Resilient Rascals Grow Up

Save the date! On Friday, March 6, 2009 (please note date change), at the Shoreline Center, we'll be hosting our third "Raising Resilient Rascals" adoption and foster care conference. We're still working on the precise lineup, but the general focus will be on older child and adolescent issues. Possible talks:

• When to worry about mental health issues versus "normal" teen behaviors
• "Parenting Pitfalls" vignettes and open mic, with booby prize for best worst parenting moment
• How adopted adolescents construct their identity, and how to help
• Living with an older child with executive function difficulties - practical tips
• A mother and adopted daughter discuss transracial adoption
• Adult adoptee panel

Details to follow ... stay tuned! And feel free to just go ahead and register.

Help for the Holidays - Deborah Gray

Deborah Gray, MSW, MPA, author of Attaching in Adoption and Nurturing Adoptions and therapist extraordinaire, has shared a nice set of handouts for the holidays with us, reproduced here with kind permission. They're written for parents raising kids affected by histories of neglect, trauma, and anxiety. She has two slightly different versions, one for parenting kids with trauma histories, and one for children with anxiety. Good stuff to think about as a particularly stressful holiday season is upon us. I hope you find something helpful here, and we at the Center for Adoption Medicine send you happy and as-relaxing-as-they-can-be holiday wishes.

• Help for the Holidays - Trauma Version
• Help for the Holidays - Anxiety Version

Melamine and Chinese Adoptions

What We Do and Don't Know About Melamine

As details of the melamine contamination scandal continue to emerge, many of our pre- and post-adoptive parents are wondering how potential exposure to this chemical may affect their child. I wish we knew more. But I'd like to start by offering some general information about melamine, and some tentative guidelines about how to manage this issue.

Melamine is a chemical with a number of industrial uses, and an already scandalous history as one of the major contaminants in the 2007 Chinese pet food debacle. It is suspected that it was added to milk at milk collecting stations in China to disguise the fact that milk was being watered down, since melamine artificially increases the testable protein content. We don't yet know how long this has been a problem. According to Sanlu, a popular budget formula manufacturer implicated in this event, contaminated milk was used in the manufacture of infant formula processed before 8/6/08, as well as in other dairy products like liquid milk, frozen yogurt, and coffee creamer.

There is essentially no reliable toxicology information about melamine and human consumption. The animal data suggests that it is not metabolized in the body, and is excreted in urine. At high doses in animals, it can cause bladder stones, and inflammation of the bladder. Over time, this may be carcinogenic, but we have no human studies to evaluate this risk. 

The high number of serious kidney complications and deaths in pets exposed to contaminated food has been linked to the particularly toxic combination of melamine and cyanuric acid. We have not seen reports of cyanuric acid in human-consumed milk products, but it can be a contaminant in melamine products.

What is additionally confusing is that in animals, melamine alone can cause bladder stones (a mixture of melamine, protein, uric acid and phosphate), but has not caused kidney stones or kidney failure. The preliminary reports from China, however, do indicate that a small fraction of children who received contaminated formula have been diagnosed with kidney stones, reportedly containing uric acid. We are told that 4 infants have died, perhaps from obstruction of their kidneys from such stones, and 150 children have had renal failure. I don't know what to make of the high number of reported hospitalizations (over 14,000), and suspect that some of those may have been for workup and not because of illness.

Symptoms to Watch For

Please keep in mind that recently adopted children have plenty of more common and benign reasons for crying. That said, here are some things to watch for that would deserve prompt evaluation:

• Unexplained crying episodes or abdominal pain, especially with urination
• Passing blood, crystals, or particles in urine
• Dramatic decrease in urine output
• Swelling of the hands, feet, or around the eyes (edema)
• Pain when tapped over the kidneys
• Unexplained lethargy or vomiting

Our Evolving Approach

What remains unclear is which children deserve what workup. I'll cover our clinic's current approach here (which may be updated as consensus evolves and new information becomes available):

