A: There is no best country to adopt from, including the U.S. Adoption whether it is domestic or inter-country is really a personal process, a journey, if you will, for each person or family. Some people look at their family history and find a richness of connections in countries abroad from the family tree; others have an interest in particular cultures and are drawn to political issues in a country, (i.e. an infant girl abandonment in China). You can create a family from any country. This is a time for pursuing your dreams and educating yourselves. You can make it happen!
|Q: When you review a referral
of a child for adoption, can you diagnose mental retardation?
A: Mental retardation is very difficult to diagnose in an infant, toddler, or young child for that matter, regardless of whether the child is adopted. Unless a child has fairly obvious neurologic manifestations with severe motor delays, the child's intellect/cognitive profile will not be clearly apparent until well into the toddler period when language can be assessed. Receptive and expressive language are the manifestations of a child's intellect. When I review a referral of a child from an orphanage, I have so little information about the child. I may have the ability to observe some rudimentary motor function, but rarely do I experience language. Most children living in orphanages are understimulated and malnourished and in an environment bereft of human interaction; there is little language development whether receptive or expressive. When I look at tapes I rarely hear a child vocalizing. Does this mean that the child is retarded? No, it means that I have little to rely on for an assessment of cognition. I can do a rudimentary evaluation of gross and fine motor skills and I can infer social development if the child has an interaction with an adult caretaker in the video. Eye contact is a focus for me when I review a video and photographs in a referral. This connection can be very powerful even if I see it for a fleeting moment. When the child appears to be opening his/her mouth expressively, I see this as a form of communication. If there appears to be a movement of the eyes in the direction of the adult who holds the baby, I am encouraged by that connection. Finally, I can comment on developmental delays in a limited fashion as I have outlined above, but it would be rare that I could diagnose mental retardation from a referral. I would however be able to comment on the potential for mental retardation if the head circumference was marginal or in the microcephalic domain.
|Q: Can you diagnose Reactive
Attachment Disorder from reviewing a video and a medical?
A: Reactive attachment disorder is a rare disorder. The criteria for diagnosing RAD found in the Diagnostic and Statistical Manual IV version is a work in progress. There are few tried and true management strategies presently. There are many fringe treatments for attachment disorder, which may or may not work in helping families deal with children with attachment problems. Children with attachment disorder require individualized therapeutic programs to help them with their bonding issues. Attachment is a complex topic. Normal, healthy, non-institutionalized babies learn to attach over time. Parents attach to children over time. It is a process; no one is born attached. Attachment evolves. The video that is part of some referrals is a snippet of a child's life. Most videos last only a few minutes. The child may be hungry, tired, sick, depressed and withdrawn. To expect to diagnose attachment disorder from a video would be an unrealistic expectation. Some families look at the videos and experience a vacant, far off expression, irritable cry, lack of emotional affect, stereotypies (rocking, head banging) or poor eye contact with the stranger who holds them in the video and inquire whether the child has attachment disorder. I think that this is an unrealistic expectation of the process of the review. If I see difficulty with social interaction in a video of an older child, I may certainly ask the family to gather more information about this child. If the child is rocking throughout the video, I may ask the family to get another video so that we can see that the child does have the capacity for social interaction. The video and the referral information are rudimentary tools.
|Q: Is head banging and
rocking a symptom of reactive attachment disorder?
A: Head banging and rocking are part of the family of stereotypies, which are repetitive behaviors. Stereotypies are common in normal healthy children and reflect periods of tension and anxiety. Institutionalized children may chronically exhibit these behaviors due to boredom, lack of stimulation, anger, and a need to provide their own form of rhythmic stimulation. The brain requires a certain amount of external stimulation, which should have some basic rhythm and in a sense provide the central nervous system with a sense of existence. In essence, if a person rocks then that rhythm gives feedback to the brain that there is life and activity. Head banging, also reflects an inner silence, which is not easily tolerated by the nervous system. The brain requires that there be input for the cells to grow and organize themselves. With proper stimulation, these stereotypies disappear naturally. There is no need to extinguish them with punishment. Parents need to trust that as a child adjusts to their new family and home environment, that these repetitive activities will dissipate. The child needs to be protected from hurting himself when there is very violent head banging. Providing an area with soft mats can serve to lessen the inherent dangers of head banging.
|Q: How do you diagnose
FAS? FAE? Is FAS more common in children from Eastern Europe and Russia
than in other countries?
