Ronald Federici and Heather Forbes Offer Aggression Workshop in July 2011

Dr. Ronald Federici and his colleague, Heather Forbes LCSW are offering a special workshop on aggression.

The workshop will be held in Denver, CO on July 23 and July 24.

More information is available here.

Dr. Ronald Federici: Noted Expert Witness

An example of expert testimony provided by Dr. Ronald Federici can be found here.

Dr. Ronald Federici: Siret Orphan Reunion

Ron Federici

On June 26, Washington, D.C. will play host to a reunion of the first children rescued from orphanages in Siret, Romania. The horrific conditions of orphans in Siret and other Romanian institutions were brought to light by a 1990 ABC Turning Point report, “The Lost Souls” and a follow-up in 1997 entitled “Romania: What Happened to the Children.” The exposé launched efforts around the United States to help the neglected and abused children.

The Romanian crisis, which has a long history related to communism and economic turmoil, continues today. Dr. Ronald Federici discussed the current state of orphanages in Romania and other parts of the world, as well as the adoption programs in the United States. Dr. Ronald Federici is a psychologist and founder of several American relief efforts for the Romanian orphans.

He first visited Siret’s orphanages in 1996 as a consultant for the follow-up report. Federici, who has adopted two Romanian orphans, is founder of the American chapter of theRomanian Challenge Appeal. He is also the author of Help for the Hopeless Child: A Guide for Families.

Read the transcript below.

Washingtonpost.com: Welcome to our discussion Dr. Federici. To get us started, could you give us some background about this week’s reunion of the Siret adoptees?

Ron Federici: After working in one of the most dismal institutions in Romania known as Siret, our humanitarian efforts were able to extract fourteen children from this place and find families to adopt them here in the States. The event on Saturday, 26 June, will involve American and Romanian specialists and dignitaries working collaboratively in discussing even more aggressive programs for de-institutionalization. This will be the first time the adopted children from Siret will see each other on American soil, which really highlights how a project can come together with the help of concerned people in both countries.

Washington, D.C. : Dr. Federici,

Can you tell us a little bit about how you got involved in Romanian orphanages.

Ron Federici: I have been performing neuropsychological evaluations on very damaged children for 20 years and have seen numerous children from international settings. I was asked to be a medical consultant for ABC News in 1996 in which Tom Jarril wanted to revisit the tragedy of Romanian institutions. When I went over to Romania it really made it clear to me as to how the children I had already been seeing had become damaged. I now continue to work with an international humanitarian group and experts regularly in Romanian institutions, performing evaluations and setting up treatment programs while coordinating activities with the government.

El Paso, TX: Can you comment on the subject of attachment disorder and the Romanian adoptees? Have any longitudinal studies been undertaken? Does consistent nurturing seem to overcome some of the initial problems seen in these cases?

Ron Federici: Specialists in International Adoption Medicine have been collecting a tremendous amount of data about the effects of institutionalization. Psychological experts are now revisiting earlier studies in the 40′s and 50′s on the effects of deprivation from Spitz and Bowlby. For all of the older children, beyond adoption age of 2 and 3, attachment problems are almost guaranteed as these children never lived with any type of positive parental figure, nor are they typically afforded proper care. The child under the age of 2 years old stands the best chance and will benefit the most by intensive nurturing and attachment whereas the older adopted child just does not have the ability to benefit from love and nurturing alone. Actually, those of us working in attachment disorders are finding that parents who try to provide an abundance of love to the older child only wind up with more problems as the post-institutionalized child just does not process or comprehend these emotional concepts. We are now breaking down attachment disorders into children with cognitive problems who lack the innate ability to comprehend human emotions and children who appear to have primarily psychological damage causing attachment disorders.

In my book, “Help for the Hopeless Child; A Guide for Families”, I discussed a very radical but successful treatment program for parents adopting older children in order to rapidly work on the effects of institutionalization and attachment disorders. Again, providing just love and affection can often cause more problems as this is more what parents need to do than what the child can handle. More and more research studies are being published but the current focus continues to be more on medical issues. The psychological data will continue to be available in book form and in subsequent research articles.

Bethesda, Md.: Has democracy in Romania done anything to improve the condition of the orphanages?

Ron Federici: Romania will take years to evolve as they are in a terrible economic crisis. Children continue to enter institutions due to poverty and deprivation with very few funds being channeled to these institutions. International aid is in great demand as the conditions continue to be VERY poor for these children. Democracy has allowed growth, but the country is still in great despair. It is evolving, however.

Alexandria, VA: Doctor Federici, we’ve had cases in the U.S. of parents putting their children up for adoption and then changing their minds and wanting to regain custody of their children. Do situations like these ever complicate your efforts in Romania?

Ron Federici: It is a tragedy that children are adopted and then relinquished. This is due directly to the fact that adoptive parents are typically not well prepared, trained or informed by their adoption agencies. Families have one opinion that the child will just fall in place, but when the damage surfaces, many ill-prepared families are overwhelmed and disappointed to where they want to give up the child.

The Romanian Department of Child Welfare is very troubled regarding this situation and feel that there should be a much better family assessment and binding contract to where families are not able to quickly relinquish their child. this is the importance of an IMMEDIATE and thorough assessment of the child’s needs by proper specialists and to provide vast support to the families in order to prevent relinquishment. If it continues, in these cases, the Romanian Government will most likely require more stringent contracts between agencies and their government in order to insure the best interests of the child to remain in the home.

Washington, DC: Is it true that the older children get, the worse the conditions are in orphanages? I have visited orphanages in Russia and this is the case — abuse gets much worse as the children get moved from a small kids to an older kids orphanage.

Ron Federici: As children grow older, they continue to be channeled in any available institution where the range can be from 4 years old to 25 years-old. This is a huge problem as children become more vulnerable and more abused and more emotionally damaged by being even further lost in a hopeless system. This is the tragedy of Eastern European institutions which have a long history through Communist times. This is the importance of trying to find a way to prevent more children from entering the institutions, as once they get in, they may never leave

Arlington, VA: Dr. Federici, are you and your colleagues trying to close down Siret or reform it? What is the response-reaction of the Romanian government?

Ron Federici: We have had tremendous support from the Romanian government regarding our humanitarian efforts in Siret. We now have a full-time group of volunteers from all disciplines working in Siret and they have allowed our medical team to set up pediatric, psychiatric, medication, and educational programs . We have built two group homes and have used Siret as a model for de-institutionalizing children. Our ultimate goal is to provide new training and models on ways for institutional children to leave the place and become productive Romanian citizens but they need a great deal of guidance from outside experts. We have total support from the government, and, I believe, Siret will stay open as they are very proud of our accomplishments, and often reference our work to other sections of Romania. We travel around Romania evaluating institutions. There may be some that close, but at the current situation, chidren will just remain in the institutions as there is no other place for them to go.

