Sleep Health among Children Adopted from Foster Care: The Moderating Effect of Parent-Child Sleep Interactions.

OBJECTIVES: Sleep disruption is prevalent among children placed in foster care, elevating risk for a range of deleterious outcomes. Theoretically, achieving permanency via adoption may have a positive influence on children's sleep via the presence of various factors, but little is known about the sleep health of children adopted from foster care, including predictors and moderators of sleep health. METHOD: The current study included 226 parents who adopted a child from foster care in the U.S. (aged 4-11 years) within the past two years and a propensity score matched sample of 379 caregivers of children currently in foster care. Both samples completed online questionnaires about their child's sleep, physical, and mental health. RESULTS: Comparatively, children in foster care experienced more nightmares, night terrors, moving to someone else's' bed during the night, and worse overall sleep quality, whereas adopted children were reported to experience significantly more nighttime awakenings. In the adopted sample, a greater number of prior foster placements unexpectedly predicted lower total sleep disturbance scores, but this relationship was moderated by parent-child interactions around sleep. In general, greater parental involvement in children's sleep was associated with lower levels of child sleep disturbance. CONCLUSIONS: Findings suggest that while specific sleep problems might remit after children in foster care achieve permanence, nighttime sleep fragmentation often persists. Parent-child interactions surrounding sleep may be pivotal in improving sleep health in this population.

Trends in Anthropometric Measurements of Internationally Adopted Children.

OBJECTIVE: The objective of this study was to describe anthropometric measures from internationally adopted children. Internationally adopted children are at risk for poor growth and development and there is no standardized growth chart evaluation for internationally adopted children due to variations in growth, genetics, and environmental exposures. METHODS: This is a retrospective chart review of 882 patients seen in an international adoption clinic between 2010 and 2017. Anthropometric measurements were converted to Z scores for weight, height, head circumference, and body mass index. RESULTS: A total of 41 countries and 16 subregions were represented. Central America, northern Africa, southern Africa, and southern Europe were the only subregions that had positive mean Z scores for weight, and southeast Asia had the lowest mean Z score for weight (n = 40, -1.76). No subregion had a positive mean Z score for height, and western Asia had the lowest overall mean Z score for height (n = 2, -2.44). Mean Z score for body mass index was positive in several subregions. CONCLUSIONS: Growth is an important predictor of health and development, and this study adds to the literature on growth patterns of internationally adopted children.

Ethical Challenges for Plastic Surgery in Treating Internationally Adopted Children With Cleft Lip and Palate.

A large number of children with cleft lip and palate (CLP) were adopted to Sweden in the last decade, mainly from China. Most of the children arrived with unoperated palates and at later ages than earlier years. This article aims to present an overview of ethical challenges within the practice of international adoption of children with CLP from the perspective of plastic surgery in a welfare health care system. An overview of CLP treatment is presented, followed by a normative discussion and ethical analysis using the 4 principles of Beauchamp and Childress: non-maleficence, beneficence, autonomy, and justice. The following themes and subthemes were analyzed: the search for normality and the potential challenge of being adopted and having CLP-treatment autonomy of the child and future preferences, adoptive parents' expectations of plastic surgery, the journey of the adoptee and the adoptive parents; and general issues-reconstructive possibilities and consequences of CLP in the country of origin, information to the adoptive parents, health care needs, and reconstructive possibilities for children with CLP in the receiving country. Clinical implications are discussed, and suggestions for future research are provided.

The adult outcome of childhood quasi-autism arising following extreme institutional deprivation.

BACKGROUND: Rutter and colleagues' seminal observation that extended early life exposure to extreme institutional deprivation can result in what he termed quasi-autism (QA), informed both our understanding of the effects of adversity on development and the nature of autism. Here we provide the first detailed analysis of the adult outcomes of the group of institutionally deprived-then-adopted children identified as displaying QA. METHODS: Twenty-six adult adoptees identified with QA in childhood (Childhood QA+) were compared to 75 adoptees who experienced extended institutional deprivation (>6 months) but no QA (Childhood QA-), and 116 adoptees exposed to Low/No institutional deprivation. The outcomes were child-to-adult developmental trajectories of neuro-developmental symptoms (autism, attention-deficit/hyperactivity disorder (ADHD), disinhibited social engagement (DSE) and cognitive impairment), adult functioning, life satisfaction and mental health. RESULTS: Childhood QA+ was associated with elevated and persistent trajectories of broad-based autism-related difficulties, ADHD and DSE symptoms and low IQ, as well as adult mental health difficulties and functional impairment, including high rates of low educational attainment and unemployment. Life satisfaction and self-esteem were unaffected. Autism-related communication problems, in particular, predicted negative adult outcomes. Childhood QA+ was still associated with poor outcomes even when ADHD, DSE and IQ were controlled. CONCLUSIONS: Early and time-limited institutional deprivation has a critical impact on adult functioning, in part via its association with an early established and persistent variant of autism, especially related to communication difficulties. Apparent similarities and differences to non-deprivation related autism are discussed.

