An excerpt from the forthcoming book “Trauma and the Post-Institutionalized Child” by Mary Beth Williams, PH.D.

Dear Reader:

Adoption is an ongoing process not a static event, a process worthy of discussion, recognition, and honor.

Are you choosing to be one of the growing number of American families who adopt internationally or are you receiving referrals from newly adoptive families that have trauma-related issues that are bringing them to treatment? For example, 12,596 children were internationally adopted in 1997, an 11% increase over 1996 and a 71% increase over 1993 (U.S. Immigration and Naturalization Service, 1998). All parents want a healthy child, whether that child joins a family through birth or adoption. It is probable that they will want a child to

  • be able to attach and be intimate
  • become autonomous and independent over time
  • feel safe and secure with them
  • trust them
  • develop self esteem
  • develop a conscience

Any individual, child or adult, of any ethnicity, has 5 basic psychological needs – safety, trust, power/control, esteem and intimacy (Rosenbloom & Williams, 1999). A major task of parenting is to help a child develop the abilities to meet these needs with self, others, and the world. If a child is above the age of 1 when adopted, she has already begun the journey of meeting her needs or having needs met. Once a child is adopted, it is the charge of parents to meet those needs and to help their child meet her needs in the order listed above with safety first, above all else. This is particularly relevant when recognizing that many children have not had a safe environment prior to adoption.

As an adoptive parent, or as a professional working with post-institutionalized internationally adopted children, hopefully you will be thinking about the impact of the world in which that child lived prior to being adopted. In some instances, the child will have lived with a foster care family rather than in an orphanage. In others, the child will have known only one or several institutions. In those institutions, the child may have been unable to meet her needs for food, attention, touch, and comfort when in pain. Over time, she may have learned not to look for those needs to be met and may have come to distrust the adults in his or her world. Also, the child may have experienced neglect, poor nutrition, lack of stimulation and potential for attachment, inconsistent caregivers, and various forms of traumatic experiences including physical abuse, sexual abuse, and witnessing of violence toward others (including other children). Thus, it is important to begin to think about what will happen in this child’s life as she grows into maturity and how his environment has impacted her.

Trends In International Adoption

A growing number of families in a growing number of countries are looking to other countries to find children. In fact, a plethora of books has recently appeared on the market concerning international adoption, seeking to keep pace with the increasing numbers of families who are adopting. To reiterate, according to Immigration and Naturalization Service(INS) statistics from the year 2000, in 1995 Americans adopted 9679 children from international sources; by 1997, the number was 13,620; by 1999, 16,396; and by 2000, 18,537 (Meese, 2002). By the late 1990’s over 14,000 children were adopted annually from other countries (Federici, 1998). The INS website at can give more recent statistics.

And just why are families choosing to go out of the country to adopt? First, there is a shortage of adoptable children in the United States of the age range (young) and racial characteristics (Caucasian) desired. Second, families may have closer ethnic ties with specific foreign countries. In some cases there is a fear that birth parents in the United States can change their minds and will come to take back their children, even after an adoption has occurred. (Johnson, 1999) The initial FRUA (Families of Russian and Ukranian Adoption and Neighboring Countries) survey looked at motivation of parents adopting from Russia, the Ukraine, and neighboring countries. The first reason for adopting in those areas was availability of children. Only about half of those responding said that the race/ethnicity of the child was an important factor.

International adoption often is a very expensive process. By the time a family is finished with paperwork, travel, and home study, expenses may run between $25,000 – 30,000 for one or two children, depending on their country of birth. Generally, prospective parents receive very little information about their child’s history –in any form. Medical information may be inaccurate, if not untrue. In some countries, children in the past were given false medical diagnoses to “get them out of the country” as damaged children. This was true of some adoptions from Kazakhstan as recently as 2002. Today, there is a growing recognition that even what seemed to be false or inaccurate diagnoses may have some basis in fact.

Factors Influencing Successful Adoption

McKelvey and Stevens (1994) believe that the following factors are most important in primary prevention for a successful adoption:

  • adopting an infant or as young a child as possible
  • having a permanency plan for children put in the foster care system developed at the time they enter care
  • providing consistent care giving
  • having minimal moves between homes, orphanages, caretakers
  • providing pre-placement education and services to potential parents
  • trying to ensure a sense of fit between parent and child in terms of temperament
  • fully disclosing the child’s known history
  • conducting realistic risk appraisal about the child if nothing or little is known
  • doing pre-placement preparation for toddlers and older children to transfer attachment if it does exist
  • providing post-placement support and intervention before crises happen
  • providing ongoing education, support and therapeutic services through adolescence
  • understanding losses in both the parent, and child
  • knowing the nature, quality, and patterns of prior attachments the child has (have) had
  • exercising immediate “claiming” of child to parent and parent to child as a family with a family identity
  • pre-considering the place of the child in the new family system in terms of roles, behaviors, and status
  • developing pre-placement realistic expectations for parent and child, based on knowledge of history, life circumstances, system influences (foster care, orphanage, etc.), child development stages and actualities
  • educating parents about appropriate parenting strategies (Levy & Orlans, 1998) for adopted children.

Initial Post-Placement Roles

Attachment between a parent and a post-institutionalized child begins with the parent. It is up to the adult to begin the process by creating an empathic, safe, caring, loving environment for a new child. It is up to the adoptive parent to model communication, affection, coping, and emotional modulation. It is up to him or her to remain in control if and when the child does not. It is up to the parent to take good care of him/herself above all else in order to take good care of the family. Parents will provide the love and nurturing and will provide the rules and structure (Ibid., p. 200). Treating new children with respect and maintaining a sense of hope will instill that hope in them that they have found a forever family. Suggestions for modeling and instilling hope include the following:

  • addressing the child in positive language
  • recognizing and stating that behavior is bad, the child is not
  • providing physical nurturing and attention
  • providing emotional nurturing
  • being the lead on giving affection and encouraging reciprocity from the child
  • setting a sense of order and structure
  • setting realistic limits and rules
  • having consistency in bedtime, mealtime and other routines
  • stopping manipulation of parents (if there are 2) immediately by being on the “same page”
  • holding the child accountable to learn and to abide by the rules
  • practicing healthy self care by having a life outside the home
  • using eye contact with the child
  • praising the child’s behavior (he did a good job)
  • keeping calm when the child is having a meltdown, to the best of a parent’s ability
  • teaching the child to problem solve as soon as language allows; prior to that, keeping language short and simple
  • giving the child choices right from the beginning
  • developing time out strategies for bad situations

Helpful Factors in International Adoption

According to Hopkins-Best (1996), there are pre-institutional and institutional factors that help children adjust to their adopted families. Children who have had the fewest number of moves during their pre-adoptive years fare better, unless they have been seriously abused and/or neglected in any placement. Those who have had a secure attachment to a caregiver are more likely to attach to new parents. If the child had an opportunity to see that figure before leaving the institution or, if the caregiver was in a previous orphanage, had the chance to go back to see that caregiver to say good-bye, then the child could transition with the blessings (and often tears of joy) of that caretaker. Toddlers who have had a chance to transition to the adoptive family with preparation and even gradual visitation and overnights do better than those who suddenly are placed with a family, never to return to the orphanage again, not able to say good-bye to friends and caretakers. Also, as will be discussed later, some children are just more resilient than others.

In lieu of the 26 December 2004 massive earthquake and subsequent tsunami in southeast Asia which has left hundreds of thousands dead and millions homeless. Among those surviving are countless orphans with few or no extended family members able to care for them. Initially, to stop the potential for human trafficking and exploitation, potential adoption of orphans to foreigners was stopped. Over time, perhaps some or many of these children will become available for adoption. It is possible that many will be extremely traumatized and will need intervention.

I. Risk Factors In International Adoption

Things to Consider, While You are Hither

The Situation In Orphanages

In general, what might a child’s life have been in an Eastern block orphanage?
Johnson (2000) notes that orphanages generally have a lack of stimulation, inconsistent caregivers, poor nutrition, abuse, and poor medical care. Even the best institutions have the following:

  • uneducated or minimally trained caregivers
  • rotating caregivers on shifts
  • abrupt transfers to different orphanages or sections of an orphanage
  • loss of peers as those children are adopted or transferred
  • limited language interaction with adults
  • regimented daily activities: eating, sleeping, toileting all at the same time
  • lack of spontaneous activities
  • absence of personal possessions
  • limited activities to develop motor skills – no use of markers, pencils, equipment
  • exposure to toxins including lead (Meese, 2002, pp. 9-10)

Orphanages generally do not accommodate individual needs (Jamieson, 1991). Parents who have gone to an orphanage on several occasions, not just when a child was being readied to meet that adoptive parent, gain important information. For example, children might be dressed neatly when staff know a parent is coming but might be dressed in underwear and a hat to play outside in the dirt, otherwise. What does it say if a four-year-old girl has no idea as to the “purpose” of a doll? What if she simply stands and makes faces at the doll? In reality, in many of these orphanages, there often are only a few toys (many broken) that are available for play.

And what about the physical and developmental condition of the children? Children in many orphanages are frequently nutritionally deprived and often have low muscle tone. Playground equipment may be non-existent or, if present, may be in disrepair. Children may be over-responsive when put in high-stimulus situations. Speech acquisition because of minimal exposure and subsequent minimal usage of words may be extremely delayed and it may take a long time to develop appropriate articulation and grammar. Brian Norden (February 19, 2003) in a message to the list serve noted that his daughters (older, 16 and 13) came to the United States with “no ability to make decisions. At the orphanage they did what everyone else did, ate when everyone else ate, went to school when they were told, or when everyone else did, even using the restroom on a schedule. They were given two outfits at the beginning of the week and wore which ever until laundry day.. . It was actually very stressful for them to have to make decisions. . . With food . . . they didn’t know what they liked or didn’t like.” What this means is that they were never encouraged to make (good) decisions and no one talked to them about choice making – key essentials to personal success and active coping.

At first sight, the child may appear to be overly mature and “too good,” “well trained,” ready at age 4 (for example) to learn how to do work and to care for younger children. They may know how to dress themselves, go to the bathroom totally independently, sweep floors with a large broom, and sit quietly without any argument for long periods of time. Older siblings in a sibling group may also be parentified, having been taught to take care of younger brother(s) and sister(s). In reality, their often traumatic experiences within the institution have taught and conditioned them to be hypervigilant and take on expected roles without consideration or even recognition of their own individual desires or needs.

