Educational outcomes of children adopted from Eastern Europe, now Ages 8-12.

Abstract. More than 230,000 children have been adopted from other countries by American parents since 1989, including more than 72,000 from Eastern Europe. Many arrive with growth and developmental delays, and medical problems. Yet, little is known about the long-term outcomes for these children. Therefore, we assessed long-term developmental, neurobehavioral, and educational performance outcomes in a group of adopted 8- to 12-year-old children from Eastern Europe. A parent questionnaire was mailed to families of school-age Eastern European adopted children who had been in the United States for two years or more. Of the 81 children (33M: 48F) described in the returned surveys, 84 percent were 3 years old or older at adoption. Sixty-one percent of the children received special education services, and 32 percent received occupational therapy. Fifty-two percent had language disorders, 38 percent had attentional problems, and 36 percent had learning disabilities. Thirty-five percent had multiple neurodevelopmental diagnoses. Thirty-two percent of the children had post-traumatic stress disorder; these children were older at adoption than those without this problem (p = 0.04). Anxiety and depression each occurred in 19 percent of children; 66 percent of those with depression also had anxiety (p = 0.0001). Most children attended school willingly (70 percent), had a best friend (63 percent), and got along with their parents (75 percent). Although nearly two-thirds of the internationally adopted children received special education services and 35 percent had multiple neurodevelopmental disorders, most children displayed remarkable social, peer, and family integration skills.

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More than 230,000 children have been adopted internationally since 1989 by parents in the United States (U.S. Department of State, 2005). Of these, more than 72,000 were adopted from orphanages in Eastern Europe, primarily Russia and Romania. In 2005 alone, American parents adopted more than 6,300 children from Eastern Europe (U.S. Department of State, 2005). Perinatal complications are common among this group of children: over 50 percent had low birth weights, many were born prematurely, few had prenatal care, and some were exposed to alcohol or drugs in utero (Johnson, D., 2000; Johnson, D. E., 1997). Nearly all resided in orphanages or other institutional care prior to adoption. Many experienced malnutrition, lack of stimulation, and neglect during institutionalization. Some children, particularly those adopted from Romanian orphanages in the late 1980s to the early 1990s, experienced severe deprivation during institutionalization (Benoit, Jocelyn, Moddemann, & Embree, 1996; Johnson et al., 1992; Rutter & English and Romanian Adoptees Study Team, 1998).

After adoption, many post-institutionalized children have medical problems and developmental delays (Albers, Johnson, Hostetter, Iverson, & Miller, 1997; Hostetter, Iverson, Dole, & Johnson, 1989; Hostetter et al., 1991; Jenista & Chapman, 1987; Johnson et al., 1992; Miller & Hendrie, 2000; Miller, Kiernan, Mathers, & Klein-Gitelman, 1995). These problems may affect children's later cognitive, learning, and emotional performance. Abnormal sensory processing, neurocognitive delays, and emotional problems also have been reported (Cermak & Groza, 1998; Cermak & Daunhauer, 1997; Groza & Ryan, 2002; Rutter & English and Romanian Adoptees Study Team, 1998). However, most studies have focused on children shortly after adoption, usually within the first two years of placement.

Many of the children adopted from Eastern Europe are now of school age; some have nearly completed elementary or middle school. Little information is available about the long-term developmental and behavioral outcomes for these children and their school performance. To examine these long-term outcomes, we therefore surveyed the parents of school-age children adopted from Eastern Europe. We aimed to determine: the children's educational achievements (including the proportion of children with language delays and learning disabilities); the proportion of children with neuropsychiatric disorders; the services provided by the school system and the number of children with individualized educational plans (IEPs); and the children's social function among peers and family.

Methods

Subjects

The Human Investigation Research Committee of New England Medical Center (NEMC) approved the survey. Subjects were recruited from three sources: the International Adoption Clinic at NEMC, a private neuropsychological practice in Virginia specializing in adopted children, and a Massachusetts adoption agency. Inclusion criteria were: ages between 8 and 12 years old and adopted from Eastern Europe. NEMC subjects meeting these criteria were identified in a database maintained by the International Adoption Clinic. Surveys were mailed to the parents/guardians with a stamped, addressed return envelope. Returned surveys were confidential and anonymous, unless the parents chose to identify themselves. One hundred seventy-three surveys were distributed from the International Adoption Clinic at New England Medical Center in Boston, 75 were distributed from the private clinic, and 2 were distributed from the adoption agency. In total, 81 surveys (N = 81) were returned: 63 from the International Adoption Clinic at New England Medical Center, 16 from the private neuropsychological practice, and 2 from the adoption agency. Overall, 32 percent of the surveys were returned.