Rosslyn, VA: In the wake of the Columbine shootings, can the ideas in your book be applied to older children? Also, how is the traumatization of older children different than that of younger children?

Ron Federici: Columbine was a tragedy but reflects how damaged children can become – the epitome of an unattached child. Families must use principles of aggressive reattachment and demanding that their child get back in the family, comply with requirements, but also learn and practice how to relate at a deeper level. While sections of my book may seem aggressive and unconventional, what choice do we have when children are slipping away into deep despondancy and rage?

We must find ways to aggressively to hold them in the family ,train them and recondition their thinking and behaviors. While there still may be failures, aggressive attempts on the part of parents of the older child stands a much better chance of success than allowing the damaged child to drift away into tragic outcomes.

No. Virginia: What happened to the Romanian children who came to the U.S. and then started to have severe psychosocial problems. Were some of them sent back to Romania or did they go into new foster homes?

Ron Federici: So many of the children have chronic problems and have overwhelmed the families to where the families have given up even trying. Some have gone to foster homes or residential care, which is like another institution for them, and promotes a deeper attachment disorder. We are trying very hard to train mental health professionals on more proper and aggressive treatment models for the post-institutionalized child as opposed to the “wait-and-see or let them adjust” model. These children have gone through so many experiences that we cannot comprehend and need experts who truly understand children and the effects of deprivation. Treatment has to be unconventional as the child with an attachment disorder can often be smarter than the therapist or the parent. We are setting up international adoption clinics across the country with the Parent Network for the Post-Institutionalized Child (e-mail: pnpic@aol.com), setting up training for families at least three to four times per year across the country.

Washington, D.C.: Do the orphans tend to have psychological damage before entering these orphanages or does it come from living in them? How do you -or other professionals in this area- address these youngsters psychological problems?

Ron Federici: Many of the children who enter institutions have been damaged either medically or psychologically simply by poverty and deprivation. Many of my Russian and Romanian colleagues tell me that “why do you think we place the children in the institutions – because they are healthy?” Poverty is certainly the number 1 reason for children to be placed in institutions, although given the severe medical, nutritional, environmental, and economic hazards, the mothers and children are clearly at risk which results in either cognitive or emotional impairments when the child enters the institutions and gets worse as the years go by.

Washington, DC: How long does the adoption of foreign children take today? Because of the Romanian Challenge Appeal, is adoption of Romanian children quicker than children from other countries?

Ron Federici: Families wanting to adopt must go through an international adoption agency which can take anywhere from 8 months to two years depending on the problem. Most people want infants, which is smart. Older children are more readily available with an abundance of handicapped children.

Our Romanian Challenge Appeal focuses only on institutionalized children who clearly have emotional damage and need a very strong familiy. We have the strong support of the Romanian government to expedite handicapped adoptions as this has been the priority of the Secretary of State, Dr. Tabacaru, who sees the handicapped child as the most vulnerable and in quickest need of a family who can handle them. We have had wonderful families taking on our children from Siret, with the adoptions being done within 4-6 months and at virtually no cost aside from basic requirements (e.g., translations, INS, court fees, etc.).

Arlington, Virginia: Dr. Federici, I read the recent Washingtonian article about your work. How have your boys recovered from their surgery since the article’s publication? I hope they are well.

Ron Federici: Our children were almost dead when we found them and are now very much alive. They have defied all odds and are walking and at the top of their classes. They are an amazing pair and show how a strong brain and a strong soul can prevail. it too tremendous medical and psychological work to get them to this point. Tom Jarriel, from “20/20″ ,will be seeing them this Saturday, as he and I saw them at their worst condition years ago. Thank you for your kind words.

Arlington, VA: In 1990 Romania was seen at the forefront of the problem orphanage scene. Where are troublespots around the globe for this problem today?

Ron Federici: International adoptions are a real risk, as we just do not know genetic backgrounds, accuracy of records, the amount of care provided or how the older child really is. People are still adopting in volumes but I think families really need to be prepared for potential problems and hope that they will be able to find a healthy child or at least be able to aggressively deal with problems as they surface. Think of it this way, how would you function if you lost everything, had poor medical and nutritional care and had no one to take care of you and you had these experiences for years? Would you be healthy? And how long would it take for recovery to occur? Some do much better than others, with the goal being to get out of the institution as early as possible.

Herndon, VA: Have you heard evidence of similar problems with children adopted from other places under similar circumstances?

Ron Federici: Problems are not only in Romania. In my work in evaluating over 2000 internationally adopted children, there are problems in any country having institutional care. There is no such thing as a good institution – only some that do better than others. Whether it be Russia, Romania, Poland, Central and south America, the Far East, or even China, there are going to be problems if children remain in institutions. It is just not the place where children need to remain. Again, families must become more educated regarding the effects of abandonment and neglect, and that recovery takes a long time. it will often need more than love and a good home.

Garland, TX: Earlier, you mentioned the Parent Network for the Post-Institutionalized Child. What other types of support are available for adoptive parents once they’ve brought these orphans home?

Ron Federici: There are more support groups forming, such as Friends of Russian and Ukranian Adoptions (FRUA). The Parent Network does the most trainings and has satellite branches across the country. There are also international adoption clinics, and international adoption specialists across the country providing support and services. The Parent Network is centered in Dallas, TX, under the direction of Kathieseidel@juno.com, or you can e-mail PNPIC@aol.com to get the exact location. There are also support programs in Fort Worth, TX, at the Child Development Program at TCU, which is now doing a summer camp program for intensive rehabilitation of the post-institutionalized child. I trained their staff.

Oakland, California: Dr. Federici: Many people who have escaped from or are familiar with Rumania believe that orphanages in that country are -or were- a tool of “ethnic cleansing.” Are there any statistics available as to the ethnicity of the children in orphanages, i.e., Rumanian, German, Hungarian, Sekler, Gypsy, etc.? Thank you.
C. Rekay

Ron Federici: I agree that there was probably some “ethnic cleansing” during the Communist years. I do not know if anybody knows the statistics. What we do know is that any child with ANY type of deformity, medical, intellectual, or even suspected anomaly, went into the institution. Caucecscu did not like anything but perfection and mandated that women have many children to increase the work force. But, when the conditions were bad, sick children were born. This was how the institutions became so overcrowded. A real human tragedy which continues. However, this new government, particularly Secretary of State, Dr. Tabacaru, who is in Washington DC at this moment having many meetings with governmetn officials, is trying his best to get as much medical and economic support as possible.

Rosslyn, VA: Do many people still adopt Romanian orphans? I remember a number of American families adopted needy babies after political changes in Romania about 10 years ago or so.

Ron Federici: People are still adopting Romanian children. But it is slower because it is harder to find healthy infants. The older children have problems and many people choose not to adopt them as their problems are quite evident. If families work with a good agency and a good Romanian foundation, good adoptions can be done. I know for a fact that the Romanian government wants to continue working with the United States. The Romanian Secretary of State is meeting with the head of international adoption agencies in Washington on Tuesday to discuss these matters.

