Articles on adoption, foster care, & pediatrics

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Raising Resilient Rascals ... Takes Flight!

We're back for our fourth year! All-new presentations on the most requested topics from previous years! At the Museum of Flight! It's a two-day conference with valuable information for foster/adoptive parents and professionals, presented by experts in the field.

Friday March 5th and Saturday March 6th, 2010


Friday, 9am-4pm:


Welcome - Julian Davies, MD 

Thank you for choosing us today and we hope you have a pleasant flight. Please turn off all electronics during today's flight.

Building Attachment in Infant and Early Childhood Adoptions - Kristie Barber, MSW

Parents traveling with small children may board the plane at this time.

Sleep and Adoption - Julian Davies, MD

The Captain will be turning off the cabin lights. Slides and resources here.

Understanding and Building Childhood Executive Functioning - Gwen Lewis, PhD

This is your Captain speaking, please direct your attention to the front of the cabin.  

Advocating for Your Child's School Needs - Panel Discussion

Please find information about today's flight in the seat packet in front of you. If you have any special needs, please contact a crew-member for assistance.

Saturday, 9am-4pm:


Building Healthy Parent-Child Attachments - Deborah Gray, MSW

Make sure that all baggage you have brought on today's flight is securely stowed. The crew will take you through some safety procedures.

The Importance of Self-Care for Parents - Deborah Gray, MSW

Put on your oxygen mask first before helping others with theirs.  In your in-flight magazine, you will find exercises you can do during the flight.

Emerging Health Issues - Cynthia Kertesz, MD

Upon arrival in customs, travelers should expect a screening for infectious diseases

Parenting the Adopted Adolescent - Paulette Caswell, MSW

We're expecting turbulence, so please keep your seat belt fastened at all times. For your own health and the safety of others, we ask that you observe the no-smoking signs at all times. 

Trans-Racial, Trans-Cultural Adoption Issues - Suzanne Engelberg, PhD

Your flight crew will be passing out entry documents you need to fill out before arrival in this foreign country.

Trans-Racial, Trans-Cultural Adoption - Panel Discussion

Have your passports ready for going through customs.

Details

Cost: $85 for one day; $155 for both days. In-flight lunches will be provided.

Venue: The Museum of Flight
9404 E. Marginal Way S

Seattle, WA  98108

Presented by: Center for Adoption Medicine at the University of Washington, Cascadia Training, Northwest Adoption Exchange, and Nurturing Attachments

CEUs: 7 CEUs per day, 14 total, no additional charge.

For more info or to register: Call 800-298-6515 or 206-441-6892, or visit www.cascadia-training.org

Flyer: Please share this flyer with your friends and colleagues!

Friendships, Social Skills, and Adoption

In our practice we see a unfortunate number of children with friendship problems. It can be one of the more painful issues that arises for our clients. But there is also hope - some good resources are available to help children with social skills difficulties, and there is much that parents can do to help.

What we hear from some of our families is that their children “feel” younger than they are, and gravitate towards younger children, or are more drawn to adults than peers. It can be hard for them to “share” conversation; they may divulge too much personal information, or have difficulty finding interests in common. They may have trouble joining their classmates in play. They often lack a sense of how to be a good host when having friends over (controlling the play, etc). Boys may take things too far, getting too rough or out of control. Girls may be clingy or bossy. Children may not get invited to play-dates or parties, and may lack a good friend.

Childhood friendship problems is a topic that raises strong feelings in many adults. I don’t know anyone that had a perfectly socially successful childhood, and just reading the previous paragraph can bring up memories of loneliness and rejection. When we see our children having such difficulties it’s truly challenging to stay present and clear-minded about what’s going on. But it is important to find a balance of appropriate concern and involvement. Blaming the peer group, assuming things will be better in another school, or otherwise neglecting the issue isn’t helpful; neither is overreacting, anxious hovering in social situations, or trying to bribe or force other children to include your child.

Causes of Friendship Problems in Fostered and Adopted Kids

Social skills problems in the context of foster care and adoption have not been well-researched, but the causes likely lie in a combination of:

  • Lack of early secure attachments leading to more anxious/controlling behaviors in later relationships
  • Rough and unsupervised early interactions with peers
  • Poor social boundaries and judgement, difficulty reading others’ social cues
  • A higher prevalence of impulsivity, ADHD, and externalizing (acting-out) behavioral problems
  • Poor emotional regulation (quick to anger at perceived slights and rejection, etc)
  • Delayed social/emotional development
  • Challenges in social communication and language, making it hard to keep up with the increasingly fast-paced world of their peers

These risks are not shared by all of the adopted children that we see, but they are more common. In the world of social skills interventions, many of the participants are children (boys, usually) with ADHD, acting-out behavioral problems, or autistic spectrum issues. If you substitute "institutional autism", or general lack of appropriate formative social experiences, that's a combination of issues that fits many adopted and fostered children.