• So far, we are checking a urinalysis with microscopy (to look for blood or crystals), and an electrolytes/BUN/creatinine panel (to look for signs of impaired kidney function) on all new Chinese adoptees. We may also add more routine ultrasound of kidneys, ureters, and bladder to look for stones themselves (see below).
• Many of our previously adopted children have had some of these tests, but we are asking any symptomatic children (see above) to come in for urine & blood testing, and for an ultrasound, or perhaps CT scan if our suspicion is very high.
• Children who came home from China in the past 3 or so years (vague because we don't know how long melamine has been a contaminant) who are asymptomatic should probably have at least a non-urgent urinalysis, if they have not previously had one. If they've been growing well and are asymptomatic, and have no other reason to need a blood draw, I'm not convinced that bloodwork is necessary. But we may start ultrasounding more routinely for this group as well.
• A reasonable diagnostic code to use would be V87.39: contact with and (suspected) exposure to other potentially hazardous substances (for asymptomatic children), or codes based on a child's specific symptoms.
• As for specific testing for melamine itself in blood or urine, we are not doing that at this time. Such testing is investigational and hard to come by, and given the expected fairly rapid excretion of melamine, may not be of much clinical use. Plus, children may be exposed to insignificant amounts of melamine from other sources, which would complicate interpretation of results.
• Treatment of children with stones may involve close observation, IV fluids and urine alkalinization, medical management of acute renal failure if present, and various procedures to break up and remove recalcitrant or obstructing stones.

What is currently controversial is whether ultrasounds should be a routine screening test for asymptomatic Chinese adoptees with normal urinalysis. Thus far, we're not sure, and we have a low threshold to order ultrasounds if we're not sure about the "symptomatic" part, and are happy to order them for concerned parents. There have been several reports of renal stones diagnosed by ultrasound in otherwise asymptomatic children with normal urinalysis and bloodwork. If more of these are confirmed, we probably will start routinely ultrasounding. What remains unanswered is how common are these cases, and what needs to be done if asymptomatic stones are discovered.

We are in discussion with our local kidney and urology specialists, as well as other adoption docs, about the advantages and drawbacks of more universal ultrasound screening for Chinese adoptees. There are other radiographic approaches, such as a CT KUB (non-contrast) or CT urogram (with contrast), which can give better resolution for children in whom we highly suspect stones based on symptoms or labs, but the substantial amount of radiation exposure (and cost) with CT scans makes them unattractive for routine screening.

We've not yet seen any children in our practice with diagnosed kidney stones or other complications. According to informal data from Half the Sky, less than 5% of exposed children in the orphanages they work with have been diagnosed with kidney problems. And without stones and renal complications, we think it unlikely that melamine-exposed children will have significant long-term impacts. But we will keep you posted here as we learn more. And as always, please do involve your child's medical provider. Their opinion on this as-yet-fuzzy issue may not be the same as ours, and they know your child better than the internet does.

Useful Melamine Resources

• The World Health Organization (WHO) has an excellent overview of melamine contamination in China
• The Hong Kong Journal of Pediatrics has published an excellent melamine overview and editorial (pdf), with new details and thoughtful analysis (link courtesy of Dr Gordina)
• The New England Journal of Medicine has a good overview of the global implications of the melamine contamination scandal
• JCICS has posted a helpful FAQ, including some reports from Half the Sky about affected children in their orphanages
• The Canadian Public Health Agency has a helpful set of melamine resources
• Our Centers for Disease Control (CDC) has a good FAQ as well
• "China Milk Issue" YahooGroup, an active listserv of concerned parents (and a few docs), with database of their test results
• Parent-organized survey collecting preliminary data regarding results of tests on children adopted from China who may have been exposed to melamine. Please consider adding your information here, to better understand the scope of the problem.

Recommendations from the Chinese Ministry of Health:

(via the WHO, as of 10/08 - check here for updates):

The World Health Organization has agreed to circulate the information contained herein regarding the treatment plan that is being implemented in China by the Ministry of Health. The information below does not reflect the rules, regulations, policies and guidelines of the World Health Organization.

The following regimen has been issued by the Ministry of Health, China.

