Dr. Ronald Federici: Romanian Orphans Q&A

Friday, June 25, 1999

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 the Romanian 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.

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Posted in adoption, Advocates for Children in Therapy, Children in Therapy, dr. ron federici, Dr. Ronald Federici, independent adoptions, orphan, orphanage, private adoptions, romania, ron federici, ronald federici, siret
12 comments on “Dr. Ronald Federici: Romanian Orphans Q&A
  1. limewire says:

    dang nice stuff man.

  2. Hi, Dr. Federici! It’s hard to believe that it was a year ago I first sent you an email regarding a family consult. I hope you and all of your family are doing well. From some of the listserves, it sounded like you went ahead and moved your office? If so, I hope that all went well for you too. I’m in the middle of opening a larger ABA center here in Southern Indiana, so I can appreciate the challenges!

    Your help has proven invaluable with the children. While we continue to work through some issues with several of them as would be expected, they’ve all made huge strides forward this past year, in a large part because of your guidance and direction. Here’s a quick update on each child, plus a request below:

    Kris is like a completely new person. He seems like a weight has been lifted and he’s doing extremely well. We’ve not seen the dark days for a long time from him and he’s worked through a lot of stuff with us. He just returned from his first mission trip (Jamaica) and that also has had a very positive impact, it seems.

    Will’s change is incredible. We were able to explain to the school that we all had been operating under a misdiagnosis and convinced them to build him, Cary and Adam a language-based program within their existing school, customized in many ways for their specific needs based on your recommendations. Will went from starting the year reading at pre-K levels and nearly zero math ability to now reading at 80% proficiency on 3rd grade sight words, and large improvements in occupational math capability. Cary and Adam both had their best years ever, though both have a long way to go. Cary’s just so extremely hyper, it still it drives folks around him batty, plus he has a hair-trigger temper and has gotten a lot more mouthy. But it happens less frequently and in between, he’s actively trying to do things to improve his behavior and relationships. Thankfully, the darkness has abated quite albeit though it still shows up periodically. Adam still struggles, but the med trials on the Abilify didn’t go well, though the Welbutrin seems to help some. The local doc is trying him on a low dose of Risperdal, but we’re being very cautious given his earlier unusual reactions. It seems like his development – physically, mentally and emotionally has just stopped for the most part. It’s worrisome, as he seems totally out of touch with other people and is adamant his view of the world is accurate.

    Ava is a pretty moody 13-year-old, but seems to be doing well most of the time. We try to get her out and involved in other things so she gets a break from the stress around here, but she still prefers to be a homebody, so we’ll keep working on that.

    Kristie’s anxiety continues to be a major source of issues for her, but that seems to be improving some. She deals with some paranoia now too and the morning mania continues to be a major issue, but I’m doing some behavioral interventions with her that she finally seems to be responding to most days. We’re also seeing a lot more smiles, conversation and interest in what other people are doing, so that’s positive.

    So that is the update. Again, I can’t really adequately express how much I appreciate all you’ve done for our family. You gave us the window we needed into our children so we could help them more appropriately and for most of them, it seems to be working. You also helped Jim and I take a very hard look at what was going on with us and that situation has improved dramatically over the past year also.

    Thank you again for everything and may God bless you and your family…

    With appreciation,

    Kim Derk

    “Dr. F: I had another thought about topic to include in Anna’s ‘needs/problems’ section of report: “She may reach puberty by ___ years of age, and will need direct teaching and hands-on assistance to manage self-care during menstrual periods, and cannot reliably relay menstrual pain due to high pain tolerance/thalamic pathway-sensory nerve involvement, which may create unpredictable moods and behavior”, or something akin to this. Hope it’s not too late. Off to take in sights with lots of layers to keep us Southerners warm. Everytime we leave hotel or restaurant or Metro stop, Anna announces “Dr ‘Rici is CLOSED, Mommy”. When we ask if she likes you, she says “Ye. . . . NOOOOOO!”. Guess that sums it up. Who really LIKED their drill sergeant, but am sure she has a love spot in her heart for you.
    Thank you for everything. You met and exceeeded our every expectation, and we thank God for you. May you have blessed holiday season. Sincerely”


    “Dr. Federici. Thank you for everything. You met and exceeeded our every expectation, and we thank God for you. We have been to so many “experts” over the years, and you nailed it in two days, and have helped us see hope and a light at the end. We have learned more from you in these past days, than from years of ‘therapy”.
    May you have blessed holiday season. Sincerely”

    Jeri H. , Houston, Texas

    “You are a life-saver, Dr. Federici! Your quality evaluation and comprehensive parent training has saved our family! We went through so many people, and you are the ONLY one who gets it with post-institutionalized kids. We owe you so much…thanks for helping all the families out there. God Bless!”

    Will/Mary V., PA

    “Hi. Just want to thank you for finding the time to meet with the Boyle child and the state department family/parents (from Africa). I read the report of your eval and just get blown away. This was the BEST evaluation and treatment plan we have ever seen for one of our state Department kids adopted from Ukraine. Actually, it was the best Neuropsychological Evlautaion we have seen altogether. This is a life long challenge for these parents. Your eval/recommendations was certainly something deeply needed and appreciated by them. Thanks for all the great support to our families serving abroad Thanks again”

    D. Supervisor, Exceptional Programs, US Department of State

    “May I ask what Dr. Federici does for….assessment?”
    “Federici conducted 34 tests, held a diagnostic clinical interview and reviewed seven years worth of reports for my chld. I doubt that most other clinical psychologists are as thoroughly versed in the pre and postnatal challenges that confront Romanian children at least. In my experience, they don’t conduct as many tests.

    My child was in his office from 8 in the morning until 6 p.m. Some children will receive additional testing; in our case, quite a bit had already been done, so Federici looked those results over and made sure to widen the testing to not duplicate (and/or to corroborate) what had been done before. Federici likes to do a great deal of testing by way of simulating a school day. He discovers what the mentally fatigued child does, what the low frustration child does, etc., what the “give up” child does, what the “dependent” child does…my child found it challenging, just like learning in school…

    Within three weeks of our visit, Federici compiled and sent me a highly useful 37-page report. He also revised the few inaccuracies immedaitely when I made the request. Not only did his assessment provide the interconnected aspects of my child’s learning, pulled together to show how, for example, short term memory and attention were involved. He made sense of a complicated history, noting subtle and obvious issues in a way that made the report’s findings difficult to ignore in public school. Furthermore, because Dr. Federici has the credentials in psychopharmacology, he indicated which medications might help my child. I felt that I had received a thorough, competent evaluation.

    I went to Federici because I was frustrated with the ignorance or “sluff off” factor I was encountering locally. …. I chose to go to Federici because of his knowledge base and the awareness that he could deliver a report (and revise it!) much more quickly than a hospital center.”

    Hi Dr. Federici, sorry it has taken me so long to write back. You may recall I was struggling a couple of months ago with the Adults Only program. I reread your book, watched the tape (Saving Dane), and reread Wendy’s program. We got over the bumpy spots and things went relatively well.

    Katie is able to be redirected verbally when she engages in body movements or “silly talk.” She returned to school in late August and has made a smooth transition to a new school, new teacher, and new classmates. Staff there is also finding her easy to redirect and Katie is now being mainstreamed again in the 3rd grade for math and some of the other subjects.

    Katie has also transitioned to a new daycare setting (she is taken by bus to a different school) and has handled the change well. I am very pleased with the results I’ve seen as a result of implementing your program. I wish I could clone you and move you closer. Once I enjoy the fruits of our labors, I’ll be ready for the next steps! Thanks for providing such a wonderful service!”

    Pat M.

    “My daughter and I would not be where we are with peace in our home, and secure signs of attachment without the intervention and support of this team. My message to anyone adopting an older child is early intervention and consultation with this team of professionals.”

    P.R., Indianapolis

    “A great expert in the field of Child Psychology. We need him here in the U.K and Ireland”

    J.R., England

    ” Extremely talented and skilled Clinician, Presentor and Parent!”

    Mental Health Staff and Parents, Iceland

    ” Always a Professional we welcome here to lecture and train”.

    Adoption Society, Australia

    “Dr. Federici is the only neuropsychologist qualified enough to evaluate and treat the most complex children, especially post-institutionalized children”.

    T.T., Founder, PNPIC

    “Ron Federici and his group were the only ones that could handle my out of control child who had failed multiple treatments. His group has the best treatment team for the family in need”.

    B.C., California

    “This group of professionals evaluated and treated our situation, pro bono, because we were in dire need. The evaluation and program for my son helped immensely.”

    K.C., New York

    “If it weren’t for the most professional evaluation and intensive treatment program given our family with our adopted child, we would have been destroyed.”

    K.J., Fort Worth, TX

    “NBC-Dateline “Saving Dane–Saving a Family” which highlighted Dr. Federici’s expertise with the most disturbed children was an inspirational show of recovery.” Professional review, NBC Dateline June 2003.

    “Dr. Ron Federici and his staff are an unmatched resource for families experiencing the challenges of parenting children with complex behavioral and learning problems. As an adoptive parent of a number of post-institutionalized children, Dr. Federici understands the emotional as well as the clinical issues facing each family. His superb diagnostic acumen is paired with an excellent track record of effective interventions.”

    Dana E. Johnson, M.D., Ph.D., Professor of Pediatrics, University of Minnesota

    “Given his extensive professional and personal experience with children of international adoption, Dr.Federici provides families with a uniquely informed and invaluable assessment of each child’s cognitive, academic and emotional strengths and weaknesses as impacting children’s functioning in home, school and other settings. His comprehensive neuropsychological assessments and expertise with post-institutionalized children, offered in conjunction with practical strategies, provides parents with tools and a much needed and individualized road map to identify the critical educational, medical and behavioral supports known to be essential for the promoting the wellbeing of these often misunderstood children and their families.”