Chevy Chase, MD: Nearly a decade has passed since the ABC report. You have been their many times–how has Siret changed over the years?

Ron Federici: The only reason Siret has changed is because of the Romanian Challenge Appeal, groups both here and in Great Britain. This is a terrible institution but we have been able to maintain the best group of volunteers imaginable to work with the children. Now that the government and the institution allows us to intervene we have been making some real improvements but it is a very difficult task. There are so many children. If we can help ten or 20 % then we have done well.

Washington, D.C. : Did the television coverage of the Romanian orphanages in the early 1990s help to improve conditions there?

Ron Federici: The first TV show brought awareness but then everybody flocked to adopt these damaged children only to be ill-prepared for the effects of institutionalization. Media coverage certainly put pressure on Romania to allow other concerned parties to help, which is what we are doing.

I can’t say enough positive things about this new government. The Department of Child Welfare is really trying to do good things but they often struggle with older ideologies. It is an evolution that requires many outside consultants that can work with the Romanians at their level of transition.

Arlington, VA: How would you address criticism of Americans rushing to adopt Romanian -and other European- children over the thousands of orphans in their own country?

Ron Federici: Families adopt internationally because it is quicker, cheaper, and avoids contact with the biological parents. We have a tremendous amount of children here from families, that are also abused. But it is interesting that families here do not want to adopt children from “our system” as they feel the child is damaged when the same type of damage is possible or probable for the institutionalized child in Eastern Europe. It gets back into families being better prepared for a child’s problems. Also, many families go internationally as they view these children as cute and attractive and not having the problems of our abused children here in the States. This is so incorrect. Children everywhere need a family.

Garland, TX: Where can I send a financial contribution to help these kids?

Ron Federici: Thank you very much. The Romanian Challenge Appeals office is at 400 South Washington St., Alexandria Va 22314. Phone number – 703 660 6079. Donations should be clearly marked to the Romanian Challenge Appeal. You can also ask for our entire programs available.

Washington, D.C.: How would you characterize the local adoption system?

Ron Federici: The local adoptions systems in the States tend to be very quick if you adopt from Social Services. If you use international adoption agencies you must interview them and make sure they provide you with all the necessary training and information, which includes potential risks and resources if problems occur. Don’t go with the person who says “love and a good home will make it better.” This is certainly a very important intervention but commonsense must prevail as these children often need a lot more than love and a good home. With proper understanding and interventions, the goal is to bring the child to their optimal potential.

Washingtonpost.com: We’re out of time now, so let’s bring this discussion to a close. Thanks to Dr. Federici and to all who participated today.

Dr. Ronald Federici: Offering Independent Adoptions in Russia and Ukraine

Dr. Ronald Federici is one of the world's experts in the diagnosis and treatment of institutionalized children.

To assist families, he has established the Russian and Ukrainian Private Adoption Project.

Private adoptions offer more flexibility, and more information, especially medical, is available. The Project also has the resources to conduct in-country examinations.

Dr. Federici is the proud father to seven adopted children of his own, and oversees each adoption himself.

BAAF Winter 2007

BAAF (British Association for Adoption & Fostering) Winter 2007 - Vol 31 (4)

Editorial
Roger Bullock

Newspoints

The experience of adoption (1): a study of intercountry and domestic adoption from the child’s point of view
Amanda Hawkins, Celia Beckett, Jenny Castle, Christine Groothues, Edmund Sonuga-Barke, Emma Colvert, Jana Kreppner, Suzanne Stevens and Michael Rutter

Key words: adoption, children’s views, children’s attitudes, intercountry adoption, ERA study, Romania

The study team compared views about adoption for two groups of 11-year-old children (n = 180). Their analyses compared the views of children according to their pre-adoption background: UK domestic adoptees placed before the age of six months versus intercountry adoptees who had experienced extreme deprivation for up to three-and-a-half years in Romania prior to placement. Remarkably few differences were found between these groups, with the exception of two areas. Older-placed adopted children from Romania were significantly more likely to find it difficult to talk about adoption than domestic adoptees, and to feel different from their adoptive families. However, supplementary analyses suggested that these differences were due to increased levels of difficulties within the older-placed Romanian group, rather than whether they were adopted internationally or domestically. The implications of the similarities and differences between these groups for policy and practice are discussed.

The authors are researchers, Social, Genetic and Developmental Psychiatry Centre, Institute of Psychiatry, King’s College, London, UK.

Celia Beckett is also a senior social worker for PACT (Parents and Children Together), Reading, UK

Edmund Sonuga-Barke is Professor of Psychology Developmental Brain-Behaviour Unit, School of Psychology, University of Southampton, UK and the Child Study Center, New York University, USA

An examination of adoption support services for birth relatives and for post-adoption contact in England and Wales
Clive Sellick

Key words: birth family support services, adoption support, post-adoption contact

Support services for the birth relatives of adopted children have received far less research scrutiny than those for adopters and the children themselves. Sellick reports the first stage ‘mapping’ survey of a government commissioned study into birth relative support services and services supporting contact following changes in policy and legislation. The type, range and delivery of such services, commissioned or provided, by local authority and voluntary adoption agencies and adoption support agencies in England and Wales are examined. The survey found that good opportunities exist for linking birth relative and contact support services. However, real challenges remain in promoting support services and reaching birth relatives, and in funding and commissioning such services, particularly from the non-governmental sector.

Clive Sellick is Senior Lecturer in Social Work and Director of International Programmes, School of Social Work and Psychosocial Sciences, University of East Anglia, Norwich

The Child Wise Programme: a course to enhance the self-confidence and behaviour management skills of foster carers with challenging children
Martin Herbert and Jenny Wookey

Key words: challenging behaviour, looked after children, foster carers, attachment, Child Wise Parent Training Programme, cognitive-behavioural training, collaborative group work, placement instability

Looked after children with a history of maltreatment and abandonment are prone to develop high rates of mental health difficulties. They tend to suffer from multiple impairments, sometimes involving cognitive deficits and extremes of antisocial behaviour. Foster carers' management skills and emotional resources are tested to the limit. A further concern is the contribution of challenging behaviour to the unplanned termination of foster placements. Carers, if they are not to feel deskilled by the increasing numbers of children with special needs placed with them, require a more focused preparatory and follow-up training than they usually receive. This study questioned whether a broadly based cognitive behavioural programme could, by increasing carers’ behaviour management skills and self-assurance, reduce the challenging behaviour of looked after children and the resultant instability of placements. The answers were sought from a randomised controlled study of foster carers attending the parent training Child Wise Programme (CWP) designed by the authors. The programme combines course leaders’ professional experience of working with challenging children and parent groups, and foster carers’ personal expertise based on living with and caring for challenging children.

