After School Programs
Many children receive most of their recreational experiences through these programs. Coaches can be wonderful mentors and for some families after school programs eliminate some daycare needs.

Audiologist
An audiologist provides intervention strategies and services for individuals with deafness or hearing impairments.

Classroom Teacher
Your child’s classroom teacher is the person who will spend the most time with your child and will know her best. A classroom teacher is a valuable resource for helping identify any educational, emotional or social issues the child may be having in school.

Early Intervention Services
Every state offers an early intervention program to help identify infants and toddlers (up to age three) who may have developmental delays or disabilities. An evaluation is completed to determine the child’s cognitive, physical/motor, speech, language, social, emotional and adaptive development. A physician or the local school district can direct families to those services.

Educational Advocate
An Educational Advisor or Advocate helps parents work with the child’s school. As an additional member of an Individual Education Plan (IEP) team, an Educational Advocate provides additional experience and expertise to get the best outcome for the child.

Occupational Therapist
An occupational therapist is a licensed health professional who provides strategies and services to assist individuals with motor or sensorimotor functions, including fine motor manipulation, self-help, adaptive work skills, and play or leisure skills.

Physical Therapist
A physical therapist is a licensed health professional who works with individuals with motor or sensorimotor functioning in such areas as mobility and positioning.

School Counselor
A school counselor may assist in the identification of a child’s needs and may help to determine appropriate responses.

School Nurse
A school nurse provides medical care during the school day, monitors allergic reactions and may administer medication needed during school hours.

School Psychologist
A school psychologist assists in the identification of a child’s behavioral, social, emotional, educational and vocational needs and helps to determine appropriate responses.

School Social Worker
A school social worker is trained to assess a child’s educational needs including social, emotional, behavioral and adaptive needs. She provides intervention services including individual, group, parent and family counseling and serves as liaison between home, school and community.

Special Education Instructional Specialist
The special education instructional specialist provides ongoing support to special and general education instructional personnel. The specialist helps to identify and plan for the least restrictive environment appropriate for the child.

Speech-Language Pathologist
A speech-language pathologist provides intervention strategies and services related to speech and language development as well as disorders of language, voice, articulation and fluency.

Transportation Specialist
A transportation specialist works with the school district to provide special transportation and equipment for students with disabilities.

Tutoring Services
Many children can benefit from short or long-term use of a tutor. Families receiving federal (and some state) subsidies should look to the schools for help rather than Children and Family Services.

Growth failure is the most common medical problem identified after arrival in the adoptive home. Children in institutions may suffer from psychosocial growth retardation which is caused by extreme emotional deprivation or stress. The symptoms include decreased growth hormone, short stature, weight that is inappropriate for height, and immature skeletal age. Children with psychosocial growth retardation may exhibit unusual behaviors, including eating and sleeping disorders, head banging, over friendliness, apathy and depression.

An institutionalized child will lose one month of linear growth for every 3-4 months spent in an orphanage. After placement in adoptive families almost all children experience rapid linear growth. It is important to follow the child’s height, weight and head circumference measurements closely after arrival. If rapid growth is not observed during the first 12 months, further investigation is warranted.

Microcephaly is a condition where the head circumference is smaller than average for the person’s age. It may be congenital or it may develop in the first years of life. Microcephaly is common in internationally adopted children for many reasons – prenatal exposures, environmental deprivation, malnutrition, and birth injuries.

Head circumference is often one of the few pieces of objective information available in the referral documents. About 40% of preadoptive referrals indicate that the child has microcephaly. However, head circumference may not be a reliable indicator of brain health or long-term developmental potential.

Circumference tests can be inaccurate for many reasons: incorrect measurement, inaccurate measuring devices, and improper translation. Growth charts may not reflect norms for the child’s country of origin. Head circumference should not be interpreted in isolation, if possible. Additional risk factors and growth patterns of the head over time help strengthen the predictive value of head circumference.

Young adopted children may exhibit increased head growth after adoption. However, a consistently small head circumference markedly increases the risk for mental retardation. The smaller the head, the greater the deficit. In general, the more typical the head size, the better the expected outcome.

It is often difficult to determine the correct age of an internationally adopted child. Abandoned children may have had birth certificates completed long after the fact. Transcriptions and translations of documents lead to errors. Non-Western cultures may use different methods of recording birth or age. Even if an age is literally accurate, it may not be developmentally accurate.

