• Cognitive language deficiency that blocks cognitive processing (Haywood, Brooks, & Burns, 1992; Kaler & Freeman, 1994; Tartter, 1998; Hodges & Tizard, 1989; Connor & Rutter, 1999; Rutter, 1999).
• Lack of age-appropriate cognitive skills that results in progressive cognitive/behavioral incompetence. (Haywood, 1987; Sattler, 1992; Das, Naglieri, & Kirby, 1994; Connor & Rutter, 1999).
• Insufficient task-intrinsic motivation in cognitive activities, which may exacerbate attention and memory problems (Haywood, 1987; Gindis, 2001).
• Chronic mismatch between an individual's learning ability and the learning setting, teaching style, or level of instruction (Haywood, 1987; Gindis, 2001).

Cumulative cognitive deficit may cause (or be associated with) certain emotional/behavioral problems. Cognitive difficulty and constant failure "...feeds upon itself in a negative spiraling fashion" (Haywood, 1987, p. 198), which results in low self-esteem, lack of interest in and constant frustration associated with cognitive efforts. Inadequate intrinsic motivation in cognitive activities grows with age and becomes one of the major characteristics of cumulative cognitive deficit (Gindis, 2001). The phenomenon of CCD is attributed to cultural/educational deprivation experienced in the early formative years and is traditionally associated with children from low socio-economic status families (Cox, 1983; Parker, Greer, & Zuckerman, 1988; Duyme, 1988; Duyme, Dumaret, & Tomkiewicz, 1999).

The nature, causes, and dynamic of cumulative cognitive deficit in international adoptees, however, may be different in certain aspects from what we know about cumulative cognitive deficit in the population at large, and this uniqueness must be recognized and addressed in our remedial efforts. Traditionally, in education and in cognitive psychology, the causes of cumulative cognitive deficit have been attributed mostly (if not exclusively) to a "culture of poverty," that is, to ongoing cultural/educational deprivation resulting from poverty (Mackner, Starr, & Black, 1997; Duyme, Dumaret, & Tomkiewicz, 1999). In contrast to this "single cause approach," the determinants of cumulative cognitive deficit in international adoptees may be associated with a combination of medical (e.g. failure to thrive syndrome), socio-economic (neglect, abuse, poor nutrition), and cultural and educational deprivation in early childhood. Consequently, the remedial efforts should be multifaceted. The subtractive nature of new language acquisition in international adoptees definitely contributes to cumulative cognitive deficit (Gindis, 1999, 2001) and may constitute the "core" factor in cumulative cognitive deficit in post-institutionalized children.

The vast majority of international adoptees have deficiencies and delays in their native languages due to the lack or inadequacy of specific social/cultural mediation usually provided by adults during the normal language acquisition period (Dubrovina, 1991; Locke, 1993). This makes it more difficult for them to learn their new language. (Glennen, 2002). It has been suggested that cumulative cognitive deficit in IA children is reinforced during the time when the first language is lost for all practical purposes and second language is barely functional communicatively and not in existence cognitively (Gindis, 1999a; 2001). The overall length of this period depends on the children’s age and many individual differences, but practically all international adoptees adopted after three years of age appear to experience this period, and for some of them it is the time when their cognitive weaknesses are consolidated into cumulative cognitive deficit. In internationally adopted “older” (school-age) children, there are cultural differences that could contribute to social, cognitive, or adaptive behavior difficulties during the initial adjustment period. Thus, cultural differences may influence the value placed on cognitive activity, the level of intrinsic motivation in cognitive operations, learning behavior in general, and attitudes towards teaching authority (Gindis, 2001).

We have to understand that cumulative cognitive deficit in international adoptees is diagnosed against American middle class norms and expectations. The relationship between the cultural differences (in both international adoptees and their adoptive families) and cumulative cognitive deficit should be further explored and explained. In general, the emotional/behavioral aspect of cumulative cognitive deficit has not been studied and discussed in related literature, with the notable exception of Haywood’s (1987) article. There is, however, a strong correlation between cumulative cognitive deficit and different forms of emotional and conduct disorders in international adoptees. It is difficult to differentiate at times the primary (is it mostly cognitive?) and secondary (is it mostly emotional?) disabilities in an internationally adopted child referred for “academic” problems.Further research is needed to sort out the relationship between the cognitive and emotional factors in international adoptees’ school functioning. It appears likely that emotional/behavioral and cognitive/language difficulties, tightly intertwined, constitute a very important characteristic of cumulative cognitive deficit in post-institutionalized children.