Developmental trajectories of behavioral inhibition from infancy to age seven: The role of genetic and environmental risk for psychopathology.

The present study leveraged data from a longitudinal adoption study of 361 families recruited between 2003 and 2010 in the United States. We investigated how psychopathology symptoms in birth parents (BP; Mage  = 24.1 years; 50.5-62.9% completed high school) and adoptive parents (AP; Mage  = 37.8 years; 80.9% completed college; 94% mother-father couples) influenced children's behavioral inhibition (BI) trajectories. We used latent growth models of observed BI at 18 and 27 months, and 4.5 and 7 years in a sample of adopted children (Female = 42%, White = 57%, Black = 11%, Multi-racial = 21%, Latinx = 9%). BI generally decreased over time, yet there was substantial variability in these trajectories. Neither BP nor AP psychopathology symptoms independently predicted systematic differences in BI trajectories. Instead, we found that AP internalizing symptoms moderated the effects of BP psychopathology on trajectories of BI, indicating a gene by environment interaction.

Navigating puberty, identity, and race among transnationally, transracially adopted Korean American adolescents.

This exploratory study examined the relation between pubertal timing and dimensions of ethnic-racial identity among adopted Korean Americans raised transracially in White families. The study also examined whether internalized racism moderated the association between pubertal timing and ethnic-racial identity. Adopted Korean American adolescents (N = 202; 108 females; ages 13-19 years) completed measures of pubertal development, ethnic-racial identity, and internalized racism in 2007. There was no significant main effect of pubertal timing for either male or female adolescents. Internalized racism moderated the relation between pubertal timing and ethnic-racial identity clarity (B = -.16, p = .015) among male adolescents. Specifically, earlier pubertal timing was significantly associated with lower ethnic-racial identity clarity for male adolescents with higher levels of internalized racism.

Health of Post-Institutionalized Haitian Children Adopted to the United States.

OBJECTIVES: Haiti remains a principal placement country for intercountry adoptees to the United States. This project reports the health status of children adopted from Haiti arriving to the U.S. and compares them to intercountry adoptees from other regions. METHODS: A retrospective chart review was conducted of adoptees placed in the U.S. from Haiti (n=87), age and sex matched with intercountry adoptees placed in the U.S. from Asia (n=87) and Latin America (n=87) between January 2010 and November 2019. Data on immunization status, contagious diseases, and nutrition and growth were analyzed via linear, logistic, and multinomial regression. RESULTS: After adjusting for age, sex, and standardized height, children adopted from Haiti, compared to adoptees from Latin America and Asia, demonstrated a lack of immunity to hepatitis B (OR=5.89;6.87), increased immunity to hepatitis A (OR=0.38;0.30), infection by two or more parasites (OR=8.43;38.48), high lead levels (OR=23.79;7.04), and anemia (OR=15.25;9.18). Unexpectedly, children adopted from Haiti had greater standardized height (-1.28 vs. -1.82 and -2.13) and standardized weight (-0.32 vs. -0.57 and -1.57) than their counterparts from Latin America and Asia. CONCLUSIONS: Children adopted from Haiti face complex medical challenges undoubtedly related to the country's low socioeconomic status (SES) and the impact of recurrent natural disasters and governmental neglect on public health infrastructure. Appropriate care is critical in preventing and avoiding transmission of infectious diseases in adoptees and family members. The high incidence of anemia and elevated lead levels may further exacerbate the developmental effects of early institutional deprivation.

Facial emotion recognition in adopted children.

