Growth and development in internationally adopted children: extent and timing of recovery after early adversity

Depósito de Investigación de la Universidad de Sevilla https://idus.us.es/ This is the peer reviewed version of the following article: Palacios, J., Román, M., & Camacho, C. (2011). Growth and development in internationally adopted children: extent and timing of recovery after early adversity. Child: Care, Health and Development, 37(2), 282–288, which has been published in final form at https://doi.org/10.1111/j.1365-2214.2010.01142.x This article may be used for non-commercial purposes in accordance with Wiley Terms and Conditions for Use of Self-Archived Versions. This article may not be enhanced, enriched or otherwise transformed into a derivative work, without express permission from Wiley or by statutory rights under applicable legislation. Copyright notices must not be removed, obscured or modified. The article must be linked to Wiley’s version of record on Wiley Online Library and any embedding, framing or otherwise making available the article or pages thereof by third parties from platforms, services and websites other than Wiley Online Library must be prohibited. Review Copy Growth and development in internationally adopted children Journal: Child: Care, Health & Development Manuscript ID: Draft Manuscript Type: Original Article Keywords: Adoption, Development, Developmental Delay, Growth Child: Care, Health and Development Review Copy Abstract Background: Following their initial adversity, internationally adopted children join their new families with significant growth and developmental delays. Although recovery after adoption has been widely documented, much less is known about its extent and timing several years after placement and in children with a diversity of preadoption experiences. Methods: 289 children adopted from six countries into Spanish families were studied. Growth and psychological development were considered both on their arrival and at an average of more than three years later. Results: Severe growth and developmental delays on arrival were found in a substantial percentage of children. Post-adoption recovery seemed quicker and more complete in weight and height than in head circumference and psychological development. Initial and later values were correlated, but the relation between growth and development on arrival subsequently lost its significance. Most of the catch-up happened in the first 2-3 post-adoption years. Conclusions: Adoption offers an impressive opportunity for recovery after previous adversity, although continuity between past and present values persists. The improvement is more limited in some areas than in others and is a time-bound process, at least for the contents here studied. Page 1 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 2 Introduction Although most children experience a fair degree of continuity throughout their life, discontinuity is a distinctive quality for others. In the case of adoption, children experience a dramatic change in their circumstances and this discontinuity opens up opportunities for both paediatric and psychological research. This paper tackles two of the contents that have attracted adoption researchers’ attention, namely growth catch-up and psychological recovery post-adoption, as well as the underexplored domains of the timing of recovery and the long-term connections between both domains. With nearly one million children adopted internationally in Western countries between the end of the Second World War and the present (Selman, 2009), the social relevance of these issues parallels their interest for those who are professionally in charge of caring about their health and development. Research on the growth of internationally-adopted children has documented the high frequency of significant delays when placed with their adoptive families, as well as their noteworthy recovery thereafter (Johnson, 2000; Johnson et al., 1992; Judge, 2003; Miller et al., 2009; O’Connor, Rutter, Beckett, Keaveney & Kreppner, 2000; Pomerleau et al., 2005). Van IJzendoorn, Bakermans-Kranenburg and Juffer's (2007) meta-analysis showed that children suffered considerable delays in height, weight, and head circumference on adoptive placement, with a more complete post-adoption catch-up with regard to the former two compared with the latter. While the recovery is clear, much less is known about its timing. If children lose a month of linear growth for approximately every three months spent in institutional care (Johnson, 2000), what is their catch-up rate post-adoption? Does recovery tend to happen over several years or is it more evident shortly after adoption? To answer this question, data are needed spanning several years. However, with some exceptions, Page 2 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 3 studies tend to document only the changes that occur within the first year with the new family. A similar situation applies to psychological development. Although initial impairment and later recovery have been widely documented (see, e.g., Pomerleau et al., 2005; Vorria et al., 2006, and the meta-analysis by Van Ijzendoorn, Juffer, & Klein Poelhuis, 2005), little is known about the timing of recovery, and whether post-adoption changes occur mainly in the first post-placement years or subsequently. Rutter and his colleagues found that the Romanian adoptees whom they studied experienced the most dramatic changes during their early post-adoption years (Rutter, 2006), although cognitive improvements were documented for this same sample still several