Raising Resilient Rascals Conference

Raising Resilient Rascals:

Integrative, Brain-Based and Practical Ways
to Nurture Adopted and Fostered Children

 
Save the date! On Feb 2nd we'll be hosting an all-day conference with Deborah Gray and colleagues.  We're aiming to be interesting and informative for both parents and professionals interested in adoption. Check out the topics below, and sign up at the Cascadia Training website.

Topics include:

 

The "Decade of the Brain" Came and Went - What Have We Learned?

The past 10 years brought many advances in neuro-imaging, and better understanding of the effects of prenatal drug and alcohol exposures, malnutrition, maltreatment, lack of attuned care giving, and stress on the developing brain.  What can the latest research tell us about how these all-too-frequent influences affect the neurodevelopment of adopted and foster children?  We will explore different regions of the brain, and aspects of learning and behavior, with an emphasis on avenues for intervention at home and school.

Loving the Child Who Bites You - Disciplining Scared/Aggressive Kids. 

Children who have been maltreated or lost attachment figures desperately need to form secure attachments with their parents.  Often the children are aggressive and/or immature and impulsive.  What strategies are useful when children show limited empathy?  We will look at approaches designed to bring out the best in children whose histories of maltreatment have resulted in dysregulation and behavior problems.

From Snake Oil to Fish Oil - Integrative Medicine and Adoption. 

A lively romp through the wilderness of complementary/alternative therapies commonly used by adoptive families, from an "alterna-friendly" pediatrician.  We'll review the evidence or lack thereof, safety, and cost of interventions ranging from vitamins, minerals, essential fatty acids, and other "nutriceuticals", herbs and homeopathy, elimination diets, chelation therapy, bodywork and chiropractic, developmental movement therapy, sensory and auditory integration, and bio/neurofeedback.  We'll also cover ways to evaluate therapies and practitioners, and the cardinal signs of quackery.

Adderall and Risperdal et al. - Meds and Adoption.  

In this part of our talk, we'll address the use of psychiatric medications with adopted and fostered children.  Stimulants, antidepressants, mood stabilizers, blood-pressure medications, and atypical anti-psychotics are being used more and more with younger and younger children.  Unfortunately, the evidence for safety and efficacy in children for many of these drugs is lacking (as are the child psychiatrists!)  What do we know about these meds and children?  What goes into the decision to medicate a child for specific psychiatric conditions like ADHD, depression, anxiety, and bipolar disorders, as well as less defined emotional and behavioral problems?  What sort of monitoring is important?

Creating Resilience in Children: What areas promote competencies in children?  What are we doing well?  What are we missing?   How should we be doing it? 

The remarkable increase in the number of adoptions of children adopted after trauma and neglect has pushed the need for support.  But, professionals and parents alike need to know when to obtain support.  This talk describes symptom clusters in childhood trauma, neglect's impact on children's functioning,  and best practices in providing help.  We will also discuss what to look for in acquiring help and what to avoid.

Resilience Panel

The day will end with a panel to include all the speakers and a few invited guests.  The panel will discuss resilience factors, resilience gene, adult influences, orphanage interventions, goodness of fit, what can parents do to prepare/promote resilience?  There will be plenty of time to take attendee questions.

About the presenters:

Julia Bledsoe, MD, is a Clinical Associate Professor of Pediatrics at the University of Washington, and a staff pediatrician at the UW Fetal Alcohol Syndrome Diagnostic and Prevention Network in Seattle.  She founded the Center for Adoption Medicine, and has worked in the field of international adoption for ten years, with travels to Russia, Romania, China, and Guatemala.  She has two children adopted from Korea, one of whom has Tourette's Syndrome and ADHD.

Julian Davies, MD, is a Clinical Assistant Professor of Pediatrics at the University of Washington, and the other pediatrician at the UW FAS Clinic.  He is also the Co-Director of the Center for Adoption Medicine, where he provides pre-adoption consultations, post-placement evaluations, and ongoing general pediatric care for adopted children.  He is the primary author for www.adoptmed.org, an online resource for medical and developmental issues in adoption and pediatrics.  He has traveled, clowned, and volunteered extensively in Russia, with an arts rehabilitation program and summer arts camp for Russian orphans.

Deborah Gray, MSW, MPA, is a national trainer, a psychotherapist in private practice, and the author of the well-received book, Attaching in Adoption: Practical Tools for Today’s Parents, Perspectives Press, 2002. Deborah has spent 20 years helping children develop attachments and work through trauma and grief. She teaches in the Trauma Certificate Program at the Univ. of WA School of Social Work and both graduate adoption therapy programs at Portland State University and Northwest Adoption Exchange. Her second book on best practices with children after neglect and trauma is in preparation.

About the particulars:

Location: Tukwila Community Center
When: February 2nd, 2007
Hours: 8:30am-5:00pm
Fee: $65.00 US
CEU info: 7 CEU's 
Cascadia Training is approved by the NASW, Washington State Chapter, to provide continuing education units to Licensed Social Workers, Mental Health Counselors and Marriage and Family Therapists.  Certificates of Completion are awarded to attendees at the end of each workshop.  Provider number #1975-118; Cascadia is an OSPI approved provider of in-service education.  This is a "Washington State Approved Clock Hour Offering Workshop."

Potty Training - Get Ready, Get Set, Go!

By Elizabeth Pantley, Author of The No-Cry Potty Training Solution

 Get Ready

If your child is near or has passed his first birthday, you can begin incorporating pre-potty training ideas into his life. They are simple things that will lay the groundwork for potty training and will make the process much easier when you're ready to begin.

• During diaper changes, narrate the process to teach your toddler the words and meanings for bathroom-related functions, such as pee-pee and poo-poo. Include descriptive words that you'll use during the process, such as wet, dry, wipe, and wash.
• If you're comfortable with it, bring your child with you when you use the toilet. Explain what you're doing. Tell him that when he gets bigger, he'll put his pee-pee and poo-poo in the toilet instead of in his diaper. Let him flush the toilet if he wants to.
• Help your toddler identify what's happening when she wets or fills her diaper. Tell her, "You're going poo-poo in your diaper." Have her watch you dump and flush.
• Start giving your child simple directions and help him to follow them. For example, ask him to get a toy from another room or to put the spoon in the dishwasher.
• Encourage your child to do things on her own: put on her socks, pull up her pants, carry a cup to the sink, or fetch a book.
• Have a daily sit-and-read time together.
• Take the readiness quiz again every month or two to see if you're ready to move on to active potty learning.
  

Get Set

• Buy a potty chair, a dozen pairs of training pants, four or more elastic-waist pants or shorts, and a supply of pull-up diapers or disposables with a feel-the-wetness sensation liner.
• Put the potty in the bathroom, and tell your child what it's for.
• Read books about going potty to your child.
• Let your child practice just sitting on the potty without expecting a deposit.
  

Go

• Begin dressing your child in training pants or pull-up diapers.
• Create a potty routine - have your child sit on the potty when she first wakes up, after meals, before getting in the car, and before bed.
• If your child looks like she needs to go - tell, don't ask! Say, "Let's go to the potty."
• Boys and girls both can learn sitting down. Teach your son to hold his penis down. He can learn to stand when he's tall enough to reach.
• Your child must relax to go: read a book, tell a story, sing, or talk about the day.
• Make hand washing a fun part of the routine. Keep a step stool by the sink, and have colorful, child-friendly soap available.
• Praise her when she goes!
• Expect accidents, and clean them up calmly.
• Matter-of-factly use diapers or pull-ups for naps and bedtime.
• Either cover the car seat or use pull-ups or diapers for car trips.
• Visit new bathrooms frequently when away from home.
• Be patient! It will take three to twelve months for your child to be an independent toileter.
  

