Plasticity of growth in height, weight, and head circumference: meta-analytic evidence of massive catch-up after international adoption

Head circumference at birth and postnatal growth trajectory in vulnerable groups from Argentina

OBJECTIVES

To investigate the association between the anthropometric status at birth and brain and bone growth during the first year of life. According to the brain-sparing hypothesis, we expect catch-up to be faster in head circumference (HC) than in body length.

METHODS

This is a longitudinal design that included Argentinian infants under 12 months of age with at least three anthropometric records. We classified study participants into four growth status categories according to z-scores for HC (HCZ) and length (LAZ) at birth, with z-score = -2 as a threshold. We used the Count model to describe growth trajectories in HC and length in the first year of life according to the growth status at birth. Recovery indicator for HC and length was taken as the time until the predicted growth trajectory surpassed the threshold curve predicted by z-score = -2 for age.

RESULTS

Growth models included 3399 infants. There were significant differences in the growth parameters between groups in all cases (p < 0.05). Within the group with a low HCZ and a low LAZ at birth, HC recovery was faster than length. In the case of a low z-score for only one of the variables, newborns with a low HCZ recovered faster than individuals born with a low LAZ.

CONCLUSIONS

The postnatal growth pattern in HC and length is associated with the growth status of HC and length at birth. As we hypothesized, the fastest postnatal recovery occurs for HC in cases of intrauterine delayed growth.

A four-year multi-wave prospective study on the role of parental reflective functioning and parenting stress in the development of socio-emotional problems in internationally adopted children

Parental reflective functioning (PRF) plays a protective role in the development of children with histories of early adversity, including adopted children. This is the first study to investigate the developmental trajectories of PRF and children's socio-emotional problems in the first 4 years after international adoption (N = 48 families, mean age (T1) = 20.7 months) and to examine the mediating role of parenting stress in the relation between PRF and child socio-emotional problems. Multilevel modeling indicated that age at adoption and parent gender moderated the development of PRF and child socio-emotional problems. Moreover, decreases in PRF were associated with more socio-emotional problems in the children. These relations were mediated by parenting stress, and particularly feelings of incompetence and marital dissatisfaction.

Socio-ecological drivers of vulnerabilities of children living within orphan homes and the implications for their nurturance care

At the heart of the Sustainable Development Goals (SDG) is the vision to "leave no one behind, and to see that all children survive, thrive and transform. However, some categories of children may remain left behind owing to their disproportionate exposure to the risk of threats and deficit of attention to the social and ecological climate that characterizes the various systems in which they are found. This study is concerned with one major question: Despite diverse local and international instruments that favor full nurturance and development of children, what social forces play as threat to full nurturance care in the context of children living in Orphan homes? Nurturing care framework and Brofenbrener's ecological system theory were adopted as the analytical frameworks. Research design was exploratory. Data were collected through sessions of in-depth-interview with orphanage managers, caregivers, and social workers on the socio-ecology drivers of threat to children living within the orphan home space and its implications for nurturance care across the various complex systems of the child's environment. The study found various factors across the complex systems of child development - microsystem, mesosystem, exosystem, microsysm and lastly, chronosystem- which undermine caregivers' delivery and increases children's vulnerability and risk of missing out on effective nurturance care. These vulnerabilities are endemic realities of social, and bio-ecologcal space in which child development occurs. This study recommends specialized interventions and policy directives relevant for each identified threat. It also calls for a stronger political will in improving the conditions of this category of the children while within the orphan home space and ultimately, actions towards deinstitutionalization of children.

Intercountry adoption of children with complex health conditions and disabilities: A systematic review

PURPOSE

The rate of children with complex health conditions or disabilities who are intercountry adopted (ICA) is increasing. These children have unique physical, developmental, and psychological needs that must be addressed as they integrate into adoptive families. The purpose of this systematic review is to identify considerations nurses must recognize when caring for children with complex health conditions or disabilities who are ICA and their families.

DESIGN AND METHODS

A systematic literature review in accordance with the PRISMA guidelines was conducted. Four databases (PubMed, PsycINFO, Web of Science, and ERIC) located 365 articles about intercountry adoption and complex health conditions or disability. Articles that were non-English language, focused on attachment disorder or infectious disease, book chapters, dissertations, or case studies were excluded. Sixteen articles met inclusion criteria and informed this review.

RESULTS

The systematic review identified eight themes: primary care resources, interdisciplinary care teams, cost, developmental difficulties, nutritional challenges, mental health issues, parental need for knowledge, and parental need for support. These themes correspond to nursing assessments that should be conducted during clinic visits for children with complex health conditions or disabilities who are ICA.

PRACTICE IMPLICATIONS

This systematic review demonstrates that a multidisciplinary approach is necessary to address the needs of the child diagnosed with a complex health condition or disability and their family in the context of intercountry adoption. Children with a complex health condition or disability who are ICA have unique needs and require individualized care planning to maximize growth and developmental potential. Adoption is a life-long process and adjustment is complicated by the medical needs that children with complex health conditions or disabilities experience. Parents will benefit from additional support and education as they integrate a new family member while also learning about the medical care needs of a child with a complex health condition or disability.

Postnatal growth of small for gestational age late preterm infants: determinants of catch-up growth

BACKGROUND

Failure to recover growth is a risk reported in late preterm population. This study aimed to evaluate the auxological outcome of late preterm infants and identify factors associated with failure to recover growth.

METHODS

We enrolled late preterm infants with birth weight ≤10th percentile, followed up at High-Risk Infant Follow-up Service. We collected data at birth and at follow-up visits. A logistic regression analysis was performed to assess variables independently associated with growth failure.

RESULTS

The population consisted of 175 preterms. The percentage of children showing no weight recovery was 34% at 36 months. At logistic regression analysis, infants who had not regained weight at 12 months had a higher risk of not regaining weight even at 36 months. The same risk factor was highlighted for length catch-up growth. Moreover, infants fed any human milk at discharge were protected from not achieving both weight and length catch-up growth at 36 months.

CONCLUSION

These results indicate that children born late preterm and small for gestational age could fail to recover weight and stature growth in the first 36 months. The protective effect of human milk on failure to thrive highlights the importance of promoting breastfeeding in this population.

IMPACT

A significant number of SGA late preterms show a failure to recover weight and statural growth. Having experienced intrauterine growth restriction is associated with a greater chance of achieving statural catch-up growth. Being born singleton represents a risk factor for slower weight and height growth velocity. Breastmilk has a protective effect on failure to recover adequate weight and length in preterm SGA infants. This finding highlights the importance of promoting breastfeeding in this population.

Early-life stress and current stress predict BMI and height growth trajectories in puberty

In cross-sectional analyses, early institutional care is associated with shorter stature but not obesity during puberty in children adopted into US families. We examined whether shorter stature and leaner body composition in youth adopted internationally from institutions would continue as puberty progressed. We also examined whether current psychosocial stress would moderate the association between early institutional deprivation and growth during adolescence. Using an accelerated longitudinal design and linear mixed-effects models, we examined the height and body mass index (BMI) of 132 previously institutionalized (PI) and 176 nonadopted (NA) youth. We examined youth aged 7-15 at the beginning of the study three times across 2 years. Nurses assessed anthropometrics and pubertal status. Current psychosocial stress was measured using the Youth Life Stress Interview. Our results indicated that PI youth remained shorter and leaner across three assessments than NA youth. However, age-and-sex-adjusted BMI increased faster in PI youth. Psychosocial stress during puberty predicted greater age-and-sex-adjusted BMI, but this effect did not differ by group. The gap in BMI but not height appears to close between PI and NA youth. Higher psychosocial stress was associated with higher BMI during puberty.

