Notes on ADHD in internationally adopted children

ADHD in post-orphanage children is a matter of great practical significance and is an emotionally charged issue for adoptive parents. I have to point out that the core of ADHD - impulsivity, restlessness, and inattentiveness - may be symptoms of many other disorders, or just one of the characteristics of post-orphanage behavior, or social adjustment. Thus, it is a mistake to think in terms of "What is the singular cause of this behavior?" and not "What are the multiple causes?" There is no doubt that many international adoptees have genuine ADHD and may respond well to a traditional treatment that, in most cases, is just medication. Nevertheless, there are other explanations and other treatments of what looks like an ADHD behavior in international adoptees.

One thing that most orphanage survivors have in common is poor emotional and behavioral self-regulation. Hyperactive, disorganized, and disregulated behaviors that are typical for children with ADHD, may in internationally children reflect the impact of abnormal environmental factors of orphanage life on development. I personally believe in a significant social/cultural influence on the origin of this deficit: it is due, at least partially, to the lack of modeling, mediating, and assistance usually provided to children by a caregiver in the family-based upbringing.

Language also plays a critical role in the development of self-regulation, because it allows children to gain some control over manifestations of their feelings, helps them inhibit impulsive responding and behave in a more organized way. Therefore, the issue of specificity of ADHD in post-institutionalized internationally adopted children is a complex one and more research and more careful thinking is needed. It is likely that we are dealing with what could be defined as an atypical attention deficit disorder in children who have a very atypical psychological profile stemming from an atypical background and development.

Look at what Michael Rutter and his associates have found. He studied a sample of Romanian adoptees for approximately ten years. They found a high rate of what they called "inattentive-hyperactive" behavior. They pointedly avoided calling this ADHD, since they found significant differences between this condition and ADHD as it is manifested in "typical" Canadian and American kids. For example, in "typical" ADHD, there is a high correlation between the inattentive/impulsive behavior and aggression (70% co-morbidity), while in the adoption sample, the kids were not aggressive. Similarly, in "typical" ADHD, the overwhelming majority (again, over 70%) of affected kids are boys, while in the adoption sample boys and girls were equally affected. These researchers were very careful in their conclusions about this, but expressed concern that IA kids were being lumped with, and treated like typical ADHD kids when the etiology and symptoms are probably different in significant ways. All children in that study showed improvement over time, with some - catching up completely and others remaining - below their peers despite considerable gains.

It has been well-established through hundreds of studies that the most effective treatment for children over the age of 4 with ADHD is a combination of medication and behavioral therapy. There are some children who don't have symptoms severe enough to warrant medication and can get by on behavior modification alone, but for children with a more serious condition, medical management is needed. I do not see here a place for moral or social value judgment: as one parent stated: "If your son had diabetes, you would give him daily medication without giving it a second thought. ADHD is a medical issue, period." On the other hand, medication doesn't cure ADHD, and as many people have said, "pills don't teach skills." Stimulant medications shouldn't be used as an alternative to teaching a child how to behave and learn in the classroom, particular with ID children were an issue of self-regulation is so urgent.

I believe that social skills training along with language therapy are the most promising counterpart to medical treatment for an IA child who has symptoms of ADHD.