Stop

• If your child has temper tantrums or sheds tears over potty training, or if you find yourself getting angry, then stop training. Review your training plan and then try again, using a slightly different approach if necessary, in a month or two.
  

This article is an excerpt from The No-Cry Potty Training Solution: Gentle Ways to Help Your Child Say Good-Bye to Diapers by Elizabeth Pantley (McGraw-Hill, 2006). Used with permission.

Prenatal Methamphetamine Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Methamphetamine abuse has increased dramatically in the United States in the past decade, especially in the western and midwestern states [105]. In Russia, cheap imported heroin still prevails, but abuse of home-produced ephedrine-based “vint” and other injectable amphetamines is on the rise and already predominates in certain cities, including Vladivostok and Pskov [106]. Methamphetamine abuse is a significant problem in Southeast Asia as well, with 19% of Thai female students using methamphetamine in one school-based study [107]. The UNODC reports large increases in methamphetamine production and abuse in China, Singapore, and Thailand [35]. Because methamphetamine is relatively cheap to manufacture from readily available products, “home labs” are becoming increasingly common in many parts of the world. Unfortunately, the chemicals and byproducts involved are highly toxic and flammable.

Methamphetamine is a CNS stimulant that releases large amounts of dopamine, resulting in a sense of euphoria, alertness, and confidence [108]. It can be injected, smoked, snorted, or ingested orally. Prolonged use at high levels results in dependence and erratic behavior [105]. Evidence on the effects of prenatal methamphetamine use is still emerging, but effects on prenatal growth, behavior, and cognition have been described.

Mechanism

Studies of adult methamphetamine abusers have shown potential neurotoxic effects on subcortical brain structures, namely, decreased dopamine transporters, brain metabolism, and perfusion [108]. Although the impact of methamphetamine use during human pregnancy is currently unknown, animal studies have demonstrated neurotoxic effects of amphetamines and remodeling of synaptic morphology in response to prenatal methamphetamine exposure [109]. One study did describe a smaller putamen, globus pallidus, and hippocampus in methamphetamine-exposed children [108].

Pregnancy

Women using methamphetamine during pregnancy may have an increased rate of premature delivery and placental abruption [110]. Methamphetamine use during pregnancy is linked to fetal growth restriction and, occasionally, withdrawal symptoms requiring pharmacologic intervention at birth [111]. Clefting, cardiac anomalies, and fetal growth reduction have been described in infants exposed to amphetamines during pregnancy. These findings have been reproduced in animal studies [112].

Child Health

Late effects on child health resulting from prenatal methamphetamine use are unknown. Children who live at or visit methamphetamine home labs face acute health and safety hazards from fires, explosions, and toxic chemical exposures, however. The caregiving environments of methamphetamine users are often characterized by chaos, neglect and abuse, and criminal behavior as well as the presence of firearms, contaminated sharps, and other risks [113].

Behavior and Cognition

The scant research describing the outcomes of methamphetamine-exposed children describes possible links with aggressive behavior, peer problems, and hyperactivity [114], [115]. A small recent study found that methamphetamine-exposed children scored lower on measures of visual motor integration, attention, verbal memory, and long-term spatial memory [108]. In rats, even low doses of prenatal methamphetamine exposure can alter learning and memory in adulthood [116].

Selected References

[105]   Anglin M.D.,  Burke C.,  Perrochet B.,  History of the methamphetamine problem. J Psychoactive Drugs (2000) 32 : pp 137-141.
[106]   Rhodes T.,  Bobrik A.,  Bobkov E.,  HIV transmission and HIV prevention associated with injecting drug use in the Russian Federation. Int J Drug Policy (2004) 15 : pp 1-16.  
[107]   Sattah M.V.,  Supawitkul S.,  Dondero T.J.,  Prevalence of and risk factors for methamphetamine use in northern Thai youth: results of an audio-computer-assisted self-interviewing survey with urine testing. Addiction (2002) 97 : pp 801-808.
[108]   Chang L.,  Smith L.M.,  Lopresti C.,  Smaller subcortical volumes and cognitive deficits in children with prenatal methamphetamine exposure. Psychiatry Res (2004) 132 : pp 95-106.
[109]   Weissman A.D.,  Caldecott-Hazard S.,  Developmental neurotoxicity to methamphetamines. Clin Exp Pharmacol Physiol (1995) 22 : pp 372-374.
[110]   Eriksson M.,  Larsson G.,  Winbladh B.,  The influence of amphetamine addiction on pregnancy and the newborn infant. Acta Paediatrica Scandinavica (1978) 67 : pp 95-99.  
[111]   Smith L.,  Yonekura M.L.,  Wallace T.,  Effects of prenatal methamphetamine exposure on fetal growth and drug withdrawal symptoms in infants born at term. J Dev Behav Pediatr (2003) 24 : pp 17-23.
[112]   Plessinger M.A.,  Prenatal exposure to amphetamines. Risks and adverse outcomes in pregnancy. Obstet Gynecol Clin North Am (1998) 25 : pp 119-138.
[113]   Swetlow K.,  Children at clandestine methamphetamine labs: helping meth's youngest victims 2003. Washington, DC: US Department of Justice, Office of Justice Programs, Office for Victims of Crime.  
[114]   Billing L.,  Eriksson M.,  Jonsson B.,  The influence of environmental factors on behavioural problems in 8-year-old children exposed to amphetamine during fetal life. Child Abuse Negl (1994) 18 : pp 3-9.
[115]   Eriksson M.,  Billing L.,  Steneroth G.,  Health and development of 8-year-old children whose mothers abused amphetamine during pregnancy. Acta Paediatr Scand (1989) 78 : pp 944-949.
[116]   Williams M.T.,  Moran M.S.,  Vorhees C.V.,  Behavioral and growth effects induced by low dose methamphetamine administration during the neonatal period in rats. Int J Dev Neurosci (2004) 22 : pp 273-283.

Prenatal Cocaine Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Cocaine has received much attention since the 1980s, when crack cocaine began to plague urban America. Early alarmist predictions about an epidemic of neurologically damaged “crack babies” gave way to guarded optimism with early reports of neurodevelopmental functioning reporting no differences attributable to cocaine exposure. Follow-up studies with more specific measures, however, suggest effects of prenatal cocaine abuse on aspects of neurobehavior and language, as demonstrated with specific developmental tasks.

The rate of prenatal cocaine exposure in the United States ranges from 0.3% to 31% depending on the population surveyed and method of ascertainment [77], [78] and was 10% in the ongoing Maternal Lifestyle Study [34]. In our clinic's experience, reports of cocaine exposure in the international adoptee population are quite rare. The UNODC estimates the lifetime prevalence of cocaine consumption to be approximately 2% to 5% in a study of Guatemalan teenagers; in Russia, China, Korea, and other frequent countries of international adoption, the prevalence seems to be much less [35].

Mechanism

Cocaine and its metabolites readily cross the placenta, concentrating in amniotic fluid, and may produce direct neurotoxic effects, disturb monoaminergic (eg, dopamine, norepinephrine, serotonin) pathways, and cause vascular-mediated damage [91].