Does rapid rebound height growth come at a neurocognitive cost for previously institutionalized youth?

BACKGROUND

Height growth faltering is associated with less optimal behavioral outcomes and educational achievement. Although catch-up growth after growth delay may result in developmental gains, it may also present as a double-edged sword, with consequences for neurocognitive functioning such as symptoms of inattention and hyperactivity. As previously institutionalized (PI) children experience height delays at adoption and catch-up growth after adoption, they provide a cohort to test associations between catch-up growth and attention deficit hyperactivity disorder (ADHD) symptoms.

METHODS

This study used latent growth curve modeling to examine how catch-up in height-for-age growth is related to attention problems in a population of PI youth followed from adoption in infancy through kindergarten. Participants were assessed within three months of arrival into their families (age at entry: 18-36 months). Anthropometrics were measured four times, approximately 7 months apart. Two visits measured behavioral outcomes with parent and teacher reports of ADHD, internalizing, and externalizing symptoms at age 5 and kindergarten.

RESULTS

The slope of growth in height z-scores, but not the intercept, was positively associated with parent- and teacher-reported ADHD symptoms in children. A one standard deviation increase in the slope of height z-scores across four assessments was associated with a 0.252 standard deviation increase in ADHD symptoms after controlling for internalizing and externalizing problems, iron status, duration of institutional care, sex, and age. The slope of growth was also associated with internalizing but not externalizing symptoms.

CONCLUSIONS

This study demonstrates that PI children exhibit individual trajectories of height growth postadoption. Higher rates of change in height-for-age growth were associated with increased ADHD symptoms. These results suggest that catch-up growth comes 'at the cost' of poor attention regulation and hyperactive behavior.

Early deprivation alters structural brain development from middle childhood to adolescence

Hypotheses concerning the biologic embedding of early adversity via developmental neuroplasticity mechanisms have been proposed on the basis of experimental studies in animals. However, no studies have demonstrated a causal link between early adversity and neural development in humans. Here, we present evidence from a randomized controlled trial linking psychosocial deprivation in early childhood to changes in cortical development from childhood to adolescence using longitudinal data from the Bucharest Early Intervention Project. Changes in cortical structure due to randomization to foster care were most pronounced in the lateral and medial prefrontal cortex and in white matter tracts connecting the prefrontal and parietal cortex. Demonstrating the causal impact of exposure to deprivation on the development of neural structure highlights the importance of early placement into family-based care to mitigate lasting neurodevelopmental consequences associated with early-life deprivation.

Standardization of a Participatory Questionnaire to Assess the (Fulfilment of) Needs of Children in Care (QANCC) In India

India has approximately 23 million children without parental care, who need alternative forms of care (MOSPI, 2018). Udayan Care, an NGO, designed an innovative group care model for children and youth in need of care and protection, implementing the indigenously developed LIFE (Living in Family Environment) strategy in 17 Udayan Ghars. (Sunshine Homes). With child participation as a core pillar, Udayan Care developed a Questionnaire to Assess the Needs of Children in Care (QANCC) in 2011, which is to be filled up by children annually, as a longitudinal study. The tool is conceived to ascertain whether children in the Ghars perceived if their rights were being fulfilled and that their needs were being addressed. With "meaningful participation" of children stipulated by the United Nations Convention on the Rights of the Child (UNCRC), the objective was to develop an evidence-based tool to assess the views of children on the services meted out to them, from their standpoint, and inform actual care practices annually. The self-assessment tool consists of questions, assessing the four dimensions of basic/fundamental, emotional, educational, and interpersonal needs, on a four-point Likert rating scale. A convenient purposive sampling is done on children, aged 10 to 18 years, who receive care and protection at the Ghars, and have resided there for a minimum of 6 months. This paper has two objectives, where at one end, the deductions of the previous years' data are made (2011-12 to 2016-17) with demarcating the differences with year 2018-19 data and at the second level, there is an update on the efforts made to establish the reliability and validity of the tool and create a standardized tool that can be implemented by other child care organizations in India. The paper illustrates how listening to direct voices of children and incorporating their inputs into actual care practice, can go a long way in improving the holistic wellness of children living in an alternative care setting. The results indicate that all needs of the majority of the children in Udayan Ghars.

Intervening With Attachment and Biobehavioral Catch-Up to Reduce Behavior Problems Among Children Adopted Internationally: Evidence From a Randomized Controlled Trial

Children who have been adopted internationally often exhibit persistent behavior problems. The current study assessed the efficacy of the Attachment and Biobehavioral Catch-up intervention (ABC; Dozier & Bernard, 2019) for reducing behavior problems in 122 children adopted internationally. Behavior problems were measured via parent-report using the Brief Infant Toddler Social Emotional Assessment at a pre-intervention visit and after the intervention when children were between 18 and 36 months. Children's behavior problems were also observed using the Disruptive Behavior Diagnostic Observation Schedule (DB-DOS) after the intervention when children were 48 and 60 months. Parents who received ABC reported fewer child behavior problems than parents who received the control intervention immediately after the intervention through 1.5 years post-intervention. Additionally, children whose parents received ABC exhibited fewer behavior problems within the parent context of the DB-DOS when they were 48 months old (2 years post-intervention) than children whose parents received the control intervention. There were no significant intervention effects on children's observed behavior problems within the examiner contexts. These results support the efficacy of ABC in reducing behavior problems among children adopted internationally. Trial registration: ClinicalTrials.gov NCT00816621.

Maternal and child social support and food availability in relation to child growth in four low- and middle-income countries

Previous studies showed positive associations between specific types of social capital and child nutritional status. Our study examined whether improved food availability mediates the impact of maternal and child social support on child nutritional status in four low- and middle-income countries. We used data from the Young Lives cohort study, comprising 1,000 children aged 8 and 12 in Vietnam and Ethiopia, 1008 in India, and 714 in Peru. The outcome variables were the z-scores for height for age and body mass index (HAZ and BAZ, respectively). The causal mediation analysis framework was used. In Peru, above-median values of maternal social support and receiving child financial support were positively associated with HAZ at age 12. The level of maternal financial support was positively associated with BAZ among 12-year-old children in India. Peru was the only country where a positive association was found between food availability and maternal financial support among children aged 12. However, food availability did not mediate the effect of maternal financial support on HAZ at age 12. Strengthening social support to improve child nutritional status, especially by improving food availability, may not be a sufficient intervention in resource-poor settings because sources of support may lack sufficient food resources to share. However, more comprehensive measurements of social support and food security are necessary to better understand the mechanism of social support and child nutritional status.

Postnatal Stature Does Not Largely Mediate the Relation between Adverse Birth Outcomes and Cognitive Development in Mid-Childhood and Early Adolescence in Rural Western China

BACKGROUND

Preterm birth and fetal growth restriction are associated with linear growth faltering and suboptimal cognitive development in childhood.

OBJECTIVES

We aimed to investigate whether and to what extent the associations between adverse birth outcomes and cognitive development in mid-childhood and early adolescence are mediated by postnatal stature.

