Identification of the causes and nature of developmental delays and disorders in internationally adopted children is critically important for selecting effective remedial approaches and timely intervention for them, and it remains a complicated and many-folded task for a child psychologist. In one of my articles on the effects of traumatic background of internationally adopted children on their development Developmental Delays in Internationally Adopted Children (see http://www.adoptionarticlesdirectory.com/ArticlesUser/articles_view.php?editid1=Developmental%20Delays%20in%20Internationally%20Adopted%20Children) I spoke already about Developmental Trauma Disorder (DTD) and Cumulative Cognitive Deficit (CCD) as two major self-propelling causes and effects of prolonged developmental delays in international adoptees. In this discussion I would like to dwell more on the difference between Post-Traumatic Stress Disorder (PTSD), Attention Deficit Hyperactivity Disorder (ADHD), and Developmental Trauma Disorder (DTD) that are so typical for internationally adopted children.

PTSD is a condition in which victims of overwhelming negative experiences are affected by intense feelings of fear, helplessness, and vulnerability. PTSD is well researched in adults: clinical description and medical diagnostic criteria are presented in current DSM-lV-TR and ICD-10 publications. It is recognized that this medical condition causes severe anxiety that can develop after exposure to a traumatic event.

Within the last 30 years significant research was done on the same condition in children. It was found that PTSD in children and adults, although common in many aspects, has important differences in clinical picture and means of recovery from this disorder.

In both adults and children PTSD symptoms may last for a long time, and may include disturbing memories or flashbacks (nightmares and fear of re-experiencing traumatic event), avoidance behavior (avoiding thoughts, feelings, conversations regarding an event), hyper-arousal (hyper-vigilance, exaggerated startle response) and hypo-arousal (withdrawn, depression-like behavior).

PTSD is diagnosed in many internationally adopted post-institutionalized children. Moreover, there is an opinion that all international adoptees have PTSD to some degree. This view is somewhat speculative because it is based not on clinical or research data, but rather on the assumption that if institutionalization (and previous life in a neglectful and abusive family) is so traumatic, it must result in PTSD. However, even hypothetically, this is not accurate, because we know that PTSD is the product of the interplay between the nature of a specific traumatic experience and the psychological makeup of the recipient. In other words, the same experience may lead to PTSD in some individuals but not in the others. Vulnerability to PTSD depends on many factors, such as age, previous experiences, general sensitivity, pre-existing medical and psychological conditions, etc.

From the educational and mental health perspectives, it is not productive to accept a notion that all former orphanage-raised children have PTSD as part of their psychological makeup. Although it is true that they as a group are more at risk for PTSD than their peers at large, this diagnosis must be made on an individual basis by a trained mental health professional because the triggers of PTSD reactions in international adoptees may be so diverse and so different from our cultural background that it takes a specialist in psychological issues of international adoption to figure it out.

Thus, some of the triggers could be as common as threat of physical punishment: it was reported by many adoptive parents that any action that had even remote resemblance to corporal punishment may trigger a reaction that can only be explained by previous traumatic experiences.

At the same time some triggers could be rather "exotic", such as the sight of falling snow flakes or the sound of the child's native language.

Once the clients in my office mentioned, among other problems with their 8 year old daughter adopted from Russia 4 years ago, that she cannot use hot or even warm water, and her bathing is a "big deal" in their family: she cries and screams every time and looks horrified. At that moment I was unable to explain this phenomenon, just mentioned that this looks like PTSD type behavior. Only next day, reviewing the original (in the Russian language) court documents, related to adoption and not translated to the adoptive parents, I found that the biological mother of the girl was incarcerated for spraying her daughter with boiling water. The child was rescued by the relatives, the burn marks on her skin were barely noticeable by now and could not be explained to the adoptive parents - the girl was only 8 months old at the time of this incident. She, of course, did not remember this experience consciously, but her body did remember the trauma and hot water was a real trigger of PTSD in her.

As with other behavior issues in IA children, it's important to determine which PTSD symptoms are mild, manageable and probably transitional in nature, and which are threatening symptoms of a long-lasting trouble. For example, if the symptoms are observed during the first several weeks at home, they may still be due to the initial adjustment period, produced by the situation of unsettledness, anxiety, native language loss, and new language development. In such case time is needed to get over the culture shock and test the new environment; time is needed to switch from old orphanage behavior to a new family oriented behavior.

Therapy is a proven effective way of PTSD treatment in adults. Not necessarily so with children, particularly internationally adopted children: any sensible treatment of PTSD via "talking" therapy is based on the person's language ability. And this is in itself an issue for international adoptees: their limited English (or quickly disappearing native language capacity) may result in their inability to express their feelings and verbalize memories, completely blocking PTSD rehabilitation.

PTSD is a distinct medical condition and is not to be confused with another syndrome known as Developmental Trauma Disorder.

Dr. Tronick, in his simple experiment with a young child and his mother who stops reacting for a short time at her child's attempts to communicate with her (see his presentation at http://www.youtube.com/watch?v=apzXGEbZht0&feature=player_embedded ) showed that even a very minimal distress may become a traumatic experience for a child.

Clinical practice revealed that many internationally adopted post-institutionalized children frequently suffer from repeated traumatization of immense proportion in their early childhood. Such chain of trauma-producing events included:

The consequences of multiple traumatic events can have a lifelong effect on a child, so the notion of 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, see http://www.apa.org/monitor/mar07/trauma.aspx ).

