Cognitive Deficit in international adoptees:
its origin, indicators,
and means of remediation
Boris Gindis, Ph.D.,
We keep telling
his teachers that it's as if he has no "hooks" to clip
information onto in his brain,
and he needs to learn how to
They keep telling us that it's just a language barrier,
from one language to the other.
I feel it's much more than that.
How can I help my son?
From an adoptive
Deficit - origins
Many parents of school age internationally
adopted children have concerns about their children's slower-than-expected
progress in school. After the initial phase of seemingly fast new
language acquisition and adjustment, some of these children show
significant difficulty in their academic work, which, in turn, often
brings behavioral and emotional problems. Their learning difficulties
persist and even worsen well beyond the time when academic problems
can be attributed to language learning and school adjustment. As
they progress through the developmental stages and school grades
they fall farther and farther behind in academic tasks; their overall
dynamic of cognitive/language development and academic performance
fails to match the comprehensive and relentless efforts of the adoptive
parents and educational professionals.
These children may experience what is
known in cognitive psychology and remedial education as "Cumulative
Cognitive Deficit" (CCD). CCD is a downward trend in measured
intelligence and scholastic achievement of culturally and socially
disadvantaged children relative to age-appropriate societal norms
and expectations. The current understanding of CCD is that children
who are deprived of enriching cognitive experiences during their
early years are less able to profit from a new and enriched environmental
situation because of a mismatch between their cognitive maturity
and the requirements of this new, more advanced learning situation.
Young children learn in two major ways:
directly (through observing, experimenting, experiencing, and imitating)
and indirectly (through adults who mediate knowledge for children
by selecting and modifying input from the outside world and directing
children's responses). A child may observe steam coming out of a
teapot. By touching this teapot and experiencing pain the child
learns that steam is associated with something hot and that may
be painful. The same knowledge can be mediated by the parent, who
points to a boiling teapot, saying "Hot" and imitating
pain from a burned finger. Through direct and mediated learning
major cognitive skills and processes are formed and put in action.
Deprived of such experiences, children are indeed disadvantaged
and may have problems moving to more advanced levels of learning.
When a child misses certain stages of normal cognitive development
and never learns generic concepts necessary for successful schooling,
the educational matter this child is taught simply does not have
any structural support upon which to be understood, remembered,
Let's consider a clinical case of CCD in a child
adopted from an overseas orphanage.
Anya was adopted at age 7, having completed 1st grade
in her native Ukraine. She had been in an orphanage since birth.
Her medical documentation described her premature, suffering from
anemia, rickets, and malnutrition. The records showed a diagnosis
of "delays in psychological and language development,"
almost a standard feature of children adopted from Eastern European
orphanages. No evidence of neurological impairment was found during
Anya's examination by a developmental neurologist in the USA. At
the time of her initial psychological evaluation Anya was a practically
monolingual (Ukrainian only) child. Her academic skills were tested
against the Ukrainian curriculum in language, math, and general
knowledge. She was found to have unevenly developed and rather delayed
literacy skills. Her developmental status, estimated in terms of
skills of daily living, self-help, socialization, and gross/fine
motor skills, appeared age-appropriate. Her cognitive functioning
was tested through the Universal Nonverbal Intelligence Test and
through several language-based tasks presented in Ukrainian. Anya's
performance, although inconsistent, was judged to be within average
age-appropriate range. Her particular weakness was in sequential
skills: it was difficult for her to recall auditory and visual information
in proper sequence and detail and to apply cognitive strategies
that require step-by-step procedures. Like a much younger child,
she needed constant visual references to support her understanding
or reasoning. Although her communicative fluency in her native language
was age-appropriate, her ability to use language as a tool of mental
operations was limited and ineffective. Anya was losing her native
language while second language acquisition was somewhat slow. Despite
the obvious mismatch between Anya's level of readiness and the demands
of her school setting, she was placed by age in a regular 2nd grade,
with English as a Second Language instruction and no remedial services.