As a caution, however, through research and data collection, Families for Russian and Ukrainian Adoption and Neighboring Countries (FRUA) has discovered that many observed behaviors of children in these institutions are based on cultural differences. In some cultures, all children are potty trained by 18 months of age. Just because certain behaviors appear to be “appalling” by American standards, it does not mean that one needs to make a negative inference as to motivation of caretakers or about the situation. The behavior may be a cultural difference that is a normal part of a child’s background from his original part of the world.

Potential Sources of Trauma: More on Life in Orphanages

Food and Eating

Children in institutions have little opportunity to express their own desires about food. Imagine a group of 20 toddlers sitting around a table waiting for food. They are given a bowl of soup with a small piece of meat in it and a large spoon. These children are adept at using a spoon but do not know a fork or knife. It does not matter if they like the soup or not, soup and a piece of bread, are all they get to eat. Now imagine a group of 20 younger children who want their breakfast. They are allotted 30 minutes to be served and to eat all their porridge. Serving these children quickly is a daunting task that does not allow time for individualized attention including hand feeding, time for the children to play with their food, or even have time to interact with one another. There is no fruit, no cheerios as finger foods, no granola bars or sippy cups, and generally no variation in the diet offered.

FRUA’s informal orphanage survey, based on what parents reported seeing while in-country, found that infant bottles were often propped with towels during eating. Children were rotated through the caregivers arms for clean-up and burping afterwards.

When a child who has had more than formula (whatever that formula may be) comes home and is presented with food other than that which is familiar, there may be many reactions. Initially, the child may eat everything in sight because there is food available, without expressing preference. It was not unusual in the hotel restaurant in Kazakhstan to see small children devour two or three full adult breakfasts in the first days post-placement. The child may appear to have unending thirst and drink glass upon glass of juice to the point you wonder if the child may have diabetic inclinations. The child may wolf down any food placed in front of him without hesitating to even look at what is being given. It may not be until weeks later that she might begin to express any food preferences or dislikes. It may also take a few weeks for the child to understand that the abundance of food before him is not just a one-time event but is the norm for his family.

For example, the typical daily routine for children and their diet in Baby Home # 4 (which houses children up to 4 years of age) in Almaty, Kazakhstan is the following: The babies get a bottle of formula called Kiefer (similar to yogurt) at 6:00 a.m. and then have play time until 8:00 a.m. Next, they nap between 8 – 10:00 a.m. and are fed kasha at 10:00 a.m. Kasha is a rice or wheat porridge; twice weekly, when kasha is served, it has ¼ of an egg mixed in it. The children take naps between 12-2:00 p.m. and then eat a meal that consists of vegetable and meat foods. They have play time until 4:00 p.m., nap again between 4-6:00 p.m., followed by Kasha again, play until 8:00 p.m. and then go to bed for the night, with a bottle at 10:00 p.m. The schedule is very strictly kept and persons bringing children back have said that it is easier for children to adjust if parents keep a similar one (February 10, 2003 message on the website).

Just what did a child have to eat in the institution–was it porridge for breakfast, soup for lunch, and a rice mixture for dinner? Did the child get any treat of candy, if ever? Was food used as a reward? Imagine two groups of 20 children playing together on a dirt playground assigned to each group. An agency coordinator comes with a bag of candy in hand. She gives the candy to the group that her agency has been assigned but the other group on the neighboring playground, assigned to a different agency, sees the candy. The children run over and began to beg and hold out their hands. Their caretaker gets upset and tries to call them back but the children ignore her. Their desire for a piece of candy overrides their desire to listen!

In addition, the child may have had little or no exposure to the common (more costly to produce) ethnic foods of his native land. If a parent has the opportunity prior to returning to the United States, should that parent go to pick up the prospective child overseas, it might be important as part of parental (and child) cultural education to take him to native restaurants to experience authentic food. The child may never have seen, let alone eaten, a banana, cherry, apple, or orange. While taking my children from the orphanage for a day, as we walked along the streets of Almaty, Kazakhstan, we came to a fruit vendor. I bought bananas and cherries for the girls. They had no clue what to do with either and began to try to eat the banana without peeling it. Once they had tasted the fruit, every time we went by a similar stand, we had to stop to buy something. They were eager to try the new tastes and had only a few gastro-intestinal problems from their new dietary additions. This is not always the case, however. Parents need to be wary to introduce new foods to the child. When returning home, parents also need to introduce new foods slowly, one at a time. Many cannot process certain foods quickly or all at once or they may have allergic reactions to others. For example, some children have broken out in hives after eating strong citrus fruits. It is important to recognize that these children may be overly sensitive to preferences and have stomach upsets and varied comfort levels. A child who may never have eaten textured foods such as granola or cheerios or even ice cream and cow’s milk can have some initial digestive upsets when presented with these or similar foods.

Federici (1998) notes that many institutionalized children become rigid and inflexible in their eating preferences once they leave the institutional setting. Therefore, even in the first days of post-institutional living, it is important that parents not give in to every whim a child has. Allow the child to drink and eat reasonable amounts but be careful she does not gorge into illness. Getting food can become an obsession. Introducing new foods gradually limits intestinal problems. It is also important to be observant that the child does not hoard foods or hide food.