METHODS

We used data from a prospective birth cohort of children born to women who participated in a large cluster-randomized trial of antenatal micronutrient supplementation in rural western China. Children were followed up for anthropometric assessments at 6, 12, and 24 mo of age and in mid-childhood (7-9 y). Cognitive development was assessed in mid-childhood (n = 669) and early adolescence (n = 735; 10-12 y) using the Wechsler Intelligence Scale for Children-IV. We conducted a causal mediation analysis to evaluate the proportion of the association of low birth weight (LBW; <2500 g), small-for-gestational age (SGA; <10th percentile), and preterm birth (<37 weeks of gestation) with cognitive development in mid-childhood and early adolescence that was mediated by postnatal length/height-for-age and -sex z score (LAZ/HAZ) during the first 2 y of life and in mid-childhood.

RESULTS

LBW and SGA, but not preterm birth, were associated with lower cognitive test scores in mid-childhood and early adolescence. The proportion of the total association of SGA with adolescent cognitive development that was mediated by LAZ/HAZ at 6, 12, and 24 mo of age and in mid-childhood was 25%, 32%, 32%, and 27%, respectively. The corresponding proportions for LBW were 25%, 32%, 16%, and 24%, respectively.

CONCLUSIONS

The association of LBW and SGA with cognitive development in mid-childhood and adolescence is not largely mediated by postnatal stature during the first 2 y of life. Postnatal interventions that address the antecedent causes of poor child growth and development, rather than early childhood growth alone, are more likely to mitigate the risk of suboptimal development among SGA and LBW children. This trial was registered at www.isrctn.com as ISRCTN08850194.

Anthropometrics of Estonian children in relation to family disruption: Thrifty phenotype and Trivers-Willard effects

Background and objectives

The thrifty phenotype hypothesis proposes that at resource limitation, the growth of some organs/tissues is selectively spared to preserve more critical ones, such as the brain or lungs. The Trivers–Willard hypothesis (TWH) predicts that boys are more vulnerable in the case of resource limitation than girls. Both hypotheses were tested in children from disrupted families, differing in the extent of deprivation/adversities imposed on them.

Methodology

In a retrospective cohort study in the mid-20th century Estonia (Juhan Aul’s database), different types of orphans and children of divorced parents (treatment groups; n = 106–1401) were compared with children from bi-parental families (control groups; n = 2548–8648) so that children from treatment groups were matched with control children on the basis of sex, age, year of birth, urban versus rural origin and socioeconomic position.

Results

Children in orphanages suffered strong growth suppression, best explained by psychosocial deprivation. Their feet were on average 0.5 SD shorter than the feet of the controls, followed by height, leg/torso ratio and cranial volume that differed from controls by ca 0.4 SD. Weight difference was 0.2 SD units, while body mass index did not differ from controls. The growth of boys and girls in orphanages was suppressed to the same extent. Boys whose mothers were dead were relatively smaller and less masculine than girls from such families. Fathers’ absence was unrelated to growth suppression. Sons of divorced parents had broader shoulders than boys whose fathers were dead.

Conclusions and implications

Prediction of TWH about the greater vulnerability of male growth may hold under some conditions but not universally. Predictions of the thrifty phenotype hypothesis were partly supported: trunk growth was spared at the expense of leg growth; however, no evidence for brain sparing was found. Comparison of children of divorced versus dead fathers may appear useful for indirect assessment of sexual selection on offspring quality.

Lay Summary: Boys and girls in orphanages suffered similarly strong growth suppression, best explained by psychosocial deprivation. Boys whose mothers were dead were relatively smaller and less masculine than girls from such families. The occurrence of sex-specific associations between family structure and children’s growth depends on the type of family disruption.

Are fathers a good substitute for mothers? Paternal care and growth rates in Shodagor children

Biparental care is a hallmark of human social organization, though paternal investment varies between and within societies. The facultative nature of paternal care in humans suggests males should invest when their care improves child survival and/or quality, though testing this prediction can be challenging because of the difficulties of empirically isolating paternal effects from those of other caregivers. Additionally, the broader context in which care is provided, vis-à-vis care from mothers and others, may lead to different child outcomes. Here, we examine the effects of paternal care on child growth among Shodagor fisher-traders, where fathers provide high levels of both additive and substitutive care, relative to mothers. We modeled seasonal z-scores and velocities for height, weight, and body mass index (BMI) outcomes using linear mixed models. Our evidence indicates that, as predicted, the context of paternal care is an important predictor of child outcomes. Results show that environmental seasonality and alloparental help contribute to a nuanced understanding of the impact of Shodagor paternal care on child physiology.

Integrating anthropometric and cardiometabolic health methods in stress, early experiences, and development (SEED) science

Within Stress, Early Experiences, and Development (SEED) science, there is a growing body of research demonstrating complex associations not only between stress, development, and psychopathology, but also with chronic disease risk factors. We argue that it is important for SEED researchers to consider including child anthropometric and physical health measures to more comprehensively capture processes of risk and resilience. Broader adoption of harmonized anthropometry and health measures in SEED research will facilitate collaborations, yielding larger datasets for research in high-risk populations, and greater opportunity to replicate existing findings. In this review, we identify optimal anthropometric and cardiometabolic health measurement methods used from infancy through adolescence, including those that are low-burden and inexpensive. Methods covered include: waist, hip, and head circumference, height, length, weight, pubertal development, body composition, blood pressure, arterial stiffness, carotid intima media thickness, and serum measures of cardiometabolic risk and inflammation. We provide resources for SEED researchers to integrate these methods into projects or to better understand these methods when reading the literature as well as where to find collaborators for more in-depth studies incorporating these measures. With broader integration of psychological and physical health measures in SEED research, we can better inform theory and interventions to promote health and resilience in individuals who have experienced early stress.

Infections and nutritional status of internationally adopted children in France

AIM

In the context of global changes in the epidemiology of internationally adopted children (IACs), the prevalence of infectious diseases and nutritional impairment has not been recently reviewed. Moreover, in France, these characteristics of the children according to their continents of origin and preadoption special needs (SN) status have been incompletely explored.

METHODS

Demographic, infectious data and anthropometric of all the newly arrived IACs seen in a specialised clinic for international adoptees in Paris, France, between 2013 and 2016 were retrospectively reviewed.

RESULTS

Three hundred and fifty IACs [mean age: 3.4 years (±2.7), 204 male] from 39 countries were included; 55% had SN. Ninety-nine patients had at least one infection, 42% being classified as 'serious' (chronic viral infection, tuberculosis or malaria). Chronic viral infection was diagnosed in 26 (7%) patients (HIV: 16 cases, HBV: 5, HCV: 4) and affected especially Asian children (P < .001). The prevalence of stunting, underweight, wasting and microcephaly was, respectively, 25%, 22%, 15% and 8%. Stunting was more frequent in children from Eastern Europe (P = .02), while SN children were more often microcephalic or underweight (respectively P = .03 and .02).

CONCLUSION

The prevalence of serious infections and nutritional impairment remains high in IACs and requires early detection and careful follow-up.

The Nutritional Status of Individuals Adopted Internationally as Children: A Systematic Review

Since 1955, international adoption has been a way of finding homes for children who have been orphaned or abandoned. We aimed to describe the nutritional status of individuals adopted internationally and their long-term nutritional and health outcomes. We searched four databases for articles published from January 1995 to June 2020, which included information on anthropometric or micronutrient status of children adopted internationally (CAI). Mean Z-scores on arrival to adoptive country ranged from -2.04 to -0.31 for weight for age; -0.94 to 0.39 for weight for height; -0.7 to 0 for body mass index; -1.89 to -0.03 for height for age; -1.43 to 0.80 for head circumference for age. Older children, those adopted from institutionalized care or with underlying disability, were more likely to be malnourished. Though long-term data was scarce, mean Z-scores post-adoption ranged from -0.59 to 0.53 for weight for age; -0.31 to 1.04 for weight for height; 0.39 to 1.04 for body mass index; -1.09 to 0.58 for height for age; -0.06 to 1.23 for head circumference for age. We conclude that though CAI are at high risk of malnutrition at baseline, marked catch-up growth is possible, including for those older than two years of age on arrival. This has implications not only for CAI but for the wider population of malnourished children worldwide. Research on how to optimize catch-up growth is a priority.