Anya's next test was two years later, requested by
parents concerned with Anya's slow progress in school. As two years
earlier, Anya was a monolingual child, this time in English: she
had completely lost her native language. Although her communicative
fluency in English seemed to be at least functional, her academic
English was very limited: at least 2 grades below her 4th grade
academic placement. Standardized testing showed a Low Average to
Borderline range of intellectual functioning. Further testing of
cognitive abilities revealed many deficiencies: Anya demonstrated
poor comprehension of concepts and limited ability to memorize academic
information. Her learning behavior was inefficient and immature:
she was engaged in impulsive and disorganized "exploratory"
actions, mostly through "trial-&-error" attempts.
Her short-term memory was weak, with particular difficulty in grasping
the sequence in which tasks were presented. Her attention, motivation,
and ability to tolerate frustration in cognitive activities were
noticeably worse than before. It was obvious that Anya's cognitive
and language abilities developed too slowly to meet the changing
demands of her educational setting. Still, the school refused to
classify Anya as a student with an educational handicapping condition,
explaining her difficulties by her detrimental past and simply giving
her more time for recovery.
A year later, mostly due to Anya's escalating behavior
problems (anger, refusal to participate in classroom activities,
failure to submit homework, etc.) the school initiated a comprehensive
evaluation. Anya's progress was discussed in comparison with the
requirements of her current grade curriculum: 5th grade. She made
only a few gains in her academic advancement, and her insufficiency
in cognitive/academic functioning continued to increase. An examination
completed by a school psychologist using the Stanford-Binet Intelligence
Scale, revealed Borderline to Mental Deficiency range of general
cognitive ability - a decline since her previous evaluations. Anya
revealed difficulties in all language-based tasks that measured
comprehension. Her selective attention, processing speed, and mastery
of cognitive operations (such as: associations, categorization,
classification, discrimination) were found to be well below age
expectations. Anya's teachers also reported delayed academic skills
in reading and writing activities, poor comprehension of abstract
notions and concepts, incompetence in many age-appropriate mental
activities, constant "tiredness", "daydreaming",
and "boredom" in classroom (which was in sharp contrast
to her keen interest and energy in social situations). There was
an obvious disparity between her current instructional setting and
her ability to benefit from it. This time the educational classification
"learning disabled" was assigned and the remedial work
was spelled out in Anya's Individual Educational Plan. But the valuable
time was lost.
Cumulative Cognitive Deficit in international adoptees
There are several major intertwined characteristics
- Lack of age-appropriate cognitive skills, resulting
in progressive cognitive and behavioral incompetence.
- Poor organization of knowledge base, resulting
in ineffective learning, constant forgetting of learned material,
and inability to transfer knowledge and skills from one situation
- Very limited meta-cognitive skills, such as monitoring
one's own thinking or learning how to study by mastering learning
strategies and methods.
- Cognitive language deficiency, often existing concurrent
with age-appropriate social "every-day" language.
- Immature self-regulation of behavior, resulting
in poor concentration and limited attention span.
- Lack of intrinsic motivation for learning or achieving
in learning activities
- Chronic mismatch between the child's learning capacity
and academic placement, teaching style, and level of instruction
From educational perspectives, CCD is complex: a combination
of internal (language, cognition, motivation) and external (teaching
methods, learning environment, peer interaction) factors. To complicate
the picture, due to its "summative" nature CCD can go
undetected in the early stages of the child's educational journey:
it takes time for the cognitive deficit to become "cumulative."
Almost all cognitive abilities are developmentally hierarchical;
the appearance of more complex cognitive structures rests upon the
prior appearance of simpler components. The psychological roots
of CCD are in the absence of a viable foundation for productive
development of more complex cognitive skills and processes. For
example, elementary cognitive skills like patterning or sequencing,
typically formed between 3 and 5 in a normally developing child
through direct experience and mediated learning, may not be present
in a 7 or 8 year old former orphanage resident. However, more complex
math and reading skills rest on these basic cognitive notions, so
without re-building the base, no successful remediation is possible.
Unfortunately, traditional remediation in schools simply assumes
the presence of an appropriate base and tries to build compensatory
structures upon it.
