Sunday, April 14, 2013

Post-Orphanage Behavior in Internationally Adopted Children

Here is an interesting article by Boris Gindis, Ph.D. that was originally posted on the Center for Cognitive-Developmental Assessment & Remediation. Here is a link to their site:

After reading this article, it was amazing to me how many of these our son exhibits. Hopefully this will be a help to others as well.

The psychological effect on child's behavior produced by living in orphanage did not attract the attention of scientists until the first international adoptees from Romania arrived to America. The last US orphanage was closed almost 70 years ago, and the notion of "orphanage behavior" disappeared from the researchers' radar. But when adoption of children from the overseas orphanages reached big numbers during the last two decades, the monster returned but was not recognized. It was given many fancy names, from "institutional autism" to "attachment disorder." In cases of "institutional autism," those children would be later diagnosed with "real" autism or, more often, their behavior would gradually morph into normal family-oriented and acceptable patterns (see my article Institutional autism in children adopted internationally: myth or reality?). The situation with attachment diagnoses was even more complex (see my article Attachment disorder: are we trying to fit square pegs into the round holes? ), as a child's unruly or unusual behavior in a family setting was not necessarily a sign of any medical/psychiatric condition. In fact, in many cases this was a post-orphanage behavior, magnified by an early childhood trauma and reinforced by the abrupt loss of first language and new negative circumstances.
We all intuitively understand that an institutional culture must be the breeding ground for institutional behavior among children who do not get adequate care and proper mediation from adults in their early most formative years, are continuously traumatized, and often forced into survival mode. We do not have any reliable research on these depraving forces, but we do see the psychological effects and consequences of these conditions for children in their post-institutional period, which I will identify and describe based on my observations and on hundreds of psychological assessments I have conducted over 20 years.

Post-Orphanage Behavior (POB) syndrome is a cluster of learned (acquired) behaviors that could have been adaptive and effective in orphanages but became maladaptive and counter-productive in the new family environment. I believe that to some extent we can initially observe some patterns of POB in the majority of post-institutionalized children. As one can see further, some characteristics of POB may even contradict each other (e.g., learned helplessness and self-parenting), but nevertheless can still be found in the same child. In fact, the illogical combination of seemingly opposite characteristics is the very essence of POB.
Though it is difficult to trace the direct link between certain environmental conditions affecting a former orphanage resident with the resulting psychological traits of the growing up person who now lives in the family - it's always a complex combination of biological and social aspects - we have to identify the main patterns of expected and common post-orphanage behavior and separate temporary from long-term psychological problems. Below we will look at several components of post-orphanage behavior. They are most common among international adoptees, but there may be some additional traits which I do not review here like hoarding, stealing, habitual lying, and other anti-social acts reported by adoptive parents.

Poor self regulation
A peculiar combination of rigid routine with ongoing uncontrollable changes in the environment is typical for foreign institutions: constant turnover of caregivers and frequent transfers of children between institutions create unpredictability in living arrangements and lead to a tremendous sense of instability and lack of control. On the other hand, children's everyday routines are fixed with rigid schedules, virtually no personal choices, and no private possession of toys or other goods. As a result of this everyday routine combined with sudden uncontrollable change, there is a minimal need for behavioral self-regulation, long-term planning, or a need to practice goal-directed consistent behavior. The orphanage residents live in a "reactive" mode, surviving "one day at a time." Immaturity in self-regulation of behavior and emotions can be seen in such behavior patterns as:

  • Difficulties with sustaining goal-directed behavior, independent generating of problem-solving strategies and methods toward achieving goals, carrying out multi-step activities and following complex instructions, monitoring/checking and keeping track of performance.
  • Emotional volatility - the inability to modulate emotional responses. These children are easily aroused emotionally - whether happy or sad, the speed and intensity with which they move to the extreme of their emotions is much greater than that of their same age peers; they are often on a roller coaster ride of emotions. As observed by one parent: "When my 8-year-old is happy, he is so happy that people tell him to calm down. When he is unhappy, he is so unhappy that people tell him to calm down."
  • Reluctance/unwillingness to perform tasks that are repetitive, uninteresting, require effort, and that have not been chosen by the child (but that is what life in general and school learning in particular consist of!). It is very hard for them to shift (to make transitions, change focus from one mindset to another, switch or alternate attention) and to inhibit, resist, or not act on an impulse, including an ability to stop one's activity at the appropriate time.
  • Difficulty with delaying gratification and accepting "No" for an answer. In this respect many post-institutionalized children are rather similar to much younger children than to their peers.
These are only a small sample of the characteristics of immature self-regulation, which, being a part of POB, may appear as symptoms of ADHD and other neurologically-based disorders.

Mixed maturity
Poor self-regulation often comes across as phenomenon of mixed maturity, when the same post-institutionalized child at times may demonstrate the behavior of an older child and at times of a much younger one. For example, in terms of self-care and performed chores, a child may be well advanced for their age, may tend to interact more with older children and have interests advanced for their age, but in reaction to stress and frustration they may behave in a way that is usually expected from a child several years their junior. This obvious inconsistency is very confusing for parents and teachers.

Self-parenting in adopted children (not to be confused with the psychological technique of "inner talk" promoted by Dr. J. Pollard) is, in essence, an attempt to assume the role of parent, thus denying the actual parents their major social role. Post-institutionalized children may:
  • Constantly attempt tasks that are normally beyond their age level abilities and skills.
  • Resort to taking "justice" into their own hands in their relationships with peers instead of appealing to adults in resolving conflicts as is expected at a certain age.
  • Try to reverse the child-parent role by "supervising" parents and generally "bossing around" both their siblings and adults.
Although sometimes looking "funny" and even "cute" (when a seven year old girl teachers her mother how to use makeup or a nine year old boy gives his father instructions on how to drive a car), these patterns of behavior can be quite annoying for parents. Such behaviors may impede the bonding process and negatively affect biological children. In essence, such inappropriate social skills reveal an attempt to prove one's own self-esteem and self-worth and are an intrinsic part of POB.

Learned helplessness
This behavior seems to be the opposite of "self-parenting" but can be found in the same child. Both patterns of behavior are clearly "learned skills" in origin. Children in orphanages have been conditioned to get more attention from caregivers when they appear helpless: the more independent children in an institutional environment are, the less attention they receive. Some post-institutionalized children have deeply internalized this behavior and manage to appeal to a wide audience with demonstrated helplessness. This behavior has also been observed in abused children, who would rather have negative reinforcement than no attention at all. Learned helplessness is tolerated by society much longer than acting-out behavior. Many of these children actually have the needed skills or knowledge, but are resistant to any attempt to encourage them to act independently. There is, of course, a genuine need for help, but sometimes the line between learned helplessness and real need may be rather thin.

Controlling and avoiding behavior
Another important characteristic of POB is a global sense of insecurity that results in controlling and avoiding behaviors. It takes different forms in school and at home. In school, with their fragile and vulnerable sense of competence, a former orphanage resident feels (subconsciously) that it is better to be perceived as being uncooperative rather than an underachiever. Being insecure and too sensitive to failure, these children tend to avoid classroom assignments or activities that they perceive as "difficult," hence their refusal or noncompliance. It can be open defiance or hidden sabotage, but it is rooted in their overwhelming need to be always in control, to be on known and manageable "turf." This is an obstacle in their learning: to be a good learner means to take risks, to step into unknown territory, to be sure of one's own ability to cope, and to be prepared to accept help.
A substantial part of controlling and avoiding behavior comes from separation anxiety that may be a bizarre form of fear of being sent back to the orphanage, being passed to another family, or just being left alone. For a long time this fear stays in the mind of many international adoptees in spite of verbal assurances of their adoptive parents, and it may interfere with normal functioning in school and in the family.

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." The question remains to what extent this "disorder" is a learned survival skill for achieving security as understood by a traumatized child.

