Articles on adoption, foster care, & pediatrics

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Sensory Integration and Sensory Processing Disorder

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Sensory integration dysfunction (DSI), or as it is currently known, sensory processing disorder (SPD) is a complicated, somewhat controversial disorder of "sensory processing" - the ability to take in, filter, and respond appropriately to sensory input (touch, movement, vision, hearing, taste, and smell). Some children are felt to be "sensory-avoiding", or "sensory-defensive" - feeling bombarded by overly intense experiences of touch, lights, sound, and so on. Some children are "sensory-seeking", or "sensory under-responsive" - seeking intense stimulation, bashing and crashing around, and seeming less aware of pain and touch. Some children have trouble using sensory inputs to plan and perform gross and fine motor tasks ("dyspraxia", or motor planning disorder).

SPD is one of those diagnoses where definitive research on prevalence, validation of diagnostic tools, and effective therapy is lacking. It's especially hard to know when normal developmental, temperamental, and other individual differences in sensory responsiveness becomes a "disorder". It's underdiagnosed in many arenas, and overdiagnosed in others, just like any disorder where convenient but unvalidated checklists proliferate on the web, and where "cottage industries" marketing products and treatments are competing for your parental attention and money.

Having worked with a lot of post-institutionalized and alcohol-exposed children (two populations that are at higher risk for SPD), I am convinced that there are many such children for whom SPD is a real disorder - one that significantly impairs their function in home, social, and school environments. And I've seen children respond well to occupational therapy (OT) sensory interventions, especially functional approaches that integrate sensory work with the child's needs in motor skills and social interactions.

Even if your child's issues are more reflective of developmental immaturity or individual temperament than a definitive disorder, the sensory approaches can be fun, stimulating, and helpful with self-regulation and self-soothing. It's still hard to convince insurers and schools to fund such interventions, and depending on your situation, sensory-based therapy may not be the most pressing use of your time and money ... but here are some good resources on the topic. A lot of interventions are ones that you can do at home, and while there are scads of nifty products marketed for SPD, you can get a lot done with simple, cheap, or home-made tools and toys.

Sensory Processing Disorder Resources:

Café-au-lait Spots and Neurofibromatosis

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There is a group of genetic neurologic conditions called neurocutaneous syndromes where skin findings can be the first clue to a broader syndrome. One of the most common is neurofibromatosis type 1 (NF1), which occurs in up to 1 in 3000 individuals. This is a condition where benign tumors grow on nerve tissue, causing skin, bone, and sometimes brain issues.

One of the first signs of NF1 can be "café-au-lait spots", which are typically light to dark-brown flat, discrete, round or oval skin patches. These spots become more common with age, and can be more common in African-Americans, but most of us have 3 or less. If more than 5 café-au-lait spots (>5mm each) are seen, this should be considered NF1 until proven otherwise. Other findings like freckling in the armpits or groin, or firm, rubbery neurofibromas typically show up later, in preadolescence. Many with NF1 only develop a few fibromas, but they can be quite cosmetically significant for some.

Mental retardation is rare with NF1, but attentional and specific learning issues are common in this disorder. While fibromas are benign, there is a somewhat increased risk of malignancy (3-5%), and brain fibromas can be associated with epilepsy. Short stature and large head are common in NF1.

The majority of folks with NF1 have mild disease, and complications are often correctable to some degree. Treatment focusses on surgery for painful or cosmetically significant fibromas, and addressing learning issues through early intervention and school supports.

Here are the diagnostic criteria for NF1 (2 or more are required for the diagnosis), from GeneReviews:

  • Six or more café au lait macules over 5 mm in greatest diameter in prepubertal individuals and over 15 mm in greatest diameter in postpubertal individuals
  • Two or more neurofibromas of any type or one plexiform neurofibroma
  • Freckling in the axillary or inguinal regions
  • Optic glioma (tumor of the optic pathway)
  • Two or more Lisch nodules (iris hamartomas)
  • A distinctive osseous lesion such as sphenoid dysplasia or thinning of long bone cortex with or without pseudarthrosis (related orthopedic issues)
  • A first-degree relative (parent, sib, or offspring) with NF1 as defined by the above criteria

Additional Resources:

Birth-to-Age-5 Timeline of Development

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The Talaris Research Institute in Seattle has a fantastic research-based Timeline of Development that illustrates how children develop in the first five years. Milestones are organized into Social/Emotional, Cognitive, Language, Sensory, and Motor. You can click on each milestone to learn more about it, with links to reference texts; many of them link to Talaris Research Spotlights. You'll note that each milestone has a pretty wide age-range, and that it's usually more useful to focus on the sequence and tempo of developmental achievement rather than on comparisons with that precocious neighbor kid, or the cousin who didn't talk until he was 4 but went to Stanford.

