Health of Children Adopted from Guatemala: Comparison of Orphanage and Foster Care

Health of Children Adopted From Guatemala: Comparison of Orphanage and Foster Care

Laurie Miller, MD; Wilma Chan, BS; Kathleen Comfort, PT, MHA; and Linda Tirella, OTR/L, MHA, MS

ABSTRACT. Objective. Since 1986, American parents those who resided in foster care before adoption had have adopted >17 300 children from Guatemala. This better measurements for height, weight, and head cir- study assessed the health, growth, and developmental cumference at arrival to the United States. Moreover, status of 103 Guatemalan adopted children (48 girls; 55 those who resided in foster care scored significantly bet- boys) after arrival in the United States. Physical evidence ter for cognitive skills than those who had previously suggestive of prenatal alcohol exposure and adequacy of resided in orphanages (96.3% of age-expected compared vaccinations administered were also reviewed. with 88.3% of age-expected); other skills did not differ Methods. Retrospective chart review was conducted between the 2 groups. No differences were found be- of 103 children who were evaluated after arrival in the tween the 2 groups of children related to prevalence of United States in an international adoption specialty medical diagnoses or phenotypic evidence suggesting clinic, and a case-matched study was conducted of a prenatal alcohol exposure. subgroup of 50 children who resided in either an orphan- Conclusions. Guatemalan adoptees display similar age or foster care before adoption. Mean age at arrival overall patterns of growth and developmental delays as ؎ was 16 19 months. Before adoption, 25 children resided seen in other groups of internationally adopted children, in orphanages, 56 resided in foster care, and 22 resided in although not as severe. Younger children had better mixed-care settings. The 25 children who had resided in growth and development (cognition, language, and activ- orphanages before adoption were matched for age at ities of daily living skills) than older children, regardless arrival, interval from arrival to clinic visit, and gender of location of residence before adoption. Among children with a child adopted from foster care. Health and devel- who were matched for age, gender, and interval from opmental status of these matched pairs were compared, adoption to evaluation, those who had resided in foster allowing the first direct comparison of children raised in care had better growth and cognitive scores than children orphanages or foster care before adoption. who had resided in orphanages before adoption. These Results. Mild growth delays were frequent among findings support the need for timely adoptive placement the children. Mean z scores for weight, height, and head ؊ ؊ of young infants and support the placement of children circumference were, respectively, 1.00, 1.04, and in attentive foster care rather than orphanages when ؊1.08. Children from foster care had significantly better feasible. Pediatrics 2005;115:e710–e717. URL: www. z scores for height, weight, and head circumference than pediatrics.org/cgi/doi/10.1542/peds.2004-2359; interna- those from orphanage or mixed care. Among children tional adoption, orphanage, foster care, Guatemala. who were younger than 2 years at arrival, growth measurements correlated inversely with age at arrival. Infec- tious diseases included intestinal parasites (8%) and doption of children from other nations has latent tuberculosis infection (7%). Other medical condi- significantly increased in the past 2 decades. tions included anemia (30%), elevated lead levels (3%), Ͼ and (using strict criteria) phenotypic facial features sug- Since 1986, 230 000 children have been A 1 gestive of prenatal alcohol exposure (28%). Adequacy of adopted from other countries by American parents. vaccine records from Guatemala was assessed: 28% met More than 17 300 of these children arrived from Gua- American Academy of Pediatrics standards for vaccine temala; all indications suggest that this number will administration. Unsuspected significant medical diag- continue to increase. Guatemala has been among noses, including congenital anomalies and ocular, neu- the top 5 birth countries for internationally adopted rologic, and orthopedic problems, were found in 14%. children arriving in the United States since 1992. Most children were doing well developmentally (80–92% Adoptive parents often select Guatemala because of of expected performance), but 14% had global develop- the availability of young infants and because many mental delays. Cognition, expressive and receptive language, and activities of daily living skills correlated in- children reside in foster care before adoption. Some versely with age at arrival for children who