Developmental and behavioral profile in a domestic adoptees sample: a new challenge for the pediatrician

BACKGROUND

The aim of this study is to investigate the changes of developmental and behavioral profile in a domestic adoptees sample.

METHODS

Thirty-six domestic adoptive families were recruited, resulting in a sample of 39 children. Families were sent a general questionnaire for collecting data related to the children demographic variables, infant's background (time spent in institutional care, age at adoption), children's health status and anthropometric measures at T<inf>0,</inf> T<inf>1</inf>, T<inf>2</inf>, and T<inf>3</inf>. Moreover, the Infant Behavior Questionnaire-Revised Very Short Form and a modified version of parent-report of Child Behavior Checklist were used to assess temperament and to detect behavioral problems.

RESULTS

As regards the psychopathological evaluation, behavior problems were more common in older children, especially among girls. In particular they exhibited a higher frequency of internalizing problems versus externalizing.

CONCLUSIONS

Children in foster care suffer discontinuity of care that negatively affects their emotional and physical development. It is important for pediatricians to be aware of the special needs of adopted children, providing adequate support to adoptive families.

Emotional Deprivation in Children: Growth Faltering and Reversible Hypopituitarism

Emotional deprivation can lead to growth faltering of infants and children. The mechanism(s) involved differ in that for infants, the major metabolic problem is inadequate energy intake for growth. In young children, it is likely that the emotional deprivation causes a syndrome not only of growth faltering, but with bizarre behaviors, especially with regard to food: hoarding, gorging and vomiting, hyperphagia, drinking from the toilet, and eating from garbage pails. Other disturbed behaviors include, poor sleep, night wanderings, and pain agnosia. The pathophysiology appears to be reversible hypopituitarism, at least for the growth hormone and hypothalamic-pituitary- adrenal axes. The review begins with an historical perspective concerning stress, children and growth and then moves to the issue of hospitalism, where young infants failed to thrive (and died) due to inadequate stimulation and energy intake. Refeeding programs at the end of World Wars I and II noted that some children did not thrive despite an adequate energy intake. It appeared that in addition taking care of their emotional needs permitted super-physiologic (catch-up) growth. Next came the first notions from clinical investigation that hypopituitarism might be the mechanism of growth faltering. Studies that address this mechanism from a number of observational and clinical research studies are reviewed in depth to show that the hypopituitarism was relieved upon removal from the deprivational environment and occurred much too quickly to be due to adequate energy alone. These findings are then compared to those from malnourished children and adoptees from emerging countries, especially those from orphanages where their psychosocial needs were unmet despite adequate caloric intake. Together, these various conditions define one aspect of the field of psychoneuroendocrinology.

A Systematic Review of Reviews of the Outcome of Severe Neglect in Underresourced Childcare Institutions

The aim of the systematic review described in this article was to determine the outcomes for individuals exposed to severe neglect in congregate care institutions such as orphanages. In this context, severe neglect refers to failure to meet children's basic physical, developmental, and emotional needs due to inadequate resources. In this systematic review of previous systematic reviews and meta-analyses, searches of 10 databases were conducted, 18 papers that met inclusion and exclusion criteria were selected for review, their quality was assessed, and data were extracted and synthesized. The 550 primary studies included in the 18 systematic reviews and meta-analyses were relatively well designed, allowing confidence to be placed in their results. Severe neglect was associated with a wide range of problems in the domains of physical development, cognitive development, attachment, and mental health. The severity of adverse outcomes was partly influenced by the duration and severity of deprivation and a constellation of risk and protective factors. Prevention policies should aim to eliminate large underresourced congregate care institutions for infants. In taking steps toward this, policies should aim to adequately resource congregate care institutions to meet children's developmental needs for nutrition, stimulation, and attachment to a stable primary caregiver with adequate parenting skills and training. Early placement in adoptive or foster families, with access to routine physical and mental health-care service available in developed countries, is the most viable effective intervention for child survivors of severe neglect.

Can Children Catch up from the Consequences of Undernourishment? Evidence from Child Linear Growth, Developmental Epigenetics, and Brain and Neurocognitive Development

Recovery from nutritionally induced height deficits continues to garner attention. The current literature on catch-up growth, however, has 2 important limitations: wide-ranging definitions of catch-up growth are used, and it remains unclear whether children can recover from the broader consequences of undernutrition. We addressed these shortcomings by reviewing the literature on the criteria for catch-up in linear growth and on the potential to recover from undernutrition early in life in 3 domains: linear growth, developmental epigenetics, and child brain and neurocognitive development. Four criteria must be met to demonstrate catch-up growth in height: after a period in which a growth-inhibiting condition (criterion 1) causes a reduction in linear growth velocity (criterion 2), alleviation of the inhibiting condition (criterion 3) leads to higher-than-normal velocity (criterion 4). Accordingly, studies that are observational, do not use absolute height, or have no alleviation of an inhibiting condition cannot be used to establish catch-up growth. Adoption and foster care, which provide dramatic improvements in children's living conditions not typically attained in nutrition interventions, led to some (but incomplete) recovery in linear growth and brain and neurocognitive development. Maternal nutrition around the time of conception was shown to have long-term (potentially permanent) effects on DNA methylation in the offspring. Undernourishment early in life may thus have profound irreversible effects. Scientific, program, and policy efforts should focus on preventing maternal and child undernutrition rather than on correcting its consequences or attempting to prove they can be corrected.

Risk of eating disorders in international adoptees: a cohort study using Swedish national population registers

AIMS

Compared to the general population, adoptees are more often referred to specialist psychiatric treatment, exhibit increased risk of suicide and display more symptoms of attention-deficit/hyperactivity-disorder. However, little is known about the impact of being an adoptee on the risk of developing an eating disorder. The aim of the present study was to assess whether international adoptees have a higher risk for eating disorders than native Swedes.

METHODS

In the present retrospective cohort study, data from the Swedish total population registers on individuals born between 1979 and 2005 were used to assess whether international adoptees residing in Sweden (n = 25 287) have a higher risk for anorexia nervosa (AN) and other eating disorders (OED) than non-adoptees with Swedish-born parents from the general population (n = 2 046 835). The patterns of these results were compared to those for major depressive disorder (MDD), obsessive-compulsive disorder (OCD), and anxiety disorders to determine whether any observed effects were unique to eating disorders or reflected a more general impact on mental health outcomes.

RESULTS

A survival analysis adjusting for relevant demographic covariates revealed an elevated risk of all examined psychiatric disorders in international adoptees: hazard ratios (95% confidence intervals) are 1.21 (1.04-1.41) for AN, 1.60 (1.44-1.79) for OED, 1.90 (1.81-2.00) for MDD, 1.25 (1.09-1.44) for OCD, and 1.69 (1.60-1.78) for anxiety disorders.

