International Adoption: A 4-Year-Old Child With Unusual Behaviors Adopted at 6 Months of Age* CASE running into streets and climbing onto the roof from Jenny, a 4-year-old child adopted from an orphan- a window. She said to her mother, “The cars will not age in St Petersburg, Russia, at 6 months of age, is kill me.” She frequently imitates behaviors of the seen for an initial office visit by a new pediatrician. family cat and eats from the floor. According to the parents, she received poor nutrition Challenged by Jenny’s background and current and limited stimulation in the orphanage setting. behaviors, her pediatrician attempts to understand During her first several months after arrival in her Jenny’s developmental course and develop a plan for new home, Jenny avoided the gaze of her parents effective interventions. and looked away when they attempted to engage her in play or participation in feeding. She did not dem- INDEX TERMS. international adoption, attachment, attachment onstrate any preference for her parents for several disorder, resiliency. months. She appeared to be quite “aloof and sol- emn.” She was easily frightened by certain visual Dr Martin T. Stein and auditory stimuli such as ceiling fans. By 1 year of The current generation of pediatricians have cared age she spoke several words, followed simple direc- for thousands of children adopted from orphanages tions, and walked. Jenny had difficulty tolerating in Eastern Europe, Russia, and Asia. Medical, devel- many textures of foods. She often mouthed inedible opmental, and behavioral conditions occur in these objects during her second year of life and performed children with a higher frequency and greater severity repetitive behaviors including dumping and filling compared with most children born in the United containers. She was clumsy for her age. Her parents States. In many internationally adopted children, sig- felt that she was “on the fringe of the family.” nificant developmental delays in motor, language, Jenny received occupational and speech and lan- and social skills associated with growth failure and guage therapy at a functional feeding program that malnutrition are seen when they arrive in the home addressed her food intolerance and oral sensitivity. of their adopted family. Remarkably, many of these During her third year, defiance, noncompliance, and children reveal a physical and psychologic resiliency anger occurred frequently. She often placed herself as age-appropriate neuromaturational milestones are in dangerous situations. She burned her hand and achieved in a catch-up pattern. In addition, growth lower lip on a light bulb after being told to stay away parameters are often expressed on growth charts as from it. She frequently ate out of the garbage. Jenny an accelerated velocity from adequate nutrition and was described as “highly verbal” and “superficially nurturance. charming.” Jenny followed women other than her Other children in these circumstances do not catch mother in public spaces and wanted to hold their up so dramatically. Failure to thrive, feeding prob- hands and sit on their laps. lems, and behavioral disorders emerge in the first She began play therapy at age 3 years, while her year after the adoption. The cause of some of these mother received individual counseling with another conditions is often puzzling; treatment is always therapist because she was having difficulty “bonding challenging. In some larger communities and medi- with Jenny” and felt rejected. At age 4 years, Jenny is cal centers, pediatricians, nutritionists, and mental described as “aloof and often angry.” She is ex- health colleagues have developed special programs tremely jealous of attention directed toward her 6- to serve these children and their families. and 3-year-old brothers. Her mother feels she is This Challenging Case illustrates many of the be- “stuck like glue” to her. She will often talk nonstop havioral conditions seen in the most severely af- and ask repetitive questions. Jenny has difficulty fected internationally adopted children. Dr Scott drawing a circle. She seems to be obsessed with the Faber is Director of Developmental-Behavioral Pedi- color purple, certain toys, and anything to do with atrics at Mercy Children’s Medical Center in Pitts- the “Lion King.” She has been asked to leave every burgh, Pennsylvania. He has significant experience preschool and camp she has attended because of working with children who are adopted from other nonstop talking, severe noncompliance, and unac- countries. Dr Susan Berger is a developmental psy- ceptable behaviors such as constantly asking her chologist and Program Director for the Developmen- peers, “Do you poop in your pants?” Recently, Jenny tal-Behavioral Pediatric Resident Training Program has performed more dangerous behaviors such as at the Children’s Memorial Hospital, Northwestern University School of Medicine in Chicago, Illinois. She also teaches attachment theory and its applica- * Originally published in J Dev Behav Pediatr. 