Patterns of Peer Problems 

The literature on social skills problems in general suggests that there are a few patterns of peer problems that are most worrisome, and deserving of intervention. Researchers in this field often categorize children by interviewing their peers to come up with how liked (or not) and influential they are. This all sounds a bit harsh, but no one knows better how children are doing socially than their peer group, and the categories that follow aren’t nearly as hurtful as peers can be. In this research context, children are grouped as:

  • Average (well-enough liked and influential)
  • Popular (desired as a friend and influential)
  • Neglected (not influential)
  • Controversial (both liked and disliked, also influential)
  • Rejected (disliked)

Interestingly, “popular” as derived from peer ratings is not the same as just asking who’s popular. The “sociometrically popular” kids are well-liked, good problem-solvers, and trustworthy - a good friend. The “popular kids” are actually seen as dominant and “stuck-up”. Neglected children may be shy or less motivated to join peers; they seem do well academically, and can start over in new groups and shed the “neglected” status. Controversial children are sociable but tend to use more social aggression and hostility; this also may not be a very stable category over time.

Rejected Children 

But the “rejected” group is the most concerning. Children with rejected status in one group tend to be rejected in new groups as well. Without intervention, they are likely to stay rejected over time, and are more likely to have later difficulties with delinquency and adult maladjustment.

Children who are classified by observers as socially withdrawn, plus rejected by peers (thus, not withdrawn by choice), are more likely to have internalizing problems like depression and anxiety. There are two sub-groupings of boys who are “rejected”: rejected plus aggressive (verbal aggression, rule-breaking, etc), and rejected with odd, immature, or “quirky” behaviors. The rejected-aggressive boys are more likely to have academic difficulties and ADHD. Girls have rates of rejection similar to that of boys, but are a lot less likely to be referred to social skills interventions; it may be that rejected boys stand out more and have more externalizing behaviors, while rejected girls have fewer overt problem behaviors.

If this sounds like your child, you should consider learning more about how to help your child with play dates and friendships (since you’ve got the potential to make a big positive impact), and explore local options for social skills groups. Here are a few tips, but the resources that follow will be more helpful:

Help your kids with the basics of social interactions

  • Teach your child learn appropriate social greetings-and-responses, and what degree of physical contact is appropriate for whom (how not to be a "space invader")
  • Encourage and model use of positive statements like praise and agreement
  • Help your kids learn to share a conversation (reciprocity)
  • Practice these skills over and over and over

Help children have frequent, successful play dates

  • For younger/less mature children, having shorter, more structured play dates can help
  • Practice being a good host beforehand, and come up with possible activities that their guest may enjoy
  • When it comes to games, emphasize shared fun over winning/losing, and "good sport" behaviors (make sure to model these as well!)
  • As a parent, stay aware of how things are going without hovering

Support your child in making and keeping friends

  • Make friends with neighbors with children, allow your kids to get to know each other
  • Get to know the parents of your kids potential friends (and enemies!)
  • Make your child's friends feel welcome in your home (greet them warmly, compliment them directly and to their parents when they pick them up)
  • Socialize across generations: make time for extended family, hang out with other entire families together, look for a range of ages for your child to get to know. Such shared family gatherings can provide models of interaction, unhurried time for children to get to know each other, and can keep parents in touch with how their kids are doing socially.

Help your children deal with the pain of rejection

  • Remember that some pain around peer issues is inevitable and a normal part of childhood; try not to overreact or get too caught up in your own issues
  • Don't nurture resentments, add fuel to feuds, or attempt to coerce other children into including your child
  • But do employ "active listening"; acknowledge and reflect back the emotions that you see your child having
  • Once your child feels heard and understood, help your child with self-soothing strategies like deep breathing, muscle relaxation, and active play
  • If bullying at school is involved, insist that it be appropriately addressed; most schools these days have policies, if not effective interventions, in place to deal with bullying
  • If your child falls into the "rejected status" category above, seek further help (see below)

Resources for Families 

One book for parents that I’ve really liked is “Best of Friends, Worst of Enemies: Understanding the Social Lives of Children”. Several of the tips above come from this book, which deftly summarizes the research about how children’s friendships evolve as they mature, and has solid suggestions for each developmental stage. Another book is "It's So Much Work to Be Your Friend: Helping the Child with Learning Disabilities Find Social Success". But having a good book probably isn’t enough for children that fall into the socially rejected category. That’s where social skills groups come in ...

Social Skills Interventions 

Social skills interventions for children do exist that have been well-studied, and show measurable improvements in parent and teacher ratings of social success. One such intervention is Children’s Friendship Training, which was developed at UCLA. Some of their work has specifically looked at children with ADHD, ODD (oppositional-defiant disorder), ASD (autistic spectrum disorders), and even FAS (fetal alcohol syndrome). I like this approach, as they’ve evaluated it with the types of problems my patients have, they have a rigorous approach to testing their program in general, and they include an important parent educational component which helps the gains children make in group generalize to the rest of their lives.