Resembling the population at large in its nature,
CCD in internationally adopted post-institutionalized children has
specificity which must be recognized and addressed in remedial efforts.
- In international adoptees with CCD there is a high
likelihood of some neurological weaknesses, mostly related to
premature birth, birth-related traumas, malnutrition, and many
subtle neurological impairments not easily detectable in a developmental
neurologist's office but observable in immature self-regulation
of emotions and behavior, inability to concentrate and be attentive,
in fatigue during mental efforts, nervous tension, and decreased
memory capacity. The correlation between these medical conditions
and substandard school performance is a well-established fact.
Thus, inadequate nutrition - a common occurrence in overseas orphanages
- effects functional and structural elements of the developing
nervous system and impairs cognition. Even when a child is adopted
at a younger age, the risk of CCD may still be present.
- Abrupt first language attrition is one of the most
stunning features of international adoption. Most international
adoptees age 3 and up learn their new language in the "subtractive"
model, with English quickly replacing the first language. This
type of language acquisition contributes to CCD, and it is very
likely that CCD is reinforced when the first language is lost
for all practical purposes while the second language is barely
functional communicatively and not in existence cognitively. The
overall length of this period depends on the child's age and personality.
- In internationally adopted children CCD can occur
concurrent with or as a consequence of serious emotional and behavioral
difficulties such as Attention Deficit Hyperactivity Disorder,
Post-Traumatic Stress Disorder, or Anxiety Disorder. Although
more research is needed to define and explain this clinically
observed correlation, the educational implication is obvious:
if CCD occurs against the background of serious emotional disturbances,
treatment must include a medical component.
- In school-age internationally adopted children
the value of cognitive activity, intrinsic motivation in cognitive
operations, learning behavior in general, and attitude toward
teaching authority may be influenced by cultural differences.
We have to realize that CCD in international adoptees is diagnosed
on the basis of US middle class norms and expectations. The relationship
between cultural differences (in both internationally adopted
children and adoptive families) and CCD should be further explored
- CCD in the population at large is traditionally
associated with children from poor and uneducated families. Most
international adoptees live in middle-class families with well-educated
parents. For the first time families are not ongoing contributing
factors in CCD; on the contrary, they can be a powerful remedial
factor. Due to adoptive parents' sensitivity and awareness of
possible learning problems in their children and because of higher
parental expectations, symptoms of CCD are reported earlier and
more often to professionals.
Does CCD constitute
a learning disability?
This is a complex question. We have to distinguish
between the legal definition of learning disability and actual functional
symptoms of this handicap. Learning disability as formulated under
Individuals with Disability Education Act (IDEA), reauthorized in
2004, explicitly states that it does not include learning problems
resulting from "environmental, cultural, or economic disadvantage."
CCD is mostly the outcome of educational neglect and cultural deprivation,
so CCD cannot be presented in school as the basis for special education
services. On the other hand, CCD functionally presents a psycho-educational
profile typical for the "Learning Disability" (LD) condition
and most certainly creates an educationally handicapping condition.
There is also a strong likelihood of a neurological component in
CCD and it's often impossible to separate the social and neurological
elements of this phenomenon. Thus, clearly identifiable language
impairment may be present along with CCD; ADHD - a clinical condition
- can be a powerful contributor to CCD. From the legal point of
view CCD may be presented in a school context as a part of an educationally
handicapping condition already recognized by law, such as Learning
Disability, Other Health Impairment, Speech and Language Impairment,
or Multiple Disabilities. The exact educational classification may
vary depending on the individual educational needs of the child.
Questions of great practical significance for many
adoptive families are to what degree can CCD be remedied and what
is the most effective treatment. CCD is a complex psycho-educational
phenomenon, so remedial approaches will also be multifaceted. Let's
consider remediation of a child with CCD in three domains: at school,
in the community, and at home.
To qualify for school-based remediation, a child has
to have an educationally handicapping condition recognized by IDEA.