were younger children, however, reside in orphanages before than 2 years at adoption. Among the 50 matched children, adoptive placement. Little is known about the quality of care provided in either of these settings. The health of Guatemalan children after arrival in the From the Department of Pediatrics, New England Medical Center, Boston, United States has not been evaluated comprehen- Massachusetts. Accepted for publication Dec 20, 2004. sively. Adoptive parents, adoption agencies, and doi:10.1542/peds.2004-2359 physicians who care for internationally adopted chil- No conflict of interest declared. dren have wondered whether the young age at place- Address correspondence to Laurie Miller, MD, Department of Pediatrics, ment and residence in foster care (rather than or- New England Medical Center, 750 Washington St, Boston, MA 02111. phanages) reduce the frequency of health and E-mail: [email protected] PEDIATRICS (ISSN 0031 4005). Copyright © 2005 by the American Acad- developmental issues such as those described in chil- emy of Pediatrics. dren who are adopted from Russia, Romania, China,

e710 PEDIATRICS Vol.Downloaded 115 No. 6 from June www.aappublications.org/news 2005 www.pediatrics.org/cgi/doi/10.1542/peds.2004-2359 by guest on September 26, 2021 and other countries.2–12 Other speculations include laboratories. Intradermal testing with purified protein derivative the possibility that Guatemalan children are less (5 tuberculin units) was performed on all children. Preadoptive records were obtained at the time of the child’s likely to be exposed prenatally to drugs or alcohol first clinic visit or, for some families, at the time of a preadoptive than children from other regions and that their vac- consultation with International Adoption Clinic staff. Vaccination cine records are more “believable” than those from status before adoption was assessed for adequacy according to the some other countries.13 Moreover, although foster American Academy of Pediatrics recommended childhood immu- 14 care is widely believed to result in better health and nizations for age. developmental status for children without parents, a Description of Subjects direct comparison of the status of children who are The group of 103 children, adopted by 89 families, ranged from raised by these 2 methods of care has not previously 3 months to 110 months (9 years 2 months) at arrival in the United been reported. Therefore, we reviewed the health States (mean Ϯ SD: 16.0 Ϯ 19.13 months). There were 48 girls and and developmental status of children who were 55 boys. Age at the first visit to the clinic ranged from 4 months to Ϯ Ϯ adopted from Guatemala and were evaluated in our 110 months (mean SD: 18.6 20.52 months). Most (71%) were evaluated within 2 months after arrival; 87% were seen within 4 International Adoption Clinic. We assessed their vac- months of arrival. Parents obtained preadoptive consultations cine records for completeness for age and assessed with the International Adoption Clinic staff for approximately one each child for phenotypic evidence suggestive of fourth of the children (n ϭ 28 [27.2%]). prenatal alcohol exposure. Furthermore, we took ad- Adoptive families varied considerably in size and composition. Twenty-two children were adopted by single parents, and the vantage of the unusual circumstance of children who remainder were adopted by dual-parent families (including 16 were adopted from the same country at comparable same-gender parent pairs). Thirty-three families had 1 or more ages from either orphanages or foster care to com- adopted children before the addition of their Guatemalan child, 9 pare their health and developmental status at arrival families had 1 or more birth children, and 6 families had 1 or more birth and adoptive children. In the remaining 35 families, the to the United States. Guatemalan child was the first child in the family. Fourteen families adopted Ͼ1 Guatemalan child, including 1 set of 3 siblings, 1 set of twins, and 1 pair of birth siblings adopted 2 years apart. METHODS Between April 1988 and May 2004, the International Adoption Statistics Clinic at the Floating Hospital for Children evaluated 2157 new For comparing children of different ages, all anthropometric patients. Of these, 103 were adopted from Guatemala by 89 fam- measurements were converted to z scores (the difference between ilies and are the subject of this survey. This retrospective chart the child’s measurement and the age mean divided by the SD for review was approved by the Human Investigation Review Com- the child’s age). For weight, height, and head circumference, z mittee of New England Medical Center. All children were self- scores were calculated using the program Epi Info 2004, Version referred to the clinic by their families