years after adoption (Beckett et al., 2006), albeit only for the initially more impaired group. Finally, the relation between the growth and development of international adoptees remains largely unexplored. Several studies have found both aspects to be related prior to as well as shortly after adoption (Miller, Chan, Comfort & Tirella, 2005; Pomerleau et al., 2005), but what happens in the long-term remains unexplored. The scant evidence suggests that both domains could be related initially, but that this diminishes over time. Rutter’s English-Romanian Adoption (ERA) project is unique in terms of both its wealth of information and its longitudinal nature, but their sample had experienced global, severe institutional deprivation, which raises the question: how far do children who have experienced less extremely adverse pre-adoption circumstances follow the patterns described by the ERA team? While not ideal, there are institutions that differ from the post-Ceaucescu Romanian orphanages (e.g., see the description of certain Russian institutions, with their mainly emotional-relational privations, by the St. Petersburg-USA Orphanage Research Team's, 2008). Although there has been some Page 3 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 4 research on children from different countries (e.g., Pomerleau et al., 2005), the vast majority focuses on children from one country, so research covering different geographical areas, and various pre-adoption circumstances, are required. The current study refers to adoptees from six different countries and considers growth and developmental status on arrival as well as at an average of more than three years after placement. Four hypotheses are tested: 1) international adoptees are expected to arrive with important growth and developmental delays, as well as to recover significantly from these deficits thereafter; 2) Since the pre-adoption circumstances adoption differ between countries of origin, significant differences are expected depending on this variable, at least on the adoptees’ arrival; 3) As far as the relation between growth and development is concerned, it is expected that the initial correlations will diminish or even disappear after a significant time spent in the new situation; 4) Finally, regarding recovery, it is hypothesized that the catch-up will be more significant shortly after arrival for both growth and psychological development, with a decreasing slope of change thereafter. Methods 289 children constituted the research sample. All were adopted in four Spanish regions that contain approximately 50% of the total Spanish population (Palacios, SánchezSandoval, León y Román, 2007). The countries of origin (China, Colombia, Guatemala, India, Romania and the Russian Federation) were selected because they represented 80% of all international adoptions undertaken in Spain at the time. The proportion of adoptees from the different countries in the sample mirrored that throughout Spain at that time; i.e. 24% were from China, 18% from Colombia, India and the Russian Federation, 12% from Romania and 10% from Guatemala. The average age at adoption was 34.9 months (31.7 s.d.) and all of the children had spent at Page 4 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 5 least a year with their new family. Girls (63.7%) outnumbered the boys in the sample, and were on average almost a year younger (31.1 months versus 41.5, p<.01). Data in Table 1 show the sample diversity in terms of age at adoption and institutional experience. Table 1 here Adoptive parents’ personal information is confidential and the families had to be contacted through each region’s child protection authority. All adoptions in Spain are handled by the public authority, which commissioned the study and provided a list of adopters matching the study criteria without any identifying information. The sampled families were contacted by the public agency. Around 80% of the approached families agreed to participate and allowed their personal information to be sent to the researchers, who could then arrange a home visit. In one of the regions, a higher percentage of adopters chose not to participate (almost 40%), with a particular incidence of those who adopted in Romania. In later contact with some of these families, they stated that they were unhappy with the public agency and/or tired of follow-ups. The families were visited in their homes an average of 38 months following the adoption. During the interviews, information was gathered about their child’s preadoptive history, as well as their height, weight and head circumference on arrival (from the initial paediatric assessment, 244 parents had written information on weight and 218 on height, but only 69 on head circumference). Developmental status on arrival was assessed during the home visit using the parents as informants with a retrospective version of the Battelle screening scale in which gross developmental indicators (e.g., the presence of pointing, smiling, walking, etc.) are considered (Newborg et al., 1988). Current weight, height and head circumference were obtained during the home visit, in Page 5 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 6 which children up to 6 years were also assessed with the complete Battelle scales, and those older than 6 were assessed using WISC-r (Wechsler, 1974). As in previous studies, the adoptive parents’ country norms were used for height, weight and head circumference (Hernández et al., 2002). Following common practice, growth scores above or below 6 standard deviations were not used, as they are so extreme that