2012. Vol.3, No.2, 175-182
Published Online February 2012 in SciRes (
Copyright © 2012 SciRes. 175
The Effects of Early Neglect on Cognitive, Language, and
Behavioral Functioning in Childhood
Eve G. Spratt1,2*, Samantha Friedenberg2, Angel a L aR osa 1, Michael D. De Bellis3,
Michelle M. Macias1, Andrea P. Summer1, Thomas C. Hulsey1,
Des K. Runyan4, Kathleen T. Brady2
1Department of Pedia t rics, Medical University of South Carolina, Ch a rleston, USA
2Department of Psychiatry and B ehavioral Sciences, Medical Uni v e rsity of South Carolina, Charleston, USA
3Department of Psychiatry a nd Be hav ioral Sciences, Duke University, Durham, USA
4Department of Pediatri c s, University of North Carolina School of Medicine, Chap e l Hill, USA
Email: *
Received October 5th, 2011; revised November 21st, 2011; accepted December 24th, 2011
Objectives: Few studies have explored the impact of different types of neglect on children’s development.
Measures of cognition, language, behavior, and parenting stress were used to explore differences between
children experiencing various forms of neglect, as well as to compare children with and without a history
of early neglect. Methods: Children, ages 3 to 10 years with a history of familial neglect (USN), were
compared to children with a history of institutional rearing (IA) and children without a history of neglect
using the Differential Abilities Scale, Test of Early Language Development, Child Behavior Checklist,
and Parenting Stress Index. Factors predicting child functioning were also explored. Results: Compared
with youth that were not neglected, children with a history of USN and IA demonstrated lower cognitive
and language scores and more behavioral problems. Both internalizing and externalizing behavior prob-
lems were most common in the USN group. Externalizing behavior problems predicted parenting stress.
Higher IQ could be predicted by language scores and an absence of externalizing behavior problems.
When comparing the two neglect groups, shorter time spent in a stable environment, lower scores on lan-
guage skills, and the presence of externalizing behavior predicted lower IQ. Conclusion: These findings
emphasize the importance of early stable, permanent placement of children who have been in neglectful
and pre-adoptive international settings. While an enriching environment may promote resilience, children
who have experienced early neglect are vulnerable to cognitive, language and behavioral deficits and
neurodevelopmental and behavioral evaluations are required to identify those in need of intervention.
Keywords: International Adoption; Child Neglect; Childhood Adversity
Neglect is the most prevalent form of child maltreatment in
the United States [1] and has been associated with negative
social, behavioral, and cognitive consequences [2,3]. In addi-
tion to physical and emotional neglect in a home setting, ne-
glect can take place in international institution environments
where a lack of consistent caregivers, crowded conditions, and
too few employees may lead to an infant or toddler not having
their physical, social, and/or emotional needs met [4]. Early
childhood is a vulnerable period for the acquisition and devel-
opment of cognitive, language, and emotion regulation abilities,
and therefore neglect in early childhood is of particular concern
[5]. Normal development may be disrupted by deprivation as-
sociated with neglect and can result in dysregulation of neural
systems during vulnerable periods of brain development [6-9],
leading to pronounced neurocognitive deficits due to maltreat-
ment [10-13].
Low-stimulation environments and inconsistent parenting
(lack of rules, failure to monitor child, inconsistent punishment
and reward) [14], common in both physical neglect environ-
ments and orphanage setting [15,16], can lead to lower scores
on intelligence and language tests [17-19]. A study including
33 mother-child dyads found that children with a history of
neglect scored significantly lower on measures of syntactic
ability and receptive vocabulary when age and maternal IQ
were controlled [18]. A 2001 study found progressive cognitive
decline in children experiencing substantiated neglect in com-
parison to non-neglected children [19]. Children reared in in-
stitutional settings fall victim to similar risk factors; there are
poor child-caregiver ratios, inadequate cognitive, sensory, and
linguistic stimulation, and unresponsive care-giving practices
[20]. Therefore, the children may exhibit delays in development
of IQ, language, and social emotional functioning as well as
impaired attachment [21-24].
