"Birth-to-Three" Early Intervention

If you have a concern about your infant or toddler's development, discuss it with your pediatrician, but also consider an Early Intervention evaluation. Your pediatrician may be able to reassure you that your child is developing typically, but if you're not convinced, this program can serve as a "second opinion", and provide developmental services if your child is indeed delayed. It's nice to be formally referred by your pediatrician, but you can self-refer if need be.

Early Intervention centers have family resource coordinators, physical therapists, occupational therapists, and speech and feeding therapists, all with expertise in early childhood development. They may draw upon your insurance, but the rest of the costs are typically covered by the state. For families in Washington State, you can get a referral to a nearby center from WithinReach, at 1-800-322-2588. I also recommend "A Family's Guide to Early Intervention in Washington State". Oregon residents can use this brochure.

For international adoptees, who often have multiple prenatal and postnatal risks, and delays from neglect and institutionalization, the decision to involve your child in early intervention is a bit trickier. The major intervention in your child's life is adoption itself, and you should expect rapid developmental catchup by virtue of your love, attention, stimulation, and nutrition. However, if your child is more delayed than other orphanage-raised children on arrival, has other known developmental risks like prenatal alcohol/drug exposures and prematurity, or is not making rapid catchup progress in the first 1-2 months home, then early intervention is recommended. Even if your child is "typically delayed", many parents don't feel comfortable doing this on their own, and want help assessing development, tracking progress, and with practical tools and guidance for their home interventions, as well as direct therapy services.

Puget Sound Parenting Calendar

This exhaustive and up-to-date Puget Sound Parenting Calendar is published by PSAS - their description follows ...

"A nonprofit educational organization founded in 1975, the Puget Sound Adlerian Society (PSAS) offers information, referrals, workshops, lectures, courses, and other resources and support to parents, parent educators, teachers, counselors, social workers, workplace managers, and other people who are inter­ested in mutually respectful, cooperative relationships—community-building—in families, classrooms, workplaces, and everywhere else. Parent education has been our primary focus. We help parents choose attitudes and actions of respect for their children and themselves—attitudes and actions that strengthen a child’s sense of belonging and strengthen the family. Kids don’t come with instructions: it is all too easy to put children, family relations, and marriages at risk when parents just need some new skills and attitudes.

... Choosing “kind and firm” attitudes and actions (kind = respecting the child, and firm = respecting the situation) is essential for parents, teachers, and others who live or work with children.

... Democratic parents are still authoritative and set clear limits in matters of safety, health, and morality.  For other matters, we work out guidelines, choices, and solutions, often together in family meetings.  We chose to encourage children and help them learn to solve problems rather than to order, reward, and punish them as in the authoritarian model.  Barbara Coloroso, author of Kids Are Worth It!, calls this “giving your child the gift of inner discipline,” or helping our children learn how to think, not what to think."

Prenatal Drug Exposures

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

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.

Anemia and Iron Deficiency

We'll update this soon with our take on this VERY common issue in international adoption, but for now, here are some good resources on the topic. A quick reminder: liquid iron supplements can cause temporary staining of the teeth - squirt towards the back of the mouth, and have the child drink some OJ afterwards (vitamin C boosts iron absorption).

Anemia and Iron Deficiency

• Anemia - KidsHealth
• Excellent tips on boosting iron intake from DrGreene

Thalassemias

• "What Is Thalassemia?" - Cooley's Anemia Foundation
• Comprehensive Thalassemia Resource from Children's Hospital in Oakland
• Thalassemias - KidsHealth

Hepatitis B

Quick bottom line - we're seeing fewer and fewer Hepatitis B "surprises" in our clinic, although they still rarely happen. The future for children with Hep B is felt to be bright, with promising ways to manage, if not cure, what is generally a chronic infection in children who acquire this at birth.

Our detailed thoughts coming soon ... in the meantime, some good links to get you started:

Hepatitis B Resources:

Transitional Feeding Difficulties

While many international adoptees have no trouble eating & drinking & growing & gaining, some children from orphanage or neglectful backgrounds have initial trouble with age-appropriate foods. Feeding difficulties are some of the hardest to cope with emotionally, since feeding your likely malnourished child gets at the core of parenting.

The trouble you may have likely has little to do with you or your feeding skills. If you just received the child, they may be scared, stressed, grieving, and just not that hungry. Also, their past experiences with feeding have a large influence on your early mealtime issues.  Prior feeding practices may have including bottle-propping with wide-open nipples (chug-chug-chug passive feeding with little active sucking involved), uncomfortably hot or cold foods, sweeter formulas thickened with cereal, and limited or no introduction of solid foods. These practices can lead to markedly immature oral-motor-feeding skills, aversions to feeding, fear of novel food experiences, and taste/temperature sensitivities. Some kids have the feeding ability, but just want things the familiar way, so if you get the opportunity, do ask their caregivers what that way is.

