Articles on adoption, foster care, & pediatrics

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Giardia and Other Stool Parasites

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Giardia is the most common parasitic infection in international adoptees, and is also frequently implicated in day-care center diarrhea outbreaks. Studies have shown that it is found in up to 20% of international adoptees, particularly older adoptees from Eastern Europe; in our experience it seems to come in clusters, averaging around 10-20% of our adoptees, and we do see it from China as well.

It's a microscopic flagellated protozoan parasite that is quite infectious (it can take as few as 10 cysts to cause infection), and it is typically spread by drinking contaminated water or fecal-oral transmission. So ... wash hands scrupulously after diaper changes, toilette, and before meals/food prep until giardia is ruled out, and don't have new arrivals share baths with other children at first.

Giardia can be asymptomatic, but symptoms often include loose, watery stools, with a certain foul-smelling greasy, floaty, frothy je ne sais quoi. Flatulence, cramps, bloating, and malaise can also be present. Chronic giardia may be associated with significant weight loss and failure-to-thrive. It also can cause secondary lactase deficiency - interfering with the intestine's ability to digest lactose. Even after successful treatment, loose stools can persist for a month or two. Cutting back on lactose, and supplementation with probiotics (unproven but likely to be safe) may help during this time period.

To diagnose giardia and other intestinal parasites, we recommend submitting 3 stool samples collected 2-3 days apart (preserved promptly after passage in a polyvinyl alcohol kit) for ova and parasite (O&P) examination, and one fresh (<1hr old) sample for Giardia antigen. Some refugee centers treat empirically with albendazole on arrival; we don't, because we prefer to know what we're treating, and because albendazole is ineffective against some of the common parasitic infections in adoptees. If the initial stool tests (remember, collect them 2-3 days apart to increase the chances of finding something) are negative but symptoms consistent with intestinal parasites persist, consider rescreening the stool; initial stool examinations miss infections in some children.

It's also important to do a "test-of-cure" giardia antigen test 1-2 months after treatment to confirm treatment success. If an adoptee tests positive for giardia, we treat, regardless of symptoms. You may not realize until later that the giardia was in fact causing symptoms, including malaise and poor growth; we also do this for the "public health" of the adoptive family.

Folks who don't see a lot of giardia often prescribe flagyl (metronidazole); in our experience this has an unacceptable failure rate. A better choice is Tinidazole, which was recently FDA approved for this indication, but has been in off-label use for some time, even in children <3yo. A convenient one-time 50mg/kg dose (max 2g) is what we use. It's mighty bitter, so mix with espresso syrup or other intensely sweet/flavorful option. See our medication tricks and tips for other ideas. Clark's Pharmacy in Bellevue, WA (425-881-0222) has it available in convenient dosing, is giardia savvy, and does mail order. Alinia is another recently approved medication for giardia that seems to be a reasonable alternative.

We don't automatically test or treat family members if giardia is promptly diagnosed in a new arrival, but if the child has been home awhile, if there are other young children around, or if anyone else is symptomatic then they should get checked as well.

Other stool parasites like Ascaris lumbricoides, Blastocystis hominis, Dientamoeba fragilis, Entamoeba histolytica, Trichuris trichiura, hookworms, and pinworms are also commonly identified in international adoptees. O&P results will often include non-pathogens, or commensals, which are not felt to cause illness and do not require treatment. However, they can be a sign that other parasites are present, and you should make sure that all 3 stool samples are evaluated. Links with good information about these and other, less familiar parasites are listed below.

Other Stool Parasite Resources:

The "Difficult" Child

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Some children, whether we blame temperament, genetics, neurochemistry, prenatal exposures, and/or early childhood experiences, are just plain difficult to parent - intense, needy, easily frustrated, inflexible, inattentive, hyperactive, impulsive, and so on. Or, if you prefer to look on the bright side of life ... spirited, sensitive, perceptive, persistent, and energetic.

If you're nodding your head, read on ... there are effective ways to parent, and perhaps even embrace these traits. The good news is, kids can change - but often we need to change our understanding and approach first. A good place to start would be with one or more of these resources. But bring it up with your doc as well, and consider a specialized parenting class, family counseling, "positive behavior support", or consultation with a developmental/behavioral specialist if you find yourself out of ideas or optimism.