Survey

The survey was made up of 61 questions. Background information about the child (including birth country, orphanage experience, gender, and age at adoption) and the adoptive parents (including age, race, marital status, combined family income, level of education, and type of community) was collected. Parents were asked to supply available medical information about their child, especially related to prenatal alcohol exposure and pre-adoptive abuse and neglect. Parents were asked if their child had any disabilities or formal medical diagnoses, and how these were determined. They were asked to identify all post-adoption services and supports that the child received since arrival in the United States. Some questions also pertained to the child's school experience and the parents' relationship with the education team. The survey included five open-ended questions (with "yes/no" responses followed by "If yes, please describe") that dealt with the possibility of unidentified medical issues prior to adoption, changes in the child's needs over time once home, the need to advocate for educational services post-adoption, and a description, if known, of any abuse the child may have suffered prior to adoption. There were five parent/child relationship questions, and those used a 4-point Likert scale from 1 (very well) to 4 (very poorly). There were three parent/school relationship questions using a 5-point Likert scale from 1 (poor) to 5 (excellent). The computer programs Stat-view (Abacus Concepts, Berkeley, CA) and SPSS (SPSS Inc., Chicago, IL) were used to analyze the results. At the end of the survey, parents were given the opportunity to describe their child in their own words: "As if to paint a picture of what your family life is like with your adopted child."

Results

Demographics

Of the 81 children described in the returned surveys, 33 were boys and 48 were girls. Forty-eight (60 percent) were born in Russia. Other countries of origin included Bulgaria (7), Romania (6), Ukraine (5), Lithuania (4), Moldova (3), Latvia (2), and Belarus (1) (see Figure 1). In five cases, the country of origin was not specified.

[FIGURE 1 OMITTED]

The age of the children at adoption ranged from 1 year to 8 years (mean [+ or -] SD = 54 mo [+ or -] 27 mo). Ten (12 percent) were adopted before age 24 months, and 14 (17 percent) were adopted between 24 and 36 months. Thus, 70 percent were adopted after age 3 and therefore did not qualify for early intervention services upon their arrival to the United States.

At the time of the survey, the children had lived in the United States with their adoptive families for one to nine years (mean [+ or -] SD = 4.5 yrs [+ or -] 2 yrs); 72 percent of the children had lived in the United States with their adoptive families for 4 or more years (see Figure 2).

[FIGURE 2 OMITTED]

School and Neurobehavioral Issues

Fifty-nine of the children (73 percent) attended public school, 18 (22 percent) attended private school (2 residential placements due to behavioral concerns), and 4 (5 percent) attended charter school or were home schooled. Most children (71 percent) were in age-appropriate grades; the remaining 29 percent were only one grade below the expected. More than half of the children (49 of 81, or 61 percent) had individualized educational plans (IEPs) in place at school.

Language disorders were common: 52 percent of the children had various language problems, including difficulties or delays in expressive language, written language, abstract reasoning, understanding humor, and auditory processing. Forty percent of the children received speech and language services as part of their IEP.

Learning disabilities were reported for 36 percent of the children. Learning disabilities included difficulties or delays in math, reading, written language, and visual perception. Thirty-two percent of the children received occupational therapy to address sensory integration dysfunction and fine motor delays. More than one-third of children (38 percent) had been diagnosed with attention deficit hyperactivity disorder (ADHD). Other neurobehavioral diagnoses included: anxiety (19 percent), depression (19 percent), reactive attachment disorder (16 percent), post-traumatic stress disorder (32 percent), motor coordination disorder (7 percent), obsessive-compulsive disorder (5 percent), bipolar disorder (1 percent), pervasive developmental disorder (1 percent), autism (1 percent), and Asperger syndrome (1 percent). Children with post-traumatic stress disorder were older at adoption than those without this problem (61.0 [+ or -] 4.6 months vs. 50.2 [+ or -] 3.8 months, p = 0.04). Otherwise, age at arrival, gender, country of origin, and age at survey did not relate to specific diagnoses. More than one-third (35 percent, n = 28) of the children had two or more of these disorders (see Figure 3). Of those with multiple diagnoses, 68 percent had ADHD, 71 percent post-traumatic stress disorder, 43 percent reactive attachment disorder, 54 percent depression, 54 percent anxiety, and 14 percent obsessive-compulsive disorder. Depression and anxiety occurred together frequently (10 out of 15 children with depression also had anxiety, p = 0.0001, chi square analysis with continuity correction). The presence of multiple diagnoses did not relate to age at arrival or age at survey.