    Lisa M.H. Albers, MD, MPH, Director, Adoption Program, Children’s Hospital/Harvard Medical School

    “I have worked with Dr. Federici for 10 years and have traveled with him to Romania on many medical missions. I learned about the plight of orphans from Dr. Federici and he inspires me daily. I send families to him because he knows the intricacies of the mind of an orphan mentally maimed by the harsh and unimaginable conditions of orphanages all over the world. He saves the souls of children. He is a creative and daring psychologist who drains his soul to help the hopeless!”

    Dr. Jane Aronson, International Pediatric Health Services, PLLC

    “Hello Dr. Federici and Leslie: I just wanted you to know that we have turned a HUGE corner! I called in desperate need 2 weeks ago and only 1 1/2 days later Michael decided to begin to comply.

    I did have an emergency visit with his Psychiatrist, but we only decided to increase his Tenex to 1 mg b.i.d. I am very glad that is the only change we made because the difference in Michael and his behaviors is like nothing I have ever seen!

    I have a new analogy for you to use. When I was pregnant people would tell me about their labor and delivery pains, but because I have never been through this I could only imagine. And, of course, my own labor and delivery would be my own personal experience. This is how I perceive explaining “extinction burst”. If you have never been through it, or seen it, you can only imagine what it will be like. And, of course, it is different for every child. I now understand that what Michael was doing on that Wednesday (hurting himself and me) was a true “extinction burst” (UGLY) (and perhaps a little something else). He was fighting for his life to try to get his old behaviors to work!

    Well, I am happy to say that his old behaviors did not work 🙂
    We are committed to the program and now even more so. The changes are so unbelievable!

    Thank you, thank you. The work that Dr. Federici and you do is invaluable to families like ours.

    Will keep you posted, and I’m sure have additional questions along the way. We just wanted you to hear some GOOD NEWS!”

    Kelly F. (Rick, John and Michael too)

    “did they determine over the phone before you traveled which of your children would need the extensive evaluation ?”

    We knew that Kat was either on the way out or we needed to do something “really different”. When we made an appointment for Kat, we were willing to pay what ever was needed for peace (what price do I put on that).

    We sent (our other children) to stay with my brother for the 4 days we were in DC with Federici. When we came home and started to work the Federici program with Kat, our youngest son’s Autistic behaviors were amplified. He displayed very stereotypical behaviors. We decided to take him to Federici for a full evaluation. After it was all said and done; the biggest suggestion was to try and reduce stress in his life and redirect him whenever he displayed stereotypical behaviors and get him around better role models (Kat was not a good role model for him). Our son was diagnosed as above average intelligence and many other positive dx’s.

    “I’m also wondering if there is any testing that can be done locally through the child’s pediatrician that can help to minimize Federici’s cost.”

    We could not face another person that was not willing to believe us. We were not willing to waste another nickel on “She’s Cute, She’s Adorable”.

    We had tried local stuff only to be told that “everything was fine” and “she’s cute and getting better”. This was not the case at home. I video taped what was going on in our home and the therapist was beside herself stating “I had no idea it was like this”. We gave up on local’s and decided to try something extreme.

    The result has been extraordinary. Kat is not a perfect, normal 4 year old however, she is nowhere near the behavior monster she was last year. She can sit and eat dinner, she can play with her brother, she will use the toilet for its intended purpose. This is priceless! We had lost all hope for Kat until we saw Federici.

    Many may disagree with his tactics and call it barbaric or something along those lines. They may say that I have violated my child’s rights. I can tell you that my child has a right to life. The path she was on was a suicidal path, self mutilation, running into traffic, throwing herself into moving cars, the fireplace, the wall, the doors. We have done all we could do to save her from herself.

    She is a different person today. I know this helps. I think very Highly of Dr Federici and his staff because “it worked for us” and “saved our family” on many fronts.”

    B.D., New Jersey

    “Hi Dr. Federici, We thought we would touch base with you and give you an update as to how things are going with W and D since our visit with you two years ago.

    We still speak and enforce your level program EVERYDAY. Of course, we have made revisions from time to time to keep up with development, responsibilities and privileges, but the basics are the same. The kids are very used to this in their lives by now. Tracking their token count is a daily part of their lives, much like brushing their teeth! They have had their ups and downs, mostly due to lying – but we seem to have gotten a better grip on that lately.

    W has come a long way. He thrives on his schedule and is quite self-directed. He doesn’t like bumps in his road or unexpected transitions, but he’s doing better at accepting them when they happen.

    D struggles with many thinking errors as well, especially when it comes to relationships. She will continue to be a handful, for us and for whoever else in her future!

    Overall they (we) are doing wonderful compared to where we were two years ago. On your 50-80% improvement scale, we give W a 75% and D a 60%. We expect more…still lots of room for improvement.

    They even get themselves up with their own alarm clocks, get dressed, make their beds, feed our pets, get their own breakfast all on their own! Sounds a tad different from their experience in your waiting room two years ago!

    Thank you again for all you did for us. We still hope to come back some day so you can see the progress for yourself. I’m sure you could put W’s anger control skills to a mighty test, but hopefully he would show improved survival skills! Sincerely,”

    TJ & K., Boise, Idaho

    “When we brought home our daughter Grace from Ukraine in March of 2004, we wondered if we would be able to parent her. She was 17 months old, 13 pounds and one big bundle of nerves. Grace has fetal alcohol syndrome, a disorder prevalent in the Eastern European orphan population. We are so grateful to have had that diagnosis which is necessary to getting her the proper help. Giving her love and time was not going to unwind the condition she was in.

    It wasn’t just FAS that brought Grace to this level of stress, but a combination of unfortunate life stunting scenes. She was the 6th child born to a 26yr old alcoholic in Crimea. Born full term she weighed 4 pounds and micro cephalic. At three days she was taken from the hospital to the orphanage where she lay wrapped tightly swaddled in a blanket. Over the course of the following year and a half she would experience a constant set of illnesses including acute bronchitis, pneumonia, chicken pox, measles, salmonella poisoning as well as malnourishment that kept her too ill to be kept with the healthy orphans. Her main stay would be in the infirmary, a small dim room with a few cribs, no toys, and no stimulation day after day.

    When we met Grace for that very first time we could hardly hold her because her body literally didn’t want to bend. It’s like picking up a wet, mad cat out of the bath tub- legs stick out everywhere. While she didn’t scream at us, she didn’t really look at us either. She had been deprived of so much that she couldn’t understand people. And deprived as she was, she was most content to be left in her crib where she could rock and bang her head and flick her fingers on metal screws. That was how she knew the world. So imagine her reaction when we took her away from that existence.

    R and I were sure that she would thrive and be excited at discovering her new world. We couldn’t have been more wrong. Her behavior deteriorated more so upon our arrival home. She wanted to be able to continue what R and I termed “zoning out.” If she could sit and gaze or stick her finger in a hole and stare at it all day, she would have. We tried everything you could imagine. We left her alone to do it; in the case she might feel comfortable enough to enter our world. That didn’t work. We put socks over her hands so she couldn’t cram them up her nose anymore but then she’d only gaze or enter into another activity with her feet. Pretty soon, we realized there was no chance at bonding because we were so focused on how to get her into our world.

    Looking back we were beyond clueless. While we had the diagnosis of fetal alcohol syndrome, there was nobody in our community to train us in how to parent her. And even if we found someone who understood FAS, we needed someone who would also understand the type of conditions she existed under in the orphanage. Love alone would not heal this little girl. As the first months passed, R and I were becoming the bundle of nerves that Grace was. Admittedly, I wondered if I could do this parenting thing with Grace and more selfishly, I was exhausted.

    A friend of ours gave us some information about Dr. Federici and his practice in Alexandria, VA and we contacted them. By then I had been on all of the adoption forums on the internet and was convinced Grace had reactive attachment disorder as well as a host of other disorders. I had contacted a few different therapists through email explaining our situation only to be encouraged to disrupt the adoption. We felt at the end of our rope. What Dr. Federici and our occupational therapist, Wendy Schmidt were able to explain to us is why Grace was this way and what we needed to do to help her.

    The severe lack of stimulation and neglect from her stay in the infirmary in addition to her malnourishment caused her to enter into a pseudo autistic state; a dissociative state where she used these maladaptive self soothing coping behaviors to exist. Dr. Federici has written on the subject calling it institutional autism. In order to bring her out of these “basement” behaviors, it would take minute to minute daily structure with me, her mom by her side. We needed to recreate a new world and in order to do that she needed consistency and repetition. And further, I would have to stop her “zoning.” Life in our home for those months was a bit like the movie Groundhog Day. Each day was a replicate of the day before. For a few weeks I think I must have cursed Dr. Federici and our therapist a few times a day. Each time she withdrew into her “zone,” I held her in my arms in what is called a “settle hold.” This is not to be confused with holding therapy techniques. I simply held her in a cradle like you would a small baby so that she couldn’t continue the maladaptive behaviors. She screamed and screamed. Days went by like this. I seriously questioned if any of this was working. Slowly she stopped the screaming and then began to look around, still refusing to look at me. Eye contact was particularly difficult. I wanted to put her down on the floor so many times and to be able to go on with my life.

    I admit that I became so frustrated, I wondered if this was going to be what life would be like forever. If only I could set her down on the floor. She would have been happy to have been left alone to continue her “zone” and I could be sure of some quiet time. Isolation was setting in for me. Not only was I staying home everyday with a screaming child in my arms, but most of my community didn’t understand what it was I was doing or why I was doing it. I was tired of the explanations and the strange looks. I know they meant well but the best thing friends and family can do is be a support and not offer advice based on the normal healthy child they are raising at home.