You and your providers may also consider diagnoses such as ADHD, RAD, SPD, ODD, OCD, FASD, and other 3- and 4-letter-words. I'm not label-happy, and agree that it's easy to get lost in this "alphabet soup", but I am a believer in early, accurate diagnosis and treatment when neurologic and mental health disorders are involved. One way to start evaluating concerns about emotions, behavior, attention, and peer difficulties is with a screening tool like the Strengths & Difficulties Questionnaire.

Transforming the Difficult Child, by Howard Glasser and Jennifer Easley, is my favorite book for parenting, and yes, transforming, older children (over 5-6yo) who are difficult to parent, including kids with ADHD. It's also a lovely, positive parenting approach for "easier" kids. If you want a sample, check their website, and I've posted the first 2 chapters on our site as well. Glasser's belief is that normal parenting and teaching methods are designed for the "average child", and that the harder normal methods are applied to difficult children, the worse the situation can get, despite the best of intentions.

I really think this approach has arrived at a simple, but essential truth about parenting ANY child - we need to reverse our typical, inadvertent pattern of paying more attention to misbehavior than to good behavior. Instead of making a big deal over negativity ("why water the weeds?"), make a big fuss over the good stuff. Their Nurtured Heart approach has 3 basic aspects:

  • Super-energizing experiences of success
  • Refusing to energize or accidentally reward negativity
  • While still providing an ideal level of limit-setting and consequences

In Glasser's words, this approach helps therapeutically shift intense children to using their intensity in wonderful ways, and creates a world of first-hand experiences of prosocial behavior: "Here you are being successful ..." This is more than "catching kids being good", it's about having powerful ways to make any moment an opportunity to create success, by finding the good in what IS happening, but also in what ISN'T happening.

Do I love this approach? Yes indeed. You're very likely to find something useful, if not transformative, in this resource. As for his take on medications, I find it to be provocative, but not as much in line with our experience. The "energy" that kids with significant ADHD or FAS have is not always a gift to be cherished, and medications can be invaluable, as part of a comprehensive plan like the Nurtured Heart approach and school accommodations. But I am increasingly recommending a dedicated trial of this approach, plus the therapeutic parenting ideas in Gabor Mate's Scattered, before prescribing medications.

Another book that folks have liked is The Difficult Child: Expanded and Revised Edition by Stanley Turecki, which focuses on nine particularly difficult temperaments: high activity level, distractibility, high intensity, irregularity, negative persistence, low sensory threshold, initial withdrawal, poor adaptability, and negative mood.

A classic in the "insert-euphemism-here" child literature is Raising Your Spirited Child: A Guide for Parents Whose Child Is More Intense, Sensitive, Perceptive, Persistent, Energetic by Mary Sheedy Kurcinka, and her Raising Your Spirited Child Workbook.

"Inflexible, intolerant, and explosive" child? Try The Explosive Child: A New Approach for Understanding and Parenting Easily Frustrated, Chronically Inflexible Children by Ross Greene.

"Challenging" child? See The Challenging Child: Understanding, Raising, and Enjoying the Five "Difficult" Types of Children, by child development guru Stanley Greenspan, for positive parenting insights into "the sensitive child, the self-absorbed child, the defiant child, the inattentive child, and the active/aggressive child".

A website that draws on a number of these books, as well as her own experience parenting and running groups, is Elaine Gibson's The Challenge of Difficult Children. Lots of good, opinionated, from-the-trenches advice to be found here.

My favorite temperament resource is the "Preventive Ounce" website, for children up to 5 years old.  Learn where your child is on scales of Sensitivity, Movement, Reactivity, Frustration Tolerance, Adaptability, Regularity, and Soothability. Then check out a wealth of sound, temperament-specific parenting advice on issues that your child is likely to encounter in the next year. A good temperament site for school-aged children is INSIGHTS, with its online temperament profile.