Children adopted from public care are more likely to experience emotional and behavioural problems. We investigated two aspects of emotion recognition that may be associated with these outcomes, including discrimination accuracy of emotions and response bias, in a mixed-method, multi-informant study of 4-to-8-year old children adopted from local authority care in the UK (N = 42). We compared adopted children's emotion recognition performance to that of a comparison group of children living with their birth families, who were matched by age, sex, and teacher-rated total difficulties on the Strengths and Difficulties Questionnaire (SDQ, N = 42). We also examined relationships between adopted children's emotion recognition skills and their pre-adoptive histories of early adversity (indexed by cumulative adverse childhood experiences), their parent- and teacher-rated emotional and behavioural problems, and their parents' coded warmth during a Five Minute Speech Sample. Adopted children showed significantly worse facial emotion discrimination accuracy of sad and angry faces than non-adopted children. Adopted children's discrimination accuracy of scared and neutral faces was negatively associated with parent-reported behavioural problems, and discrimination accuracy of angry and scared faces was associated with parent- and teacher-reported emotional problems. Contrary to expectations, children who experienced more recorded pre-adoptive early adversity were more accurate in identifying negative emotions. Warm adoptive parenting was associated with fewer behavioural problems, and a lower tendency for children to incorrectly identify faces as angry. Study limitations and implications for intervention strategies to support adopted children's emotion recognition and psychological adjustment are discussed.

Longitudinal data on speech outcomes in internationally adopted children compared with non-adopted children with cleft lip and palate.

BACKGROUND: At the beginning of the 21st century, international adoptions of children with cleft lip and/or palate increased dramatically in Sweden. Many children arrived partially or totally unoperated, despite being at an age when palatoplasty has usually been performed. To date, the speech development of internationally adopted (IA) children has been described up to age 7-8 years, but later development remains unstudied. AIMS: To investigate speech development between ages 5 and 10 years in children born with cleft lip and palate (CLP) adopted from China and to compare them with non-adopted (NA) children with CLP. A secondary aim was to compare the frequencies of secondary palatal surgery and number of visits to a speech and language pathologist (SLP) between the groups. METHODS & PROCEDURES: In a longitudinal study, 23 IA children from China were included and matched with 23 NA children born in Sweden. Experienced SLPs blindly reassessed audio recordings from routine follow-ups at ages 5 and 10 years. Velopharyngeal function (VPF) was assessed with the composite score for velopharyngeal competence (VPC-Sum) for single words and rated on a three-point scale (VPC-Rate) in sentence repetition. Target sounds in words and sentences were phonetically transcribed. Per cent correct consonants (PCC) were calculated at word and sentence levels. For in-depth analyses, articulation errors were divided into cleft speech characteristics (CSCs), developmental speech characteristics (DSCs) and s-errors. Information on secondary palatal surgery and number of visits to an SLP was collected. OUTCOMES & RESULTS: VPF differed significantly between the groups at both ages when assessed with VPC-Sum, but not with VPC-Rate. Regardless of the method for assessing VPF, a similar proportion in both groups had incompetent VPF but fewer IA than NA children had competent VPF at both ages. IA children had lower PCC at both ages at both word and sentence levels. More IA children had CSCs, DSCs and s-errors at age 5 years, and CSCs and s-errors at age 10. The development of PCC was significant in both groups between ages 5 and 10 years. The proportion of children receiving secondary palatal surgery did not differ significantly between the groups, nor did number of SLP visits. CONCLUSIONS & IMPLICATIONS: CSCs were more persistent in IA children than in NA children at age 10 years. Interventions should target both cleft and DSCs, be comprehensive and continue past the pre-school years. WHAT THIS PAPER ADDS: What is already known on this subject At the beginning of the 21st century, IA children with cleft lip and/or palate arrived in Sweden partially or totally unoperated, despite being at an age when palatoplasty has usually been performed. Studies up to age 7-8 years show that adopted children, compared with NA peers, have poorer articulation skills, demonstrate both cleft-related and developmental articulation errors, and are more likely to have velopharyngeal incompetence. Several studies also report that adopted children more often require secondary palatal surgery due to fistulas, dehiscence or velopharyngeal incompetence compared with NA peers. What this paper adds to existing knowledge This longitudinal study provides additional knowledge based on longer follow-ups than previous studies. It shows that the proportion of children assessed to have incompetent VPF was similar among IA and NA children. It was no significant difference between the groups regarding the proportion that received secondary palatal surgery. However, fewer IA children were assessed to have a competent VPF. Developmental articulation errors have ceased in most IA and all NA children at age 10 years, but significantly more adopted children than NA children still have cleft-related articulation errors. What are the potential or actual clinical implications of this work? Speech and language therapy should target both cleft-related and developmental articulation errors. When needed, treatment must be initiated early, comprehensive, and continued past the pre-school years, not least for adopted children.

Attachment dimensions and cortisol responses during the strange situation among young children adopted internationally.

Children's attachments to their parents may help regulate their hypothalamic-pituitary-adrenal (HPA) axes. Prior research has largely focused on children with relatively consistent and low-risk caregiving histories, resulting in limited knowledge about the associations between attachment quality and HPA axis reactivity among children who have experienced early adversity. This study investigated whether dimensional measures of attachment quality were associated with HPA responses to the Strange Situation Procedure (SSP) among 64 children ages 11-33 months adopted internationally from institutional or foster care. Children who showed high levels of attachment avoidance exhibited a blunted cortisol response during the SSP. Conversely, children who sought proximity and contact with their adoptive parents exhibited an increase in cortisol reactivity during the SSP, followed by a return to baseline levels after the completion of the procedure. This association was independent of the previously reported association between parental insensitivity and blunted cortisol responses in this sample.

Family environment and development in children adopted from institutionalized care.

BACKGROUND: After adoption, children exposed to institutionalized care show significant improvement, but incomplete recovery of growth and developmental milestones. There is a paucity of data regarding risk and protective factors in children adopted from institutionalized care. This prospective study followed children recently adopted from institutionalized care to investigate the relationship between family environment, executive function, and behavioral outcomes. METHODS: Anthropometric measurements, physical examination, endocrine and bone age evaluations, neurocognitive testing, and behavioral questionnaires were evaluated over a 2-year period with children adopted from institutionalized care and non-adopted controls. RESULTS: Adopted children had significant deficits in growth, cognitive, and developmental measurements compared to controls that improved; however, residual deficits remained. Family cohesiveness and expressiveness were protective influences, associated with less behavioral problems, while family conflict and greater emphasis on rules were associated with greater risk for executive dysfunction. CONCLUSIONS: Our data suggest that a cohesive and expressive family environment moderated the effect of pre-adoption adversity on cognitive and behavioral development in toddlers, while family conflict and greater emphasis on rules were associated with greater risk for executive dysfunction. Early assessment of child temperament and parenting context may serve to optimize the fit between parenting style, family environment, and the child's development. IMPACT: Children who experience institutionalized care are at increased risk for significant deficits in developmental, cognitive, and social functioning associated with a disruption in the development of the prefrontal cortex. Aspects of the family caregiving environment moderate the effect of early life social deprivation in children. Family cohesiveness and expressiveness were protective influences, while family conflict and greater emphasis on rules were associated with a greater risk for executive dysfunction problems. This study should be viewed as preliminary data to be referenced by larger studies investigating developmental and behavioral outcomes of children adopted from institutional care.

The effects of maternal input on language in the absence of genetic confounds: Vocabulary development in internationally adopted children.

Previous studies have found correlations between parent input and child language outcomes, providing prima facie evidence for a causal relation. However, this could also reflect the effects of shared genes. The present study removed this genetic confound by measuring English vocabulary growth in 29 preschool-aged children (21 girls) aged 31-73 months and 17 infants (all girls) aged 15-32 months adopted from China and Eastern Europe and comparing it to speech produced by their adoptive mothers. Vocabulary growth in both groups was correlated with maternal input features; in infants with mean-length of maternal utterance, and in preschoolers with both mean-length of utterance and lexical diversity. Thus, input effects on language outcomes persist even in the absence of genetic confounds.

Timing of adoption is associated with electrophysiological brain activity and externalizing problems among children adopted internationally.

This study investigated middle childhood resting electroencephalography (EEG) and behavioral adjustment in 35 internationally adopted children removed from early caregiving adversity between 6 and 29 months of age. Older age of adoption was associated with more immature or atypical profiles of middle childhood cortical function, based on higher relative theta power (4-6 Hz), lower relative alpha power (7-12 Hz), lower peak alpha frequency, and lower absolute beta (13-20 Hz) and gamma (21-50 Hz) power. More immature or atypical EEG spectral power indirectly linked older age of adoption with increased risk for externalizing problems in middle childhood. The findings add to existing evidence linking duration of early adverse exposures with lasting effects on brain function and behavioral regulation even years after living in a stable adoptive family setting. Findings underscore the need to minimize and prevent children's exposures to early caregiving adversity, especially in the first years of life. They call for innovative interventions to support neurotypical development in internationally adopted children at elevated risk.

The impact of childhood deprivation on adult neuropsychological functioning is associated with ADHD symptom persistence.