A: I have a lengthy article, Alcohol Related Disorders in the Medical Resources/Fetal Alcohol Syndrome section this web site. Also, there is a bibliography with this article for the reader to do more extensive reading on this topic. This article is actually a chapter from the book recently published by the Child Welfare League Association, Adoption and Prenatal Alcohol and Drug Exposure, and edited by Barth, Brodzinsky and Freundich. The diagnosis of FAS/FAE is not easy, but hopefully this article can shed some light on the condition.
|Q: What does a sweaty head
in a child adopted from China mean?
A: Sweaty heads are commonly associated with Rickets, which is a vitamin D and calcium deficiency. Though this has been a well-recognized symptom of rickets for centuries, there is no adequate scientific explanation for the sweaty head of a child with rickets. When the rickets resolves, the sweaty head remains. It is not a disease and need not be treated.
|Q: If my child has a positive
skin test for Tuberculosis (positive PPD), does this mean the child has
A: There is a skin test that is done by your doctor to assess whether you child has been exposed to actual Tuberculosis. This skin test is called the Mantoux test or the PPD (Purified Protein Derivative). It is not a multiple puncture test; it is a test wherein 0.1 cc of liquid containing some inactivated tuberculosis bacteria that cannot cause the patient any harm, is injected under the skin. There is a bubble which you can see forming as the doctor pushes the liquid from the needle into the skin. This bubble disappears and then the skin is observed for the development of a bump over the next 48-72 hours. The skin must be observed by a healthcare professional, i.e. doctor, nurse, nurse practitioner, physician assistant, between 48 and 72 hours. This test should not be read by a parent unless the parent is a healthcare professional who is trained to read TB skin tests. If the skin is raised and properly measured with a metric ruler and the "induration" (bump) is greater than or equal to 10 mm, then the person is considered to have been exposed to Tuberculosis. This is called "Latent Tuberculosis Infection" (LTBI). At that point, a chest x-ray is ordered to see if the patient actually has any abnormal findings in the lungs. If the chest film is normal, then the person does not have Tuberculosis disease. The patient has been exposed to TB. It is recommended that the patient receive preventive medication called Isoniazid (INH) for 9 months. Because those who have a positive skin test are at risk for the development of Tuberculosis disease, they need to be treated with this medication to eradicate the Tuberculosis bacteria that may be hiding in white cells called macrophages somewhere in the body. The medication is easily tolerated in children. It is taken once a day and most children do not have to have liver enzymes evaluated while the medication is being administered over the 9 months. If for some reason the child has a known elevation of liver enzymes or an underlying liver condition, then the child should have the liver enzymes checked periodically. Please note that many lay people as well as healthcare professionals believe that TB skin tests should not be administered to children with a past history of Bacille-Calmette-Guerin vaccine (BCG) which is a vaccine given in many countries outside of the U.S. to prevent Tuberculosis. The vaccine does not prevent Tuberculosis in the lungs of children. The BCG vaccine may cause some minor induration in the skin when the skin test is administered, but because TB is clearly a health issue in most of the countries where children are adopted from, we consider any induration greater than or equal to 10 mm indicative of exposure and the American Academy of Pediatric Redbook 2000 recommends 9 months of preventive INH in this context.
For more information about tuberculosis, read Tuberculosis in the Medical Resources/Infectious Diseases and Parasites section of this website.
|Q: If a lot of kids from
orphanages have parasites, then why not just treat them with anti-parasite
medications presumptively when they first arrive in the U.S.?
A: 20% of children adopted from abroad have parasitic infections which means 80% of the children do not have parasitic infections. It seems obvious that it would be ill-advised to treat 80% of the children for a disease that they did not have. If a child has a parasitic infection, it can be diagnosed even if it is missed initially. Presumptive treatment for parasites precludes the elucidation of the actual medical diagnosis. It is never prudent to treat someone for a disease that is assumed rather than clearly demonstrated. Medications have side effects and treatment may also mask other diseases.
|This page last updated November 13, 2002 11:28 PM EST|