Clinical manifestations

• Unexplained crying, especially when urinating, possible vomiting
• Macroscopic or microscopic haematuria
• Acute obstructive renal failure: oliguria or anuria
• Stones discharged while passing urine. For example, a baby boy with urethral obstruction with stones normally has dysuria
• High blood pressure, edema, painful when knocked on kidney area

Key diagnostic criteria

• Been fed with melamine-contaminated infant milk formula
• Having one or more of the above clinical manifestations
• Laboratory test results: routine urine tests with macroscopic or microscopic haematuria; blood biochemistry; liver and kidney function tests; urine calcium/creatinine ratio (usually normal); urinary red blood cell morphology shows normal morphology of red blood cells (not glomerular haematuria); parathyroid hormone test (usually normal).
• Imaging examination: preferably ultrasound B exam of urinary system. If necessary, abdominal CT scan and intravenous urography (not to be used in case of anuria or renal failure). Kidney radionuclide scans can be used where available to evaluate renal function.
• Ultrasound examination features:
  • General features: bilateral renal enlargement; increased echo on solid tissue; normal parenchyma thickness; slight pyelectasia and calicectasis; blunt renal calyx. If the obstruction locates in the ureter, then the ureter above the obstruction point dilates. Some cases have edema with perinephric fat and soft tissue around the ureter. As the disease develops, the renal pelvis and ureter wall may have secondary edema. A few cases have ascites.
  • Stone features: most stones affect the collecting system and ureters on both sides. Ureteral stones are mostly at pelviureteral junction, the part where the ureter passes across iliac artery, and ureter-bladder junction. Stones stay collectively, covering massive areas. Lighter echo in the background. Most stones are different from the calcium oxalate stones. Urinary tract is mostly completely obstructed by the stones.

Differential diagnosis

• Haematuria differentiation: need to rule out glomerular haematuria.
• Stone differentiation: the stones are normally radiolucent and have a negative image on urinary tract x-ray. This feature differentiates the stones from those of radiopaque stones of calcium oxalate and calcium phosphate.
• Differentiation of acute renal failure: need to rule out pre-renal and renal failure.

Clinical treatment

• Immediately stop using melamine-contaminated infant formula milk powder.
• Medical treatment: use infusion and urine alkalinization to dispel the stones. Correct the water, electrolyte and acid-base imbalance. Closely monitor routine urine tests, blood biochemistry, renal functions, ultrasound findings (with particular attention to the renal pelvis, ureter expansion, and the change of the stones in shape and location). If the stones are loose and sand-like, they are very likely to be passed out with urine.
• Treatment of complicated acute renal failure: priority should be given to the treatment of life-threatening complications such as hyperkalemia. Measures include the administration of sodium bicarbonate and insulin. If possible, blood dialysis and peritoneal dialysis can be used early. Surgical measures can be taken to remove the obstruction if necessary.
• Surgical treatment: if medical treatment is not effective, and hydrocele and kidney damage present, or blood dialysis and peritoneal dialysis are not available in case of renal failure, surgical methods can be considered to remove the obstruction. Stones can be removed by different methods including cystoscope retrograde intubation into the ureter, percutaneous kidney drainage, surgical removal and percutaneous kidney stone removal. Extracorporeal shock wave lithotripter (ESWL) is greatly limited in its application, because the stones are loose and mainly composed of urate, and the patients are infants.

Follow-up

Once the urinary obstruction is relieved, and the general condition and renal function and urination are back to normal, the children can be discharged.

Key issues to follow-up

Urine routine tests; ultrasound of urinary system; renal function tests; IVP (intravenous pyelogram) if necessary.

FASD & Adoption Radio Show

I had the pleasure of being interviewed on "Blog Talk Radio" today by Dawn Davenport, author of www.creatingafamily.com and "The Complete Book of International Adoption: A Step by Step Guide to Finding Your Child".