Stuttering

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Many children from age 18 months to 5 years old have occasional initial syllable or word repetitions, or use of filler pauses ("Umm ...") - this is called disfluency, and is usually a normal developmental stage where the mind is thinking of words faster than the mouth can utter them.

True stuttering is more common in boys, if there's a family history of stuttering, with later onset of symptoms, if there are speech/language delays, and if the stuttering is more often present than not, especially if present for 6-12 months or more.

Some characteristics of true stuttering include:

  • frequent repetitions of sounds, syllables, or short words
  • frequent hesitations and pauses in speech
  • absence of smooth speech flow
  • tense facial expressions or facial tics
  • a fear of talking
A nice guide for parents trying to sort this out is "If You Think Your Child is Stuttering ...", from the Stuttering Foundation (they have a great website). I also really like their streaming video, with examples of disfluencies and true stuttering, and helpful advice.

Prenatal Drug Exposures

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Enough with the Alcohol Already… Other Prenatal Drug Exposures:


Prenatal Drug Research in General

•    Impossible to fully control for genetic (cognitive, mental health), other prenatal exposures, LBW/prematurity, and environmental factors
•    Alcohol may be cofounder in many studies
•    Prenatal drug exposure may make kids more vulnerable to other biomedical and environmental risks

Tobacco

•    BIG association with low birth weight
•    Higher rates of spontaneous abortion, late fetal deaths, prematurity, cleft lip
•    SIDS, ear infections, asthma, etc …
•    Impaired infant state regulation
•    Assoc with lower mental scores/babbling @1yo – cognitive effects minimal by 2yo
•    More externalizing behaviors and inattention/hyperactivity

Marijuana

•    Modest effect on fetal growth (hypoxia)
•    Some subtle infant neurobehavior effects
•    No cognitive /language effects at 1-2yo
•    Memory and verbal outcomes at 4yo possibly impacted by heavy prenatal exposure
•    Some impact on motor development as well

Opiates (heroin, methadone)

•    Low Birthweight (more with heroin)
•    Newborn withdrawal syndrome: jitters/tremor, hypertonia, irritability, high-pitched cry, convulsions, stuffiness, fever, mottling, sweating, loose stools/vomiting, poor feeding
•    Treated with slow opiate taper
•    “Subacute withdrawal” – 3-6mo with irritability, poor state control
•    Subtle late differences in visual-motor and perceptual tasks

Cocaine and Crack

•    Spont abortion, abruption, stillbirths, prematurity, distress (vasoconstriction)
•    Neonatal stokes, focal seizures
•    Urogenital and other malformations
•    Microcephaly
•    Early excitability/irritability in infancy
•    Preschool impulse control issues
•    No cognitive differences on broad scales ...
•    Subtle differences in specific functions (state regulation, lang, attn/impulsivity, visual memory, temperament, aggression)

Speed and Meth

•    Sharp rise in the 90s, especially rural
•    Meth labs – bigtime fire and chemical risks
•    Preterm delivery, abruption
•    LBW, cardiac and cleft defects, smaller subcortical brain volumes
•    Not much data on developmental effects
•    Visual memory, verbal memory, executive function, attention/impulsivity, and long-term spatial memory may be affected

Want more detailed information and some country-specific statistics?  Click the headings above ...

Books for Speech/Language Delays

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Speech and language delays are some of the most prominent issues in our toddler adoptees. At our visit, we'll discuss hearing, comprehension, early nonverbal social communication (eye contact, peekaboo, pointing), gestures/signs, amount/quality of vocalizing, and expressive speech (how many spoken words? combining words?). Many of our kids are primarily "late talkers", with other fundamentals of language more intact.

But don't just wait for them to "learn English" - if you're delayed in your native language it's harder to learn a new one. So be proactive and pick up one of these books - they're both chock full of practical tools to help your child catch up. We'll be happy to refer you to a speech/language pathologist (therapist) and audiologist if you or we are concerned about language, but YOU will still be the biggest "therapist" in your child's life.