    Ever so slowly, as we inched ahead day by day, we began to see the unraveling of this tightly wound bundle of nerves we met that first day. She began to look at my face, only to glance away if our eyes met. And then she began touching my face while I held her. I began to add something new to our schedule as she was ready for it. Nearly three months passed before I left the house to take her out to public places. I realize now how vital that time was for her to be able to feel safe. She began to giggle and understand “silliness.” She no longer reached for strangers as if they were equal to me.

    We even had to teach Grace what it meant to feel pain. For all of the times she felt pain and cried as an infant and nobody came to soothe her, she ceased “feeling” the pain. Crying and acknowledging hurt for her was useless. We taught her this by each time she fell we ran and scooped her up and made a big deal about what happened and told Grace she was hurt and cried with her. Basically the exact opposite of what we did with our two biological boys. But it worked! She needed to have her feelings validated and to be able to once again connect her physical pain and appropriate emotional response. This was key to helping cure the “zone out” periods. Grace learned that Mommy and Daddy fixed pain not gazing, hair pulling, eye poking or any one of her other coping mechanisms.

    Today Grace is three years old and we have had her with us for 18 months. In that period of time she has truly blossomed reaching more goals than we ever imagined for this short period of time. For a child that had to learn to suck from a bottle when we brought her home, she is now learning to chew solid foods. A child that couldn’t walk until 21 months is now running and jumping a year later. A girl that didn’t understand what a Mommy and Daddy was, now calls out to them for hugs and kisses. A babe that didn’t know what smiling was for, now laughs heartily at a tickle or the cat’s tail brushing across her skin.

    There is no greater joy than watching the emergence of life in a child that was in many ways lifeless. She only existed and now she is exuberantly alive! And you know what, I wouldn’t change a thing. It’s easy to say now of course, but in many ways her special needs humbled me, carving in me, a new patience and a whole new compassion for what many children experience in the orphanage setting.

    Grace will never be cured of fetal alcohol syndrome and the secondary effects of it. She is frustrated easily with not being able to talk and to communicate her needs and wants. She will slowly achieve more goals as the time passes but she will forever have to live with the brain damage that cannot be reversed and we her family will need to adjust with her. R and I never set out to adopt a child with special needs, we only trusted that God would take us to the child He wanted us to have. And in doing so, we have received His grace and our Grace.”

    T&R, Arkansas

    Hi Dr Federici:
    Just a quick update on Kristina: Heavy metals (blood and urine) were negative. Risperidol is GREAT! We now have a child psychiatrist managing the meds and doing fine at 0.25 BID. Her voice is not as loud, less rocking, crashing, banging, less agitation, staying on task/focused, especially at school. Unfortunately last weekend, we had 4 days of hell (she acted like she did pre-risperidol). I called child psych and she upped the dose to 0.25 TID (8 am- 4 pm/ after school- and bedtime). Things are better now.

    Child psych ordered a fasting lipid panel which was abnormal. Note it was ordered/drawn 3 weeks after starting drug. Kristina must have crappy genes as she is not diabetic or obese. Her cholesterol is 197. Her HDL is 38 (low) and LDL is 145 (high). As you know, the HDL should be high and the LDL low. Hers are reverse and indicative of “moderate CHD risk”. Child psych doubts it is from the risperidol as she has not been on it long enough. We are redrawing labs in 6-8 weeks, if lipids are higher, she will pull her off resperidol and try another drug. Any thoughts on abnormal labs and/or drug effect?

    Peds endo at Childrens Mem’l Hosp won’t see Kristina unless she is off the growth chart. She is at 10% now.

    Peds neuro at Childrens is admitting her next week for a 24 hour EEG and comprehensive neuro exam, per your recommendations. Do u want results?

    By the way, liked your commentary in PEOPLE mag last week. Both Kristina’s teacher and principal stopped to tell me they recognized your name in the magazine.

    IEP implementation meeting is Monday with the whole team. School district has ABA trainer that will work with Kristina’s school and us to put behavioral program in place (finally). They are following your recommendations and for that we are eternally grateful to you. Feel free to use us a a reference for other families. We think you are terrific! Regards,

    Karen J.

    Hello Dr. Federici,
    I just wanted to say thanks again a million times for your help with Irina. We took your advice on the Risperdal and kept her on it. It has been 2 weeks now on the medication and 1 month out of school and she is like a different child. She is so much better. She is sleeping good and her mood swings, hyperness and anger have greatly improved. We can see some hope now! Just wanted to share with you the good news about her and say thank you so very much for doing what you are doing for the kids.

    Lori and Mike, VA Beach, VA

    Hello Dr. Federici!
    I am writing you to share good news about a former patient — D.S.. We visited you in August of 1999 from Cleveland, Ohio … and have corresponded several times since them. D. was selected to be the valedictorian of his confirmation class at our synagogue. Today he delivered his speech in front of the congregation. It was a moving and meaningful experience. The entire congregation was crying …the cantor said it was the most powerful confirmation speech she had heard in her 25 years at the synagogue. We thought you might enjoy reading it. And … you should know … that you were included in his first version of the speech as one of the reasons why he has reached the point he has. (the first version of the speech was more like a book … and needed editing). Thank you again for your guidance and expertise.

    H.S., Ohio

    Dr. Federici,

    I was very moved by the Episode of Dateline “Saving Dane” I think your program is wonderful, and I can’t tell you how wonderful I think Dane’s parents are. I can only hope that all parents would be so patient with there children. They were amazing. Please if you are still in contact with them. They did a wonderful job on Dane. I couldn’t get over what a happy little boy he was towards the end of the show. I’m just hoping that his road has gotten easier and that he is just as happy if not happier these day . . . . My name is Allison, i’m from Tracy, California and I was very moved by this story.

    Dr. Federici:

    On behalf of Debbie and myself and especially little Miss Kelly, thank you not only for attending today’s meeting but for using your expertise to make the meeting a done deal in our favor before it even started. Today was the polar opposite of the meeting 3 months ago, which was a done deal against us before it even started, and the chair of the meeting was even condescending and rude, refusing to even consider your test results. But when the meeting started today I sensed a change in attitude within the first five minutes. The “educational establishment” was in our corner after looking at the data and wanted to work with us “in good faith,” as they put it. As I told Debbie after today’s meeting, when the odds are stacked against you, it is time to bring in superior firepower: Dr. Ronald Federici. Cordially,


    Just a note to say that Mihaela is doing really well since we started Sensory Processing Therapy and implemented all your recommendations. We have been in therapy for almost a year and the change in her is unbelievable. Can you tell me is Sensory Processing something that needs to be continued for a long time with children from Romania? I am sure that it depends on the child. What books can you recommend on the treatment at home for SPI? We have also seen an endocrinologist for her as well. I don’t know what we would have done without your help with Mihaela. You have been a life saver to us Dr. Federici and I just want to tell you THANKS!

    Mihaela’s Mom

    Dr. Ron:
    We want to tell you that Dane continues to excel all around since we completed the “program” featured on “DateLine NBC” over 4 years now. NO MORE rages and uncontrollable episodes! Never a dull moment at our house! On a happy note, the kids are doing great!!! Megan is making A’s in her honors college program and enjoying her new apartment and roommates nearby. Dane is a speedy cross country runner (carrying the team’s first place trophy) on the JV team at his new high school. Both love us at this point in time, Praise God!!! Our family is blessed and has been restored thru so much.

    Dear Dr. Federici,
    Four years ago I contacted you about my then 9 year old son, Joshua. Although I had to modify your program due to Josh being my foster son at that time, your program still worked. Josh is now happy & healthy and learning to enjoy life after being abused and neglected for the first 8 1/2 years before he came ‘home’ to us. He still suffers permanent brain damage (FAS/E) but he is completely mainstreamed now and last quarter he made the honor roll! And today Josh won three out of his four of his wrestling matches and won 2nd place in his division! Not bad for a kid I was told may never heal who used to bite me, kick me, spit on me and try to kick the windows out of the van. THANK YOU, THANK YOU, THANK YOU!

    Again, I can’t thank you enough for helping us save Josh. I need another miracle now to save Justin. Thank you so much for helping our family, again.




    Dear Dr. Federici,
    We really enjoyed the opportunity to work with you and we both sensed a genuine desire on your part to help children. What you do for children and their families is amazing and your strength of character and knowledge was truly apparent throughout our visit. Your perspectives on parenting Andrew were insightful and we can clearly see benefits in the short period of time we have tried to implement the techniques. In a sense, the methods you taught are liberating in that we now understand that it is not necessary to constantly cater to Andrew’s wants and needs. Best Regards,

    J & D from Connecticut

    Hi Dr. Federici and Nadya,

    We wanted to follow up with you and inform you on how our son, Sam , is doing. We had met with both of you back around May 2007.

    Dr. Federici, after all your testing, your conclusion was that Sam had depression and you recommended that we put him a low dosage of an anti-depressant. Well we finally found a child psychiatrist in New Jersey which was no easy task. We showed her your report and she acceded to prescribe a very low dosage of Prozac, which she recommended.

    Well we are so happy to tell you that is exactly what Sam needed. He is a completely different boy now. He’s generally happy and acts like a normal boy. His self esteem has markedly increased and it has had an incredibly positive impact on the whole family!

    We are still working on bonding issues, but after dealing with four years of his depression, we feel the bonding will come in time. We are trying to incorporate some of Nadya’s recommendations regarding this issue.

    We do thank the Lord that he is doing so much better now.

    Thank you and may you continue to assist so many families that are in such difficult situations.