The immediate focus in children with marked feeding difficulties or refusal should be on keeping up hydration; that said, it is VERY unusual for a child to refuse himself into severe dehydration. Solid foods can wait until you get home. Formula is still the drink of choice, as your child will need the calories. If your child is refusing the bottle, you might try some of the following tweaks:

• try the familiar local stuff, in a local bottle (straight bottle, big open nipple)
  
• experiment with various formula brands (see Choosing a Formula)
  
• add in 1 tsp of sugar per 6-8oz bottle if the local stuff is sweeter (but wean this over the next 1-2 weeks)
• try a slightly more dilute formula (not for more than a day or so)
  
• mix in some rice cereal to the formula (I don't love this practice but they're often used to it)
• play with temperature (from cooler to warmer than you'd think, but test it on your wrist first)
• and definitely try different nipple styles or open up the nipple you do have
  

The massive transition you're going through together may also contribute to your child's energy level and interactivity. Keeping as much routine as possible around meals/snacks/sleep, nesting in your hotel room, and avoiding crowded and overwhelming spaces can help.

The solid foods can happen at their pace ... oral defensiveness is certainly something that we see. What these children need is a gradual, persistent, and consistent approach to introducing textures (simple to more complex) and tastes (bland to more stimulating). The same approach should be used for children with difficulty making transitions from one feeding stage to the next (pureed to junior textures, bottle to cup). If they don't progress in the next few weeks then visiting a feeding/speech/oral-motor therapist on return would be a good idea.

Things that also may contribute - any painful-looking mouth sores or teeth (emerging or decayed)? Any painful reflux behaviors (sour face, arching back)? Any cough/sputter with eating? Vomiting/diarrhea, or bad constipation? Other concerning signs of illness? If so, let us or your doctor know.

Outcomes of Prematurity

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:

• Outcomes of Prematurity (1.8 MB - big download) - a textbook chapter that nicely reviews the developmental outcomes of prematurity, with good statistics and tables
• Developmental Outcomes of Premature, Low Birth Weight, and Medically Fragile Infants - a good review article from Medscape (free registration required)
• Prematurity.org - Preemie Parent Information and Support

Head Circumference Issues

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.

Evaluating Growth in Adoptees

Almost every medical report has at least one set of growth measurements. It is always advisable, and usually possible, to request an updated series of measurements on a newly referred child. Growth is an objective measure of the child’s nutritional and medical status and may be the most reliable information available prior to adoption. However, weight errors can occur from measuring children in winter clothes versus unclothed, and height and head circumference seem especially susceptible to erratic measurements, due to technique or old stretched-out measuring tapes. Growth charts specific to children from certain countries are available, but these measurements are usually plotted on the revised United States growth charts (see below). It is generally the pattern of growth over time, rather than growth indices at a specific age, that is of greatest value.

Unfortunately, an orphanage is far from the ideal environment for childhood growth. Many children exhibit evidence of malnutrition and psychosocial dwarfism. Most are stunted in linear growth (height). Generally, we expect children to lose about 1 month of linear growth for every 3 months in institutional care. Although most children who are malnourished and poorly stimulated maintain brain growth, over time even head circumference may not be spared. Microcephaly is a red flag. Children who have microcephaly that is extreme or present from early in infancy may have medical diagnoses other than malnutrition or deprivation, such as fetal alcohol syndrome, a genetic disorder, or a perinatal brain injury. Although most orphans exhibit dramatic catch-up growth after adoption, even in head circumference, it is not yet known whether this recovery of brain mass means that the brain will function normally.

We recommend that you download the revised CDC growth charts for tracking weight, height, and head circumference along with us. These are what we use for children from Eastern Europe, as well as most children from other regions. While there are some ethnic differences in growth, many of the country-specific growth charts are problematic – for example, the China growth charts date from the early 1960s, and may be “normalizing” malnutrition.

For children from China or Korea with borderline growth it may be reasonable, however, to give them the benefit of the doubt. Growth charts for these populations and for premature infants can be found in our Growth Charts section.

If percentiles are confusing at first, think of it this way - a child at the 10th percentile for height is 10th in line of a hundred kids of the same age and gender lined up by height. 50th in line, or 50th percentile, is average. The broad definition of "normal" is from the 3rd percentile to the 97th percentile, or "within 2 standard deviations of the mean", for the engineers out there. But again, trends of growth over time are usually more meaningful than the percentile at any given moment .