or primary pediatricians; 3.2.2, based on means for age and SDs published by the Centers most were seen soon after arrival into the United States. All for Disease Control and Prevention.20 This program provides a set patients were assessed by a developmental therapist and a pedi- of growth measurements that are standardized among an ethni- atrician who were experienced in international adoption and had cally diverse population. Statistical comparisons included paired t the complete medical evaluation recommended for internationally tests, analysis of variance, frequency distribution, and regression adoptees.2,14 analysis and were performed using the computer program Stat- Routine evaluation included a complete history and physical view (Calabasas, CA). For comparing children who were adopted examination by a pediatrician. Supine length (0–24 months of age) from foster care with those who were adopted from orphanages, Ͼ or standing height ( 2 years), weight, and head circumference each of the 25 children who were adopted from orphanages was were measured. Physical examination included determination of matched for age at arrival, interval from arrival to clinic visit, and 4-digit diagnostic code for fetal alcohol spectrum disorders,15,16 gender with a child who was adopted from foster care. Results of although this test has not been standardized in Guatemalan chil- growth measurements, health assessments, and developmental dren. This method uses a 5-point Likert scale to score appearance status then were compared by paired 2-tailed t tests. of the lip and philtrum (reflecting upper lip circularity and philtrum smoothness) and determination of palpebral fissure length to calculate a score for sentinel physical findings (facial features RESULTS suggestive of prenatal alcohol exposure). Likert scores (4-point scale) for growth deficiency and central nervous system damage Subjects (normal, neurobehavioral disorder, or static encephalopathy) were Foster and orphanage care placements were de- 15,16 also determined, using specific definitions. Scores then were fined as the setting in which the child resided after 1 converted to general diagnostic categories, using tables supplied in references that describe this method.15 In this population, pre- month of age until adoption. Slightly more than half natal alcohol exposure was unknown. of the children (n ϭ 56 [54%]) resided in foster homes Developmental evaluation was performed in all children using before adoption. Twenty-five (24%) children were the University of Michigan Early Intervention Development Pro- placed into orphanage care before adoption. Some 17 18 file or Mullen Scales of Early Learning and clinical assessment children (n ϭ 22 [21%]) lived in mixed-care settings of neuromuscular development. Developmental scores were determined for gross motor skills, fine motor skills, cognition, recep- before adoption, which included various combina- tive and expressive language, social-emotional skills, and activi- tions of living with the birth family, in foster care, ties of daily living and converted to percentage of chronological and/or in orphanage care. Twenty resided with birth age for each domain. Children were considered delayed when relatives (mother, grandmother) for periods ranging developmental scores were Յ66%.6,19 The designation “globally Ϯ delayed” was assigned to children with 3 or more developmental from 1 month to 5 years (mean: 21.5 20.23; range: domains with scores Յ66%. 1–60 months). Of these children, 13 then were placed Laboratory testing for each child included a complete blood cell into orphanage care, and the remaining 7 were count; urinalysis; lead level; rapid plasma reagin; thyrotropin; placed into foster care (including 1 who resided in 3 thyroxine level; serum aspartate aminotransferase; hepatitis B sur- different foster homes before adoption). Of the re- face antigen, antibody, and core antibody; hepatitis C antibody; HIV-1 and HIV-2 antibody screen; and stool ova and parasites. maining 2 children with mixed care before adoption, Tests were performed by standard methods in the clinical labora- details of placements were not completely known. tories of the New England Medical Center or local reference There was no difference in the ratio of boys to girls

Downloaded from www.aappublications.org/newswww.pediatrics.org/cgi/doi/10.1542/peds.2004-2359 by guest on September 26, 2021 e711 in any of the 3 groups or in the time interval after arrival to the first clinic visit. However, the age at arrival varied depending on location of residence before adoption (P Ͻ .001). Children who were adopted from foster care arrived at 7.1 Ϯ 0.37 months, whereas those from orphanages arrived at 12.6 Ϯ 2.3 months and those from mixed care arrived at 42.2 Ϯ 5.4 months.