Upon arrival the physician should measure the child’s height, weight and head circumference, and these should be plotted on a chart with growth information for the child’s birth country. Dental age and bone age can be used to determine a child’s chronological age, though both may be affected by the child’s health background.

Most medical practitioners don’t question the age assignment of a child unless the parents have reason to be suspicious. Age assessment is difficult, since most internationally adopted children have some kind of growth and developmental delays. Some parents prefer to legally change their child’s age to match their developmental age so that school placement will be a more accurate match to educational capacity and needs. Most children should be observed for a minimum of four to six months before any age reassignment. Rapid growth and development during the post-adoption period may make the correct age more obvious.

After about six months, the amount of progress in growth, dentition, skeletal maturity, and development should be calculated. If an age reassignment is warranted, a letter recommending the change should be submitted to the judge overseeing the adoption. The parent will then need to petition the State Department so that the legal age on the immigration record will reflect the child’s new legal age. Please note however that it may take up to 24 months for bone age to catch up to actual age if the child had been in poor health prior to the adoption.

TIP: Bone age is rarely advanced. It is more likely to indicate the possible age rather than suggest the child is older than he really is. The closer your child is to attending school the more important age can be. Going with the youngest possible age can be advantageous for school placement.

Some studies have shown that children, primarily girls, adopted internationally are at risk for precocious puberty. Precocious puberty is the onset of signs of puberty in girls before age seven or eight and in boys before age nine. Indications of precocious puberty in girls includes: breast development; pubic or underarm hair development; rapid height growth; onset of menstruation; acne; and “mature” body odor.

If precocious puberty is not treated, a child may not achieve her full adult height potential. When puberty ends, bone growth stops. Early puberty will make the child taller than her peers for a time, but she will stop growing sooner and up shorter than her peers. Early puberty can cause social and emotional upheavals for children, whose physical changes can be ridiculed by their peers. It is disconcerting to have a first period in third grade. Also, if precocious puberty is not treated, a child may be flooded with adolescent hormones and the attention of older children or adults of the opposite sex.

Parents who see indications of premature puberty should contact the child’s physician who should refer them to a pediatric endocrinologist. The window of opportunity to delay adolescent onset is brief, so this action should be considered in a timely manner. A gonadotropin-releasing hormone (GnRH) can delay puberty and prolong the growth period, and will also allow time for psychological maturation. The addition of growth hormone has been shown to improve final average height for children with precocious puberty. It also gives the child more time to be a kid before entering the hormone storms and social challenges of adolescence. For children with emotional healing work to do, and for their parents, this may be a welcome respite.

Mongolian Blue Spots are flat birthmarks with wavy borders and irregular shapes, common among people of Asian, East Indian, African, and Latino heritage. They may be seen in about 10% of Caucasians to over 90% of African Americans.

Bluish gray to deep brown to black skin markings with normal skin texture, they often appear on the base of the spine, on the buttocks and back and even sometimes on the ankles or wrists. Mongolian spots may cover a large area of the back. They are commonly present at birth or appear shortly after birth and may look like bruises. Some medical records will indicate a child is special needs just for having a Mongolian spot anywhere other than at the base of the spine.

Mongolian spots are benign skin markings due to a collection of pigment cells under the skin and are not associated with any illnesses, complications, or risk factors. They generally fade in a few years and disappear by puberty. Though occasionally they persist into adulthood, there is no need for treatment.

TIP: Because Mongolian spots can be mistaken for bruises, have your agency worker and pediatrician document their existence in their files.

Lead poisoning is a global problem. Children adopted from China are particularly likely to have elevated blood lead levels. Lead exposure may come from paints, cooking utensils or from environmental exposures like industrial emissions and leaded gasolines.

Lead exposure can have serious impacts on cognitive function, growth, behavior and attention, and many of these effects can be long lasting. Prenatal exposure is associated with low birth weight and decreases early weight gain. School age children may have an inability to focus, have reading disabilities, impaired language processing, behavior problems, and decreased motor and visual functions.

Lead levels should be tested upon arrival and monitored over time, but improvement in lead level will not necessarily correct deficits or restore IQ.

