SELECTED ARTICLE
Author
Boris Gindis, Ph.D. 
Article Title
Difficulties with socialization and peer interaction in older internationally adopted children 
Posted Date
12/29/2013 
 
Difficulties with socialization and peer interaction in older internationally adopted children

Surveys of adoptive parents (McCarthy, 2005, National Survey of Adoptive Parents, 2010), research (Meese, 2005, Gunnar, 2007, Bruce, 2009), and my own clinical experience (Gindis, 2006) suggest that a disproportionally large number of internationally adopted (IA) children fail to establish and maintain age-appropriate peer relations during their formative years. It is particularly evident in so-called "older" adoptees, those who were adopted after the age of 5. Difficulties with peer relations are, in a certain way, their "trade-mark": teachers and parents in unison report that too many IA children are less socially successful than their age counterparts. In this article I discuss their difficulties in the process of gaining the knowledge, social skills, and appropriate language that allow for integration into a peer group. This process implies accepting, either consciously or subconsciously, the values, attitudes, norms, social roles and manners of interaction that are prevalent in the group (Ryan, 2000).

The Consequences of Negative Peer Relations

In all periods of childhood, but particularly during the pre-adolescent and adolescent years, peer interactions and friendships constitute the core of socialization and provide a feeling of belonging and self-validation, a context for self-disclosure and emotional security (Ryan, 2000,Thompson & O'Neill, 2001). Peer friendship is a form of attachment, while peer rejection and bullying are psychologically traumatic. Inadequate socialization causes adjustment difficulties, emotional instability, and anxieties. Rejection by peers has a negative effect on a child's self-esteem and contributes to development of loneliness and gloominess (Ryan, 2000, Thompson & O'Neill, 2001, Ronk, 2011). Rejected children often gravitate towards one another, thus escalating each other's depressive or acting out behavior. International adoptees have a tendency to associate with younger children, children with learning or behavior issues, and those who are the least popular (McCartney, 2005, Gindis, 2006). If this issue is not properly addressed, IA children may accumulate the experience of being rejected - a typical background for future emotional and behavioral problems.

The Causes of Peer Rejection

Rejections may occur for a variety of reasons. As noted by their parents, a typical base for rejection of IA children by their peers is their aggressive or odd (quirky, "strange") behavior. Because of their immature and at times challenging behavior, IA children may require more supervision and thus are less likely to be invited to their friends' houses. Adoptive parents, in turn, are concerned about their child's behavior when they cannot monitor it, so they are also reluctant to permit play dates away from home. Rare after-school contacts do not facilitate companionship and offer no opportunities to develop the closeness between friends that encourages self-disclosure and the provision of emotional support. So, what is behind those "atypical" behaviors in IA children and what are its manifestations?

Aside from personal qualities, there are objective circumstances in the former and current environment of IA children which make it difficult for them to acquire new social norms and skills. By the time of adoption, their psychological profile already includes many characteristics that can hinder interpersonal connections. Let's look at these characteristics in order to better understand how deeply they may be ingrained into an IA child's psychological makeup and how to help children overcome these traits after the adoption.

Poor Self-Regulation

Starting life in a dysfunctional family and then experiencing a peculiar combination of rigid routine with ongoing turnover of caregivers and frequent transfers of children within and between institutions creates unpredictability in living arrangements and leads to a tremendous sense of instability and lack of control. With virtually no personal choices and no private possession such as toys or other goods, there is a minimal need for behavioral self-regulation, long-term planning, or goal-directed consistent behavior. And, of course, there are no adults in their lives who can model and support self-regulatory skills. Orphanage residents live in a "reactive" mode, surviving one day at a time. Limitations with self-regulation of behavior and emotions are evident in emotional volatility, difficulty with delaying gratification, making transitions between activities and, most of all, in difficulties with resisting acting on an impulse. Imagine a nine year old with these characteristics trying to engage with a group of peers playing organized sport or working on a group project in the classroom.