they could reflect incorrect or incomplete data (14 children on arrival and 3 at present were discarded for this reason). According to the World Health Organization (1995) recommendations, z scores below -2 represent a severe delay in growth, those between -1 and -2 a moderate delay, and those over -1 are considered normal. Only total scores were used for both Battelle and WISC-r, using Spanish norms. For Battelle, the screening scales used to assess initial development only provide categorical z scores and, as in growth, the children can be classified as severely, moderately or not delayed (Newborg et al., 1988). For WISC-r, IQ scores of 77 or below (equivalent to -1.5 standard deviations) were considered an indicator of severe difficulties, whereas scores between 78 and 89 were considered an indicator of moderate problems (Weschler, 1974). A psychological development index on arrival and at present was calculated by subtracting the chronological age from the mental age, so developmental data will be expressed in months. As in Johnson’s (2000) analysis, the growth delay and catch-up can also be examined in terms of linear lag, which expresses the distance between the values observed at a given age (initial or current) and the norm values for the age. So, if a girl arrives at 20 months with a height equivalent to 13 months, her linear height lag would be -7. Page 6 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 7 For the timing of recovery, the rationale of the analysis is as follows: to recover from their initial delays, children need to progress by more than 12 months in a year (to grow faster), the question then being how many months per year additional to 12 each child grows/develops after arrival. For example, if in the 12 post-placement months the girl in the previous example grew from an initial height of a 13 month-old to that of a 28 month-old, she developed 15 months in 12 months: she gained 3 additional months in a year. Since, at the time of study, by sampling decision, all children had been with their adoptive families for over a year, four groups were created, based on the time after arrival: 2 years or less (n=69), 2-3 years (n=94), 3-4 years (n=59), and over 4 years (n=67). Knowing how many additional months per year were gained by the children in these groups reveals the speed or timing of their recovery. Results Growth and development on arrival Growth: When they arrived with their new families, the average z scores were -1.48 for weight, -1.46 for height and -1.71 for head circumference. A severe delay (stunting) was present in 32.4% of children for weight, in 37.2% for height, and in 37.7% for head circumference (initial values, Table 2). In terms of linear growth lag, the initial average values were -10.62 months for weight, -5.86 months for height and -7.13 months for head circumference (initial values, Figure 1). Table 2 and Figure 1 here and For children with complete data, only 15.2% had a normal level in all three anthropometric indicators. There were positive correlations between them: weight with height, r=.55; weight with head circumference, r=.58; height with head circumference, r=.57 (all three, p< .001). Page 7 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 14 Dobrova-Krol, Van IJzendoorn, Bakermans-Kranenburg, Cyr and Juffer (2008), and Miller et al. (2007). However, Sonuga-Barke et al. (2008), in their analysis of Romanian adoptees, reported that, under 6 months, there was an association between head circumference and duration of deprivation only when sub-nutrition was present, whereas for those adopted after 6 months, there was a substantial reduction in head circumference regardless of their nutritional status. Significant positive correlations between initial physical and psychological scores suggest that the whole child is negatively affected by early adversity, but, confirming our third hypothesis, growth and developmental scores were no longer correlated after a significant time with the adoptive family, as elsewhere (Judge, 2003; O’Connor et al., 2000). Together with the less complete recovery in head circumference and psychological development, this suggests that the recovery processes follow different patterns for different aspects, with more similarity between weight and height, on one side, and between head circumference and psychological development, on the other. While pre-adoption impairment seems to occur synchronically, post-adoption recovery appears asynchronic. This parallels data reported by Vorria et al. (2006) (complete recovery in weight and height, but not in intelligence), as well as by SonugaBarke et al. (2008) (contrast between weight and both head circumference and IQ). As for the timing of recovery, the first 2-3 post-adoption years witness a substantial amount of improvement, thus confirming our fourth hypothesis and other data (Rutter, 2006). If, prior to their adoption, children lose 4 months of linear growth for every year in institutional care (Johnson, 2000), our data suggest that, in the first two post-adoption years, they make an additional gain of around 3 months per year in both height and psychological development, with a catch-up even faster and more pronounced in the case of weight. Although less steep, the recovery in the third postPage 14 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 15 adoption year seems also noticeable, but the speed of recovery decreases thereafter, especially for psychological development. For head circumference, the evidence here reported suggests a pattern more similar to psychological development than to weight