[FIGURE 3 OMITTED]

Mental health diagnoses were made by the child's pediatrician (8 percent), neurologist (2 percent), psychiatrist (5 percent), and/or psychologist (31 percent). Parents also were asked if they suspected any undiagnosed problems in their child. The most common undiagnosed conditions suspected by parents were: learning disabilities (9 percent), post-traumatic stress disorder (9 percent), obsessive-compulsive disorder (9 percent), and anxiety/obsessive compulsive disorder (9 percent).

When asked if their child's needs for special education services changed over time, 80 percent of the parents responded affirmatively. As children grew older, language deficits, impaired social interaction, and auditory processing difficulties became more obvious.

Parents were asked if they needed to advocate for their children in the school system to receive services. Eighty-five percent of the parents responded affirmatively. Their comments included: "I had to fight for everything," "I didn't realize how hard it would be to receive services," and "I needed to monitor services." Nonetheless, 78 percent of parents described their child's educational program as adequate to excellent when asked to rate it on a Likert scale from 1 (poor) to 5 (excellent) (see Figure 4). The remaining 22 percent described their child's educational program as poor to fair. Approximately 60 percent of the parents felt that their relationship with the special education team was adequate to excellent, while approximately 20 percent of described this relationship as poor.

[FIGURE 4 OMITTED]

Social/Emotional Development

The survey also assessed children's social adjustment with peers in school, the community, and within their families. Parents reported that 70 percent of the children were willing to go to school. Sixty-three percent reported that their child had a best friend; however, the remaining 37 percent stated that their child did not have a best friend. Some parents reported that their child had difficulty in large social settings, and had trouble responding to social cues or understanding humor. Parents reported negative behaviors and/or tantrums occurring in novel or "overstimulating" situations.

Families perceived that they generally functioned well; a 4-point Likert scale from 1 (very well) to 4 (very poorly) was used to determine how well parents were getting along with their child (see Figure 5). Ninety-three percent of the parents felt that they got along "very well" or "fairly well" with their child and 65 percent of the parents felt their child was trustworthy.

[FIGURE 5 OMITTED]

As a final, open-ended question on the survey, parents were given the opportunity to "paint a picture" of their relationship with their adoptive child. Parents supplied a wide range of responses, some with exciting descriptions of success and others with detailed stories of challenges and a need for multiple services and supports. The diversity of outcomes is represented in the following two case studies:

Case Study #1

Medical History: S was adopted from Russia at 12 months of age. He had been institutionalized since birth. No medical issues were identified prior to adoption; specifically, no note of neglect/abuse or prenatal alcohol exposure was included in his records. The only medical finding after adoption was a positive test for intestinal parasites (Giardia lamblia), which was successfully treated. He did not receive early intervention. He attended a private preschool with no therapeutic services.

Current Performance: S is 8 years, 11 months of age, in the 3rd grade, attending a regular education classroom without an IEP. He is above-grade level for reading and spelling. His parents report that their child is well-liked by peers and is an excellent athlete.

Case Study #2

Medical History: R was adopted from Russia at 8 months of age. Prior to adoption, he lived for 3 months in a maternity hospital and 5 months in an orphanage. Russian medical records listed prematurity (uncertain gestational age), periventricular hemorrhage, and strabismus as diagnoses. There was no mention of neglect, abuse, or prenatal alcohol exposure. After adoption, his diagnoses included: moderate iron deficiency anemia, sensory integration dysfunction, reactive attachment disorder, behavioral and attention issues. R received early intervention and, after age 3, received occupational therapy, physical therapy, speech, sensory integration therapy, and counseling services.

Current Performance: The child, now age 8, is in the 1st grade in a public school, in a classroom with a designated aide. He occasionally bites other children, hoards food, still has difficulty chewing solids, smells objects obsessively, and exhibits moderate anxiety. He appears clumsy, with poor pro-prioceptive abilities. R's attention span is scattered, and his academic skills are weak. IEP services include: occupational therapy, physical therapy, speech, academic support, social skills training, and reading instruction. Current medications are Risperdone and Clonidine. His parents report that he is well-liked by younger children in school, but has very limited social engagements. Family stress level is reported as high.

Discussion

Adverse prenatal exposures, malnutrition, micronutrient deficiencies, exposure to infections, and environmental and emotional deprivation are common experiences of internationally adopted children from Eastern Europe. Among these children, impaired growth and cognitive development are frequent sequelae noted at their arrival in the United States (Albers et al., 1997; Hostetter et al., 1989; Hostetter et al., 1991; Jenista, 2000; Jenista & Chapman, 1987; Johnson, D., 2000; Johnson, D. E., 1997; Johnson et al., 1992; Kaler & Freeman, 1994; Mainermer, Gilman, & Ames, 1998; Miller, 2000; Miller & Hendrie, 2000; Miller et al., 1995; Morison, Ames, & Chisholm, 1995). Several studies suggest an increased frequency of behavioral disturbances among international adoptees at school age; however, these studies included few children adopted from Eastern Europe. These children may have more difficult experiences in early life, as reflected in their medical and developmental problems noted at the time of adoption.

Although the number of internationally adopted children of school age has increased dramatically in the past 10 years, little is known about their educational experiences as they progress through later childhood and adolescence. Our survey was designed to assess the performance of a group of 8- to 12-year-old Eastern European adoptees. In comparison to typically developing school-age children, a large percentage of the surveyed children (61%) received special education services under an individualized educational plan (IEP), 61 percent vs. 12 percent (U.S. Department of Education, 2001). Speech and language disorders were present in 52 percent of children, who had been in an English-speaking environment for an average of 4.5 years since adoption. Most internationally adopted children arrive with delays in pre-verbal skills and their birth languages, likely reflecting adverse prenatal exposures and the paucity of language exposure in the orphanage environment (Gindis, 1998; Glennen & Masters, 2002; McGuinness & McGuinness, 1999). Thus, these deficiencies do not represent simply the difficulties of a child learning English as a second language. Some children's delays persist even after immersion in the language-rich environment of the adoptive home. Such early language delays have been linked to reading problems (Scarborough, 1990; Scarborough & Dobrich, 1990).

Strikingly, ADHD had been diagnosed in 38 percent of the children in this survey. ADHD is the most common neurobehavioral disorder of childhood, affecting between 4 percent and 12 percent of elementary school-age children in the United States (Brown et al., 2001). Although the reason for the high prevalence among international adoptees is unknown, such factors as adverse prenatal exposures, genetics, and institutionalization may predispose children to attentional problems. Alternatively, other conditions, such as sensory integration dysfunction, post-traumatic stress disorder, learning disabilities, or reactive attachment disorder, may have been misdiagnosed as ADHD in this vulnerable population.

Attachment problems, post-traumatic stress disorder, sensory integration disorder, and other neuropsychological problems have previously been identified in post-institutionalized children (Cermak & Groza, 1998; O'Connor et al., 2003; Rutter et al., 1999; Rutter & English and Romanian Adoptees Study Team, 1998; Tizard, Cooperman, Joseph, & Tizard, 1972; Tizard & Hodges, 1978; Tizard & Joseph, 1970). In our survey, neuropsychiatric diagnoses were frequent. Moreover, 28 out of 81 (35 percent) children had two or more neuropsychiatric diagnoses. Neuropsychiatric problems and learning disabilities may not be immediately apparent at adoption, but emerge later during early childhood and school age. In the initial post-adoption period, most children demonstrate rapid acquisition of language, developmental catch-up, and adjustment to their new homes and schools. As children progress through the school system, the academic, social, and communication demands placed on them increase. Children must process and produce progressively more complex language (both written and spoken), process a multitude of sensory inputs, follow rules, and socially engage with peers and school staff(Federici, 1999; Gindis, 1998). We found that learning difficulties become more evident as children age. Parents reported that these were difficult challenges for many of the children participating in this project. Although the majority of the children (71 percent) are enrolled in an age-appropriate classroom, many (61 percent) receive special education support services. Parents often chose public school enrollment for their children to facilitate access to special education services. Nonetheless, 85 percent of parents felt the need to advocate for their children.

