Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) Symptomatology in a High-Risk Clinical Sample.

Attachment relationships are broadly considered foundational to child development as such attachment disorders, reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED), pose a severe threat to children's safety and developmental trajectory. This study examined the prevalence of full diagnosis and symptoms of RAD and DSED in a high-risk sample of adopted children (n = 98; mean age: 46.26 months; range: 16.09 months-6.51 years). Consistent with existing literature, a full diagnosis of RAD and DSED was rare, 1% (n = 1) and 8.1% (n = 8), respectively. However, over half of the sample presented with at least one clinically concerning symptom of RAD or DSED. Given the nature of attachment disorders and the level of concern associated with symptoms, these findings emphasize the need for effective mental health screening, sensitivity beyond just a full diagnosis, and early interventions for adopted children.

IMPACT OF JOINT ATTENTION ON SOCIAL-COMMUNICATION SKILLS IN INTERNATIONALLY ADOPTED CHILDREN.

Internationally adopted (IA) children have often experienced early adversity and are at risk for long-term deficiencies in multiple developmental domains. This study examined the association between IA children's joint attention (JA) soon after arrival and later cognitive, communicative, and socioemotional competency 6 months' postadoption. We expected a child's initial JA would positively predict later cognitive, communication, and social ability. IA children (n = 63) adopted from Eastern Europe were seen soon after their arrival into the United States to assess their JA. Their socioemotional competency, social communication, and cognitive abilities were measured at a follow-up session 6 months' postadoption. We found that higher order JA was positively associated with measures of social relatedness. Furthermore, individual hierarchical regressions of each measure of JA (higher order JA, initiating JA, responding to JA, and initiating behavior requests [BR]) considered with age-at-adoption showed that each measure was an independent and positive predictor of Mullen outcomes in the receptive and expressive language domains. These results suggest that JA may be a sensitive predictor of subsequent functioning in the social, communicative, and cognitive domains. Thus, assessing JA soon after arrival has the potential to identify at-risk IA children, and interventions targeting JA may support those children in overcoming the negative impacts of early adversity.

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.

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.

Choline supplementation in children with fetal alcohol spectrum disorders: a randomized, double-blind, placebo-controlled trial.

BACKGROUND: Fetal alcohol spectrum disorders (FASDs) are conditions characterized by physical anomalies, neurodevelopmental abnormalities, and neurocognitive deficits, including intellectual, executive, and memory deficits. There are no specific biological treatments for FASDs, but rodent models have shown that prenatal or postnatal choline supplementation reduces cognitive and behavioral deficits. Potential mechanisms include phospholipid production for axonal growth and myelination, acetylcholine enhancement, and epigenetic effects. OBJECTIVE: Our primary goal was to determine whether postnatal choline supplementation has the potential to improve neurocognitive functioning, particularly hippocampal-dependent memory, in children with FASDs. DESIGN: The study was a double-blind, randomized, placebo-controlled pilot trial in children (aged 2.5-5 y at enrollment) with FASDs (n = 60) who received 500 mg choline or a placebo daily for 9 mo. Outcome measures were Mullen Scales of Early Learning (primary) and the elicited imitation (EI) memory paradigm (secondary). RESULTS: The administration proved feasible, and choline was well tolerated. Participants received a dose on 88% of enrolled days. The only adverse event linked to choline was a fishy body odor. Choline supplementation improved the secondary outcome (EI) only after immediate recall performance was controlled for, and the outcome was moderated by age. The treatment effect on EI items recalled was significant in the younger participants (2.5- to ≤4.0-y-olds); the young choline group showed an increase of 12-14 percentage points greater than that of the young placebo group on delayed recall measures during treatment. However, there was a marginal baseline difference in delayed item recall between the young choline and placebo groups as well as a potential ceiling effect for item recall, both of which likely contributed to the observed treatment effect. We also observed a trend toward a negative effect of choline supplementation on the immediate EI recall of ordered pairs; the young placebo group showed an increase of 8-17 percentage points greater than that of the choline group during treatment. There was an inverse relation between choline dose (in mg/kg) and memory improvement (P = 0.041); the data suggest that weight-adjusted doses may be a better alternative to a fixed dose in future studies. Limitations included trend-level baseline differences in performance, the post-hoc determination of age moderation, and potential ceiling effects for the memory measure. CONCLUSIONS: This pilot study suggests that an additional evaluation of choline supplementation as an intervention for memory functioning in children with FASDs is warranted. The observed interaction between age and choline's effect on EI suggests that potential sensitive periods should be considered in future work. This trial was registered at clinicaltrials.gov as NCT01149538.