DTD is different from PTSD in its effect on child's behavior and development. While PTSD is a discrete biological and behavioral response to reminders of a specific traumatic event that produces a specific temporary pattern of emotions and behavior, DTD adversely affects the entire maturation of the child by inhibiting the integration of cognitive, emotional, and sensory functions into a cohesive whole. The victims of DTD were uniformly observed to present with what is called "mixed maturity." They in some circumstances 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 may be very different from what is expected from children of their age.

One of the most typical features of the emotional make-up of a child with DTD is "hyper-arousal." Dr. Bruce Perry (see http://www.childtrauma.org/), has shown that traumatic events have the capacity to change Central Nervous System of children the way that it stays in the aroused state much longer, and every perceived threat (real or imagined), reinforces the sensitized neuronal pathways for the heightened fear/stress response. Perceived threats can objectively be typical day-to-day events (new environment, a loud re-direction, disrupted routine, perceived rejection, etc.), thus regularly and negatively reinforcing this hyper-arousal state and causing an immature, aggressive, and socially inappropriate response to routine family events.

Because of this constant state of hyper-arousal, a child with DTD may present patterns of behavior often associated with ADHD, such as difficulty with sustaining attention, restlessness, and impulsivity. An interesting study performed recently in Canada (see Richard Morrow, at. al. "Influence of relative age on diagnosis and treatment of attention-deficit/hyperactivity disorder in children" at http://www.cmaj.ca/content/early/2012/03/05/cmaj.111619) showed that the younger boys and girls in the same grade are significantly more likely to be diagnosed with ADHD than their classmates: immaturity has a strong correlation with ADHD-like behavior! No wonder that such behavior is typical for internationally adopted children, especially with DTD, who are immature even in comparison with children of their own age: they consistently present with ADHD-like behavior.

The clinical picture becomes even more complex when ADHD in international adoptees co-exists with anxiety. Still another specificity of ADHD in international adoptees, reflected in the patterns of their behavior and normally not found in "classical" ADHD, is the effect of lacking social/cultural influences: a lack of modeling, mediating, and assisting usually provided by caregivers in family-based upbringing.

In internationally adopted children with a history of several years of institutional care, developmental trauma disorder can be complicated by what is known as Post Orphanage Behavior (POB) syndrome. Being a typical behavior of post-institutionalized children, this cluster of behavior patterns is poorly understood and often overlooked and downplayed due to a lack of experience with children living in foreign orphanages (the last orphanage was closed in the US over 60 years ago).

POB is in certain ways a normal adaptive behavior typical for an orphanage, allowing a child to survive institutional care. However, the same behavior which is "adaptive" for an institution is "mal-adaptive" for life in the family and the community at large. The major components of institutional behavior are hyper-vigilance, "pro-active aggressiveness," controlling and avoiding behavior, feeling of entitlement, self-parenting, extreme attention seeking, and indiscriminate friendliness with strangers. (For more information please refer to Gindis, B. (2005). "Cognitive, Language, and Educational Issues of Children Adopted from Overseas Orphanages". Journal of Cognitive Education and Psychology, 4, 3, pp. 290-315. http://www.iacep.coged.org.)

With older children, there are also certain cultural differences between the adopted child and their family as a unit that remain strong enough to complicate life for both parties. These differences may include expression of emotions, interaction with adults and peers, and manners and mannerisms in everyday life.

These difficulties are amplified by the language deficiencies. Language plays a critical role in development of self-regulation, because it allows children to gain some control over manifestations of their feelings and helps them inhibit impulsive responses and behave in a more organized way. The specificity of ADHD in international adoptees is presented in my article "Attention Deficit Hyperactivity Disorder in Internationally Adopted Children," available at: http://www.adoptionarticlesdirectory.com/ArticlesUser/articles_view.php?editid1=Notes%20on%20ADHD%20in%20internationally%20adopted%20children.

Despite some pronounced similarities between DTD and ADHD, especially in the area of child's self-regulation, these are two different developmental issues, with different resulting approaches to patient's remediation.

It should be noted that until Developmental Trauma Disorder secures its place as a legitimate diagnosis in our psychiatric nomenclature, the best available identifiers of internationally-adopted post-institutionalized child's social/emotional states described above are: Post-Traumatic Stress Disorder and Generalized Anxiety Disorder. (See: Rolnick, A. (2010). Persistent Fear and Anxiety Can Affect Young Children's Learning and Development . National Scientific Council on the Developing Child, Center on the Developing Child at Harvard University, Working Paper No. 9, pp. 1-11. Retrieved from: http://www.developingchild.harvard.edu).

Because of their emotional fragility, internationally adopted post-institutionalized children are more vulnerable to the mismatch between their academic readiness and level of instruction; they are less robust 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. 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, interact in the age-appropriate manner with peers, and accept guidance from teachers. When doing the educational and family planning for these children, their emotional state is to be taken into serious consideration. Indeed, educational professionals working with these children have to walk a fine line providing them with intense and focused remediation and at the same time not overwhelming them with unreasonable expectations and demands. These children should not be exposed to the undue stress of facing a challenge that is beyond their actual readiness. Structure and consistency must be prominent elements of their support, and they are to learn self-regulation through direct and mediated learning. Their progress in the area of social/emotional functioning is as important as in the academic area.

Due to a combination of neurological and social factors, internationally adopted post-institutionalized children are diagnostically complicated and their clinical picture is often not consistent with any diagnostic entity. Indeed, co-morbidity (simultaneous co-existence of several medical and psychological conditions) is common in this population, and a differential diagnosis between ADHD, PTSD, and DTD is crucial for their proper medical and psychological treatment and educational remediation.