The intervention, with an experimental group of 67 foster carers and a comparative waiting-list control group of 50 carers, succeeded in meeting just over half of its key aims. An increase in the confidence of the carers was a significant gain. Also positive was the majority of personal reports indicating improvements in looked after children's behaviour, changes generally attributed to the acquisition of new behaviour management skills. Although some of the statistical comparisons were disappointing in their failure to reach significant levels (eg the reduction in placement breakdowns), they provided useful information about ways of improving the training. Qualitative methods were used to explore the subjective responses of participants to the Webster-Stratton and Herbert (1994) collaborative style of training employed. These produced valuable insights into the personal and professional dilemmas of a foster carer's role, as well as data which contributed to the evaluation of the training programme.

Martin Herbert is Emeritus Professor in Clinical and Community Psychology at
Exeter University, and Honorary Consultant Psychologist at the Royal Devon
and Exeter NHS Health Care Trust

Jenny Wookey is a Consultant Clinical Psychologist at the Plymouth Hospitals
NHS Trust, and a Supervisor for the Clinical Psychology Doctoral courses at
Plymouth and Exeter Universities

The Hope Connection: a therapeutic summer day camp for adopted and at-risk children with special socio-emotional needs
Karyn B Purvis, David R Cross, Ron Federici, Dana Johnson and L Brooks McKenzie

Key words: international adoption, adoption, child behaviour, attachment, sensory, self-regulation, intervention, camp

Large numbers of North American and Western European families are adopting children with serious socio-emotional needs. Other children experience similar deficits as a result of neglect and abuse by carers. Often these children are diagnosed with psychopathology and receive drug treatments that can be ineffective and even detrimental. The authors report on The Hope Connection, a project designed to meet the needs of these at-risk children and their families. Its core is a theoretically integrated summer day camp offering activities that are attachment rich, sensory rich and behaviourally structured. Pre-test and post-test data indicate that summer camp had a significant impact on the children’s behaviour (n = 19), as indicated by parent-report measures of child behaviour problems and attachment. These findings are discussed with regard to possible future directions of programmeme implementation and evaluation.

Karyn B Purvis and David R Cross are Associate Directors of the Institute of Child Development, and Professors of Psychology, and L Brooks McKenzie is an MA-Doctoral student, Texas Christian University

Ron Federici is a Neuropsychologist, Federici & Associates

Dana Johnson is Director of the Division of Neonatology and Director of the International Adoption Clinic, University of Minnesota

Inside the foster family: what research tells us about the experience of foster carers’ children
Robert Twigg and Tracy Swan

Key words: Foster carers’ children, foster family, foster care

Although foster care is the main source of out-of-home care for children and young people, little is known about the dynamics of the foster family. This article focuses on one subsystem of the foster family system, the foster parents’ own children. Fourteen research studies (nine published, five unpublished) were reviewed which involved approximately 232 respondents ranging in age from seven to 32 when interviewed and including nearly equal numbers of males and females. Findings include benefits of fostering, impact of fostering on foster carers’ children, responses to loss of role and parental attention, and the impact of the child welfare or foster care system. The authors conclude with several recommendations designed to make fostering a more positive experience.

Robert Twigg is Associate Professor, Faculty of Social Work, University of Regina, Canada

Tracy Swan is Assistant Professor, Memorial University of Newfoundland, Canada

Training and experience: keys to enhancing the utility for foster parents of the Assessment and Action Record from Looking After Children
Sarah Pantin and Robert Flynn

Key words: Looking After Children, Assessment and Action Record, foster care, training, Canada

The Looking After Children (LAC) approach is now widely used internationally in child welfare. The approach, which originated almost two decades ago, aims systematically to raise the standard of corporate parenting and improve the outcome of young people in out-of-home care. The Assessment and Action Record (AAR) from LAC is used to monitor young people’s developmental progress on a year-to-year basis. Clearly, foster carers are central to the successful implementation of LAC and it is important that they perceive the AAR to be useful in carrying out their fostering duties. Previous research in the UK and Australia found that foster carers believed the Record to be useful, especially if they were just getting to know the child or if the child had been in multiple placements. The study reported here draws on survey information provided by 93 foster carers in the province of Ontario, Canada. The authors found that foster carers who had received what they saw as higher-quality training rated the AAR as being more useful in their work. Interestingly, however, the amount of experience they had had in using the instrument was unrelated to their ratings of its usefulness. Overall, high-quality training emerged as a central feature of effective implementation. Specific recommendations were made in relation to LAC training curriculum requirements and stakeholder involvement.

Sarah Pantin is a graduate of the Clinical Psychology programme, University of Ottawa, Canada

Robert Flynn is Professor of Psychology and Director of the Centre for Research on Educational and Community Services at the same university

Legal notes: England and Wales
Deborah Cullen

Legal notes: Scotland
Alexandra Plumtree

Legal notes: Northern Ireland
Kerry O’Halloran

Health notes: Obtaining children’s health information
Kim Golding

Book reviews

Abstracts

Diary

Raising the Post-Institutionalized Child

Raising the Post-Institutionalized Child Risks, Challenges and Innovative Treatment

By Dr. Ronald S. Federici

Introduction and Background

Adoptions have always been a very important part of American culture with a recent "evolution" to a higher volume of international adoptions as opposed to adopting from our United States social systems. Many people have chosen to adopt a child from a foreign country as they find the procedure quick and cost effective with very little waiting time and an abundance of younger children readily available. Furthermore, many people choosing international adoption have the belief that adopting an infant or even older child from another country will spare them the pain and hardship of waiting for a child to become available or, more commonly, having the opportunity to "pick and choose" from a large volume of children who the family believes will rapidly "fit in" to their current family structure, physical appearance, and greatly appreciate all what they can offer them in our somewhat extravagant and over stimulating American lifestyles. American families also believe they will be spared any possibility of involvement with the biological parents if they adopt from another country as there have been numerous high profile cases in the United States in which the biological parents come forward after an adoption in an effort to reclaim their child based on a defense of incorrect adoption, improper legal proceedings, or even a "change of heart".

Adopting the child who has been raised in an institutional setting abroad poses some very important "risk factors" which are not always properly understood, disclosed or explained to families. The statistics of families adopting abroad beginning almost three decades ago when Korean adoptions set the stage for international adoptions have grown at an astronomical rate. Central and South America have always been very prominent countries allowing international adoption but, following the fall of the dictator Ceaucesceu in Romania in 1989 and the multitude of dramatic television portraying the plight of the Romanian orphan housed in the most damaging of conditions brought thousands of Americans and Europeans to Romania on their own to adopt these very special children with unknown pre and post risk factors (Kifner, 1989; Battiata 1990, 1991) Romanian adoptions set the stage for other Eastern Bloc countries to open their doors to Americans and Europeans, with the former Soviet Union allowing for a great volume of international adoptions beginning in 1993. Many other Eastern European countries followed suit in international adoptions with the most recent surge of adoptions occurring in Southeast Asia, particularly China and now Vietnam as well as long-standing programs in Korea.

