bs_bs_banner Child: care, health and development Original Article doi:10.1111/cch.12112 Family environment and attention-deficit/ hyperactivity disorder in adopted children: associations with family cohesion and adaptability T. M. Crea,* K. Chan† and R. P. Barth‡ *Graduate School of Social Work, Boston College, Chestnut Hill, MA, USA †School of Social Welfare, SUNY Albany, Albany, NY, USA, and ‡School of Social Work, University of Maryland, Baltimore, MD, USA Accepted for publication 7 September 2013 Abstract Background Positive family environments are crucial in promoting children’s emotional and behavioural well-being, and may also buffer development of attention-deficit/hyperactivity disorder (ADHD). ADHD is highly heritable, but psychosocial factors in the family environment, particularly family cohesion and communication, may mediate genetic predispositions. The purpose of the current study is to examine the mediating influence of the adoptive family environment between pre-adoptive risk factors and youths’ ADHD symptomatology at 14 years post adoption. Methods The data used in this study were obtained from the fourth wave of the California Long-Range Adoption Study (CLAS) (n = 449). Using structural equation modelling (SEM), family sense of coherence and family adaptability were tested as possible mediators between environmental and biological predictors and ADHD symptomatology. Predictors included birthweight, gender, age at adoption, adoption from foster care, transracial adoption status, Keywords ADHD, adoption, ethnicity and having a previous diagnosis of ADHD. attention-deficit/ Results Results show that, while adoption from foster care is negatively associated with family hyperactivity disorder, family environment, SEM functioning, higher family cohesion and adaptability mediate this influence on children’s ADHD symptomatology. Older age of adoption directly predicts greater ADHD symptoms with no Correspondence: mediating influence of the family environment. Thomas M. Crea, Conclusions The mediating influence of the family environment between children’s risk factors Graduate School of Social Work, Boston College, 140 and ADHD symptoms suggests that family intervention strategies may be helpful in improving Commonwealth Ave., adopted children’s outcomes. Once children are adopted, targeting family communication patterns McGuinn 302, Chestnut Hill, MA 02467, USA and dynamics may be an additional part of developing an evidence-based, post-adoption services E-mail: [email protected] toolkit. ing family conflict (Jaycox & Repetti 1993), family cohesion Introduction (Moos & Moos 1994) and family coherence and adaptabil- Positive family environments are crucial in promoting chi- ity (Antonovsky & Sourani 1988), and generally refers to ldren’s emotional and behavioural well-being, and may also families where members are mutually supportive within a buffer development of attention-deficit/hyperactivity disorder predictable and nurturing environment. In regards to ADHD, (ADHD) (Mulligan et al. 2011). The term ‘family environ- research has shown that, while ADHD has a strong genetic ment’ encompasses multiple, closely related concepts, includ- component (Burt 2009), psychosocial adversity in the family © 2013 John Wiley & Sons Ltd 853 854 T.M. Crea et al. environment may trigger an underlying predisposition disentangle whether ADHD is the cause or result of factors (Biederman 2005). within the family environment (Howe 2010), clearly the envi- ADHD is characterized by inattention (daydreaming, diffi- ronment plays an important role in the course of developing culty focusing on a single task, distractibility) and hyperactivity symptomatology. (excessive talking, fidgeting, restlessness; Biederman 2005). It is often difficult to determine whether these symptoms are the Family environmental contributors to ADHD causes or consequences of a dysfunctional family environment Several studies have shown higher rates of family dysfunction in (Howe 2010), as biological traits – such as shared ADHD families with children diagnosed with ADHD, particularly between parents and children – contribute to environmental related to problems in communication, relationships and conditions that reinforce children’s symptoms (Cadoret et al. problem solving (Cunningham & Boyle 2002), higher family 1995; Leve et al. 2010b). Given the absence of genetic links in an conflict and lower levels of organization (Foley 2010; Mulligan adoptive family, the influence of a chaotic family environment et al. 2011). Some of these problems may be related to parental related to parental psychopathology (Biederman et al. 2002; psychopathology, or poor parenting practices (Cunningham & Schroeder & Kelly 2009), has, in theory, been isolated (Cadoret Boyle 2002; Deault 2010) possibly related to parental ADHD et al. 1995; Leve et al. 2010b). Yet, while data are scarce, esti- symptoms (Daley 2006). mates of ADHD