Pregnancy

The use of cocaine in pregnancy has been associated with a number of obstetric complications, such as stillbirth, placental abruption, premature rupture of membranes, fetal distress, and preterm delivery [92]. Growth restriction is often reported but may require higher levels of exposure and does not seem to persist after birth [93]. There may be a dose-response effect of cocaine on newborn head circumference [94]. Other CNS lesions (eg, stroke, cystic changes, possible seizures), cardiac defects, and genitourinary (GU) anomalies have also been reported, but the few available large, controlled, population-based studies on cocaine exposure and malformations have reached contradictory conclusions [95].

Behavior and Cognition

Prenatal cocaine abuse may cause specific neurobehavioral and learning problems, although it is not associated with global cognitive deficits [96], [97]. The largest matched cohort study to date found no significant covariate-controlled associations between cocaine exposure and mental, psychomotor, or behavioral functioning through 3 years of age [98]. Infant neurobehavioral abnormalities like irritability or excitability, sleep difficulties, and state regulation difficulty as well as transient neurologic abnormalities like tremor, hypertonia, and extensor posturing have been reported [99], [100]. Heavy prenatal cocaine use has been linked to poor memory and information processing in infancy [101]. At 3 years of age, increased fussiness, difficult temperament, and behavior problems were described [102]. Language delay has also been described, with foster or adoptive caregiving described as a promising protective factor [103], [104].

Selected References

[91]   Chiriboga C.A.,  Fetal effects. Neurol Clin (1993) 11 : pp 707-728.
[92]   Kain Z.N.,  Mayes L.C.,  Ferris C.A.,  Cocaine-abusing parturients undergoing cesarean section. A cohort study. Anesthesiology (1996) 85 : pp 1028-1035.
[93]   Nordstrom-Klee B.,  Delaney-Black V.,  Covington C.,  Growth from birth onwards of children prenatally exposed to drugs: a literature review. Neurotoxicol Teratol (2002) 24 : pp 481-488.
[94]   Bateman D.A.,  Chiriboga C.A.,  Dose-response effect of cocaine on newborn head circumference. Pediatrics (2000) 106 : pp E33-.
[95]   Vidaeff A.C.,  Mastrobattista J.M.,  In utero cocaine exposure: a thorny mix of science and mythology. Am J Perinatol (2003) 20 : pp 165-172.
[96]   Wasserman G.A.,  Kline J.K.,  Bateman D.A.,  Prenatal cocaine exposure and school-age intelligence. Drug Alcohol Depend (1998) 50 : pp 203-210.
[97]   Singer L.T.,  Minnes S.,  Short E.,  Cognitive outcomes of preschool children with prenatal cocaine exposure. Obstet Gynecol Surv (2005) 60 : pp 23-24.  
[98]   Messinger D.S.,  Bauer C.R.,  Das A.,  The maternal lifestyle study: cognitive, motor, and behavioral outcomes of cocaine-exposed and opiate-exposed infants through three years of age. Pediatrics (2004) 113 : pp 1677-1685.
[99]   Tronick E.Z.,  Frank D.A.,  Cabral H.,  Late dose-response effects of prenatal cocaine exposure on newborn neurobehavioral performance. Pediatrics (1996) 98 : pp 76-83.
[100]   Chiriboga C.A.,  Brust J.C.,  Bateman D.,  Dose-response effect of fetal cocaine exposure on newborn neurologic function. Pediatrics (1999) 103 : pp 79-85.
[101]   Jacobson S.W.,  Jacobson J.L.,  Sokol R.J.,  New evidence for neurobehavioral effects of in utero cocaine exposure. J Pediatr (1996) 129 : pp 581-590.
[102]   Richardson G.A.,  Prenatal cocaine exposure. A longitudinal study of development. Ann NY Acad Sci (1998) 846 : pp 144-152.  
[103]   Delaney-Black V.,  Covington C.,  Templin T.,  Expressive language development of children exposed to cocaine prenatally: literature review and report of a prospective cohort study. J Commun Disord (2000) 33 : pp 463-480.
[104]   Lewis B.A.,  Singer L.T.,  Short E.J.,  Four-year language outcomes of children exposed to cocaine in utero. Neurotoxicol Teratol (2004) 26 : pp 617-627.

Prenatal Marijuana Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Marijuana is a popular recreational drug in many parts of the world. In the United States, 22% of high school students have used marijuana in the past month [76]. Estimates of marijuana use during pregnancy vary between 2% in broad surveys using maternal self-report [77] and 20% to 27% in higher risk populations using urine screens [78], [79]. In the experience of our international adoption clinic, referrals outside North America have not included reports of prenatal marijuana exposure, but the United Nations Office on Drugs and Crime (UNODC) estimates that the annual prevalence of marijuana use is 3.9% in the Russian Federation, 2.4% in Kazakhstan, 0.3% in China, 0.1% in South Korea, and 3.2% in India [35]. In Guatemala, where the rate of drug consumption among young people is on the rise, marijuana consumption by teenagers is at 4% to 6.7% [80].

Mechanism

The principle psychoactive substance in marijuana, delta-9-tetrahydrocannabinol (THC), rapidly crosses the placenta and may remain in the body for 30 days before excretion, thus prolonging potential fetal exposure. THC is also secreted in breast milk. Marijuana smoking produces higher levels of carbon monoxide than tobacco [38], which is hypothesized to be a potential mechanism of action of prenatal marijuana exposure's impact on the developing fetus.

Pregnancy

Marijuana use during pregnancy may have a modest effect on prenatal growth, but the results are inconsistent from study to study and diminish when potential cofounders are controlled [81], [82], [83], [84]. These effects, if any, are not associated with later growth deficiency, although a few studies have suggested an impact on height [81] as well as persistent negative effects on head circumference in the offspring of heavy marijuana users [63]. This review found no consistent link between prenatal marijuana exposure and other adverse pregnancy outcomes or congenital malformations [85].

Behavior and Cognition

Subtle effects of prenatal marijuana exposure on cognition have been observed in two large well-controlled study groups: a predominantly low-risk Ottawa cohort and a higher risk Pittsburgh population. The Ottawa authors argue that although prenatal tobacco exposure is associated with deficits in IQ, impulse control, and other fundamental aspects of performance, prenatal marijuana exposure does not impair IQ or basic visuoperception but influences the application of these skills in problem-solving situations requiring visual integration, analysis, and sustained attention [86]. Marijuana is thus argued to have an impact on higher level executive function and performance in a “top-down” fashion, in contrast to tobacco's “bottom-up” effects [87]. The Pittsburgh study group finds links to inattention and/or impulsivity [88] and subtle deficits in memory and learning [89]. This group also connects prenatal marijuana exposure with academic underachievement, perhaps reflecting less buffering of marijuana's effects by environment in this higher risk population [90].

