Executive Functions in Adopted Kids

Julia Bledsoe, MD, just did a webinar on a hot topic in development and psychology: Executive Functions, which are higher-level cognitive skills that are frequently impacted in internationally adopted children.

Julie's talk is great - she gave it at our latest Resilient Rascals conference and at the national JCICS conference. She defines executive functioning, why it's vulnerable in our population of kids, and what you can do about it! You can see the webinar after a free registration with Children's Home Society & Family services here. Her teaser for the talk:

What can improve brain function? Many children adopted internationally and domestically have learning difficulties, specifically problems with higher order learning – what we call “executive functioning”. There are now many programs that claim their systems and supplements improve executive functioning. I will review these programs and the evidence about whether or not they work.

Advocating for Your Child's School Needs

At our recent adoption and foster care conference, Raising Resilient Rascals … Takes Flight, we had a panel discussion that was so full of useful tips that I couldn't resist sharing them here. Thanks so much to our panelists: Julia Bledsoe, Larry Davis (of www.specialeducationadvocacy.org), Lisa Konick-Seese, Gwen Lewis and Kate Molendijk. Some of their "pearls" follow, but first, some basics:

Getting Started

For children under three with developmental concerns, parents can (and should) call their local Early Intervention (also know as "Birth-to-3", or "ITEP") Center. You don't need a referral to start the process. They should do any necessary screening tests, and if your child falls below a certain threshold, they will qualify for subsidized developmental therapies. Increasingly, the center's therapists will meet the child at their home or child care center to provide these services. Find out more here.

For children over 3, your local school district is responsible for developmental screening and providing supports, even if your child isn't in school yet, or is home-schooled, or attends private school. In the latter cases, accessing those supports may not be easy or convenient, but it should be possible. Contact your school district's "Child Find" office to initiate this process.

IEPs and 504 Plans

If your child has a documented disability, which has an impact on your child's education, then your child should be eligible for either 504 Plan accommodations, or an Individualized Educational Plan (IEP).

Generally speaking, if tweaks to general education are deemed adequate to meet your child's needs, a 504 plan will be suggested. One drawback to 504 plans is that the school is not so accountable, oversight being at the federal level.

If your child needs more significant "specially designed instruction," then they should receive an IEP. With an IEP, the school is more accountable (oversight tighter, at the state level).

General School Tips

• It helps to develop an ally or friendly resource at the school that seems to understand and appreciate your child. This person can be invaluable for informal mediation, advocacy, advice about next year's classroom, and so on.
• Invite the teacher to dinner once a year. This used to be common, and some teachers still do it, in the younger grades. It gives them a more holistic sense of your child, and helps build a collaborative relationship.

Tips for IEP Meetings

• IEP meetings, especially your first, can be very stressful for parents, and it's easy to feel powerless, unable to effectively advocate for your child. These tips should help.
• Make sure you "check your own pulse" before the meeting starts. It's natural to feel defensive, or scared, or upset at how things have been going (or not going). You may find that you're in revved-up "mama bear" or "papa bear" mode. That's understandable, but also counter-productive. Make sure you're as calm and centered as possible, and use some of the following strategies to advocate for your child.
• The room may be packed with professionals, but remember that you are the expert in your child.
• Feel free to "stack the deck" in your favor at IEP meetings.
• Bring friends, support, other caregivers, prev. teachers, consultants.
• If you've developed an ally at school, have them there if possible.
• Bring treats. Break bread together. It can't hurt.
• Consider passing around a sign-in sheet (if unfamiliar folks will be there), with phone/email info for later contact.
• School culture can be geared toward "no", especially in these budget crunch times. Build a succession of yes's about your child first, instead of starting with your requests or demands.
• Do that by creating a sense of shared understanding, based on data if possible, about your child's unique background, weaknesses, and strengths. You and the staff should be recognizing your child in what each other has to say: "Yes, that's my child/student." Then the requests should flow more naturally and collaboratively.
• Then again, it may take 3-4 meetings for some staff to "get it." Call followup meetings if need be (it's your right, when you have an IEP), until they do.
• Before a school transition, have a meeting the preceding spring with a representative from the new district/school, to develop the IEP using folks that know your kid, and get a headstart on next year's plan.
• Think carefully about closing out an IEP, even if you decline services. They can be harder to get later.

School Bureaucracy

• School districts have strict timelines for responding to requests around evaluations and special education. Learn them, and keep track. 
• Use email or get copy of letter stamped at school when dropped off. This starts the clock ticking.
• Keep notes, folders for each child, or email folders, to a court-worthy standard (dated, no missing pages from notebooks, etc). Hopefully you won't end up there, but if you do ...

If Things Still Aren't Going Well

• You may consider an independent educational evaluation (IEE), a "second opinion" about your child's abilities.
• An educational advocate may also be useful.
• Consider formal mediation as well.
• Your child has the right to a "Free and Appropriate Public Education"; unfortunately, this does not equal a "Free and Perfect Public Education." We are not funding our schools as we should, and they have limited resources to meet the needs of many students. 
• Trust your instincts about whether this school or program is working for your child (but get some second and third opinions too!). Some families decide that private, parochial, or home-schooling is a better fit for their child's needs. This, of course, can be expensive, especially with added private therapists if those are necessary.

Resources

• NICHCY.org is my favorite website for disability and special education ​resources
• WrightsLaw is also an excellent resource for special education law, education law, and advocacy for children with disabilities.
• For local info, see the WA State official special education website.
• The WA State Office of the Education Ombudsman (OEO) "helps solve conflict and disputes between Washington families and elementary and secondary public schools so that students have every opportunity to stay in school and succeed." They are part of the Governor’s Office and function independently from the public school system.
• Another excellent source of info in our state is Kristin Hennessey, the Special Education Ombudsman at OSPI, at (360) 725-6075 or kristin.hennessey@k12.wa.us.

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.

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.

Atopic Dermatitis & Eczema

The Itch That Rashes ...

There are many good resources on this topic, so I won't reinvent this particular wheel, but since it comes up so often in our office, let me share my favorite sensitive skin and eczema tips. As to why this this is SO COMMON in our adoptees, particularly those from China, I suppose it's a combination of ethnic predisposition, climate, harsh orphanage soaps and detergents, institutional disinfectants, malnutrition, chronic stress, poor skin care, and lack of appropriate treatment. While atopic dermatitis is a chronic tendency towards sensitive, dry, rash-prone skin, it tends to eventually improve when children come home, especially with the techniques below ...

Everyday Prevention 

• Avoid triggers, like perfumed products, non-cotton clothes, dust mites, heat/sweat, bleach, disinfectants, and chemical/fragranced soaps and laundry detergents (try Charlie's Soap ...)
  
• Do bathe your child 1-2 times per day in tepid-warm water for 10-15 minutes. You can add oatmeal-in-a-stocking or Aveeno to the bath, but oils just make things very slippery. Minimal, if any, soap ... use unscented Dove, Cetaphil cleanser, or similar. Don't use Ivory, scented soaps, or bubble bath.
  
• Alternately, bathe 1-2 times per week. The "wet" and "dry" approaches to atopic dermatitis both work - it's the hot, soapy baths that aren't followed by moisturizer application that are trouble, as they remove protective skin oils and leave the skin dry and itchy.
• Immediately after the bath, pat your child somewhat dry, apply any necessary topical medication, and then dip your child into a big vat of thick, greasy moisturizer. Seriously, you need to be applying a greasy, scoop-it-out-with-your-hand moisturizing ointment at least once a day, to seal in moisture and provide a protective barrier for the skin. No pump lotions ... you need a TUB, like Cetaphil-in-a-tub, Eucerin, Vaseline, or similar products. Most contain petrolatum - it's been used for centuries and has a good track record. If you must avoid the petroleum products, vegetable shortening, shea butter, or other balms might be an option. Happy to hear feedback on these. Daily, religious moisturizing is the key to this chronic condition, especially in winter.
• Some newer "active" moisturizers are coming onto the market that are touted to be better at retaining moisture in the skin, and restoring the skin barrier. Some are also mildly anti-inflammatory, equivalent to hydrocortisone cream. They may be useful for children with moderate-severe eczema as a way to need topical steroids less often. Some of the ceramide products (CeraVe, Triceram) are over-the-counter; others, like MimyX and Atopiclair are by prescription.
  
• If you're in a hot climate, creams might be preferable to ointment mositurizers. Lotions still not recommended, since they can actually be drying to the skin.
  
• All-cotton clothes, ideally. No wool or short-fiber synthetics - they itch. Do thoroughly prewash new clothes to remove sizing and other itchy products.
  
• Keep nails trimmed and itchy areas covered by clothing.

Treatment Strategies

• For face, neck folds, armpit folds, and groin area, don't use anything stronger than Hydrocortisone 1% ointment (OTC) without discussing the pros and cons with your provider.
  
• For the rest of the body, prescription ointments like Desonide 0.05% (a low-potency topical steroid) or Triamcinolone 0.025-0.1% (a mid-potency steroid) twice a day will help itchy, inflamed areas that don't respond to hydrocortisone. Apply a thin layer underneath the moisturizer, and use only long enough to control the itchy flare. Not for daily longterm use - if it doesn't help by 1-2 weeks, see your provider.
  
• For those of you scared by the word "steroid", remember that chronic skin inflammation and itching is miserable, can cause infections, growth failure, sleep & behavioral problems, and overall irritability. Untreated eczema can cause longterm changes to the skin, just like overuse of potent topical steroids.
  
• I don't use Elidel or Protopic so much these days ... waiting for more safety data.
  
• For itch relief, an ice cube can substitute for scratching. Benadryl (OTC) or Atarax (Rx) at night (Allegra, Claritin, or Zyrtec during the day) are antihistamines that can help with miserable itching. Sometimes we need to use higher doses for severe itching - ask your provider what would be safe.
  
• Check behind the ears ... eczema likes that spot too.
• If an area is especially weepy, red, painful, or crusted consider using Bactroban cream for antibacterial help. If this is widespread, ask your provider about using an oral antibiotic to cover staph bacteria.
• Don't forget scabies ... very very itchy bumps on hands, feet, abdomen, or any really prominent, itchy, chronic-looking rash in a child residing in orphanage care could be scabies. Have it checked, and have a low threshold to treat with Elimite.

Complementary Approaches

• Probiotic supplements or daily active-culture yogurt or kefir seem promising for folks with eczema.
  
• Some studies suggest benefit from Evening Primrose Oil (EPO), which contains GLA, an omega-6 essential fatty acid. Some recent studies don't. Probably safe to try, in moderate-severe eczema, at 3g/day in divided doses. May take 1-2 months to work.
• Don't use tea tree oil - it may be antibacterial, but it can trigger eczema flares (and may have hormonal effects in boys).
• Consider dust mite control measures, like mattress/pillowcase covers, high-filtration vacuuming, and removing frilly dust mite traps in the room. May be more effective for asthma and nasal allergies, but kids with eczema often have those too.
• As for diet, perhaps 10-20% of kids with eczema have associated food triggers; this percentage is higher for infants or children with severe eczema. Generally, unless the eczema is chronic and more than a mild nuisance, I don't go chasing food allergies, since the only reliable test for food allergies is a strict elimination trial, with reintroduction of the suspicious food. Blood tests (RAST) and skin-prick tests can rule out certain allergens, but positive results may not indicate a true food sensitivity, so they are of limited use. Stay alert for quackery when it comes to this issue, consult your provider and an allergist if need be, and please involve a nutritionist if you are considering prolonged eliminations of major food groups, especially in young children.
  

Atopic Dermatitis Links

• Atopic dermatitis: Taming "the itch that rashes" - Contemporary Pediatrics
• Article about the newer "active" moisturizers
  
• Diet and Eczema

  Overview from the (British) National Eczema Society

Coughs, Congestion, and Colds

"There's only one way to treat the common cold - with contempt"

    - the esteemed Sir William Osler, MD

Ah, the common cold. Common, indeed - the average preschooler has six to 10 colds per year, with each illness lasting 10 to 14 days. And the sad truth is, Dr. Osler's 1890s-era wisdom is still largely correct. He went on to say, "... toss the pills into the ocean. So much the better for mankind, so much the worse for the fish"!

For children less than 5, there just isn't any safe, effective treatment available to treat the common cold. None of the common cold medicines can convincingly outperform sugar water, and the FDA has warned of a number of serious adverse reactions when used in children under 2 (our advice: don't risk it). But that doesn't seem to keep cold remedies from being a billion-dollar-a-year industry.

We all know what a cold looks and feels like, although we sometimes seem to forget when it comes to our own kids. Signs of something more serious like pneumonia, bronchiolitis, or asthma could be:

• Prolonged or high fever (more than 2-3 days, or >102 degrees)
• Breathing fast (count breaths over one full minute while quiet or asleep; infants should breathe <50-60 times per minute, toddlers <40x/min, older children <30x/min)
• Working hard to breathe (heaving chest, visible rib movement, nasal flaring, grunting)
• Getting dehydrated (not drinking enough, no tears/drool, less than 3 urinations/day)
• Acting really ill or lethargic

If those are happening, please let us know - if you're travelling, we may want to start the zithromax, and possibly find someone to evaluate in person. We do have a lower threshold to start antibiotics when we can't see kids ourselves.
 

Other Complications:

If nasal congestion and wet cough last more than 2-3 weeks then it may be bacterial sinusitis, which can be helped by antibiotics as well; the color/consistency of the snot doesn't tell us if this is viral or bacterial, unfortunately. Ear infections can be a complication of colds, often marked by new fever and irritability when a cold seems to be running its course. Ear tugging and fiddling is not a reliable sign of ear infection in preverbal children, unfortunately.
 

Let's review the common medications and treatments for the common cold:

• Decongestants (pseudephedrine, etc) - Somewhat effective for daytime relief in adults and school-age kids, but they just don't work in young kids. Besides, does putting your ill, sleepless child on over-the-counter speed seem like a good idea?
• Decongestant Nasal Sprays (Afrin, Dristan, etc) - These work for short-term congestion emergencies (less than 2 days at a time) but can be nasally addictive, causing "rebound congestion" when you stop using them. Not routinely recommended, and not for infants/toddlers.
• Antihistamines (Benadryl, etc) - A good treatment for allergies, but colds are caused by a viruses; useful only for their sedative effect in desperate sleepless situations. Beware - 1 in 5 kids gets LOOPY on benadryl.
• Cough Suppressants (dextromethorphan, codeine, etc) - It sure is tricky suppressing that cough reflex without putting your child in a coma. Safe doses of codeine and it's synthetic cousin, dextromethorphan, don't seem to be that effective at suppressing this vital reflex. Codeine is also just not safe enough to use in kids anymore, especially in Ethiopian adoptees. That said, in older children with a lingering, nagging, non-productive cough, you might try some Delsym (long-acting dextromethorphan).
• Expectorants (guaifenesin) - These don't work in young children, who don't need any help making copious secretions. In older kids and adults, they may make phlegm thinner, but so does drinking lots of fluids. Mucinex is a single-ingredient, extended release form of this for older kids and adults.
• Tylenol or Ibuprofen - IF your child is uncomfortable from fever, or in pain, these can help. Otherwise you may be suppressing the body's immune response.
• Antibiotics - No. Nyet. Bu.
• Zinc - Yuck. Zinc lozenges and zinc up the nose have not shown to be effective in kids. But zinc deficiency is associated with poor immune function (and many adoptees are zinc deficient). There's lots of zinc in high-protein foods like meats, seafood, milk, and fortified breakfast cereals. A "complete" multivitamin with minerals can also help.
• Vitamin C - Controversial. Large doses may shorten symptoms in adults, but megadoses are not clearly safe in kids, and can cause diarrhea. Like zinc, let's just make sure you're getting enough, and some extra at the first signs of a cold may help.
• Echinacea - Recent study done here found no clear benefit at reducing symptoms in kids. Bummer.
• Probiotics - Lactobacillus milks, active culture yogurts, and probiotic supplements are emerging as a good thing, although definitive studies are still pending, and it's not at all clear that they treat colds. They may be effective at preventing colds, allergies, and diarrhea, with a host of other potential benefits.
• Andrographis (Kan Jang) - Herbal remedy that's all the rage in Scandinavia. Some smaller studies showing benefit in colds and flu. Promising, but larger studies may sink this ship as well.
• Umcka drops - Ancient Zulu Homeopathic Geranium-ness. Germans love this stuff, available here through Nature's Way. Some promise for sinus, throat, and bronchial infections, large high-quality studies are lacking, so who knows, really? If you enjoy taking the latest natural sounding probable placebos, give it a try.
• The Stuff That Teacher Invented Who Never Ever Got Another Cold (Airborne) - It was on Oprah, so it must work. This contains Lonicera, Forsythia, Schizonepeta, Ginger, Chinese Vitex, Isatis Root, Echinacea, along with vitamins, zinc and magnesium. Phew. Feels a bit faddish to me, with a few too many ingredients.
• Whiskey - Dr. Osler's preferred cold remedy: "hang your hat on the bedpost, get into bed, start drinking whisky. When you see two hats stop!" Not an option for the kids, but what you do with the colds they give us is entirely up to you.
• Humidification - Unclear benefit from humidifiers and vaporizers, but they feel good for many, and may keep nasal secretions easier to clear. If you use these, clean them obsessively, as they are effective at aerosolizing molds and bacteria.
• Menthol, Eucalyptus, VapoRub - Studies show that people think these are working even if they aren't. You can put them in the vaporizer, plug a gizmo into a wall outlet, or rub them onto your child. That may be the key ... with the massage, you get the healing power of relaxation and parental tender loving care.
• Chicken Soup - Yup, small studies and grandmothers actually agree on this one.
• Nasal Saline Drops/Sprays and Bulb Suction - This really can help infants and toddlers, who can't effectively blow their nose. Infants, in particular, have tiny nasal passages that they depend on for sleeping and eating. You can buy nasal saline or make it with 1/2 tsp salt in 1 cup warm water. Put 1-2 drops in each nostril before suctioning to help clear dry nasal secretions. A bulb syringe is most effective if you squeeze it, put the tip in one nostril, and pinch the nose to get a good seal on the side you're suctioning and close off the side you're not, and SLUUURP. Don't go too crazy with this, as you don't want to overly irritate the nasal mucous membranes.
• Plenty of Rest and Plenty of Fluids - Yes. Da. Shi.
• and finally ... Tincture of Time - The ONLY cure for the common cold. Support the immune system in its good work with rest, fluids, love, and attention, and otherwise stay out of the way.

Updated 8/07

Constipation

It's a sad day when poop just isn't funny anymore ... at least for someone like me who does enjoy poop humor and things scatological (it's an occupational hazard). That sad day is a lot more likely to happen when travelling to adopt a child. In fact, constipation is so common a concern for travelling adoptive parents that I've taken to inventing medical terminology with a reassuring cachet such as "transitional slowed bowels", just to take the edge off of the hour-and-minute countdown since last passed stool. It's also a problem for many other children in my practice ... our modern processed diet may be to blame, as a diet low in fiber, low in fluids, and high in sugars predisposes kids to constipation.

In general, constipation is defined more by what your child is passing rather than how often. Normal stool frequency in infants varies from several times a day to 1-2 times per week. But if your child is passing painful, hard "rocks", "golf balls", or "boulders" (egad), especially if there is intermittent leakage of more liquid stool (encopresis), then indeed we've got a problem. If your child is vomiting, or has a full, tight, and tender belly, then we've really got a problem needing urgent medical attention.

In the recently adopted child, constipation is often blamed on iron, when in fact it's more likely to be from the stress of travel and transition, dietary changes, and perhaps dehydration. The association between iron and constipation is overrated, and since most adoptees are iron-deficient, it's not wise to try and limit their iron intake.

Soy formula can cause harder stools, so you may not want to switch your child to this if constipation is an issue. Luckily, cow milk intolerance is another overrated issue - most infants and young toddlers tolerate cow milk products just fine (rarely, cow milk protein allergy can be associated with intractable constipation).

To assist you in your quest for smooth bowel movements, or Smoovements^TM, if you will ... I will now share with you ancient secrets of "FPBM - For Proper Bowel Movements". Let's start with F - FLUIDS, FRUITS, and FIBER are your Friends when it comes to constipation.

