Differential Plasticity in the Recovery of Adopted Children 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., Moreno, C., León, E., & Peñarrubia, M.-G. (2014). Differential Plasticity in the Recovery of Adopted Children After Early Adversity. Child Development Perspectives, 8(3), 169–174, which has been published in final form at https://doi.org/10.1111/ cdep.12083 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. For Review Only Differential Plasticit y in Adopted Children’s Recovery after Early Adversity Journal: Child Development Perspectives Manuscript ID: 2014-005.R2 Wiley - Manuscript type: Review (invited) Keywords: adoption, growth, neuropsychological development Abstract: Since early adversity is usually involved, adoption allows its negative consequences and the recovery processes to be studied once the child is integrated into a protective, loving and stimulating family context. This article explores the recovery process in three areas: growth, neuropsychological development and attachment. Differential plasticity within each of these domains is proposed, in such that generalizations about physical, neuropsychological and emotional recovery must be avoided. Likewise, diversity within adopted children is analyzed, as it is a much more heterogeneous group than suggested by a single generic label. Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 2 ABSTRACT Adoption research contributions to understanding developmental plasticity are explored in this article. Since early adversity is usually involved, adoption allows its negative consequences and the catch-up processes to be studied once the child is integrated into a protective, loving and stimulating family context. Post-adoption recovery is analyzed in three developmental domains: growth, neuropsychological development and attachment. Differential plasticity within each of these domains is proposed, in such that generalizations about physical, neuropsychological and emotional recovery must be avoided. Key-words: Adoption, growth, neuropsychological development, attachment Page 1 of 22 Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 3 Defined as the capacity of the organism to adjust to changing circumstances and demands of the context (Lerner, 1984), plasticity is a key component of human development. Given our susceptibility to environmental influences “for better and for worse” (Belsky, Bakermans-Kranenburg & van IJzendoorn, 2007), the study of plasticity has an extended tradition in developmental psychology. Recently, adoption researchers have added their contributions to a relevant issue for both the understanding of human development and the application of developmental knowledge. Adopted children’s experiences before and after adoption create an ideal context to study their plasticity “for worse and for better”: the negative consequences of preadoption adversity and the possibilities of their post-adoption recovery (Palacios & Brodzinsky, 2010). Our goal here is to analyze the extent of post-adoption catch-up in different developmental domains. Differential plasticity refers to the fact that recovery after early adversity is more complete in some aspects than in others. ADOPTION, ADVERSITY AND RECOVERY Although adopted children vary in terms of their pathways to adoption (Grotevant & McDermott, 2014) and the characteristics of their detrimental initial circumstances, some level of early adversity is normally involved. This could be genetic, prenatal or perinatal adversity; or neglect and abuse during the initial stages of life; unstable placements from one family to another or institutionalization under more or less adverse conditions. Normally, it is an accumulative combination of any one or all of these sources of risk occurring during crucial developmental stages. Research has repeatedly shown the negative consequences of initial adversity in maltreated (Tabone et al., 2011) and post-institutionalized (PI) children (McCall, Van IJzendoorn, Juffer, Groark, & Groza, 2011). It has also been repeatedly reported that the degree of deterioration Page 2 of 22Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 4 depends on the severity and duration of the adverse circumstances (Van IJzendoorn & Juffer, 2006). There is also a plethora of meta-analytical and longitudinal literature showing the extent of the recovery once adoption introduces a dramatic change in the life and relational circumstances of children with early adversity (Van IJzendoorn & Juffer, 2006). Evidence seems to indicate that although not restricted to that period, a good amount of the catch-up takes place in the first post-adoption period (e.g., Miller et al. 2010). Our research has substantiated all these findings regarding initial delays, subsequent recovery and its incidence during the first post-adoption years (Palacios, Román & Camacho, 2011). We have also suggested that while the negative consequences of adversity happen synchronously when children are subjected to negative circumstances, recovery tends to happen asynchronously, with certain aspects improving earlier and more completely than others (Palacios et al., 2011). DIFFERENTIAL PLASTICITY A great deal of adoption research has analyzed the influence of different circumstances on adopted children’s trajectories of change. Factors such as being adopted from foster care or from orphanages, duration of adversity and adoption age have all received repeated attention in adoption research (Van IJzendoorn & Juffer, 2006). Our interest in this article is not about plasticity in individual trajectories, but rather in developmental domains. Research