CONCLUSIONS

Elevated risk of eating disorders as well as of MDD, OCD, and anxiety disorders was found in international adoptees. A parallel pattern between AN and OCD was observed, which both display less elevated rates than the other diagnoses. A considerable number of biological, environmental, and societal factors have been suggested to explain the observed differences in mental health between adoptees and non-adoptees, but they remain primarily theoretical.

Early childhood deprivation is associated with alterations in adult brain structure despite subsequent environmental enrichment

Millions of children worldwide live in nonfamilial institutions. We studied impact on adult brain structure of a particularly severe but time-limited form of institutional deprivation in early life experienced by children who were subsequently adopted into nurturing families. Institutional deprivation was associated with lower total brain volume in a dose-dependent way. Regionally specific effects were seen in medial prefrontal, inferior frontal, and inferior temporal areas. Deprivation-related alterations in total brain volume were associated with lower intelligence quotient and more attention deficit/hyperactivity disorder symptoms; alterations in temporal volume seemed compensatory, as they were associated with fewer attention deficit/hyperactivity disorder symptoms. We provide evidence that early childhood deprivation is related to alterations in adult brain structure, despite environmental enrichment in intervening years.

Early childhood deprivation is associated with higher rates of neurodevelopmental and mental disorders in adulthood. The impact of childhood deprivation on the adult brain and the extent to which structural changes underpin these effects are currently unknown. To investigate these questions, we utilized MRI data collected from young adults who were exposed to severe deprivation in early childhood in the Romanian orphanages of the Ceaușescu era and then, subsequently adopted by UK families; 67 Romanian adoptees (with between 3 and 41 mo of deprivation) were compared with 21 nondeprived UK adoptees. Romanian adoptees had substantially smaller total brain volumes (TBVs) than nondeprived adoptees (8.6% reduction), and TBV was strongly negatively associated with deprivation duration. This effect persisted after covarying for potential environmental and genetic confounds. In whole-brain analyses, deprived adoptees showed lower right inferior frontal surface area and volume but greater right inferior temporal lobe thickness, surface area, and volume than the nondeprived adoptees. Right medial prefrontal volume and surface area were positively associated with deprivation duration. No deprivation-related effects were observed in limbic regions. Global reductions in TBV statistically mediated the observed relationship between institutionalization and both lower intelligence quotient (IQ) and higher levels of attention deficit/hyperactivity disorder symptoms. The deprivation-related increase in right inferior temporal volume seemed to be compensatory, as it was associated with lower levels of attention deficit/hyperactivity disorder symptoms. We provide compelling evidence that time-limited severe deprivation in the first years of life is related to alterations in adult brain structure, despite extended enrichment in adoptive homes in the intervening years.

Enhancing Parenting Quality for Young Children Adopted Internationally: Results of a Randomized Controlled Trial

Children adopted internationally are often dysregulated biologically and behaviorally due to prior experiences of institutional care or caregiving changes and thus are in need of enhanced parental care. The present study assessed whether parents randomized to receive Attachment and Biobehavioral Catch-up (ABC) demonstrated significant improvements in parenting quality when compared to parents receiving a control intervention. Participants were 120 internationally adopted children and their adoptive parents. Sixty-three (52.5%) of the children and 113 (94.2%) of the primary caregivers were female. Children were adopted from several countries and predominantly from China, Russia, South Korea, and Ethiopia. The majority of parents identified themselves as White/non-Hispanic (95.0%). At the start of intervention, parents ranged in age from 26.2 to 51.1 years old (M= 39.7, SD = 6.0), and children ranged in age from 6.8 months to 48.4 months (M = 21.9, SD = 9.0). Sensitivity (i.e., contingent responsiveness to a child's cues), intrusiveness (i.e., physical and/or verbal behavior that interferes with a child's autonomy), and positive regard (i.e., positive affect expressed towards a child) were assessed at preintervention, immediately postintervention, and at annual follow-up visits. Parents who received ABC showed better parenting quality at postintervention than parents who received a control intervention, and these effects persisted at a 2-year follow-up. Findings add to the growing evidence that ABC improves parenting abilities, extending findings to adoptive parents and demonstrating that improvements in parenting quality were sustained several years after completion of the intervention. Trial registration: ClinicalTrials.gov NCT00816621.

Early Deprivation Revisited: Contemporary Studies of the Impact on Young Children of Institutional Care

There is clear evidence that early deprivation in the form of early institutional care affects children both immediately and long after they are removed from the institution. This article reviews the modern literature on the impact of institutional care from animal models to longitudinal studies in humans. Importantly, we examine the current understanding of neuroendocrine regulation in the context of early deprivation. We discuss the opportunities and limitations of studying the effects of deprivation in previously institutionalized children, review behavioral findings and related neurobiological studies, and address the physical health ramifications of institutional care. Finally, we touch on future directions for both science and intervention.

The psychobiological consequences of child separation at the border: lessons from research on attachment and emotion regulation

In the spring of 2018, the Attorney General of the United States issued a memorandum declaring a "zero tolerance policy" under which all adults entering the United States illegally would be criminally prosecuted, and, if traveling with minor children, forcibly separated from their children. Although the government was ordered to reunite the children with their parents it is still unclear how many children have been or remain separated. Given the high risk of permanent harm to a vulnerable population, and the fact that this risk may continue into the near future, we present a review of what nearly eight decades of scholarly research has taught us about the damaging impact of deprivation and separation from parents. The article briefly reviews the origins of attachment theory as well as empirical studies that examine the psychobiological impact on children who experienced parental deprivation or separation. The paper concludes with recommendations, for future research.

Auxo-endocrinological features in a cohort of internationally adopted children in Italy

BACKGROUND

Internationally adopted children (IAC) can present growth impairment at arrival, which usually recovers over time. Moreover, a major prevalence of precocious puberty has been reported in this group.

METHODS

All IAC referred to a tertiary level hospital in Italy from January 2016 to June 2017, underwent a standardized screening protocol and were prospectively enrolled in the study. The analyses of possible risk factors for growth impairment and precocious puberty were performed.

RESULTS

Overall, 422 children were included (males 59.5%), with median age of 6.5 years (IQR 9.4-3.9), 29.9% adopted from Europe, 26.8% from Asia, 23.9% from Africa and 19.4% from Latin America. Children were in Italy from a median of 75 days (IQR 137.0-38.7). Stunting was observed in 12.9% of children, wasting in 4.3%, underweight in 12.9%. Precocious puberty was diagnosed in 2.2% of children. 17.1% IAC had diagnosis of special needs. Fetal alcohol spectrum disorders represented the 41.7% of children with special needs and 48.1% of Russian children. Independent predictive factors for stunting were age < 5 years, a diagnosis of special need and having been living in Italy for < 60 days since the arrival.

CONCLUSION

Stunting among IAC is a frequent finding especially in children < 5 years and in those with special needs, independently from their geographical origin.

Pubertal recalibration of cortisol reactivity following early life stress: a cross-sectional analysis

BACKGROUND

Children adopted from orphanages or other such institutions tend to display blunted reactivity to stressors - even years after arriving in their generally supportive and highly resourced postadoption homes. Puberty, a proposed sensitive period for environmental influences on stress-mediating systems, may provide an opportunity for postinstitutionalized children to recalibrate stress response systems in accordance with their now more supportive living situations.

METHODS

This cross-sectional study examined the hypothalamic-pituitary-adrenocortical (HPA)-axis reactivity of 280 children ages 7 through 14 years; 122 children were adopted from institutions in 14 countries between the ages of 6 months and 5 years, after spending an average of 95% of their lives in institutional care, and 158 children of similarly high socioeconomic status in their biological families served as the nonadopted comparison group. All of the children were assessed by nurses for Tanner stage and, on a different day, completed the Trier Social Stress Test for Children.