We had an hour-long discussion about rough estimates of alcohol risk for various countries, the fetal alcohol spectrum, things to look for in a referral, how to address alcohol concerns post-adoption, and the long-term outlook. There's lots more we could have covered, but we ran out of time, so we hope to do this again in several months, focusing on post-adoption FASD issues. In general, I hope to get more audio and video presentations up on the site in coming months, including some highlights from our Raising Resilient Rascals conferences.

• Stream this interview on their site (ads and window resizing alert)
  
• Download as an mp3 "podcast"
• Or play it using this Flash embedded player:

Raising Resilient Rascals Returns!

Our adoption and foster care conference is back, and bigger than ever! This year, on February 1st and 2nd, 2008 in Edmonds, we'll have two days of talks for parents and professionals, from a panel of local and national experts. With the "Resilient Rascals" conferences, we and our colleagues at Nurturing Attachments and Cascadia Training try to schedule a lineup of talks that we'd be excited to attend, and give ourselves a push to do talks that go beyond "Adoption 101".

We're very excited to be able to host Dana Johnson, MD, this year. Dr. Johnson directs the University of Minnesota International Adoption Clinic, which is the country's longest-running IA clinic. He has been a passionate advocate for children, and Dr. Bledsoe and I are fortunate to count him as a mentor.

Dr. Johnson and his colleagues have been responsible for much of the seminal research on international adoption. They've just completed an truly impressive study: the Bucharest Early Intervention Project, which is the first and hopefully the last randomized controlled study of foster care versus orphanage caregiving. Results have recently been published in Science, and Dr. Johnson has a remarkable presentation prepared on what they've found. Not to be missed - Dr. Johnson is a dynamic speaker, and this is a landmark study.

But wait, there's more:

• I'll be covering "The Nature and Nurture of the Brain", which will review the latest brain research, and how it can help us parent and advocate for fostered and adopted children.
  
• Paulette Caswell, MSW, will address domestic foster care research and outcomes.
  
• Stephen Glass, MD, will cover Sensory Processing and other facets of neurology that impact our kids.
  
• Gwen Lewis, PhD, will answer the question "Why Does My Rascal Go Ballistic?" with a talk on the executive functions, the brain skills that help us regulate our behavior.
• Julie Bledsoe, MD, will review research-based "Interventions for the Fetal Alcohol Spectrum".
• Margaret Cashman, MD, a child psychiatrist and sleep specialist, will present on the use of psychiatic medications in fostered and adopted children.
• We'll have a whole panel of folks addressing the ever-present problem of "Sleep and Adoption".
• In "Om a Little Teapot", I'll put you to sleep (in a good way) with practical techniques for relaxation and self-regulation.
• Deborah Gray, MSW, will present "Five Faves for Anxious Children", an upbeat skills-building workshop for parenting children with anxiety or traumatic stress.
• Plus plenty of time for Q&A, and we'll wrap things up with a panel to discuss some challenging cases.
  

As ever, we'll aim to be informative and entertaining, and to filter the latest research through a practical parenting lens. Sign up now at the Cascadia Training website! We hope to see you there ...
 

Friendships, Social Skills, and Adoption

In our practice we see a unfortunate number of children with friendship problems. It can be one of the more painful issues that arises for our clients. But there is also hope - some good resources are available to help children with social skills difficulties, and there is much that parents can do to help.

What we hear from some of our families is that their children “feel” younger than they are, and gravitate towards younger children, or are more drawn to adults than peers. It can be hard for them to “share” conversation; they may divulge too much personal information, or have difficulty finding interests in common. They may have trouble joining their classmates in play. They often lack a sense of how to be a good host when having friends over (controlling the play, etc). Boys may take things too far, getting too rough or out of control. Girls may be clingy or bossy. Children may not get invited to play-dates or parties, and may lack a good friend.

Childhood friendship problems is a topic that raises strong feelings in many adults. I don’t know anyone that had a perfectly socially successful childhood, and just reading the previous paragraph can bring up memories of loneliness and rejection. When we see our children having such difficulties it’s truly challenging to stay present and clear-minded about what’s going on. But it is important to find a balance of appropriate concern and involvement. Blaming the peer group, assuming things will be better in another school, or otherwise neglecting the issue isn’t helpful; neither is overreacting, anxious hovering in social situations, or trying to bribe or force other children to include your child.

