- Email: [email protected]
studies of adoptees from psychiatrically disturbed biologic parents
B E H A V IO R A L P E D IA T R IC S
RichardW.Olmsted, Editor
Studies of adoptees from psychiatrically disturbed biologic parents 11. Temperament, hyperactive, antisocial, and developmental variables
Temperament, hyperactivity, antisocial behavior, and developmental milestones were assessed in two groups of adoptees by interviewing the adoptive parents. One group, the "experimental, "' was born of psychiatrically disturbed biologic parents (N = 59). The second group, the "control,'" had psychiatrically "normal'parents (N = 54). Infants in each group were separated from their biologic parents at birth and had no further contact with them. Male "'experimental" adoptees had excess number o f temperament traits characteristic of the "difficult" child, as well as an excess of antisocial behaviors when contrasted with male control subjects. No differences between control and experimental females were found for these variables. Hyperactive behavior in the adoptees o f each sex was associated more with antisocial parentage than in those of "normal" parentage.
Remi J. Cadoret,* Lynn Cunningham, R o s e m a r y L o f t u s , and James Edwards, I o w a City, l o w a
IN A PREVIOUS R E P O R T 1 the present authors assessed psychiatric disability in two groups of adoptees: one, composed of 59 offspring of psychiatrically disturbed biologic parents (the experimental adoptees); and the second, composed of 55 offspring of apparently psychiatrically "normal" biologic parents (the control adoptees). Both experimental and control adoptees had been separated at birth from their biologic parents and had had no further contact with other biologic relatives. The two groups of adoptees were matched for sex, age, and age of mother at time of adoptee birth. Table I details the types of biologic parental matings for both adoptee groups. On the basis of information collected by a telephone interview with the adoptive parents we were able to determine the behavioral adjustment of each adoptee and in many cases arrive at a specific psychiatric diagnosis. The major finding from the previous study was that 37% of all the experimental adoptees received professional treatment for a behavior disorder compared to only *Reprint address: Psychopathic Hospital, University of Iowa College of Medicine, 500 Newton Rd., Iowa City, Iowa 52242.
14% of the control adoptees (X2 = 6.45, df = 1, 0.02 > p > 0.01). Furthermore, 59% of the 32 male experimental adoptees received treatment for a behavior disorder in contrast to 30% of the 27 female adoptees--an even more highly significant difference. Most of the excess of ill experimental male adoptees was accounted for by one diagnosis: hyperactivity. Seven out of the eight hyperactive-experimental adoptees were male. The control group contained only one hyperactive adoptee, The difference between control and experimental groups was significant (X2 = 3.90, d f = 1, 0.05 > p > 0.02). The purpose of the present report is to analyze other important childhood behaviors in the adoptees and relate these behaviors to the psychiatric diagnosis of the biologic parents. Recent advances in child psychiatry have emphasized the importance of temperament in behavior and in the genesis of later disorders of behavior. ~ As part of the behavioral picture of the adoptees, we assessed some of the childhood temperament factors described by Thomas and associates,2 and this report contains the results of analyses of temperament in these adoptees. In the former paper 1 we gave each child a diagnostic The Journal ofPEDI ATRICS VoL 87, No. 2, pp. 301-306
301
302
Cadoret et al.
The Journal of Pediatrics August 1975
Table I. Matings of biologic parents
Psychiatric diagnosis of biologic parents "Normal" mother/"normal" father Mother antisocial/"normal" father Father antisocial/"normal" mother Mother affective disorder/"normaI" father Mother affective disorder/antisocial father Mother major psychosisi"normal" father Mother mentally retarded/"normal" father Mother undiagnosed/"normal" father Mother undiagnosed/antisocial father Mother diagnosed (alcoholic or neurotic)/"normal" father Mother "normal"/alcoholic father
Experimental (N=59)
Control (N=55)
18 1 4
55 ---
1
-
8
-
11
-
10 2 3
---
1
-
label, an approach which does not examine the more subtle quantitative aspects of behavior: how many behaviors of a certain type does an individual demonstrate? For example, only a few adoptees were diagnosed as having antisocial personalities, yet a far larger n u m b e r of these children had more than a few of the behaviors usually associated with antisocial personality. Similarly with hyperactivity, more individuals were reported to have some of the characteristic behaviors of this condition (such as distractibility), but not enough of these behaviors to warrant the diagnostic label. We have, therefore, analyzed antisocial- and hyperactive-type behaviors in terms of numbers of behaviors per child of the types complained of by the adopting parents. Developmental variables, such as usual motor milestones, were also analyzed because of the inclusion in the experimental group of adoptees of biologic parents with mental retardation, and because of the possibility that developmental problems were associated with such behaviors as hyperactivity. Disorders occurring during development, such as so-called "neuropathic" traits (nailbiting, thumb sucking, and enuresis), were also analyzed. METHODS