    God Bless,

    Paul and Vicky B




    Comprehensive Psychological and Neuropsychological/Neurodevelopmental Assessments:

    Cognitive-Intellectual Evaluations ( from Infancy to Adults )
    Dual-Language Assessments (Russian, Romanian, Italian and German Languages , Culture-Free and Non-Verbal Intellectual Testing)
    Academic Achievement Testing (ALL AREAS)
    Attention Deficit Hyperactivity Disorder Evaluations and co-existing conditions
    Non -Verbal Learning Disabilities and Visual-Perceptual Impairments affecting learning
    Comprehensive Speech and Language Evaluations/Auditory Processing Testing
    Learning Disabilities/Dyslexia/Multiple Handicapping Conditions
    Autistic Spectrum Disorders
    Testing for school and standardized testing accommodations (ADHD,GT,SAT,LSAT,MCAT,GRE,etc)
    IEP Reviews and Consultations

    Assessment of Organic Brain Syndromes/Traumatic Brain Injury and Trauma-Developmental Disorders:

    Fetal Alcohol/Drug Related Birth Defect Syndromes (FAS/ARND)
    Assessment of “Developmental Failures/Traumas” affecting brain growth and development (pre-post natal factors, malnutrition, neglect, heavy metal exposure, delayed growth, institutionalization and trauma)
    “Second opinions” for complex diagnostic cases
    Cases previously unresponsive to treatment
    Neuropsychological evaluations of Post-Institutionalized Children (Developmental Disabilities; Post Traumatic Stress Disorders; Institutional Autism; and the Neuropsychology of Bonding/Attachment Disorders)
    Organic Mood Disorders
    Executive Dysfunction
    Pre and Post Adoption Consultations
    Coordination with agencies and therapeutic treatment centers
    Cognitive Rehabilitation to improve behaviors

    Clinical Interventions For Individuals and Families:

    Family Cognitive-Behavioral-Reality Therapy Strategies for Acting-Out and Behaviorally Challenging Children
    Structural and Strategic Parenting Training to gain rapid control over unmanageable children (NO HOLDING THERAPY TECHNIQUES USED-ONLY SAFETY TRAINING FOR FAMILIES)
    Assertiveness Training for Parents and Anger Reduction Techniques for children
    Psychotherapeutic approaches emphasizing social skills, relationship building, and teaching respect / responsibility and self-control
    Trauma Therapy for Post-Abuse Syndromes/Post Traumatic Stress Disorder
    Family Therapy emphasizing bonding / attachment and family structuring and preservation

    Highly Specialized and Intensive Treatment Services:

    Comprehensive Neuropsychological and Neurodevelopmental Evaluation of all Autistic-Spectrum Disorders (ASD/Aspergers Syndrome/PDD)
    Assessment of atypical “Institutional Autism” following adoption/trauma/institutionalization
    Intensive evaluation and interventions for cases previously described as ‘non-responsive to treatment’
    Second opinion evaluation and treatment of “resistant” children–especially post-institutionalized cases
    Application of intensive ‘Applied Behavioral Analysis’ and ‘Verbal Behavior Therapy’ for all autistic-spectrum disorders and children with severe neurodevelopmental and behavior al disorders
    Intensive In-Home, crisis management and reconstructive therapy. Highly experienced therapists will travel to your home to do crisis assessment, therapy and long-term family programming in-home. Our highly specialized service has been featured on ‘Dateline NBC’ and is available for families who are at the point of crisis and/or disruption in their adopted or biological child. This is an outstanding alternative to hospitalization or residential care.

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    Providing Comprehensive Assessment and Innovative Treatment
    12704 Chapel Road, Clifton, VA 20124 (Main office)
    1479 Chain Bridge Road, McLean, Virginia 22101
    Phone: (703)830-6052, (703)734-1012, (703)548-0721 Fax: (703) 830-6054

  4. Neuropsychological and Family Therapy Associates, under the Directorship of Board Certified Dr. Ronald Federici (father to seven internationally adopted children), maintains an international reputation in the assessment and treatment of the most complicated neuropsychological, developmental and brain traumatic disorders.

    Neuropsychological and Family Therapy Associates is committed to providing the most comprehensive evaluation and state-of-the-art treatment services for children having the “full range” of Developmental and Psychiatric Disorders. Conditions such as autistic spectrum disorders; complex learning and attentional disorders; minimal brain dysfunction conditions; severe disruptive and behavioral disorders; chronic psychiatric disorders ; attachment-related disorders; post-traumatic stress disorders (following abuse and neglect from early childhood experiences); and chronic stress affecting family functioning.

    Individuals and families from across the United States and abroad come to our specialty clinic for first, second and third opinions for answers and treatment recommendations no one else has been able to provide. Virtually all of our children and families have felt overwhelmed and unable to understand the special needs of their children or their own diagnoses. All of us in the practice are experts with decades of experience in complex neurodevelopmental evaluations and comprehensive family treatment. Our work has been featured on national television (Dateline NBC: Saving Dane, Saving a Family”), with our clinicians forming a “multi-discipline treatment team”.

    We are proud of our reputation and take on the most difficult cases, particularly internationally adopted children. We also have a division in our clinic which handles domestic adoptions, abuse and neglect, and general child developmental psychology.


    For appointment availability, scheduling and fees, please call the main office at (703) 548-0721.

    12704 Chapel Road, Clifton, VA 20124

  5. The Neuropsychology of Bonding and
    Attachment Disorders

    By Dr. Ronald S. Federici

    While the role of the Developmental Neuropsychologist is to evaluate intellectual-cognitive, memory processing, learning aptitude, and problem-solving strategies, a critical duty may actually be in the evaluation of a child’s emotional integrity and perception of relationships. The interplay between neurocognitive development and emotions encompasses basic neurobiology which suggests that human emotions, reactions, interactions and attachments may be strongly mediated by a combination of genetic, neurochemical, neurocognitive and environmental factors. As there has been a tremendous amount of discussion regarding “attachment disorders” in the post-institutionalized child, the current psychological research focuses almost solely on the effects of deprivation and abandonment and the creation of an “attachment disorder” without a more detailed understanding of the role of innate neurocognitive functioning.

    While abandonment and institutionalization most certainly has a profound impact on a child’s ability to develop trust, bonding and security in newly adoptive relationships, an emphasis needs to be placed on the integrity of the post-institutionalized child’s higher-level neurocognitive abilities with a comprehensive assessment regarding the availability of “innate skills” needed for bonding, attachment and the development of appropriate social-interactional and reciprocal behaviors. While many children with post-institutionalized attachment disorders may display a combination of unattached or even indiscriminant behaviors (Ames, 1997), many post-institutionalized children display a very intense pattern of behavioral dyscontrol; aggression and violence; destructiveness to self and others; a lack of cause-and-effect thinking; indiscriminant affections to strangers as evidenced by being inappropriately demanding and clingy; or a pattern of social withdrawal, isolation and maintaining a self-stimulating posture. A principle complaint from parents adopting an older child is that the child may be out of synchrony with their environment resulting in difficulties in providing management, structure and organization.

    The concept of a “neuropsychologically-based attachment disorder” seems most appropriate for many post-institutionalized children, particularly the child who shows a history of high risk pre and post-natal factors which may have influenced neurocognitive development. For example, there is a documented interaction between growth parameters and neurologic competence in profoundly deprived institutional children assessed in Romanian institutions (Johnson and Federici et.al., 1999). Children who have shown documented medical and neurological impairments along with extended time in institutional settings typically display very pronounced impairments in the development of appropriate social-interactional skills. Combined with suspected impairments in neuropsychological abilities, behavioral patterns can often be quite aberrant and intense in nature, often overwhelming the newly adoptive family.

    Therefore, it seems only appropriate to broaden the horizon when assessing children for bonding, attachment or general psychological dysfunction by including a comprehensive assessment of neurocognitive abilities or deficit patterns. As children from institutional settings are at highest risk for medical, neuropsychological and emotional problems, an assessment of only the psychological or behavioral manifestations provides only a partial understanding of the adjustment issues which often produce tremendous stress on the newly adoptive families and treatment providers attempting to intervene and provide services (Johnson, 1997; Federici, 1999).

    Careful differential diagnosis regarding neuropsychological versus psychosocially-based attachment disorder can help provide newly adoptive families with better parameters of understanding the post institutionalized child. Additionally, neuropsychological and neurocognitive rehabilitation approaches should typically supersede solely psychological or psychiatric/pharmacological therapies as providing direct interventions and increasing speech and language, sensory-motor, abstractive logic and reasoning and, of greatest significance, visual-perceptual analytic abilities. These brain behavior interventions strengthen the post-institutionalized child’s ability to adequately “perceive” and process human relationships, emotions, facial expressions, social cues, and the necessary sequential “steps” needed to move towards a more healthy level of bonding and attachment. Too often, children from institutional settings are quickly categorized as having either a “reactive attachment disorder” or modicum of psychiatric syndromes ranging from Attention Deficit Hyperactivity Disorder, Bipolar Disorder, Post Traumatic Stress Disorder, varying types of depression and anxiety conditions or, very commonly, oppositional and conduct disorders or even autism/pervasive developmental disorders. While many of these psychiatric patterns may be co-morbid conditions, there needs to be a very aggressive but yet conservative approach in assessing the post-institutionalized child. Rank ordering developmental disabilities of the child as opposed to relying solely on the assessment of families or treatment providers may avoid misleading diagnoses and nonproductive therapeutic interventions.

    Home | About | Services | Staff | Testimonials | Articles | News | Links


    Neuropsychological and Family Therapy Associates
    Providing Comprehensive Assessment and Innovative Treatment
    1479 Chain Bridge Road, McLean, Virginia 22101
    Phone: (703) 548-0721 or (703) 734-1012 Fax: (703) 734-2735

  6. Neuropsychological Evaluation and
    Rehabilitation of the Post Institutionalized Child

    By Dr. Ronald S. Federici
    Presented at the Conference for Children and
    Residential Care Stockholm, Sweden May 3, 1999

    International adoptions have become prominent worldwide with the United States receiving the largest amount of immigrant visas issued to orphans. Eastern European countries, particularly the former Soviet Union and Romania, have been attracting families from all over the world due to the high volume of available children with desirable ages, ratio characteristics, and the definitive aspect of parental rights termination which has been a subject of recent controversy in the United States. Recently, there have been landmark cases in the United States overturning long-term custody of the adoptive parents due to the resurgent interest of the biological parents years later. In general, families completing international adoptions find the procedures much more expedient and cost effective as opposed to waiting on a list for infants in the United States which can be years of waiting, or the worrisome possibility of adopting an older child who has a clear documented history of abuse and neglect. Another motivation for families moving towards international adoptions has been media presentations worldwide which have highlighted deprived children residing in Eastern European institutions. Thousands of families have flocked to these countries with the hopes of rescuing a child from life-long institutionalization.

