Infants and Children in Context. Tara L. Kuther

      Lives in Context: Cultural Context

      Development of Internationally Adopted Children

      Over the past 5 decades, international adoption has become commonplace. In many countries throughout the world, children are reared in orphanages with substandard conditions—without adequate food, clothing, or shelter and with poorly trained caregivers. Such orphanages have been found in a number of countries, including China, Ethiopia, Ukraine, Congo, and Haiti, accounting for over two-thirds of internationally adopted children (U.S. Department of State, 2014). Underfunded and understaffed orphanages often provide poor, nonnurturing care for children, increasing the risks for malnutrition, infections, physical disabilities, and growth retardation (Leiden Conference on the Development and Care of Children Without Permanent Parents, 2012). With high infant-to-caregiver ratios, children available for adoption often spend a significant amount of time deprived of consistent human contact.

      Few internationally adopted children enter the United States healthy and at age-appropriate developmental norms. Not surprisingly, the longer the children are institutionalized, the more developmental challenges they face (Jacobs, Miller, & Tirella, 2010). Physical growth stunting is directly associated with the length of institutionalization, but catch-up growth is commonly seen after adoption (Wilson & Weaver, 2009). As with growth, the time spent in an orphanage predicts the degree of developmental delay. Longer institutionalization is associated with delays in the development of language, fine motor skills, social skills, attention, and other cognitive skills (Mason & Narad, 2005; Wiik et al., 2011).

      Speech and language delays are among the most consistent deficiencies experienced by internationally adopted children, especially those adopted after the age of 1 (Eigsti, Weitzman, Schuh, de Marchena, & Casey, 2011). However, more children reach normative age expectations 1 to 2 years postadoption (Glennen, 2014; Rakhlin et al., 2015). Generally, the younger the child is at adoption, the more quickly he or she will adapt to the new language and close any gaps in language delays (Glennan & Masters, 2002; Mason & Narad, 2005). Some research suggests that internationally adopted children are prone to long-term deficits in executive function likely due to neurological factors (Merz, Harlé, Noble, & McCall, 2016). The presence of a high-quality parent–child relationship promotes development of language, speech, or academic outcomes, and most children reach age-expected language levels (Glennen, 2014; Harwood, Feng, & Yu, 2013).

      As adolescents, all children struggle to come to a sense of identity, to figure out who they are. This struggle may be especially challenging for internationally adopted children who may wonder about their native culture and homeland (Rosnati et al., 2015). Frequently, adolescents may want to discuss and learn more yet inhibit the desire to talk about this with parents (Garber & Grotevant, 2015). Parents who assume a multicultural perspective and provide opportunities for their children to learn about their birth culture support adopted children’s development and promote healthy outcomes (Pinderhughes, Zhang, & Agerbak, 2015). Internationally adopted children seek to understand their birth culture and integrate their birth and adopted cultures into their sense of self (Grotevant, Lo, Fiorenzo, & Dunbar, 2017). A positive sense of ethnic identity is associated with positive outcomes such as self-esteem in international adoptees (Mohanty, 2015). Although there are individual differences in the degree of resilience and in functioning across developmental domains, adopted children overall show great developmental gains and resilience in physical, cognitive, and emotional development (Misca, 2014; Palacios, Román, Moreno, León, & Peñarrubia, 2014; Wilson & Weaver, 2009).

      What Do You Think?

      In your view, what are the most important challenges internationally adopted children and their families face? Identify sources and forms of support that might help adopted children and their parents.

      The most widespread and routine diagnostic procedure is ultrasound, in which high-frequency sound waves directed at the mother’s abdomen provide clear images of the womb represented on a video monitor. Ultrasound enables physicians to observe the fetus, measure fetal growth, judge gestational age, reveal the sex of the fetus, detect multiple pregnancies (twins, triplets, etc.), and determine physical abnormalities in the fetus. Many deformities can be observed, such as cardiac abnormalities, cleft palate, and microencephaly (small head size). At least 80% of women in the United States receive at least one prenatal ultrasound scan (Sadler, 2018). Three to four screenings over the duration of pregnancy are common to evaluate fetal development (Papp & Fekete, 2003). Repeated ultrasound of the fetus does not appear to affect growth and development (Stephenson, 2005).

      Ultrasound technology enables health care professionals to observe the fetus, measure fetal growth, detect physical abnormalities, and more.

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      Fetal MRI applies MRI technology to image the fetus’s body and diagnose malformations (Griffiths et al., 2017). Most women will not have a fetal MRI. It is often used as a follow-up to ultrasound imaging to provide more detailed views of any suspected abnormalities (Milani et al., 2015). Fetal MRI can detect abnormalities throughout the body, including the central nervous system (Saleem, 2014). MRI in the obstetrical patient is safe for mother and fetus in the second and third trimesters but is expensive and has limited availability in some areas (Patenaude et al., 2014).

      Amniocentesis is a prenatal diagnostic procedure in which a small sample of the amniotic fluid that surrounds the fetus is extracted from the mother’s uterus through a long, hollow needle that is guided by ultrasound as it is inserted into the mother’s abdomen (Odibo, 2015). The amniotic fluid contains fetal cells, which are grown in a laboratory dish to create enough cells for genetic analysis. Genetic analysis is then performed to detect genetic and chromosomal anomalies and defects. Amniocentesis is less common than ultrasound, as it poses greater risk to the fetus. It is recommended for women aged 35 and older, especially if the woman and partner are both known carriers of genetic diseases (Vink & Quinn, 2018a). Usually amniocentesis is conducted between the 15th and 18th weeks of pregnancy. Conducted any earlier, an amniocentesis may increase the risk of miscarriage (Akolekar et al., 2015). Test results generally are available about 2 weeks after the procedure because it takes that long for the genetic material to grow and reproduce to the point where it can be analyzed.

      During amniocentesis, ultrasound is used to guide the insertion of a long, hollow needle into the mother’s abdomen in order to extract a sample of the amniotic fluid that surrounds the fetus. The amniotic fluid contains fetal cells, which are grown in a laboratory dish and tested for genetic and chromosomal anomalies and defects.

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      Chorionic villus sampling (CVS) also samples genetic material and can be conducted earlier than amniocentesis, between 10 and 12 weeks of pregnancy (Vink & Quinn, 2018b). CVS requires studying a small amount of tissue from the chorion, part of the membrane surrounding the fetus. The tissue sample is obtained through a long needle inserted either abdominally or vaginally, depending on the location of the fetus. Results are typically available about 1 week following the procedure. CVS is relatively painless and, like amniocentesis, has a 100% diagnostic success rate. Generally, CVS poses few risks to the fetus (Beta, Lesmes-Heredia, Bedetti, & Akolekar, 2018; Shim et al., 2014). However, CVS should not be conducted prior to 10 weeks’ gestation, as some studies suggest an increased risk of limb defects and miscarriages (Shahbazian et al., 2012).

      Noninvasive prenatal testing (NIPT) screens the mother’s blood to detect chromosomal abnormalities. Cell-free fetal DNA (chromosome fragments that result in the breakdown of fetal cells) circulates in maternal blood in small concentrations that can be detected and studied by sampling the