Self-soothing and self-stimulating behavior
A consistent state of abandonment, deprivation, and neglect of basic emotional needs "educates" orphanage residents on how to "take care" of their own emotional needs with self-soothing and self-stimulating behavior, which might have been copied or arrived at independently by a child. These might be:
  • Withdrawal/aloofness with finger sucking, hair twisting, full-body spinning and rocking, head spinning and banging, covering ears to block out even ordinary sounds.
  • Active resistance to any changes in routine and environment, excessive reaction to even ordinary stimuli, extreme restlessness, obsessive touching of self and objects, unusual reaction to some sensory stimuli (taste, smell, touch), making unusual, animal-like sounds.
Hyper-vigilance and "pro-active" aggressiveness
Children who are neglected and traumatized during early formative years tend to display higher levels of aggressive behavior (Gunnar, M., & Van Dulmen, M. (2007). Behavior Problems in Post-institutionalized Internationally Adopted Children. Development and Psychopathology, 19, 1, pp. 129-148). "Hyper-arousal," a heightened alertness and vigilance combined with an inability to correctly interpret the emotional side of the situation, is typical for many post-orphanage children, and it often results in inadequate social interactions both with peers and adults. Perceived threats can objectively be typical day-to-day events (like a new environment, loud re-direction, the mother's simple request to clean the table, disrupted routine, perceived rejection by peers, etc.). 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 present themselves in a seductive and promiscuous way, trying to control the situation by means unexpected in their age group.

Feeling of entitlement
Due to the very nature of orphanage life, when "goods and services" come from "out of the blue" and are delivered seemingly evenly to everyone in the group, it produces the feeling of entitlement in the orphanage inmates. The dictionary defines "entitle" as "to furnish with a right or claim to something." Entitlement is a normal stage of human development: when an 18-month-old demands possession of everything he sees, it is a natural and passing stage of growth. However, for a 9-year-old it is not appropriate developmentally: a child should have learned by this time to balance taking and giving. A normally developing child of a certain age (at least by the toddler stage) learns that goods (e.g.: toys) come as rewards for achievements or as presents given in certain situations (birthday, holidays, etc.) and not just because the "thing" exists and he/she wants to have it. When a child whines and screams, demanding a new toy she sees on the store shelf or a new pair of sneakers he has seen his classmates wear, or a new cereal just advertised on TV - this is the feeling of entitlement of which we are speaking. A child who was raised in an ordinary family may also have a sense of entitlement, of course. But children raised in orphanages have this feeling on much greater scale. They are conditioned to the notion that if one member of a group has something (say, is given a pencil or a notebook), other members of the same group are supposed to get the same, too, whether they need it or not. They may not understand the appropriateness of their demand (when a 17-year-old sibling has a privilege of returning home at 10 in the evening, a 12-year-old may hysterically request the same privilege for himself). While a sense of entitlement in children raised in families may result from poor parental techniques (like giving rewards randomly and for no reason), in orphanage residents this is a survival skill determined by institutional care. As such, it is only one small step away from the feeling of entitlement to obtain things though theft, robbery, or deception.

Extreme attention seeking
Adult attention is a rare and most valuable commodity in an orphanage, and children there fiercely compete for adult attention, sometimes through negative behavior (it is better to be punished than ignored). Orphanage residents constantly seek adult attention, approval, and encouragement. Often, no matter what they do, the motivation is to evoke a reaction from the grown-up, not to solve a problem or achieve some goal. This extreme urge to obtain attention is borderline with pathology. Thus, I often observe in post-institutionalized children what I call "person-oriented" versus "goal-oriented" behavior. For example, during testing the child is asked to make a block design according to a model presented in a booklet in front of her. However, the girl will not look at the model but will keep looking at me, randomly moving blocks in anticipation of my reaction. As soon as she infers that I am pleased with her performance, she stops her activity, in spite of the fact that her result is not the same as the model. Her motivation is not to accomplish the task but to please the adult and evoke his sympathy and attention. This urge to win an adult's attention and approval is typical for children in general, but in post-institutionalized children it often reaches extremes at the expense of independent goal-directed activity. It may adversely affect their performance on standardized tests where the examiner's behavior, by definition, is supposed to be "neutral" and "impartial." In such situations, post-institutionalized children may lose interest and motivation to perform: to "achieve" for many of them means to get an adult's approval, not to accomplish the task.