BACKGROUND: Institutional deprivation in early childhood is associated with neuropsychological deficits in adolescence. Using 20-year follow-up data from a unique natural experiment - the large-scale adoption of children exposed to extreme deprivation in Romanian institutions in the 1980s -we examined, for the first time, whether such deficits are still present in adulthood and whether they are associated with deprivation-related symptoms of attention-deficit/hyperactivity disorder (ADHD) and autism spectrum disorder (ASD). METHODS: Adult neuropsychological functioning was assessed across five domains (inhibitory control, emotion recognition, decision-making, prospective memory and IQ) in 70 previously institutionalized adoptees (mean age = 25.3, 50% female) and 22 non-deprived UK adoptees (comparison group, mean age = 24.6, 41% female). ADHD and ASD symptoms were assessed using parent-completed questionnaires. RESULTS: Early institutionalization was associated with impaired performance on all tasks in adulthood. Prospective memory deficits persisted after controlling for IQ. ADHD and ASD symptoms were positively correlated. After controlling for ASD symptoms, ADHD symptoms remained associated with deficits in IQ, prospective memory, proactive inhibition, decision-making quality and emotion recognition. ASD symptoms were not independently associated with neuropsychological deficits when accounting for their overlap with ADHD symptoms. Multiple regression analysis revealed that the link between childhood deprivation and adult ADHD symptoms was statistically explained by deprivation-related differences in adult IQ and prospective memory. CONCLUSIONS: These results represent some of the most compelling evidence to date of the enduring power of early, time-limited childhood adversity to impair long-term neuropsychological functioning across the lifespan - effects that are linked specifically to deprivation-related adult ADHD symptoms.

Disentangling nature from nurture in examining the interplay between parent-child relationships, ADHD, and early academic attainment.

BACKGROUND: Attention deficit hyperactivity disorder (ADHD) is highly heritable and is associated with lower educational attainment. ADHD is linked to family adversity, including hostile parenting. Questions remain regarding the role of genetic and environmental factors underlying processes through which ADHD symptoms develop and influence academic attainment. METHOD: This study employed a parent-offspring adoption design (N = 345) to examine the interplay between genetic susceptibility to child attention problems (birth mother ADHD symptoms) and adoptive parent (mother and father) hostility on child lower academic outcomes, via child ADHD symptoms. Questionnaires assessed birth mother ADHD symptoms, adoptive parent (mother and father) hostility to child, early child impulsivity/activation, and child ADHD symptoms. The Woodcock-Johnson test was used to examine child reading and math aptitude. RESULTS: Building on a previous study (Harold et al., 2013, Journal of Child Psychology and Psychiatry, 54(10), 1038-1046), heritable influences were found: birth mother ADHD symptoms predicted child impulsivity/activation. In turn, child impulsivity/activation (4.5 years) evoked maternal and paternal hostility, which was associated with children's ADHD continuity (6 years). Both maternal and paternal hostility (4.5 years) contributed to impairments in math but not reading (7 years), via impacts on ADHD symptoms (6 years). CONCLUSION: Findings highlight the importance of early child behavior dysregulation evoking parent hostility in both mothers and fathers, with maternal and paternal hostility contributing to the continuation of ADHD symptoms and lower levels of later math ability. Early interventions may be important for the promotion of child math skills in those with ADHD symptoms, especially where children have high levels of early behavior dysregulation.

No Evidence for Passive Gene-Environment Correlation or the Influence of Genetic Risk for Psychiatric Disorders on Adult Body Composition via the Adoption Design.

The relationship between genetic and environmental risk is complex and for many traits, estimates of genetic effects may be inflated by passive gene-environment correlation. This arises because biological offspring inherit both their genotypes and rearing environment from their parents. We tested for passive gene-environment correlation in adult body composition traits using the 'natural experiment' of childhood adoption, which removes passive gene-environment correlation within families. Specifically, we compared 6165 adoptees with propensity score matched non-adoptees in the UK Biobank. We also tested whether passive gene-environment correlation inflates the association between psychiatric genetic risk and body composition. We found no evidence for inflation of heritability or polygenic scores in non-adoptees compared to adoptees for a range of body composition traits. Furthermore, polygenic risk scores for anorexia nervosa, attention-deficit/hyperactivity disorder and schizophrenia did not differ in their influence on body composition traits in adoptees and non-adoptees. These findings suggest that passive gene-environment correlation does not inflate genetic effects for body composition, or the influence of psychiatric disorder genetic risk on body composition. Our design does not look at passive gene-environment correlation in childhood, and does not test for 'pure' environmental effects or the effects of active and evocative gene-environment correlations, where child genetics directly influences home environment. However, these findings suggest that genetic influences identified for body composition in this adult sample are direct, and not confounded by the family environment provided by biological relatives.

