Practically all children from foreign institutions (even adopted as infants) come into their adoptive families with a developmental delay of some sort. This is a well known fact and a commonly expected condition that often causes prospective parents ask questions about developmental delays as well as research them on the Internet. Unfortunately the information from many websites on "developmental delay" and "global developmental delay" is rather vague and amounts mostly to saying that "children with developmental delays reach the same developmental milestones and acquire the same skills as every child, but just a bit slower." The situation is more complicated than that when we talk about post-institutionalized adopted children. First, we have to differentiate between two terms sometimes (wrongly) used interchangeably: developmental disorder and developmental delay. The first term, developmental disorder (or developmental disability), is used in the domain of psychiatry and psychology and deals with specific neurologically-based weaknesses that are typically diagnosed in infancy, childhood, or adolescence. The examples would be:

These delays are not medical diagnoses per se, but, rather, are the terms used to indicate observed deficiencies in the child's adaptive skills, school readiness, emotional maturity, behavior self-regulation, etc. in comparison with their peers. The degree of delays may be very different, ranging from a relatively mild gap between the norms and the actual developmental status of the child to a significant developmental disability. Thus, the degree of needed rehabilitation is also different: from a minimal remedial support service to a full time special education program.

The recovery from any developmental delay in international adoptees is a highly individualized process with different outcomes that depend on the underlying causes, the child's age, timely applied remediation, and the appropriateness and intensity of selected remedial strategies. The public at large, parents, and health and educational professionals typically are well aware of the necessity of effective rehabilitation for children with developmental disorders. At the same time, there is still a lot of misunderstanding or bluntly wrong assumptions regarding developmental delays of the non-organic nature. In internationally adopted children such delays, if not addressed, may lead to very significant consequences, no less disruptive and debilitating than organic-based disorders. So let us have a closer look at this phenomenon.

There are two major causes of developmental delays of non-organic nature in international adoptees: Developmental trauma that results in "mixed maturity" and emotional/behavioral problems and can accumulate into Developmental Trauma Disorder and a profound cultural/educational neglect that leads to Cumulative Cognitive Deficit in these children. Both causes may often co-exist in a particular child.

A significant body of research and clinical practice have confirmed that many internationally adopted post-institutionalized children demonstrate the presence of developmental trauma as a result of repeated traumatization in their early childhood (deprivation of their basic physical and emotional needs, abandonment, life in an institution, adoption and sometimes disruption and re-adoption, transition to a foreign country, the loss of culture and language, ongoing frustration at school, etc.). The consequences of early developmental trauma can have a lifelong effect on a child, so the notion of Developmental Trauma Disorder (DTD) was suggested by a group of prominent researchers and practitioners dealing with neurological effects of trauma on children (currently under consideration for introduction into the DSM-V Manual).

Developmental Trauma Disorder is different in its effect on a child's behavior and development from Post-Traumatic Stress Disorder - PTSD, also commonly found in international adoptees. PTSD is a discrete conditioned behavioral and biological response to the reminders of a specific traumatic event. While PTSD produces a specific pattern of behavioral and emotional response, DTD adversely affects the entire maturation of the child by inhibiting the integration of cognitive, emotional, and sensory functions into a cohesive whole. In victims of DTD (post-institutionalized children, as well as children who have experienced abuse and neglect by their own parents), we observed what is called "mixed maturity." In some circumstances, a child of a certain chronological age may behave like someone much younger, and in other situations, may act like a much older person. Their reactions to social events, interpersonal relationships, academic learning, and overall adaptive behavior could be very different from what is expected from children of their age.

Children with Developmental Trauma Disorder are more vulnerable to a mismatch between their academic readiness and the level of instruction; they are more fragile in their ability to withstand the stress related to school performance, and they are less self-sufficient in overcoming the emotional strain which is a part of competing in the school environment.