Most internationally adopted children now live in middle-class families with well-educated parents. Probably for the first time in the history of cumulative cognitive deficit (CCD) families themselves do not constitute ongoing contributing factors to CDD; on the contrary, they may be considered powerful remedial factors. Due to the adoptive parents' sensitivity to and awareness of possible learning problems in international adoptees and because of higher parental expectations in this respect, symptoms of cumulative cognitive deficit are reported earlier and are subjected to professional attention. In most international adoptees, the cumulative cognitive deficit phenomenon creates a situation of “too slow progress” in regard to the intensity of remedial efforts. It may appear as if many IA children are “racing against time,” unable to catch up with age-level academic standards. Because of the discrepancy between steadily rising academic requirements and relatively slow cognitive and language growth in international adoptees, the overall trend seems to be a “downward” one.

The question of great practical significance for many adoptive families as well as school professionals is to what extent cumulative cognitive deficit can be remedied and what are the most promising treatments to overcome such a deficit. With international adoptees, remedial efforts should be as diversified as the causes of their cumulative cognitive deficit. Thus, from a pediatric perspective, rehabilitation strategies for cognitive problems are concentrated on medical intervention, proper nutrition, and vitamin supplements (Miller, 2004). Nutritional intervention is a necessary but not sufficient mode of treating cognitive and academic difficulties in general and cumulative cognitive deficit in particular. Current scientific data demonstrate that adequate medical and nutritional intervention alone produces no changes in intellectual development and may not restore developmental functions to the right track of timely development (Mackner, et al., 1997; MacLean, 2003). T

he overall body of research data indicates that the cognitive difficulties due to early malnutrition and environmental deprivation are treatable only through interventions that include nutritional, medical, and developmental/educational components. Although currently our experience with international adoptees having cumulative cognitive deficit is limited, there are some research data, as well as practical "know-how," that relates to cumulative cognitive deficit in the population at large. One of the remarkable findings is that "traditional" remediation (that is, more intense work individually or in a small group using basically the same teaching methodology as in the classroom) is not effective or at times may be counterproductive in attempts to overcome cumulative cognitive deficit (Das & Conway, 1992). Cumulative cognitive deficit has the complex nature of an interweaving of internal (language, cognition, motivation) and external variables, including teaching methods, learning environment, and peer interaction. This complexity makes the phenomenon a challenge for educators.

To complicate the picture further, due to the “summative” nature of cumulative cognitive deficit it may not be found in the early stages of a child's educational experience. It takes time for cognitive deficits to become "cumulative;" therefore, when cumulative cognitive deficit is properly diagnosed, it may not be responsive to even heroic efforts from parents and school alike if they use traditional remediation methods. One of the possible explanations of the reduced effectiveness of the mainstreamed remedial methodology may be that the cognitive deficiencies in international adoptees are deeply rooted in early childhood experience. All cognitive abilities are developmentally hierarchical, that is, the appearance of more complex cognitive structures rests upon the prior appearance of simpler cognitive components (Piaget, 1971; Vygotsky, 1987). Traditional remediation "assumes" the presence of the appropriate base in cognition upon which one tries to build the compensatory structures.

The lack of the proper cognitive foundation constitutes a major source of difficulty in reversing the negative trend in cumulative cognitive deficit. Effective and appropriate teaching methods are critical elements in remediation of children with CCD. Both research and practice point to "cognitive education" as one of the effective methods of remediation of cumulative cognitive deficit in international adoptees. There are many "cognitive education" approaches created for different age groups. A review of these methods in social/cultural context can be found in Gindis (1999b, 2003). Among the most well known are Instrumental Enrichment (Feuerstein & Gross, 1997), Bright Start (Haywood, et al., 1992), PASS Remedial Program (Das, Carlson, Davidson, Longe, 1997), and Cognitive Instruction System (Kirby & Williams, 1991). All these (and other) different systems of cognitive remediation are based on the assumption that cognitive processes are acquired mental operations that can be mastered through appropriate learning. In this respect "cognitive" is different from "intellectual" (the former is said to be learned while the latter is seen as “native ability that is largely genetically determined” (Haywood, 1987, p. 193). The efficiency of learning cognitive skills depends, of course, on "inborn” intellectual capacity; however, the learning environment has at least comparable significance and tremendous remedial potential. "Cognitive education" methodology assumes that whereas children with cumulative cognitive deficit have difficulty in generating cognitive strategies spontaneously, they can be taught how to create cognitive algorithms and to apply them to cognitive tasks. Through carefully crafted methods, they may be taught to inhibit impulsive responses, to analyze problems using certain "algorithms," and to experiment mentally with alternative possible solutions to problems. In other words, they must be specifically taught "how to learn" (this is the core of cognitive education) and how to apply their learned cognitive skills ("generalization" of cognitive processes). In order to compensate for the detrimental effect of cumulative cognitive deficit in international adoptees, cognitive intervention must be age-appropriate, well-planned, and persistent. It should be applied through four closely connected directions, suggested by Haywood (1987): (a) enriching cognitive language, (b) teaching specific cognitive processes (thus increasing cognitive competence), (c) facilitating task-intrinsic motivation, and (d) providing appropriate (optimal) learning settings.