The purpose of the current study was to compare cognitive,
language, and behavioral functioning of children with no his-
tory of neglect to children with early neglectful situations, spe-
cifically those who experience physical and emotional neglect
from a caregiver or deprivation due to pre-adoptive placement
in an international institution environment. This study exam-
ined children who had the experience of international institution
life and were then adopted into higher socioeconomic status
(SES) households. This international adoption group was com- pared
with United States born children with a history of physi-
*Corresponding author.
cal or emotional neglect. These children remained in a similar
SES when placed in an extended family member’s household
(grandmother, great aunt) post-removal from neglectful envi-
ronment. Both neglect groups (international adoption and US
neglect) were also compared to a control group of United
States-born children without a history of neglect.
Following previous research on the effects of neglect and
child resilience [20,25], we hypothesized that the control group
would have significantly better scores than either of the neglect
groups on all cognitive, language, and behavioral measures. It
was also hypothesized that adopted children would have lower
language scores but less behavior problems and parental stress
than US neglect children. In the neglect groups, we predicted
that behavior problems would be associated with parental stress,
and that a longer time in a non-neglectful environment would
account for any differences in externalizing and internalizing
symptoms between the two neglect groups.
A cohort of 60 children was divided into three groups: 1) US
children with a history of physical or emotional neglect as de-
fined by the Barnett Child Maltreatment Classification Scheme
(MCS) [26] (USN); 2) children adopted from international in-
stitutions (IA); and 3) US children with no history of neglect,
abuse, or adoption (Control).
Participants were between the ages of three and ten years.
Seventeen children met criteria for the USN group and were
living with a care-giving relative, a rehabilitated offending
parent, or a non-offending parent at the time of the study. Fif-
teen children met criteria for the IA group; one child was from
a Central American foster home and the rest were from Eastern
European institutions. These children were living with their
adoptive families at the time of the study. Twenty-eight chil-
dren had neither experienced neglect nor out-of-home place-
ment and met criteria for the control group.
Participants with any of the following conditions were ex-
cluded from the study: 1) malnutrition as indicated by Centers
for Disease Control charts [27] (weight adjusted for stature <1st
percentile); 2) morbid obesity (Body Mass Index over 40); 3)
birth complications (birth weight <2500 g, gestational age <37
weeks, or respiratory distress syndrome); 4) IQ below 70; 5)
neurobiological disorders (Cerebral Palsy, Childhood Schizo-
phrenia, Autism, Morbid Obesity, or Central Nervous System
Disorders); 6) known in-utero substance exposure that led to a
prolonged hospital stay for the infant or, 7) a serious medical
condition. It is also important to note that children in current
Child Protective Services (CPS) and/or foster care were ex-
cluded from the study because the state agency would not give
permission to do research with this population.
Research Procedures
This study was approved by the Institutional Review Board
(IRB) at the Medical University of South Carolina (MUSC) and
sponsored by the National Institutes of Health and the MUSC
Clinical and Translational Research Center (CTRC).
Children and their caregivers participating in the study were
referred by medical or mental health practitioners or were
self-referred after reviewing flyers. The caregivers signed a
release of information form to obtain educational, medical
(birth records, prenatal care of mother, and ongoing medical
and mental health care), and adoption records. Families were
interviewed to clarify details about the child’s clinical and ne-
glect history. All participants signed a release to allow access to
the state’s Child Protective Services (CPS) records to assure
that controls had no abuse or neglect history and to obtain addi-
tional details on cases that were involved with CPS. For clari-
fication, Child Protective Services is a government agency in
many states that responds to reports of child abuse or neglect.
The Department of Social Services includes CPS, as well as
assistance with Medicaid, child support, public housing, foster
care, adoptions, Adult Protective Services, and a supplemental
nutrition assistance program. Once informed consent was ob-
tained, children and their caregivers attended an appointment at
the CTRC outpatient clinic where the child underwent a physi-
cal examination, which included vital signs, head circumfer-
ence, height, weight and collection of serum, urine, and saliva.
Standardized measures of language and cognitive abilities were
administered to children, and caregivers completed question-
naires assessing child behavioral functioning and parental stress.
Psychometric and cognitive evaluations were administered by a
licensed psychologist.
All tests administered were standardized, and testing was al-
ways done with a measure appropriate for the participant’s age.