Causes of Friendship Problems in Fostered and Adopted Kids

Social skills problems in the context of foster care and adoption have not been well-researched, but the causes likely lie in a combination of:

• Lack of early secure attachments leading to more anxious/controlling behaviors in later relationships
• Rough and unsupervised early interactions with peers
• Poor social boundaries and judgement, difficulty reading others’ social cues
• A higher prevalence of impulsivity, ADHD, and externalizing (acting-out) behavioral problems
• Poor emotional regulation (quick to anger at perceived slights and rejection, etc)
• Delayed social/emotional development
• Challenges in social communication and language, making it hard to keep up with the increasingly fast-paced world of their peers

These risks are not shared by all of the adopted children that we see, but they are more common. In the world of social skills interventions, many of the participants are children (boys, usually) with ADHD, acting-out behavioral problems, or autistic spectrum issues. If you substitute "institutional autism", or general lack of appropriate formative social experiences, that's a combination of issues that fits many adopted and fostered children.

Patterns of Peer Problems 

The literature on social skills problems in general suggests that there are a few patterns of peer problems that are most worrisome, and deserving of intervention. Researchers in this field often categorize children by interviewing their peers to come up with how liked (or not) and influential they are. This all sounds a bit harsh, but no one knows better how children are doing socially than their peer group, and the categories that follow aren’t nearly as hurtful as peers can be. In this research context, children are grouped as:

• Average (well-enough liked and influential)
• Popular (desired as a friend and influential)
• Neglected (not influential)
• Controversial (both liked and disliked, also influential)
• Rejected (disliked)

Interestingly, “popular” as derived from peer ratings is not the same as just asking who’s popular. The “sociometrically popular” kids are well-liked, good problem-solvers, and trustworthy - a good friend. The “popular kids” are actually seen as dominant and “stuck-up”. Neglected children may be shy or less motivated to join peers; they seem do well academically, and can start over in new groups and shed the “neglected” status. Controversial children are sociable but tend to use more social aggression and hostility; this also may not be a very stable category over time.

Rejected Children 

But the “rejected” group is the most concerning. Children with rejected status in one group tend to be rejected in new groups as well. Without intervention, they are likely to stay rejected over time, and are more likely to have later difficulties with delinquency and adult maladjustment.

Children who are classified by observers as socially withdrawn, plus rejected by peers (thus, not withdrawn by choice), are more likely to have internalizing problems like depression and anxiety. There are two sub-groupings of boys who are “rejected”: rejected plus aggressive (verbal aggression, rule-breaking, etc), and rejected with odd, immature, or “quirky” behaviors. The rejected-aggressive boys are more likely to have academic difficulties and ADHD. Girls have rates of rejection similar to that of boys, but are a lot less likely to be referred to social skills interventions; it may be that rejected boys stand out more and have more externalizing behaviors, while rejected girls have fewer overt problem behaviors.

If this sounds like your child, you should consider learning more about how to help your child with play dates and friendships (since you’ve got the potential to make a big positive impact), and explore local options for social skills groups. Here are a few tips, but the resources that follow will be more helpful:

Help your kids with the basics of social interactions

• Teach your child learn appropriate social greetings-and-responses, and what degree of physical contact is appropriate for whom (how not to be a "space invader")
  
• Encourage and model use of positive statements like praise and agreement
• Help your kids learn to share a conversation (reciprocity)
  
• Practice these skills over and over and over
  

Help children have frequent, successful play dates

• For younger/less mature children, having shorter, more structured play dates can help
• Practice being a good host beforehand, and come up with possible activities that their guest may enjoy
• When it comes to games, emphasize shared fun over winning/losing, and "good sport" behaviors (make sure to model these as well!)
  