Selected References

[76]   Grunbaum J.A.,  Kann L.,  Kinchen S.,  Youth risk behavior surveillance—United States, 2003. MMWR Surveill Summ (2004) 53 : pp 1-96.  
[77]   Ebrahim S.H.,  Gfroerer J.,  Pregnancy-related substance use in the United States during 1996–1998. Obstet Gynecol (2003) 101 : pp 374-379.
[78]   Zuckerman B.,  Frank D.A.,  Hingson R.,  Effects of maternal marijuana and cocaine use on fetal growth. N Engl J Med (1989) 320 : pp 762-768.
[79]   MacGregor S.N.,  Sciarra J.C.,  Keith L.,  Prevalence of marijuana use during pregnancy. A pilot study. J Reprod Med (1990) 35 : pp 1147-1149.
[80]   United Nations Office on Drugs and Crime—Guatemala country profile. Available at: http://www.unodc.org/mexico/country_profile_guatemala.html. Accessed June 10, 2005.
[81]   Cornelius M.D.,  Goldschmidt L.,  Day N.L.,  Alcohol, tobacco and marijuana use among pregnant teenagers: 6-year follow-up of offspring growth effects. Neurotoxicol Teratol (2002) 24 : pp 703-710.
[82]   Fried P.A.,  James D.S.,  Watkinson B.,  Growth and pubertal milestones during adolescence in offspring prenatally exposed to cigarettes and marihuana. Neurotoxicol Teratol (2001) 23 : pp 431-436.
[83]   Cornelius M.D.,  Taylor P.M.,  Geva D.,  Prenatal tobacco and marijuana use among adolescents: effects on offspring gestational age, growth, and morphology. Pediatrics (1995) 95 : pp 738-743.
[84]   Day N.L.,  Richardson G.A.,  Geva D.,  Alcohol, marijuana, and tobacco: effects of prenatal exposure on offspring growth and morphology at age six. Alcohol Clin Exp Res (1994) 18 : pp 786-794.
[85]   Shiono P.H.,  Klebanoff M.A.,  Nugent R.P.,  The impact of cocaine and marijuana use on low birth weight and preterm birth: a multicenter study. Am J Obstet Gynecol (1995) 172 : pp 19-27.
[86]   Fried P.A.,  Watkinson B.,  Gray R.,  Differential effects on cognitive functioning in 9- to 12-year olds prenatally exposed to cigarettes and marihuana. Neurotoxicol Teratol (1998) 20 : pp 293-306.
[87]   Fried P.A.,  Adolescents prenatally exposed to marijuana: examination of facets of complex behaviors and comparisons with the influence of in utero cigarettes. J Clin Pharmacol (2002) 42 : pp 97S-102S.
[88]   Goldschmidt L.,  Day N.L.,  Richardson G.A.,  Effects of prenatal marijuana exposure on child behavior problems at age 10. Neurotoxicol Teratol (2000) 22 : pp 325-336.
[89]   Richardson G.A.,  Ryan C.,  Willford J.,  Prenatal alcohol and marijuana exposure: effects on neuropsychological outcomes at 10 years. Neurotoxicol Teratol (2002) 24 : pp 309-320.
[90]   Goldschmidt L.,  Richardson G.A.,  Cornelius M.D.,  Prenatal marijuana and alcohol exposure and academic achievement at age 10. Neurotoxicol Teratol (2004) 26 : pp 521-532.

Prenatal Tobacco Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

Tobacco smoking during pregnancy is one of the most ubiquitous prenatal exposures. The prevalence of smoking during pregnancy in the United States is estimated by maternal self-report at 11% and is higher in teens (18%) and women with less than 12 years of formal education (27%) [44]. Fortunately, these rates are declining [45]. In Russia, the prevalence was 16% of pregnant women in one study and seems to be increasing [46]. In Kazakhstan, it is estimated that one third of the adult population smokes [47]. In China, the prevalence of tobacco use among pregnant women has been estimated at 2% but is increasing [48], and 60% of nonsmoking pregnant women in Guangzhou had husbands who smoked [49]. The World Health Organization reports that in South Korea, 7% of women smoke tobacco; in Guatemala, 17% of women smoke [47]. True exposure rates are likely to be significantly higher, because parental self-report routinely underestimates actual exposure. Unfortunately, adoptee tobacco exposure status is often unknown.

Prenatal tobacco exposure has consistently been associated with poor fetal growth and is the single most important cause of LBW in developed countries [50]. Even environmental smoke exposure has been implicated in LBW, fetal death, and preterm delivery [51]. Myriad perinatal complications and child health problems are linked to fetal and childhood smoke exposure. Finally, a growing body of evidence is implicating smoking during pregnancy in a range of adverse behavioral and cognitive outcomes.

Mechanism

Cigarette smoke contains tar, nicotine, and carbon monoxide. Tar contains numerous substances (lead, cyanide, cadmium, and more) known to be harmful to the fetus [52]. Nicotine readily crosses the placenta and distributes freely to the CNS, having direct and indirect effects on neural development [38]. Intrauterine hypoxia, mediated by carbon monoxide and reduced uterine blood flow, is a major mechanism of the growth impairment linked to prenatal tobacco exposure.

Pregnancy

Tobacco smoking during pregnancy has been associated with placenta previa, placental abruption, premature rupture of membranes, preterm birth, intrauterine growth restriction, and sudden infant death syndrome (SIDS) [53]. A dose-dependent association with cleft lip anomalies has also been noted [54].

Tobacco's impact on fetal growth is perhaps the most consistent and concerning, given the range of potential impacts on health and developmental outcomes. Maternal smoking has an impact on fetal growth symmetrically in a dose-related fashion [55] and causes an estimated 5% reduction in relative weight for every pack of cigarettes smoked per day [56]. Because pregnant women who smoke deliver babies weighing 150 to 250 g less than babies of nonsmokers, tobacco smoking essentially doubles the chance of having a LBW baby [57]. Unfortunately, maternal smoking is also associated with a smaller head circumference at birth [58].

Child Health

It is difficult to differentiate the impact of prenatal smoking and environmental tobacco smoke on childhood health problems, such as respiratory and ear infections, pulmonary function, asthma, and SIDS. Postnatal smoke exposure increases the incidence of middle ear disease, asthma, wheeze, cough, phlegm production, bronchitis, bronchiolitis, pneumonia, and impaired pulmonary function, and it has also been associated with snoring, adenoidal hypertrophy, tonsillitis, and sore throat [59]. Smoking during pregnancy does cause poor lung growth, affecting pulmonary function in infancy and childhood [60], [61], and seems to confer additional risk to postnatal smoke exposures [62].

With respect to tobacco-associated growth impairment, children generally demonstrate “catch-up” with their weight and height percentiles during their first few years of life, with less catch-up noted in head circumference [63], [64]. In fact, a trend toward obesity is noted [65].

Behavior and Cognition

Dose-effect impacts of prenatal tobacco exposure on behavioral and cognitive outcomes of children have been reported, even after controlling for confounders like socioeconomic status, parental education and mental health, prenatal growth, other prenatal exposures (eg, alcohol), and postnatal disadvantages [66].

Infants born to mothers who smoke tobacco display higher rates of impaired neurobehavior, with reduced habituation, lower arousal, hypertonicity and tremors, sucking difficulties, worse autonomic regulation, and altered cries [67]. Nursery evaluations suggest a withdrawal effect as well [68]. The international adoptee population seems less likely to have these dysregulations repaired by consistent and regulating caregiving while residing in a hospital or orphanage.

There is a consistent association described between prenatal exposure to tobacco and attention deficit hyperactivity disorder (ADHD)–like symptoms [67] and externalizing behavior problems [69], [70]. Antisocial traits like disruptive behavior, conduct disorder, and later delinquency have been linked to prenatal tobacco exposure as well [71]. Although these associations are clear, proving the causal relation is challenging, because not all these studies control for confounders, such as prenatal alcohol exposure.
There is a stronger link between prenatal smoking and behavioral outcomes than that described with impaired cognition. Smoking during pregnancy was associated with decreased IQ scores for children by an average of 4 points [72], however, which was prevented by smoking cessation [73]. Other studies are inconsistent but have suggested persistent deficits in auditory-related tasks like verbal memory, language, and auditory processing [74].