Growth On arrival, z scores for weight ranged from Ϫ4.66 to 1.75 (mean: Ϫ1.00), for height from Ϫ3.64 to 1.18 (mean: Ϫ1.04), and for head circumference from Ϫ4.27 to 1.37 (mean: Ϫ1.08). z scores less than Ϫ2 were found in 16% of the children for height, 20% for weight, and 17% for head circumference. Growth measurements varied depending on location of residence before adoption (Fig 1). Children who resided in orphanages had significantly lower z scores for all 3 anthropometric measurements than those who resided in foster care before adoption (height, P ϭ .03; weight, P ϭ .01; head circumference, P ϭ .001). Chil- dren from mixed care had intermediate measurements. For children who were younger than 2 years at arrival, regardless of location of residence before adoption, z scores for growth measurements correlated inversely with age at arrival (height r ϭ 0.30, P ϭ .004; weight r ϭ 0.37, P ϭ .0004; head circumference r ϭ 0.26, P ϭ .0149; Fig 2).

Infectious Diseases Intestinal parasites were found in 8% of children (mostly Giardia lamblia or the nonpathogen Blastocys- tis hominis; 1 child had both Trichuris trichiura and Hymenolepis nana). No child had hepatitis B surface antigen, although 2 had hepatitis B core antibody (probable maternal antibody); 73% had hepatitis B surface antibody. One child had antibodies to hepatitis C; these disappeared consistent with maternal antibodies. No child had HIV infection or syphilis (although 1 child had been born to an HIV-infected mother and another had congenital syphilis that was treated in Guatemala). Seven percent had positive Fig 2. z scores for growth measurements (height [A], weight [B], tuberculin skin tests and were placed on Isoniazid and head circumference [C]) inversely correlated with age at arrival for children who were adopted at Յ24 months of age. For height, r ϭ 0.302, P ϭ .0047; weight, r ϭ 0.371, P ϭ .0004; and head circumference, r ϭ 0.262, P ϭ .0149.

prophylaxis after additional clinical assessment. Fifty seven of 84 had Bacille Camille-Gue´rin scars. Other infectious problems identified at arrival included oti- tis media (10 children), diarrhea (6, including 1 with rotavirus), caries and/or dental abscesses (4), head lice (3), scabies (3), conjunctivitis (2), pneumonia or bronchitis (3), pyelonephritis (2), roseola (1), and yeast dermatitis (1). No differences were found in the incidence of clinical or laboratory markers for infectious diseases related to location of residence before adoption. Fig 1. z scores for growth measurements of 103 Guatemalan children were significantly lower for those who resided in orphanages Other Medical Conditions (ᮀ) before adoption compared with those who resided in foster care (■) (height, P ϭ .03; weight, P ϭ .01; head circumference, P ϭ Various other medical conditions were diagnosed .001). Those who resided in mixed care (o) had intermediate by screening tests and physical examination. Thirty results. percent of children had anemia (hematocrit Ͻ30%);

e712 GUATEMALAN ADOPTEES:Downloaded from COMPARISON www.aappublications.org/news OF ORPHANAGE by guest on AND September FOSTER 26, 2021 CARE 4% had mild eosinophilia (absolute eosinophil TABLE 1. Adequacy of Vaccine Records for Guatemalan counts: 720–886); 3% had elevated lead levels Adoptees (9.9–33 ␮g/dL); 11% had abnormal urinalyses (indic- Vaccine (N) Inadequate, %* Adequate, %* Excessive, %* ative of urinary tract infections in all but 1 child, who DTP (53) 23 75 1.8 had isolated hematuria); 6% had minor, transient Polio (56) 18 78 3.6 abnormalities of thyroid function tests; and 23% HIB (47) 43 57 0 had mildly abnormal liver function tests (elevated Hep B (47) 17 83 0 transaminases [less