Social issues and peer relationships are also of equal concern to many of the families. Thirty-seven percent of the children in this study reportedly do not have a best friend. Parents commented that their children displayed immature behaviors and struggled in social settings. Adoptive parents have noted that their children's emotional/interpersonal skills have shown the least improvement following adoption, in comparison to other areas of development (Fries & Pollak, 2004). Children were "over-stimulated" in novel situations and often displayed increased negative behaviors, tantrums, or "meltdowns." Parents commented that sensory integration therapy and social skills training helped their children to develop coping skills and interact appropriately with adults and peers.

We recognize the potential limitations of this survey. Subjects were largely drawn from a specialty clinic for internationally adopted children, raising the question of whether this population is biased towards more severely impaired children. However, the families attending the clinic schedule their appointments prior to traveling to receive their child. Furthermore, we have previously noted no difference in the incidence of medical and developmental problems in children attending this clinic compared to those who did not (Miller & Hendrie, 2000). Because this was an anonymous mail survey, we did not have the opportunity to clarify ambiguous or incomplete responses, nor to characterize responders compared to non-responders for bias. Responders may have been more likely to have developmentally disabled children, but it is also plausible that parents who felt their children were successful were more likely to respond. It is possible that the large proportion of children with learning problems and other diagnoses reflects adoptive families' attentive care and demand for supportive services. Parents who adopt internationally tend to be well-educated and able to advocate effectively for their children (Judge, 2003; Miller, 2005). These findings may not be applicable to all international adoptees, because our survey was limited to families who had adopted from Eastern Europe. This included six children from Romania, who likely experienced more severe deprivation in early life than those from other countries. Finally, 71 children included in this study were adopted after age 2 and 57 were adopted after age 3. Duration of orphanage confinement is an important determinant of developmental and growth delays at the time of adoption (Albers et al., 1997; Johnson, D. 2000; Johnson, D. E., 1997; Johnson et al., 1992; Miller & Hendrie, 2000; Rutter & English and Romanian Adoptees Study Team, 1998) and likely at follow-up as well, although this has not yet been definitively demonstrated.

Nonetheless, the findings in this survey suggest that there is at least a subset of children adopted from Eastern Europe who have significant educational and neuropsychiatric issues. Nearly two-thirds of the internationally adopted children from this study received special education services, and many had complex learning difficulties and other diagnoses. However, the social functioning, family relations, and community involvement of the children were remarkably good. In view of the multiple risk factors faced by these children prior to adoption, the image of social and peer integration that emerged from this survey was impressive. These outcomes are strong testaments to the resilient nature of the children, the enriched environment of their adoptive homes, and the school systems, which have identified the special needs of these children and are making every effort to address these needs through individualized education.

Expanded study of educational outcomes and social/emotional development of internationally adopted children as adolescents and young adults will be useful to broaden understanding of risk factors and resilience among these children. Standardized intelligence and achievement testing and reporting of social/emotional development from multiple sources (parent, child, teacher) would provide additional, useful, and objective information. Determining how many internationally adopted children continue to need an IEP in high school, how many graduate from high school, and how many enroll in and complete undergraduate college programs would expand awareness of the spectrum of outcomes for this vulnerable population of children.

Acknowledgments: We would like to thank all of the families who took the time to complete this survey and share their stories. We also would like to thank Ronald Federici, Ph.D, Sharon Cermak, EdD, OTR/L, FAOTA, and Lisa Albers, MD for their valuable suggestions and support during this project. We are grateful to the LEND program at the Eunice Kennedy Shriver Center in Waltham, Massachusetts, for their financial support with the mailing expenses. We also want to thank Maryellen Mahoney for proofreading and editing earlier drafts of this article. Portions of this paper were presented at Joint Council on International Children's Services Medical Institute, Washington, D.C., in April 2002.

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Linda Grey Tirella, OTR/L, M.S., M.H.A.*

Wilma Chan 

Laurie C. Miller, M.D.

International Adoption Clinic

Tufts University School of Medicine