According to current US INS statistics, approximately 16,396 children were adopted from abroad by Americans in 1999. Although international adoption has been gradually increasing in the United States since the 1950s, it has dramatically increased over the course of the past decade. For example, from 1992 to 1999 alone, international adoptions in the United States increased from 6,536 to 16,396 children, representing a 250% increase in only 7 years. (U.S. Immigration and Naturalization Service, 2000). The principal reason for this huge increase in international adoption has been directly related to the shortage of adoptable children in the Unites States as most families desired young, healthy and Caucasian infants which typically resulted in years of waiting or the extensive time it took for the birth parents rights to be relinquished.

The incredible number of children arriving from overseas post-institutional settings has been directly linked to ongoing media attention and the creation of literally hundreds of adoption agencies specializing in international adoptions. United States has stayed in the forefront of international adoptions followed closely by Italy, Germany, France, United Kingdom and Israel. Many of the countries have tried very hard to promote inter-country adoptions or some type of alternate placement such as foster care programs, but due to the poor economic conditions, international adoptions have continued to be a more viable option. Families from all over the world have offered to provide a stable home and environment for these special and potentially high risk children who have been housed in institutional settings, some better than others, but the majority having deplorable conditions and extremely limited caretaking.

Institutionalization: What are the risk factors?

Many people ask "what do you think it was like for our internationally adopted child?" This is an extremely powerful question as it involves a discussion of the high-risk pre and post-natal factors, genetic risks, poor medical and nutritional care and, primarily, children who have lived without strong maternal bonding and attachment during critical formative years. Commonly, institutional settings have very poor caretaker-to-child ratios with some countries in Eastern Europe having 1 caretaker per 50 infants or even older children. Many people attempt to seek out the most optimal or sophisticated country to where children are provided better care and, for these reasons, South America and Southeast Asia are often looked upon as a better "risk" because of their fostering programs or abundance of paid caretakers. In the former Soviet Bloc countries, the decades of oppression and neglect as well as the extremely poor medical care and nutrition have been linked to delays in brain and physical growth and development as well as delays in social-emotional development and, primarily attachment (Johnson et al, 1992, 1996, 1997; Rutter, 1998).

After Internationally Adopting: What Do We Do?

Children being adopted from other countries come to the United States at varying ages and in varying medical conditions. There are many families who are very much aware of a child’s specific physical or emotional disability and chose to adopt anyway. The majority of the children who have been adopted have very little accurate medical information which leaves huge gaps in understanding the child’s early developmental experiences. With this paucity of information, families attempt to set forth and raise their child the way they were raised or in a similar manner should they have biological children.

With families who have adopted infants and toddlers (understanding that many countries will not allow a child to be adopted until they reach at least an age of 4-6 months with previous policies forcing the parents to wait until the child is 18 months of age), the natural parent-child cycle is to provide an abundance of nurturing, stimulation, developmental activities and active involvement by all immediate and extended caretakers. While this is certainly the most optimal form of intervention for the infant or early toddler, there may be medical and psychological factors which the family is unaware of or may not know the outcome for several years.

For example, the effects of malnutrition on mental development are well known and have often been linked to later learning and behavioral problems (Galler and Ross, 1998; Miller et al, 1995). Fetal Alcohol Syndrome and Effects are common risk factors which can produce physical, learning and neurobehavioral difficulties (Johnson, 1997; McGuinness 1998). Additionally, the effects of institutionalization on even the youngest of child can have profound effects on attachment, safety, security and coddling behaviors. Failure to Thrive Syndrome and early infant-toddler restlessness, sleep and feeding disorders, and even early onset emotional-behavioral problems have been reported by many researchers who have followed internationally adopted children (Ames, 1997; Zeanah, 1999, in press). Revisiting the profound effects of early maternal deprivation and care as pioneered by Bowlby, 1951, and Spitz, 1945, have clearly listed out that even brief periods of early infant-maternal separation can lead to a combination of cognitive, attachment and behavioral difficulties.

Most families provide tremendous nurturing and attention for their infant-toddler, but there are a select group who must return to work and place the child in some type of daycare or preschool program at a very early stage of "reattachment" to the new parents. For the child who may have medical and/or psychological-attachment-deprivation risk factors, a placement out of the home for extended periods of time can only promote further unattachment or indiscriminant attachment to other caretakers as opposed to the primary parental figures. Zeanah’s work on infant-maternal attachment promotes the need for strong and consistent "reparenting" of the child who has already been deprived during critical developmental stages (Zeanah, 1993, 1996). The importance of aggressive reattachment and reparenting for a young child coming out of an institutional setting is of paramount importance as the child has had a loss of maternal attachment, stimulation and developmental experiences ranging from birth through 24 months with the damaging effects of early childhood deprivation expanding exponentially as the child becomes older and remains in institutional care.

Infants and toddlers most certainly require a stable and secure parental-family unit and hierarchy, and an abundance of pure maternal and paternal physical and emotional experiences. Research provided by Cermak and Daunhauer (1997) have consistently shown "sensory defensiveness" in the infant and toddler who has not been exposed to normal child rearing strategies. Therefore, many newly adoptive parents who have infants and toddlers may become shocked and overwhelmed when their affections are rejected as it should be emphasized that, even very young children who have been removed from institutional settings, can still be highly sensory and tactilely defensive and reject human contact because their preverbal and sensory-motor experiences do not allow for maternal comfort and nurturing to be so readily accepted. Newly adopted parents must be very sensitive to this issue and adequately prepared for this potential and somewhat provocative experience prior to their adopting an infant or toddler. While many families have extremely positive experiences after adopting the younger child, there are many families who try very hard to force the child into their arms for comfort and nurturing when the child’s innate capabilities for this type of infant-maternal attachment are not yet formed.

Other methods which have been found to be extremely helpful for parents who have adopted infant-early toddlers from post-institutionalized settings is to provide a wide range of developmental play activities which involve parent-child involvement. For example, infant toys involving different textures, colors, noises and music in addition to frequent movement activities on the part of the child with the parents physical involvement will allow the child a "safety net" and feel connected to a person and reality as opposed to remaining alone and isolated in a crib by themselves which has been their earliest experiences. There are many infant-toddlers who may be defensive and inconsolable but parents need to continue to provide constant human contact, warmth, texture, stimuli to all of the senses and working through nutritional problems such as failure to thrive or oral-motor defensiveness. This takes tremendous patience and tolerance on the part of the parent which is why the child must have only the primary caretakers work consistently on these issues as opposed to ancillary figures such as nannies, daycare providers or even extended family members.

With gradual and consistent attempts at reattaching and soothing this type of post-institutionalized infant-toddler along with the ongoing introduction of developmental stimulation, sound and visual inputs, nutrition (which can sometimes be a source of aversion for the new child based on their early "imprint" of poor nutrition), the newly adopted child has a much stronger chance of rapidly overcoming this "defensive pattern" and learning how to become reattached in a healthy and mutually rewarding manner. It is often the parents frustration over the child’s continual crying, lack of accepting soothing and nurturing, or even quasi-autistic tendencies such as rocking and self-stimulating which can promote parents becoming angry and detached themselves (Federici, 1998; Rutter, 1999).