Mixed Maturity

The development of many international adoptees was mediated by a chain of traumatic events in their early childhood such as abandonment, hunger, deprivation of basic physical and emotional needs, abuse, institutionalization, and finally adoption to another country. This pattern of development may result in what is known as Developmental Trauma Disorder, adversely affecting the entire maturation of the child by inhibiting the integration of cognitive, emotional, and sensory functions into a cohesive whole. Victims of DTD present with "mixed maturity" (Cogen, 2008): at times they may demonstrate the behavior of an older child and at times of a much younger one. For example, in terms of self-care, alertness to the environment and basic survival skills post-institutional children may be well advanced for their age, but in reaction to stress and frustration they may act like a child several years younger. Their reactions to social events, interpersonal relationships, academic learning, and their overall adaptive behavior are often different from what is expected at their age. As a result, it is difficult for them to interact with peers, to share interests, to participate in conversation, to engage in play, sports, or learning activities. They may be isolated in Scout groups, excluded from different spontaneous "projects," and left out during parties.

Hyper-Arousal

One of the most typical features of the emotional make-up of IA children of both genders is a constant state of hyper-arousal - continuous readiness for fight or flight (Gunnar, 2007, Gindis, 2006 & 2008, Bruce, 2009, Merz, 2010). Frequent traumatic events in the past have reinforced the sensitized neural pathways of a child's Central Nervous System for a heightened fear/stress response. With an over-reactive nervous system, objectively typical day-to-day events may be easily misconstrued and cause withdrawal or aggressive and otherwise socially inappropriate responses. Because of the constant state of hyper-arousal, an IA child may present patterns of behavior often associated with ADHD, such as restlessness and impulsivity. Hyper-arousal may result in proactive aggressiveness, edginess, recklessness, and unpredictability in sheared activities. No wonder peers prefer to avoid a hyper-aroused child during common activities.

Post-Institutional Behavior

We all intuitively understand that orphanage life and the kind of circumstances that led children there are the breeding grounds for the specific behaviors among children who are continuously traumatized and often forced into survival mode - no human being can escape such conditions unscarred. We can now see the psychological effect and consequences of those prior conditions. These are behavior habits - deeply embedded patterns of survival skills known as post-institutional behavior (Gunnar, 2007, Gindis, 2008).

Post-institutional behavior is a cluster of learned behaviors that could have been effective before adoption but become maladaptive and counter-productive in the new family and school environment. These traits are powerful factors in destroying peer relationships, family life, and school functioning. Practically all parents can observe in their IA children at least some patterns of behavior caused by deeply imbedded patterns of institutional behavior which now problems for proper socialization and peer interaction. Let us look at some prominent features of these patterns:

Controlling and avoiding behavior

A global sense of insecurity results in controlling and avoiding behaviors, which take different forms in school and at home. In school, with their fragile and vulnerable sense of competence and being too sensitive to failure, these children tend to avoid classroom assignments or activities that they perceive as difficult. They prefer to present themselves as non-complaint rather than non-competent, as that is less painful to their self-perception. They can present open defiance or hidden sabotage, but their behavior is rooted in their overwhelming need to be always in control, to be on known and manageable "turf." Such an attitude discourages teachers and classmates: any shared activity is difficult given this stance.

The early childhood experiences of deprivation and insecurity force a post-institutionalized child to fight for control at home. This fight may assume ugly forms and can be very upsetting for parents. Controlling and avoiding behavior is often considered to be the core of "attachment disorder," though it's often a learned social behavior that served quite well in the orphanage and is now failing the child in his/her social relatedness.

Pro-active aggressiveness

Children who are neglected and traumatized during their early formative years tend to display higher levels of aggressive behavior. A heightened alertness and vigilance, combined with an inability to correctly interpret the emotional side of the situation, are typical for many IA children and often result in inadequate social interactions both with peers and adults. In such situations boys can be "tough" and proactively aggressive in their urge to dominate peers and protect themselves from the "expected" hostility of their environment. Girls can be aggressive or present themselves in a seductive and promiscuous way, trying to control the situation by means unexpected in their new environment.

Extreme attention seeking

Orphanage residents constantly seek adult attention, approval, and encouragement. No matter what it is that they do, their motivation is to evoke a reaction from the grown-ups, not to solve a problem or achieve some goal. This urge to win an adult's attention and approval is typical for children in general, but in IA children it often reaches extremes; this does not facilitate peer interactions. Extreme attention seeking may at times take the form of learned helplessness. Children in orphanages have been conditioned to get more attention from caregivers when they appear helpless: the more independent children are, the less attention they receive. Some children have deeply internalized this behavior and manage to appeal to a wide audience with demonstrated helplessness. Learned helplessness is tolerated by society much longer than is acting-out behavior. Many of these children actually have the needed skills or knowledge but will resist any attempts to encourage them to act independently. Learned helplessness is an acquired survival skill for achieving attention as understood by a traumatized child, but it may come across as a "strange" behavior for peers.

Feeling of entitlement

The dictionary defines "entitle" as "to furnish with a right or claim to something." When a child whines and screams, demanding a new expensive toy she sees on the store shelf or a new pair of sneakers he saw his classmate wear - this is the feeling of entitlement. Children raised in orphanages are conditioned to the notion that if one member of a group has something, the other members of the same group are supposed to get the same thing, too, whether they need it or not. In former orphanage residents this is a survival skill determined by institutional care. As such, it is only one small step away the feeling of entitlement to obtaining things through theft or deception.

Lagging Social Language Development

Communication with friends increases dramatically during pre-adolescence and the adolescent years. The content and dynamic of verbal exchange is characterized by rapid topic changes, slang expressions, subtleties of irony and sarcasm that infuse peers conversations and, of course, by rich nonverbal language cues. Adolescents with limited language skills cannot efficiently participate in the rapidly changing, emotionally tense social language processes in peer groups (Turstra, 2003). On the other hand, having well-developed, age-appropriate language proficiency highly correlates with successful peer interactions and friendship. An adolescent with good language skills is successful in detecting and using humor, sarcasm, persuasion, deceit, empathy, and flattery. In negotiation or conflict situations, he or she can understand their partners' motives and collaborate to achieve a mutually acceptable outcome (Ryan, 2000).

In typical development, social interaction skills are mastered during the process of maturation without any conscious effort or formal instruction. Comprehension of the language of communication comes to us simultaneously with the 'reading' of non-verbal clues (facial expressions, body language, tone of the voice, etc.) and the understanding of the context of communication (previous knowledge of the subject of conversation). There are, of course, individual differences in the level of proficiency and sophistication of a child's mastery of communicative skills, but there are certain societal expectations as well: we have different expectations for a 4-year-old and a 12-year-old, and we may easily recognize "immature" or "advanced" social language skills in a particular child.

With all their diverse ethnic, age, and cultural differences, all IA children have to live through the period of rapid native language attrition and learning of a new language. For the majority of them, the abrupt loss of one language and much slower acquisition of another is no less than an interruption in language development (Gindis, 1999, 2006, 2008).

For international adoptees, learning English is a survival skill. In less than two years after joining the adoptive family, most adopted children don't seem to differ from their peers. They can chat on everyday subjects and it looks like they managed to move on with their lives and blend into the new lingo-sphere. Alas, that's true only at the first glance. The recorded conversations of adopted kids with their peers and parents reveal a lack of age-expected language mastery. Their speech is full of circumlocutions, with simplified and at times wrong grammar. The child does not pause to search for a word, but it's more babble than substance. The content carries little informative value with frequent fillers. Another, not immediately apparent distinction, is that their word meaning understanding may be extremely literal. Once I was testing a girl who has been in the country for eighteen months. Her native language was gone without a trace, and the assessment was conducted in English. I explained the problem: use the cubes with different side designs to recreate the pattern shown on a card. "This is the cube's top," I pointed. "Here are the sides. Now, show me the bottom." We were sitting in my office, separated by the desk and facing each other. I shuffled the cubes. "Bottom?" she echoed, with her eyes rounded. Then she slid down the chair, turned around and pointed to her buttocks. For her bottom had a precise, unambiguous, mono-semantic meaning.

The example of literal understanding of an English phrase or word by their IA children are often brought up by the parents: "One evening early on, after a particularly insane dinner, I held up my forefinger and thumb and exclaimed, "I am this close to the edge, and when I go, it won't be fun". My 5 year daughter, adopted at age 4, hopped out of her seat, came over and hugged me saying, "It's OK Mama, I go with you!"

Another parent recalled: "Nina was at home to about a year….we were leaving to go somewhere; I looked at her and said: "OK, let's hit the road." She replied: "Oh no...that hurt." I realized she assumed I meant literally go out and hit the road surface."

Difficulties with Identifying Other Individual's Feelings

In my clinical practice I have found that many IA children are proficient with recognizing simple emotions based on facial expressions, but have notorious difficulty in "mind reading" other individuals, in interpreting socially complex emotions such as irony, sarcasm, or disdain. For example, the, majority of IA children perform close to age expectations on the NEPSY-II "Affect Recognition" subtest, however, on the "Theory of Mind" subtest they show weaker comprehension of other people's perspectives and experiences. The first test reflects "survival" skills, while the second indicates a level of socialization.

Another example is the "Perception of Emotions" test from the Neurocognitive Assessment Battery. The child's assignment is to match a picture expressing certain emotions (facial expression, body posture, and gestures) with a word that describes this emotion, such as sad, in doubt, angry, calm, etc. Reaction time between exposure and response is measured. I found that in many cases the reaction time was unusually long, well exceeding the average for the age group - IA examinees took a longer time to process social/cognitive information so they could accurately recognize the emotion. At the same time, these children acted impulsively before they were able to recognize the emotion. As a result, they made an unusually high number of errors. In the next few seconds they might have been able to recognize the mistake and correct themselves, but the harm was done. Unfortunately, in real life situations they may perform the same way: be too slow with cognitive information processing and too quick with acting-out behavior. In many ways internationally adopted children's ability to infer emotional reactions in social situation is similar to one found in children with severe language impairment, as described in Ford & Milosky (2003).

Social Skills Development

We know that social skills depend on proper application of both verbal and nonverbal behaviors. What types of behaviors are associated with competent group entry? Research (Ronk, 2011) suggests that socially competent children use a range of entry tactics from 'low risk' to 'high risk.' Low risk behaviors are those that are unlikely to evoke either positive or negative reactions from the peers a child is trying to join. For example, a low-risk strategy would be hovering near peers who are playing together and just observing their activity. Using this approach, the child could gradually get a sense of the group's activities and norms, and eventually comment on what was going on, e.g., "looks like a fun game - mind if I watch for a while?" Through these kinds of actions, the competent child manages to gradually blend in with the group. Less socially competent children either never move beyond the 'hovering' stage or engage in 'high risk' strategies that may yield either positive or negative reactions. This includes comments and questions that divert peers from what they are doing and call attention to oneself. Less skillful children have a difficult time matching their activity to the group's 'frame of reference' and unobtrusively blending in. My observations and parents/teachers reports (using different behavior scales) suggest that many IA children have an initial tendency to engage into a "high-risk" social behavior.

Differences in Cultural Background and Values

An IA child's arrival to a new country is typically accompanied by confusion and anxiety. They are often disoriented and overloaded with information they cannot process: a classical "cultural shock" with a clash of cultures, full of misinterpreted social patterns and confusing situations. Their perception of basic social/cultural conventions can differ from their parents' and peers'. Cultural stereotypes are ingrained so deeply that we don't perceive them as culture-specific and as a hindrance in communications. Such pseudo-universal conventions include:

  • Expression of emotions. Hugging and returning "I love you, too" is almost reflexive in many American families. At the same time, in many other countries a normal and expected behavior is the opposite: reservation and timidity. Instead of "sorry" when pushing someone unintentionally, a child recently adopted from Ukraine may exclaim "Oy!" and give a guilty look. They may interpret asking forgiveness as a weakness, outward emotions as insincerity, smiles as trickery.
  • Interaction with adults. Children coming from Eastern Europe and China have a much stronger understanding of social distance separating them from adults than do American kids. Some languages promote this, implementing a special respectful form of addressing adults; a child would never confuse grown-ups with peers and must maintain this distinction by understanding roles and responsibilities.
  • Gender interaction. Gender equality is far from an everyday reality for most foreign children. They differentiate male vs. female behavior. They may shake hands with a man but not a woman, etc.
  • Manners and mannerisms. The ways people eat, talk, accept help, or express disgust are different in different cultures. Before being upset with the child's conduct, the parents need to understand its cultural component. Nonverbal communication differences among cultures are evident but are not necessarily known and understood in the families of IA children

From the cultural perspective, adoption erases or at least modifies the child's pre-adoption socio-cultural mold. In most cases the new social imprint has to be developed from scratch. One example of such re-training is language attrition. The old and the new languages are tenants of the same psychological space. Instead of peaceful coexistence, in case of IA children one aggressively pushes the other out. The cultures are no different in this aspect. It takes time to get rewired for the new culture. The time of transition depends on age, social conditions, and individual factors, but eventually most adopted children do transition. However, cultural differences may affect peer relations months and years after adoption. In fact, misunderstanding and misinterpretation of various behaviors by parents and children alike are often the beginning of the incompatibility, hurt feelings, deep disappointment, extreme reactions, and, in some cases, the renowned "Attachment Disorder" diagnosis for the child.

What Has to Be Done?

The importance of social and cultural competence cannot be overestimated as it is associated both with peer acceptance and with academic achievement. IA children are not represented in research related to social skills training, but some findings about children with different medical conditions, such as Autism or ADHD, can be applicable to them as well. Basically, there are two ways to help IA children with socialization: direct teaching and environment organization.

Direct instruction in social skills

It is necessary and possible to increase social interactions for international adoptees by explicitly teaching them specific, new, and often culturally different social skills and values, raising their awareness of the need to see another person's perspective. Consider these methods:

  • Take the role of an instructor in friendship "know-how" by modeling, explaining, and practicing specific social skills like greeting, parting, welcoming, declining, etc. according to the child's age. Model appropriate behavior when your child has classmates or neighbor's kids visiting him/her at home.
  • Selecting skills valued by peers and teachers increases the odds of their use and reinforcement. Pay special attention to social skills that are of critical importance, such as sharing, accepting criticism, giving and receiving compliments, taking conversational turns, respecting others' personal space, following directions, controlling anger, etc. Skills teaching can be embedded into everyday life activities or become "special sessions" during "quality time" when alone with the child.
  • Model how to be emotionally aware of other person's feelings by recognizing your child's emotions, listening to them empathetically, and trying to understand the situation from their perspective. Validating their emotions does not signify approval, just understanding. Your interpretation of their emotions and the causes of these emotions could be instructive educationally and healing therapeutically (that is what "talking" therapy is all about).
  • Teach your child how to deal with bullies. Despite the schools' effort to prevent bullying, harassment can be subtle and still painful. Many typically developing children experience the stress of bullying and rejection - it is a part of normal maturation. IA children, however, experience this stress to a much higher degree than can be considered "normal".
  • At an age-appropriate level, try to provide social skill analysis, discussing with the child after the fact what the child did, what happened when the child did it, what the outcome was (positive or negative), and what the child will do the next time.
  • There are a number of interactive, developmentally appropriate computer games that develop social skills. Most of these technologies have been developed for children with Autistic Spectrum Disorders (see http://www.sst-institute.net/au/parents/computer-game-pack/ ). However, some of these programs, particularly those designed for high functioning autism, could be useful for international adoptees. Some, like the Anger Control Games at http://www.researchpress.com/product/item/5231/, have been highly praised by many parents of IA children.
  • If your child has an Individual Educational Plan (IEP) at school, social skills improvement goals are to be clearly formulated and included in it. Those goals may look like this:

    a) John will understand and respond appropriately when others accidentally or intentionally do something he doesn't like (ex. talking loud, touching his things, etc.).
    b) When frustrated, John will choose and apply one of several prior scripted strategies of self-regulation and self-calming.
    c) When wanting the attention of another person, John will wait for the appropriate time to speak.
    d) John will share preferred object or activity with peer upon request with minimal adult prompting.
    e) John will be taught how to understand and respond appropriately to the nuisances of unkind jokes.

Direct instruction in the English language and American cultural background and values

  • Familiarize the child with American books, stories, games, songs, sayings, jokes, tales, and environments (ex.: Disney characters), which they may have missed by arriving into your family at an older age. Try your best to close cultural gaps - this alone will help children tremendously with better and quicker understanding of various cultural references used by peers. Go back culturally to the beginnings - everything that surrounds a child born into this culture has to be introduced into your adopted child's life and reinforced through multiple repetitions and references. It's just as important as learning the ABCs. Go as far back developmentally as you can, making sure every new piece of information and experience is linked to something they have already acquired.
  • Talk to your children: explain and use double meaning expressions in everyday life, play word-based games with your child. Make sure the child indeed understands you correctly. There are a number of special educational programs that facilitate social and cognitive language development. One such program, called SmartStart, was modified specifically for IA children (http://www.bgcenter.com/smartstart.htm). This program stresses the utmost importance of adult mediation, which was lacking in your adopted child's early stages of learning (Gindis, 2006).