Predictors of developmental status in young children living in institutional care in Kazakhstan.

The main objective of this study was to assess the developmental status of children living in the severely adverse environment of institutional care and the examination of risk factors with regard to developmental status, including degree of stunting and emotional-behavioral and anemia status. The Bayley Scales of Infant Development were used to assess development status in 103 children aged 14.9 months (SD = 6.8) in six Kazakh institutions. The Behavioral Rating Scales were used to assess emotional-behavioral regulation. Physical growth measures were converted to z scores using World Health Organization growth charts. Venous blood was collected for assessment of anemia. Our findings indicated that young children in institutions were developmentally compromised, with duration of institutional care correlated with the severity of delay. Negative predictors of developmental status included: Poor emotional-behavioral regulation, degree of stunting and age at assessment. A particularly large percentage of children were found to be anemic. Additionally, low birth weight was found to be a significant negative predictor of development. Our findings indicate that institutional care has a detrimental impact on the development and emotional regulation of young children. Time in institutional care is a negative predictor for cognitive status for children placed at birth. Moreover stunting was found to be a useful indicator of the degree of impact of early adversity on cognitive development. Particular attention is needed for special-needs children such as those with low birth weight, since their development was found to be more sensitive to early adversity than that of normal birth weight children.

Beyond stimulus deprivation: iron deficiency and cognitive deficits in postinstitutionalized children.

Children adopted from institutions have been studied as models of the impact of stimulus deprivation on cognitive development (Nelson, Bos, Gunnar, & Sonuga-Barke, 2011), but these children may also suffer from micronutrient deficiencies (Fuglestad et al., 2008). The contributions of iron deficiency (ID) and duration of deprivation on cognitive functioning in children adopted from institutions between 17 and 36 months of age were examined. ID was assessed in 55 children soon after adoption, and cognitive functioning was evaluated 11-14.6 months postadoption when the children averaged 37.4 months old (SD = 4.9). ID at adoption and longer duration of institutional care independently predicted lower IQ scores and executive function (EF) performance. IQ did not mediate the association between ID and EF.

Choline supplementation in children with fetal alcohol spectrum disorders has high feasibility and tolerability.

There are no biological treatments for fetal alcohol spectrum disorders (FASDs), lifelong conditions associated with physical anomalies, brain damage, and neurocognitive abnormalities. In preclinical studies, choline partially ameliorates memory and learning deficits from prenatal alcohol exposure. This phase I pilot study evaluated the feasibility, tolerability, and potential adverse effects of choline supplementation in children with FASD. We hypothesized that choline would be well tolerated with minimal adverse events. The study design was a double-blind, randomized, placebo-controlled trial. Participants included 20 children aged 2.5 to 4.9 years with prenatal alcohol exposure and FASD diagnoses. Participants were randomly assigned to 500 mg choline or placebo daily for 9 months (10 active, 10 placebo). Primary outcome measures included feasibility, tolerability, adverse effects, and serum choline levels. Seventeen participants completed the study. Compliance was 82% to 87%, as evidenced by parent-completed log sheets and dose counts. Periodic 24-hour dietary recalls showed no evidence of dietary confounding. Adverse events were minimal and were equivalent in the active and placebo arms with the exception of fishy body odor, which occurred only in the active group. There were no serious adverse events to research participants. This phase I pilot study demonstrates that choline supplementation at 500 mg/d for 9 months in children aged 2 to 5 years is feasible and has high tolerability. Further examination of the efficacy of choline supplementation in FASD is currently underway.