than twofold elevation], which MMR (14) 14 86 0 Varicella (11) 0 100 0 subsequently returned to normal). No child had information available about prenatal DTP indicates diphtheria-tetanus-pertussis; HIB, Haemophilus in- exposure to alcohol. The 4-digit diagnostic code for fluenzae type b; Hep B, hepatitis B; MMR, measles-mumps-rubella. * Of those with a record to review. fetal alcohol spectrum disorders was used to catego- rize evidence of prenatal alcohol exposure in children who were seen more recently, although this test birth weight listed on 39 records (mean: 2814 g; has not been standardized in Guatemalan children. range: 1876–3842), birth heights on 12 records (mean: Of these 67 children, 48 (72%) were categorized as 48 cm; range: 46–51), and head circumference on 12 “no sentinel physical findings or central nervous sys- records (mean: 33.7 cm; range: 31.4–35). Gestational tem abnormalities, alcohol exposure unknown”; 14 age, when recorded (18 records), was always stated (21%) as “sentinel physical findings, alcohol expo- as “40 weeks” or “full-term.” Although the numbers sure unknown”; 4 (6%) as “sentinel physical find- were small, no differences were found in birth mea- ings/neurobehavioral disorder, alcohol exposure surements or gestational age and location of resi- unknown”; and 1 (1.4%) as “sentinel physical find- dence before adoption. Apgar scores were seldom ings/static encephalopathy, alcohol exposure un- listed. Little medical information was given besides known.” In most cases, the sentinel physical findings occasional growth measurements, short descriptions reflected smoothness of the philtrum and diminished of the child’s development, and lists of administered upper lip circularity. vaccines. Blood test results for HIV, hepatitis B, and Other medical problems identified at first visit syphilis were provided occasionally; in some cases, included various minor birth defects and birth marks the results of testing of the birth mother was given. including 2 or more cafe´-au-lait spots (20 children), preauricular ear pits (7), asymmetric ears (6), unilat- Developmental Assessment eral ptosis (4), heart murmurs (5), strabismus (5), All children underwent complete developmental hypospadias (2), developmental dysplasia of the hip screening at the time of their visit to the International (1), club feet (1), skull asymmetry (1), small phallus Adoption Clinic. Mean scores (ϮSE) for gross and (1), and hemangioma (1). Neurologic diagnoses at fine motor, cognition, social-emotional, receptive arrival included hypotonia (12 children), clonus (6), language, expressive language, and activities of daily hypertonia (2), spastic tetraparesis (1), pervasive de- living were, respectively, 85 Ϯ 2.0%, 89 Ϯ 2.0%, 91 Ϯ velopmental delay (1), mental retardation (1), and 2.2%, 92.5 Ϯ 2.6%, 82.2 Ϯ 2.2%, 80.3 Ϯ 2.3%, and 84 Ϯ tremors (1). Neuropsychiatric findings on arrival in- 2.5%, reflecting that most children were doing well cluded “self-comfort” or self-stimulatory behaviors developmentally. Some children scored poorly in all such as rocking or head-banging (8 children), depres- domains; 14% were determined to have global de- sion (1), posttraumatic stress disorder (1), eating dis- velopmental delay. Neither location of residence be- order (1), and severe sensory integration disorder (1). fore adoption nor age at arrival correlated with the Other diagnoses included uncertain age (4, all from presence of global developmental delays. The do- the mixed-care group) and 1 patient each with pre- main with the broadest range of scores was expres- adoptive child abuse, rickets, hemoglobinopathy sive language (range: 27–136%, likely reflecting the (hemoglobin AC), hemophilia A, and lactose intoler- broad variability in time to learn a new language as ance. well as the variation in exposure to spoken language before adoption). Cognition, expressive and recep- Adequacy of Vaccinations tive language, and activities of daily living skills Fifty-six (54.3%) children had vaccine records from correlated inversely with age at arrival for children Guatemala to evaluate. Age-appropriate standards who were younger than 2 years at the time of adop- for vaccination were applied to these records. Num- tion (respectively, r ϭ 0.34, P ϭ .003; r ϭ 0.32, P ϭ bers of vaccinations and appropriate intervals were .003; r ϭ 0.45, P ϭ .0001; and r ϭ 0.33, P ϭ .03; Fig 3). assessed for each vaccine administered (Table 1). Thus, children with higher scores in these areas Overall, 29 (28%) children had vaccine records that tended to be younger at arrival. met American Academy of Pediatrics age standards. Evaluation of Pair-Matched Children From Orphanage Preadoptive Medical Records or Foster Care Preadoptive medical records from Guatemala var- For comparing the health and developmental sta- ied in quality and scope. In this group, 39 had pre- tus of children who were cared for in orphanages or adoptive medical records for review. Twenty eight of foster care before adoption, each of the 25 children these had been reviewed before adoption by the who were adopted from orphanages was matched International Adoption Clinic staff. Information on for age at arrival, interval from arrival to clinic visit, birth measurements was recorded sporadically, with and gender with a child who was adopted from

Downloaded from www.aappublications.org/newswww.pediatrics.org/cgi/doi/10.1542/peds.2004-2359 by guest on September 26, 2021 e713 Fig 3. Developmental scores as percentage of chronological age were inversely correlated to age at arrival for children who were adopted at Յ24 months of age for cognition (r ϭ 0.34, P ϭ .0031), expressive language (r ϭ 0.32, P ϭ .0031), receptive language (r ϭ 0.445, P ϭ .0001), and activities of daily living (r ϭ 0.331, P ϭ .0395). foster care. The reasons that individual children were adoption (Fig 4). Children who had resided in or- assigned to orphanage or foster care before adoption phanages before adoption were significantly smaller were unknown. The mean age at arrival was 11.6 Ϯ for height, weight, and head circumference (P ϭ .03, 2.2 months for both groups. The age at visit to the .05, and .04, respectively) than those who had re- clinic was 13.8 Ϯ 2.3 months for the orphanage care ceived foster care. The prevalence of medical condi- group and 13.0 Ϯ 2.2 months for the foster care tions (infectious diseases, anemia, lead poisoning, group (nonsignificant). The male/female ratio was elevated liver transaminases, elevated thyroid func- 13:12 for the orphanage group and 16:9 for the foster tion tests, and abnormal urinalyses) did not differ care group. between the 2 groups, although sample sizes were Among these pair-matched children, z scores for small. Furthermore, no significant differences were growth correlated with location of residence before found in the distribution of 4-digit diagnostic codes for prenatal alcohol exposure among the 2 groups. Developmental achievement for the matched pairs of children did not differ for gross or fine motor skills, expressive or receptive language skills, social- emotional skills, or activities of daily living, although sample sizes were small. However, those who had resided in foster care had significantly higher scores for cognitive achievement at arrival (96 Ϯ 4.6% vs 88 Ϯ 2.8%; P ϭ .021) compared with those who had resided in orphanages.