and height. Although the average recovery in terms of psychological development seems modest after the third post-adoption year, this finding requires at least two qualifications. Firstly, the content of our psychological index is biased towards intelligence, as children over 6 years-old were assessed by an IQ test. Perhaps other psychological contents follow a different pattern of recovery, with a time frame for substantial improvement that is not limited mainly to the first three post-placement years. Secondly, the data here reported are average and reflect the general trend. However, in their study of Romanian adoptees, Beckett et al. (2006) for intelligence and Sonuga-Barke et al. (2008) for head circumference have shown that the initially more impaired children were still making some progress several years after their adoption. In general, however, as Rutter (2006) has indicated, it seems that head circumference and IQ are more susceptible than weight and height to persistent deficits following early adversity. Globally, confirming earlier research, the data reported in this article show that recovery after adoption does not imply an endless progress, but probably a time-limited improvement, at least for some contents and for the dramatic changes observed in the first few years after adoption, something of importance when working with prospective adopters as well as with adoptive parents in paediatric, clinical and psychological contexts. Also of interest is the positive correlation between initial and current scores in all of the studied domains. The implied continuity has also been found by others (e.g., Page 15 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 16 Judge, 2003; O’Connor et al., 2000; Pomerleau et al., 2005). The children’s past continues, then, to play a role in their current status. Although adoption is mainly about change, continuity also exists, a message to bear in mind for both preand postadoption services. Finally, our data suggest that the international adoptees are a heterogeneous group, even when they come from the same country. Crude generalizations about children adopted at a particular age or from a given country should be avoided, as they imply a determinism that is incompatible with the research findings. Three limitations in this study need to be highlighted, which remain relevant despite the fact that they are shared by many other inter-country adoption studies. Firstly, although the sample size as a whole is relatively large, the number of children from each of the six countries is indeed reduced and does not allow an analysis of within-country differences. Also, the number of children with reliable head circumference values on arrival is small, which limits the interpretation of these data. Secondly, the information about the prior-adoption children’s experiences is limited and comes from the adoptive parents, who know little about the children’s past. Finally, the assessment of psychological development on arrival through parental retrospective report is clearly problematic, even if the behaviours involved are not finely detailed and even if a similar approach has proved satisfactory in other studies (Beckett et al., 2006). In conclusion, although children adopted internationally are a very heterogeneous group in all regards, substantial initial delays are present in both their growth and psychological development, at least in part in relation to their previous experiences of institutionalization. After a significant period in their new context, clear improvements are observable, with a satisfactory catch-up in weight and height, but more limited progress in head circumference and psychological development. Most Page 16 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 17 changes occur in the first two or three post-placement years, with more modest gains thereafter. Although adoption is mainly about change and discontinuity, the influence of the early adversity does not disappear completely, as attested by the correlations between the initial and later values. Page 17 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 18 Key messages: - Adopted children join their new families with significant growth and developmental delays, related at least in part to the duration of their institutional experiences and age at adoption - After a significant period with their new families, children show a significant recovery, more complete for weight and height than for head circumference and psychological development - There are no systematic differences depending on country of origin, highlighting the heterogeneity of pre-adoption circumstances both between and within countries - Recovery after initial adversity seems to be a time-bound process, with most recovery taking place in the first three post-adoption years - Although the new life after adoption brings about new opportunities, the influence of the children’s past does not completely disappear. Page 18 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 19 References Beckett, C., Maughan, B., Rutter, M., Castle, J., Colvert, E., Groothues, C., Kreppner, J., Stevens, S., O'Connor, T.G. & Sonuga-Barke, E. (2006) Do the effects of early severe deprivation on cognition persist into early adolescence? Child Development, 77, 696-711. Dobrova-Krol, N. A., Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., Cyr, C. & Juffer, F. (2008) Physical growth delays and stress dysregulation in stunted and non-stunted Ukrainian institution-reared children. Infant Behavior and Development, 31, 539-553. Gunnar, M.R., Bruce, J. & Grotevant, H.D. (2000) International