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Transition Behavior

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Last week we looked at The Handbook of International Adoption Medicine: A Guide for Physicians, Parents, and Providers and what to expect the first time you meet your adopted child. Today, we look at what king of behavior to expect during the transition.

For first-time parents, a review of expectations for normal behavior, sleeping, eating, and elimination, including the wide range of normal and common alterations seen in children from orphanages, will be reassuring. Behaviors such as hyperactivity, passivity, clinginess, and temper tantrums may be prominent in the first few weeks after adoption but quickly abate afterwards.

9780195145304.jpgChildren may become distressed when confronted with unfamiliar routines, for example, with food, bathing, and toileting. Whatever techniques parents use are different from what is familiar to the child: from the child’s point of view, everything the parents do is “wrong.”

Parents must understand the immensity of the transition their child is experiencing and be empathetic about the adjustments the child is making to new styles of care and parenting.

Sleep
Sleep schedules. Many parents are given their child’s daily schedule from the orphanage and wonder how strictly to adhere to this after adoption. Most orphanage schedules include lengthy nap times and early bed times. In Romania, one orphanage for healthy 4- to 7-year old children enforced a 3-hour nap for the children every afternoon. Children may be accustomed to such schedules, but quickly adapt to change. Jet lag may interfere with sleep schedules for a time after arrival home.

Sleep quality. Sleep disturbances are extremely common among international adoptees, especially in the first few months after adoption. Children often display anxiety at bed or nap times. Nightmares, “daymares” (during naps), and night terrors are common among this group of children, but these usually subside over the first few weeks after adoption. Most children have never been alone in a bed and definitely not alone in a room. The American custom of placing children in their own rooms to sleep may be frightening. Some children (notably those from Korea and Cambodia) have become accustomed to sleeping with caregivers and are inconsolable when expected to sleep alone. Some children awake crying and become alarmed when their parents arrive to comfort them—some parents have felt the children were expecting someone else (a previous caregiver, for example)—and are disoriented to find someone else responding to them. For some children, sleep states seem to be associated with grieving for lost caregivers; some children cry sadly and deeply when going to sleep or awakening.

Psychological processing of the immense changes in the child’s life may manifest as sleep disturbances, although this is difficult to prove. Parents must recognize that insecurity and anxiety underlie most of these “early-onset” sleep disturbances among internationally adopted children. This is in contrast to manipulative behaviors related to sleep and bedtime that sometimes develop in young children. Management of these sleep problems requires specific attention to the underlying psychological issues. Many parents find that co-sleeping for the first few weeks or months after adoption greatly reduces the child’s anxiety. Transition to more conventional sleep arrangements is easily accomplished when bonding to the family is more firmly established. Repeated expressions of love and provision of needed attention and security are key methods to manage sleep problems in newly adopted children.

Food
Amount. Unusual behaviors related to food are common among post-institutionalized children. Parents frequently report that their children are ravenous, consuming “unbelievable amounts” of food, and still wanting more. Most children with these behaviors have suffered significant hunger and should be offered food freely. Older children may be more confident about the food supply if given a small box to store a personal supply of food to consume as wished. Other children inspect the refrigerator and cupboards frequently to be sure that food is available; others hoard or hide food or stuff it in their mouths (“chipmunk cheeks”). Parents should be encouraged to offer food freely; usually the voracity diminishes within a few days or weeks when the child becomes confident that the food supply is reliable. Some parents find it useful to calmly offer more food to the child after he is done eating, even if he has eaten an enormous amount of food.

Sensory issues related to food.
A surprising number of children have sensory issues related to food. The most common is an inability to tolerate textures. Many children have subsisted on soups, liquids, and purees, and have missed some of the oral-motor milestones related to chewing solids. Nipples used for bottle feeding in many orphanages have large openings, probably to speed feeding. Children fed in this manner develop oral-motor reflexes to prevent choking, but have reduced oral motor tone.

These children may be “open mouthed” in appearance and may drool excessively. When offered conventional nipples, the children have difficulty producing an adequate suck to withdraw the formula. These children may have considerable difficulty tolerating a spoon because of overactive tongue thrust and may become distressed when presented with foods containing any texture (lumps). Some of these children also have “chipmunk cheeks”; one speculation has been that overstretching of baroreceptors in the oropharynx is needed for the child to sense where the food is in the mouth. Usually these difficulties abate within a few weeks, but some children have exceptional difficulties and may benefit from the assistance of a feeding team. In some children, esophageal reflux contributes to food aversions.

Introducing a new diet. Parents often wonder if the orphanage diet should be maintained during the transition, and especially whether formula must be gradually switched from a local brand to an American brand. Although some children appear sensitive to changes in diet, the vast majority of children do well, and graded switching is not necessary. Misplaced concerns about lactose intolerance in Asian infants often need to be allayed.

Some children display a pronounced unwillingness to try new foods. Whether this relates to taste or texture can be difficult to determine. Orphanage diets tend to be bland and predictable. For children in this category, slow introduction of new foods may be better tolerated than presentation of a wide array of tastes and textures.

Indifference to food. Surprisingly, some children, even if malnourished, are indifferent to food. These children usually have significant failure to thrive, but normal or near-normal cognitive development. These children often seem oblivious of hunger and never request snacks and meals. Their dismayed parents are at a loss to understand why a malnourished child refuses food or is indifferent to food; psychological problems between parent and child often ensue. These children must be carefully evaluated for medical reasons for failure to thrive. Occasionally, supplemental nighttime feeds are needed, and may eventually trigger normal hunger responses. The etiology of this syndrome is not clear. Delayed gastric emptying, inadequate food in the orphanage, and the extra attention from caregivers for the child refusing food may interact to alter the biochemical signals of hunger and satiety. Careful interventions may allow these children to eventually learn to eat properly; many never seem to particularly enjoy eating.

Toileting
Toilet training expectations and methods differ among cultures and are managed differentl in institutional care than in families. Many parents are told in advance that their child is “potty-trained,” only to discover to their chagrin (especially if they have come without diaper supplies) that this is not true. Most orphanages regularly schedule “potty-time” after each meal or snack. Infants even as young as 6 months may be placed on a potty—often tied on to the potty seat if too young to maintain balance— for lengthy periods after eating. This routine minimizes the number of soiled or wet diapers over the course of the day. Adoptive parents inevitably abandon this schedule because of the irregular events during the transition period (court appearances, travel, etc.), with the result that the “potty-training” vanishes. Parents adopting children less than age 3 or even 4 years of age should prepare for diapers, at least until they return home and establish some routine in the course of the day. Many children are remarkably apprehensive about diaper changes. Prior painful experiences during diaper changes, the proprioceptive stimulus of being placed supine, fear of clothing removal, or simply a change in the technique of the diapering could contribute to the child’s anxiety. Regardless of the cause, this fear usually abates within a short time.

Bathing
Attempts to bathe the child may be met with crying and distress. In orphanages, bathing may not be a pleasant experience (cold water, rough wash cloths and towels, etc.). Understandably, orphanage workers must bathe many children quickly. Bathing usually does not include pleasant, soothing waterplay. Children take some time to realize that bath-time means warm water, enjoyable sensations, and a chance for interesting play.

Clothes and Toys
One of the tangible expressions of the adoptive parents’ love for the new child is the desire to provide material items such as clothing and toys. Usually one of the strongest urges of a new parent is to undress and inspect the child, then to bathe her and dress in her in all new clothing. Parents should be cautioned to restrain these impulses during the early hours of the transition. Under most circumstances, the child has abruptly lost all that is familiar language, culture, people, places, and things. All that remains is her clothes, which smell and feel familiar. These should be removed and replaced only after the child has had a period of time with her new family. Stiff, new clothes may feel uncomfortable and unfamiliar; new clothes are a rarity in the orphanage. Most items should be washed prior to use and tags removed to prevent irritation.

Similarly, encounters with multiple new toys may be unfamiliar and frightening for children who have never had personal possessions. A child living in institutional care may never have had someone show him how to play with (as opposed to fling or bang) toys. Assisting the child’s interaction with toys is a valuable activity for parents in the early days of the transition.

Institutional Behaviors
Institutional behaviors often are noted in the early hours and days after adoption. These behaviors may be upsetting to unprepared parents. Occasionally institutional behaviors are captured on videos supplied to parents prior to adoption; however, this is uncommon. More frequently, these behaviors are observed after the child is placed with the family. These behaviors provide self-comfort, sensory stimulation, or attract adult attention. For children lacking physical comfort, toys, social interactions, and other experiences, these behaviors are adaptive and promote neurologic development in an abnormal environment. Some of these behaviors may be considered survival skills…

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