    Interest in the post-institutionalized child has gained great attention in all medical and psychological disciplines throughout the United States and in the United Kingdom. International adoption clinics have surfaced throughout the United States following pioneering efforts by Dana Johnson, M.D., Ph.D. of the University of Minnesota, International Adoption Clinic; and Laurie Miller, M.D., Director of the International Adoption Clinic at the Floating Hospital for Children in Boston, Massachusetts. As there has been a significant increase in the amount of internationally adopted children coming to the United States (up nearly 130% since 1990), the need for international adoption medical specialists has surfaced. Specialists from all disciplines of pediatrics and developmental psychology have been on the forefront of evaluating internationally adopted children of all ages. Research has shown the long-term neuropsychological and neurocognitive status of these children can often present a challenge to adoptive families as the “hidden disabilities” of the effects of institutionalization may not surface until the child is of school age.

    Post-institutionalized children have been exposed to a volume of high risk pre and post-natal factors such as poor maternal care, malnutrition, fetal alcohol exposure, smoking, neurotoxins, infections, prematurity, low birth weight, and a host of other potential complications. Goldfarb (1943), Bowlby (1951) and Spitz (1945) have clearly defined the effects of institutionalization or “hospitalism” as being strong contributing factors to later neurocognitive and emotional problems, particularly bonding and attachment deficits. Johnson (et.al., 1997) along with numerous medical researchers have intensely researched the health status of children from the former Soviet Union and Eastern Europe and have further documented the high risk factors which may impact later cognitive, learning and emotional performance. Rutter (1998) discusses developmental catch-up and deficits following adoptions after severe global early deprivation and finds a strong tendency towards resilience and short-term catch-up in the younger child group (adoptions completed prior to 25 months). Rutter goes on to explain that global cognitive improvement over the long course of time is still an unknown factor in many of the Romanian adoptees who have been exposed to high risk factors.

    There is controversy regarding assessment and treatment procedures for the post-institutionalized child. Many professionals believe that the effects of institutionalization and deprivation will spontaneously abate and a “wait and see” is adopted in addition to the ideology that parents should “give the child time to adjust” as opposed to implementing aggressive assessment or premature diagnoses of handicapping cognitive or emotional conditions. Federici (1998) has emphasized the importance of immediate and aggressive neuropsychological and neurodevelopmental evaluations for all children, particularly the older post-institutionalized child who may present with very prominent behavioral and adjustment difficulties, whereas the child under the age of 24 months requires time to re-stimulate and reattach. Evaluations in the child’s native language are of paramount importance. Many families worldwide are adopting children greater than 4 years of age and often find the child very challenging from the first day of adoption although may have been advised by various professionals or agency personnel that there needs to be this “adjustment period” and a family system emphasizing intensive stimulation, love and bonding in order to promote “developmental catch up” and normal family adjustment.

    Given the research and current understanding regarding the damaging effects of institutionalization and the numerous high risk medical factors which may lead to neurocognitive and emotional delays and deficits, the need for aggressive neurodevelopmental and neuropsychological assessment of impairments followed by aggressive neurocognitive and psychological rehabilitation appears to be a necessary inter-vention for children coming from profoundly depriving backgrounds. While long-term follow up regarding the internationally adopted child are still being gathered, early information strongly suggests both neuropsychological and emotional sequalae of institutionalization for a large percentage of children being adopted at an age greater than 4 years. While many children appear to have been unscathed as the result of institutionalization, Johnson (1997) suggests that children who have resided in institutional care become a high risk population. Early intervention programs appear to be a critical factor in promoting optimal development and recovery from institutional damage although many “delays” may be chronic and static in nature.


    The importance of comprehensive neuro-psychological and neurocognitive assessments will help determine baseline strengths and deficits, and plot out the appropriate interventional strategies. The neuropsychological definition of developmental delay is defined as a “documented impairments in neurocognitive functioning which may impact optimal intellectual, learning and emotional performance”. This definition may help families understand their adoptive child’s current cognitive and emotional status while aggressively addressing areas of impairment requiring immediate intervention as opposed to allowing the child to struggle unattended with cognitive deficits or continue a pattern of inappropriate emotional and behavioral manifestations.

    While neuropsychological evaluation may not definitively diagnose genetic and biological factors, a detailed assessment of all areas of cognitive functioning can help suggest a “pattern analysis” or level of cognitive organization and hierarchy which may be amenable to cognitive rehabilitation strategies (Reitan, et.al. 1978; Luria, 1976). Neuropsychological evaluation of the post-institutionalized child goes well beyond assessing a fundamental “intelligence quotient”. The importance of native language evaluation immediately upon arrival serves as a “baseline” for later longitudinal and cross-sectional evaluations. Many language and culture free instruments are available such as the Leiter International Performance Scales, Universal Nonverbal Intelligence Test (UNIT), Comprehensive Test of Nonverbal Intelligence (CTONI), in addition to many of the “performance measures” of standardized intelligence scales such as the Wechsler and Stanford-Binet. Additionally, simple visual-perceptual screening measures such as the Bender-Gestalt were used at the turn of the century to differentiate organic brain conditions versus psychiatric conditions versus normal populations (Bender, 1929). Projective psychological measures can also help guide the examiner regarding levels of cognitive and emotional sophistication for any child with great sensitivity given to cultural and environmental influences.

    An extremely important aspect of the neuropsychological evaluation is to supplement pediatric and developmental neurology assessments. Basic evaluations of sensory-motor, visual-perceptual, memory processing and problem solving strategies are extremely important in determining the presence or absence of hard and soft neurological signs which may be indicative of brain dysfunction or specific neurological disorders which may require more urgent medical interventions. Additionally, and of greatest importance, is the evaluation of receptive and expressive language as language functioning has the highest correlation to later impairments in other neurocognitive areas such as logic, reasoning, abstractive skills, problem solving, and the general development of academic abilities.

    A controversial position may be that the post-institutionalized child has little, if any, practical experience in order to engage in and complete a battery of neuropsychological and neuro-developmental tests. While this ideology certainly has a degree of relevance, it seems exceedingly important to assess the older internationally adopted child’s “baseline” level of strengths, weaknesses and, primarily depth of impairment, in order to properly advise the adoptive family regarding the degree or intensity of rehabilitation strategies necessary in order to promote more expedient improvement in multi-sensory skills. Acculturation and family “adjustment” tend to be matters of contentment as opposed to truly understanding the needs of the post-institutionalized child. Fundamental principles of developmental neuropsychology emphasize the importance of assessing both neurocognitive and neuropsychiatric factors which may be indicative of impairments of primary brain behavior relationships as opposed to solely adjustment factors. Furthermore, the role of the developmental neuropsychologist seems critical in working with families having adopted a post-institutionalized child as a better understanding regarding the “interplay” between brain development and emotions may better explain certain behavioral and emotional manifestations while more clearly defining deficits in bonding and attachment cycles (i.e., reactivity to situations, processing of new experiences and bonding/attachment patterns).


    While the role of the Developmental Neuro-psychologist is to evaluate intellectual-cognitive, memory processing, learning aptitude, and problem-solving strategies, a critical duty may actually be in the evaluation of a child’s emotional integrity and perception of relationships. The interplay between neurocognitive development and emotions encompasses basic neurobiology which suggests that human emotions, reactions, interactions and attachments may be strongly mediated by a combination of genetic, neurochemical, neurocognitive and environmental factors. As there has been a tremendous amount of discussion regarding “attachment disorders” in the post-institutionalized child, the current psychological research focuses almost solely on the effects of deprivation and abandonment and the creation of an “attachment disorder” without a more detailed understanding of the role of innate neurocognitive functioning.

    While abandonment and institutionali-zation most certainly has a profound impact on a child’s ability to develop trust, bonding and security in newly adoptive relationships, an emphasis needs to be placed on the integrity of the post-institutionalized child’s higher-level neurocognitive abilities with a comprehensive assessment regarding the availability of “innate skills” needed for bonding, attachment and the development of appropriate social-interactional and reciprocal behaviors. While many children with post-institutionalized attachment disorders may display a combination of unattached or even indiscriminant behaviors (Ames, 1997), many post-institutionalized children display a very intense pattern of behavioral dyscontrol; aggression and violence; destructiveness to self and others; a lack of cause-and-effect thinking; indiscriminant affections to strangers as evidenced by being inappropriately demanding and clingy; or a pattern of social withdrawal, isolation and maintaining a self-stimulating posture. A principle complaint from parents adopting an older child is that the child may be out of synchrony with their environment resulting in difficulties in providing management, structure and organization.

    The concept of a “neuropsychologically-based attachment disorder” seems most appropriate for many post-institutionalized children, particularly the child who shows a history of high risk pre and post-natal factors which may have influenced neurocognitive development. For example, there is a documented interaction between growth parameters and neurologic competence in profoundly deprived institutional children assessed in Romanian institutions (Johnson and Federici et.al., 1999). Children who have shown documented medical and neurological impairments along with extended time in institutional settings typically display very pronounced impairments in the development of appropriate social-interactional skills. Combined with suspected impairments in neuro-psychological abilities, behavioral patterns can often be quite aberrant and intense in nature, often overwhelming the newly adoptive family.

    Therefore, it seems only appropriate to broaden the horizon when assessing children for bonding, attachment or general psychological dysfunction by including a comprehensive assessment of neurocognitive abilities or deficit patterns. As children from institutional settings are at highest risk for medical, neuropsychological and emotional problems, an assessment of only the psychological or behavioral manifestations provides only a partial understanding of the adjustment issues which often produce tremendous stress on the newly adoptive families and treatment providers attempting to intervene and provide services (Johnson, 1997; Federici, 1999).

    Careful differential diagnosis regarding neuro-psychological versus psychosocially-based attach-ment disorder can help provide newly adoptive families with better parameters of understanding the post institutionalized child. Additionally, neuropsychological and neurocognitive rehabili-tation approaches should typically supercede solely psychological or psychiatric/pharmacological therapies as providing direct interventions and increasing speech and language, sensory-motor, abstractive logic and reasoning and, of greatest significance, visual-perceptual analytic abilities. These brain behavior interventions strengthen the post-institutionalized child’s ability to adequately “perceive” and process human relationships, emotions, facial expressions, social cues, and the necessary sequential “steps” needed to move towards a more healthy level of bonding and attachment. Too often, children from institutional settings are quickly categorized as having either a “reactive attachment disorder” or modicum of psychiatric syndromes ranging from Attention Deficit Hyperactivity Disorder, Bipolar Disorder, Post Traumatic Stress Disorder, varying types of depression and anxiety conditions or, very commonly, oppositional and conduct disorders or even autism/pervasive developmental disorders. While many of these psychiatric patterns may be co-morbid conditions, there needs to be a very aggressive but yet conservative approach in assessing the post-institutionalized child. Rank ordering developmental disabilities of the child as opposed to relying solely on the assessment of families or treatment providers may avoid misleading diagnoses and nonproductive therapeutic interventions.


    Comprehensive medical and neuropsychological evaluation helps define current and future needs of the post-institutionalized child. Many children who have resided in very deprived institutional environments may present with a pattern of autistic-type behaviors which can often present as being overwhelming and confusing to newly adoptive families and treatment providers. Pervasive Developmental Disorders and autistic spectrum disorders typically involve biological and genetic abnormalities; coexisting mental retardation; varying levels of speech/language; motor and sensory impairments; stereotypic movements and ADHD patterns; obsessive-compulsive behaviors; and varying levels of impairments in social-reciprocal relationships. Newer findings in the causes and treatment of autism are focusing on a multi-factorial approach in the assessment and treatment with extra emphasis on understanding dopaminergic and serotonergic systems relevant to the pathophysiology of pervasive developmental disorders (Potenza, 1997).

    A child with multi-sensory neuro-developmental delays can often be diagnosed as having mental retardation with coexisting autistic spectrum disorder. Many children from post-institutionalized settings live in an environment where there is a mix of neurologically delayed children with children who have been abandoned and neglected. While there is certainly a high incidence of children with classic neurologic disorders and neurogenetically-based autism or mental retardation, careful research and evaluation of children residing in Romanian institutions have strongly suggested a pattern of atypical autism that may be related to institutionalization or an “Acquired Syndrome” (Federici, 1996, 1998). While accurate statistics are not yet available, more cases of atypical autism in post-institutionalized children are being reported by families and treatment providers around the world.

    Rutter (1998) discusses Quasi-Autistic Patterns following global privation in Romanian and Eastern European orphans. Rutter discusses “autistic features” which were evident in children raised in severely deprived environments, with these features being very similar in some respects to those found in “ordinary” autism. These quasi-autistic patterns were found to be associated with prolonged deprivation and grossly interfered with the ability of the child to develop appropriate attachments and reach optimal cognitive potential.

    A child’s neurocognitive and emotional development rapidly moves towards a downward spiral following extended time in an institution. Hopelessness and helplessness sets in, with an increase in anger, frustration and extreme loneliness and despair. For children who have a relative degree of cognitive and emotional stability at the time of institutionalization, these relative “skills” can often be compromised following an ongoing lack of human contact and stimulation, or a chronic exposure to children having significantly more neurocognitive and neurodevelopmental impair-ments. In particular, children who may show classic autism or mental retardation in an institutional setting typically have very pronounced self-stimulating behaviors and rituals which tend to be automatic neurologic responses, whereas the relatively stronger institutionalized child may develop or “imitate” these responses over time as a way of finding a degree of social interaction, attachment and mode of passing time. These ritualistic behavior patterns may also serve to “detach and defend” against profound anaclytic depression and despair (Spitz, 1945).

    More specifically, as children in institutional settings become more resigned to the pattern of despair, trauma, emptiness and true “detachment” from an outside world, a loss of developing motor, sensory and intellectual-cognitive skills ensues. Regression begins and becomes an insidious pattern. While there may be no precise measure to assess how long this regression (and loss) of neurocognitive abilities may take, estimates suggest that for every two months of institutionalization that a child may be delayed one month in cognitive and emotional skills (Johnson 1997).

    Federici postulates that, as a child’s memory of the few positive experiences of life gradually fades away, he or she may regress to the most infantile (safe) stages of development. This regression can ultimately lead to a very infantile and autistic state in which the child exhibits an emotionally detached and preoccupied personality structure and presentation which is virtually indistinguishable from classic autism.

    Additional characteristics of Institutional Autism (or an “Acquired Syndrome”), are as follows:

    Actual loss of physical height, weight and growth in the absence of a documented neurological condition. The profound negative effects of malnutrition, untreated medical problems and social deprivation may result in a degree of psychosocial dwarfism.
    The child does not look to be anywhere near their actual age, nor is the sex of the child easily discerned.

    A cessation of current language functioning with a documented history of appropriate language usage.

    Rapid deterioration of behaviors to the point where the child exhibits primitive acting out behaviors due to profound attachment disorder and institutional trauma.

    Profound nutritional and medical neglect over the course of years which may mediate body and brain development with the gradual emergence of an organic brain syndrome impairing language, attention and concentration, development of confusional behaviors and deficiencies in memory and learning.

    Complete regression to self-stimulating behaviors such as rocking, head banging, hair pulling, self-injurious behaviors, and institutional language.

    Regression and “detachment” from relative healthy and normal human contact to an “attachment” to others with similar pathology. This “group model” represents survival in an alternate form of social-interaction based on modeling, imitation and developing any type of attachment in order to survive institutional life.

    Improvement in autistic symptoms following removal of trauma and with cognitive and emotional rehabilitation. Resurgence of autistic symptoms upon returning to institutional environment.

    In promoting a better understanding of this unique and highly complex institutional autistic syndrome, families may be better prepared to adopt and raise an older child from an institutional setting. Furthermore, more in-depth understanding of a potentially institutionally autistic child may help neuropsychologists and allied medical and mental health professionals appreciate the impact of institutional effects on neurologic and psychologic functioning which is then altered over the course of time. Awareness of acute and chronic trauma on brain behavior relationships may expedite the implementation of cognitive rehabilitation strategies to be used by families immediately after adopting a post-institutionalized child.

    In summary, comprehensive neuro-psychological evaluation and proper understanding of the post-institutionalized (potentially traumatized) child may help develop an assessment and treatment model as current neurological and psychiatric categorization often does not allow for the nuances of atypical patterns. The complexities of many internationally adopted children has now presented families with a new set of challenges requiring multidiscipline interventions.


    Medical specialists clearly outline all necessary interventions for the post-institutionalized child. Developmental neuropsychologists have attempted to augment medical assessment and interventions and provide a more detailed and precise program of interventions as opposed to often vague and obscure psychological therapies.

    Post-institutionalized children under the age of 2 years certainly require a tremendous amount of stimulation, bonding and attachment as they continue to be at a very critical level of both brain and emotional development. The younger post-institutionalized child certainly has a lesser degree of risk based on a lesser amount of time spent in an institutional environment, whereas the older child may have already “progressed” to a level of regression in both neurocognitive and emotional functioning. The institutionally autistic child may have reached the most profound level of regression and require the most immediate of interventions.

    Stimulation of vestibular and proprioceptive systems for the post-institutionalized child has been a widely used intervention for children of all ages (Cermak and Daunhauer, 1997). The emerging field of sensory-integration therapy has been found to be beneficial, although neurology researchers question the need for more specific interventional strategies (Pearl et.al., 1999).

    The importance of careful differential diagnosis cannot be minimized in the post-institutionalized child. Proper assessment of medical, neurological, neuropsychological and psychological/psychiatric conditions seems paramount prior to establishing a treatment program. Traditionally, the “wait and see” assessment and intervention model has been utilized although with the wide spread research regarding the damaging effects of institutionalization on both cognitive and emotional development, specialists from all disciplines are now ascribing to a more aggressive treatment program. Frequently, families have embarked on long-term psychological and pharmacological treatment programs only to later find the core symptoms and disorders remained.

    Traditional psychological and family therapies have been recommended such as holding time to address attachment disorders and behavioral dyscontrol (Federici, 1998; Hughes, 1998; Keck and Kupinsky, 1998 and Welch 1998). The most common complaint families present to mental health providers involves a newly adoptive child’s deficiencies in behaviors, self-control, aggressive and destructive outbursts, mood changes, low frustration tolerance, social skills and indiscriminant attachment behaviors. Psychological therapies emphasizing bonding and reattachment, rage reduction and family restructuring are certainly critical, but for the child with neuropsychological impairments or institutional autistic characteristics based on extended time in an institutional environment, an aggressive and innovative approach is recommended. Additionally, speech and language and sensory-integration therapies have been widely used as a form of cognitive and neurological remediation, but are typically not implemented immediately upon the child joining their newly adoptive family.

    For the older adopted child who presents with a pattern of cognitive and emotional delays as the result of extended institutionalization with questionable co-morbid brain dysfunction, Federici (1998) developed a therapeutic family program which has been found to be highly effective but yet controversial in comparison to more traditional family therapy approaches.