adoption of institutionally reared children: Research and policy. Developmental Psychopathology, 12, 677-693. Hernández, M., Castellet, J., Narvaiza, J., Rincón, J., Ruiz, E., Sánchez, E., et al. (2002) Curvas y tablas de crecimiento. Bilbao, Fundación Orbegozo. Johnson, D. E. (2000) Medical and developmental sequelae of early childhood institutionalization in Eastern European adoptees. In The effects of early adversity on neurobehabioral development. The Minnesota symposia on child psychology (Ed. C.A. Nelson), pp. 113-162. Mahwah, NJ, Erlbaum. Johnson, D. E., Miller, L. C., Iverson, S., Thomas, W., Franchino, B., Dole, K., et al. (1992) The health of children adopted from Romania. Journal of the American Medical Association, 268, 3446-3451. Judge, S. (2003) Developmental recovery and deficit in children adopted from Eastern European orphanages. Child Psychiatry and Human Development, 34, 49-62. Miller, B.S., Kroupina, M.G., Iverson, S.L., Masons, P., Narad, C., Himes, J.H., Johnson, D.E. & Petryk, A. (2009) Auxological evaluation and determinants of Page 19 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 20 growth failure at the time of adoption in Eastern European adoptees. Journal of Pediatric Endocrinology, 22, 31-39. Miller, L., Chan, W., Comfort, K., & Tirella, L. (2005) Health of children adopted from Guatemala: Comparison of orphanage and foster care. Pediatrics, 115, 710-717. Miller, L. C., Chan, W., Litvinova, A., Rubin, A., Tirella, L., & Cermak, S. (2007) Medical diagnoses and growth of children residing in Russian orphanages. Acta Paediatrica, 96, 1765-1769. Newborg, J., Stock, J., Wnek, L., Guidubaldi, J., Svincki, J., Dickson, J., et al. (1988) Battelle developmental inventory: Screening test manual. Allen, TX, DLM. O’Connor, T. G., Rutter, M., Beckett, C., Keaveney, L., Kreppner, J. M. and the ERA team (2000) The effects of global severe privation on cognitive competence: Extension and longitudinal follow-up. Child Development, 71, 376–390. Palacios, J., Sánchez-Sandoval, Y., León, E. & Román, M. (2007). La aventura de la adopción internacional. Barcelona, Teresa Gallifa. Pomerleau, A., Malcuit, G., Chicoine, J. F., Seguin, R., Belhumeur, C., Germain, P., Amyot, I. & Jéliu, G. (2005) Health status, cognitive and motor development of young children adopted from China, East Asia, and Russia across the first 6 months after adoption. International Journal of Behavioral Development, 29, 445-457. Rutter, M. (2006) The psychological effects of early institutional rearing. In The development of social engagement (Eds. P.J. Marshall & N. Fox) pp. 355-391. New York, Oxford University Press. Selman, P. (2009). From Bucharest to Beijing: Changes in countries sending children for international adoption 1990 to 2006. In International advances in adoption research for practice (G.M. Wrobel & E. Neil, eds.), pp.41-69. New York, Wiley. Page 20 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 21 Sonuga-Barke, E. J. S., Beckett, C., Kreppner, J., Castle, J., Colvert, E., Stevens, S., et al. (2008) Is sub-nutrition necessary for a poor outcome following early institutional deprivation? Developmental Medicine & Child Neurology, 50, 664671. The St. Petersburg-USA Orphanage Research Team (2008) The effects of early socialemotional and relationship experience on the development of young orphanage children. Monographs of the Society for Research in Child Development, 73 (3, No 291) Van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., & Juffer, F. (2007) Plasticity of growth in height, weight, and head circumference: Meta-analytic evidence of massive catch-up after international adoption. Journal of Developmental and Behavioral Pediatrics, 28, 334-343. Van Ijzendoorn, M. H., Juffer, F., & Klein Poelhuis, C. W. (2005) Adoption and cognitive development: A meta-analytic comparison of adopted and non-adopted children’s IQ and school performance. Psychological Bulletin, 131, 301-316. Vorria, P., Papaligoura, Z., Sarafidou, J., Kopakaki, M., Dunn, J., Van IJzendoorn, M. H., et al. (2006). The development of adopted children after institutional care: A follow-up study. Journal of Child Psychology and Psychiatry, 47, 1246-1253. Wechsler, D. (1974) Weschler intelligence scale for children-revised. New York, The Psychological Co, World Health Organization (1995) Psysical status: The use and interpretation of anthropometry. Report WHO Expert Committee. Technical report series 854. Page 21 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 22 Table 1. Children’s pre-adoption characteristics by country of origin. Mean age on arrival in months (s.d.) Mean age at time of study in months (s.d.) % girls % in orphanages Months in orphanage (s.d.) China 19.76 (13.23) 57.79 (21.48) 97.1 88.2 13.05 (8.83) Colombia 37.77 (29.36) 80.37 (37.79) 36.5 38.8 5.35 (10.31) Guatemala 18.47 (20.62) 67.13 (25.79) 60 34.5 5.96 (10.10) India 45.82 (38.93) 79.92 (40.91) 86.3 100 30.6 (24.77) Romania 34.89 (20.36) 66.83 (20.55) 37.1 94.3 25.14 (18.63) Russian Federation 51.27 (41.91) 85.76 (52.74) 43.1 100 28.21 (25.71) Page 22 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 Review Copy 23 Table 2. Recovery after adoption: initial and current scores Weight Height Head circumf. Psychological dev. Initial Current Initial Current Initial Current Initial Current No delay 37,3% 84,5% 38,9% 75,6% 33,3% 65,8% 38,3% 62,3% Moderate delay 30,3% 14,4% 23,9% 18,1% 29% 21,5% 18,2% 20,5% Severe delay 32,4% 1,1% 37,2% 6,3% 37,7% 12,7% 43,5% 17,2% Page 23 of 26 Child: Care, Health and Development 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60