• As a parent, stay aware of how things are going without hovering

Support your child in making and keeping friends

• Make friends with neighbors with children, allow your kids to get to know each other
• Get to know the parents of your kids potential friends (and enemies!)
• Make your child's friends feel welcome in your home (greet them warmly, compliment them directly and to their parents when they pick them up)
• Socialize across generations: make time for extended family, hang out with other entire families together, look for a range of ages for your child to get to know. Such shared family gatherings can provide models of interaction, unhurried time for children to get to know each other, and can keep parents in touch with how their kids are doing socially.
  

Help your children deal with the pain of rejection

• Remember that some pain around peer issues is inevitable and a normal part of childhood; try not to overreact or get too caught up in your own issues
• Don't nurture resentments, add fuel to feuds, or attempt to coerce other children into including your child
  
• But do employ "active listening"; acknowledge and reflect back the emotions that you see your child having
• Once your child feels heard and understood, help your child with self-soothing strategies like deep breathing, muscle relaxation, and active play
• If bullying at school is involved, insist that it be appropriately addressed; most schools these days have policies, if not effective interventions, in place to deal with bullying
• If your child falls into the "rejected status" category above, seek further help (see below)
  

Resources for Families 

One book for parents that I’ve really liked is “Best of Friends, Worst of Enemies: Understanding the Social Lives of Children”. Several of the tips above come from this book, which deftly summarizes the research about how children’s friendships evolve as they mature, and has solid suggestions for each developmental stage. Another book is "It's So Much Work to Be Your Friend: Helping the Child with Learning Disabilities Find Social Success". But having a good book probably isn’t enough for children that fall into the socially rejected category. That’s where social skills groups come in ...

Social Skills Interventions 

Social skills interventions for children do exist that have been well-studied, and show measurable improvements in parent and teacher ratings of social success. One such intervention is Children’s Friendship Training, which was developed at UCLA. Some of their work has specifically looked at children with ADHD, ODD (oppositional-defiant disorder), ASD (autistic spectrum disorders), and even FAS (fetal alcohol syndrome). I like this approach, as they’ve evaluated it with the types of problems my patients have, they have a rigorous approach to testing their program in general, and they include an important parent educational component which helps the gains children make in group generalize to the rest of their lives.

There are two local groups I’m aware of that draw on this intervention for their social skills groups. One is BeFriended, which runs social skills and friendship groups in collaboration with Nurturing Attachments. The other is FASt Friends, a family support group for families impacted by prenatal alcohol exposure, who run Children’s Friendship Training groups for teenagers.

In the interests of full disclosure, BeFriended was started by my lovely and talented wife, Kim. I’ve been a bit involved with its conception ... for professionally selfish reasons, I’ve really wanted to see an adoption-savvy social skills intervention come to town! But I also want to be fair to the other good folks in town that I don’t happen to be married to. I’ve heard nice things about all of the following social skills practices, and I’m happy for people to post more in the comments. Choice is a good thing. Best of luck to all of our families that are struggling with this issue!

Puget Sound Social Skills Groups:

• BeFriended
• FASt Friends Teen Groups
• Wally’s Club
• Friendship Group
• Carla Brooks and Associates
• Your child’s school may have a social skills program or friendship group as well
  

Raising Resilient Rascals Conference

Raising Resilient Rascals:

Integrative, Brain-Based and Practical Ways
to Nurture Adopted and Fostered Children

 
Save the date! On Feb 2nd we'll be hosting an all-day conference with Deborah Gray and colleagues.  We're aiming to be interesting and informative for both parents and professionals interested in adoption. Check out the topics below, and sign up at the Cascadia Training website.

Topics include:

 

The "Decade of the Brain" Came and Went - What Have We Learned?

The past 10 years brought many advances in neuro-imaging, and better understanding of the effects of prenatal drug and alcohol exposures, malnutrition, maltreatment, lack of attuned care giving, and stress on the developing brain.  What can the latest research tell us about how these all-too-frequent influences affect the neurodevelopment of adopted and foster children?  We will explore different regions of the brain, and aspects of learning and behavior, with an emphasis on avenues for intervention at home and school.