Infants:

• several ounces of 100% fruit juice 1-2x/day, especially prune, pear, or apple juice
• fewer white foods like bananas, rice, soy, cheese, white flour products, and ...
• more "P" fruits and veggies like pears, peaches, prunes, plums and peas
• substitute barley cereal for rice cereal
• in hot climates where dehydration is a concern, a few extra ounces of water can help, but since our kids usually need the calories, I'd stick with juice or watered-down juice
• if you've gone more than 3-4 days with no stool, and your child seems to be in pain or straining a lot, try a glycerin suppository and a warm bath; you can also gently lubricate around the anus with vaseline or diaper cream
• if your child is straining, you might try bicycling their legs or holding them upright in squatting position (their back against your chest, holding their knees up towards their chest)

Toddlers and Older Children:

• fruit juice, and fewer white foods/more "P" fruits and veggies as above can help ...
• ... but in this age group, we should focus more on fiber and fluids: goal is at least their age in years plus 5-10 grams of dietary fiber per day, with lots of fluids
• whole grain cereals (read the label - lots of fake "whole grain" stuff out there) - remember "Colon Blow Cereal" from Saturday Night Live? That's the ticket - bran cereals, whole grain cereals, muesli, mini-wheats, etc ...
• bran muffins, cookies, crackers, and pancakes with whole grains. Metamucil makes some psyllium fiber cookie-type wafers as well ...
• Benefiber is a nongritty, flavorless fiber supplement that dissolves more completely than Metamucil, for when you can't meet the fiber goal through diet alone
• You can also get your 100% juice plus 10g fiber premixed in one convenient but pricey juice box (they also carry fiber cookies)
• dried fruits (prunes, apricots, figs, raisins, etc)
• beans, peas, and lentils
• fresh fruits and veggies with fiber - carrots, cabbage, celery, rhubarb, prunes, pears, peaches, plums, apricots
• the constipation chapter below has nice recipes for "Right and Regular" jam and fruit/fiber smoothies
• you can try 1/2 tsp unprocessed bran or flax seed mixed with food 1-2x/day but only if your child is drinking adequate fluids
• for kids 4yo and up, popcorn is a great, tasty source of fiber, as are seeds and nuts

"B"-havior: 

• in older children with constipation, suggesting regular sitting sessions 2x/day can help - after meals is the best time
• reward successes, lay off the failures (it's bad enough as it is)
• regular exercise keeps you regular
• for kids who are fearful of pooping from passing painful large-caliber stools, sitting backwards on the toilet leaning onto the tank can help
• 3-5yo "magical thinkers" often feel that if they withhold stools after they've had a painful experience the poop will disappear. It won't. It'll just add to their "boulder collection". Reinforce that the poop needs to come out every day, and help it do so with diet, regular sitting, and Miralax.
• counseling may be necessary (and very helpful) for older children with encopresis

Medications that start with M:

• if diet isn't working, if symptoms are severe, if your child is withholding stool, or if there's leakage (encopresis) you need to talk to your doc
• my hands-down favorite laxative is Miralax, a tasteless powder mixed into your choice of fluids that is very safe, well-tolerated, and effective ... and now available over-the-counter
• if you've been dealing with long-standing constipation or encopresis, you need to continue interventions like Miralax for 2-3 months at least, to help the rectum and colon recover to a normal caliber
• Maltsupex or Milk of Magnesia are also frequently used
• Mineral oil is another old favorite but it's yucky (try it in ice cream) and can pose an aspiration risk in younger children
• bowel stimulant products like senna can be used occasionally but are not for chronic use
• DON'T enemize your child without consulting a physician, and avoid frequent rectal interventions in general (unnecessary and traumatizing)
• DON'T give honey or karo syrup to infants - there have been cases of botulism from this. UPDATE: Karo syrup manufacturing processes are now considered safer, but karo syrup no lomnger contains some of the helpful glycoproteins, so it may be less effective.

Remember, it's all about FPBM - "For Proper, Pleasing, Painless, and Punctual Bowel Movements"

• Fluids, Fruits, Fiber are your Friends
• Prunes, Pears, Peaches, Plums, Peas, Psyllium, Peanuts and Popcorn
• Bran, Beans, Benefiber, and Behavioral interventions
• Miralax (and/or Maltsupex, Milk of Magnesia, Mineral Oil)

Other Resources:

• Need more help? See this excellent book from a local colleague: The Ins and Outs of Poop
• Constipation Advice from DrGreene.com
• KidsHealth Soiling (Encopresis) Article
• Parent guide: Stool holding: When your child holds back bowel movements and is not toilet trained
• eMedicine Constipation Guide

"Birth-to-Three" Early Intervention

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

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

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