Cognitive functioning. The Differential Abilities Scale for
Children (DAS): Third Edition [28] is a standardized cognitive
assessment for children between 2 years 6 months and 17 years
11 months [28] and is particularly useful when testing children
in the late toddler and early childhood range. The DAS yields
17 cognitive and 3 achievement subtest scores and enables
identification of a child’s cognitive capabilities with a score for
General Conceptual Ability (GCA). The GCA is derived from
only those subtests which have high correlations to overall
general abilities. The cluster scores yield broad measures of
verbal ability, nonverbal reasoning ability, and general concep-
tual ability (GCA) [29]. The standard scores, ranging from 20
to 80, for each subtest are based on age with a mean of 50 and a
standard deviation of 10. Percentiles may also be expressed.
Language functioning. The Test of Early Language Devel-
opment: Third Edition (TELD) [30] is a standardized, norm-
referenced test that was designed to measure the expressive and
receptive language development of children ages 2 through 6
years 11 months. Standard scores are provided for Receptive
Language, Expressive Language, and an overall Oral Language
Composite. A standard score has a mean of 100 and a standard
deviation of 15, and percentiles are usually listed for clarifica-
tion. All participants in the international adoption group had to
meet language competency skills to participate in the study.
Children above the TELD age range were given the Test of
Language Development (TOLD). If the children were between
the ages 7 to 9 years, they were given the TOLD-Primary. This
assessment looks at nine sub-categories of oral language com-
petency and is approved for children ages 4 to 9 years. If the
children were above 9 years old, they were given the TOLD-
Intermediate. This assessment examines six sub-tests and is
approved for children ages 8 to 18 years old. Both the TOLD-
Copyright © 2012 SciRes.
Copyright © 2012 SciRes. 177
Primary and the TOLD-Intermediate are used to assess the oral
language proficiency of children [31].
Behavioral functioning. The Child Behavior Checklist
(CBCL) [32], measures caregiver ratings of behavioral and
emotional functioning of children ages 1 1/2 to 18 and includes
three broad band behavior problem scales: Internalizing, Ex-
ternalizing, and Total. Subscales include withdrawn, anxious/
depressed, somatic complaints, attention problems and aggres-
sive behavior. The score on each syndrome is derived from
summing the numbers circled by the parent. The percentile of
the national normal sample for each syndrome score is used
through comparison to give a T score. Using the T score, prac-
titioners are able rank the child’s score and percentile as com-
pared to thousands of other same gender and age children. For
example, if a child was at the 69th percentile, then 69% of the
children in the national normative sample scored either at or
below this score. There are several cutoffs for normal range,
borderline range, and clinical range to categorize behavior
Parenting Stress Index (PSI-SF) [33]. The PSI Short Form is
a 36-item parent self-report instrument containing three fac-
tor-analytically-derived subscales (Parental Distress, Parent-
Child Dysfunctional Interaction, and Difficult Child) and a
Total Stress score. Each subscale consists of 12 items that can
be rated from 1 to 5 (strongly disagree to strongly agree). It is a
sound, brief screening measure of parenting stress where higher
scores on subscales and total scores indicate greater amounts of
Child Maltreatment—Neglect. Measurements used to deter-
mine neglect and other maltreatment summary variables were
obtained from archival record data including CPS, medical,
mental health and institutional records. After reviewing archival
data and interviewing the current guardian, investigators deter-
mined whether the child experienced neglect (physical or med-
ical) and/or abuse (physical, sexual, or emotional). It was also
noted if the child witnessed domestic violence. Out of the 32
children from the international adoption and US neglect groups
combined, it was known that 8 (25%) had a previous caregiver
who abused drugs, 11 (34.4%) who abused alcohol, and 13
(40.6%) who smoked in utero. In reference to the neglect and
abuse findings, 18 (56.3%) children were known to have ex-
perienced physical neglect, 6 experienced medical neglect
(18.8%) (with 4 being from no prenatal care), 7 (21.9%) ex-
perienced physical abuse, 1 (3.1%) experienced sexual abuse,
and 3 (9.4%) experienced emotional abuse. Seven (21.9%)
children witnessed domestic violence.
It is important to note that these measurements, evaluations,
and parental reports were obtained after all neglected children
were placed in a stable, non-neglectful environment for at least
a year by adoptive parents or a relative. The IA group had an
average time of 51.6 months in a stable environment, and the
USN had an average time of 27.5 months. The control group
participants had always been living in a stable environment.
Although spending time in a stable environment prior to testing
may be seen as a limitation, the time frame could have served
as an adjustment period to better understand the long term per-
vasive and more deeply rooted cognitive, emotional and be-
havioral concerns.
