International adoption: a four-year-old child with unusual behaviors adopted at six months of age.

CASE. Jenny, a 4-year-old child adopted from an orphanage in St. Petersburg, Russia, at 6 months of age, is seen for an initial office visit by a new pediatrician. According to the parents, she received poor nutrition and limited stimulation in the orphanage setting. During her first several months after arrival in her new home, Jenny avoided the gaze of her parents and looked away when they attempted to engage her in play or participation in feeding. She did not demonstrate any preference for her parents for several months. She appeared to be quite aloof and solemn. She was easily frightened by certain visual and auditory stimuli, such as ceiling fans. By 1 year of age she spoke several words, followed simple directions, and walked. Jenny had difficulty tolerating many textures of foods. She often mouthed inedible objects during her second year of life and performed repetitive behaviors including dumping and filling containers. She was clumsy for her age. Her parents felt that she was on the fringe of the family. Jenny received occupational and speech and language therapy at a functional feeding program that addressed her food intolerance and oral sensitivity. During her third year, defiance, noncompliance, and anger occurred frequently. She often placed herself in dangerous situations. She burned her hand and lower lip on a light bulb after being told to stay away from it. She frequently ate out of the garbage. Jenny was described as highly verbal and superficially charming. Jenny followed women other than her mother in public spaces and wanted to hold their hands and sit on their laps. She began play therapy at age 3 years, while her mother received individual counseling with another therapist because she was having difficulty bonding with Jenny and felt rejected. At age 4 years, Jenny is described as aloof and often angry. She is extremely jealous of attention directed toward her 6- and 3-year-old brothers. Her mother feels she is stuck like glue to her. She will often talk nonstop and ask repetitive questions. Jenny has difficulty drawing a circle. She seems to be obsessed with the color purple, certain toys, and anything to do with The Lion King. She has been asked to leave every preschool and camp she has attended because of nonstop talking, severe noncompliance, and unacceptable behaviors such as constantly asking her peers, Do you poop in your pants? Recently, Jenny has performed more dangerous behaviors such as running into streets and climbing onto the roof from a window. She said to her mother, The cars will not kill me. She frequently imitates behaviors of the family cat and eats from the floor. Challenged by Jenny's background and current behaviors, her pediatrician attempts to understand Jenny's developmental course and develop a plan for effective interventions. J Dev Behav Pediatr 24:63-69. 2003.