Ear and sinus infections are the most common problems that internationally adopted children experience. Institutions are fertile breeding grounds for upper respiratory infections, and the practice of “bottle propping” and large holes in nipples can cause flooding of the Eustachian tubes. Orphanage-reared children are also susceptible to food and environmental allergies which can lead to frequent and persistent ear infections.

A child who has spent time in institutions is likely to have had multiple ear infections, which either went untreated or were treated with strong doses of antibiotics. Persistent ear infections can have many complications: Permanent or temporary hearing loss; language delays; behavior problems (because of pain); learning disabilities; problems with balance; poor appetite, vomiting and diarrhea; poor weight gain; frequent upper respiratory infections; resistance to multiple antibiotics; sleep problems. Multiple antibiotic exposures can have similar complications.

Before you bring your child home you should gather as much information as you can. Don’t be afraid to ask questions and write everything down: How often was your child sick with colds and did he or she “shake it off” easily? What helped? Was the child ever hospitalized? What were the diagnoses? What medications were used? Also, have your child’s ears checked before you fly home. If you have ever flown with an ear infection you know how miserable this can be and your child doesn’t need to rupture her ear drum on her trip home.

It is important to communicate this information to your child’s pediatrician. Keep in mind that your child may not know that pain in the ears is abnormal and therefore may not complain. Early and aggressive treatment is usually necessary when an adopted child has an ear infection. If the infection does not clear, then the child should be referred to a specialist for ear tube placement and/or removal of adenoids and tonsils (if necessary). Formal hearing tests should be performed.

The symptoms of thyroid issues in children may be hard to recognize because changes in appetite, sleep patterns, emotions, and energy levels are all part of normal development. These changes are all especially likely to increase for a child traveling and joining a new family. So, these symptons shouldn’t cause alarm but should be monitored.

There are two major thyroid issues. Hypothyroid is when the thyroid gland is under producing thyroid hormone. Hyperthyroid is where the thyroid gland produces too much thyroid hormone. Both can produce consequences that affect your child’s growth, health, mood, and ability to concentrate and learn.

Sexual abuse is a specific type of trauma. It can include touching and non-touching behaviors (such as voyeurism), affect girls and boys, and perpetrators can be adults or children. If you are parenting a child who has been removed from their family, lived on the streets, or lived in an orphanage, you may not know if they were abused. Your child may tell you once they feel safe and secure in your home or they may never tell you. You can look for signs of abuse such as imitation of sexual acts with stuffed animals or toilet issues or bedwetting. Your doctor may test for sexually transmitted infections. If you suspect abuse, seek professional help. Sexual abuse can have a profound impact on the child and the entire family.

Although routine screening for sexually transmitted infections beyond syphilis and HIV is not recommended, some experts will screen all children older than 5 years of age for chlamydia and gonorrhea. In addition, if there is any question or concern of sexual abuse, chlamydia and gonorrhea screening should be done for a child of any age.

For more on this topic, see our webinar Sexual Abuse: Recognize, Respond and Protect: Advice for Parenting The Sexually Abused Child which is available on-demand.

Autism is a developmental disorder characterized by difficulties in social interaction and communication and by restricted or repetitive patterns of thought and behavior. Because the severity and patterns of impairment vary, it is described as a spectrum.

Autism Spectrum Disorder is a single disorder described in the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). The diagnostic category no longer includes separate diagnoses for Asperger’s Syndrome and Pervasive Developmental Disorder-Not Otherwise Specified. The DSM-5 also includes a related, but distinct, diagnostic category of Social Communication Disorder. Autism spectrum disorders are estimated to occur in as many as one in every 59 children.

Down syndrome is a genetic disorder caused when abnormal cell division results in a third 21st chromosome. Down syndrome usually causes delays in physical, intellectual and language development. There is wide variation in mental abilities, behavior and physical development in individuals with Down syndrome.

Children with Down syndrome may also have poor muscle tone, heart defects, and gastrointestinal issues.

While there is no cure, children benefit from medical intervention and early intervention.

Pediatric dentists recommend that all children see the dentist before their first birthday. For those adopted internationally, dentists suggest bringing them in within the first few months home. Prenatal and postnatal mineral deficiencies, orphanage feeding practices, and the likelihood of minimal dental care can all lead to issues.