Detecting and Remediating
the Cumulative Cognitive Deficit
in School Age Internationally Adopted Post-institutionalized Children
Published in: THE POST (The Parent Network
for the Post-Institutionalized Child), Issue # 27, 2000-1, Meadow Land,
PA, pp. 1-6.
Boris Gindis, Ph.D.,
NYS Licensed Psychologist
Definition and structure of CCD
Parents of school
age internationally adopted post-institutionalized (IAPI) children
sometimes express their concerns and frustrations over the slower
than expected academic progress of their children in school. After
an initial phase of seemingly fast new language acquisition and
adjustment to their new homes and schools, some of these children
may show significant difficulty in their academic work (which, in
turn, often brings behavioral and emotional problems). Their learning
difficulties may persist and even worsen, well after the time when
their academic problems may be attributed to bilingual and adjustment
issues. Moreover, as they progress through the developmental stages
and school grades, they seem to fall farther and farther behind
in their performance on academic tasks and cognitive tests. What
happens even more often, the overall dynamic of cognitive/language
development and academic performance of some IAPI children fails
to match the comprehensive and relentless efforts of their adoptive
parents and professionals in different fields.
These IAPI children
may experience what is known as the "Cumulative Cognitive Deficit"
(CCD) - a term coined by a psychologist, M. Deutsch in the 1960s
(see: Cox, 1983). CCD refers to a downward trend in the measured
intelligence or scholastic achievement of culturally/socially disadvantaged
children relative to age-appropriate societal norms and expectations.
The theory behind cumulative deficit is that children who are deprived
of enriching cognitive experiences during their early years are
less able to profit from environmental situation because of a mismatch
between their cognitive structural maturity and the requirements
of the new, more advanced learning situation. According to current
research, there are several major characteristics of CCD:
- Cognitive language deficiency
(that blocks cognitive processing).
- Lack of age-appropriate cognitive
skills (which results in progressive cognitive/behavioral incompetence).
- Insufficient task-intrinsic motivation
in cognitive activities (which may appear as an attention and memory
- Chronic mismatch between a child’s
learning capacity and his/her academic placement , teaching style,
and level of instruction.
CCD is usually associated with
certain emotional/behavioral problems. Constant failure in cognitive
activities feeds upon itself in a negative spiraling fashion which
results in low self-esteem, lack of interest in and constant frustration
associated with cognitive efforts. Lack of intrinsic motivation
in cognitive activities grows with age and becomes one of the major
characteristics of CCD.
The causes, nature, and dynamic
of CCD in IAPI children, are in many ways akin to the same phenomenon
in the general population. There are, however, some substantial
differences that must be recognized and addressed in our remedial
efforts. In order to do this, let us consider a clinical case of
an IAPI child who experienced cumulative cognitive deficit.
A Clinical Case
Alyona was adopted
at the age of 8, having completed the 1st grade in her native Russia.
She had been brought up in an orphanage since her birth. Her medical
documentation confirmed her as a "basically healthy" child at the
time of adoption. Nevertheless, in her early childhood, she suffered
from anemia (iron deficiency), rickets (vitamin D deficiency), severe
underweight (malnutrition), and delays in gross-motor development.
The same medical record carried the diagnosis of "delays in psychological
and language development" (which is almost a "standard feature"
of children coming from Russian orphanages). She was evaluated within
two months of her arrival in the USA in order to verify this diagnosis
and recommend the appropriate academic placement for her.
No evidence of
neurological impairment was found during her examination by a developmental
neurologist. At the time of her initial psychological evaluation,
Alyona was a practically monolingual (Russian) child. It was a challenge
to meaningfully quantify cognitive ability of this limited English
proficiency child with an "atypical" background through standardized
testing. Alyona's academic skills were tested informally against
the Russian curriculum (pre-school to grade 1) in language, math,
and general knowledge. She was found to have unevenly developed
and rather delayed literacy skills, being an "emerging reader" at
best. Her developmental/functional 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 classical Piagetian tasks (presented orally in Russian)
on hierarchical classification, comprehension of sequential events,
and understanding of "double-meaning" expressions. Alyona's performance,
although inconsistent and somewhat immature, was judged to be within
the 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 in applying cognitive strategies
that require step-by-step procedures. As 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
operation was limited, immature, and ineffective. It was observed
by the examiner, that Alyona was in the escalating process of losing
her native language while the second language acquisition process
was somewhat slow. At that time, Alyona's relatively weakness in
cognitive/ language skills was attributed to her background of deprivation
and hope was expressed that she would "catch-up", given
the appropriate educational opportunities. In spite of the obvious
mismatch between Alyona's level of readiness and the demands of
her school setting, she was placed according to her age in a regular
3rd grade with ESL and remedial reading as supportive services.