Finally, a brief note on The Strong-Willed Child. James Dobson and his "embrace-your-inner-bully" theories are emphatically NOT RECOMMENDED, particularly for a child who has already experienced lack of attuned caregiving, violence, or other trauma.  The man beats his pet daschund with a belt on page 3 ... this is the guy you want helping you raise your kids? There are much better Christian parenting books out there that don't involve spanking your children into submission. The research on corporal punishment is overwhelmingly against it, and no amount of "folksy take-charge wisdom" or selective Bible interpretations should convince you to hit your kids.

Home Biofeedback

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True confessions - both Dr Bledsoe and I have something at home called "Journey to Wild Divine". It's a home biofeedback system and "Myst-style" computer game that uses the same biofeedback technology (finger sensors measuring heart rate variability and skin conductance) that our local hospital's adolescent clinic uses to help with headaches, pain syndromes, self-regulation, and chronic stress.

We think it's an engaging and remarkably effective way to learn self-calming, better emotional control, and alertness, and have been recommending it to our older school-age patients with low frustration tolerance, poor self-regulation, ADHD, anxiety, and stress-related issues like headaches and chronic abdominal pain. The sensors measure signs of your nervous system's balance between sympathetic tone (energized, agitated, "fight-or-flight") and parasympathetic tone (calm, relaxed, "rest-and-digest"). Children who've experienced early stress and neglect tend to be chock-full of the former, with precious little of the latter. With practice, you and your kids can learn to calm yourselves much more quickly and effectively.

In the game, you move through an idyllic landscape, performing various tasks using your developing abilities to become calmer or more alert and energized. Levitating and gently lowering rocks, juggling balls, building stairways, and other nifty activities let you hone these skills until they become effortless. This game is begging for a Star Wars version, since it's really all about the Force, and Yoda would be quite at home with the game's collection of gurus ...

It's not cheap ($159), but that's about what one biofeedback clinic session would cost, and you can do it at home whenever you want. It's actually quite a good deal compared to other home biofeedback devices like HeartMath's emWavePC, handheld emWave (excellent portable device) and StressEraser, which I also like. You will need a fairly modern PC or MAC, since it uses a lot of processing and graphics power. You will also need a modicum of tolerance for SNAG's (Sensitive New Age Guys/Gals) and "what's my mantra?" mysticalisms.

I also recommend their followup game, "Wisdom Quest", which uses the same software but has 30 new biofeedback activities, which are easy to access through a new "Guided Activity Mode". You should also download a free update for their first game that enables a similar "Chapter Tour", so that you can revisit favorite activities without having to load saved games.

Another device that we have no experience with whatsoever but is appealing to my inner geek is S.M.A.R.T. Brain Games, a home neurofeedback device that uses actual brain wave sensors (instead of heart and sweat sensors) mounted in a bike helmet to help control Playstation (or Xbox) video games with your mental states. They use the ratio of beta to theta brain waves (a measure of focussed alertness and concentration) to control your speed and progress in off-the-shelf Playstation games, especially racing and jumping games.

The cost of this "brain training system"? $600 for the helmet, neurosensors, processor, and modified Playstation controller. Yowzah! But again, possibly cost-effective if you were planning on paying out-of-pocket for actual neurofeedback clinic sessions. For folks desiring neurofeedback treatment for a specific condition (like ADHD), you'd probably be best off starting, at least, with an experienced neurofeedback provider ... EEG Spectrum is a good place to start for general information and local providers.

The research on neurobiofeedback and ADHD is quite promising, if not yet definitive; see this "Play Attention!" article for a favorable take on this particular system, and The Role of Neurofeedback in the Treatment of ADHD for a review of the latest research. My opinion is that neurofeedback may well be a useful adjunct to other medical or behavioral treatments for ADHD. My hope is that it will be more broadly helpful for my patients with anxiety, dysregulation, PTSD, and perhaps even aspects of attachment difficulties. I'll keep you posted as I learn more ...

 

Language Development In Internationally Adopted Children

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Initial delays in speech and language are almost universal in children adopted from institutions, with expressive language (talking) usually more delayed than nonverbal social interaction skills. Those of us who work with a lot of adopted children develop a rough sense of what are "typical" orphanage delays, but fortunately, we're also seeing some useful research data on what actually is "normal" language development in internationally adopted children.