It is unclear if these outcomes can be attenuated by nurturing and regulating home environments and to what extent the effects of tobacco interact with other biologic, prenatal, and postnatal risk factors. For internationally adopted children, the potential interaction of these developmental modifiers seems particularly complex, with tobacco-associated risks (eg, LBW and microcephaly, infant neurobehavior, toddler negativity [75], childhood attention and/or impulse control deficits, antisocial behavior) occurring within a trajectory of caregiving moving from early institutional neglect to later nurturing and stimulating family environments.

Selected References

[44]   National Center for Health Statistics Health. United States, 2004, with chartbook on trends in the health of Americans 2004. Hyattsville, MD: National Center for Health Statistics.  
[45]   Hamilton B.E.,  Martin J.A.,  Sutton P.D.,  Births: preliminary data for 2003. Natl Vital Stat Rep (2004) 53 : pp 1-17.
[46]   Grjibovski A.,  Bygren L.O.,  Svartbo B.,  Housing conditions, perceived stress, smoking, and alcohol: determinants of fetal growth in Northwest Russia. Acta Obstet Gynecol Scand (2004) 83 : pp 1159-1166.
[47]   World Health Organization Tobacco or health. A global status report. Available at: http://www.cdc.gov/tobacco/who/. Accessed June 10, 2005.
[48]   Lam S.K.,  To W.K.,  Duthie S.J.,  The effect of smoking during pregnancy on the incidence of low birth weight among Chinese parturients. Aust NZ J Obstet Gynaecol (1992) 32 : pp 125-128.  
[49]   Loke A.Y.,  Lam T.H.,  Pan S.C.,  Exposure to and actions against passive smoking in non-smoking pregnant women in Guangzhou, China. Acta Obstet Gynecol Scand (2000) 79 : pp 947-952.
[50]   Kramer M.S.,  Intrauterine growth and gestational duration determinants. Pediatrics (1987) 80 : pp 502-511.
[51]   Kharrazi M.,  DeLorenze G.N.,  Kaufman F.L.,  Environmental tobacco smoke and pregnancy outcome. Epidemiology (2004) 15 : pp 660-670.
[52]   Lee M.J.,  Marihuana and tobacco use in pregnancy. Obstet Gynecol Clin North Am (1998) 25 : pp 65-83.
[53]   Andres R.L.,  Day M.C.,  Perinatal complications associated with maternal tobacco use. Semin Neonatol (2000) 5 : pp 231-241.
[54]   Chung K.C.,  Kowalski C.P.,  Kim H.M.,  Maternal cigarette smoking during pregnancy and the risk of having a child with cleft lip/palate. Plast Reconstr Surg (2000) 105 : pp 485-491.
[55]   Macmahon B.,  Alpert M.,  Salber E.J.,  Infant weight and parental smoking habits. Am J Epidemiol (1965) 82 : pp 247-261.
[56]   Kramer M.S.,  Olivier M.,  McLean F.H.,  Determinants of fetal growth and body proportionality. Pediatrics (1990) 86 : pp 18-26.
[57]   Samet J.M.,  The 1990 report of the Surgeon General: the health benefits of smoking cessation. Am Rev Respir Dis (1990) 142 : pp 993-994.
[58]   Kallen K.,  Maternal smoking during pregnancy and infant head circumference at birth. Early Hum Dev (2000) 58 : pp 197-204.
[59]   DiFranza J.R.,  Aligne C.A.,  Weitzman M.,  Prenatal and postnatal environmental tobacco smoke exposure and children's health. Pediatrics (2004) 113 : pp 1007-1015.
[60]   Stick S.M.,  Burton P.R.,  Gurrin L.,  Effects of maternal smoking during pregnancy and a family history of asthma on respiratory function in newborn infants. Lancet (1996) 348 : pp 1060-1064.
[61]   Gilliland F.D.,  Berhane K.,  McConnell R.,  Maternal smoking during pregnancy, environmental tobacco smoke exposure and childhood lung function. Thorax (2000) 55 : pp 271-276.
[62]   Jedrychowski W.,  Flak E.,  Maternal smoking during pregnancy and postnatal exposure to environmental tobacco smoke as predisposition factors to acute respiratory infections. Environ Health Perspect (1997) 105 : pp 302-306.
[63]   Fried P.A.,  Watkinson B.,  Gray R.,  Growth from birth to early adolescence in offspring prenatally exposed to cigarettes and marijuana. Neurotoxicol Teratol (1999) 21 : pp 513-525.
[64]   Vik T.,  Jacobsen G.,  Vatten L.,  Pre- and post-natal growth in children of women who smoked in pregnancy. Early Hum Dev (1996) 45 : pp 245-255.
[65]   Wideroe M.,  Vik T.,  Jacobsen G.,  Does maternal smoking during pregnancy cause childhood overweight?. Paediatr Perinat Epidemiol (2003) 17 : pp 171-179.
[66]   Weitzman M.,  Byrd R.S.,  Aligne C.A.,  The effects of tobacco exposure on children's behavioral and cognitive functioning: implications for clinical and public health policy and future research. Neurotoxicol Teratol (2002) 24 : pp 397-406.
[67]   Olds D.,  Tobacco exposure and impaired development: a review of the evidence. MRDD Research Reviews (1997) 3 : pp 257-269.  
[68]   Law K.L.,  Stroud L.R.,  LaGasse L.L.,  Smoking during pregnancy and newborn neurobehavior. Pediatrics (2003) 111 : pp 1318-1323.
[69]   Williams G.M.,  O'Callaghan M.,  Najman J.M.,  Maternal cigarette smoking and child psychiatric morbidity: a longitudinal study. Pediatrics (1998) 102 : pp e11-.
[70]   Fergusson D.M.,  Horwood L.J.,  Lynskey M.T.,  Maternal smoking before and after pregnancy: effects on behavioral outcomes in middle childhood. Pediatrics (1993) 92 : pp 815-822.
[71]   Wakschlag L.S.,  Pickett K.E.,  Cook E., Jr,  Maternal smoking during pregnancy and severe antisocial behavior in offspring: a review. Am J Public Health (2002) 92 : pp 966-974.
[72]   Olds D.L.,  Henderson C.R., Jr,  Tatelbaum R.,  Intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics (1994) 93 : pp 221-227.
[73]   Olds D.L.,  Henderson C.R., Jr,  Tatelbaum R.,  Prevention of intellectual impairment in children of women who smoke cigarettes during pregnancy. Pediatrics (1994) 93 : pp 228-233.
[74]   Fried P.A.,  O'Connell C.M.,  Watkinson B.,  60- and 72-month follow-up of children prenatally exposed to marijuana, cigarettes, and alcohol: cognitive and language assessment. J Dev Behav Pediatr (1992) 13 : pp 383-391.
[75]   Brook J.S.,  Brook D.W.,  Whiteman M.,  The influence of maternal smoking during pregnancy on the toddler's negativity. Arch Pediatr Adolesc Med (2000) 154 : pp 381-385.

Prenatal Opiate Exposure

Excerpted from our review article for health care providers - Prenatal Alcohol and Drug Exposures in Adoption, originally published in Pediatric Clinics of North America - © 2005 Elsevier Inc. All Rights Reserved.

