychiatric problems in children exposed to early deprivation.

Integrity signals

Registry

Crossref · 10.1017/s0033291715002020

Cites

55 of 55 references verified0 citation errors · 0 not checkable

Statistics

Nothing to recompute.

Claims the paper makes

0 of 31 cited sources checked · 0 supported · 0 flagged

  • Findingown data

    Impulsivity was not associated with PAL stages completed on first trial.

    “No association was observed between impulsivity and PAL stages completed on first trial.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Institutionalized children had significantly higher impulsivity scores than community controls.

    “Children with history of institutionalization had significantly higher inattention (F1,193 = 49.01, p < 0.001), and impulsivity (F1,192 = 32.87, p < 0.001), than the community controls (Table 2).”
    Quote in the paperSubstantial claim
  • Findingown data

    Institutionalized children had significantly higher inattention scores than community controls.

    “Children with history of institutionalization had significantly higher inattention (F1,193 = 49.01, p < 0.001), and impulsivity (F1,192 = 32.87, p < 0.001), than the community controls (Table 2).”
    Quote in the paperSubstantial claim
  • Findingown data

    Impulsivity correlated with the number of SOC problems solved in minimum moves.

    “and the number of SOC problems solved in minimum moves.”
    Quote in the paperNot a substantial claim
  • Findingown data

    Impulsivity showed a marginal association with accuracy on the longest delay DMS trials.

    “and a marginally significant association between impulsivity and accuracy in the longest delay trials of the DMS.”
    Quote in the paperNot a substantial claim
  • May combine two claims. 14
  • Classified as probably not a substantial claim. 14

  • May combine two claims.

    Findingown data

    Children exposed to institutional rearing performed significantly worse than never institutionalized children on multiple executive functioning measures, including DMS, PAL, SWM, Flanker, and SOC tasks.

    “Results are presented in Table 3 and show that children in the EIG performed significantly more poorly than NIG children on multiple dimensions of executive functioning as measured by our CANTAB battery and the Flanker task.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Foster care did not show an intervention effect on ADHD symptoms or any EF measure.

    “Consistent with our previous reports, we did not observe an intervention effect of foster care on symptoms of ADHD (t94 = 1.13, p = 0.26 for inattention; t93 = −0.07, p = 0.94 for impulsivity) or any of the EF indices (their corresponding p values ranged from 0.38 to 0.80) in this sample.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Institutionalization was associated with higher scores on both internalizing and externalizing symptom scales of the HBQ.

    “Institutionalization was indeed associated with elevations in both of these scale scores on the HBQ (details not presented but available upon request).”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    The association between early institutionalization and ADHD symptoms was partially explained by working memory deficits for both inattention and impulsivity, and by response inhibition deficits for impulsivity only, but not by planning ability.

    “The association between early institutionalization and ADHD symptoms was partially explained by deficits in working memory (for both inattention and impulsivity) and response inhibition (for impulsivity only), but was not accounted for by planning ability.”
    • Also stated in: § Discussion · plain
      “This study identified working memory and response inhibition as partial mediators of the association between institutional rearing and ADHD symptoms at 8 years of age in children who were exposed to severe psychosocial deprivation in orphanages in Romania.”
    • Also stated in: § Discussion · plain
      “Second, our finding that the association between institutional rearing and ADHD was mediated specifically by working memory and inhibition, but not by planning”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    ADHD symptoms at age 41⁄2 years were assessed in the BEIP using a parent-reported interview, and no associations were observed between earlier ADHD symptoms and EF at age 8 years.

    “However, ADHD symptoms at age 4½ years were assessed in the BEIP using a parent-reported interview, and we observed no associations between earlier ADHD symptoms and EF at age 8 years.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Findingown data

    Previously institutionalized children performed reasonably well at maintaining a stimulus in working memory for short periods, but maintaining this representation over time was more challenging for them.

    “Although previously institutionalized children performed reasonably well at maintaining a stimulus in working memory for short periods of time, maintaining this representation over time was more challenging for them”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Premisecitation

    Earlier reports from this sample found that previously institutionalized children had more inattention and impulsivity symptoms and poorer working memory and inhibition performance.

    “Previous reports on these data showed that the children with history of institutional rearing had increased inattention and impulsivity symptoms (McLaughlin et al. 2014) and decreased performance on working memory (Bos et al. 2009) and inhibition (McDermott et al. 2013).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites McLaughlin et al. 2014

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    • cites Bos et al. 2009

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    • cites McDermott et al. 2013

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  • May combine two claims.

    Interpretationcitation

    The association between institutionalization and ADHD symptoms found here is consistent with results from several other studies and with earlier BEIP assessments.

    “The association between institutionalization and symptoms of ADHD observed here are consistent with results from a number of other studies (e.g. Kreppner et al. 2001; Stevens et al. 2008; Wiik et al. 2011), as well as our own work in the BEIP when the children were assessed at earlier ages (Zeanah et al. 2009).”
    Quote in the paperNot a substantial claim0 of 3 sources checked
    • cites Kreppner et al. 2001

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    • cites Stevens et al. 2008

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    • cites Wiik et al. 2011

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    All analyses adjusted for age and gender.

    “Age and gender were included as covariates in all analyses, and statistical significance was evaluated at the 0.05 level, using two-sided tests.”
    Quote in the paperNot a substantial claim

  • May combine two claims.

    Study design and conductcitation

    The HBQ has shown good reliability and both convergent and discriminant validity.

    “The HBQ has been used extensively with children of preschool age to adolescence, and has demonstrated good reliability and convergent and discriminant validity (Essex et al. 2002; Lemery-Chalfant et al. 2007).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Essex et al. 2002

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    • cites Lemery-Chalfant et al. 2007

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  • Classified as probably not a substantial claim.

    Premisecitation

    Prior studies of previously institutionalized children have found poorer performance on executive function tasks.

    “Consistent with this hypothesis, poorer performance on EF tasks has been observed in prior studies of previously institutionalized children (e.g. Colvert et al. 2008; Pollak et al. 2010; Merz & McCall, 2011; Hostinar et al. 2012; Merz et al. 2013).”
    Quote in the paperSubstantial claim0 of 3 sources checked
    • cites Colvert et al. 2008

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    • cites Pollak et al. 2010

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    • cites Merz & McCall, 2011

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductown data

    Twenty-nine previously institutionalized children were lost to follow-up.

    “A total of 29 previously institutionalized children (17 from CAUG, 12 from FCG) were lost to follow-up (the main reasons for attrition were lost contact and refusal to participate).”
    Quote in the paperNot a substantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductcitation

    The CANTAB has been extensively validated in school-age children and distinguishes well between clinical and typical populations.

    “The CANTAB has been validated extensively on samples of school-age children and has been found to discriminate well between clinical and standard populations (Luciana & Nelson, 2002).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Luciana & Nelson, 2002

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  • Probably not a substantial claim: may not pass S3 (load-bearing). May combine two claims.

    Study design and conductown data

    The groups had similar gender distributions but differed significantly in age at testing and ethnicity.

    “Descriptive data on demographic variables for the institutionalized and non-institutionalized children are presented in Table 1 and show equal gender distributions but significant differences in age of testing and ethnicity in the two groups.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Premisecitation

    Previous investigations in the BEIP and other samples of children adopted from Eastern Europe have identified several neurobiological factors that partially or fully mediate the association between institutionalization and ADHD.

    “Previous investigations in the BEIP and other samples of children adopted from Eastern Europe have identified several neurobiological factors that partially or fully mediate the association between institutionalization and the incidence of ADHD.”
    Quote in the paperSubstantial claim0 of 2 sources checked
    • cites McLaughlin et al. 2010a

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    • cites McLaughlin et al. 2014

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    In the BEIP sample, delayed cortical maturation (atypical EEG frequency band signals and reduced cortical thickness in multiple brain regions) has been found to partially mediate the link from early deprivation to ADHD at 41⁄2 and 8 years.

    “In our own sample, delayed cortical maturation manifesting in atypical EEG frequency band signals and reduced cortical thickness in multiple brain regions has been found to partially mediate the link from early deprivation to ADHD at 4½ and 8 years (McLaughlin et al. 2010a, 2014).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites McLaughlin et al. 2010a

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    • cites McLaughlin et al. 2014

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  • Classified as probably not a substantial claim.

    Interpretationreasoning

    The concurrent measurement means the findings could also reflect earlier-onset ADHD predicting disruptions in EF, rather than the reverse.

    “This suggests that our findings could also reflect earlier-onset ADHD predicting disruptions in EF, rather than the reverse.”
    Quote in the paperSubstantial claim

  • May combine two claims.

    Interpretationown data

    The current findings point to specific cognitive functions that link institutionalization to ADHD, but these are not common to other externalizing or internalizing psychopathology.

    “Our findings point to specific cognitive functions that link institutionalization to ADHD, but not common to other forms of externalizing psychopathology or to internalizing psychopathology.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    These findings are consistent with previous work showing that performance on the SWM sub-test, but not the planning subtest of the CANTAB, predicts symptom severity in adolescents with ADHD.

    “These findings are consistent with previous work that demonstrates that performance on the SWM sub-test, but not the planning subtest of the CANTAB predicts symptom severity in adolescents with ADHD (Coghill et al. 2014).”
    Quote in the paperNot a substantial claim0 of 1 sources checked
    • cites Coghill et al. 2014

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  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Study design and conductreasoning

    Psychopathology was assessed only using teacher questionnaires, whereas previous studies used psychiatric interviews and/or parental reports.

    “Second, psychopathology was only assessed using teacher questionnaires; previous studies have made use of psychiatric interviews and/or parental reports in obtaining child psychopathology data.”
    Quote in the paperNot a substantial claim

  • Classified as probably not a substantial claim.

    Interpretationown data

    This lack of association provides further support for the interpretations of the age-8 associations.

    “This provides further support for our interpretations of these associations at age 8 years.”
    Quote in the paperSubstantial claim

  • Classified as probably not a substantial claim.

    Study design and conductown data

    Our findings are based on EF and ADHD data collected at the same point in development, the first point that EF was assessed in the study.

    “First, our findings are based on EF and ADHD data collected at the same point in development, this first point that EF was assessed in the study.”
    Quote in the paperSubstantial claim

  • Probably not a substantial claim: may not pass S3 (load-bearing).

    Premisecitation

    Good response inhibition functions as an index of resilience following exposure to environmental adversities.

    “the finding that good response inhibition functions as an index of resilience following exposure to environmental adversities (Nigg et al. 2007; McDermott et al. 2013).”
    Quote in the paperNot a substantial claim0 of 2 sources checked
    • cites Nigg et al. 2007

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    • cites McDermott et al. 2013

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  • May combine two claims.

    Premisecitation

    Only one prior report (Colvert et al. 2008) tested mediation and suggested inhibition might mediate the link, but its analyses showed only a non-significant trend.

    “To best of our knowledge, only one report (i.e. Colvert et al. 2008) has tested mediation and suggested that inhibition might play a mediating role in this link, but the analyses showed only a trend that failed to attain statistical significance.”
    Quote in the paperSubstantial claim0 of 1 sources checked
    • cites Colvert et al. 2008

      Not checked in the free run.

  • Probably not a substantial claim: may not pass S2 (checkable), S3 (load-bearing). May combine two claims.

    Study design and conductnone given

    It is possible that symptoms observed at school are only part of the problematic behaviors shown in other environments, and other informants or diagnoses might reflect the problem more adequately.

    “Nevertheless, it is possible that symptoms observed at school are only part of the problematic behaviors shown in other environments, and that other informants and/or the use of diagnoses might reflect more adequately the manifestations of the problem.”
    Quote in the paperNot a substantial claim
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  • The paper relies on this without support.

    The pathways connecting institutionalization to ADHD are not well understood.

    “Yet the mechanisms that mediate the link between institutionalization and elevated risk for ADHD are poorly understood.”

  • The paper relies on this without support.

    The mediation model correctly assumes that institutionalization influences EF, which then influences ADHD.

    “we predicted that elevations in ADHD symptoms in the institutionalized children would be mediated by differences in EF abilities.”

  • The paper relies on this without support.

    No confounders other than age and gender affect the relationships among institutionalization, EF, and ADHD.

    “Age and gender were included as covariates in all analyses”

  • The paper relies on this without support.

    The mediation model is not confounded by unmeasured factors (e.g., prenatal, genetic, medical, socioeconomic) that could explain the link between institutionalization, executive function, and ADHD.

    “Finally, we were not able to account for the possible influence of other factors (e.g. prenatal, genetic risks, or medical illnesses during the gestational or early infancy periods, and socioeconomic status) that might have played a direct or interactive role in the link between early deprivation and ADHD”
4 of 4

Claims other papers make about this one

Each is checked against this paper’s own text: does it say what the citing paper says it does?

  • Children raised in institutions exhibit poor performance on tests of working memory, inhibition, planning, sustained attention, and cognitive flexibility.

    “Children raised in institutions exhibit poor performance on tests of working memory, inhibition, planning, sustained attention, and cognitive flexibility(98, 109, 121–127)”

    From Neglect as a violation of species-expectant experience: neurodevelopmental consequences (2017) · cites this paper as [121]

Self-check

Percentages, sums and reported differences re-computed from the paper’s own numbers.

Each contradiction between two passages listed here was confirmed by an independent check.

  • Abstract overstates response-inhibition mediation

    Major

    The abstract presents response inhibition as mediating both ADHD symptom scales, but the results say its indirect effect for inattention was not statistically significant. The Discussion likewise limits that mediation finding to impulsivity.

  • Recruitment age range differs between sections

    Minor

    The abstract gives a maximum recruitment age of 30 months, while the Method section gives 31 months.

2 of 2

Cites

Flagged first, then by citations

Research works printed but not linked: 2

  1. 2010, At Home or in a Home?
  2. Barkley, 2001, The inattentive type of ADHD as a distinct disorder: what remains to be done, Clinical Psychology: Science and Practice, 8, 489

Cited by

Sorted by citations

Authors
Tibu, F., Sheridan, M. A., McLaughlin, K. A., Nelson, C. A., Fox, N. A., & Zeanah, C. H.
Affiliations
  • University of North Carolina at Chapel Hill (US)
  • University of Washington (US)
  • Boston Children's Hospital (US)
  • University of Maryland, College Park (US)
  • Tulane University (US)
Corresponding author
Tibu, F.
ORCID
Venue
Psychological Medicine
Publisher
Cambridge University Press (CUP)
Published
2015-10-16
Volume
46
Issue
3
Pages
529-541
ISSN
  • 0033-2917 (ISSN-L)
  • 1469-8978
DOI
10.1017/s0033291715002020
PMC
PMC4739820
OpenAlex
W2269754811
Cited by
66
References
55
Citations by year
2026: 3 · 2025: 4 · 2024: 5 · 2023: 6 · 2022: 10 · 2021: 7 · 2020: 6 · 2019: 10 · 2018: 5 · 2017: 6 · 2016: 4
FWCI
4.06
Type
journal article
Language
en
Open access
Licence
www.cambridge.org/core/terms (unspecified)
Locations
  • Psychological Medicine (publishedVersion)
  • PubMed (publishedVersion)
  • PubMed Central (acceptedVersion)
Funders
  • John D. and Catherine T. MacArthur Foundation
  • National Institute of Mental Health (R01MH091363, K01MH092526)
  • Eunice Kennedy Shriver National Institute of Child Health and Human Development (U54HD090255)
Topics
  • Health Sciences › Medicine › Psychiatry and Mental health › Attention Deficit Hyperactivity Disorder
  • Social Sciences › Safety Research › Child Welfare and Adoption
  • Social Sciences › Psychology › Clinical Psychology › Child Abuse and Trauma
Keywords
institutionalization, attention deficit hyperactivity disorder, working memory, response inhibition, executive function, psychosocial deprivation, inattention, impulsivity, planning, mediation, early childhood
MeSH terms
Attention, Attention Deficit Disorder with Hyperactivity, Child, Child, Institutionalized, Child, Preschool, Female, Humans, Impulsive Behavior, Infant, Inhibition, Psychological, Institutionalization, Male, Memory, Short-Term, Psychosocial Deprivation, Surveys and Questionnaires, Residence Characteristics, Romania, Executive Function

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