Aloyna's next testing took place
two years later, this time requested by the school district due
to her "slow progress" in academic subjects. As it happened two
years ago, Alyona again was virtually a monolingual child, this
time, however, in English. She had completely lost her native language,
not only in the expressive mode, but in the receptive one as well,
to say nothing of her literacy skills - a case of the so-called
"subtractive bilingualism". Although her communicative fluency in
English seemed to be at least functional, her cognitive/academic
English was very limited, as measured by the Woodcock-Munoz Language
Survey. Her academic level was 3 to 4 grades below her current academic
placement (5th grade). Standardized testing (WISC-V) showed a Low
Average to Borderline level of intellectual functioning. A "dynamic
assessment" through the Application of Cognitive Functioning
Scale in a "test-teach-test" format revealed many cognitive
deficiencies: Alyona demonstrated distorted spatial and temporal
sequencing, incorrect comprehension of notion/concept meaning, and
poor ability to recall/memorize academic material (or just about
any abstract material for that matter). She revealed poor mastery
of language as an instrument for cognitive activity. 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 ("working 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 even worse than two years earlier.
It was obvious that Alyona did not take advantage of her new environment:
her cognitive functioning was progressing too slowly in comparison
with the changing demands of her educational setting. This time,
Alyona was classified as a "learning disabled" student
and a recommendation for a "small class" (special education) with
language therapy was made.
A year later, during an annual
review, Alyona's progress was discussed again, vis-à-vis
the requirements of her current grade curriculum. She made only
a few gains in her academic achievements and her deficit in cognitive
functioning continued to increase. An examination completed by a
school psychologist using the Stanford-Binet, revealed Borderline
to Mental Deficiency range of general cognitive ability - a decline
since her previous evaluations. She revealed particular 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. Alyona's teachers
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 class (which is 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.
The Essence and Specificity of Cumulative
Cognitive Deficit in IAPI children
Alyona’s case illustrates the essential
qualities of CCD: it looks as if this child has been "racing
against time" being unable to catch up with age-appropriate
academic standards. Because of the discrepancy between steadily
rising academic requirements and relatively slow cognitive/language
progress in some of the IAPI children, the overall trend appears
to be a "downward" one. Resembling the population at large
in its nature and dynamic of development, the CCD in IAPI children
has the following specific features:
- Traditionally, in education
and cognitive psychology, the causes of CCD have been attributed
mostly (if not exclusively) to a "culture of poverty", that is,
to ongoing cultural/educational deprivation. As opposite to this
"single cause approach", the determinant of CCD in IAPI children
may be associated with a combination of medical (e.g. failure
to thrive syndrome), socio/economical (neglect/abuse, poor nutrition),
and cultural/educational deficiencies in early childhood. Consequently,
the remedial efforts should be multifaceted.
- The effect of bilingualism on
cognitive functioning depends in part on whether children are
adding a second language to a well-developed first language (the
so-called "additive" model) or whether a second language is sharply
replacing the first language (the "subtractive" model). The subtractive
nature of new language acquisition in IAPI children definitely
contributes to CCD (Gindis, 1999) and may constitute the "core"
factor in cumulative cognitive deficiency in IAPI children. It
may even be suggested that CCD might be reinforced during the
time when the first language is lost for all practical purposes
and second language is barely functional communicatively and not
in existence cognitively. The overall length of this period depends
on child’s age and individual differences, but all IAPI children
adopted after three years old appeared to live through this period
and for some of them, it is the time when their cognitive weaknesses
were consolidated into CCD.
- In internationally adopted "older"
(school-aged) children, there are cultural differences that may
be perceived as "incompetence" (McGuinness, 1998) in social, cognitive,
or adaptive behavior domains. A 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 understand that CCD in IAPI children is
diagnosed against the US middle class norms and expectations.