Detailed methodology regarding selection and sampling of adoptees is presented in the previous report.' Informed consent was obtained from the adoptive parents before calling them to conduct the interview. Adopting parents were interviewed by telephone regarding a number of developmental and behavioral facts about their adopted child. The median age of adoptees at the time of
interview was 17. The professional social worker who interviewed the adoptive parents was "blind" to the status (whether control or experimental) and diagnosis of the biologic parent of the adoptee. The physicians who diagnosed the psychiatric conditions in the biologic parent s were also "blind" to the condition of the adoptees. Similarly, the physician who put a diagnostic label on each adoptee was unaware of whether an adoptee came from a control or experimental biologic parent. Criteria for psychiatric diagnoses can be found in the previous report as well as brief case summaries of "ill" adoptees.1 To organize the temperament and other behaviors into meaningful categories we have used the following classifications: (1) temperament, (2) hyperactivity, (3) antisocial, (4) physical development, and (5) "neuropathic" traits. A comparison was made between scores for the experimental and control group holding sex constant. Differences were assessed by the Mann-Whitney U Test. Onetailed probabilities are reported for all differences which reached the 10% level of significance. I. Temperament variables. Thomas and associates-' describe a cluster of behaviors which characterize the difficult child. These are (1) irregular biologic functions, (2) withdrawal in new social situations, (3) slow to adapt to new situations, (4) intense reactions, and (5) a high frequency of negative moods. Our questionnaire contained eight items relating to the "difficult child diagnosis." In scoring, the answers to those items shown in italic type were rated as positive, and each child was characterized by the number of positive temperament answers (possible range of 0 to 8 positive). 1. Is there a variation from the day-to-day schedule of sleeping, eating, bowel movements, and elimination or is this fairly consistent? 2. Does he/she adjust easily to new situations and experiences? Yes or no. 3. Does he/she approach new situations with ease or does he/she withdraw from these new situations and experiences? 4. When there are changes in immediate environment, is he/she bothered by them or does he/she adjust well? 5. When there are new changes, experiences, and situations, does he/she react violently or mildly voice his/her dislike? 6. Is he/she generally contented at all times or does he/ ~he become easily upset or fussy? 7. Did he/she have frequent temper tantrums? Yes or no.
8. Is he/she emotional and sensitive? Yes or no. II. Hyperactivity variables. The questionnaire contained the following items covering this area of behavior.
Volume 87 Number 2
Studies o f adoptees
303
Table II. T e m p e r a m e n t , hyperactivity, a n d antisocial b e h a v i o r traits in m a l e a n d f e m a l e adoptees Behavioral areas
I.
Thomas-Chess-Birch temperament items
Adoptee status
Males Females
II.
Hyperactive behavior items
M~les Females
III. Antisocial behavior items
Males Females
IV. Physical developmental milestones
Males Females
V.
"Neuropathic" traits
Males Females
No. items positive
Significance (Mann-Whitney U)
0
1-2
3-4
Exp Cont Exp Cont
8 16 13 19
17 5 9 6
4 2 4 5
3 ~ 1 1 ~ 1
Exp Cont Exp Cont
0 18 19 14 19
1 6 5 7 9
2 7 0 6 2
3 1 ~ 0 0 ~ 1
Exp Cont Exp Cont
0 9 13 16 15
1-2 10 6 6 9
3-4 5 4 1 4
5 8 ~ 1 4 ~ 3
0 12 13 10 10
1-2 14 11 13 14
3 6 ~ 0 4 ~ 7
1 13 11 8 12
2 3 5 4 3
3 0 ~ 1 1 ~ 2
Exp Cont Exp Cont Exp Cont Exp Cont
0 16 7 14 14
5 0.006 NS*
0.076 NS
0.038 NS
0.091 NS
NS NS
Exp = experimental group; Cont = Control group. *NS = significancegreater than 10%.
Answers to hyperactive items in italics were rated as positive (possible r a n g e o f 0 tO 3 positive). 1. Is h e / s h e overactive during quiet periods or c a n h e / s h e rest and'fie quietly d u r i n g quiet periods? 2. W h e n involved in a n activity, c a n h e / s h e c o n c e n t r a t e for ten minutes or more? Yes or no. 3. W h e n involved in a n activity c a n h i s / h e r a t t e n t i o n be easily diverted? Yes or no. III. Antisocial items. Antisocial items were p a t t e r n e d after the antisocial criteria o f Robins3; the following questions dealt with these behaviors. 1. Has h e / s h e ever b e e n t r u a n t f r o m school? Positive = 2 or more times. 2. Has h e / s h e h a d a n y trouble with t e a c h e r s or a d m i n istrators? Positive = in trouble for disciplinary reasons. 3. Has h e / s h e ever b e e n s u s p e n d e d or expelled? Positive = yes, for disciplinary reasons or fighting. 4. Has h e / s h e b e e n i n v o l v e d in fights at school? Positive -- yes. 5. Has h e / s h e frequently b e e n d i s o b e d i e n t a n d / o r h a r d to punish? Positive = f r e q u e n t and difficult p u n i s h m e n t .