DISCUSSION Guatemala has been increasing in popularity as a source of children for American parents who adopt internationally. More than 2300 Guatemalan children Fig 4. z scores for growth measurements of matched pairs of arrived in the United States in 2003. Many interna- Guatemalan children were significantly better for those who resided in foster care (■) compared with those who resided in tional adoptions are arranged by private attorneys, a orphanages (ᮀ) before adoption (height, P ϭ .03; weight, P ϭ .05; different system than in most other countries from head circumference, P ϭ .04). which American parents adopt. Most Guatemalan

e714 GUATEMALAN ADOPTEES:Downloaded from COMPARISON www.aappublications.org/news OF ORPHANAGE by guest on AND September FOSTER 26, 2021 CARE children are referred to their adoptive parents ized care in a group setting that can be superior to shortly after birth. However, the lengthy time re- indifferent foster care. Likewise, the quality of care quired for all legal requirements to be met postpones that the children in the group who received mixed the placement of children into their adoptive homes. care could not be assessed specifically. Nonetheless, Despite these delays, some adoption professionals we found that there were significant differences in have supposed that Guatemalan children are the growth and developmental status of young chil- “healthier” than children who are adopted from dren who had resided in these 3 disparate settings other countries. Reasons suggested include the before adoption. Children who had resided in foster young age of many children at arrival and, for many, care had better growth and cognitive development residence in foster care before adoption. Further- than those who resided in orphanages before adop- more, there is a perception that there is reduced tion, whereas children who received mixed care had likelihood of prenatal exposure to drugs or alcohol in intermediate results for growth. Guatemala. No previous analysis of this population The circumstances under which an individual of children has specifically addressed these ques- child was placed in an orphanage or in foster care tions. were also unknown. In most cases, poverty was the In this survey of health and developmental status likely trigger for relinquishment of the child. It of 103 children who were adopted from Guatemala, would be worthwhile to determine whether the we found several notable findings. For children who health status of children who were placed in orphan- were adopted before 2 years of age, the age at adop- ages or foster care differed at entry into those set- tion inversely correlated with developmental scores tings. The birth records that were available for re- for cognition, expressive and receptive language, view did not highlight any differences in birth and activities of daily living. Thus, the longer chil- measurements or gestational age among the 3 groups dren waited for adoptive placement, the lower their of children, although such records were sketchy. developmental achievements in these important ar- This group of Guatemalan children had a similar eas. For example, children who were placed with pattern of medical and infectious diagnoses to that their adoptive families at “older” ages had lower reported among children who were adopted from scores in the important areas of cognition and lan- other countries. However, compared with children guage, even children who had resided in foster care in our previously reported study of 452 Chinese before adoption. Furthermore, age at adoption in- adoptees, the incidence of lead poisoning and hepa- versely correlated with growth. The older the chil- titis B were less among the Guatemalan children dren at the time of adoption, the smaller they were (14% vs 3% and 6% vs 0%, respectively).9 The Gua- compared with nonadopted peers. Again, similar temalan children also had less frequent global devel- patterns were found for both the orphanage and the opmental delays (14% vs 44%) and overall better foster children. These findings strongly support the growth measurements for height and head circum- need for timely adoptive placement of young in- ference (z scores less than Ϫ2 in 16% and 17% vs 39% fants.21,22 and 24% for the Chinese children). The incidence of The reasons for these deficits are unknown, al- other infections and medical problems was compa- though delayed growth and developmental mile- rable in both groups. stones have been reported among children who were No information about prenatal alcohol exposure adopted from orphanages,3–7,9,23,24 and the adverse was available for any children in this review. Alcohol effects of orphanage life on child development have use in Guatemala varies widely; between 20% and been described comprehensively.25–32 Among or- 48% of women use alcohol.34 Using the 4-digit diag- phans in Iraqi Kurdistan, behavioral problems in- nostic scale for prenatal alcohol exposure, we found creased in children who resided in orphanages