RESULTS

Using a linear mixed-effects model and seven measures of salivary cortisol, results indicated that early-pubertal postinstitutionalized children showed blunted HPA axis reactivity compared to nonadopted children, but mid/late-pubertal postinstitutionalized children displayed higher reactivity similar to the nonadopted comparison children.

CONCLUSIONS

This is the first evidence of possible pubertal recalibration of HPA axis reactivity to a psychosocial stressor in postinstitutionalized children, which provides a promising avenue for future research regarding the protective factors of the postadoption environment and subsequent physiological, behavioral, and psychopathological outcomes.

Caregiving Disruptions Affect Growth and Pubertal Development in Early Adolescence in Institutionalized and Fostered Romanian Children: A Randomized Clinical Trial

OBJECTIVES

To determine the effects of foster care vs institutional care, as well as disruptions in the caregiving environment on physical development through early adolescence.

STUDY DESIGN

This was a randomized controlled trial of 114 institutionalized, though otherwise healthy, children from 6 orphanages and 51 never institutionalized control children living in birth families (family care group) in Bucharest, Romania. Children were followed from baseline (21 months, range 5-31) through age 12 years for caregiving disruptions and growth trajectories and through age 14 years for pubertal development.

RESULTS

Children randomized to the foster care group showed greater rates of growth in height, weight, and body mass index (BMI) through age 12 years than institutionalized group. Tanner development was delayed in institutionalized group boys compared with foster care group and family care group boys at 12 but not 14 years. There were no differences in Tanner development and age of menarche among foster care group, institutionalized group, and family care group girls at ages 12 and 14 years. More disruptions in caregiving between 30 months and 12 years moderated decreases in growth rates of height in foster care group and weight in foster care group and institutionalized group across age. institutionalized group boys with ≥2 disruptions showed lower Tanner scores at age 12 vs institutionalized group and foster care group boys with <2 disruptions. foster care group girls with ≥2 disruptions had higher Tanner scores at age 14 vs foster care group girls with <2 disruptions. Age of menarche was not affected by caregiving disruptions.

CONCLUSIONS

For children who experienced early institutionalization, stable placement within family care is essential to ensuring the best outcomes for physical developmental.

TRIAL REGISTRATION

clinicaltrials.gov: NCT00747396.

Catch-up growth, metabolic, and cardiovascular risk in post-institutionalized Romanian adolescents

BACKGROUND

Reduced prenatal growth followed by rapid postnatal weight gain are risk factors for developing metabolic and cardiovascular disease. Children reared in institutions experience a similar pattern of growth restriction followed by catch-up growth after removal. We explored whether patterns of catch-up growth affect metabolic and cardiovascular outcomes in previously institutionalized adolescents.

METHOD

A longitudinal study of institutionalized infants randomized to care as usual (n = 68) or foster care intervention (n = 68), and never institutionalized controls (n = 127). Body mass index (BMI) was measured at baseline (20 months), 30, 42 months, and ages 8, 12, 16. At age 16, metabolic and pro-inflammatory markers were derived from blood samples.

RESULTS

Four BMI trajectories were derived (i.e., average-stable, low-stable, elevated, and accelerated). The accelerated trajectory was comprised predominately of children randomized to foster care, who also exhibited higher levels of glycosylated hemoglobin and C-reactive protein than the other three trajectories. Also, children placed in foster care at younger ages were more likely to be on the accelerated rather than the average-stable trajectory.

CONCLUSIONS

Although catch-up growth is viewed as a positive improvement among post-institutionalized children, rapid/continuous increases in body size pose a health concern. Attention should be given to monitoring weight gain, diet, and physical activity.

Using a population-based survey approach to estimate child separation after a natural disaster: findings from post-Hurricane Haiti

Introduction

This study explores findings of a population-based approach to measure the prevalence of unaccompanied and separated children (UASC) during the Hurricane Matthew aftermath in Haiti.

Methods

We conducted a cross-sectional survey using two-stage cluster sampling. Participants were asked to provide information on their own household composition, as well as the household composition of their closest neighbour (the Neighborhood Method). The study took place between February and March 2017 in Haiti's Sud Department, a region severely affected by Hurricane Matthew in October 2016. 1044 primary respondents provided information about their own household, and 4165 people in the household of their closet neighbour. The primary outcome measured was the prevalence of UASC in the Sud Department following Hurricane Matthew. Secondary outcomes of interest included the characteristics of these children, including age, sex, reason for separation and current caregiver.

Results

Of the 2046 children currently living in the surveyed households, 3.03% (95% CI 2.29% to 3.77%) were reported to have been separated from their normal caregiver during Hurricane Matthew. Among these 62 children, 9 were unaccompanied, and there were slightly more boys than girls (56% vs 44%, p=0.37). Of the 2060 children who lived in surveyed households when the hurricane hit, 1.12% (95% CI 0.67% to 1.57%) had since departed without their caregiver. The prevalence of separation reported for neighbours' households was not significantly different from that in respondents' households (p values between 0.08 and 0.29).

Conclusions

This study is the first known attempt to measure the prevalence of child separation following a natural disaster. Overall, the rates of separation were relatively low. Similarities between primary and secondary reports of child separation via the Neighborhood Method indicate that this may be a viable approach to measuring UASC in certain contexts.

Delayed age at transfer of adoptees to adoptive parents is associated with increased mortality irrespective of social class of the adoptive parents: a cohort study

BACKGROUND

Adverse early life experience and development may have long-term health consequences, but later environmental conditions may perhaps protect against the effects of such early life adversities. The aim was to investigate whether cause-specific and overall mortality rates among adoptees are associated with the age at which they were transferred to the adoptive family and whether the social class of the adoptive family modifies this association.

METHODS

A cohort of 10,592 non-familial adoptions (biologically unrelated adoptee and adoptive parents) of Danish-born children formally granted in 1924-47 and with follow-up of total and cause-specific mortality through ages up to 85 years. The rates of death after the age of 16 from all causes combined, all natural causes, all external causes, and suicide were compared according to the age at which adoptees were transferred to their adoptive family by estimating hazard ratios in Cox regression models.

RESULTS

Death rates from all causes were significantly higher in adoptees transferred between age 1 month and 4 years compared to those transferred immediately after birth with the hazard ratio peaking at 1.19 (95% confidence limit: 1.08 to 1.32) for adoptees transferred between 6 and 11 months. This result was primarily driven by a similar pattern for natural causes of death. For death from external causes and for suicide the hazard ratios were increasing with increasing age at transfer, and tests for trend were statistically significant. The social class of the adoptive family did not significantly modify these associations.

CONCLUSIONS

Transfer to an adoptive family later than at the time of birth may have adverse long-term consequences affecting overall and cause-specific mortality. These effects were not modified by the environment provided by the adoptive family as indicated by the social class of these families.

Growth recovery in newly arrived international adoptees in Italy: relation to parenting stress

BACKGROUND

Following initial adversities, most internationally adopted children arrive with significant growth delays. Postplacement recovery has been widely documented, but research about risk or protective factors is still limited. Even less is known about the relationship between growth recovery and the quality of the family environment.

METHODS

Twenty-eight children in 26 adoptive families were involved in this longitudinal study. A comprehensive evaluation (including anthropometry, cognitive assessment [using the Leiter International Performance Scale-Revised], and completion by both parents of the Parenting Stress Index - Short Form) was done at arrival of the child, and 1 year later.