6, Does h e / s h e lie frequently? Positive = yes. 7. Has h e / s h e ever stolen a n y t h i n g ? Positive = yes. 8. Has h e / s h e ever r u n away from h o m e ? Positive = yes, stayed away overnight. 9. Does h e / s h e bully o t h e r children? Positive = yes. 10. Is h e / s h e careless in p e r s o n a l a p p e a r a n c e ? Positive -- yes. ll. Has h e / s h e ever b e e n fired f r o m a job? Positive = yes. 12. Has h e / s h e h a d any experience with drugs or alcohol? Positive = illicit drug use (e.g., m a r i j u a n a or " h a r d " drugs such as heroin). 13. Has h e / s h e come to the a t t e n t i o n o f the police or juvenile authorities? Positive = yes. IV. Developmental variables. Dates o f the usual m o t o r a n d v e r b a l milestones were a part o f the q u e s t i o n n a i r e . These items were: A t w h a t age could h e / s h e sit alone? Stand alone? Walk? Talk in complete sentences? F o r each o f these d e v e l o p m e n t a l milestones a m e d i a n age was c o m p u t e d for each sex. i n d i v i d u a l a d o p t e e s were characterized by b e i n g a b o v e or below t h a t m e d i a n
304
Cadoret et al.
The Journal of Pediatrics August 1975
Table IlL Temperament, hyperactivity; and antisocial traits in adoptees from antisocial and other biologic backgrounds Oth'er parental A ntisociat psychiatric No. items parentage l conditions positive (N = 22) (iv= 37)
5 8 4 0
16 9 5
1
6
0
4 9
P = NS ? 23
1
4
9
2 3
8 5 l 0 N p = 0.034/ 9 16
Thomas-Chess: Birch temperament items
Hyperactive behavior items
Antisocial behavior items
0
1
l
3
6
2 3 4
0 5 0
3 1 3
5
4
p = NS/8
NS = Significancegreater than 10%. (positive = above inedian). The total number of positive developmental items for each individual defined the physical development score. V. The questions relating to "neuropathic" traits. An addition enquiry was made into the presence of abnormal behavior s generally known as neuropathic traits: enuresis, nail biting, and excessive thumb sucking. 1. Did he/she wet the bed beyond age three? Positive = yes. 2. Did he/she suck his/her thumb; fingers, or a pacifier beyond age three? Positive = yes. 3. Does he/she bite his/her nails? Positive = yes. The total positives for these three items defined an 9index for neuropathic ffaits. RESULTS Differences between control and experimental adoptees in temperament and behavior characteristics and the relationship of these characteristics and biologic parent diagnosis are as given below. I. T e m P e r a m e n t variables. The frequency table of restilts in Table II Shows that significantly more male experimental ad0ptees have a higher number of "positive" temperament items, i.e., had traits in childhood and infancy characterized by withdrawal from new situations or intense negative reactions. The most common pattern
of temperament traits appears to be close to the description of the "difficult child," who can be described as having four out of the following five characteristics described by Thomas and associatesY: (1) irregular biologic functions; (2) Withdrawal in new situations; (3) slow to adapt to new situations; (4) primarily negative moods; and ~(5) intense reactions. Using this criterium the experimental group of adoptees contains six difficult children (five males, one female) and the control adoptees, one difficult child (one male). The difference between control and experimental groups is not significant, but the overall sex difference (six males to one female) suggests a preponderance of males with this syndrome. Everyone of these difficult children received a diagnosis in the previous study1: three were mentally retarded, one was hyperactive, one antisocial, one encopretic (the control adoptee), and one developed a major psychosis (schizophrenia) in his teens. We did not find any clear-cut cases of other temperament types described by Thomas and associates, 2 such as children who are slow to warm-up or who are especially persistent children. ii. Hyperactive behavior. In the previous report, 1 significantly more children with ti:eated hyperactivity were found among the experimental adoptees. This difference is reflected in the results listed in Table II where the number of traits composing the hyperactive syndrome are higher in the experimental males, though not to a significant extent. The total number of positive items for male and female experimental adoptees is significantly different from the total items positive in tile control groups, however. IlI. Antisocial behavior. In the previously reported analysis, antisocial diagnoses were made in three children of the control group adoptees and in four of the experimental group. When viewed this way, there does not appear to be a difference. However, when we count the number Of antisocial behaviors shown by each adoptee we find a significant difference: experimental males have a higher number of antisocial behaviors than the male controls (Table II). IV. Physical developmental milestones. Results of this analysis are listed in Table ii. There was a slight trend for the experimental males to take somewhat longer to teach their developmental milestones, but this difference was not'significant. V. "Neuropathic" traits. None of the control versus experimental adoptee differences showed any trends for these behaviors (Table II). Biologic parent diagnosis. The relationship of temperament and other behavioi" items to biologic parent diag: nosis is complicated by the heterogeneity of psychiatric
Volume 87 Number 2