Overview

In the United States, 2.3% of pregnancies in the Maternal Lifestyle Study involved heroin or methadone exposure [34]. In international adoption, the most commonly reported prenatal opiate exposure is heroin. Heroin use has made a resurgence in recent years, particularly in Eastern Europe and the former Soviet Union. The United Nations Office for Drug Control and Crime Prevention reported that the number of known heroin addicts rose by 30% in Russia in 1999 and had quadrupled since 1995, with a current prevalence of heroin abuse at 2.1% [11], [35]. In Kazakhstan, the prevalence of heroin abuse is estimated at 1.3% [35]. Opiate use is also prevalent in the countries of Southeast Asia and parts of China, particularly near areas where opium is grown and in more urban areas. Although there are no official reports from China, unofficial estimates say that there could be up to 12 million total heroin users [36]. Pregnant women who enter drug treatment programs for addiction receive another opiate, methadone, as a substitute for heroin or opium. Because drug treatment programs are on the rise in Russia and China, prenatal exposure to methadone may also occur [36], [37].

Mechanism

Despite the detrimental effects of opiates on the user, including the risk of addiction and exposure to the hazards of intravenous drug use (hepatitis B and C and HIV), opiate exposure to the developing fetus is not considered teratogenic. There is no known congenital malformation associated with prenatal opiate exposure. There have been harmful fetal effects described with heroin and methadone use, however, and infants born to addicted women can suffer withdrawal in the newborn period. Any child referred for international adoption with a maternal history of intravenous drug use should be considered at increased risk for HIV and hepatitis B and C.

Pregnancy

LBW and symmetric intrauterine grown retardation have been reported in the offspring of heroin abusers [38]. Pregnant heroin addicts also have a statistically significant increased risk of preterm delivery. Methadone use seems to have less effect on fetal growth and has not been shown to increase the risk of premature birth. For children born after a pregnancy complicated by opiate use, prenatal growth may be affected by maternal malnutrition and comorbid infections as well as by opiate exposure.

Neonatal Abstinence Syndrome

Neonatal abstinence syndrome (NAS) has been well described in infants born to opiate-dependent mothers. The symptoms of NAS include CNS symptoms (eg, hyperirritability, tremors, convulsions), gastrointestinal distress, respiratory distress, and autonomic disturbances [39]. It has been reported that the infants of methadone-addicted mothers experience more severe symptoms for a longer time, partly because of the longer half-life of this opiate. Treatment of symptomatic infants generally consists of providing children with a tapering schedule of tincture of opium, morphine, or phenobarbital while monitoring clinical symptoms. During the withdrawal period, infants may dramatically influence normal caretaker interactions because they are often resistant to cuddling or soothing and have a decreased ability to respond normally to auditory or visual stimuli. The long-term impact of these early alterations in socialization may be detrimental, particularly in an orphanage setting, where nurturing caretaking may already be less frequent.

The onset of withdrawal symptoms is usually between 48 and 72 hours after birth. It is highly unlikely that a child born overseas is going to be available for adoption at this point; thus, most families adopting internationally do not directly encounter NAS. Clues to NAS may be present in the preadoption record, however, and should alert families and professionals to the possibility of prenatal opiate exposure and other risks associated with injection drug use in birth mothers (HIV and hepatitis B and C).

Behavior and Cognition

In some early studies, concerns about prenatal opiate exposure and poor developmental outcome were described. Reported neurodevelopmental problems included a short attention span, hyperactivity, and sleep disturbances in prenatally exposed children assessed at the age of 12 to 34 months [40]. More recent studies also suggest mild memory and perceptual difficulties in older children, but overall test scores are still within the normal range [41]. In general, it is difficult to differentiate the impact of a poor postnatal environment and prenatal heroin exposure on children's long-term outcome. One study suggests that opiate-exposed children have increased susceptibility to adverse environmental influences compared with nonexposed children [42]. Conversely, a study from Canada suggests that drug-exposed infants adopted out at birth were equivalent to Canadian matched controls in terms of educational achievement and IQ. The adopted children did, however, have increased rates of early adult depression [43].

Selected References

[34]   Lester B.M.,  El Sohly M.,  Wright L.L.,  The Maternal Lifestyle Study: drug use by meconium toxicology and maternal self-report. Pediatrics (2001) 107 : pp 309-317.  
[35]   UNODC Research and Analysis Section United Nations Office on Drugs and Crime—World Drug Report 2004. Available at: http://www.unodc.org/unodc/world_drug_report.html. Accessed June 10, 2005.
[36]   Kulsudjarit K.,  Drug problem in southeast and southwest Asia. Ann NY Acad Sci (2004) 1025 : pp 446-457.  
[37]   Somlai A.M.,  Kelly J.A.,  Benotsch E.,  Characteristics and predictors of HIV risk behaviors among injection-drug-using men and women in St. Petersburg, Russia. AIDS Educ Prev (2002) 14 : pp 295-305.  
[38]   Chiriboga C.A.,  Fetal alcohol and drug effects. Neurologist (2003) 9 : pp 267-279.  
[39]   Finnegan L.P.,  Effects of maternal opiate abuse on the newborn. Fed Proc (1985) 44 : pp 2314-2317.  
[40]   Rosen T.S.,  Johnson H.L.,  Long-term effects of prenatal methadone maintenance. NIDA Res Monogr (1985) 59 : pp 73-83.  
[41]   Lifschitz M.H.,  Wilson G.S.,  Patterns of growth and development in narcotic-exposed children. NIDA Res Monogr (1991) 114 : pp 323-339.  
[42]   Marcus J.,  Hans S.L.,  Jeremy R.J.,  A longitudinal study of offspring born to methadone-maintained women. III. Effects of multiple risk factors on development at 4, 8, and 12 months. Am J Drug Alcohol Abuse (1984) 10 : pp 195-207.  
[43]   Lipman E.L.,  Offord D.R.,  Boyle M.H.,  Follow-up of psychiatric and educational morbidity among adopted children. J Am Acad Child Adolesc Psychiatry (1993) 32 : pp 1007-1012.  

Mandarin for the Adoptive Parent

These key words and phrases for the adoptive parent, with Pinyin pronunciation and audio links, are invaluable for parents traveling to China and in the first weeks home.

Here's a Guide to Pronouncing Mandarin in Romanized Transcription.

Another nice resource is Zhongwen.com, an in-depth guide to Chinese characters and culture, with spiffy clickable character definitions and language genealogy.

Some of our families have found the Simple Language for Adoptive Families booklets/CDs helpful as well.

Nutritional Supplements in Adoption

Background

Internationally adopted children tend to suffer more from micronutrient (vitamin and mineral) deficiencies and lack of attuned, stimulating care than from protein/calorie "macronutrient" malnutrition. Basically, most kids in orphanages get enough protein and calories to grow, but don't because of stress, neglect, and, perhaps, some micronutrient deficiencies. Iron and iodine deficiencies are well documented, as are vitamin A and D deficiencies.

The iron deficiencies (+/- anemia) may worsen during the catchup growth period, as children outstrip their limited iron supplies. This makes getting extra iron important for most internationally adopted children, for as long as they're having catchup growth. The constipation angle is overrated, in my experience, and I'd rather manage the constipation than see your child's brain development impaired by lack of adequate iron.

Vitamin and trace mineral deficiencies may also be implicated in the high rate of initial skin and hair symptoms. Zinc deficiency has been linked to stunting, poor healing, diarrhea, and cognitive delays in developing countries. I also wonder about essential fatty acid levels, and if we should be doing something to support the rapid brain growth we so often see. Many of the placing countries in international adoption also have environmental toxin issues (former Soviet Union, India, and China among others), but fortunately the lead issues we saw in years past are better these days.