RESULTS

Results evidenced that on arrival nearly half of children had growth measurements in the normal range. All the children showed a significant recovery in height and weight at 6 and 12 months postplacement. Initial and follow-up growth measurements correlated strongly. Growth recovery was related to the age of the child at adoption, the proportion of time the child had resided in institutional care, as well as parenting stress. Results suggested that the higher the parenting stress experienced the less improvements occurred in children: for mothers for height and weight, for fathers for all the growth indicators.

CONCLUSIONS

Results suggested the critical importance of family factor in influencing children's growth recovery.

Development of children adopted to the United States following a social-emotional intervention in St. Petersburg (Russian Federation) institutions

This study is a post-adoption follow-up of a social-emotional intervention in St. Petersburg, Russian Federation Baby Homes (BHs). Children previously resided in BHs and received Care as Usual (CAU, N=220), Training Only (TO, N=94), or Training plus Structural Changes (T+SC, N=45). This study examined intervention effects 0-6.5 years post-adoption to the USA, at age 9 months to 7 years old. Adoptive parents completed questionnaires on their child's social and behavioral development. Intervention graduates had better attachment security, less indiscriminate friendliness, and fewer behavior problems than CAU graduates. Children who had longer exposure to intervention conditions had better attachment security, but poorer executive function, externalizing and internalizing problems, and competence. Thus, although post-institutionalized children were generally functioning in the normal range in early childhood and effect sizes were small, a social-emotional intervention in institutions is associated with modest benefits to attachment and behavior problems and apparent decrements to executive function.

CAREGIVER-CHILD INTERACTION, CAREGIVER TRANSITIONS, AND GROUP SIZE AS MEDIATORS BETWEEN INTERVENTION CONDITION AND ATTACHMENT AND PHYSICAL GROWTH OUTCOMES IN INSTITUTIONALIZED CHILDREN

This report describes a secondary analysis of data from a comprehensive intervention project which included training and structural changes in three Baby Homes in St. Petersburg, Russian Federation. Multiple mediator models were tested according to the R.M. Baron and D.A. Kenny () causal-steps approach to examine whether caregiver-child interaction quality, number of caregiver transitions, and group size mediated the effects of the intervention on children's attachment behaviors and physical growth. The study utilized a subsample of 163 children from the original Russian Baby Home project, who were between 11 and 19 months at the time of assessment. Results from comparisons of the training and structural changes versus no intervention conditions are presented. Caregiver-child interaction quality and number of caregiver transitions fully mediated the association between intervention condition and attachment behavior. No other mediation was found. Results suggest that the quality of interaction between caregivers and children in institutional care is of primary importance to children's development, but relationship context may play a less direct mediational role, supporting caregiver-child interactions.

Biological embedding of perinatal social relationships in infant stress reactivity

Whereas significant advances have been made in understanding how exposure to early adversity "gets under the skin" of children to result in long term changes in developmental outcomes, the processes by which positive social relationships become biologically embedded remain poorly understood. The aim of this study was to understand the pathways by which maternal and infant social environments become biologically embedded in infant cortisol reactivity. Two hundred seventy-two pregnant women and their infants were prospectively assessed during pregnancy and at 6 months postpartum. In serial mediation analyses, higher perceived social support from partners during pregnancy was associated with lower infant cortisol reactivity or larger decreases in cortisol in response to a stressor at 6 months of age via lower self-reported prenatal maternal depression and higher mother-infant interaction quality. The findings add to our understanding of how perinatal social relationships become biologically embedded in child development.

Child violence experiences in institutionalised/orphanage care

Institutions are not necessarily good environments for children. In the face of challenges such as HIV, Ebola, poverty, conflict and disaster the numbers have grown rather than reduced. Some countries have closed institutions down -driven by findings that cognitive developmental delay is associated with institutional care. Yet insight into abuse and violence within institutionalised settings is neglected. Maltreatment -violence and abuse -may be an issue. This systematic review series addresses violence and abuse experiences in institutionalised care, exploring firstly the frequency of abuse/violence in institutions, secondly any interventions to reduce such violence or abuse and thirdly the perpetrators of such violence or abuse. The final systematic review updates the findings on cognitive delay associated with institutionalised care. With a violence lens, cognitive delay may well be considered under the umbrella of neglect. Maltreatment and abuse may be a driver of cognitive delay. The keyword search covered several electronic databases and studies were included for data abstraction if they met adequacy criteria. Eight studies were identified on the prevalence of abuse in institutions and a further three studies reported on interventions. Only one study was identified documenting peer on peer violence in institutions. Sixty-six studies were identified examining cognitive development for institutionalised children. All but two of these record cognitive deficits associated with institutionalisation. Only two asked about violence or abuse which was found to be higher in institutionalised children. Overall the abuse experiences of children in institutions are poorly recorded, and in one study violence was associated with high suicidal attempts. The major intervention pathway for ameliorating cognitive challenge seems to be placement out of the institutions which shows benefits and redresses some cognitive outcomes - yet not a total panacea. The single study providing training and monitoring of harsh punishment and maltreatment showed immediate and decided reductions. This data suggest, despite the paucity of studies, violence and abuse, by commission or omission is prevalent in institutions, has an effect on child well-being and is amenable to intervention. Simple training or more complex structures to place children within conducive alternative environments (or to avoid institutionalised placements in the first place) seem to be the main pathway of intervention.

Nutritional status of foster children in the U.S.: Implications for cognitive and behavioral development

OBJECTIVE

Children in foster care are at greater risk for poor health, physical, cognitive, behavioral, and developmental outcomes than are children in the general population. Considerable research links early nutrition to later cognitive and behavioral outcomes. The aim of this narrative review is to examine the prevalence of poor nutrition and its relation to subsequent health and development in foster children.

METHOD

Relevant studies for inclusion were identified from numerous sources (e.g., PubMed, Google Scholar, and reference sections). Inclusion criteria were studies published between 1990 and 2016 of (i) the nutritional status of children in foster care or (ii) the nutritional status of children exposed to early adversity (e.g., low-income and internationally adopted children) or (iii) the developmental effects of poor nutrition and micronutrient deficiencies.

RESULTS

Two key findings that have adverse implications for cognitive development emerged: (i) the prevalence of anemia and iron-deficiency anemia is higher among foster children than among the general population of children in the U.S., and (ii) the developmental demands of catch-up growth post-placement may lead to micronutrient deficiencies even after children have begun sufficient dietary intake of these nutrients. Moreover, there is a paucity of recent studies on the nutritional status of children in foster care, despite the multiple factors that may place them at risk for malnutrition.

CONCLUSION

Attention to nutritional status among care providers and medical professionals may remove one of the possible negative influences on foster children's development and in turn significantly alter their trajectories and place them on a more positive path early in life. Recommendations for further research, policy, and practice are discussed.

The Development of Children Placed into Different Types of Russian Families Following an Institutional Intervention

This study examined whether interventions in Russian Baby Homes promoting warm, sensitive, and responsive caregiver-child interactions and relationships would be associated with advantages in those children's behavior years after they transitioned to family care. Children (N = 135) who had resided for at least 3 months (M = 13.8 months) in one of three intervention institutions were subsequently placed in Russian families (relatives or non-relatives) for at least 1 year (M = 33.5 months). When children were 1.5-10.8 years of age, parents provided ratings of attachment, indiscriminate friendliness, executive functioning, social-emotional development, and behavior problems. Despite very substantial differences in the developmental status of children at departure from the three institutions, there were fewer than expected significant differences between children from the three institutions at follow-up or as a function of being placed with relatives or non-relatives. Specifically, children reared in the most improved institution displayed less indiscriminate friendliness, were less aggressive/defiant, and had less externalizing behavior. Children from all three institutions who were placed into families at older ages tended to be rated more poorly on some measures. These results suggest that previously institutionalized children adjust well to family life, but improved institutional caregiving can have some persistent benefits over several years in children transitioned to families.