conditions in the biologic parents. In this series the most frequent psychiatric diagnosis in the biologic parent was antisocial personality (N = 22). Other psychiatric conditions were much less frequent (Table I). For purposes of crudely relating temperament to diagnoses we contrasted the adoptees from antisocial parents with all other remaining experimental adoptees. We selected three areas which, in the analyses above, showed differences between control and experimental adoptees: temperament, hyperactive, and antisocial behaviors. The results of these analyses appear in Table III. Temperament shows no correlation with parental diagnosis. Hyperactivity is significantly correlated with antisocial parentage. Antisocial behaviors, however, are not correlated with antisocial parentage. DISCUSSION The most outstanding finding of this study is the association of reported early temperament problemswith psychiatrically disturbed biologic parentage. Since these temperament items represent behavior which occurred at a considerable distance in the past (median time of approximately ten years) there would be ample opportunity for retrospective falsification or exaggeratio n. Because we have no prospective information on temperamen t , hyperactivity, etc., we are unable to determine the Validity of the information contained in our parental assessments of these early life behaviors. Recall of childhood and infant behaviors might also be affected by later parental experience such as might occur when parents bring children for professional treatment of behavior problems. In our data, treatment and early positive Thomas temperament traits are highly correlated in both control and experimental adoptees-as might be expected on both the hypothesis of biased recall and actual presence of these behaviors. We have no independent evidence such as behavior or complaints recorded during theinfancy or childhood of the adoptees, such as might be foundon a well-baby check. However, our data do Provide some evidence on the effect of treatment on number of Thomas temperament items reported. There were 37 children in the experimental group who had no treatment , and of these, 18 (48.6%) had one or more positive Thomas temperament items. In the control group in 47 untreated adoptees there were 16 (34%) with one or more positive temperament items. Although this difference is not significant (X2 = 1.27, df = 1, p < 0.10), it does go in the direction of a higher number of temperament items reported in the experimental group by parents who have never sought treatment for a behavior problem in their adopted child. Obviously the ultimate evidence for validity of these findings will have to be based on
Studies of adoptees
305
prospective studies or upon information recorded (in an unbiased manner) at the time it occurred, The other important finding of the study is the correlation of hyperactive behaviors with antisocial biologic parents. Longitudinal studies of hyperactive children have reported high rates of later (adult) antisocial behaviorr The latter studies suggested a "developmental" relationship between antisocial behau and childhood hyperactivity; our study suggests thai the relationship may ir~volve a genetic element as well. What role that adoptive parents play in the development of the hyperactive and antisocia! behaviors is not clear. Some have postuIated that anxiety and concern in adoptive parents could be a factor in eliciting hyperactive and antisocial behavior in adoptees. 9 According to this model, our experimenta! adoptive parents might have had increased anxiety due to being told that their ad0Ptee came from a psychiatrically disturbed biologic background. However, at th e time these children were adopted it was the policy of the involved agencies not to impart information of this type tO adoptive parents, so there is no reason to consider tha t anxiety levels would be higher in experimental than control adoptive parents. In the past, so-ca!led neuropathic traits have been described as indicators of future psychopathology as well as present problems. However, some studie s have reported poor predictability of future psychopathology using these traits? Furthermore, present views of such behaviors as enuresis make more of a case for an inherited maturational or structural condition 7 and family and twin studies of nail biting suggest an inherited basis for this behavior. 8 The present data show no trend for an association of the neur0pathic traits with biologic parental psychopathology - either when considered as a total (Table II) or singly. Because we have no information on nail biting and enuresis in the biologic parents, we cannot verify the importance of genetic factors in these conditions The major findings of this study relating hyperactivity and antisocial behavior to biologic parental background should give the practicing pediatrician a more biologic perspective on the genesis of these conditions. REFERENCES
1. Cunningham L, Cadoret RJ, Loftus R, and Edwards J: Studies of adoptees from psychiatrically disturbed biological parents I. Psychiatric conditions in childhood and adolescence, Br J Psychiatry 1975 (in press). 2. Thomas A, Chess S, and Birch HG: Temperament and behavior disorders in cMldren, New York, 1968, New York Universjty Press. 3. Robins L: Deviant children grown up, Baltimore, 1966, The Williams & Wilkins Company. 4. Weiss G, Minde K, Werry J, Douglas U, and Nemeth E:
306
Cadoret et al.
Studies on the hyperactive child VIII. Five year follow-up, Arch Gen Psychiatry 24:409, 1971. 5. Cantwell, D.: Psychiatric illness in hyperactive children, Arch Gen Psychiatry 27:414, 1972. 6. Crowe RR: An adoption study of antisocial personality, Arch Gen Psychiatry 31:785, 1974. 7. Bakwin H, and Bakwin R: Clinical management of behav-
The Journal of Pediatrics August 1975
ioral disorders in children, ed 4, Philadelphia, 1972, WB Saunders Company. 8. Massler M, and Malone AJ: Nail-biting: a review, J PEDIATR 36:523, 1950. 9. Reese S, and Levin B: Psychiatric disturbances in adopted children: a descriptive study, Social Work 13:101, 1968.
RichardW.Olmsted, Editor
Studies of adoptees from psychiatrically disturbed biologic parents 11. Temperament, hyperactive, antisocial, and developmental variables
Temperament, hyperactivity, antisocial behavior, and developmental milestones were assessed in two groups of adoptees by interviewing the adoptive parents. One group, the "experimental, "' was born of psychiatrically disturbed biologic parents (N = 59). The second group, the "control,'" had psychiatrically "normal'parents (N = 54). Infants in each group were separated from their biologic parents at birth and had no further contact with them. Male "'experimental" adoptees had excess number o f temperament traits characteristic of the "difficult" child, as well as an excess of antisocial behaviors when contrasted with male control subjects. No differences between control and experimental females were found for these variables. Hyperactive behavior in the adoptees o f each sex was associated more with antisocial parentage than in those of "normal" parentage.
Remi J. Cadoret,* Lynn Cunningham, R o s e m a r y L o f t u s , and James Edwards, I o w a City, l o w a
IN A PREVIOUS R E P O R T 1 the present authors assessed psychiatric disability in two groups of adoptees: one, composed of 59 offspring of psychiatrically disturbed biologic parents (the experimental adoptees); and the second, composed of 55 offspring of apparently psychiatrically "normal" biologic parents (the control adoptees). Both experimental and control adoptees had been separated at birth from their biologic parents and had had no further contact with other biologic relatives. The two groups of adoptees were matched for sex, age, and age of mother at time of adoptee birth. Table I details the types of biologic parental matings for both adoptee groups. On the basis of information collected by a telephone interview with the adoptive parents we were able to determine the behavioral adjustment of each adoptee and in many cases arrive at a specific psychiatric diagnosis. The major finding from the previous study was that 37% of all the experimental adoptees received professional treatment for a behavior disorder compared to only *Reprint address: Psychopathic Hospital, University of Iowa College of Medicine, 500 Newton Rd., Iowa City, Iowa 52242.
14% of the control adoptees (X2 = 6.45, df = 1, 0.02 > p > 0.01). Furthermore, 59% of the 32 male experimental adoptees received treatment for a behavior disorder in contrast to 30% of the 27 female adoptees--an even more highly significant difference. Most of the excess of ill experimental male adoptees was accounted for by one diagnosis: hyperactivity. Seven out of the eight hyperactive-experimental adoptees were male. The control group contained only one hyperactive adoptee, The difference between control and experimental groups was significant (X2 = 3.90, d f = 1, 0.05 > p > 0.02). The purpose of the present report is to analyze other important childhood behaviors in the adoptees and relate these behaviors to the psychiatric diagnosis of the biologic parents. Recent advances in child psychiatry have emphasized the importance of temperament in behavior and in the genesis of later disorders of behavior. ~ As part of the behavioral picture of the adoptees, we assessed some of the childhood temperament factors described by Thomas and associates,2 and this report contains the results of analyses of temperament in these adoptees. In the former paper 1 we gave each child a diagnostic The Journal ofPEDI ATRICS VoL 87, No. 2, pp. 301-306
301
302
Cadoret et al.
The Journal of Pediatrics August 1975
Table I. Matings of biologic parents
Psychiatric diagnosis of biologic parents "Normal" mother/"normal" father Mother antisocial/"normal" father Father antisocial/"normal" mother Mother affective disorder/"normaI" father Mother affective disorder/antisocial father Mother major psychosisi"normal" father Mother mentally retarded/"normal" father Mother undiagnosed/"normal" father Mother undiagnosed/antisocial father Mother diagnosed (alcoholic or neurotic)/"normal" father Mother "normal"/alcoholic father
Experimental (N=59)
Control (N=55)
18 1 4
55 ---
1
-
8
-
11
-
10 2 3
---
1
-
label, an approach which does not examine the more subtle quantitative aspects of behavior: how many behaviors of a certain type does an individual demonstrate? For example, only a few adoptees were diagnosed as having antisocial personalities, yet a far larger n u m b e r of these children had more than a few of the behaviors usually associated with antisocial personality. Similarly with hyperactivity, more individuals were reported to have some of the characteristic behaviors of this condition (such as distractibility), but not enough of these behaviors to warrant the diagnostic label. We have, therefore, analyzed antisocial- and hyperactive-type behaviors in terms of numbers of behaviors per child of the types complained of by the adopting parents. Developmental variables, such as usual motor milestones, were also analyzed because of the inclusion in the experimental group of adoptees of biologic parents with mental retardation, and because of the possibility that developmental problems were associated with such behaviors as hyperactivity. Disorders occurring during development, such as so-called "neuropathic" traits (nailbiting, thumb sucking, and enuresis), were also analyzed. METHODS