    In order to effectively and aggressively work with the post-institutionalized child, a “detoxification from institutionalization” program was created. The following steps outline the basic principles of this gradual detoxification and rehabilitation program:

    Pre and post-adoptive counseling to families regarding the high risk factors in children from institutional settings.
    For a minimum of 3-to-6 months, keeping up the “institutional life” in terms of native language, food and routines.
    Restraint in exposure to social and environmental stimuli.
    Initial focus of caretakers to remain somewhat detached and objective as opposed to promotion of indiscriminant attachments.
    Avoidance of “splitting” attachments by having secondary or alternate caretakers.
    Intense focus on behavioral control and immediate compliance with parental and home directives.
    Proper use of holding techniques for aggressive outbursts which are to be expected.
    Gradual and incremental detoxification off the institutional mentality and introduction into new environment, relationship and routines.
    Complete “adults only” supervision by primary caretakers only.
    Continually assess neurocognitive and emotional strengths and deficit patterns.
    Continual behavioral rehearsal, role playing, conditioning and counter-conditioning techniques.
    Continual positive reinforcement for any and all type of prosocial behavioral and cultural/environmental transitions.
    Well supervised school routines.
    Needs of the post-institutionalized child must outweigh the needs of the parents to provide “immediate love and affection”.
    All privileges and activities earned with a family “contingency plan”.
    Conservative pharmacological interventions.
    Of primary importance is providing theolder post-institutionalized child a safe and highly structured environment needed for restructuring cognitive and behavioral patterns associated with institutional life. As this program involves aggressive family and professional interventions, the child and family is continually modified, rehearsed and reinforced regarding new modes of interaction as opposed to allowing long periods of time to elapse without immediate interventions and corrections. While this type of program may present as a controversial and somewhat uncomfortable approach to many families and mental health providers, the short and long-term needs of the post-institutionalized child must outweigh the short-term needs of the families who may be desperate to attach and create family harmony immediately.

    Following the transition of a child from institutionalization to their new (and often over-stimulating) home, additional neuropsychological interventions can be implemented:

    Sensory-integration therapy.
    Language therapies, particularly auditory processing training.
    Occupational/sensory input-output therapies.
    Logic/problem solving therapy.
    Cognitive therapies (rational restructuring).
    Neurolinguistic programming.
    Computers assisted training to improve visual-perception and language.
    Reality therapy.
    Concrete behavioral rehearsal and role playing.
    Behavior modification (earning program).
    Brain rehabilitation techniques.
    Supervised social and play therapy.
    Ongoing conservative medication interventions.

    The developmental neuropsychologist offers valuable information to the medical, neurological, occupational, physical, educational and psychological treatment provider working with the post-institutionalized child. Precision and accuracy in neurocognitive assessment promotes a better understanding of brain behavior relationships and emotional development. The neuropsychologist offers a unique perspective regarding neurodevelopmental delay syndromes, particularly in the differential diagnosis of organic versus functional disorders, in addition to providing an additional perspective regarding pervasive developmental disorders versus Institutional Autism: An Acquired Syndrome.

    The neuropsychology of bonding and attachment disorders is a critical part of assessment as neurocognitive rehabilitation techniques may be a valuable tool in teaching the post-institutionalized child brain improvement strategies which can enhance their ability to process and organize human emotions and enhance a greater depth of interpersonal relating. With the increasing number of internationally adopted children of all ages coming to the United States, a multidiscipline team of medical experts will provide further research into the long-term effects of institutionalization while also developing the subspecialty known as International Adoption Medicine.


    Albers, L. H., Johnson, D.E., Hostetter, M.K., Iverson, S., and Miller, L.C. (1997) Health of Children Adopted from the Former Soviet Union and Eastern Europe. Journal of the American Medical Association, 278, 922-924.

    Ames, E.W. (1997). The Development of Romanian Orphanage Children Adopted to Canada. Burnaby, B.C.: Simon Frasier University.

    Bender, L. (1929) Assessment of Organic Conditions, Orthopsychiatry.

    Bowlby, J. (1951) Maternal Care and Mental Health. World Health Organization Monograph No. 2. Geneva: World Health Organization

    Cermak, S.A. & Daunhauer, L.A. (1997) Sensory Processing in the Post-Institutionalized Child. The American Journal of Occupational Therapy, 51, 500-507

    Federici, R. (1996) Institutional Autism: An Acquired Syndrome. The Post: The Parent Network for the Post-Institutionalized Child, 14, November-December

    Federici, R. (1998) Help for the Hopeless Child: A Guide for Families (with Special Discussion on Assessing and Treating the Post-Institutionalized Child): Dr. Ronald S. Federici and Associates

    Galler, J. and Ross, R. (1998) Malnutrition and Mental Development. The Post: The Parent Network for the Post-Institutionalized Child, 6: 1-7

    Goldfarb, W. (1943) Effects of Early Institutional Care on Adolescent Personality. Journal of Experimental Education, 12, 106-129

    Goldfarb, W. (1945) Psychological Privation in Infancy and Subsequent Adjustment. American Journal of Orthopsychiatry, 14, 247-255

    Goldfarb, W. (1947) Variations in Adolescent Adjustment of Institutionally Reared Children. American Journal of Orthopsychiatry, 17: 449-457

    Hughes, D. (1997) Facilitating Developmental Attachment. Jason Aronson

    Johnson, D.E. (1997) Adopting the Institutionalized Child: What Are the Risks? Adoptive Families, 30, 26-29

    Johnson, D.E., Aronson, J.E., Cozzens, D., Federici, J., Federici, R., Pearl, P., Sbordone, R., Storer, D., Zeanah, P., and Zeanah, C. (1999) Growth Parameters Help Predict Neurologic Competence in Profoundly Deprived Institutionalized Children in Romania. Pediatric Research (in press).

    Johnson, D.E., Aronson, J.E., Federici, R., Faber, S., Tartaglia, M., Daunhauer, L., Windsor, M. and Georgieff, M.K. (1999). Profound, Global Growth Failure Afflicts Residents of Pediatric Neuropsychiatric Institutes in Romania. Pediatric Research (in press).

    Keck, G. & Kupecky, R. (1998) Adopting the Hurt Child. Pinon Press

    Luria, A.R. (1976). The Working Brain. Pergammon Press.

    Pearl, P., Johnson, D., Federici, R., Tartaglia, M., Gaillard, W., Lavenstein, B, McClintock, W., Conry, J. and Weinstein, S. (1999). Neurological and Medical Evaluation of Institutionalized Children in Romanian Orphanages. Journal of Pediatric Neurology (in press)

    Potenza, Marc (1997). New Findings on the Causes and Treatment of Autism. Journal of Child Psychiatry, Vol.2

    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 Psychiatry (in press)

    Spitz, R. (1945). Hospitalism: An Inquiry Into the Genesis of Psychiatric Condition in Early Childhood. The Psychoanalytic Study of the Child, Vol.1 (page 53-74). New York, International Universities

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  7. Institutional Autism

    By Dr. Ronald S. Federici

    This article is an excerpt from Dr. Federici’s book, Help For The Hopeless Child: A Guide For Families

    Over the past decade there has been a tremendous influx of children coming from post-institutionalized settings in various Easter Bloc, South American and Far Eastern countries. These children have often been placed in hospital-based or classic institutional settings following illnesses or even death of the biological parents or the parents general inability to care for the child’s emotional needs. Children from Eastern Bloc countries in particular have been rapidly placed in institutionalized settings due to the demise of the communist systems which have rendered many people poverty stricken and homeless with a subsequent inability to care for an of the medical, physical or psychological needs of their children.

    Children having any type of medical problem (even mild) are often placed in hospital settings or institutional care programs which are state run. For example, children who have been described as being somewhat “slow” or even suspected to have mental retardation (i.e. the Russian word Oligophrenia) are often called morons, imbeciles or some other term pertaining to mental deficiency. These types of children are often placed in neuropsychiatric facilities in great volumes.

    Additionally, children with even mild medical problems such as orthopedic damage or some other type of crippling pattern in which they are not able to walk (but could be walking with adequate surgical interventions and physical therapy) are also placed in hospital-based institutions.

    Children with somewhat more complicated medical problems such as hepatitis, hemophilia, congenital malformations and deformities, mental retardation or classical autism are often placed institutions for the rest of their lives.

    The principal problem with this situation of placing children in hospital-based or institutional settings for a defined “problem” is that many of the diagnoses are typically incorrect or over exaggerated. Once the children are placed in institutional settings, particularly those in the Easter Bloc countries of Romania, Moldovia, and various sections of the former Soviet Union, they are destined to remain there for life without appropriate medical or psychiatric/psychological interventions.

    In particular, many of the children who are placed in neuropsychiatric facilities have been termed mentally deficient or Oligophrenic. More often, the child’s mental delays are the direct result of very poor pre and post-natal factors, nutritional and medical neglect, in addition to a child having a situation such as simple speech and language delays in their own native language which have been misconstrued as mental deficiencies.

    Once children are placed in these types of institutional settings, they are often moved repetitively. For example, infants are often placed in some type of hospital or nursing setting for the first 1-2 years of their life and then transferred to another setting which can often last from 2-5 years. It should be emphasized that, during these critical years (birth through 4-5 years old) these institutions typically lack any and all type of stimulation, language and intellectual-cognitive development, early school-based programs or even appropriate medical diagnosis are care. So often, children are starved, neglected, and isolated to their cribs.

    It has been well documented that many of these children have been found to be tied to their cribs or isolated and sheltered from human contact. Combined with profound medical, nutritional and often physical neglect and abuse, these children regress to very primitive states to where any and all type of sensory-motor, speech and language, and even intellectual abilities have become stagnated and, over the course of time, typically regress and deteriorate to levels where they appear truly mentally deficient when this was not the starting pattern in their lives.