Adoptive Gay Father Families: A Longitudinal Study of Children's Adjustment at Early Adolescence.

Findings are presented from the second phase of a UK longitudinal study of 33 gay father, 35 lesbian mother, and 43 heterosexual parent families when their adopted children reached early adolescence. Participants predominantly lived in urban/suburban areas and were mostly white and well-educated. Standardized interviews, observations, and questionnaires of parental mental health, parent-child relationships, and adolescent adjustment were administered to parents, children, and teachers between 2016 and 2018. There were few differences between family types. However, adjustment problems had increased in all family types, with better parenting quality and parental mental health associated with fewer adjustment problems. The findings contribute to adoption policy and practice, and to theoretical understanding of the role of parental gender in child development.

Improving social-emotional competence in internationally adopted children with the Attachment and Biobehavioral Catch-up intervention.

Children adopted internationally experience adverse conditions prior to adoption, placing them at risk for problematic social-emotional development. The Attachment and Biobehavioral Catch-up (ABC) intervention was designed to help internationally adoptive parents behave in ways that promote young children's social-emotional competence. Participants included 131 parent-child dyads randomly assigned to receive either ABC (n = 65) or a control intervention (n = 66). In addition, 48 low-risk biologically related parent-child dyads were included as a comparison group. At follow-up assessments conducted when children were 24 to 36 months old, internationally adopted children who received the ABC intervention had higher levels of parent-reported social-emotional competence than children who received a control intervention. In addition, observational assessments conducted when children were 48 and 60 months of age showed that internationally adopted children who received ABC demonstrated higher social-emotional competence than children who received a control intervention. Adopted children who received the control intervention, but not the ABC intervention, displayed more difficulties with social-emotional competence than low-risk children. Finally, postintervention parent sensitivity mediated the effect of ABC on observed child social-emotional competence in parent interactions, controlling for preintervention parent sensitivity. These results demonstrate the efficacy of a parenting-focused intervention in enhancing social-emotional competence among children adopted internationally.

Charting the trajectories of adopted children's emotional and behavioral problems: The impact of early adversity and postadoptive parental warmth.

Children who are adopted from care are more likely to experience enduring emotional and behavioral problems across development; however, adoptees' trajectories of mental health problems and factors that impact their trajectories are poorly understood. Therefore, we used multilevel growth analyses to chart adoptees' internalizing and externalizing problems across childhood, and examined the associations between preadoptive risk and postadoptive protective factors on their trajectories. This was investigated in a prospective longitudinal study of case file records (N = 374) and questionnaire-based follow-ups (N = 96) at approximately 5, 21, and 36 months postadoptive placement. Preadoptive adversity (indexed by age at placement, days in care, and number of adverse childhood experiences) was associated with higher internalizing and externalizing scores; the decrease in internalizing scores over childhood was accelerated for those exposed to lower levels of preadoptive risk. Warm adoptive parenting was associated with a marked reduction in children's internalizing and externalizing problems over time. Although potentially limited by shared methods variance and lack of variability in parental warmth scores, these findings demonstrate the deleterious impact of preadoptive risk and the positive role of exceptionally warm adoptive parenting on children's trajectories of mental health problems and have relevance for prevention and intervention strategies.

Pseudoparalysis of parrot - Re-emergence of the great mimicker.

We present the case of a 2-month-old adopted female seeking evaluation in the pediatric emergency department due to a one-day history of decreased right arm movement and fussiness. The physical exam was largely unremarkable with the exception of decreased spontaneous movement of the right upper extremity, obvious discomfort with passive movement and subtle edema of the forearm. Because of concern for non-accidental trauma, plain films were obtained which revealed no signs of traumatic injury. Subsequently, a broader investigation ensued with infectious etiologies in mind. Laboratory evaluation demonstrated anemia, transaminitis, and elevated inflammatory markers. These abnormalities led to the consideration of congenitally acquired infections, specifically syphilis, and serologies were confirmatory. Ultimately, the infant was diagnosed with Pseudoparalysis of Parrot - a rare musculoskeletal manifestation secondary to painful syphilitic periostitis. As Emergency Medicine physicians, it is important to be aware of the growing burden of syphilis infection and reacquaint ourselves with its numerous presentations in the young infant.