Inadequate intake of nutrients essential for neurodevelopment in children with fetal alcohol spectrum disorders (FASD).

This study evaluated dietary intake in children with fetal alcohol spectrum disorders (FASD). Pre-clinical research suggests that nutrient supplementation may attenuate cognitive and behavioral deficits in FASD. Currently, the dietary adequacy of essential nutrients in children with FASD is unknown. Dietary data were collected as part of a randomized, double-blind controlled trial of choline supplementation in FASD. Participants included 31 children with FASD, ages 2.5-4.9 years at enrollment. Dietary intake data was collected three times during the nine-month study via interview-administered 24-hour recalls with the Automated Self-Administered 24-hour Recall. Dietary intake of macronutrients and 17 vitamins/minerals from food was averaged across three data collection points. Observed nutrient intakes were compared to national dietary intake data of children ages 2-5 years (What we Eat in America, NHANES 2007-2008) and to the Dietary Reference Intakes. Compared to the dietary intakes of children in the NHANES sample, children with FASD had lower intakes of saturated fat, vitamin D, and calcium. The majority (>50%) of children with FASD did not meet the Recommended Dietary Allowance (RDA) or Adequate Intake (AI) for fiber, n-3 fatty acids, vitamin D, vitamin E, vitamin K, choline, and calcium. This pattern of dietary intake in children with FASD suggests that there may be opportunities to benefit from nutritional intervention. Supplementation with several nutrients, including choline, vitamin D, and n-3 fatty acids, has been shown in animal models to attenuate the cognitive deficits of FASD. These results highlight the potential of nutritional clinical trials in FASD.

Iron deficiency after arrival is associated with general cognitive and behavioral impairment in post-institutionalized children adopted from Eastern Europe.

To investigate the role of iron deficiency in general cognitive and behavioral development in post-institutionalized (PI) children during the early post-adoption period. PI children (N = 57) adopted from Eastern Europe or Central Asia (9-46 months of age) were seen at baseline around 1 month after arrival into the US and at follow-up 6 months later. Measures included anthropometry, iron status, the Toddler Behavior Assessment Questionnaire-R (TBAQ-R), the Mullen Scales of Early Learning, and examiner-rated behaviors during testing. 26 % were iron deficient at baseline; 18 % were iron deficient at follow-up. There was a trend for those with iron deficiency at baseline to be more fearful on the TBAQ-R. Those with iron deficiency at follow-up displayed more hyperactivity on both the TBAQ-R and the examiner-rated behaviors. Those with iron deficiency at follow-up were more likely to score below average on the Mullen Early Learning Composite (iron deficient: 80 %; good iron status: 32 %). The association between iron status at follow-up and the Mullen Early Learning Composite was mediated by inattention and hyperactivity behaviors during testing. Iron deficiency is associated with neurobehavioral alterations months after arrival, mediated by the effect on attention and activity levels. Iron status needs to be monitored at least through the first half-year post-adoption, particularly in children exhibiting rapid catch-up growth. Additionally, developmental evaluation is recommended in those with iron deficiency, even in children with good iron status at arrival.

Adoption as an intervention for institutionally reared children: HPA functioning and developmental status.

Institutional care, particularly when experienced early in life, is associated with delays in social and emotional development that often persist years after adoption. It has been hypothesized that compromise of the hypothalamic-pituitary-adrenocortical (HPA) axis due to adverse condition in institutions is a mediator of later emotional and behavioral problems. The first goal of our project was to investigate whether improvements in the social and emotional environment are associated with changes in HPA axis function. The second goal was to explore whether HPA alterations related to early social adversity were associated with more compromised general development and social and emotional functioning post adoption. Children adopted from Eastern European orphanages (N = 76, mean age was 17 months, SD = 5) were followed as part of an ongoing longitudinal study. Data, including diurnal cortisol patterns, were collected at two time points: baseline (within one month of adoption) and follow-up (six months later). Cortisol values were averaged over two days of saliva sampling after wake-up and before bedtime. We found that morning cortisol values increased between the baseline assessment (M = 0.27 µg/dl, SD = 0.13) and follow-up (M = 0.33 µg/dl, SD = 0.20), t(76) = -2.1, p<0.05. HPA functioning was not associated with general developmental level at either the initial or six months post-adoption assessments. However, dysregulation of the HPA axis (i.e., flatter diurnal pattern) at follow-up was associated with more behavioral and emotional problems. Overall, these results suggest that investigating specific physiological mechanisms is important in identifying children at risk for persistent social and emotional problems and in understanding the long-term consequences of early adversity. Future work should investigate whether disturbance in the HPA system is a heightened risk for long-term negative developmental outcomes.