Language and Talking

When adopting a child who has already begun to talk in her native language, a prospective parent may wonder how long it will take for that child to understand what the parent says, let alone talk to adults in return. In some instances, institutionalized children had little or no opportunity to talk with adults at all. Their emotions and “feelings” were never considered in decision-making or in complying with institutional life. Asking these children how they feel, even through an interpreter, leads to a blank or questioning expression rather than words such as “happy, sad, frightened” that the normal American three-year old understands, uses, and applies to herself. When the coordinator talked to my children about my being their new mother, there was no consideration of their feelings toward this startling fact. When I asked the coordinator to ask them how they felt, she looked at me in a bewildered state, never having thought about that possibility.

Perry (May 19, 2000) noted that the only way give meaning to sounds is to have language exposure within the context of a relationship, allowing a child to make a connection between objects and sounds or the representation of an object (in a picture, drawing, etc.) and sounds. Body language also is a way to communicate and, when combined with words, can communicate many feelings (a gaze, pat, smack, smile). In an orphanage environment or in a neglectful or abusive environment, nonverbal communication can be very minimal or negative. In growing up, if these children had no true attention that was positive and loving, for example without someone to rock them or personally respond, they do not learn the meaning of love or how to communicate that love. Because the exposure to words can be so limited, the small number of known words has power – power to get one punished or to get minimal needs met (I hungry). Learning words with very negative meanings can shock those around the child or push people away. The first time I said “No” to my then 5 year old daughter in one of our first visits, she raised both middle fingers and said a short string of expletives of which the meaning was clear. When I repeated the jist of what I had heard to the coordinator, she was shocked and could not understand where a child had learned such horrible language. My response was that, obviously, it was from either the caregivers at the orphanage or from older children there. She quite probably did not know the meaning of the words but knew that they had power to offend, anger, and push people away, her goals for self-protection and power at that time.

Perry also notes that, “Children learn language by being spoken with and not just by hearing sounds. Children require attention, children require nurturing, and children require relationship interactions with attentive caregivers. . . one overwhelmed adult who has a limited understanding of child development . . . ” will not have given children an adequate beginning in language development as well as in other areas of development (Ibid., p., 3.) Internationally adopted children, whether from an institutional or deprivational environment, quite possibly, have not had the positive human contact necessary for social and emotional communication post-adoption.

It is amazing, though, that in less than 3 months, non-English speaking children between the ages of 3-5 understand the majority of simple language that is said to them and may, by the end of the third month, begin to use English in their everyday speech. By the end of 6 months, my daughters had forgotten all but a few Kazakh terms and talked to each other totally in English. Even the younger, whose language was quite delayed because of her quiet, non-interactive personality and immature speech sounds, had a language burst that was extremely noticeable. For example, one day in preschool, she suddenly called all the children in her class by name, surprising both them and the teacher!

Other important points about language learning and use to consider initially include the following:

  • Toddlers transfer to English in a matter of weeks.
  • These children generally do not have a working knowledge of the language of their country of origin. They are NOT acquiring/substituting a second language but are learning a first. After a few months they are monolingual in English, without the advantage of a first. Children adopted between ages 4-8 tend to lose the majority of expressive native language within 3-6 months of adoption; receptive language may last somewhat longer but all functional use disappears within the first year (Gindis, 2003).
  • They may be speaking English but must not be treated as NATIVE speakers. They will not understand idioms or subtleties that children raised hearing English from the beginning automatically understand. This level of understanding may take up to 5 years to learn.
  • Many parents see the quick transition to English as a sign of high intelligence or gifted language abilities. This is most often not the case. The child quite probably was deprived of basic forms of communication and is now learning at a faster rate than “expected” because general expectations of learning have been based on how American children learn a second language or on how an ESL (English as a Second Language) child learns English after having a well-formed primary language that generally is still spoken in her home.
  • Language influences behavior. Children with limited English fluency may appear “slow” to teachers; that child’s developmental level of functioning may be directly related to language delays.
  • A school age adopted child’s conversational proficiency in English is often not enough to ensure academic success, particularly if that child was adopted as a pre-schooler. The child’s Communicative Language Fluency (CLF) includes language skills needed for everyday social interaction in a practical context. This aspect of language is generally acquired spontaneously and is mostly oral. Cognitive Language Mastery (CLM) is language used for reasoning and is a medium for academic learning. It requires conceptual and semantic knowledge of the language and is based on the quality and quantity of early communicative experiences of infants and toddlers. Adopted children miss these early experiences and will need extended help to develop this aspect of language ( with Dr. Gindis).
  • The average dog living in a family has a 70-word vocabulary based on conditioned responses. Be careful not to read too much into how quickly your child learns conversational language or how native a speaker your child appears to be. Language learning has plateaus as well as fits and starts. About 1-2 years post-adoption, children may begin to learn to use idioms, make jokes, and sing nursery rhymes, particularly if they were adopted after age 3 or 4.
  • The impact of culture on language is great. It is important and helpful to understand the child’s culture in order to help language transitioning. Deborah Gray in her book “Attaching in Adoption” writes that a child screamed and went into a traumatic reaction upon meeting her new mother. Why? The woman was wearing red nail polish. Orphanage folklore and fairy tales had taught the child that red on nails was from the blood of children the woman had eaten. The child became totally unavailable for comforting or soothing and anything the mother tried to do to comfort the child made the situation worse because the child believed the actions were a lure.
  • Pearson (Spring 2002) notes that “language delays” . .. have such a forceful impact on literacy development. . . especially for children who arrive at school age. . . It has been estimated that for every three months spent in an institution, a child will experience a one-month delay in development . . . a critical concern (for children who have spent years in institutions) (p.4).

The Reality IS a Positive Future For Your Child

In spite of the possible abuse, deprivations, neglect, and lack of stimulation in the lives of many children who are available for adoption, children from orphanages and from the foster care system can and do adjust to their new lives. Furthermore, as Kincaid (1997) notes, “parents are the one most important educational tool for a child” who is being adopted internationally or nationally (p. 123). Motivated, aware parents are a wonderful source of information, security, support, and love for a new child. What this means is that, in spite of all the possible negative outcomes that might occur due to institutionalization and/or a history of abuse and neglect in many American families, there are also positive outcomes to placement and adoption.

Johnson (2000) notes that “most children have an immediate and dramatic surge in growth . . . probably due to both improved nutrition and improved growth hormone secretion (p. 29)” often due to human touch, love, and caring. Thus, many children who are small when adopted catch up over time.. Most children also catch up in head and brain growth. Children who have had more exposure to toys at an institution, who were favorites of the caretakers, who had been kept clean, tend to make more rapid progress in the first year after adoption (Ibid. p. 33). Children who received attention and affection from caretakers tend to seek out others for attention and can adjust well in new environments While language is the most serious area of delay in international adoptions, concrete language begins to catch up first. Over time, generally after some months, children learn to express emotions and learn how to make their needs and wishes known. Many of these children have what Johnson (2000) calls “innate resilience” that will help them (and you) make a mutual adjustment to one another as you attach.

The Hague Convention

Seven years after adoption by many other countries, the United States ratified the Hague Convention by the Intercountry Adoption Act of 2000. This legislation, once implemented in full, establishes the Department of State as central authority to set rules concerning accreditation of adoption agencies, establishes procedures to recognize adoptions finalized in other countries and determines circumstances for provision of access to adoption records, among other aspects. Russia and China were among the countries who had not yet ratified the legislation by 2003 (Hollingsworth, 2003).

The Office of Children’s Issues now coordinates policy and provides information on international adoption to the public. Adoption is a private legal matter within the judicial sovereignty of the nation in which the child resides; therefore the Department of State cannot intervene in foreign courts, but can provide general information and assistance including information about citizenship issues (e.g. when the child actually becomes an American citizen). The Hague Convention stipulates that agencies provide prospective adoption parents with comprehensive, in-depth orientation and training concerning the following topics:

  • Orientation to the intercountry adoption process; general characteristics and needs of waiting children;
  • Effects of malnutrition, environmental toxins, maternal substance abuse, genetic/health/emotional/developmental risk factors associated with institutions in a child’s country of origin;
  • The developmentally relevant impact of leaving one’s country of origin;
  • The impact of institutionalization on children and typical care provided in the child’s country of origin;
  • Information on attachment disorders and other emotional problems including the impacts of trauma and multiple caregivers;
  • Information on the laws of countries and potential delays and impediments in the adoption process;
  • Information on long term multicultural implications for families;
  • Preparation for special needs of many internationally adopted children.

An older adopted child may have never lived in a situation that is not a group situation of up to 120 persons.. This environment was very structured and times for eating, playing, sleeping, and (sometimes) educating were set. These children did not have known privacy or personal property. All toys were shared and children developed social hierarchies in order to survive. There was no encouragement or even permission of individualized expression of feelings. In fact, exposure to variations in feelings and the “grays” of life was also limited by the institutional setting. There were frequently older children who took care of the younger children and, at times, might hit or subjugate the younger children (Doolittle, et al, 1995). These children frequently had no education and little opportunity for play. They learned to operate on the offense, ready for battle. Furthermore, these children were limited in their exposure to noises that are normal in an American home – noises from stereos, lawn mowers, alarm clocks, pets, washing machines, televisions, computers, and others. The sound of a dog barking, normal in many American homes or neighborhoods, could lead to total terror if children were taught that dogs eat bad children. They also may have never been exposed to a doll, or countless other familiar toys, other than in a staged video.

Many books and researchers believe that, when a family adopts, particularly internationally:

  • You may not get an accurate medical history or may have no medical history or family background; the medical records may be sporadic and spotty and you may be given inaccurate medical information. With these facts in mind, when parents bring a child home, it is important to get a thorough medical examination, including age-appropriate screenings and an assessment of the child’s growth and development. The child may come home with an intestinal parasite, incomplete immunizations, and lead exposure difficulties. In addition, it is important that the child have an assessment of her nutritional status (Committee on Early Childhood, Adoption, and Dependent Care, 1991) and contact a pediatrician familiar with height and weight charts for the child’s birth country to help set norms for persons born in that part of the world
  • Many children have slow emotional development because they have never been allowed to express emotions (Some call this “The Silence of the Kids”). Many have never learned how to modulate emotions. They may have problems with affect dysregulation and be diagnosed as hyperactive or attention deficit disordered. They may also have affect dedifferentiation – the inability to identify specific emotions that might serve as guides to appropriate actions (Kelly, 1999). Put another way, they may have problems putting feelings into words and act out with poor impulse control instead. They may not have the words to describe internal physical or emotional states. As was noted,, in some instances, they have never even been asked how they feel, let alone know what a feeling (sad, mad, glad) is.
  • They may have an attachment disorder and have little to no ability to be affectionate and/or have little or no conscience. Many have difficulties giving and receiving love (because of their own absence of positive touch and loving,) and do not trust others, primarily due to lack of physical contact as well as emotional contact.
  • Many have a true sense of loss at leaving the orphanage and feel grief when they are separated from that world, no matter how awful it was.
  • A child adopted at over 18 months of age, in particular, may have noticeable developmental delays. There is always the possibility that the child has a history of abuse, stored as pre-verbal memories, unable to be recounted. They may even be dissociated or repressed memories..
  • Some children will be constantly on guard, looking for any danger that might befall them, fearful of exploring the environment around them.
  • Some may have symptoms of post-traumatic stress disorder, including nightmares and/or night terrors.
  • There is an initial language barrier that gets resolved rather quickly. Most older children who have fluency in a native language know some English in 6 weeks. However, the use of language itself can be a power struggle. Some children will exhibit delayed language development because of their prior environmental deprivation. It is possible that some children have never had exposure to any words except the basics needed for survival. ). It is also important to think of ways to help your child retain some native language.
  • Some children will have problems regulating and filtering sensory input which might lead to hyper and hypo-responsiveness (Doolittle, 1995). These children may have problems regulating behavior as well as “physiological, sensory, attentional, motor, or affective processes, and in organizing a calm, alert, or effectively positive state (Doolittle, 1995, pp. 11-12).” This may lead to problems with behavior control, temper control and adapting to changes. The hypersensitive child can be fearful, cautious, negative, and/or defiant. The under-reactive child may be withdrawn, hard to engage, or self-absorbed. The motorically disorganized impulsive child may have an extremely high level of activity and a lack of caution. S/he may appear to be “driven” and unable to settle down or organize behavior. S/he may over or under-react to loud, high, or low-pitched noises, bright lights, touch, foods with certain textures, coordination, touch, pain, odors, temperature, motor planning, attention, and focusing, among others.
  • Some may be inconsolable when hurt or frightened, unreceptive of attention or touch.
  • Some may have little or no conception of personal space and property, constantly tripping over their feet, falling down easily.
  • Some may have no skills for conversation.
  • “Love is not enough” for some of these children who are at risk; they cannot just be loved into normality and may need special attention (Doolittle, 1995).
  • Thus, the child may have a multisystem developmental disorder that include attachment and regulatory disorders; attachment disorders are secondary to the regulatory disorders. In time, these children do develop warm relationships, “logical thinking and problem solving, and interactive communication” if they have the right types of therapy (Doolittle, 1995, p. 13).

Ames (1997) suggests that “All adoptions of orphanage children should be considered by both prospective parents and adoption officials to be special – needs adoptions” that require “extra commitments of parents’ time, energy, acquisition of expertise, and willingness to work” with professionals, agencies, and others who have adopted. Social deprivation in orphanages potentially has a very great negative impact on a child’s development.

The Tressler Adoption Services agency, according to Kendal-Wilson (2002), offers certain items as predictors for possible difficulties with internationally adopted children or children being adopted after multiple placements in foster care. These include

  • food issues, such as hoarding, gorging, anorexia
  • anger issues, including rage outbursts and a history of violence
  • loss issues with a lack of belief in permanence; grief issues
  • sadness and depression
  • sexual acting out from a history of sexual abuse including acting out with other children or pets, open masturbation, attempts to get parents to molest (fondle, touch) the child, inappropriate touching toward parents, inappropriate language
  • multiple moves
  • medical conditions, including Fetal Alcohol Syndrome, genetic conditions, congenital conditions
  • developmental delays
  • history of early deprivation/neglect

The FRUA survey found that families were most at risk for problematic adoptions when children had emotional challenges. Many medical reports do not identify the mental health of the child and concentrate on physiological difficulties, instead. The mental health issues may not become apparent until the child is home in an unknown environment that triggers stress reactions a potential parent would not see in country.

No agency or professional can predict the future of a relationship between an adopted child and parent, nor can that agency or individual predict how a child will grow, develop, and/or learn with total accuracy. However, there is a great deal of literature and research available upon which many of the recommendations, suggestions, observations, conclusions, and strategies for working with adoptive families are based. Almost all children (except those so terribly damaged that they require hospitalization or institutionalization) will benefit from consistency, caring, and your love. However, those behaviors are often NOT enough and some forms of supportive services often will help in building a successful new family.

Federici (2001) found that between 20-25% of internationally adopted children will have relatively “clean” neuropsychological and psychological profiles. Their adjustments will be routine with some acculturation issues. They will have no major problems transitioning in their language acquisition and will have no need for other than routine medical care. Between 40-50% of children will have mild to moderate learning disabilities, speech and language disorders, behavioral and emotional problems, attachment disorders (due to cognitive issues), and ADHD. They will need some specialized services, a longer period of recovery, and possible medication management. Approximately 25-30% of adopted children (based on a sample of 1500) presenting for assessment and/or treatment had severe neuropsychological and psychological problems ranging from pervasive developmental disorder (PDD) to multiple learning disabilities to the effects of fetal alcohol exposure to severe emotional and attachment problems.

Federici (1998) described the ultimate “worst case” scenario for international adoption. Some institutionalized children, over the course of time, learn to be autistic or autistic like. They rock, pick at themselves, and may appear mentally deficient. If you see a child behaving in this manner in an institution, or if your potential child behaves in this manner, it is important to ask yourself if you truly are prepared to deal with these issues. Think long and hard about how this child would fit into your family. Remember, there are many variations and degrees of what Federici (1998) terms “Institutional Autism,” many of which are surmountable. The post-institutionalized child may show some or all of them:

  • Loss of physical height, weight, and growth. Your child may not be on a growth chart or curve when you adopt. My 5-year-old daughter grew 3 inches and gained 7 pounds in 5 months; my 4 year old grew over 4 inches. Remember to look at growth within the context of normal growth charts for the country of origin and any information about height and weight of parents.
  • Appearance as a child of a much younger age;
  • Regressive use of language due to lack of language exposure, limited emotional and pragmatic language, problems with comprehension (understanding requirements and tasks) and/or retention of language information (auditory memory), lack of ability to think about others, problems with expression of needs (oral expression), problems with attention/concentration, and problems with abstractions and sequencing (thinking for the self);
  • More primitive behavior such as problems with toileting, thumb sucking, or similar behaviors;
  • Lessened brain development due to poor nutrition with memory and attentional deficits (a great deal of ADHD, learning disabilities, and other conditions result from nutritional effects).

Other long-term effects of the lack of appropriate stimulation in these children might include a lack of cause and effect thinking, a lack of the concept of past or future time, and social unrelatedness, among others (Doolittle, 1995).

It is important to have a child fully evaluated if any aspects of this condition are or become evident. In fact, it is not a bad idea to have a child evaluated once she can communicate. So many people say “How did I miss that?” years latter because they thought the issues happened to other people’s children. One example is the post institutionalized child who always puts away her toys and cannot do anything until the toys are away. Many parents think this is a wonderful trait to have and do not recognize that it is a residual behavior from regimentation and means that the child is not thinking for herself. When the child goes to school and the teacher tells the parents that the child cannot handle transitions, it takes the parents a long time to realize that transitioning is not a learned institutional behavior. Having children evaluated sooner than later does not waste (literally) years of living in ignorance rather than using the years to shape behaviors.

The Emotional State of Adopted Children

As was noted, another area of risk for adopting children, particular older children, is that they have often lived a life of failures and, as Tobin (1991) writes, “the hurt these kids create is never greater than the hurt they feel. (p. 27).” Children who constantly seek attention need that attention. Even if parents decide to ignore the attention-seeking behavior, it is important to recognize the needs that lie behind it. Some adopted children, as trauma survivors, live in a constant state of anger and fear. These children, according to Dalenberg (2000), express their needs through their negative statements and behaviors. When they seek attention, they are signaling that they want to attach. When they tell a parent to get away or get out of their way, they are looking at ways to reach goals. When the children say “Stop that!”, they are trying to defend against real or imagined physical and emotional attacks. However, they often are afraid to send messages that are positive and, instead, seem to show free falling anger.

It is important that a parent becomes the child’s source for identification of the good in life, the positive meaning in life, the purpose in life. Through the parent, life becomes something worth living and tackling. The key to any change in a child’s life is consistency without rigidity; consistency with caring. As Tobin also notes, you have to “create a change to effect a change; (and) change something to get a change.”

Developmental Delays

Medina (1995) noted that most children adopted internationally have some degree of developmental delay and some possible health problems. Many, if not most, of these children adjust to their new lives and make progress. Some children, no matter the amount of nutrition and care by their new parents, continue to have serious delays and will need evaluation and special treatment. Even children who have had short stays in orphanages are impacted. Some of the problem areas may not become evident until the child gets older, as with non-adopted children, and problems such as a learning disability are diagnosed. Meese (2002) writes that “many experts believe that all children of intercountry adoptions are at high risk . . . particularly at risk may be those who have spent a significant portion of their early years in institutionalized environments (p. 24).”

Children who have been raised in institutions or in neglectful situations may not perform developmentally at the same pace or in the same manner as children who have been in healthy homes. Additionally, children also are impacted developmentally by cultural practices. For example, if a child has been swaddled (tightly wrapped) for the first 6 months of life, that child has not had the freedom of movement to explore and develop many physical capabilities including beginning eye-hand coordination. If a child has not been permitted to crawl, arm and leg coordination will be slower in development. If three-year old children have never had the opportunity to run freely, their gait may be more stilted and infant-like. If children have never had the opportunity to climb up and down stairs, they may not have developed the spatial and motoric skills to deal with balancing, assessing height, and navigating.

Consider the impacts of a typical day in an orphanage on a preschool child. From my observation, on warm days when new “mamas or papas” are not coming to get their children, groups of 20 children play together in the dirt in their small play area in an orphanage that may hold 300 children, ages 4-7. They wear only underpants, sandals (because their toes can stick out), and hats to protect them from the sun. They have a few broken toys, minimal broken play equipment, and generally only run, kick a ball, or play independently in the dirt. There is minimal talking and little or no conversation because their knowledge of language is minimal. No one has spent time talking to them or teaching them new words. There is little to no cooperative, imaginative play. These children sleep in one room that holds 20 small beds with 20 similar plain white sheets. The good toys hang on the wall to be used in the videos sent to prospective parents.

These children, particularly when they are in children’s homes rather than baby homes, have multiple caregivers who may stay only for a short period of time in the orphanage. Even those who stay for longer periods of time work in shifts and are not necessarily nurturing because of the daunting task of caring for 20 or more children. The children have been abruptly pulled from a baby home somewhere around the age of 4 (4 ½ if a favorite in the baby home) or may have been in more than one baby home, before being placed into a children’s home. Those who had love and caring in the baby home are devastated by the change and are not prepared for the losses. They can become depressed and withdrawn when forced to leave the only person(s) who showed them any positive affection/attention. In the children’s home, their entire lives are regimented and scheduled, with no opportunity to make independent decisions. These children have never celebrated a birthday and have no personal possessions. Life is always the same. . . always.

Development of Adopted Children

Federici (1998) writes “there are many children who have been adopted from institutional settings who do not show major medical, cognitive, or psychiatric problems (p. 66).” Children younger than 18 months have a “much better chance of recovery from the damaging effects of deprivation and institutional care” than older children. It is probable that any child over the age of 2 will have some type of attachment problems if s/he did not have a consistent attachment figure as primary caretaker. Children who spend a longer time in institutions may also have slower brain development and lowered number of acquired skills. For example, children at the age of 5 who have never held a pencil or pen will have difficulties with fine motor skills. Federici’s book “Help for the Hopeless Child” describes in detail some of the situations in orphanages in different countries or blocks of countries and how they impact development. FRUA’s study showed that children who were considered “favorites” in the orphanage faired better emotionally as individuals and in their families than children who were not favorites (e.g.the child whose parents were told “We are so glad to see she is getting adopted because we were worried she never would because she was so ugly)” or whose situation was unknown in terms of their “favorite” status.

Some of the reasons why growth /weight is impaired include:

  • genetics and family history
  • racial differences
  • swaddling that retards muscle development
  • poor diet and nutrition
  • intestinal parasites that prevent absorption of nutrients (e. g. Giardia lamblia)
  • lack of attention
  • lack of stimulation
  • emotional deprivation
  • crowding
  • confinement to cribs, cots, playpens, 1-2 rooms
  • lack of consistency in relationship
  • lack of bonding and eye contact (rocking, talking, feeding)
  • not being a “favorite” in the institution
  • trauma including abuse, neglect
  • brain chemistry changes due to changes in hormones and neurotransmitters.

Many children adopted overseas who are exceptionally small physically may have psychological dwarfism. These physically stunted children have no organic reason for their exceptionally short stature and appropriate stature-related weight. Prolonged emotional abuse or neglect appears to impact their rate of linear growth by impacting the secretion of growth hormones. In general, however, once the child is adopted, within a matter of months, a parent will see exceptionally quick physical growth (Iwaniec, 1995). In some instances, growth of three to four inches in a 6-month period of time is not unusual, especially in girls who are also at risk for precocious puberty that may accompany an excessive growth spurt.


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Buenning, W. D. (1999). Bonding and attachment. Colorado Springs, CO: Paper by Author.

Committee on Early Childhood, Adoption, and Dependent Care (September 1991). Policy statement: Initial medical evaluation of an adopted child (RF9219). Pediatrics, 88, (3), 642-644.

Doolittle, T. (March 1995). The long term effects of institutionalization on the behavior of children from Eastern Europe and the former Soviet Union. Draft Edition. Parent Network for Post-Institutionalized Children.

Federici, R. S. (2000). Understanding the complexities of U.S. and international adoptions. In T. Tepper, I. Hannon, & D. Sandstrom (Eds). International adoption: Challenges and opportunities (3rd Ed, pp. 145-164). Meadowlands, PA: Parent Network for Post-Institutionalized Children.

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Jamieson, F. (1991). The forgotten children. Nursing Times, 89 (August 28), 39-42.

Johnson, D.E. (2000). Medical and developmental sequelae of early childhood institutionalization in international adoptees from Romania and the Russian Federation. Minneapollis, MN: Self.

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McKelvey, C. A. & Stevens, J. (1994). Adoption crisis. Golden, CO: Fulcrum.

Meese, R. L. (2002). Children of intercountry adoptions in school: A primer for parents and professionals. Westport, CT: Bergin & Garvey.

Melina, R. (1995). Institutionalized children have problems, show progress after adoption. Adopted Child, 14 (11), 1-4.

Perry, B. D. (May 19, 2000). The meaning in words: A conversation between Bruce D. Perry and Helen Benham. Document Presentation. New York, NY: Scholastic’s Early Childhood Advisory Board Meeting.

Rosenbloom, D., & Williams, M. B. (1999). Life after trauma: A workbook for healing. New York: Guilford Press.

Tobin, L. (1991). What Do You Do With a Child Like This: Inside the Lives of Troubled Children Duluth, MN: Whole Person Associates.

About the author:

Dr. Mary Beth Williams is in private practice in Warrenton, VA and the proud mother of two Internationally adopted daughters. She has authored/edited 8 texts for professionals and survivors concerning treatment of PTSD. She is in the process of writing a book and producing a video on International Adoption. She is a member of Gift From Within’s Professional Advisory Board.

Dr. Mary Beth Williams
Trauma Recovery Education and Counseling Center.
9 North Third St., Suite 100 #14. Warrenton, VA 22046 USA
Phone/Fax: 540 341 7339

Additional Resources

Adoption Books

Issues of Adopted Children

Medical Issues