Do internationally adopted children in the Netherlands use more medication than their non-adopted peers?

Empirical evidence has shown that international adoptees present physical growth delays, precocious puberty, behavioral problems, and mental health referrals more often than non-adoptees. We hypothesized that the higher prevalence of (mental) health problems in adoptees is accompanied by elevated consumption of prescription drugs, including antidepressants, attention deficit hyperactivity disorder (ADHD) medication, and medication for growth inhibition/stimulation. In an archival, population-based Dutch cohort study, data on medication use were available from the Health Care Insurance Board by Statistics Netherlands from 2006 to 2011. The Dutch population born between 1994 and 2005 and alive during the period of measurement was included (2,360,450 including 10,602 international adoptees, of which 4447 from China). Their mean age was 6.5 years at start (range 1-12 years) and 11.5 years at the end of the measurement period (range 6-17 years). Chinese female adoptees used less medication for precocious puberty (as treatment for precocious puberty; odds ratio (OR) = 0.57, effect size Cohen's d = -0.31) and contraception (OR = 0.65, d = -0.24) than non-adoptees. For both males and females, non-Chinese adoptees used more medication for ADHD than non-adoptees (males: OR = 1.22, females: OR = 1.32), but the effect was small (males: d = 0.11, females: d = 0.15).

CONCLUSIONS

Adoptees in the Netherlands generally do not use more medication than their non-adopted peers.

WHAT IS KNOWN

• Meta-analytical evidence shows that international adoptees present physical growth delays and mental health referrals more often than non-adopted controls. • With the exception of one Swedish study on ADHD medication, there is no other systematic research on medication use of international adoptees. What is New: • All differences in medication use between international adoptees in the Netherlands and non-adopted controls were below the threshold of a small effect with the exception of medication for precocious puberty, but this effect was in the opposite direction with female adoptees using less medication for precocious puberty than non-adoptees. • International adoptees in the Netherlands do not use more medication despite experiences of preadoption adversity and higher rates of mental health referrals during childhood and adolescence.

Micronutrient status and neurodevelopment in internationally adopted children

AIM

To assess the status of nutrients relevant for brain development in internationally adoptees from disparate global regions and determine whether identified deficiencies are associated with neurodevelopment.

METHODS

Participants included children adopted from Post-Soviet States (n = 15), Ethiopia (n = 26) or China (n = 17), ages 8-18 months. A comprehensive nutritional battery and a neurodevelopmental assessment were completed at baseline (within one month of arrival) and follow-up (six months later).

RESULTS

At baseline, 35% were stunted, and 68% had at least one abnormal nutritional biochemical marker. The most common were low retinol-binding protein (33%), zinc deficiency (29%), vitamin D insufficiency/deficiency (21%), and iron deficiency (15%). There was significant catch-up growth in height and weight at follow-up, but little improvement in micronutrient deficiencies. Iron deficiency was associated with lower cognitive scores on the Bayley Scales of Infant Development-III, p = 0.027, and slower speed of processing, p = 0.012. Zinc deficiency was associated with compromised memory functioning, p = 0.001.

CONCLUSION

Nutrient deficiencies were common during the early adoption period in internationally adoptees from three global regions, and iron and zinc deficiencies were associated with poorer neurodevelopmental outcomes. Results emphasise the importance of monitoring micronutrient status at arrival and during the early adoption period, irrespective of country of origin.

Estimating child separation in emergencies: Results from North Kivu

Children who are separated from their families and usual caregivers in emergencies face a multitude of risks to their health and wellbeing. This study presents findings from the first known population-based estimation of separation in an emergency setting. Point prevalence and basic characteristics were measured to inform programming, policies and funding for affected populations. A household survey was carried out in the Democratic Republic of the Congo to estimate separation subsequent to an attack by the M23 militia group. Separation was tracked in terms of children arriving into the household after the M23 attacks and children who had departed from the household after the recall event without their parent or usual caregiver. Five hundred and twenty-two households were surveyed. In the sample of 2,197 children living in the respondents' homes at the time of data collection, 8.47% (n=186) were separated children who had newly arrived in the household since the M23 attack. In the sample of 2,034 children living in the respondents' homes prior to the M23 attack, 5.31% (n=108) children had since departed from the household, resulting in separation from their parents or usual caregivers. Characteristics of children who arrived and children who departed diverged in terms of age, reasons for separation and frequency of unaccompaniment. The findings indicate the potential for population-based estimation of separation to be replicated in emergency settings to inform funding appeals and programmatic response.

The development of postinstitutionalized versus parent-reared Russian children as a function of age at placement and family type

A total of 149 children, who spent an average of 13.8 months in Russian institutions, were transferred to Russian families of relatives and nonrelatives at an average age of 24.7 months. After residing in these families for at least 1 year (average = 43.2 months), parents reported on their attachment, indiscriminately friendly behavior, social-emotional competencies, problem behaviors, and effortful control when they were 1.5-10.7 years of age. They were compared to a sample of 83 Russian parents of noninstitutionalized children, whom they had reared from birth. Generally, institutionalized children were rated similarly to parent-reared children on most measures, consistent with substantial catch-up growth typically displayed by children after transitioning to families. However, institutionalized children were rated more poorly than parent-reared children on certain competencies in early childhood and some attentional skills. There were relatively few systematic differences associated with age at family placement or whether the families were relatives or nonrelatives. Russian parent-reared children were rated as having more problem behaviors than the US standardization sample, which raises cautions about using standards cross-culturally.

Associations between physical growth and general cognitive functioning in international adoptees from Eastern Europe at 30 months post-arrival

Background

Internationally adopted children have often experienced early adversity and growth suppression as a consequence of institutional care. Furthermore, these children are at risk for impaired cognitive development due to their early adverse experiences. This study examined the association between physical growth, the growth hormone (GH) system, and general cognitive functioning post-adoption. Based on previous research, we expected to find that a child’s initial physical growth status and normalization of the growth hormone-insulin-like growth factor 1 (GH-IGF-1) axis would be positive predictors of general cognitive functioning.

Methods

Post-institutionalized children (n = 46) adopted from Eastern Europe were seen approximately 1 month after their arrival into the USA to determine baseline measurements. They were seen again 6 and 30 months later for two follow-up sessions. Measures included anthropometry, insulin-like growth factor-1 (IGF-1), IGF binding protein-3 (IGFBP-3), Mullen Scales of Early Learning, and Stanford-Binet Intelligence Scales. Information about parental education was also collected.

Results

We found that a child’s general cognitive functioning at 30 months post-adoption was predicted by their general developmental scores at 6 months post-adoption, their initial height status, and markers of the growth hormone system. Children with lower initial IGFBP-3 standard deviation (SD) scores had higher verbal IQ scores at 30 months. Furthermore, a child’s initial height was found to be a significant positive predictor of non-verbal IQ.

Conclusions

These results suggest an association between a child’s suppressed physical growth in response to early adversity and alterations in GH system functioning and subsequent recovery in cognitive functioning.