Assessing and Treating the Older Post-Institutionalized Child: Challenges, Opportunities and the Need for Innovative Treatments

Many families opt to adopt older children from institutional settings from abroad. There are a large group of families who are more comfortable with having a child above the age of 3 or 4 years old as they feel they can more adequately "identify" physical, cognitive and personality traits and characteristics. Furthermore, families choosing to adopt older children are sometimes older parents who may not be interested in the "infancy period" but more interested in having an older child who may quickly assimilate into their family, particularly if they already have grown children. Adopting the older child may also make it easier on certain families who must work as the child can then be placed in a school-based program during the day while the parents maintain their jobs which, in turn minimizes daycare.

Adopting the older post-institutionalized child presents with an even greater risk than the infant-toddler. In remembering how children have lived in institutional settings, the older child has been exposed to even more years of vitamin and nutritional deficiency syndrome, poor medical care, a lack of developmental-educational experiences, in addition to being even further "detached" from maternal-caretaker relationships. The older child often develops a premature sense of independence and autonomy as they are left to their own devices to explore their institutional world; learn speech and language; toileting and eating habits; and relationships. Most of these developmental experiences are done without proper supervision, correction or effective discipline, and are often dealt with via harsh discipline, isolation to cribs or beds, or, more simply, placing all of the older children in a room together without toys, games, or recreation under adult supervision which leads to chaos and confusion and a very skewed sense of a family hierarchy. The child begins to see an "institutional hierarchy" which is very typical to the Darwinian Theory of "Survival of the Fittest". These older children learn habits such as fighting, stealing food, hoarding behaviors, indiscriminant friendliness or fearfulness of adults who randomly intervene. Often the caretaker interventions are no more than isolating the child back to their cribs or beds where they remain depressed, despondent and somewhat confused and disoriented as the only stimulation they may have is their immediate surroundings which is often bleak and impoverished.

Hopelessness and helplessness sets in rapidly for the older child in an institutional setting and symptoms of "institutional autism" or quasi-autistic characteristics continue to surface as this is a child’s means of providing self-stimulation (i.e. self-soothing via rocking and movement activities or time occupying behaviors) (Federici, 1998; Rutter, 1999). The rapid downward spiral of an older institutionalized child can be the precursor to more chronic states of unattachment, Post-Traumatic Stress, abandonment depression, fearfulness and anxiety related conditions, and behavioral disinhibition. Children become very angry and frustrated but, without a mode of expression or even an "audience", anger and despair becomes more internalized and "on hold" until the child has the next opportunity for expression.

Speech and language delays along with social-emotional delays are very common as the child continues in the institutional environment. As prospective adoptive parents review pictures, videos and medical records, this is only a "snapshot in time" as the child’s cognitive and behavioral issues typically surface after being adopted. Therefore, prospective adoptive families would greatly benefit by having extensive pre-adoption counseling and awareness of how an older child has grown up in an institutional environment and that providing a "good and loving home" may not be enough as specialized and practical treatment strategies may bring about a more positive outcome since so many families attempt to love and nurture the older child when, in fact, a gradual treatment process involving "reintegration into the family" must occur first. The best interests of the older institutionalized child must outweigh the needs of the newly adoptive parents to give rapid love, affection and attachment which are complicated emotional-behavioral patterns which may be totally foreign experiences to many of these children. If an older child has received a degree of special treatment such as foster care or a especially assigned and paid for caretaker within the institutional setting, this may certainly facilitate a smoother transition to an American home but it is so very important that newly adoptive families understand that they are a very different experience to the older post-institutionalized child who may view them as objects of indiscriminant attachment or people who can be easily manipulated into giving all the things which they never had: food, clothing, toys, games, socialization and unconditional love in the absence of structure or consistency.

Traits and Characteristics of the High-Risk Post-Institutionalized Child

Many of the older children adopted will be initially cooperative, clingy, and indiscriminant. Other reported behaviors by Ames (1997) in post-placement interviews have listed out a variety of problematic behaviors which tend to surface over the course of time. These behaviors can include engaging or charming behaviors in a superficial way; difficulties with eye contact; and indiscriminant affection with strangers; destructive and hoarding tendencies; lying and deceitful behaviors; aggressiveness; inappropriately demanding and clinging, particularly when challenged with discipline; and cognitive delays, particularly speech and language deficits. Children with these patterns of neurocognitive difficulties often struggle greatly both at home and in school if not immediately assessed. Coming out of an institutional environment has already placed the child at risk for developmental delays and the child entering into a new family and educational system with demands and expectations may be grossly unprepared which begins the "acting out cycle" which can produce a tremendous stress and burden onto newly adoptive parents, particularly if they have not had experience in child rearing.

Even the most experienced family can be challenged by the older post-institutionalized child. The temptation to give love, affection and an abundance of stimulation is so tempting due to the parents honest desire to "make up" everything they child has lost in their years of institutionalization. Often, the more the parents give immediately upon arrival, the less they get in return in the long run. Families are often counseled to provide "love, nurturing and stimulation" which may not necessarily be the best advice given the fact that that these are all experiences that the older post-institutionalized child has never experienced. Therefore, providing this level of basic indulgence or traditional parenting often promotes a mindset in the child that they will have anything and everything they want and will use "institutional behaviors" such as being demanding, yelling, aggressiveness, or self-stimulation as a means of obtaining a new set of stimuli which they are unable to adequately process or organize in a meaningful way. For the child who is cognitively delayed or impaired (i.e. mental retardation, autism or multi-sensory neurodevelopmental disorders), their ability to handle a flood of new experiences and relationships makes little sense due to processing deficits or an inability to comprehend what is actually required of them in terms of behaviors and emotional-social reciprocity.

It should also be strongly emphasized that there is almost always a degree of unattachment, post-traumatic stress and abandonment depression in the older post-institutionalized child beyond the age of 3-4 years. Many people will hold onto the belief system that they can "cure" the effects of institutionalization quickly when, in fact post-institutionalized children can show very intense patterns of childhood depression and anxiety through the manifestations of irritability, low frustration tolerance, lethargy and despondency, coldness and aloofness, indiscriminancy, or even rage and severe behavioral dyscontrol. There are many children who respond extremely well to their newly adoptive family environment which is most likely related to their having at least some developmental experiences of attachment, nurturing and maternal-caretaker involvement. This may be the exception as opposed to the rule but, nonetheless, Rutter (1998), has found that developmental catch up following adoption after severe global privation will, in fact, occur in the younger child as long as families remain involved and provide developmental-psychological interventions.

Innovative Treatments for the Post-Institutionalized Child: A Guide for Families and Mental Health Professionals

The most important intervention which families and professionals can provide to the older post-institutionalized child is an immediate and comprehensive medical and neurodevelopmental assessment. Understanding deficit patterns very early, particularly speech and language delays, cognitive-intellectual deficits, sensory-motor impairments and a rough estimate of the "stage of psychological development or trauma" will help plot out the most appropriate treatment interventions.

In expanding upon innovative treatment methodologies in dealing with the older post-institutionalized child, Federici (1998) strongly advises against the "wait and see model" as it is important to continually revisit the reality that the child has lived basically "detached" from proper maternal affection and caretaking. These are issues which need to be assessed and addressed early on with the main recommendation being for the older child is to arrange for a gradual "introduction" into a new family system, culture and language which is so foreign to all of these children a strategic and systematized plan of action should be undertaken to minimize later problems.

The following ideas and concepts may seem a bit extreme to many families who have adopted the older child, but is has been amazing as to the numbers who have come back into psychological treatment years after adopting an older child and stated "If we could have done it all over again, we would have done it much differently". Therefore, the concept of gradually "de-institutionalizing" a child at the onset of adoption makes the most sense as this will provide a true blueprint for families to follow which is organized, strategic while operating at the level of the child’s development thereby bypassing the needs of the parents which may be noble and nurturing, but incongruous with the psycho-social and cognitive stage of the child.

For the child who has been institutionalized approximately three years or greater, the following treatment approaches may lead to the most optimal outcomes:

1. Prior to adopting their child, the family should prepare for potential difficulties ahead. Preadoption counseling should be undertaken with the parents being made aware of potential high risk medical and psychological factors and the strong probability of cognitive delays, particularly speech and language. Teaching the parents awareness of quasi or institutional autistic characteristics is very important as many children from institutional environments self-stimulate which causes parents great distress.

2. Parents should be prepared for the initial "meeting and greeting" with the child. An immediate act of indiscriminant attachment does not mean that the child automatically loves you or really understands the concept of attachment and affection. Parents fall in love with their adoptive child much quicker than the adopted child falls in love with their parents. Advising parents that attachment is a developmental process and not an immediately occurrence.

3. Parents should absolutely not try to fix everything right away as recovery can sometimes take years, if not life long with some children who have experienced profound damage. Parents need to remain calm and practical, with the initial focus being on taking care of transporting the child from the country of origin to their home and addressing any urgent medical needs which may occur during the in-country adoption process. Again, careful counseling with the parents regarding how the child may react in their presence upon first meeting and on the plane ride home is very important to prevent catastrophies. Consulting with a pediatrician and possibly considering some conservative medication to ease the child’s anxiety and promote sleep can be beneficial in addition to being prepared for common medical conditions such as nausea, vomiting, diarrhea and infections. Getting the child home and into medical care is a priority.

4. Upon arrival home, it is very important for families to absolutely and unequivocally not over stimulate the child at any level. The child’s room should be kept extremely basic (if not stripped) as providing an abundance of colors, sights, sounds and toys will surely promote chaos as these are experiences the child may have never had. It is important to remember that children who have resided in an institutional setting are very accustomed to having little, if any, stimulation. As time passes, families can gradually expose their child to new things, but gradual is the word and only by the principal caretakers as opposed to having a "family reunion" which will surely overwhelm the child.

5. Institutionalized children are used to a very rigid routine which should be kept up at some level upon arrival to their new home. Keeping a well structured routine involving eating, sleeping, activities and parental attention is necessary otherwise the child will become "random and confused" due to their inability to process everything their new home has to offer.

6. It is very important that families stay at home with their newly adopted child as possible and have only very few people around, preferably the immediate family. Having extended relatives and friends from everywhere will only produce more indiscriminant attachment as everyone wants to "make the child welcome and give them things". If at all possible, the primary caretaker should remain home with the child assessing any and all nuances of cognitive and emotional patterns along with a team of developmental experts before placing the child in any type of school-based program. Daycare should be avoided for an extended period of time (at least 12 months). Remember, daycare is just another institutional setting that the child will attach and adapt to as opposed to a family unit.

7. Over the course of the first 2-to-3 months, parents should try to find a way to communicate with their child in his or her native language, even if it is very basic. The child will learn English very quickly, but will feel more comfortable if the parents are able to communicate basic commands and directives in their native language. Even poor Russian or Romanian is better than speaking to the child in English which they absolutely do not understand, let alone if they are speech and language delayed. Using visual-graphic techniques, basic sign language and gesturing, or direct training methods (i.e. showing them how to do something with the parent being right there) is recommended.

8. Most children coming out of an institutional environment have an emotional-developmental age of 2-to-3 years old at best. Therefore, they require constant training via repetition, role playing/rehearsal on most everything they do such as bathing, toileting, eating, dressing and dealing with both human and animal relationships. Many children become very aggressive and demanding and take it out on others or family pets which is why it is so very important to keep stimulation to a minimum and direct supervision to a maximum.

9. Avoid taking newly adopted children to places which are totally overwhelming such as grocery and department stores, parks and recreational activities, Disneyland, or anyplace in which there is sure to be "sensory overload". Most parents who have taken their children out in these type of public places prematurely usually regret it because the child runs aimlessly towards the stimuli and is difficult to stop.

10. Regardless of the age of the child, television and self-stimulating games such as Nintendo, videos or electronic games should be avoided as this will only promote social detachment and a new set of preoccupations.

11. A gradual introduction into socialization should occur over the course of months as opposed to the next day. Sending the child to daycare or school right away often results in disaster as the post-institutionalized child will play and socialize almost exactly the same way they did in their institution. This will usually take the form of indiscriminant attachments, aggressive play or remaining aloof and isolated.

12. Food is a very important concept to discuss as many families attempt to provide anything and everything which is contraindicated. Remember, children in the institution lived on a very regimented diet of the same things daily. If at all possible, keeping up a similar food regiment at first is recommended and then gradually introducing new food groups under strict supervision as children will often begin to hoard food or eat without any proper manners. Strict adult supervision and restriction of food intake will lead to better eating habits later on as food can often be another form of self-stimulation and self-soothing in the place of human relationships.

13. What is extremely difficult for families to do is to refrain from a child’s tendency to exhibit indiscriminant friendliness. Again, many parents hug and hold their older child very tightly and the child may reciprocate, but this may be a total indiscriminant behavior on the part of the child without any substance or depth of emotional/attachment meaning. Parents need to maintain strict boundaries and hierarchy and gradually teach the child when, where and who to touch, hold or hug. Most all older post-institutionalized children will immediately reciprocate a parental affection with their own version of affection, but this may not be genuine as again, this was not a practiced behavior in the institution. The needs of the child must outweigh the needs of the parent to "fix everything" via love and affection which is often delivered immediately and with good intentions but out of synchrony with the child’s developmental stage and depth of understanding.

14. Many children are cognitively or linguistically delayed. Parents must understand that the "wait and see model" may not be the best and that if a child is showing a pattern of impairments in their native language and behaviorally, that immediate special educational and behavioral interventions should be implemented. Examples would be providing increased structure, consistency, effective discipline and developmental therapies. The more structure, firmness and behavioral modification techniques applied early will help the child feel safe and secure even when they may rebel against the limits placed upon them. Rage and aggression should be dealt with directly by providing safe and nurturing holding techniques so no one becomes injured. Unconventional therapies should be avoided such as rage reduction or immediate "attachment therapy" for a diagnosis of Reactive Attachment Disorder which is a blurred and somewhat obscure diagnosis as all older children coming out of institutional settings have not had proper attachment experiences which is a given and should not fall into a psychiatric diagnosis immediately to where treatments or medications are prematurely provided.

15. Families must learn to rehearse and practice with their child methods in understanding personal space, boundary issues, eye contact, tone and pitch of their voice, self-control, and the ability to delay gratification and impulses. Most older post-institutionalized children have very little understanding in the recognition of facial expressions and body language which are an extremely important part in the development of proper attachment. These are skills to be taught as the child will not learn on their own or may learn from inappropriate role models.

Summary, Conclusions and Points to Ponder

To appreciate the full dimensions of an institutionalized orphan’s medical, cognitive and emotional difficulties, we need to understand the road traveled by such a child and what has happened along the path of decline.

Imagine how this child came into being. Imagine the child in the mother’s womb, assaulted by malnutrition, environmental poisons, nicotine, alcohol and perhaps life threatening medical conditions. Imagine the child born into a totally impoverished family, without enough food, shelter, clothing or medical care. Imagine that child abandoned, without the love and affection of a mother and father. Imagine the child placed in a stark and sterile hospital, with little human contact or stimulating activity, often kept tied to the crib. Obviously, such neglect can lead to psychological problems, but health problems are also a serious threat. As with any baby or young child left unattended for too long, these neglected orphans are exposed to so many high risk pre and post-natal factors that the brain and the psychology can become compromised.

After newly adoptive parents have brought their child home, the concept of recreating some aspects of their institutional setting and lifestyle may be the key to the initial stage of bonding and attachment as the child will then understand that you understand where they have come from. A gradual transition to a new and very complicated home life takes time, effort, consistency and a willingness on the part of the newly adoptive parents to implement innovative assessment and treatment strategies which may go against the grain of traditional parenting. If parents are able to objectively view how their child was raised and what their true needs are as opposed to the parents immediate need to create a family, long-term change and stability of the child will be more rapidly developed.

Never underestimate the power of the family structure and hierarchy which is vital for proper re-development of a child who may have been deprived and cognitively and/or emotionally damaged during formative years. Children of all types need supervision, support and education in a non-threatening and consistent manner with post-institutionalized children needing 50% more parenting than one had intended to give. Offering this level of intensity can be a cumbersome and overwhelming task, but it is the deep commitment that parents make to their child, whether biological or adopted, promotes the most optimal outcome.

Early assessment is the key, and problems need to be assessed the moment they arise. It has been very common in our society to view children as being able to "learn on their own and become independent" and, in no way, be overly controlled. The post-institutionalized child has already "learned on their own and was raised independent"—but not in the ways that we see as healthy. Therefore, teaching parents how to work at the level of the child is of paramount importance.

Success in parenting is driven by experience but, most importantly, proper understanding.

References

Ames, E.W. (1997). The Development of Romanian Orphange Children Adopted to Canada. Burnaby, B.C. , : Simon Frasier University.
Battiata, M. (1990a). A Ceausescu Legacy: Warehouses for Children. The Washington Post, June 7, A1-A34
Battiata, M. (1990b). 20/20: Inside Romanian Orphanages. The Washington Post, October 5, D3
Bowlby, J. (1951). Maternal Care and Mental Health. World Health Organization Monograph Number 2. Geneva: World Health Organization
Cermak, S. and Daunhauer, L. (1997). Sensory Processing in the Post-Institutionalized Child. The American Journal of Occupational Therapy, 51, 500-507
Doolittle, Teri (1995). The Long-Term Effects of Institutionalization on the Behavior of Children From Eastern Europe and the Former Soviet Union. The Post: Parent Network for the Post-Institutionalized Child, March
Federici, Ronald S. (1998). Help for the Hopeless Child: A Guide for Families (With Special Discussion for Assessing and Treating the Post-Institutionalized Child
Federici, Ronald S. (1997). Institutional Autism: An Acquired Syndrome. The Post: Parent Network for the Post-Institutionalized Child, November, Volume Fourteen
Galler, J. and Ross, R. (1998). Malnutrition and Mental Development. The Post: The Parent Network for the Post-Institutionalized Child; Volume 6: 1-7
Immigration and Naturalization Service (1998), Immigrant Orphans Admitted to the United States by Country of Origin or Region of Birth, 1989-1998. Washington, D.C.: U.S. Department of Justice
Kifner, J. (1989). Army Executes Ceausescu and Wife for Genocide Role. The New York Times, December 26, A1-A16
Johnson, D., Miller, L., Iverson, S., Thomas, W., Dole, K., Georgieff, M. and Hostetter, M. (1992). The Health of Children Adopted from Romania. Journal of the American Medical Association, 268-3446-3451
Johnson, D., Albers, L., Iverson, S., Dole, K., Georgieff, M. and Hostetter, M., and Miller, L.C., (1996). Health Status of Eastern European Adoptions Referred for Adoption, Pediatric Research, 39, 134A (abstract)
Johnson, D.E. (1997). Adopting the Institutionalized Child: What Are the Risks? Adoptive Families, 30, 26-29.
McGuinness, T. (1998). Risk and Protective Factors in Children Adopted From the Former Soviet Union. The Post: Parent Network for the Post-Institutionalized Child:8, 18, 1-5
Miller, L. and Klein, Gittleman, M. (1995). Developmental and Nutritional Status of Internationally Adopted Children. Archives of Pediatrics and Adolescent Medicine, 149, 40-44
Rutter, M. (1998). Developmental Catch Up and Deficit Following Adoption After Severe Global Early Privation. English and Romanian Adoptees (ERA) Study Team. Journal of Child Psychology and Psychiatry, 39, 465-476
Rutter, M. (1999). Quasi-Autistic Patterns Following Severe Early Global Privation. Journal of Child Psychology and Psychiatric (In Press)
Zeanah, C., Mammen, O. and Lieberman, A. (1993) Disorders of Attachment, In C.H. Zeanah (ed.): Handbook of Infant Mental Health (PP.332-349), New York, Guilford Press
Zeanah, C.H., (1996). Beyond Insecurity: A Reconceptualization of Clinical Disorders of Attachment. Journal of Consulting and Clinical Psychology, 64, 42-52
Zeanah, C.H. (1999). Disturbances of Attachment in Young Children Adopted From Institutions (in press).