com- that the majority (72%) of children had no findings pared with those who were placed in foster care.33 In suggestive of prenatal alcohol exposure, whereas the the present study, it was surprising to identify de- remaining 28% had some sentinel physical findings layed growth and development among children who (diminished lip circularity and philtrum develop- resided in foster care. For some children in this ment), although sample size was small. Seven per- study, foster care placements may have been subop- cent of these also had neurologic findings that could timal (inattentive caregivers, minimal stimulation, have reflected prenatal alcohol exposure. Although multiple children) and likely provided less enriched the applicability of this scale to Guatemalan children and supportive environments than later adoptive has not been validated specifically, it was devised for homes. Some children may have been in multiple use with a broad range of ethnic groups.15,16 How- foster placements without the awareness of their ever, conclusions about the validity of this scale in adoptive parents. Few adoptive parents had the op- Guatemalan children or use of this scale to predict portunity to meet the foster parents who had cared long-term behavioral and developmental outcome for their children or to assess the quality of care that would be premature without additional detailed in- their children received. vestigation. Comparable data on the prevalence of Unfortunately, little could be determined about phenotypic facial features suggestive of prenatal al- the details of care that the children in this survey cohol exposure has not yet been reported in children received in any of the settings where they had re- who are adopted from other countries. sided. It is likely that the quality of orphanage care In other populations of internationally adopted also varied considerably. Orphanages are not homo- children, questions have been raised about the ade- geneous; some provide attentive, loving, individual- quacy of vaccine records and the immunogenicity of

Downloaded from www.aappublications.org/newswww.pediatrics.org/cgi/doi/10.1542/peds.2004-2359 by guest on September 26, 2021 e715 administered vaccines.12,35–38 In this group of chil- 18. Mullen EM. Mullen Scales of Early Learning. Circle Pines, MN: AGS dren, only 56 (54%) had records available for review. Publishing; 1985 19. Miller LC, Kiernan MT, Mathers MI, Klein-Gitelman M. Developmental Approximately half of these children (28% of the and nutritional status of internationally adopted children. Arch Pediatr total children) had records that completely met Adolesc Med. 1995;149:40–44 American Academy of Pediatrics standards for age, 20. Centers for Diseases Control and Prevention. Epi Info 2004 Version far better than the 9% reported in a large survey of 3.2.2. Atlanta, GA: Centers for Diseases Control and Prevention; 2004 internationally adopted children (most from China 21. Winick M, Meyer KK, Harris RC. Malnutrition and environmental and Russia).35 Our study did not specifically address enrichment by early adoption. Science. 1975;190:1173–1175 22. Lien NM, Meyer KK, Winick M. Early malnutrition and “late” adoption: the immunogenicity of vaccines administered in a study of their effects on the development of Korean orphans adopted Guatemala. into American families. Am J Clin Nutr. 1977;30:1734–1739 Most dramatic, we found that Guatemalan chil- 23. O’Connor TG, Rutter M, Beckett C, Keaveney L, Kreppner JM. The dren who were matched for age at adoption, interval effects of global severe privation on cognitive competence: extension from adoption to evaluation, and gender fared mark- and longitudinal follow-up. English and Romanian Adoptees Study Team. Child Dev. 2000;71:376–390 edly better for growth and cognition when they had 24. Rutter M. Developmental catchup and delay, following adoption after resided in foster care before adoption rather than in severe global early privation. J Child Psychol Psychiatry. 1998;39:465–476 orphanages. Status at the time of adoption does not 25. McCall JN. Research on the psychological effects of orphanage care: a necessarily predict later outcome, although a grow- critical review. In: McKenzie RB, ed. Rethinking Orphanages for the 21st ing literature supports a relationship between these Century. Thousand Oaks, CA: Sage Publications; 1999 6,21–24,39–41 26. Otieno PA, Nduati RW, Musoke RN, Wasunna AO. Growth and devel- conditions. In other populations, growth opment of abandoned babies in institutional care in Nairobi. East Afr and cognitive performance in early life are related to Med J. 1999;76:430–435 42–50 later development. Our results suggest that 27. Rutter M, Andersen-Wood L, Beckett C, et al. Quasi-autistic patterns adoption professionals, governments, and other reg- following severe early global privation. English and Romanian Adopt- ulatory agencies should coordinate efforts to pro- ees (ERA) Study Team. 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