Statistical Analysis
SAS (version 9.2, SAS Institute, Inc.) or SPSS (version
16.0.1, SPSS, Inc. ) statistical programs were used for all analy-
ses. Student’s t-test or ANOVA were used to compare means of
normally distributed continuous variables. Chi Square or
Fisher’s Exact test were used to assess group differences in
categorical variables. ANCOVA (controlling for annual house-
hold income) was used to compare the three groups on meas-
ures of cognitive ability, language ability, behavioral issues,
and parenting stress. Multiple Linear Regression was used to
examine predictive models while simultaneously adjusting for
potential confounding variables.
Demographic and environmental variables are reported in
Table 1. There were no significant differences between groups
on race, age, or gender. USN group members were older at the
time of placement with a relative, non-offending or rehabili-
tated offending caregiver, t(30) = 2.82, p = .008. These children
had spent a larger proportion of time in the unstable environ-
ment than the IA group, t(30) = 3.11, p = .004. The time spent
in the current home (defined as a stable environment) prior to
study participation was greater for children in the IA than USN
group, t(30) = 4.13, p =. 010. It is however suspected that the
deprivation was more chronic and severe during the first year(s)
of life for the IA group. Although it is challenging to describe
and control for a stable environment (in the control group as
well as the neglect groups), the term is used to describe the
households who have no recent reports of child neglect or abuse
and have parents or caretakers concerned enough for these
children to be seen in medical or mental health clinics. No sig-
nificant concerns were identified when the project study coor-
dinator visited the home to obtain the informed consent. When
Table 1.
Demographic information.
Control US IA
Gender Male = 15; Female = 13 Male = 8; Female = 9 Male = 9; Female = 6
Race White = 20; Black = 6; Other = 2White = 12; Black = 2; Other = 3 White = 14; Other = 1
Age (in months) M = 67; SD = 21.4 M = 64; SD = 26.9 M = 73; SD = 12.7
Annual hous ehold income M = 109,019; SD = 54,995 M = 37,889; SD = 22,031 M = 120,466;
SD = 68,376
Age at time of removal from neglectful
environm ent (in month s ) M = 32.1; SD = 15.5 M = 20.7; SD = 13.0
Proportion of life in neglectful
environment M = 55.8%; SD = 24. 9% M = 30.9%; SD = 19. 8%
Time in current home (in months) M = 28.8; SD = 17.3 M = 51.7; SD = 28.8
studying people and their home environments, there are limita-
tions to knowing the specifics of the household and to knowing
their constant activity. The inability to measure a “stable envi-
ronment” in any way other than home observation and medical
record review could be considered a limitation of this study.
The three groups differed on annual household income, F(2,57)
= 10.48, p < .0001, with the USN group having significantly
lower current income than IA (p < .0001) and healthy controls
(p = .008).
As shown in Table 2, when controlling for annual household
income using analysis of covariance, the USN, IA, and Control
groups differed significantly on measures of cognitive and lan-
guage functioning, behavior problems, and parenting stress.
Significant group differences were explored as reported below.
Control v. US N
The control group performed significantly better than the
USN group on the DAS nonverbal (p = .05) and GCA (p = .008)
subscales as well as the TELD receptive (p = .004), expressive
(p = .006), and Oral Composite (p = .002). The USN group
scored significantly higher than controls on the CBCL Atten-
tion (p < .0001), Aggression (p < .0001), Anxiety and Depres-
sion (p < .0001), Internalizing (p < .0001), Externalizing (p
< .0001), and Total Problems (p < .0001) subscales as well as
the PSI Parent-Child Dysfunctional Interaction subscale (p
< .0001).
Control v. IA
Children in the control group performed significantly better
than children in the IA group on DAS verbal (p = .04) and
GCA (p = .003) as well as TELD receptive (p = .002), expres-
sive (p < .001) and Oral Composite (p < .001). The IA group
exhibited significantly higher scores on the CBCL Attention (p
= .002), Internalizing (p = .026), Externalizing (p = .03) and
Total Problems (p < .001) subscales.
The USN group scored significantly higher than the IA group
on CBCL Anxiety and Depression (p = .009), Attention (p
= .002), Aggression (p = .001), Internalizing (p = .02), Exter-
nalizing (p = .01), and Total Problems (p = .02) subscales.