Strong anxiety, either specific or generalized, is one of the most often observed characteristics of children with DTD. It permeates their family life and every day functioning, and undermines their self-esteem and confidence level. Their emotional fragility may constitute an educational impediment because it affects the ability to concentrate on classroom work, stay alert during lessons ("day-dreaming"), remember routines and instructions, and accept guidance from teachers. Still another typical feature of the emotional make-up of the post-institutionalized child with Developmental Trauma Disorder is what is called "hyper-arousal." Dr. Bruce Perry (see www.childtrauma.org/), one of the foremost researchers on the neurological effects of trauma on children, defined this phenomenon as "a sensitized neural response resulting from a specific pattern of repetitive neural activation due to repetitive traumatizing experiences. Sensitization occurs when this pattern of activation results in an altered, more sensitive system. Once sensitized, the same neural activity can be elicited by less intense external stimuli." (see Reference 3).

In Dr. Perry's work, as well as in other authoritative research, it was shown that traumatic events have the capacity to "redefine" the baseline level of the Central Nervous System involved in the stress response. Research suggests that when a child with DTD perceives a threat (real or imagined), he reinforces the sensitized neuronal pathways with his heightened fear/stress response. Perceived threats can objectively be typical day-to-day events like a new environment, stern and loud re-direction, disrupted routine, perceived rejection by peers, etc. Immature self-regulation of emotions and behavior contributes to socially inappropriate responses to routine school and home events. Being constantly tense and easily aroused produces restlessness, inattentiveness, and distractibility similar to behavior observed in children with Attention Deficit Hyperactivity Disorder.

Severe cultural neglect and sub-standard education, typical for post-institutionalized children, lead to what is known as Cumulative Cognitive Deficit (CCD). CCD is a downward trend in measured intelligence and scholastic achievement of culturally and socially disadvantaged children relative to age-appropriate societal norms and expectations. The current understanding of CCD is that children who are deprived of enriching cognitive experiences during their early years are less able to profit from a new and enriched environmental situation because of the mismatch between their cognitive maturity and the requirements of this new, more advanced learning situation.

Young children learn in two major ways: directly - through observing, experimenting, experiencing, and imitating, and indirectly - through adults who mediate knowledge for children by selecting and modifying input from the outside world and directing children's responses. For example, a child may observe steam coming out of a teapot. By touching this teapot and experiencing pain the child learns that steam is associated with something hot and that it may be painful. The same knowledge can be mediated by the parent, who points to a boiling teapot, saying, "Hot" and then imitating pain from a burned finger. Through direct and mediated learning, major cognitive skills and processes are formed and put into action. Deprived of such experiences, children are indeed disadvantaged and may have problems moving to more advanced levels of learning.

When a child misses certain stages of normal cognitive development and never learns the generic concepts necessary for successful schooling, the educational matter this child is taught simply does not have any structural support within which to be understood, remembered, and used. For example, elementary cognitive skills like patterning or sequencing, typically formed between ages 3 and 5 in a normally developing child through direct experience and mediated learning, may not be present in a 7 or 8-year-old former orphanage resident. More complex math and reading skills rest on these basic cognitive notions, so without re-building the base, no successful remediation is possible. Thus, a mild developmental delay has the propensity for accumulation and deepening if not addressed, especially with traditional remediation in schools that simply assumes the presence of an appropriate cognitive base and tries to build compensatory structures upon something which is not there. (For more detailed description of CCD please refer to Gindis, 2005 and 2006 in References).

The conclusion: Even a brief description of Developmental Trauma Disorder and Cumulative Cognitive Deficit - the consequences of the unacknowledged and untreated developmental delay in internationally adopted children, points out a strong need to change our attitudes towards developmental delays. Their descriptions in your child's medical records should not be dismissed as "not important," merely because they are found in so many medical histories of international adoptees. It's just prudent to find out what you are actually dealing with, and a psycho-educational screening of your child on arrival should be requested. The majority of internationally adopted, post-institutionalized children have the potential to fully compensate for their detrimental past by receiving enriched environmental stimulation, therapeutic intervention, and consistent learning experiences.

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