The relationship between the cultural differences (in both IAPI
children and the adoptive families) and CCD should be further
explored and explained.
- In IAPI children, CCD may occur
concurrently with or as one of the consequences of such behaviorally
defined disabilities as Post-Traumatic Stress Disorder and Attachment
Disorder – these are the most often psychiatric diagnoses found
in IAPI children. More research is needed, however, to define
this clinically observed correlation.
- The phenomenon of CCD is attributed
to cultural/educational deprivation experienced in the early formative
years and is traditionally associated with children from low SES
families (Parker, et al. 1988). Most IAPI children now live in
middle-class families with well-educated parents. Probably for
the first time in the history of CCD, families are not ongoing
contributing factors in CCD; on the contrary, they may be considered
as powerful remedial factors for CCD. Due to adoptive parents'
sensitivity to and awareness of possible learning problems in
IAPI children and because of higher parental expectations in this
respect, symptoms of CCD are earlier reported and are more often
subjected to professional attention.
The question of
great practical significance for many adoptive families is: to what
degree can CCD be remedied and what are the most effective treatments
to overcome such a deficit. With the IAPI children, remedial efforts
should be as diversified as the causes of their CCD.
Thus, from a pediatric
perspective, rehabilitation strategies for cognitive problems are
concentrated on medical intervention, proper nutrition and vitamin
supplements. It is well documented now that inadequate nutrition
- which is a common occurrence in overseas orphanages (see: Generation
in Jeopardy: Children in Central and Eastern Europe and the former
Soviet Union, 1999) is one of the most critical insults to early
child development. The effects of malnutrition on the developing
nervous system's functional and structural elements are known to
impair cognition. The brain is uniquely vulnerable to malnutrition
damage during the critical period of rapid brain growth which takes
place from the last trimester of gestation through the early preschool
years (Parker, et al. 1988). It means that even when a child has
been adopted younger than school age, the risk of CCD (as far as
it relates to malnutrition) may still be present. However, nutritional
intervention is a necessary but not sufficient mode of treating
cognitive difficulties. Current scientific data demonstrates that
adequate medical and nutritional intervention alone produced no
changes in intellectual development and may not restore developmental
functions to the right track of timely development (Cox, 1983).
The overall body of research data indicates that the cognitive difficulties
due to early malnutrition and environmental deprivation are treatable
only through interventions that include nutritional, medical, and
developmental/educational components. The last part of this triad
is the topic of our discussion.
Although our experience
with IAPI children having CCD is limited, we may use research data
and practical "know-how" that relates to CCD in the population at
large. One of the stunning findings was that "traditional" remediation
(that is: more intense work in a smaller group or even individually
using basically the same teaching methodology as in the classroom)
may not be effective or, at times, is just counterproductive in
attempts to overcome the cumulative cognitive deficit (Haywood,
1987). The CCD has a complex nature: it is a combination of internal
(e.g.: language, cognition, motivation) and external (e.g.: teaching
methods, learning environment, peer interaction) factors. This makes
the CCD a challenge for educators. To complicate the picture further,
due to the "summative" nature of CCD it may not be found
in the early stages of a child's educational journey: it takes time
for cognitive deficit to become "cumulative". Therefore, when CCD
is properly diagnosed, it may not be responsive to even "heroic"
efforts from parents and school alike, if they use "traditional"
remediation methods. One of the possible explanations may be that
the cognitive deficiencies in IAPI children are deeply rooted in
their early childhood experience. Almost all cognitive abilities
are developmentally hierarchical, that is, the appearance of more
complex cognitive structures rest upon the prior appearance of simpler
cognitive components (Vygotsky, 1978). Traditional remediation "assumes"
the presence of the appropriate base in cognition upon which it
tries to build the compensatory structures. However, the very lack
of the proper foundation constitutes major difficulty in reversing
the negative trend in CCD. Therefore, effective and appropriate
teaching methods are the crucial element in remediation of children
The research and
practice point to "cognitive education" as one of the
possible methods of remediation of CCD in IAPI children. There are
many "cognitive education" approaches created for different
age groups. Among the most well known are "Instrumental Enrichment"