When USN and IA groups were combined to form one child
neglect (CN) group, there were significant positive correlations
between time in stable environment and scores on the DAS
GCA scale (r = .468, p = .014) and the DAS nonverbal scale (r
=.451, p = .021). Considering the USN group individually,
there were significant positive correlations between time in
stable environment and DAS GCA (r = .535, p = .027) and
DAS nonverbal (r = .630, p = .007). Considering the IA group
individually, a significant positive correlation was observed
between time in neglectful environment and CBCL internaliz-
ing subscale (r = .542, p = .037).
Multiple Regression
A series of five multiple linear regression models was de-
veloped to examine the predictors of outcome on the DAS GCA,
PSI Total Stress scale, CBCL Internalizing, and CBCL Exter-
nalizing scales and to compare US, IA, and control groups.
Variables included in each model are listed in Table 3.
Model 1 revealed that 78% of the variance in scores on the
DAS GCA could be accounted for by scores on the TELD Oral
composite scale and CBCL Externalizing subscale. Model 2
explained that 62% of variance in PSI Total Stress scores was
accounted for by scores on the CBCL externalizing subscale.
Being a member of either the USN or IA groups was not pre-
Table 2.
ANCOVA comparison of US, IA, and control on cognitive, l a ng u a ge , and behavioral functioning with means adjusted for income.
Control US IA MSE F P
Least Squares Mean
DAS Verbal 97.77 90.44 87.33 12.40 3.74 .018
DAS Nonverbal 107.16 95.96 97.62 14.56 3.46 .025
DAS GCA 104.41 92.12 89.97 12.30 10.56 <.0001
TELD Receptive 106.14 92.40 90.49 12.74 9.33 <.0001
TELD Expressive 100.13 87.64 83.71 12.01 8.96 .0001
Oral Composite 103.84 87.76 84.00 13.50 10.69 <.0001
PSI-PCDI 17.05 28.09 20.41 7.11 7.07 .0004
CBCL Anxiety Depression t-score 51.16 61.24 54.57 5.94 9.48 <.0001
CBCL Attention t-score 51.63 67.59 58.84 6.57 21.38 <.0001
CBCL Aggression t-score 51.38 70.98 55.69 10.61 9.95 <.0001
CBCL Internalizing t-score 44.49 61.83 52.21 10.09 11.63 <.0001
CBCL Externalizing t-score 44.77 65.26 53.03 11.11 12.03 <.0001
CBCL Total t-score 43.33 66.02 55.80 10.36 18.41 <.0001
Note: DAS = Differential Abilities Scale; DAS GCA = Differential Abilities Scale General Conceptual Ability; TELD = Test of Early Language Development;
PSI-PCDI = Parenting Stress Index-Parent-Child Dysfunctional Interaction; CBCL = Child Behavior Checklist.
Copyright © 2012 SciRes.
Table 3.
Multiple linear regression models 1 - 5.
Variable β Standard Error T P
Model 1: Dependent Variable DAS GCA*
TELD Oral Composite .71.08 9.00<.0001
CBCL Internalizing Subscale –.03.13 –.23.91
CBCL Externalizing Subscale –.25.12 –2.01.05
USN 1.883.28 .57.56
IA 1.433.15 .45.65
Model 2: Dependent Variable PSI Total S tress*
TELD Oral Composite .28.17 1.67.10
CBCL Internalizing Subscale .39.28 1.39.17
CBCL Externalizing Subscale 1.11.27 4.18.0001
USN 3.206.92 .46.65
IA –1.786.66 –.27.79
Model 3: Dependent Variable CBCL Internalizing*
DAS GCA –.35.19 –1.85.07
TELD Oral Composite .11.18 .62.53
USN 12.933.89 3.33.0017
IA 2.224.27 .52.61
Model 4: Dependent Variable CBCL Externalizing*
DAS GCA –.53.19 –2.79.0076
TELD Oral Composite .22.18 1.24.22
USN 13.963.97 3.51.0010
IA .404.37 .09.93
Model 5: Dependent Variable DAS GCA**
TELD Oral Composite .71.13 5.18<.0001
CBCL Internalizing Subscale .24.17 1.41.17
CBCL Externalizing Subscale –.29.15 –2.00.06
Time in Neglectful Environment .12.13 .89.38
Time in Stable Environment .40.14 2.87.009
USN –1.553.69 –.42.68
*Controls included as intercept. **IA included as intercept. Note: DAS GCA =
Differential Abilities Scale Global Conceptual Ability; TELD = Test of Early
Language Development; USN = US born neglect group; IA = International adop-
tion group.
dictive of scores on the DAS GCA or PSI Total Stress scale.
Model 3 showed that being in the USN group significantly
predicted scores on the CBCL Internalizing subscale account-
ing for 41% of variance. Model 4 revealed that scores on the
DAS GCA and being a member of the USN group explained
49% of the variance in externalizing behavior. Model 5 includ-
ing only USN and IA groups was created to examine the pre-
dictive value of time in a stable environment on DAS GCA
scores. This model explained 71% of the variance with the
TELD oral composite scale and predicting scores related to
time in a stable environment on the DAS GCA.
As hypothesized, when controlling for SES, children in the
control group exhibited higher levels of cognitive, language,
and behavioral functioning than both neglect groups, and the IA
group exhibited better behavioral adjustment than the USN
group. The greatest differences in behavioral and cognitive
measures were found between the USN and control groups.
As children develop, the neurocognitive deficits associated
with adverse early life events can impair functioning and in-
crease the vulnerability for social and behavioral difficulties. A
cross-sectional study of 420 children indicated that those with a
history of maltreatment performed more poorly in school than
their non-maltreated counterparts [34]. When controlling for
age, maltreated children had lower grades and more suspen-
sions, disciplinary referrals, and grade repetitions in elementary,
junior high, and senior high school [34].
Neglect is the type of maltreatment most strongly associated
with delays in expressive, receptive, and overall language de-
velopment [35]. Slow language development plays a role in
behavioral difficulties across the life span, with approximately
70% of children with language impairments exhibiting co -mo rbi d
behavior problems [36]. Children who are unable to communi-
cate effectively may not have the necessary skills to negotiate
or resolve conflict and may have difficulties understanding and
relating to others. Psychiatric disorders such as attention-deficit/
hyperactivity disorder, anxiety, depression, conduct disorder,
and oppositional defiant disorder are highly associated with
language impairment, and a combination of these problems
may lead to poor social functioning as these individuals enter
adulthood [36]. Although the current sample of USN children
had difficulties in all realms tested, it may be that impaired
language development, as determined by the USN children’s
significantly lower scores on all subscales of the TELD as
compared to controls, is contributing to the higher number of
behavior problems in the USN group.
Children with a history of neglect are at risk for impaired
language development if they are not provided the complex
linguistic input and personal interactions necessary for optimal
development of language skills. Studies have shown that the
quality of mother-child interactions help predict cognitive and
linguistic outcomes in preschool-aged children of high social
risk mothers [37]. Interpersonal interaction is necessary for the
acquisition of early language [38], and these interactions may
be limited for children that have been in institutional settings
[39] or have experienced physical or emotional neglect [18]. In
addition to the hardships of neglectful environments, children
adopted internationally are also at risk for deficits in language
acquisition due to the challenges of learning a new language
In the current study, children in the IA group were living in
homes with higher annual household incomes than children in
the USN group, which may have provided greater opportunities
for enrichment and subsequent cognitive, language, and behav-
ioral development. Juffer and van Ijzendoorn (2005) found
similar behavioral results when comparing children adopted
internationally with children adopted domestically and deduced
that parents of international adoptees tend to have more finan-
cial resources to invest in the child’s development, which may
be a contributing factor to their having fewer behavioral prob-
Copyright © 2012 SciRes. 179
lems [41]. Consistent with the demographic information of our
study sample, low income is strongly associated with child
abuse and neglect [42], and children living in poverty are ex-
posed to environmental hazards such as violence, hunger, infe-
rior health care, and few recreational opportunities [43]. Al-
though both IA and USN children were exposed to neglectful
environments in early childhood, the placement of IA children
in higher income families may have provided an environment
that promoted resilience from adversity. Factors that promote
resilience for children that have experienced abuse and neglect
include structured school environment, involvement in extra-
curricular activities and the religious community, and a suppor-
tive adult providing emotionally responsive care-giving [44].
Numerous studies have examined the association between ne-
glect and poverty as well as poverty and child outcomes [45];
however, little research has investigated the association be-
tween neglect and child outcomes as mediated by annual
household income. This enrichment of cognitive and language
skills that often accompanies higher SES status in turn may
have helped to provide protection from behavioral problems
[46]. In addition, the perceived variance in language scores
between the USN group and the children in the IA and control
groups may be due in part to parental language and education
Externalizing behavioral problems of children play a primary
role in elevating stress levels for parents, particularly in con-
junction with perceived inadequacy of support and/or resources
[47]. The current study revealed an association between behav-
ior problems and parenting stress, consistent with prior research
[48-51]. Hung et al. (2004) [52] suggests that quantifying pa-
rental distress is an essential part of a diagnostic assessment for
young children with special needs. Parent support groups and
parenting education courses have proved to be useful interven-
tion strategies for stressed parents [53]. Since there is often
great diversity in the families of children with a history of ne-
glect or international adoption, successful interventions might
include components addressing parental coping styles and sup-
port in dealing with behavioral challenges. Because the current
study relied on parental report at least 1 year post-placement in
stable environment, it is unclear whether child behavior prob-
lems exacerbated parental stress or vice versa. Associations
between IQ and behavior problems can lead to increased pa-
rental stress, or stressed parents may cause children to exhibit
more behavior problems. The findings that neglected children
perform more poorly on tests of cognition and have signifi-
cantly elevated behavior problems reflect to the need for earlier
evaluations and interventions for children with a history of
Time in a stable environment does appear to be protective as
there was a positive association with measures of cognitive
ability in the USN group. These findings support the recom-
mendations of Nelson et al. (2007) that intervention as early as
possible through placement in a nurturing environment yields
improved outcomes such as increase in cognitive ability [20].
Our suspicions are that the periods of deprivation were longer
and more chronic for those in an institution vs a neglectful
home. One study has found that children with a history of ne-
glect that do not return to biologic parents may fare best [54].
The influence of time spent in neglectful environments on be-
havioral and cognitive impairment, as well as a closer examina-
tion of factors that appear to be protective against neurodevel-
opmental and behavioral problems, should be the focus of sub-
sequent research studies.
In the small number of studies examining deprivation due to
institutionalization, internationally adopted children have dem-
onstrated difficulties with attention, language, and aggression
similar to children experiencing physical neglect [55,56]. A
strength of this study is that to date, no published studies have
compared neglected children from the United States who live
with their relatives or foster families to children who have ex-
perienced early deprivation in an institution. Understanding the
differential impact of these two kinds of deprivation and ne-
glect may help with the development of family-based interven-
tions for these and other populations experiencing adverse
childhood events.
Despite a small sample size, there were statistically signifi-
cant findings which emphasize the prevalence and severity of
the issues addressed. However, all behavioral participant in-
formation obtained was by parental report (not by a blinded
rater or outside observer) and therefore might reflect the view
only of the parent. Some of the limitations faced included the
challenge of assessing the severity and chronologic sequence of
neglect, institutions differing in the quality of care, adoptive
parents being more tolerant of negative behaviors, and possible
incomplete historical records. We cannot exclude other types of
maltreatment that play a role in the outcomes of this study, but
the predominant insult for these young children was a history of
physical neglect and less than optimal care. Children in current
child protective services and foster care were not involved in
this study, leaving out the more severe US neglect cases. Future
studies would benefit from unbiased child behavioral data
through reliable coders, teachers, and whenever possible, care-
giver and child self- r ep o rt measures.
In closing, some researchers have written of the “neglect of
neglect” [45]. In the maltreatment field, there has been a ten-
dency to focus on physical and sexual abuse leaving many cli-
nicians and educators with poor understanding of the potential
impact of neglect on a young child’s cognitive, language, and
behavioral development. Neglect may be the most detrimental
maltreatment type on brain development [6,57,58]. As this
study indicates, environment post-neglect may serve as a buffer
for some problems, and children from a neglectful environment
require more intervention than placement in a non-neglectful
home. Multifaceted interventions addressing cognitive, lan-
guage and behavioral difficulties are needed to maximize the
optimum potential in each of these children.
NIH/NIMH K23MH064111: Neurodevelopmental Biology
of Neglected Children (PI: Eve G. Spratt). NIH/NIDA K24DA
00435: Midcareer Investigator Award in Patient-Oriented Re-
search (PI: Kathleen T. Brady). NIH/NIMH K24MH71434:
Midcareer Investigator Award in Patient-Oriented Research (PI:
Michael D. De Bellis). Special thanks to: Medical University of
South Carolina Clinical and Translational Research Center;
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