Your child's school may have a social skills group, and in the Seattle area there are several excellent private practice social skills interventions.

Adoption Medicine Handout

This "Medical and Developmental Issues in Adoption" handout (big download) comes from a talk that Dr. Bledsoe and I often give to parent groups, agency staff, and health care providers. More fun in person, but here it is for folks that can't make it to our travelling adoption medicine show.

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 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 ...

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:

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:

Prenatal Alcohol and Drug Exposures

We just had a review article published in Pediatric Clinics of North America, in an issue dedicated to international adoption that's chock full of articles on pre- and post-adoption medical and developmental issues. The abstract of our article is as follows:

Prenatal alcohol and drug exposures are a significant concern in many domestic and international adoptions. This article addresses the following substance exposures for children: alcohol, opiates, tobacco, marijuana, cocaine, and methamphetamines. For each substance, we review the teratogenicity of the exposure and identify the spectrum of neurodevelopmental issues that can present in children exposed to this substance. Diagnosis of the spectrum of fetal alcohol outcomes is also discussed. When possible, we provide country-specific statistics on exposure risks for adopted children.

It's a lengthy, in-depth review that was written for other health care providers, but should also be accessible to parents, caregivers, and other adoption workers. We hope you find it helpful ...

Culture for Kids

There apparently was a day and time when a Korean adoptee in a small homogenous American hamlet could grow up with most everyone pretending they were just as all-American, assimilated, and, well, white as the rest of their adoptive family and town.

Well, it's getting harder and harder to do that these days. The good revolutionaries of Adoption Nation have taken care of that ... But now that the importance of celebrating a child's culture of origin is widely acknowledged, where oh where does one turn to find appropriate bilingual and multicultural items, especially if you don't live in a big multiculti cornucopia like Seattle?

One great adoption-friendly catalog is available from Culture for Kids, who also produce Asia for Kids. The print catalogs are easier to browse than the website, in part because they carry so many bilingual and multicultural books, videos, dolls, and toys - picture dictionaries, translated children's classics from Guess How Much I Love You to Harry Potter (in 8 different languages!), immigrant stories, factbooks, the Language Little bilingual talking dolls, and more ...

Region-specific adoptive family organizations like Families for Russian and Ukrainian Adoption (FRUA) and Families with Children from China (FCC) are also good places to turn to for ideas on raising children from other cultures, meetings of local adoptive families, local language classes, and activities like culture camps.

Our Post-Placement Evaluations

Here's what we hope to accomplish during our hour-long initial appointments with new arrivals, ideally scheduled 1-2 weeks after you get home. We then like to see children roughly every 2 months until they've been home 6 months, to closely follow adjustment, growth, and developmental catchup. Our Welcome Home Guide is a printable summary of what we usually cover at our first visit, but here is a quick overview.

History and Physical Examination:

  • Review any newly acquired medical, educational, or institutional records
  • Interview older children, with interpreter
  • Discuss family concerns and adjustment issues including sleep, feeding, and attachment
  • Assess growth
  • Thorough physical examination
  • Developmental screening
  • Screen hearing and vision - hard to accomplish accurately <4 years old, so ...
  • Likely referral for audiology, opthalmology, and/or dental examinations
  • If delays are greater than expected, Early Intervention referral

Immunizations:

  • Immunizations from Korea (and sometimes Guatemala and Taiwan) are generally trusted
  • From other institutional settings, we usually combine checking titers (blood tests of immunity, not reliable <1yo) and repeating immunizations based on the individual child's age and shot record

Lab Workup:

  • Newborn screening panel (infants only)
  • Complete blood count and ZPPH or ferritin (iron deficiency tests)
  • HIV antibody; Hepatitis B panel; hepatitis C antibody (on arrival and 6 months postplacement)
  • Hepatitis A titers (asymptomatic in young children, but can make their older contacts quite ill)
  • Serologic test for syphilis
  • Thyroid function tests
  • Lead level
  • Stool examination for ova and parasites (three preserved specimens - you'll get vials at the visit to collect and drop off)
  • Stool examination for Giardia antigen (one fresh specimen)
  • Urinalysis if growth deficient, symptomatic, or any history of issues
  • Calcium, phosphorus, and alkaline phosphatase levels, if child has signs of rickets
  • If height deficiency is profound, further lab evaluation for short stature
  • Tuberculin skin or blood test (on arrival and 6 months postplacement - this is crucial)

Preparing Families for International Adoption

Dr. Bledsoe and her husband authored a lovely review article for pediatricians called Preparing Families for International Adoption, which

  • describes the changes in the demographic, medical, and developmental characteristics of internationally adopted children
  • discusses the role of the pediatrician in assessing information made available to families prior to adoption of a child abroad
  • lists conditions commonly seen in children adopted internationally and characterizes their medical, developmental, and social consequences
  • describes the current understanding of the long-term medical, developmental, and emotional outcomes of international adoption
Highly recommended as an overview of international adoption, even if it was written for health care providers ...

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 .