Articles on adoption, foster care, & pediatrics

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Resilient Rascals Grow Up

Save the date! On Friday, March 6, 2009 (please note date change), at the Shoreline Center, we'll be hosting our third "Raising Resilient Rascals" adoption and foster care conference. We're still working on the precise lineup, but the general focus will be on older child and adolescent issues. Possible talks:

  • When to worry about mental health issues versus "normal" teen behaviors
  • "Parenting Pitfalls" vignettes and open mic, with booby prize for best worst parenting moment
  • How adopted adolescents construct their identity, and how to help
  • Living with an older child with executive function difficulties - practical tips
  • A mother and adopted daughter discuss transracial adoption
  • Adult adoptee panel

Details to follow ... stay tuned! And feel free to just go ahead and register.

Help for the Holidays - Deborah Gray

Deborah Gray, MSW, MPA, author of Attaching in Adoption and Nurturing Adoptions and therapist extraordinaire, has shared a nice set of handouts for the holidays with us, reproduced here with kind permission. They're written for parents raising kids affected by histories of neglect, trauma, and anxiety. She has two slightly different versions, one for parenting kids with trauma histories, and one for children with anxiety. Good stuff to think about as a particularly stressful holiday season is upon us. I hope you find something helpful here, and we at the Center for Adoption Medicine send you happy and as-relaxing-as-they-can-be holiday wishes.

Potty Training - Get Ready, Get Set, Go!

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

 Get Ready

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

Get Set

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

Go

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

Stop

  • If your child has temper tantrums or sheds tears over potty training, or if you find yourself getting angry, then stop training. Review your training plan and then try again, using a slightly different approach if necessary, in a month or two.
This article is an excerpt from The No-Cry Potty Training Solution: Gentle Ways to Help Your Child Say Good-Bye to Diapers by Elizabeth Pantley (McGraw-Hill, 2006). Used with permission.

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:

"Transforming the Difficult Child"

The following is an excerpt from Transforming the Difficult Child, by Howard Glasser and Jennifer Easley; reprinted with permission. I've posted this as a teaser, and because I really like the ideas in Chapter 2 (below) ... the actual techniques come later in the book.

As I've written elsewhere, this is my favorite book for parenting, and yes, transforming, children who are difficult to parent - intense, needy, having difficulty regulating their energy and behavior, "ADHD-ish", with negative self-image, acting out to get attention, and so on. Sound like any older adoptees you know and love? It's also a fabulous positive parenting approach for "easier" kids. 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.

Read More

Sleep and Adoption

"People who say they sleep like a baby usually don't have one." - Leo J. Burke

The Problem ...

Dr. Sears: "Thou shalt cosleep, unless you don't really want that special bond we like to call attachment."

Dr. Ferber: "Thou shalt let them cry, unless you don't really want that thing we like to call a good night's sleep."

Dr. Dobson: "Good night's sleep? Have you considered a good night's spanking?"

Dr. Weissbluth: "If you don't sleep train them now, there's a 92% chance they'll be huffing paint behind the Quik-E-Mart by age 16."

That neighbor whose kid would have slept well even if raised by wolves: "Really? Our precious Tyler slept through the night since he was 2 months old ..."

Attachment therapist: "Never let their feet touch the ground ..."

Movement therapist: "But if she doesn't learn to crawl soon, her left brain will never talk to her right brain!"

Mother-in-law: "You're spoiling that child - she needs to cry it out."

APmom on your 4am chat group: "Cherish these magical middle-of-the-night bonding opportunities - not ever sleeping is a glorious gift!"

Dad: "Honey, the baby's crying ..."

Mom: "Honey, why don't you go cherish this particular magical moment ..."

Too many experts, not enough left brains talking to right brains. Too much opinion, not enough research. Too much crying, not enough sleeping. What's an adoptive parent to do? Read on, my sleepless friend, as we tiptoe through the too-often tendentious topic of SLEEP.

What is this thing you call sleep?

So much depends on adequate, restful sleep. We've got important work to do at night, from physical growth (80% of growth hormone is secreted while we sleep), to mental growth (integrating themes and memories of the day), to recharging cellular batteries, and other functions that we just haven't understood yet.

We all sleep in cycles, but children have unique sleep patterns. As infants, they have many sleep periods through a day, and a greater proportion of active (REM) sleep - about 50%, with the other half being "quiet sleep", a precursor to more developed Stages 1-4 of non-REM sleep. By 3-4 months, melatonin turns on, and infants organize their sleep into more of a day/night pattern. This is why it's silly to expect children to sleep through the night before 4 months.

By 6 months, the full cycle of non-REM and REM sleep is happening, but infants can get into Stages 3 and 4 (deep sleep) much faster than adults, and still spend more time in REM sleep. Deep non-REM sleep is important, since it's the most restorative phase of sleep, and is also when growth hormone is released. REM sleep seems to process and organize new memories and events, and is crucial to mental wellbeing.

By 3-4 years of age, children's sleep finally resembles adult sleep in quality, with 4-6 sleep cycles. The first half of the night has more non-REM sleep, with more REM sleep in the second half.

cycles2.jpg

Image from SleepForKids.org, an excellent resource from the National Sleep Foundation

You'd think with something this important we'd be born good at it ... but we're not. Not even close. Just like walking and talking, the ability to fall asleep and stay asleep is something that is learned at developmentally appropriate times. How and when to help your child learn is the hard part.

Why bother? Sleep deprivation is being increasingly linked to emotional and behavioral problems, poor concentration, impulsivity, ADHD misdiagnoses, impaired learning, reduced physical performance, poor growth, headaches and bellyaches, and decreased immune function, not to mention family stress.

Sleeping through the night?

As for "sleeping through the night" ... nobody does. We all wake up to some degree several times a night, often when our sleep cycles from deep to lighter sleep. Arousals after REM sleep also occur, and tend to leave you more awake and alert. You may not be up long enough to remember it (that takes 3-5 minutes), but you do wake up, even without the "help" of your less sleep-skilled child. Our goal, thus, is not to "sleep through the night", but to promote healthy sleep associations and self-soothing skills so that your kids will fall back asleep when they wake 5 times every night.

How common are night wakings that you'll notice? By 4-6 months, babies are physiologically capable of sleeping through without feeding, but according to the 2004 Sleep in America poll, 70% of these infants still wake up and need help or attention, with 47% of toddlers, 36% of preschoolers, and 14% of school-age children also with notable wakenings. The numbers seem considerably higher in new adoptees, for reasons we'll address below. As far as other sleep difficulties go, the same poll revealed that 69% of all children experience one or more sleep problems, including stalling, bedtime resistance, and daytime sleepiness.

How much sleep does my child need?

The following table is based on sleep surveys and recommendations from the National Sleep Foundation:

Sleep Needs.jpg

While each child is unique, it's rare for kids to need much less sleep than these recommendations. However, there does seem to be individual variation in amount of needed sleep, as well as "night owl" vs "early bird" variation; these patterns are present from early childhood and are fairly stable. As for the naps, children who nap are happier, have better attention spans, may learn better, and arrive at bedtime without being overly tired. Good naps lead to good night-time sleep, and vice-versa. "Sleep begets sleep." Just try to keep naps from lasting into the later afternoon. For a great discussion of the how and why of naps for one and all, see Sleepless in America.

Special Concerns in New Adoptees

Sleep disturbances are far and away the biggest initial concern for the new adoptive families that come to our clinic. Most new international adoptees sleep well enough on the trip home - quite possibly because they're thoroughly overwhelmed and emotionally exhausted by this transition. When you arrive home, 1-2 days of jet lag per time zone crossed is typical, but children often recover before grownups.

Learning as much as possible about the prior sleep environment and bedtime routines can be very helpful. But since orphanages can have unnaturally long naps and early bedtimes (often aided by medication, sadly), you may not want to follow their timetable precisely. Remember that children from orphanages may never have been alone in a room, and will need a prolonged transition to sleeping by themselves. Children in foster care may have quite evolved bedtime routines, transitional objects, and sleep habits ... such as cosleeping, which is common in Korea and many other countries. Even the clothes they came in have reassuring smells and associations, so keep them around ...

If the "cry-it-out" methods work as advertised, then why do kids from orphanages who've unfortunately been crying-it-out their whole lives sleep so poorly at first? Well, since almost every aspect of bedtime and your child's new sleep environment is different and thus "wrong" at first, it's natural that new adoptees have difficulty falling asleep and falling back asleep during night arousals. Your child's grief at the loss of familiar caregivers may erupt at night, and when you come to console them they may be expecting someone else.

New adoptees are usually so overstimulated (we call it "Disneyland syndrome") that they may blow right through sleepytime into an adrenaline-addled second or third wind. Also, your child is experiencing dramatically more love and stimulation, is having rapid catchup development, and we know that children working on new skills often obsessively practice or at least cogitate upon these new milestones. Nightime is no exception, and it's not unusual to find children happily or unhappily attempting new feats in the crib.

Children experiencing parental love and attention for the first time are understandably reluctant to give it up because someone says it's "bedtime". The early stages of a new attachment have an insecure, "velcro" quality, so it's normal for new adoptees to be anxious and insecure around bedtime. If they won't even let you have a bathroom break, how are they suppose to handle the big kahuna of daily separations - bedtime in their own crib? Add to that the fact that it's developmentally normal for kids to have a flareup of separation anxiety at around 18 months, and you got quite an anxious child on your hands.

Plus ... it's scary in the dark, even for many "home-grown" kids. On top of that, think of all the negative associations with nighttime your adoptive child may have had. Being cold, soaked through the rags that served as diapers, in a hard metal crib, with no one answering your cries, and waking up to a different shift of caregivers is not a good memory. Neither is hearing your first parents yell and hurt each other late at night.

Finally, children with histories of prematurity, prenatal substance exposures, lack of early responsive, regulating caregiving, and stressful/traumatic experiences can literally be wired differently, with real neurologic differences in sensory processing and self-regulation. Children with oversensitivities to sound, light, or touch are more likely have difficulty filtering these inputs out at night. Children with poor emotional and self-regulation experience their emotions more intensely, and have difficulty self-soothing. The process of "attunement" (a powerful emotional connection in which the caregiver recognizes, connects with, and shares the child’s inner states) with a responsive caregiver is necessary to help your child identify, organize, and work through their emotions. That attunement, more than "crying-it-out", is what will rewire your child so that they develop genuine self-soothing skills. Try to see initial nightime wakenings with empathy for where they're coming from and what they're now experiencing.

For all of these reasons, most adoption professionals do not recommend sleep training that involves prolonged crying in the first few months home. You may have brought home an 18-month-old, but he/she may be emotionally younger in many ways, and your relationship itself is a bouncing brand new baby ... one that will keep you up more than you might like in the first few months. Plan on being more emotionally and physically available at night, and try to think of these nightime interactions as an opportunity for bonding, and a way to repeatedly show your new arrival that she is loved, safe, and well-cared for.

But keep your eyes on the prize - restful restorative sleep for all. It's never too early to set up good sleep habits, and help build self-soothing skills. You'll probably want to have both a transitional sleeping plan, and a longterm plan. Get the The No-Cry Sleep Solution for Toddlers and Preschoolers or Sleepless in America, and one of the "sleep training" books (Sleeping Through the Night is my favorite, but see our list of recommended Sleep Books), and get down to learning and soul-searching about what's going to work for your family in the short and long-term. Pantley's questionnaires can help guide the discussion, and the National Sleep Foundation's Children's Sleep Diary (pdf) can help analyze a school-age child's sleep patterns (or use this simpler sleep log for younger kids) ...

While the transitional plan should probably involve some parental presence during sleep onset and night arousals, the longterm plan is up to you. It's a emotionally loaded powder-keg of competing sleep philosophies out there, and I'm not going to light the fuse. If you are loving, attentive, and attuned during the day, and have been responsive to transitional sleep issues in the first months home, you do have my permission to move into some modified "gentle" sleep training if that's what you need to do (prolonged hysterical crying does feel traumatizing to many of us, though). You also have my blessing to cosleep 'til the cows come home, as long as you're all cosleeping and not cosleepless.

Bottom line - know thyself, and know thy children. If they have histories of trauma or neglect, you don't want to reinforce those stress-forged neuro-endocrine pathways by retraumatizing them. If a method feels like torture, or just isn't helping your child, then try something else. Sleep training is not a one-size-fits-all solution; some children may settle quickly after a brief fuss that blows off some of the stresses of the day. Some will cry for HOURS and devolve into a sweaty, snot-smeared, how-dare-you-do-this-to-me, too-frantic-to-sleep zombie. And they'll do this every time the routine gets off and you have to "re-sleep-train". Weigh the risks and benefits for your family. What's worse, lonely frantic crying and loss of loving, attuned care at night, or having a dangerously sleep-deprived, depressed, not-so-attuned parent during the day? There's no right answer to that ... you need to trust your instincts here. That said, I do think Mary Sheedy Kurcinka's Sleepless in America is the closest I've read to "the right answer", since she skillfully walks you down the path of what underlies your child's sleep issues, and helps you adjust your approach to your child's temperament. Very very highly recommended.

Let's get practical ...

After all this sleep theory, I know that you wanna get practical, so let's get into practical:

Zeitgebers

But first, more theory. Ha. Just kidding. Zeitgebers are the "time-givers", the environmental cues that set or reset our biological clocks. Because we run on a 25-hour clock, and the world runs on a 24-hour clock, we need daily cues to continually set our circadian rhythms. And trust me, you need these right now, especially if you just got off the plane.

  • Light is the major zeitgeber - keep things dim in the hour before bedtime, dark at night except for a dim nightlight if necessary, and brightly lit through the day. A sunny breakfast first thing in the morning is ideal.
  • Physical handling and eye contact are potent stimuli that can boost adrenaline levels. Keep the physical play and long intense gazes for daytime ... but soothing contact like rocking and gentle backrubs work well at night.
  • Food routines can help maintain circadian rhythms, so try for consistency in your meal/snack/bottle schedule.
  • Vigorous physical activity during the afternoon can make a big difference at night as well. Go for a big hike or playground session - your new arrival may have more energy than you think.

Bedtime Routines

Even if you're a free spontaneous spirit, your child is gonna need a bedtime routine. Young children thrive on predicability and routine, and that goes double for post-institutionalized children. How long should it be? How about 30-40 minutes ... sound too long? Well, how long does your child take to actually fall asleep after you "put them to bed"? Either you've just found some time that could be better spent on a cozy, bonding bedtime ritual, or you've won the sleep jackpot (don't tell the other parents). When things are going well is when it makes sense to trim it back to 20 minutes or so. Here are some ideas for your bedtime routine ...

  • The whole hour before bedtime should be free of TV, computer games, vigorous play, or other stimulating activities.
  • Sleepy-time snacks. Preempt the "I'm still huuuungry" calls with a healthy and even sleep-inducing bedtime snack. Complex carbohydrates, as well as turkey, peanut butter, bananas, soy and dairy products (which all contain tryptophan) can help you get your sleep on. Best eaten half an hour before bed.
  • Review a pictorial sleep routine story that you wrote/drew together to reinforce the prebed ritual, and to confidently anticipate sleep successes. These sorts of personalized picture stories can really help in any anxious situation.
  • Baths. Who doesn't love a bath? Well, the kids who got stuck under a cold faucet during diaper changes don't love the bath so much at first, but usually quickly warm up to the concept. Try not to make it a wet 'n wild play session, though. Remember - "you're getting sleeeeepy ..."
  • Brush the teeth. Battery-powered toothbrushes are fun. So are tasty toothpastes. "Should I brush your teeth ... or your bellybutton?" Riff on your routine with absurd suggestions - they like it, and it builds language in the younger child or new English speaker. My niece likes to "teach the cat how to brush".
  • Change into PJs ... and don't forget to change out of PJs in the morning - helps them be a more powerful sleep association.
  • Bedtime bottle? The dentists just can't seem to win on this one ... but certainly no caloric beverages in the crib/bed, and it's nice to finish feeding 15 minutes before sleep to let saliva wash out some of those sugars, and to avoid setting up drinking as a sleep association that won't be there in the night. Milk, formula, and breastmilk are all soporrrific!
  • Take a tour of the room, saying goodnight to all the favorite toys. Doubles as a language lesson for the English learners.
  • A bedtime prayer is part of many bedtime rituals ... think about the content though. "If I die before I wake" might not be your best sleepytime thought.
  • Put your child in his bed or crib and take up your station next to him. Oh look, was there a nice little not-too-stimulating surprise waiting in bed? Maybe a sticker? Or a new book? Isn't going to bed dandy?
  • Do consider a gentle, soothing back massage or foot rub. Massage can work magic at bedtime, unless your child is overly sensitive to touch or ticklish ...
  • Bookreading. Let your child choose 2-3 books. The lights should be really dim by now, so it's not about the pictures, it's about your soothing voice. If your voice needs a rest, try a tape of you reading, or an audiobook.
  • "Goodnight, you princes of Maine, you Kings of New England ..." What will you leave your child with each night?

Bedtime Itself

It's earlier than you think. In fact the ideal toddler bedtime is often somewhere between 6:30 to 8pm.

  • Use your sleep logs to keep track of when your child shows signs of sleepyness, and when he actually falls asleep.
  • If you miss it, poof goes the easy sleepy bedtime - tired cranky adrenaline-addled children don't fall asleep well.
  • If you get home from work late, you may need to rejigger that or make early mornings your quality time.
  • If you're having sleep issues, you're well advised to keep sleep schedules the same 7 days a week. Which means keeping the bedtimes the same, but also not letting them sleep in much past their usual/appropriate wakeup time (ouch).
  • That said, sometimes your child's current circadian rhythms has him going to bed later than you think. Try letting the bedtime start out later but inch it backwards by 10-15 minutes per night.

Falling Asleep

This here is the key, folks ... the associations your child has with that golden moment of falling asleep will be the ones she needs each time she wakes in the middle of the night. Do everything in your power to let that moment be on her own. No feeding, no rocking at that moment, if you can. Stay in the room at first, by all means, stay next to the bed or even in it if you must ... you can wean that later if you want. Falling asleep is hard to do if you are anxious and having difficulty letting go ... Here are some ideas to help with the weaning process, which may take weeks to months.

  • Does your child have a "lovey", or transitional object, that can represent the emotional security she's building with you? If she didn't arrive with one, have an array of dolls, stuffed animals, and blankies around for a few days and see if she gravitates to one. Several of my patients swear by the Slumber Bear that plays womb sounds when jostled.
  • When she settles on one, experienced parents keep backup loveys on hand, and even rotate them so they're equally worn and stinky.
  • Maybe there are a few nonsense "errands" you need to do, in the room or out of it? But you'll be right back.
  • In fact, you can set a silent timer like an hourglass egg timer or visual timer and tell her that you'll be back in 3 minutes when the timer is done. Come back, check on her briefly, and repeat. Make sure you do come back.
  • Even if you're not doing the timer thing, coming back in for brief checkins when your child is not screaming for you is reassuring and rewards good bedtime behavior.
  • Successes with independent falling asleep are often followed by fewer night wakings in 1-2 weeks.

Night Wakings

Remember the sleep study statistics - 70% of infants, 47% of toddlers, 36% of preschoolers, and 14% of school-age children wake and need help at least once per night - these are normal, folks.

  • What's going on? Illness, teething, soaked diapers, recent stresses, new developmental milestones, night fears, night terrors, nightmares?
  • Again, be more responsive at first than you might eventually plan to be ...
  • But be as brief, boring, and minimalist in your interventions as possible.
  • And give brief fussing a chance to subside on it's own - your child may be having one of those night arousals that doesn't involve fully waking up.
  • Before you approach your wide-awake-and-screaming-at-4am child, take several slow, deep breaths, in through nose, out through mouth, focussing on a happier parenting moment or image of your child. Then go in.
  • Keep the "deep cleansing breath/find your happiness" thing going while you're in there. Seriously - breathing and a calm, affectionate approach is SO helpful, day or night; HeartMath's "Quick Coherence technique" is one way to get there. 
  • Review your child's sleep associations - is there anything he falls asleep to that isn't there in the night?
  • Is there something your child could do for himself that's self-soothing? Some of my older adoptees have cassette/CD players in bed with calming stories or music. If you played music at bedtime, can your child turn it back on easily?
  • Pantley has several great suggestions - giving your older child one or two Get-Out-Of-Bed-Free cards, a "Sleep Fairy" that leaves stickers under the pillow when children have had a successful night (depending on what they're working on - reward incremental successes), and even wrapped prizes in the morning for kids that have a good quiet night.
  • If you suspect night terrors, do less. They're more distressing for you than your child, and sleep experts discourage waking a child while they're having one. I've also heard that limiting fluids before bed may help, as full bladder might provoke night terrors.

Cozy Sleep Nooks

First things first - if there's a TV or computer in your child's room, banish it forthwith. They are the anti-sleep.

  • Ideally the sleep area is for sleeping and quiet resting ONLY, and perhaps separated by curtains or other dividers from the rest of the room.
  • Lots of stuffed friends can be reassuring, as are pictures of loved ones.
  • Climb in and spend some time in it yourself. Is the mattress comfortable enough? Audible household or outdoor noises? Lights shining in from the hallway or street?
  • Is there a place for you? Because that's the ultimate safe, secure "cozy sleep nook", at first. I think the ideal transitional solution is with one parent sacked out next to the child, since that will maintain a consistent sleep environment for the child when you eventually wean the parental presence.
  • If you're not there during the night, something that explicitly reminds her of you is also very important - since smell is one of the most powerful shortcuts to our primitive brain, where our senses of anxiety and security come from, perhaps an aromatic worn t-shirt or pillowcase of yours? And some photographs of you together in a loving, calm moment can be reassuring in the night.
  • Other options are having the crib or for an older child, a futon, next to your bed.
  • Cosleeping is also a popular option at first. Some adoptive parents report that their child was easily weaned after a few months to their "big girl bed", but in general, once you start cosleeping it's the hardest to wean.

Light

  • Seattle in the summer is brutal for sleep. Try creative window treatments like "blackout curtains", cardboard, aluminum foil (also adds a certain "blocking the alien mind control rays" touch to your decor) or whatever it takes to get that room dark.
  • If you do use a nightlight, keep it as dim as possible to avoid vernichten das zeitgeber, ja?  If you know what I mean ...

Sound

  • White noise can be a godsend for sleep, and is one of the first things I recommend for light sleepers.
  • A fan or aquarium pump running all night long can help drown out other intrusive noises.
  • Ocean wave noise generators, womb noises, and heartbeat lullabies are other favorites.

Smell

  • That lovey smells funky for a reason. Wash it at your peril.
  • Something that smells like you can be soothing too. See above ...
  • Aromatherapy - lavender and chamomile scents are felt to be relaxing as well. Try some "Badger Sleep Balm" ...

Touch

  • Being wet in the night is trouble, so limit fluids in the 1-2 hours before bed, use diaper doublers, and consider a nice layer of protective diaper paste before bedtime.
  • For children that seem to crave that snug-as-a-bug-in-a-rug sensation, often winding up wedged in the corner, perhaps a smallish sleeping bag or sleepsac would feel good. Grembo, LittleBigFoot, and others make zipup sleep bags for infants and toddlers. Tucking in the the sheets extra-tight may help at first, but they come undone; some parents have used a lycra sleeve around the mattress that the child slips into. Weighted blankets are available for older children with sensory issues as well.
  • Many orphanage-raised children will have pronounced self-stim/self-soothing habits like rocking, head shaking or banging, ear fiddling, or sucking on lips or fingers. These do fade with time, but may still show up in time of stress.

Temperature

  • The body tends to cool off at night, and people sleep better in a cooler environment.
  • Warm baths followed by cool bedroom may help this process along.

Does my child have a sleep disorder?

Courtesy of Dr Mindell, the following list of sleep problems may indicate that your child has a sleep disorder. If these issues are present, if sleep issues are getting worse not better, or if you're at the end of your rope, please talk to your health care provider.

  1. Loud snoring, noisy breathing, or breathing pauses while sleeping
  2. Breathing through his mouth while sleeping
  3. Appearing confused or looking terrified when he awakens during the night
  4. Frequent sleepwalking
  5. Rocking to sleep or head banging when falling asleep or during the night (ed: actually very common in orphanage raised children, and thus only a problem for them if severe or persistent)
  6. Complaining of leg pains, "growing pains", or restless legs when trying to fall asleep at night
  7. Kicking his legs in a rhythmic fashion while sleeping
  8. Sleeping restlessly
  9. Frequent difficulty falling asleep or staying asleep
  10. Sleep difficulties leading to daytime behavior problems or irritability

Additional Sleep Resources

Acknowledgements

Thanks to New Hope Child and Family Agency for the impetus, Elizabeth Pantley for many fab ideas, Drs. Mindell and Weissbluth for others, Dr. Greene for the zeitgebers, and our sleepless families for the inspiration.

Parenting by Temperament

If you are raising a child aged 4 months to 5 years old, get thee to the "Preventive Ounce" website. I'll let their blurb do the talking ...

"No child is average.

Unfortunately, most parenting advice is written for the average child.

This interactive web site lets you see more clearly your child's temperament, and find parenting tactics that work for your child.

Developed by the Preventive Ounce over the past ten years, this program has been used by more than 20,000 parents in health maintenance organizations in the Western United States.

Outcome studies show that parents who use this service avoid the anxiety, frustration and guilt that comes when they can't understand why their child acts "that way". They also avoid escalations into behavioral problems, conflicts with spouses and relatives, and unnecessary doctor visits.

As a community service, we now offer this preventive program free to all parents. To start using this program, click on Image Of Your Child. You can then:

  • Complete a short, temperament questionnaire and see immediately on-line a profile of your child's temperament.
  • Learn general strategies for managing the highs or lows of your child's temperament.
  • Discover what specific behavioral issues are normal for your child's temperament.
  • See when and how often these issues are likely to occur in the next year.
  • Get information, tailored to your child's temperament, for managing each issue you are likely to encounter. See what other parents of similar children say works well, and what doesn't."

What more can I say? It works as advertised, and it's free [er, it was. now it's $10]. You'll learn where your child is on scales of Sensitivity, Movement, Reactivity, Frustration Tolerance, Adaptability, Regularity, and Soothability. Make sure you click on the scale/subscale links first to learn what these scales mean. Then check out a wealth of sound, temperament specific parenting advice on issues that your child is likely to encounter in the next year. Some of the advice is mildly out-of-date (1990s, so not that ancient, but playpens are less common these days, for example), so use your parental "sniff test" for what's right for you and your kids, as always.

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.

The "Difficult" Child

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.

Sleep Issues In Pediatrics Presentation

Dr. Bledsoe has given this presentation on sleep issues to local parent groups. This presentation is not specifically for adoptees, but some adoptees may eventually benefit from these approaches after being home a few months. Sleep is an emotional issue, with wild claims made on all sides of the attachment parenting to sleep training continuum. We've all got our biases, and you'll need to decide for yourself which approach feels right to you. Does it fit your parenting style in other areas? Can you (and other caregivers) be consistent in implementing it? Is what you're doing now what you hope to be doing months or years from now?