(R. Feuerstein), "Bright Start" (H. C. Haywood), "Process-Based
Instruction" (B. Ashman), "PASS Remedial Program" (J. P. Das &
E. Carlson), and "Cognitive Instruction" (Kirby & Williams).
All these different systems of cognitive remediation are based on
the assumption that cognitive processes are acquired mental operations
that can be mastered through appropriate learning. In this respect
"cognitive", is different from "intellectual": the former is said
to be learned while the latter is seen as the native ability that
is largely genetically determined" (Haywood. 1987, p. 193). The
efficiency of learning cognitive skills depends, of course, on "inborn'
intellectual capacity, however, the learning environment has at
least comparable significance and tremendous remedial potential.
"Cognitive education" methodology assumes that while children with
CCD have difficulty in originating cognitive strategies spontaneously,
they can be taught how to create cognitive algorithms and to apply
them to cognitive tasks. Through carefully crafted methodology,
they may be taught how to inhibit impulsive responses, how to analyze
a problem using a certain "algorithm", and how to experiment mentally
with the possible solutions of the problem. In other words, they
must be specifically taught "how to learn" (this is the core of
cognitive education) and how to use their learned cognitive skills
("generalization" or "transference" of cognitive processes).
In order to compensate for the detrimental effect of CCD in IAPI
children, cognitive interventions must be age-appropriate, disability-specific,
well-planned, and persistent. As indicated by H. C. Heywood (1987),
these remedial strategies are to be applied through four closely
connected directions: 1/ enriching cognitive language, 2/ teaching
specific cognitive skills (thus increasing cognitive competence),
3/ facilitating task-intrinsic motivation, and 4/ providing appropriate
(optimal) learning settings.
It is the common understanding that
children who have spent any appreciable time in institutional care
are "at risk" for having cognitive deficiencies, developmental
delays and psychological problems (Ames, 1997). Why, then, do some
IAPI children have CCD and others do not? The absence of irrefutable
scientific data does not allow us to determine which specific factors
of institutionalized life are most damaging to the cognitive abilities
of children of a certain age and lead to CCD. Is it the age of placement
in an orphanage or time spent there, or, perhaps, both? We still
do not know for sure. The fact of life is that many IAPI children
seem to escape CCD and are able to fully benefit from their new
environment, to recover on their own from the detriments of their
past, and to flourish in their new homes. A study of their resilience
may help us to understand why the same protective factors failed
with other IAPI children. One of the most interesting researches
in this respect was the study by T. McGuinness (1998) of children
adopted from the countries of Eastern Europe and the former USSR.
However, we need more research data to build up effective remedial
strategies to reverse the detrimental trend in intellectual and
academic performance known as cumulative cognitive deficit.
- Ames, E. (1997). Recommendations
from the Final Report "The development of Romanian Orphanage Children
Adopted in Canada". The Post, #10, 03/97, pp. 1-3 (publication
of the Parental Network for the Post-institutionalized Child).
- Cox, T. (1983). Cumulative deficit
in culturally disadvantaged children. British Journal of Educational
Psychology. November, Vol. 53(3). pp. 317-326
- Generation in Jeopardy: Children
in Central and Eastern Europe and the former Soviet Union. (1999).
UNICEF compilation of documents, edited by A. Zouev, published
by M.E. Sharp Publication, NY
- Gindis, B. (1999). Language-Related
Issues for International Adoptees and Adoptive Families. In: T.
Tepper, L. Hannon, D. Sandstrom (Eds.) "International Adoption:
Challenges and Opportunities". PNPIC, Meadow Lands, PA, pp.
- Haywood, C.H. (1987). The Mental
Age Deficit: Explanation and Treatment. Upsala Journal of Medical
Science, 44, pp. 191-203.
- McGuinness, T. (1998). Risk
and Protective Factors in Children Adopted from the Former Soviet
Union. The POST (PNPIC, Meadow Lands, PA) Issue # 18, pp. 1-5.
- Parker, S., Greer, S., Zuckerman,
B. (1988). Double Jeopardy: The impact of poverty on early child
development. Pediatric Clinics of North America, 35, (6) 1227-1240.
- Vygotsky, L. (1978). Mind in
Society: The Development of Higher Psychological Processes. Cambridge,
MA: Harvard University Press.