My favorites are:
It Takes Two To Talk: A Practical Guide For Parents of Children With Language Delays by Jan Pepper, Elaine Weitzman (click above to order from Amazon). It costs $45, and is worth it. Lots of lovely illustrations, researched-based but actually a simple, practical, easy read. If you want a higher reading-level type book with more research citations, etc, then see below. You can also order it from the Hanen Centre, which publishes a number of excellent books.

I also really like Talking with Toddlers, by Rick McKinnon, PhD. (a local speech/language specialist), which is free and online. Instant gratification. Now he's even got a Talking With Toddlers blog - don't miss the book chapters, screening tools, and video tips in the right sidebar.

Look Who's Talking, by Laura Dyer, is well-researched, practical, and comprehensive, and covers a broader age range than the two listed above. Features specific sections on adoption and bilingual issues (but don't miss Glennen's website for more detail on language development in post-institutionalized children).

A good book with more emphasis on older, school-age children is Childhood Speech, Language, and Listening Problems: What Every Parent Should Know by Patricia McAleer Hamaguchi.

Outcomes of Prematurity

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Many international adoptees were born preterm. Premature birth is a risk factor for a number of medical and developmental outcomes, including significant disabilities like mental retardation, cerebral palsy, and profound vision or hearing loss. More subtle, but often functionally significant outcomes like early developmental delays, attentional problems, sensory integration/behavioral regulation issues, and school difficulties are also seen. The degree of prematurity, birthweight, and severity of early newborn complications all impact the risk for these outcomes.

Prematurity Resources:

Head Circumference Issues

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Why we care about head circumference issues ...

Dr. Dana Johnson's review article on head size - "Does Size Matter, Or Is Bigger Better?" - says it best. Highly recommended for parents considering referrals with head growth concerns. Growth charts are available here.

How to measure a proper head circumference ...

Bring a non-stretchable measuring tape, and practice a bit first. Wrap the tape snugly around the widest possible circumference - from the most prominent part of the forehead (often 1-2 fingers above the eyebrow) around to the widest part of the back of the head. Try to find the widest way around the head. Remeasure it 3 times, and take the largest number.

Stimulating Early Development

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Here are some resources to help with early childhood developmental concerns. What's amazing about early development is that infants and toddlers naturally gravitate to activities that are "just hard enough" to build new skills. If you provide some basic toys and materials, a safe environment, and your loving, engaged attention, development will happen. But it helps to have some tricks and tips as well, as well as activities to use with children who seem stuck, or delayed. Early Intervention can also be invaluable in such situations.

The Good Samaritan Children's Therapy Unit (in Puyallup, Washington), publishes two nice, small books by Wendy Robins Lind, OTR/L. They can be ordered by phone from the CTU using a credit card (253-697-5225), and they each cost $12.50, shipping included.

  • "Stimulating Your Child's Development Through Play (Birth to two years)" - I really like this one - lots of fun, stimulating activities for each month of age
  • "Daddy as Baby's Playground" - Nice motor activities for Daddys (and Mommys) for children up to a developmental age of 1 year, and many older adoptees without solid crawling/walking will benefit from these exercises [facial hair alert - the Daddys in this book are mightily mustachioed. I think this is more a historical artifact than an actual endorsement of facial hair as stimulating to infant development, but stay tuned, folks. Maybe they're onto something ...]

A neat bunch of free activity sheets for enhancing development through FUNdamental movement concepts is available from Sparkplug Dance Developmental Movement. "More tummy time" is oft-recommended for all infants, but especially kids with head flattening, poor "push-up" skills or other delays, and to promote postural development and integrated locomotion (crawling!). Trouble is, we rarely tell parents how to make it tolerable and fun. That's where this lovely "10 Ways to Have Fun on Your Tummy, Baby!" handout comes in handy.

A very comprehensive guide is Why Motor Skills Matter : Improve Your Child's Physical Development to Enhance Learning and Self-Esteem, by Tara Losquadro Liddle. This book fills a big gap in the literature by thoroughly and practically addressing motor and sensory issues in the 1st five years of life, including special sections on low muscle tone and prematurity. It provides excellent descriptions of appropriate play and physical activities for children at various stages of development, especially for kids that do have motor delays or low muscle tone.

Stanley Greenspans's Building Healthy Minds: The Six Experiences That Create Intelligence and Emotional Growth in Babies and Young Children is another good resource. Even if your child missed out on some of these experiences early on, it's not too late to create them. Good information on temperament and sensory processing differences here as well.

For more books on early development, please see our list of Development and Learning Books, and the following articles on our site:

Early Development Links: