I am wondering how you differentiate a child suffering from ADHD from a child who was raised for 2.5 years in an orphanage and has very limited early life data. The etiology of ADHD is difficult to ascertain and in the patient who has a history of spending part of their life growing up in an orphanage, the challenge usually is not so simple as to say whether or not someone had ADHD, but do they also have co morbid conditions which further complicate their diagnosis and their treatment. ADHD is a clinical diagnosis depending on a variety of factors and is undoubtedly caused many genetic and environmental factors. There is no test that we can do which will state whether a person has ADHD from spending time in an institution as a child or whether it is due to factors experienced perinatally or that are genetic in origin. The problem with ADHD in the internationally adopted child is that if there could be an unrecognized history of alcohol/drug use, which can cloud the issue, which is very prevalent in certain countries. The same lack of information may hide from us a family history of ADHD, mental illness, learning disabilities, minor genetic abnormalities or neonatal/ intrauterine exposure to environmental toxins. An example of this would be a baby born after a difficult delivery who had a prolonged period where the child did not get any oxygen, a child such as this later in life may have school problems similar to ADHD but without this significant history we have no way of knowing the etiology when the child is eight years old. The view of a physician, like myself, who tries to help a child with a learning deficit is to try to take an individual child who is different from every other child on the planet and fit them into a described syndrome and treat them accordingly. The patient who is internationally adopted by definition needs increased surveillance for learning disabilities and early referrals to early intervention programs and as appropriate various therapies and educational supports if they are required. by James Reilly, M.D.