Indiscriminate friendliness with strangers
Orphanage raised children, similar to patients with personality disorders, may show indiscriminate and superficial friendliness with strangers. They may behave inappropriately with complete strangers they meet at a party or in a store. In fact, to their adoptive parents' frustration, they may demonstrate more intimate feelings towards strangers than to their parents. It is always a shock to adoptive parents when I explain them that for an orphanage resident any and every adult is a potential parent, and this disconcerting attitude may stay with them for many months after the actual adoption. I remember a 7 year old boy whom I evaluated after more than a year in the adoptive family. On the second day of testing he leaned over to me and said: "Will you adopt me? I do not like them (meaning his adoptive parents), I'll better stay with you. I am good at cleaning up an apartment." The above behaviors may all be presented in the same child and with a wide range of intensity. There are no gender differences in these behaviors, except withdrawal being more typical for girls and aggressiveness being more typical for boys. Some of these behaviors are similar to those observed in a range of psychiatric conditions such as ADHD, PTSD, and RAD. It is important to note that some POB patterns are mostly found in younger and some in older children.

Managing post-orphanage behavior in your child
After adoption, a child faces the task of transforming his/her orphanage survival skills into functional family/school relationships. The child has to learn new patterns of behavior and new social skills to interact with adults and peers. The time spent in orphanage sometimes, but not necessarily always, may correlate with the intensity of orphanage behavior internalized by the child. The range of individual differences here is very broad. In some adopted children the transformation of social skills and maturation of self-regulation comes naturally with time and practice. In many cases, POB will diminish by itself through observation and participation in family life (social learning) and figuring out what the most appropriate and productive behavior is. Indeed, in some children POB may be very mild and may vanish quickly. In others it may go away quickly, but suddenly reappear under stress. In others yet it takes a long time, great effort, and special help (counseling) to get rid of POB.
It is extremely important to realize that POB has shared symptoms with serious mental/emotional disorders. Therefore, those professionals who have no experience with post-institutionalized children may be easily confused and find a host of disorders from ADHD to RAD and affective disorders in children who may in fact demonstrate just POB. On the other hand, POB may mask, be in addition to, and be reinforced by organic and neurologically based genuine disorders, as can bi-polar or ADHD. In talking about "learned" behavior, by no means do I discount the possibility that some of these children may have childhood depression, post-traumatic stress disorder, or ADHD. However, it takes time to diminish the effects of POB in order to understand the underlying emotional problems. Hopefully, a skillful clinician is able to recognize the roots of the issue before putting these children on medication. (For more info about the differential analysis of a host of medical conditions in international adoptees, see my article Cognitive, Language, and Educational Issues of Children Adopted from Overseas Orphanages.)

The question is, how long do you need to wait for POB to subside before you know "something is still not right, there is a problem"? I have no answer for all individual situations, but the rule of thumb is this: POB has a tendency to recede with time (several months to a year or longer in some cases), while a genuine disorder will stay and get worse. The bottom line is that POB is a "learned" behavior: a set of survival skills that are functional and adaptive in the specific milieu of an orphanage. Therefore, the only remedy is to substitute these orphanage skills with newly learned, different, and at times opposite behavior.


  1. Thank God that you all are such educated and patient parents who are willing to learn and get help in order to meet Cava's needs. He certainly deserves that! So many parents only see the "symptoms" or their child's abnormal behavior and don't look past that to see the "underlying emotional issues" that thankfully you and your wife clearly see.

    God Bless you guys, I'm praying for your family always.

  2. One thing that surprised me, on becoming a parent, is how completely *logical* kids are. Sure, they do things that look illogical or maladaptive from our perspective as informed adults, but a lot of times those things are completely sensible when you take into account a child's background and level of information.

    Post-orphanage behavior is a good example of that - it seems illogical and troubling from the parent's point of view, but from the child's point of view it's a completely logical reacion to what's happening to him or her.