The school's legal obligations to children with any of these recognized
conditions are spelled out in the Individual Educational Plan (IEP),
- Educational classification (this is not a medical
diagnosis, but rather a description of educational needs for which
a child must receive remedial help in school).
- Statements about educational needs.
- Goals of remediation and means of accountability
in reaching goals.
- Teaching methodologies.
- Classroom accommodations and test taking modifications.
The IEP is the most powerful tool for parents in organizing,
monitoring, and controlling their child's remediation at school.
Crucial is a proper timely assessment of the child's educational
needs. The best possible option is to obtain an initial assessment
in the child's native language within the first weeks after arrival.
This assessment should address:
- What are the child's educational needs?
- Does the child qualify for educational classification?
- What is the most appropriate educational placement?
- What supportive and remedial help does the child
- What are the goals of remediation?
- What are the methods of remediation?
- How should progress be measured?
The next step is to obtain optimal academic placement.
School districts have a tendency to place international adoptees
by chronological age, because school authorities see no difference
between them and children from immigrant families. However, chronological
age is only one of many factors to be considered. We have to take
as a reference point the child's actual developmental age and level
of functioning. Emotional, cognitive, and behavioral immaturity
is the "trademark" of post-institutionalized children.
A mismatch between the child's learning capacity and academic placement
is a recipe for CCD.
The child must be provided with supportive and remedial
services in school, based on specific needs. Speech and language,
domain-specific academic and occupational therapy are the most often
requested supportive (in general education) or remedial (in special
Remediation in school presents a problem in itself:
school personnel often do not know how to address the specificity
of international adoptees, "how to fit these square pegs into
the round holes of existing special ed programs" as one parent
said. Traditional remediation, based on more intense work in a smaller
group using the same teaching methodology as in the classroom, may
not be effective or is counterproductive in attempts to overcome
CCD. Remedial work with international adoptees having CCD should
be based on "cognitive education."
There are many cognitive education approaches created
for different age groups; the common ground is a conviction that,
while children with CCD have difficulty in originating cognitive
strategies spontaneously, they can be taught how to create cognitive
algorithms and apply them to cognitive tasks. Through carefully
crafted methodology, they should be taught to inhibit impulsive
responses, to analyze a problem, and to experiment mentally with
possible solutions. They must be specifically taught "how to
learn" (this is the core of cognitive education) and how to
use their learned cognitive skills in similar situations ("generalization"
or "transference" of cognitive processes).
In order to compensate for the detrimental effect
of CCD, remedial interventions in school must be age-appropriate,
well-planned, and persistent. They should enrich cognitive language,
teach specific cognitive skills, facilitate task-intrinsic motivation,
and provide optimal learning settings.
In the community:
There are many remedial programs outside school. Let's
consider three well known among adoptive parents seeking CCD remediation.
The Orton-Gillingham approach places
heavy emphasis on accurate word decoding (sounding out words) and
reading comprehension. It has a strong meta-cognitive component:
students are explicitly taught the rules of the language necessary
for comprehending, remembering, and communicating academic and social
information. Reading comprehension skills include summarizing, paraphrasing,
predicting and making inferences. A remedial specialist has to be
specially trained in Orton-Gillingham techniques. Most remediation
The Lindamood-Bell program is a comprehensive
remedial program based on Orton-Gillingham principles. Emphasis
is placed on learning sound-symbol associations and applying these
associations to decoding and encoding skills. It is a structured
and elaborated system with four major components: phonemic awareness,
concept imagery, symbol imagery, and mathematical reasoning. The
last is unique to the program: visualization of math symbols stimulates
the ability to verbalize concepts underlying math processes. For
students with CCD, this emphasis on mathematical reasoning is crucial.
This method is also time consuming and requires a trained clinician.