The thing to remember (and remind your pediatrician, school district, mother-in-law, etc ...) is that this is not just an ESL or bilingual issue. Internationally adopted children from backgrounds of neglect or inadequate stimulation are usually delayed in their native language.  When they are adopted, they have "arrested" development of that 1st language (unless you happen to be fluent in Russian, Mandarin, etc). They then rapidly lose what abilities they had in their native language, before their "new first language" (English) has time to develop. This leaves them in the "language lurch" for awhile, without functional abilities in either their 1st or 2nd languages.  Not an easy place to be ... this may be partly responsible for those "the honeymoon is over!" behavioral issues that many families experience several months post-adoption.

Sharon Glennen, Ph.D., CCC-SLP, has done a lot of the research on this topic, including a longitudinal study of language development in children adopted as infants and toddlers from Eastern Europe. On her website, she reviews the effects of orphanage care on language development, presents some very useful tables of typical language development in international adoptees, as well as pre-adoption language questions for parents to ask.

Other Resources:

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:

Country Profiles in Alcohol Consumption

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The World Health Organization has published the WHO Global Status Report on Alcohol 2004, an exhaustive review of drinking patterns and trends around the world. There's unfortunately very little evidence on rates of fetal alcohol spectrum disorders, but it can be helpful to read the country profiles to learn about recent trends in total alcohol consumption, binge drinking, youth drinking, traditional alcoholic beverages, and unrecorded alcohol consumption.

 

Russian for the Adoptive Parent

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I'm lucky - I've had some fabulous Russian teachers among the kids at Maria's Children, an arts rehabilitation center for orphans in Moscow. They've taught me all the different ways to say "wicked cool" (klass, kroota, preekolna, voa!), "boogers" (kaizafkee), and "butt" (popa), and delight in getting me to say said words in adult company.

Lacking their expert tutelage, what is the preadoptive parent to do? My personal favorite Russian phrasebook is The Rough Guide to Russian Phrasebook and Dictionary , which is a pocket-sized guide to pronunciation, phrases, and culture. I also whipped up a quick Arts Camp Russian Survival Guide for participants in our Maria's Children summer arts camp for Russian orphans. Beware (ostarozhna) - some of the above slang and more is to be found in this document, but then if you're squeamish about these things - hah! - welcome to parenthood ...

Parents have also liked Adopting from Russia, by Teresa Kelleher, an audio CD and handbook by a Russia adoptive parent. She also has RUSH Into English, a CD for Russian children 4-5 years and up to help them learn English.

Travel and Transition in Adoption

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    Travelling half-way around the world with a shell-shocked child who's rarely been outside of the orphanage, let alone the country, is understandably a source of anxiety for most adoptive parents; it ranks high up on the top 10 list of things to obsess about while waiting. We get a number of requests for "sedatives for travel",  and it's not always clear who's going to need them the most ... :)

    General Transition Tips:

    • Start with the Serenity Prayer ("God grant me the serenity to accept the things I cannot change; courage to change the things I can; and wisdom to know the difference ..."), or the succinct, secular, Frank Costanza version: "SERENITY NOWWW!"
    • Routine, routine, routine. The less you can change meal and sleep routines the better. That said, good luck with that while travelling.
    • Ditto for familiar clothes, toys, and lovies. As smelly as they may be (that being a good, reassuring thing to your child), wait a day or two before whipping out the brand new (but prewashed) Osh-Kosh's.
    • Don't read too much into your child's transitional behaviors - we expressly FORBID you from drawing any conclusions about attachment in the first few days. That magical instantaneous bidirectional bonding moment (cue choir and soft heavenly spotlight) is a rarity - it may take days, weeks, or sometimes months for that feeling to happen.
    • Also - if your child doesn't cry, wail, beat their breast, and otherwise bemoan their familiar caregivers for days it does not mean they have attachment disorder. Kids deal with stress, grief, and transition in all different ways - inconsolable crying, withdrawing, poor appetite, listlessness, hyperactivity, or just being a bit more subdued or irritable. You may not realize for weeks that your child actually was grieving at first.
    • In the early "velcro" phase of attachment, your child may want to be held ALL THE TIME. That's OK, that's what all those hip holders and slings are for ... but prepare for it. Seriously, kids are heavy - if you're not used to lifting things you may want to do some working out before you travel. Parenting is hard work physically, as well as emotionally.
    • Or your child may want to be on their own two feet. If you anticipate an active toddler or preschooler, consider bringing a cute animal backback with 4 ft. tail that serves as a safe connection to you. Yes, it's a leash, but being such a cute accessory it's a bit more palatable, no? Not something to overuse, but invaluable in airports and other travel situations.
    • You may want to resist sightseeing in crowded noisy places. Nesting up in your hotel room may be more useful for the overwhelmed new adoptee.
    • As long as you're nesting in the hotel, baby/toddler-proof outlets, exposed cords, and drawers with painter's tape (via the eminently practical ParentHacks).
    • Frantic cuddling and consoling and jiggling and swaddling and eye-gazing and shushing and bottle-offering can be more overstimulating than helpful for many adoptees. Kids pick up on your cues - the more serene you can be in the face of inconsolable crying and glaring co-travellers, the more you'll help your child settle. Remember to breathe.  Sometimes there's just nothing you can do - don't take it personally.
    • If your child seems overwhelmed by what you're doing, try less: try fewer sensory inputs, be a bit less intrusive, and see if their own self-soothing skills kick in.
    • The flipside is also true - if something happens that seems upsetting (head bonk, scary event, etc) but your child is not seeking consolation, give it to them anyway. They may not know to ask yet.
    • Make sure you learn some survival phrases and basic parentese in your child's native language before you travel.
    • For older children, use pictorial schedules, picture books, hand puppets, street mimes if available, or whatever else it takes to help them anticipate each day's events (see our Make-a-Schedule Software blurb).
    • It's hard to bring home too much memorabilia - orphanage and caregiver photos, artifacts, local dress and toys ... go nuts with that. It'll come in handy now and later ...

    Trains, Planes, and Automobiles

    • In all likelihood, drugging your child with benadryl will probably not help much. If you're considering this option, make sure you try it out in the hotel first, since 1 in 5 kids have a memorable "paradoxical" reaction to benadryl where they get loopy and agitated.
    • Aromatherapy? Sleepytime teas? Some families swear by these, not a lot of evidence either way. In general I don't give a lot of teas to infants - it leaves less room for more nutritious fluids, like formula.
    • Feeding onboard - bring lots of fun, tasty snacks ... and dole them out one at a time.
    • For older kids, bring a variety of activities and toys aboard, and also bring them out one-by-one. Distraction works, even better than drugs.
    • Use a carryon as a footrest for your child, so their legs don't go numb on long flights. That may help with seatback-kicking! Don't be shy about moving around the cabin, as well.
    • Ears and pressure changes - this seems more fearsome than it usually is. Here's where the serenity prayer comes in - there's nothing you can do about this. Even sucking/eating on ascent and descent is overrated; crying may help just as much. The only situation where a popped eardrum may happen is with an acute ear infection - but the holes tend to be pinpoint, they relieve the ear pain, and typically heal nicely.
    • Kids can get motion sickness too, but it's rare in under 2-year-olds.  Benadryl (see above, though), ginger (dosing for adults and children >12yo is 1,000 mg/day, taken one hour before traveling, or 250 mg 4x/day; dose is reduced by half for children 6-12yo, and by three quarters for children 3-6yo), or chamomile may help.
    • Bring a change of clothes for YOU aboard as well. Bodily fluids may be involved. Speaking of which, bring lots of alcohol-based hand gel for you and yours. Use it frequently during your travels. You don't need to gown-and-glove for diaper changes, but puhhhlease "wash" your hands carefully after doing so. You'll be very happy you did when your child tests positive for giardia.
    And finally - savor this experience, soak up your child's native culture, and take good care of each other. It probably won't be as rough as you think. If it is, have a "tagteam" signal (Serenity Now!) with your travelling partners for the moments when you'll need your own time out. Take those moments, practice good self-care, and sleep when you can - you'll need it.

    Happy travels,
    Julian and Julie

    Additional 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.