Determinants of catch-up growth in international adoptees from eastern europe.

Children raised in orphanages frequently experience growth suppression due to multiple risk factors. Placing such children in more nurturing environments through adoption leads to significant catch-up growth (CUG), the determinants of which are not entirely understood. The goal of this study was to perform an auxological evaluation and examine the degree and correlates of CUG in international adoptees. Children adopted from Eastern Europe, (n = 148, 71 males), 7 to 59 months of age, were recruited within 3 weeks of their arrival to the US. At baseline, mean height SDS was -1.2 ± 1.1 and 22% were <-2 SDS for height. IGF-1 and/or IGFBP-3 levels <-2 SDS were present in 32%. CUG, defined as a gain of >+0.5 in height SDS, was seen in 62% of adoptees at 6 months after adoption; 7% of children remained <-2 SDS for height (two had growth hormone deficiency). Growth factors improved in the majority of children. Younger age, greater degree of initial growth failure, and higher caloric intake were significantly associated with improved linear growth in multiple regression models. In summary, most adoptees demonstrate excellent CUG within six months after adoption. If growth failure persists after 6 months of appropriate caloric intake, nutrition-independent causes should be considered.

Auxological evaluation and determinants of growth failure at the time of adoption in Eastern European adoptees.

AIM: To identify factors contributing to growth failure in international adoptees (IAs) from Eastern Europe. STUDY DESIGN: 138 IAs from Eastern Europe, 6-59 months old, were evaluated within 3 weeks of US arrival. Complete history, anthropometry, and serum for growth factors were obtained. Facial features were examined for risk of prenatal alcohol exposure. RESULTS: Upon arrival, mean height (-1.23 +/- 1.07), weight (-1.43 +/- 1.29), and occipitofrontal circumference (OFC) (-0.63 +/- 1.10) SDS in IAs were significantly less than population means for US children. In a multiple regression model, age, low birth weight (LBW), insulin-like growth factor binding protein-3, and high risk for fetal alcohol syndrome were independent predictors of height SDS. LBW also independently predicted lower weight SDS and smaller OFC SDS. CONCLUSIONS: We recommend that IAs undergo screening upon US arrival to identify risk factors for poor growth, particularly evidence of LBW and fetal alcohol exposure. Catch-up growth should be monitored in all children following adoption.

Iron deficiency in international adoptees from Eastern Europe.

OBJECTIVE: To assess iron deficiency (ID) in international adoptees after adoption. STUDY DESIGN: Participants (n = 37) were adopted into the United States from Eastern Europe before they were 24 months of age. Baseline (within 1 month post-adoption) and follow-up (6 months post-adoption) assessments included routine post-adoption clinical evaluations, anthropometrics, dietary intakes, and iron measures (hemogram and serum analysis). RESULTS: At adoption and follow-up, mean percent transferrin saturation and mean corpucuscular volume were low compared with the US population. Mean serum ferritin concentration became lower than the US population at follow-up, although the mean daily iron intake was more than the Recommended Dietary Allowance. Participants with Giardia lamblia at baseline had more compromised iron status at baseline and follow-up. Growth rate (change in z-score/months between assessments) was negatively correlated with change in serum ferritin concentrations between baseline and follow-up (r = -0.34; P < .05). CONCLUSIONS: International adoptees had compromised iron status, with ID more prevalent in participants with G lamblia, a parasite that may interfere with iron absorption. The persistent ID at follow-up was likely caused by the erythropoietic demands of catch-up growth.