2002;23:37–41. doi:10.1542/peds.2004-1721F tion to pediatric care. Dr Gilbert Kliman is a child PEDIATRICS (ISSN 0031 4005). Copyright © 2004 by the American Acad- psychiatrist and psychoanalyst in San Francisco, Cal- emy of Pediatrics and Lippincott Williams & Wilkins. ifornia. He is the Director of the Children’s Psycho- Downloaded from www.aappublications.org/newsPEDIATRICS by guest on September Vol.114 27, 2021 No. 5 November 2004 1425 logical Health Center associated with the Corner- izing (impulsive/oppositional) behaviors approxi- stone Therapeutic Preschool in San Francisco. He has mately 3 years after adoption.4 Attention-deficit/ worked with foster care children who have experi- hyperactivity disorder (ADHD) is found more enced psychologic traumas associated with multiple frequently in children adopted from deprived envi- caretakers. In addition, Dr Lisa Albers and Dr Paul ronments;5 Jenny’s behaviors are consistent with the Wang, along with others, contributed insightful com- hyperactive/impulsive type of ADHD. In addition, ments to the Web site discussion. her severe oppositional behavior in multiple envi- ronments supports the diagnosis of oppositional de- Martin T. Stein, MD fiant disorder. Her behaviors have been modulated Professor of Pediatrics by the attention her parents give to her 2 adopted University of California brothers, and her extreme jealousy may have been San Diego, California exacerbated at times by the distancing and ambiva- Dr Scott Faber lence the mother experienced when witnessing Jen- Jenny experienced significant deprivation during ny’s indiscriminate sociable behaviors. her first 6 months in an orphanage in Russia. She did Jenny displays a set of obsessive fascinations to- not receive emotionally attuned interaction with lov- ward certain toys, videotapes, animals, and colors. ing caregivers until her adoption. She was unable to Combined with the tangential quality of her speech participate in “gaze transactions” (quick visual and and lack of ability to discern appropriate social clues expressive interactions with her parents) appropriate and boundaries, a mild “quasi-autistic” pattern is for a 7-month-old child, which provide the basis for discernible. Michael Rutter et al,6 in their study of communication during feeding and play.1 Months 111 adoptees from Romanian orphanages, noted a after arrival in her new home, she did not display a 6% incidence of “quasi-autistic behavior patterns” preference for her parents, although she was quickly and another 6% incidence of “milder autistic fea- catching up to her peers in cognitive and language tures.” A major concern is Jenny’s poor understand- skills. This lack of preferential attention to her par- ing of the danger involved in running into the street ents indicates the presence of a change in the normal or out a window onto the roof. Extreme impulsivity, functioning of her attachment system—a biologic associated with developmentally immature under- and psychologic set of processes involving the fron- standing of danger, significant oppositional behav- tal cortex and limbic system. This process is ad- ior, and apparent difficulty with processing certain versely affected by exposure to early neglect. Signif- aspects of physical reality, provides a high level of icantly limited interaction with prior caregivers can risk. contribute to inhibition of engagement with adoptive Jenny continues to see a psychotherapist, and a parents and set the stage for an imbalance between low morning dose of an atypical antipsychotic med- inhibition and exploration.2 Jenny became “aloof and ication, risperidone, was initiated. Physically danger- solemn.” By 2 years of age, she appeared “superfi- ous behaviors were absent after starting the medica- cially charming” and displayed indiscriminate socia- tion, and she appeared calmer and able to bility with women of maternal age. Her behavioral understand her environment. A psychostimulant pattern changed from severe inhibition and quiet- was not prescribed because of the pediatrician’s an- ness around loving parents to exuberant interaction ecdotal experience with a stimulant often exacerbat- with strangers of maternal age, often to the exclusion ing quasi-autistic behaviors in children who have of the adoptive mother. This transformation further experienced severe neglect and deprivation. Jenny supports the presence of an attachment disorder was referred to a child psychiatrist for further psy- with a clinical shift from severe inhibition to indis- chopharmacologic