Environment organization

Parents can help initiate and promote friendships through creating social opportunities for the child to be involved in different activities such as sports, art, dance, etc. The goal is to select the right activity and lead the child to at least a modest success in which they can showcase their skills and be appreciated by their peers. Every child must be successful in some activity, experience pride and be recognized as an achiever in something. This will build the platform for productive peer interaction (Reference to Simons?).

Use your immediate surroundings: your neighborhood, local organizations, and other gathering places to introduce your child to different social activities. Have your child enrolled in age-appropriate out of school organizations (e.g. local Scouts) and have him/her involved in different volunteer work. Cross gender and cross generation interaction should be a part of your child's social experience.

Be respectful of the child's cultural background, but concentrate on the cultural traditions and norms of this country: that's what your child needs to understand and internalize now. "Cultural camps" and "trips to the country of origin" are a mixed blessing, to say the least. They can be a trigger of psychological trauma and do not help in socializing here and now. Inept attempts to "keep the original culture" of adopted children can be an obstacle in their current acculturation. The appeal to honor an internationally adopted child's heritage and their "sense of identity" sounds nice, but the problem is that neither the child nor the parents can pinpoint, let alone keep, this elusive identity.

What's the cultural identity of a Gypsy child from a Romanian orphanage, who was mistreated just because she was a minority? Or a kid neglected in an Estonian orphanage simply because he was ethnically Russian? Or a Tatar boy from the Ukrainian orphanage, teased for his almond-shaped eyes and dark skin? For a social worker a Romanian Gypsy is a Romanian. The same goes for the Estonian and Ukrainian children, even though these children themselves are acutely aware that they are not welcomed in those countries. What language and culture should be saved and reinforced in the Russian children adopted from Kazakhstan who speak mostly Kazakh?

Cultural artifacts along with native language can be a definite post-traumatic stress trigger for many IA children. Even toddlers associate their pre-adoption language with the orphanage and English with their family. Depending on location, micro-cultures exist in rural and urban settings, always diverse and often incompatible with one another. For vast countries like Russia or China, there are further regional distinctions with separate traditions, mythologies, and languages. The memory of the orphanage with its rules and patterns of behavior and poorly understood remote regional customs is not necessarily something a family needs to cherish to help their child fit in here and now.

Consider this parent's testimony: "My adopted son Gregory is a Kulmyk, which is yet another ethnic minority from the Caucasus area in Russia. The more I learned about the political situation in Russia, the more I realized that this was a situation which would require some handling. He looks Asian, but came from Russia at the age of 7. He fiercely resists when people call him Russian. He said he was teased and beaten up by older children in his orphanage because he was not Russian. Now he is our son, Jewish and an American. I told him once, just before his bar mitzvah, that he should be proud of who he is and he should love his Russian heritage. He got immensely upset and said 'It is not a good thing. I am American and I am Jewish"' Last week we talked about Russian attitudes towards those from the Caucasus, based on news stories I have read and things we have learned over time. All these discussions upset Gregory. My rabbi (we belong to the Reform synagogue) keeps telling us that we have to respect his heritage and his culture. I am confused, indeed, because Gregory refuses even to hear about all this cultural stuff."

The intentions behind "keeping the child's culture" are noble (Jacobson, 2008), of course: diversity leads to social tolerance. We all strive to be unique and special later in life. But at twelve the effect is the opposite. At this age, the difference may lead to isolation and an inner sense of shame. It's especially true for singled-out adopted children. Quite often the emphasis on minority status in a teenager triggers not only mental but physical abuse. When adoptive parents think about teaching their child about cultural issues, they have to understand the entire subject first and foremost from their child's perspective and care about their child's mental health and emotional well-being.

Conclusion

Social difficulties with peer interactions are very common among children adopted internationally. As presented in this article, there are two major groups of factors that are responsible for this situation: subjective and objective. The first group of factors includes such typical characteristics of an international adoptees as complex childhood trauma resulting in mixed maturity, hyper-arousal, emotional fragility, and the learned survival skills known as post-institutional behavior. The second group of factors is the lack of language, culture, and age-specific cultural/social skills. A lot more research would be required to quantify and describe the interrelations between these factors, but in practical terms, a clear understanding of their presence may be enough to help parents approach each factor through a specific methodology which already exists.

References

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References
Boris Gindis, Ph.D.
Licensed Psychologist
Center for Cognitive-Developmental Assessment and Remediation (BGCenter)
845-533-4300 
 
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