In general, the research supports prevention and correction of deficiency, but not so much the trendy "giving more of a good thing" supplements industry for children not at risk for deficiency. A varied diet seems better for children at low risk of deficiency, although we still do recommend 600IU per day of supplemental Vitamin D for kids (Ddrops, Carlson D Drops, etc). 

Vitamins and Minerals 

While vitamins and minerals are best absorbed from healthy food sources, it can be hard to meet the complete nutritional needs of a rapidly growing adopted child (who probably arrived with micronutrient deficiencies) through diet alone, especially if they're picky or have oral-motor delays and sensitivities. For that reason, we recommend as complete a multivitamin and multimineral supplement as you can find, at least for the initial 3-6 months of catchup growth.

The ideal supplement for internationally adopted children would contain plenty (100% RDA) of Vitamin's A and D, iodine, iron, zinc, selenium, and other vitamins and trace minerals. I've not yet found the ideal liquid/powder form, and would love to see suggestions in the comments below if you find a good one. Plenty of options in the chewable format, which can be crushed, but that's extra work, and not so dissolvable.

• Enfamil's Poly-Vi-Sol with iron is a basic multivitamin plus iron liquid supplement that is easy to find, but not as complete as the others.
• Novaferrum makes a multi with iron liquid on Amazon that many families feel taste better than Poly-Vi-Sol.
• As for chewables, there are lots of options out there. Flintstone Complete and other drugstore "complete" multivitamins are easy to find, and taste good. Heck, they even make vitamin pixie sticks these days.
• Remember that iron supplements are a frequent cause of accidental overdose in children - the doses we recommend are quite safe, but please keep the tasty vitamins well out-of-reach.

Essential Fatty Acids 

We also sometimes recommend essential fatty acid supplements like fish oils for new arrivals, as it seems plausible that children from malnourished pregnancies, who weren't breastfed, who were raised on diets poor in healthy omega-fatty-acids, and who are having rapid brain growth may benefit from supplementation in this area.

Essential-fatty-acid (EFA) supplementation has shown decidedly mixed results in ADHD, which is more common in IA children. DHA is a type of omega-3 fatty acid that seems important in early brain and vision development, and is a major structural building block in the brain. EPA is another omega-3 fatty acid that may be more helpful in later issues like attention (ADHD) and mental health. Flaxseed oil contains ALA, some of which is converted to DHA/EPA.

The optimum ratios of DHA and EPA have not been fully worked out, but I like to see more DHA early on for infants and toddlers, and more EPA for older children. Some fish oil products even include some healthy omega-6 and omega-9 fatty acids, for balance. Cod liver oil is a grandma favorite that usually contains natural vitamins A & D - check the labels to make sure you're not overdoing these vitamins, especially if they're in your other supplements and formula. It would be nice to get these healthy fats from diet alone, but sadly, our fish supply isn't safe enough in terms of mercury and PCBs to safely consume enough to meet our target intakes of DHA and EPA.

Some quality fish oils that are independently tested to have adequate potency and very low levels of contaminants include:

• Nordic Naturals - lots of options here, including flavored oils and small chewable gelcaps
• Pharmax's Finest Pure Fish Oil is one of the less fishy oils out there, and their more expensive Frutol is a fish oil that's emulsified with prebiotics and fruit purees. They even make powdered versions, but I hear those are a bit fishier. Available where their probiotics are found.
• Coromega is another pricey emulsion in orange and chocolate pudding flavors for kids that won't tolerate fish oils straight up, cheaper through VitaCost.
• Carlson's Fish Oils are also easy to find, and available in child-friendly formats.
• Costco Kirkland Brand fish oil softgels are inexpensive option for folks that can swallow pills.
• Tips for taking fish oils - you can often get kids used to taking the oil straight, or try them stirred into a "shot" of juice or water, smoothies, or applesauce.
• Flaxseed oil is a vegetarian option for omega-3's. Refrigerate these oils, as they go rancid pretty easily. Ground flaxseed sprinkled on food or in baked goods is another way to go. While the ALA in flaxseed may be important in its own right, it's not very predictably converted to DHA and EPA.

Probiotics 

Another potentially helpful supplement would be probiotics, which are the good bacteria that live in your digestive tract, and that are found in yogurt. In fact, there's about 3 pounds of these bacteria in your body right now - isn't that a lovely thought? The Europeans have been big fans of probiotics for a while, and pediatricians are just starting to catch on. Probiotics seem to be a safe thing to try, especially for children with loose stools or those taking antibiotics. Since children from orphanages (where antibiotics are overused) are likely to have less-healthy "institutional strains" of these gut bacteria, it may be a reasonable thing to supplement for IA children. We've got lots more info and recommended formulations in our "Probiotics and Prebiotics" article.

Welcome Home Guide

What follows is a list of our typical recommendations at the initial post-placement evaluation. That first visit is a doozy, and much of what we say tends to get lost in the shuffle, so we'll recap many of our suggestions below. We like for folks to have a copy in hand when they leave our office, but you'll also find this article online at www.adoptmed.org/welcome, so that you can follow the links.

Medical Issues

If you are lucky enough to live within driving distance of an international adoption specialist, we highly recommend an initial evaluation 1-2 weeks after homecoming with someone experienced in the unique growth, developmental, infectious disease, and parenting issues that our children tend to bring home with them. A full list of international adoption docs can be found here, and we describe our recommended evaluations in this article, as well as in our travel packet.

Immunizations

Unless you've adopted from Korea (shots trusted), Taiwan (also trusted), or Guatemala (we sometimes trust the shots there), we recommend that you either check titers (blood tests to confirm immunity) or start over on shots.

• Hib and Prevnar (pneumococcal) immunizations are rarely performed in the typical sending countries, so we like to just start those at the first visit. Luckily, you only need 2 each of these if started >12mo, and you only need one Hib if given >15mo.

• It's also rare to see an international adoptee with full immunity to measles, mumps, and rubella, so we'll often start MMR over as well, unless MMR immunization is well-documented at >1yo, in which case we could check titers.

• Many IA children have received multiple DTP (diptheria, tetanus, and pertussis) and Polio immunizations, so those are ones we like to check with titers. However, titers done at less than 12-18mo may reflect transferred maternal antibody, so these may need to wait until the followup blood draw when children have been home ~6 months. If we have to wait to check titers, we will usually give 1-2 DTaP boosters, and perhaps one polio (IPV) booster, both to ensure coverage (lots of tetanus and whooping cough around, not so much polio in this hemisphere though) and to give the titers a good chance of proving immunity. Tdap (tetanus booster with added whooping cough protection) is a good choice for 11-18yo adoptees, and is now allowed earlier for those with uncertain immunization history.

• Hepatitis A and Hepatitis B titers are routinely checked at arrival and 6 months later, so we hold off on those shots until we see what the labs say.

• Varicella (chickenpox, 2 shots) can also be checked with titers, but the extra blood and expense may not be worth it given that we wouldn't save that many shots.

• The oral rotavirus vaccine is not an option, as the first dose must be given at 6-12 wks old, with the last dose not given later than 32 wks old.

I tend to be a "lumper" rather than a "splitter" when it comes to shots. There is no reliable evidence that immunizations "overwhelm" the immune system, and I prefer to have fewer shot visits overall than drag things out by only doing 1-2 shots at a time. 

The Vaccine Education Center at Children's Hospital of Philadelphia is my favorite online source for shot information from the generally pro-immunization perspective, as they link to relevant studies and also specifically address a lot of internet vaccine mythology.

Lab Tests 

• A list of typically performed lab tests is listed here. Yes, that's a lot of tests, but it's the only way to know if many frequently encountered problems are present or not.