prevalence in adopted children may be much Among adoptive families, Cadoret and colleagues (1995) higher than the general population: 21.8% (Simmel et al. 2001) found that children with an antisocial birth parent – who also compared with 3–8% of school-aged children (Foley 2010), and experience negative adoptive family interactions – are at greater 5.29% worldwide (Polanczyk et al. 2007). The purpose of the risk for aggressive behaviours. Research by Leve and colleagues current study is to examine the relationship of the family envi- (2010b) showed that adoptive mothers’ affective states moder- ronment, above and beyond pre-adoptive risk factors, with ated the relationship between birth parents’ and adopted chi- ADHD symptomatology among 449 adopted youths. ldren’s externalizing problems. Similarly, Tully and colleagues (2008) found that maternal depression significantly predicted The influence of the family environment children’s depression and externalizing behaviour problems for both groups, regardless of adoption status. These studies seem Measures of family environment are strongly associated with to confirm the importance of the family environment on chi- children’s behaviour problems, beyond biological and other ldren’s well-being above and beyond biological similarities psychosocial risk factors (Lucia & Breslau 2006). Higher family between parents and children, a finding particularly relevant for cohesion has been associated with lower internalizing and exter- this current study of adopted children. nalizing behaviours in children (Henderson et al. 2003), and lower rates of depression and anxiety among adolescents (Burt Research questions et al. 1988). In a study of children adopted from orphanages in the Soviet Union (McGuiness et al. 2005), only low birthweight This study uses two validated, related measures of the family and family cohesion significantly predicted variation in chi- environment – family adaptability and family sense of coher- ldren’s behavioural problems. ence (Antonovsky & Sourani 1988) – and is guided by two Studies of the family environment’s influence on ADHD have research questions: (1) To what extent does family cohesion shown similar patterns to other child well-being indicators mediate the relationship between key biological and environ- (Biederman 2005), but with a strong genetic component mental predictors, such as birthweight, age at adoption, foster (Lifford et al. 2008; Leve et al. 2010a). In a review of 20 twin care status, and ADHD symptomatology for adopted children? studies, Faraone and colleagues (2005) found that shared genes And (2) To what extent does family adaptability mediate the accounted for 76% of ADHD heritability. Some researchers relationship between these biological and environmental pre- posit that adverse environments may trigger the underlying dictors, and ADHD symptomatology? condition (Biederman 2005) such that a gene–environment Methods interaction exists (Leve et al. 2010b). Burt and colleagues (2003), for example, found that parent–child conflict is a risk Sample factor for several externalizing disorders in children, including ADHD, but that co-morbidity is likely related to psychopathol- The data used in this study were obtained from the California ogy within the family environment. Thus, while it is difficult to Long-Range Adoption Study (CLAS). Analysis for this study © 2013 John Wiley & Sons Ltd, Child: care, health and development, 40, 6, 853–862 Family environment and ADHD in adopted children 855 Table 1. Respondent characteristics and scale Full sample (N = 449) Scale means means* FSOC FAS CPRS-R n or M (SD) % M (SD) or r M (SD) or r M (SD) or r Respondent Mother 362 80.6 135.7 (18.5) 55.3 (9.8) 22.5 (18.4) Father 77 17.1 133.6 (19.9) 54.8 (11.2) 20.0 (15.9) Marital statusa Married/cohabitating 387 86.2 136.2 (17.5) 55.5 (9.7) 21.6 (17.7) Divorced/separated 36 8.0 129.9 (23.0) 52.9 (11.1) 25.7 (19.0) Single/widowed 25 5.6 126.4 (25.4) 51.8 (10.0) 24.1 (21.2) Respondent ethnicity White 364 81.1 134.8 (18.8) 54.9 (10.2) 22.1 (18.1) Hispanic 22 4.9 136.6 (18.9) 57.2 (9.7) 19.8 (16.1) Other 15 3.3 133.2 (21.8) 54.3 (10.9) 28.1 (21.6) Education High school, vocational school or 143 31.8 135.1 (19.0) 55.9 (10.0) 21.0 (18.5) community college 4-year college or above 302 67.3 135.0 (18.4) 54.8 (10.0) 22.6 (17.8) Employment status Full-time 201 44.8 135.0 (19.8) 55.1 (10.5) 22.2 (17.6) Part-time 124 27.6 135.0 (17.2) 55.4 (9.5) 19.4 (17.5) Retired 42 9.4 132.0 (18.8) 53.9 (10.7) 23.0 (17.5) Not employed 73 16.3 137.8 (16.6) 55.3 (8.8) 25.6 (19.5) No. of children No. biologicalc 0.7 (1.1) – r =−0.042 r =−0.046 r = 0.105 No. adopted 1.7 (1.0) – r =−0.028 r = 0.013 r =−0.002 FSOC (α=0.90)b,c 135.1 (18.7) – – r = 0.815 r =−0.543 FAS (α=0.88)c 55.1 (10.0) – – – r =−0.511 CPRS-R (α=0.97) 22.1 (18.0) – *Percentages may not total 100% because of missing data. aP < 0.05 for FSOC; bP < 0.05 for FAS; cP < 0.05 for CPRS-R.