The Wilson Reading System (WRS) is a
carefully sequenced, 12-step curriculum for teaching students able
to speak and understand,but not read or write English, including
ESL students. WRS directly teaches the structure of words in the
English language so students master the coding system for reading
and spelling. WRS uses a variety of remedial strategies, including
its unique "sound tapping" procedure, manipulating color-coded
syllable and word cards, performing finger tapping exercises, writing
down spoken words, reading aloud and repeating what students have
read in their own words, and hearing others read. Due to its structured
and interactive nature, adaptation to ESL students, connection with
school content, and specific emphasis on skills transfer into classroom
work, WRS is the most suitable for internationally adopted children,
including those with CCD.
All three were designed to address
language development and literacy skills acquisition in children
with language-based learning disabilities. All assume English to
be the native language and the children to be emotionally stable,
sensory sound, and cognitively capable. None is a panacea; all three
are suitable to a certain degree for our children, but expensive
and requiring long-term commitment.
The challenges of creating an effective home-based
remedial system for internationally adopted children are many. This
- Take into consideration the specificity of international
- Be simple and not require special parental skills
- Strengthen the parent's role, promoting attachment
- Be a family affair, not a school-like activity
- parents should not be second-shift teachers.
- Compliment school-based remediation.
- Address emotional needs along with cognitive issues.
Having all these requirements in mind, the SmartStart
program was created to help parents facilitate thinking
and learning in their internationally adopted children. It offers
specific activities, focusing on processes that have been found
to positively influence the cognitive development of young children.
SmartStart activities can begin at any time and are especially beneficial
if implemented in the early stages of the child's adjustment to
a new life and continued over months and sometimes years. SmartStart
attempts to address the missing links in a child's cognitive and
language development by introducing basic abstract concepts and
verbal notions that should be mastered at earlier developmental
ages. The program consciously promotes meta-cognitive skills formation
along with academic language development in children ages 3 to 8,
using simple every day activities and games. This remedial program
directly addresses CCD issues by enriching cognitive language, increasing
cognitive competence, and facilitating task-intrinsic motivation.
The program consists of an introduction and 7 selections of thematic
activities, each pursuing specific goals of cognitive development:
- Noticing our world teaches using
senses to experience the environment and learning how to notice,
how to talk about what is noticed, how to help a child pay attention
to patterns and sequences, and how to make groups based on perceived
- Let's make a plan teaches thinking
strategically, setting goals, making a plan, evaluating results,
and making changes in response. The concepts of this unit form
the basis for cooperation with others in achieving a goal.
- That's fantastic! focuses on developing
imagination and divergent and hypothetical thinking. Children
are encouraged to make "what if?" speculations and to
entertain strange combinations and alternative approaches.
- The nimble symbol directly
addresses the use of symbols in our environment and focuses on
laying a foundation for emerging literacy and numeracy.
- What's the big idea? focuses on making
rules, getting the main idea, and learning from general principles.
It teaches how to derive concepts from empirical experiences.
- Who is in charge? focuses on development
of self-regulation. Children need to learn control themselves
and to reduce their dependence on external control.
- Making connections: understanding the past
- facilitating the future emphasizes recalling and understanding
linkages between the past and the present. On a more abstract
scientific level this unit encourages cause/effect thinking.
Each unit emphasizes goals that parents should have
in mind when introducing activities to their children, details instructions
on what to do and what to say presenting an activity, contains descriptions
of activities, and is accompanied by a vocabulary list of suggested
words and phrases for parents to use during activities.
SmartStart is the only methodology specifically designed
for international adoptees ages 3 to 8. There is no remedial home-based
methodology for older internationally adopted children, but SmartStart
is appropriate for some children ages 9 to 11.
You cannot control the wind, but you
can adjust your sails
This article describes some methods of remediation
proven successful with international adoptees. We need more research
data to build effective remedial strategies to reverse the detrimental
trend in intellectual and academic performance known as cumulative
cognitive deficit. Parents and educational specialists alike, choosing
or developing remediation for international adoptees, should bear
in mind the specificity of children adopted from overseas institutions.
The majority of internationally adopted post-institutional children
have the potential to fully compensate for their detrimental past
by receiving enriched environmental stimulation and consistent learning
experiences. My appeal to parents and school personnel is to "scaffold"
these children to their American dream by providing them with appropriate