• This is standard of care for internationally adopted children, although we get a bit creative in our office with children from Guatemala and Taiwan, and don't perform routine labs for children from Korea.

• Our lab on the 1st floor downstairs, or the lab at Children's, is a good place to get these done. If the draw is not going well, you can certainly decide to try again in a few days.

• It's going to require a lot of blood, typically drawn from the elbow or back of the hand, but your child will make more. Try to be calm, supportive, and resolute during the blood draw, model deep belly breaths, and try to put worries about attachment trauma and other anxieties out of mind, since your child will respond to your emotional state.

• If your insurance company balks at coverage (tsk tsk), you and your pediatrician can adapt this insurance letter by Deb Borchers, MD. Refer them to the AAP Red Book, as well.

• In our office, you can expect a call or letter with all of the lab results in about 2-3 weeks, a bit longer if titers are perfomed. We'll call sooner with any concerning results.

• If you haven't heard by 2-3 weeks, please give the nurses a call at 206-598-3030.

• In 6 months or at 18 months-old, whichever comes later, we need to retest for HIV and hepatitis (to rule out exposures just prior to travel). This is a good time to check additional titers or follow up on earlier abnormal results, if we haven't already. We also retest for anemia and iron deficiency at the followup lab draw, since periods of significant catchup growth may cause children to outgrow their already limited iron stores. A TB followup test is also recommended.

Stool Tests

• You'll need to submit a total of 3 stool samples to check for giardia and other parasites (O&P x3 and 1 stool PCR panel or giardia antigen), collected every other day. This is important, regardless of symptoms - 15-20% of our IA children have a parasite like giardia.

• Until you know the results, be scrupulous about handwashing (Purell and other alcohol-based gels are very handy). 

• Don't let your children bathe together until you know the stools are clear - baths are a great way to share giardia.

• The lab will give you a bag with containers and instructions. Scoop a peanut-sized amount of stool into the preservative-containing vials, and on the day that you're dropping off the stools, submit a fresh (<4 hours old) sample in the screw-top plastic container as well.

• Please make sure your samples are labeled with your child's name, and write in the date and time collected.

• It's easiest for all concerned if you drop them off at our lab on the 1st floor, but you can also drop them off at a local lab, ideally a hospital lab that does this a lot. Have them fax us the results, and call us if you don't hear the results in 1 week.

• It's not unusual for this initial evaluation to miss a parasite - we've had several cases of Ascaris (white roundworm) present several months later ... so have a low threshold to retest for parasites if unexplained abdominal symptoms persist.

• If you have a positive result, we'll explain what to do, but please read our article on giardia and other stool parasites for more information.

TB Tests

•  We test for TB exposure with a skin test called a PPD, on arrival and again in 6 months after arrival. This followup test is crucial - we have a lot of kids who do have latent TB who have false-negative tests on arrival, due to stress/malnutrition.

• This skin test will need to be read by a health care professional in 48-72 hours. Our nurses can do this without an appointment. Just drop in during business hours ... bring your poop samples and drop them off at the lab on your way up.

• Children 2-5 years or older can have a blood test for TB (IGRA) instead; this is off-label but commonly done.

• You may hear that this testing is unnecessary in children who received BCG, the TB vaccine performed in many of our placing countries. This is not true. A result of 10mm or greater is a positive result, regardless of BCG status. Our children tend to come from high risk backgrounds as far as TB exposure is concerned.

Followup Visits

• We like to see children for followup visits every 2-3 months after arrival until they've been home 6 months. Our front desk can schedule these for you on the way out.

• We're happy to help you transfer care to a more local pediatrician at any point in the process. Many families stay with us until that 6-months-home visit, when labs, shots, and catchup growth and development are well underway.

Referrals

We see significantly higher rates of visual, hearing, and dental problems in children adopted from orphanages. Prenatal exposures and malnutrition, untreated ear infections, lack of visual stimulation, lack of fluoride and minerals, and poor dental care all contribute. For that reason, we recommend:

• Screening audiology evaluation by a pediatric audiologist in the first few months home. Most of our children are language-delayed on arrival, and audiology is extra important in that scenario. Parents and pediatricians miss significant hearing problems all the time, and ringing a bell next to a child's face is not an adequate test of hearing. We now have an otoacoustic emissions (OAE) gadget in our clinic for easy hearing screens, but it has a really low threshold to refer children to audiologists for further evaluation. If that happens, Children's Audiology (206-987-2000) is a good bet, since they're skilled in behavioral audiology techniques for young children. 

• Screening pediatric opthalmology evaluation in the 1st months home. We see significantly higher rates of strabismus (lazy eye) and other visual problems in IA children. The earlier this is detected, the better. David Epley (206-215-2020) and Werner Cadera (206-528-6000) are two good local pediatric ophthalmologists.

• Early dental visit. Pediatric dentists like to see children as young as 1yo. See this article for more about early dental care. We don't have a current list of favorite dentists - check here, and ask other parents in your area.

• If we recommend an early intervention evaluation, you can access the nearest center by calling WithinReach (WA state) at 1-800-322-2588 for a local referral.

Nutrition and Growth

For infants and small toddlers, we recommend an infant or toddler formula with iron and essential fatty acids for the first 2-3 months home, even past the "typical" wean to whole milk at 1yo. Formula is just more nutritionally dense than milk, juice, or water, and contains essential nutrients for rapidly growing children. When you do transition to whole milk (>1yo) or reduced-fat milk (>2yo if they've had good growth), try to limit it to under 18 ounces per day, since excess cow milk will fill up their bellies at the expense of other nutrition, and can cause anemia.

While vitamins and minerals are best absorbed from healthy food sources, it can be hard to meet the complete nutritional needs of a rapidly growing adopted child (who probably arrived with micronutrient deficiencies) through diet alone, especially if they're picky or have oral-motor delays and sensitivities. For that reason, we also recommend as complete a multivitamin and multimineral supplement as you can find, at least for the initial 3-6 months of catchup growth if not beyond. Other good sources of essential fatty acids for older adoptees include fish oils and flax seed oil. Probiotics are another supplement to consider. Please see our Nutritional Supplements in Adoption article for more information and specific recommendations.

For other nutrition ideas, you could read following resources on our site ...

• Transitional Feeding Difficulties

• Pediatric Nutrition Resources

• Picky Eating

But I have also been fortunate to collaborate with SPOON Foundation on the content for their most excellent AdoptionNutrition.org web resource. That's the place I'd start.

Development

Our website is chock full of articles, links, and book recommendations on the topic of development in internationally adopted children:

• Stimulating Early Development

• Birth-to-Age-5 Timeline of Development

• Developmental Milestones

• Language Development In Internationally Adopted Children

• Books for Speech/Language Delays

• "Birth-to-Three" Early Intervention

• Sensory Integration and Sensory Processing Disorder

• Recommended Development and Learning Books

Therapeutic Parenting

This topic should probably be listed first, as I believe it's the most important intervention for newly adopted children. Kids who've experienced orphanage caregiving, multiple placements, neglect, abuse, and other trauma do have special needs in the area of parenting and attachment. What you'll read in typical parenting books, and what may have worked with "typical" children is not always the best idea for many of our children.

Please see these excellent resources:

• Top Ten Attachment Tips for the First Year of Placement - great stuff, from Deborah Gray

• Bonding Articles from Adoptive Families magazine

• Sleep and Adoption

• Recommended Parenting Books

• Recommended Attachment Books

• The "Difficult" Child