Loving the Child Who Bites You - Disciplining Scared/Aggressive Kids. 

Children who have been maltreated or lost attachment figures desperately need to form secure attachments with their parents.  Often the children are aggressive and/or immature and impulsive.  What strategies are useful when children show limited empathy?  We will look at approaches designed to bring out the best in children whose histories of maltreatment have resulted in dysregulation and behavior problems.

From Snake Oil to Fish Oil - Integrative Medicine and Adoption. 

A lively romp through the wilderness of complementary/alternative therapies commonly used by adoptive families, from an "alterna-friendly" pediatrician.  We'll review the evidence or lack thereof, safety, and cost of interventions ranging from vitamins, minerals, essential fatty acids, and other "nutriceuticals", herbs and homeopathy, elimination diets, chelation therapy, bodywork and chiropractic, developmental movement therapy, sensory and auditory integration, and bio/neurofeedback.  We'll also cover ways to evaluate therapies and practitioners, and the cardinal signs of quackery.

Adderall and Risperdal et al. - Meds and Adoption.  

In this part of our talk, we'll address the use of psychiatric medications with adopted and fostered children.  Stimulants, antidepressants, mood stabilizers, blood-pressure medications, and atypical anti-psychotics are being used more and more with younger and younger children.  Unfortunately, the evidence for safety and efficacy in children for many of these drugs is lacking (as are the child psychiatrists!)  What do we know about these meds and children?  What goes into the decision to medicate a child for specific psychiatric conditions like ADHD, depression, anxiety, and bipolar disorders, as well as less defined emotional and behavioral problems?  What sort of monitoring is important?

Creating Resilience in Children: What areas promote competencies in children?  What are we doing well?  What are we missing?   How should we be doing it? 

The remarkable increase in the number of adoptions of children adopted after trauma and neglect has pushed the need for support.  But, professionals and parents alike need to know when to obtain support.  This talk describes symptom clusters in childhood trauma, neglect's impact on children's functioning,  and best practices in providing help.  We will also discuss what to look for in acquiring help and what to avoid.

Resilience Panel

The day will end with a panel to include all the speakers and a few invited guests.  The panel will discuss resilience factors, resilience gene, adult influences, orphanage interventions, goodness of fit, what can parents do to prepare/promote resilience?  There will be plenty of time to take attendee questions.

About the presenters:

Julia Bledsoe, MD, is a Clinical Associate Professor of Pediatrics at the University of Washington, and a staff pediatrician at the UW Fetal Alcohol Syndrome Diagnostic and Prevention Network in Seattle.  She founded the Center for Adoption Medicine, and has worked in the field of international adoption for ten years, with travels to Russia, Romania, China, and Guatemala.  She has two children adopted from Korea, one of whom has Tourette's Syndrome and ADHD.

Julian Davies, MD, is a Clinical Assistant Professor of Pediatrics at the University of Washington, and the other pediatrician at the UW FAS Clinic.  He is also the Co-Director of the Center for Adoption Medicine, where he provides pre-adoption consultations, post-placement evaluations, and ongoing general pediatric care for adopted children.  He is the primary author for www.adoptmed.org, an online resource for medical and developmental issues in adoption and pediatrics.  He has traveled, clowned, and volunteered extensively in Russia, with an arts rehabilitation program and summer arts camp for Russian orphans.

Deborah Gray, MSW, MPA, is a national trainer, a psychotherapist in private practice, and the author of the well-received book, Attaching in Adoption: Practical Tools for Today’s Parents, Perspectives Press, 2002. Deborah has spent 20 years helping children develop attachments and work through trauma and grief. She teaches in the Trauma Certificate Program at the Univ. of WA School of Social Work and both graduate adoption therapy programs at Portland State University and Northwest Adoption Exchange. Her second book on best practices with children after neglect and trauma is in preparation.