    As the institutional child continues to “transfer” from institutional setting to institutional setting, the level of deprivation often increases. Very often, children are “warehoused” in the institutional settings to where there are up to five children in a bed with literally dozens of children per on caretaker who is often completely oblivious to their physical and psychological needs. It has also been documented that there is often a “medical director” assigned to the facility who rarely shows up. The children often receive medical care when they are in an acute or life threatening situation, and the medical care is often very poor and can sometimes cause even more problems in the actual illness of the child (i.e. the treatment can sometimes be worse than the actual illness).

    It has been this writer’s experience based on visiting multiple institutions in Easter Bloc settings that the profound levels of neglect intensify with each year the child is alive. Basic physical and nutritional needs are not provided which results in the child’s brain and physical development slowing to where it is almost impossible to actually detect the age of the child. There have been many children observed who have the appearance of a 6 to 7 year old when in fact they are actually in their early or mid-teenage years. Additionally, many children have been literally tied down to their cribs for days, weeks and even months at a time, with even their feedings being given while they are in their cribs. Over the course of time, there is a literally no movement and many of the children lose many and all previously acquired language.

    Additionally, many of the children who have some level of physical problem, particularly orthopedic problems in which they are not able to mobilize around the institution, become targets of physical and sexual abuse which further causes post traumatic stress disorder features, profound depression and a “regression” to a stage of early infancy in which they are literally “shutting out” any and all type of environmental and interpersonal contact. More simply, children look for any type of safety and security when they are being totally deprived and neglected.

    What tends to emerge in the child who has received multiple institutional placements combined with profound neglect and abuse on a wide scale level is the “regression factor” or the child who “disintegrates” and loses motor, sensory, speech and language, and intellectual skills. Once this regression occurs, it tends to be insidious and progressive.

    Emergence of Institutional Autism Syndrome

    Previous sections of this book have outlined varying types of childhood pervasive developmental disorders and childhood autism. Reference was briefly made to the “Childhood Disintegrative Disorder” which seems to imply that there is a “loss of acquired skills”.

    The child from the post-institutionalized setting does not fall into any of the classic definitions of classical autism, Rhetts disorder or even childhood disintegrative disorder, although there is certainly a “disintegration” once a child has remained in an institutional setting. While there is no actual “equation” as to how long it takes for a child to become damaged while living in an institution, it appears that for every year of life in an institutional setting, there can often be a rapid rate of regression in psychological and cognitive functioning up to 6 months. For example, a child who has been institutionalized for one year most likely is “delayed” six months. A child in a setting for two years is most likely delayed a year and so on and so on. A unique institutionally specific “pattern of behaviors” which constitutes the Institutional Autism Syndrome are the following characteristics:

    1. Actual loss of physical height, weight and growth. Many of the children have been described as “not even being on the growth curve”.
    2. Inability to physically decided on the actual age of a child. Therefore, many children upon adoption are assigned on age when, in fact their actual age may be much older.
    3. Children often are not speaking any language or have language which is so regressive that it is significantly below age and grade level, and almost constitutes the “infant babbling syndrome”. Children may have been speaking in their native language, but have regressed to where there is only a partial ability to receive and express language.
    4. Children’s behaviors have rapidly deteriorated to where primitive acting out occurs. While all children in any type of institutional setting typically have behavioral control problems and a lack of social development, the majority of the children tend to be extremely regressed, emotionally and behaviorally out of control to where they present with profound attachment disorder characteristics when, in fact the attachment disorder is one of a “neuropsychologically-based” attachment disorder as cognitive problems are clearly evident.
    5. Children in institutions have experienced profound nutritional and medical neglect over the course of (often) years. These factors of profound medical neglect adversely affect the body and brain development to where many of the children clearly develop a brain syndrome which involves language deficits, attentional and concentrational problems, confusional behaviors and clearly deficient memory and learning.
    6. If and when major neurocognitive deficits and delays have been evident, children in institutional settings often have very primitive and regressive behaviors. A regression back to enuresis and encopresis (urination on themselves and self-defecation) are very common. Additionally, children can often resort to playing with urine and feces.
    7. The ultimate “institutional autistic behaviors” is a complete regression to self-stimulating behaviors as a way of “filling in the gaps” regarding loneliness, deprivation and despair. Combined with profound medical and nutritional neglect, children in institutional settings may have been able to “recall” some pleasurable activities (particularly if they were placed in the institutional setting at an older age). When these minute “recollections” of something positive in their life are gradually and consistently taken away, children tend to resort back to the most infantile stage of development to where they feel safe and secure. This typically means that children will remain very isolated, lost and alone, and resort back to rocking and other self-stimulating behaviors. It is very common for children who have been sensory deprived and socially neglected for years in an institution can find some degree of pleasure in self-stimulating rocking and movement behaviors; hyperactivity and uncontrollable rage and aggressive outbursts; in addition to self-mutilative behaviors such as hair pulling, picking at various parts of their body and, under more severe circumstances, head banging and body thrusting into inanimate objects such as walls and windows. This syndrome implies that the child is both trying to fid a way to maintain internal physical and psychological “movements” which serve as some level of stimulation while at the same time, finding ways to “pass the time” of profound loneliness and despair.

    Over the course of time and with continual “practice” of these cognitive and physical behaviors, a child develops a “repetitive pattern” of newly learned movements, mannerisms and speech. Henceforth, the concept of institutionally induced autism has come about based on this author’s many years of experience in visiting institutions and evaluation hundreds of children who have spent many years of their life in a deprived and emotionally damaged setting. Institutional autism will hopefully emerge as a more specialized “subgroup” of pervasive developmental disorder of childhood and reactive attachment disorder as this “syndrome” is specific to the child having been reared (or survived) the profound medical, psychological and environmental neglect often seen in institutional settings and hospitals in the Third World countries. A better understanding of this unique and highly complex syndrome may help families approach the entire concept of international adoptions in a different manner. Examples of improving the entire adoption of the internationally post-institutionalized child may include the following:

    1. Adoption agencies having a better awareness of the institutional autistic syndrome and concepts pertaining to post traumatic stress disorder. Setting up a “task force” of trained professionals to work in the institution where children are being adopted out would be beneficial as this may help better “prepare” and “desensitize” the child for a period of time prior to their adoptive families taking charge. Experts should be trained in severe abuse and neglect syndromes, and work with the perspective adoptive child for a minimum of 3-6 months before they are allowed to be placed with their new family.
    2. Families having adopted a child from an institutional setting should be required to attend intensive pre and post-adoptive training programs to deal with the post-institutionalized child. The Parent Network for the Post-Institutionalized Child has done an outstanding job of setting up various training programs around the country, in addition to having regular newsletters, mailings and research readily available to families in need.
    3. Families need to address specific treatment issues which are highly specialized and germane only to the post-institutionalized child with the possibility of an institutionalized autistic disorder. A unique and innovative family therapy approach should be arranged immediately upon the child’s arrival to their new family in the United States. References regarding innovative treatment are made in the treatment section of this book.

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  8. 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.

    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).

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  9. Pam H says:

    I am a single mom to two Russian sibs, 10 and 12, bio-sibs adopted just 4
    years ago from northern Kazakhstan. They are ethnically Russian. We all
    bonded quickly, but both kids have been plagued by their early traumatic
    experiences. It is so sad. We’ve been in therapy from the get-go, so I can’t
    even imagine how hard it would be if we hadn’t! Yulia has a “good little
    girl” persona, but has dissociative episodes at home. Yuri is more “out
    there” with his angry and defiant behavior – to such an extent that he has
    been moved to a behavioral classroom. Neither is able to develop interests
    that require commitment and following through. Parenting has been so
    all-consuming that I have not YET – after 4 years – been able to return to
    fulltime work. We went everywhere in the US and finally made it to Dr Federici’s

    after everyone told us he was the absolute best in the toughest situations.

    We just got back from Dr.Federici 2 weeks ago…. It was incredibly helpful
    to have many of our working hypotheses validated, but also to get new insights
    – about what meds to take, what kind of therapy will be effective, etc. So
    right now we are looking for a very seasoned trauma therapist in the NY
    area who will work with us as a family. If anyone has any suggestions on that
    front, please let me know!

    Thanks to all who referred me to this great Doctor Federici..he saved our family. the best we have met after years.


  10. Shari and Jeff, Alabama says:

    Hi Ron,

    Jeff and I can’t thank you enough for your encouragement and the abundance of knowledge you shared with us on how to heal and manage Anna’s issues! I truly meant it when I told you prior to leaving today, that you are an “angel” sent from above…..God has been so good to us by blessing us with your presence this past 3 days.

    We (or should I say , “I”) have a lot of work ahead of us but I know unequivocally we can conquer Anna’s issues due to your impeccable training techniques.

    Jeff really took to heart your insight regarding Wade – Jeff was one hurt puppy when you left. He pondered for a while your suggestions on how to help Wade and shared with me his thoughts on what we need to do going forward. Tonight, he spent some time alone with Wade to discuss your concerns. Wade openly admitted he is lonely living at his mom’s house and would like to spend some additional time with us.

    Again, our gratitude goes beyond words and know that you always have a place to stay when you visit Birmingham…the Davis family welcomes you with open arms at any time! We love that you brought us solid answers/facts on how to begin and move forward with Anna’s healing process.

    You, my friend, have an incredible heart for others, especially children…and God will continue to bless you for your love and kindness on this earth.

    Our love,
    Sheri and Jeff

  11. […] 1957 and the world has seen in the heartbreaking images of the neglect in the 1990 expose of the Romanian orphanage system that a nurturing, care-giving environment is essential to normal intellectual, emotional, and […]

  12. […] in 1957 and the world has seen in the heartbreaking images of the neglect in the 1990 expose of the Romanian orphanage system that a nurturing, care-giving environment is essential to normal intellectual, emotional, and […]

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