Detailed methodology regarding selection and sampling of adoptees is presented in the previous report.' Informed consent was obtained from the adoptive parents before calling them to conduct the interview. Adopting parents were interviewed by telephone regarding a number of developmental and behavioral facts about their adopted child. The median age of adoptees at the time of
interview was 17. The professional social worker who interviewed the adoptive parents was "blind" to the status (whether control or experimental) and diagnosis of the biologic parent of the adoptee. The physicians who diagnosed the psychiatric conditions in the biologic parent s were also "blind" to the condition of the adoptees. Similarly, the physician who put a diagnostic label on each adoptee was unaware of whether an adoptee came from a control or experimental biologic parent. Criteria for psychiatric diagnoses can be found in the previous report as well as brief case summaries of "ill" adoptees.1 To organize the temperament and other behaviors into meaningful categories we have used the following classifications: (1) temperament, (2) hyperactivity, (3) antisocial, (4) physical development, and (5) "neuropathic" traits. A comparison was made between scores for the experimental and control group holding sex constant. Differences were assessed by the Mann-Whitney U Test. Onetailed probabilities are reported for all differences which reached the 10% level of significance. I. Temperament variables. Thomas and associates-' describe a cluster of behaviors which characterize the difficult child. These are (1) irregular biologic functions, (2) withdrawal in new social situations, (3) slow to adapt to new situations, (4) intense reactions, and (5) a high frequency of negative moods. Our questionnaire contained eight items relating to the "difficult child diagnosis." In scoring, the answers to those items shown in italic type were rated as positive, and each child was characterized by the number of positive temperament answers (possible range of 0 to 8 positive). 1. Is there a variation from the day-to-day schedule of sleeping, eating, bowel movements, and elimination or is this fairly consistent? 2. Does he/she adjust easily to new situations and experiences? Yes or no. 3. Does he/she approach new situations with ease or does he/she withdraw from these new situations and experiences? 4. When there are changes in immediate environment, is he/she bothered by them or does he/she adjust well? 5. When there are new changes, experiences, and situations, does he/she react violently or mildly voice his/her dislike? 6. Is he/she generally contented at all times or does he/ ~he become easily upset or fussy? 7. Did he/she have frequent temper tantrums? Yes or no.
8. Is he/she emotional and sensitive? Yes or no. II. Hyperactivity variables. The questionnaire contained the following items covering this area of behavior.
Volume 87 Number 2
Studies o f adoptees
303
Table II. T e m p e r a m e n t , hyperactivity, a n d antisocial b e h a v i o r traits in m a l e a n d f e m a l e adoptees Behavioral areas
I.
Thomas-Chess-Birch temperament items
Adoptee status
Males Females
II.
Hyperactive behavior items
M~les Females
III. Antisocial behavior items
Males Females
IV. Physical developmental milestones
Males Females
V.
"Neuropathic" traits
Males Females
No. items positive
Significance (Mann-Whitney U)
0
1-2
3-4
Exp Cont Exp Cont
8 16 13 19
17 5 9 6
4 2 4 5
3 ~ 1 1 ~ 1
Exp Cont Exp Cont
0 18 19 14 19
1 6 5 7 9
2 7 0 6 2
3 1 ~ 0 0 ~ 1
Exp Cont Exp Cont
0 9 13 16 15
1-2 10 6 6 9
3-4 5 4 1 4
5 8 ~ 1 4 ~ 3
0 12 13 10 10
1-2 14 11 13 14
3 6 ~ 0 4 ~ 7
1 13 11 8 12
2 3 5 4 3
3 0 ~ 1 1 ~ 2
Exp Cont Exp Cont Exp Cont Exp Cont
0 16 7 14 14
5 0.006 NS*
0.076 NS
0.038 NS
0.091 NS
NS NS
Exp = experimental group; Cont = Control group. *NS = significancegreater than 10%.
Answers to hyperactive items in italics were rated as positive (possible r a n g e o f 0 tO 3 positive). 1. Is h e / s h e overactive during quiet periods or c a n h e / s h e rest and'fie quietly d u r i n g quiet periods? 2. W h e n involved in a n activity, c a n h e / s h e c o n c e n t r a t e for ten minutes or more? Yes or no. 3. W h e n involved in a n activity c a n h i s / h e r a t t e n t i o n be easily diverted? Yes or no. III. Antisocial items. Antisocial items were p a t t e r n e d after the antisocial criteria o f Robins3; the following questions dealt with these behaviors. 1. Has h e / s h e ever b e e n t r u a n t f r o m school? Positive = 2 or more times. 2. Has h e / s h e h a d a n y trouble with t e a c h e r s or a d m i n istrators? Positive = in trouble for disciplinary reasons. 3. Has h e / s h e ever b e e n s u s p e n d e d or expelled? Positive = yes, for disciplinary reasons or fighting. 4. Has h e / s h e b e e n i n v o l v e d in fights at school? Positive -- yes. 5. Has h e / s h e frequently b e e n d i s o b e d i e n t a n d / o r h a r d to punish? Positive = f r e q u e n t and difficult p u n i s h m e n t .