About the particulars:

Location: Tukwila Community Center
When: February 2nd, 2007
Hours: 8:30am-5:00pm
Fee: $65.00 US
CEU info: 7 CEU's 
Cascadia Training is approved by the NASW, Washington State Chapter, to provide continuing education units to Licensed Social Workers, Mental Health Counselors and Marriage and Family Therapists.  Certificates of Completion are awarded to attendees at the end of each workshop.  Provider number #1975-118; Cascadia is an OSPI approved provider of in-service education.  This is a "Washington State Approved Clock Hour Offering Workshop."

Medical Resources in China

This is a handy list of medical resources in China for travelling families, graciously shared by Todd Ochs, MD. 

Anhui Province

Hefei - Anhui Provincial Hospital
No. 1 Lujiang Road
0551-2652797
(VIP section for foreigners)
Hu Yunwen, MD

Anhui Provincial Children’s Hospital
No. 39 East Wang Jiang St.
230051 Hefei
Shan Hua, MD
0551-367103-3035 (off.)
13966681963 (cell)
<hua888@mail.hf.ah.cn>

Beijing - International SOS Clinic
No. 1 North Road, Xing Fu San Cun
Chaoyang District
8610-64629117 (clinic)
8610-64629100 (alarm)

Click to read more ...

Toilet Training Guides

Here are some fab resources on this subject from a pediatric toilet training guru - (a dubious honor, for some, but you can't be in pediatrics without a healthy appreciation for the bodily functions).

• Parent Guide: Toilet Training Basics (start here)
• Parent Guide: Toilet Training Resistance (if you're having trouble)
• Parent Guide: Stool holding - When your child holds back bowel movements and is not toilet trained (uhoh)
• Parent Guide: Using Incentives to Motivate Your Child (you might need this)

Dr Parker, a developmental pediatrician with a mighty fine blog, has a this post on the Poop Wars:

• Poop Culture: Potty Training Your Child
  

Elizabeth Pantley, author of several "No-Cry" and other excellent parenting books, has several articles on this topic as well, which she permitted us to excerpt here:

• Quick Facts About Potty Training
• Potty Training Readiness Quiz
• Potty Training - Get Ready, Get Set, Go!

And if these Pantley tips don't work, you can always try the Pantless method ... take one warm weekend, add one rug-free room or backyard, a nearby potty or 2, and a toddler tanked up on fluids. Subtract clothes (theirs).

Quick Facts About Potty Training

By Elizabeth Pantley, Author of The No-Cry Potty Training Solution

Potty training can be natural, easy, and peaceful. The first step is to know the facts.

• The perfect age to begin potty training is different for every child. Your child's best starting age could be anywhere from eighteen to thirty-two months. Pre-potty training preparation can begin when a child is as young as ten months.
• You can begin training at any age, but your child's biology, skills, and readiness will determine when he can take over his own toileting.
• Teaching your child how to use the toilet can, and should, be as natural as teaching him to build a block tower or use a spoon.
• No matter the age that toilet training begins, most children become physically capable of independent toileting between ages two and a half and four.
• It takes three to twelve months from the start of training to daytime toilet independence. The more readiness skills that a child possesses, the quicker the process will be.
• The age that a child masters toileting has absolutely no correlation to future abilities or intelligence.
• There isn’t only one right way to potty train – any approach you use can work - if you are pleasant, positive and patient.
• Nighttime dryness is achieved only when a child's physiology supports this - you can't rush it.
• A parent's readiness to train is just as important as a child's readiness to learn.
• Potty training need not be expensive. A potty chair, a dozen pairs of training pants and a relaxed and pleasant attitude are all that you really need. Anything else is truly optional.
• Most toddlers urinate four to eight times each day, usually about every two hours or so.
• Most toddlers have one or two bowel movements each day, some have three, and others skip a day or two in between movements. In general, each child has a regular pattern.
• More than 80 percent of children experience setbacks in toilet training. This means that what we call “setbacks” are really just the usual path to mastery of toileting.
• Ninety-eight percent of children are completely daytime independent by age four.
  

This article is an excerpt from The No-Cry Potty Training Solution: Gentle Ways to Help Your Child Say Good-Bye to Diapers by Elizabeth Pantley (McGraw-Hill, 2006). Used with permission.