6, Does h e / s h e lie frequently? Positive = yes. 7. Has h e / s h e ever stolen a n y t h i n g ? Positive = yes. 8. Has h e / s h e ever r u n away from h o m e ? Positive = yes, stayed away overnight. 9. Does h e / s h e bully o t h e r children? Positive = yes. 10. Is h e / s h e careless in p e r s o n a l a p p e a r a n c e ? Positive -- yes. ll. Has h e / s h e ever b e e n fired f r o m a job? Positive = yes. 12. Has h e / s h e h a d any experience with drugs or alcohol? Positive = illicit drug use (e.g., m a r i j u a n a or " h a r d " drugs such as heroin). 13. Has h e / s h e come to the a t t e n t i o n o f the police or juvenile authorities? Positive = yes. IV. Developmental variables. Dates o f the usual m o t o r a n d v e r b a l milestones were a part o f the q u e s t i o n n a i r e . These items were: A t w h a t age could h e / s h e sit alone? Stand alone? Walk? Talk in complete sentences? F o r each o f these d e v e l o p m e n t a l milestones a m e d i a n age was c o m p u t e d for each sex. i n d i v i d u a l a d o p t e e s were characterized by b e i n g a b o v e or below t h a t m e d i a n
304
Cadoret et al.
The Journal of Pediatrics August 1975
Table IlL Temperament, hyperactivity; and antisocial traits in adoptees from antisocial and other biologic backgrounds Oth'er parental A ntisociat psychiatric No. items parentage l conditions positive (N = 22) (iv= 37)
5 8 4 0
16 9 5
1
6
0
4 9
P = NS ? 23
1
4
9
2 3
8 5 l 0 N p = 0.034/ 9 16
Thomas-Chess: Birch temperament items
Hyperactive behavior items
Antisocial behavior items
0
1
l
3
6
2 3 4
0 5 0
3 1 3
5
4
p = NS/8
NS = Significancegreater than 10%. (positive = above inedian). The total number of positive developmental items for each individual defined the physical development score. V. The questions relating to "neuropathic" traits. An addition enquiry was made into the presence of abnormal behavior s generally known as neuropathic traits: enuresis, nail biting, and excessive thumb sucking. 1. Did he/she wet the bed beyond age three? Positive = yes. 2. Did he/she suck his/her thumb; fingers, or a pacifier beyond age three? Positive = yes. 3. Does he/she bite his/her nails? Positive = yes. The total positives for these three items defined an 9index for neuropathic ffaits. RESULTS Differences between control and experimental adoptees in temperament and behavior characteristics and the relationship of these characteristics and biologic parent diagnosis are as given below. I. T e m P e r a m e n t variables. The frequency table of restilts in Table II Shows that significantly more male experimental ad0ptees have a higher number of "positive" temperament items, i.e., had traits in childhood and infancy characterized by withdrawal from new situations or intense negative reactions. The most common pattern
of temperament traits appears to be close to the description of the "difficult child," who can be described as having four out of the following five characteristics described by Thomas and associatesY: (1) irregular biologic functions; (2) Withdrawal in new situations; (3) slow to adapt to new situations; (4) primarily negative moods; and ~(5) intense reactions. Using this criterium the experimental group of adoptees contains six difficult children (five males, one female) and the control adoptees, one difficult child (one male). The difference between control and experimental groups is not significant, but the overall sex difference (six males to one female) suggests a preponderance of males with this syndrome. Everyone of these difficult children received a diagnosis in the previous study1: three were mentally retarded, one was hyperactive, one antisocial, one encopretic (the control adoptee), and one developed a major psychosis (schizophrenia) in his teens. We did not find any clear-cut cases of other temperament types described by Thomas and associates, 2 such as children who are slow to warm-up or who are especially persistent children. ii. Hyperactive behavior. In the previous report, 1 significantly more children with ti:eated hyperactivity were found among the experimental adoptees. This difference is reflected in the results listed in Table II where the number of traits composing the hyperactive syndrome are higher in the experimental males, though not to a significant extent. The total number of positive items for male and female experimental adoptees is significantly different from the total items positive in tile control groups, however. IlI. Antisocial behavior. In the previously reported analysis, antisocial diagnoses were made in three children of the control group adoptees and in four of the experimental group. When viewed this way, there does not appear to be a difference. However, when we count the number Of antisocial behaviors shown by each adoptee we find a significant difference: experimental males have a higher number of antisocial behaviors than the male controls (Table II). IV. Physical developmental milestones. Results of this analysis are listed in Table ii. There was a slight trend for the experimental males to take somewhat longer to teach their developmental milestones, but this difference was not'significant. V. "Neuropathic" traits. None of the control versus experimental adoptee differences showed any trends for these behaviors (Table II). Biologic parent diagnosis. The relationship of temperament and other behavioi" items to biologic parent diag: nosis is complicated by the heterogeneity of psychiatric
Volume 87 Number 2
conditions in the biologic parents. In this series the most frequent psychiatric diagnosis in the biologic parent was antisocial personality (N = 22). Other psychiatric conditions were much less frequent (Table I). For purposes of crudely relating temperament to diagnoses we contrasted the adoptees from antisocial parents with all other remaining experimental adoptees. We selected three areas which, in the analyses above, showed differences between control and experimental adoptees: temperament, hyperactive, and antisocial behaviors. The results of these analyses appear in Table III. Temperament shows no correlation with parental diagnosis. Hyperactivity is significantly correlated with antisocial parentage. Antisocial behaviors, however, are not correlated with antisocial parentage. DISCUSSION The most outstanding finding of this study is the association of reported early temperament problemswith psychiatrically disturbed biologic parentage. Since these temperament items represent behavior which occurred at a considerable distance in the past (median time of approximately ten years) there would be ample opportunity for retrospective falsification or exaggeratio n. Because we have no prospective information on temperamen t , hyperactivity, etc., we are unable to determine the Validity of the information contained in our parental assessments of these early life behaviors. Recall of childhood and infant behaviors might also be affected by later parental experience such as might occur when parents bring children for professional treatment of behavior problems. In our data, treatment and early positive Thomas temperament traits are highly correlated in both control and experimental adoptees-as might be expected on both the hypothesis of biased recall and actual presence of these behaviors. We have no independent evidence such as behavior or complaints recorded during theinfancy or childhood of the adoptees, such as might be foundon a well-baby check. However, our data do Provide some evidence on the effect of treatment on number of Thomas temperament items reported. There were 37 children in the experimental group who had no treatment , and of these, 18 (48.6%) had one or more positive Thomas temperament items. In the control group in 47 untreated adoptees there were 16 (34%) with one or more positive temperament items. Although this difference is not significant (X2 = 1.27, df = 1, p < 0.10), it does go in the direction of a higher number of temperament items reported in the experimental group by parents who have never sought treatment for a behavior problem in their adopted child. Obviously the ultimate evidence for validity of these findings will have to be based on
Studies of adoptees
305
prospective studies or upon information recorded (in an unbiased manner) at the time it occurred, The other important finding of the study is the correlation of hyperactive behaviors with antisocial biologic parents. Longitudinal studies of hyperactive children have reported high rates of later (adult) antisocial behaviorr The latter studies suggested a "developmental" relationship between antisocial behau and childhood hyperactivity; our study suggests thai the relationship may ir~volve a genetic element as well. What role that adoptive parents play in the development of the hyperactive and antisocia! behaviors is not clear. Some have postuIated that anxiety and concern in adoptive parents could be a factor in eliciting hyperactive and antisocial behavior in adoptees. 9 According to this model, our experimenta! adoptive parents might have had increased anxiety due to being told that their ad0Ptee came from a psychiatrically disturbed biologic background. However, at th e time these children were adopted it was the policy of the involved agencies not to impart information of this type tO adoptive parents, so there is no reason to consider tha t anxiety levels would be higher in experimental than control adoptive parents. In the past, so-ca!led neuropathic traits have been described as indicators of future psychopathology as well as present problems. However, some studie s have reported poor predictability of future psychopathology using these traits? Furthermore, present views of such behaviors as enuresis make more of a case for an inherited maturational or structural condition 7 and family and twin studies of nail biting suggest an inherited basis for this behavior. 8 The present data show no trend for an association of the neur0pathic traits with biologic parental psychopathology - either when considered as a total (Table II) or singly. Because we have no information on nail biting and enuresis in the biologic parents, we cannot verify the importance of genetic factors in these conditions The major findings of this study relating hyperactivity and antisocial behavior to biologic parental background should give the practicing pediatrician a more biologic perspective on the genesis of these conditions. REFERENCES
1. Cunningham L, Cadoret RJ, Loftus R, and Edwards J: Studies of adoptees from psychiatrically disturbed biological parents I. Psychiatric conditions in childhood and adolescence, Br J Psychiatry 1975 (in press). 2. Thomas A, Chess S, and Birch HG: Temperament and behavior disorders in cMldren, New York, 1968, New York Universjty Press. 3. Robins L: Deviant children grown up, Baltimore, 1966, The Williams & Wilkins Company. 4. Weiss G, Minde K, Werry J, Douglas U, and Nemeth E:
306
Cadoret et al.
Studies on the hyperactive child VIII. Five year follow-up, Arch Gen Psychiatry 24:409, 1971. 5. Cantwell, D.: Psychiatric illness in hyperactive children, Arch Gen Psychiatry 27:414, 1972. 6. Crowe RR: An adoption study of antisocial personality, Arch Gen Psychiatry 31:785, 1974. 7. Bakwin H, and Bakwin R: Clinical management of behav-
The Journal of Pediatrics August 1975
ioral disorders in children, ed 4, Philadelphia, 1972, WB Saunders Company. 8. Massler M, and Malone AJ: Nail-biting: a review, J PEDIATR 36:523, 1950. 9. Reese S, and Levin B: Psychiatric disturbances in adopted children: a descriptive study, Social Work 13:101, 1968.