has differentiated between domains that are more and less impaired in adopted children. For example, cognition and attachment (Rutter, Kreppner, O’Connor, & the ERA Study Team, 2001) have been found to be more affected than self-esteem (Juffer & Van IJzendoorn, 2007). Our focus here is the differential plasticity that Page 3 of 22 Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 5 appears within certain domains in the children’s post-adoption recovery. Using data from other researchers and our own, we will illustrate this differential plasticity in growth, neuropsychological development and attachment. Differential Plasticity in Growth A combination of malnutrition, alterations in endocrine growth factors and psychosocial deprivation, growth failure (Johnson, 2000) or growth suppression (Johnson & Gunnar, 2011) is part of the PI children’s portrait. Data have shown a delay of approximately one month of linear growth for every three (Johnson, 2000) or five months (Albers, Johnson, Hostetter, Iverson, & Miller, 1997) in institutional care. These delays are important for their physical consequences, such as an increased risk of early puberty (Teilmann, Pedersen, Skakkebaek, & Jensen, 2006), but also for their connection with other developmental aspects (for example, between height at adoption and later cognitive development, Johnson & Gunnar, 2011). When studying growth in children from intercountry adoptions, the three most commonly used indicators to analyze initial delays and post-adoption recovery are weight, height and head circumference (this latter as an indicator of brain growth during the first years of life, when brain size increases most). According to the meta-analysis by Van IJzendoorn, Bakermans-Kranenburg, and Juffer (2007), while weight, height and head circumference are all affected negatively at the time of adoption, complete post-adoption recovery is seen in weight and height, but not head circumference. In the few studies included in this meta-analysis where the three parameters had been longitudinally measured simultaneously, the average time between initial and later assessments was four years. Could head circumference improve with more time after adoption? Page 4 of 22Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 6 Our longitudinal data showed that time does not seem to significantly change these results. We studied Russian children adopted in Spain at an average age of 3 years. Compared with the reference population, the initial significant differences in weight and height had disappeared at an average adoptees’ age of 10 years, but, as shown in Table 1, persisted in head circumference (Palacios, Román, Peñarrubia, & León, 2013). As an indication of the relevance of this fact, those with a more seriously affected head circumference had a significantly lower intelligence (IQ= 85) than those whose head circumference was not or only moderately affected (IQ= 97) (Cohen’s d= .83) (Palacios et al., 2013). The long-term impairment of head circumference had been also demonstrated in the follow-up at 15 years among Romanian children adopted in England after more than 6 months of institutionalization (Sonuga-Barke, Schlotz & Kreppner, 2010). Consequently, when the child’s global growth is affected by initial adversity and adoption introduces a radical change of circumstances, the later recovery appears to be significantly more complete for weight and height than for head circumference. This implies a differential plasticity for different growth-related aspects. Differential Plasticity in Neuropsychological Development As indicated by Nelson, Bos, Gunnar, and Sonuga-Barke (2011), human cerebral plasticity is a double-edged sword, favorable and positive when the upbringing is stimulating, and harmful and negative under adverse circumstances. When early adversity is implied, once the environmental inputs improve, plasticity enables the human nervous system to escape the restrictions of previous experiences by modifying the strength and mapping of preexisting connections (Pascual-Leone, Amedi, Fregni & Merabet, 2005). Page 5 of 22 Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 7 Neuropsychological development research has found a fruitful field of study in the consequences of early adversity and the possibilities for post-adoption recovery. Using both anatomical and behavioral approaches, research is paying special attention to cerebral areas that are particularly important for psychological functioning and adaptation, with the prefrontal cortex (executive function, EF) and the limbic system (emotions and memory) as the main objects of study. Both structures are affected by initial adversity, as Hart and Rubia (2012) have shown in their review of the neurological effects of early abuse and neglect, with conclusions valid for both domestic and intercountry adoption. In terms of recovery following early adversity, neuroanatomical data support the differential plasticity argument. Thus, for example, within the framework of the Bucharest Early Intervention Project (BEIP), McDermott, Westerlund, Zeanah, Nelson, and Fox (2012), using Event Related Potentials, evaluated a variety of neurophysiological indicators implicated in the resolution of an inhibitory control task involving the prefrontal cortex. Three groups were studied: children previously institutionalized randomly assigned to family care or to remain in institutions, and a third group of community children. Researchers expected that those who remained in institutions would perform the worst, with no significant differences between the two family reared groups. However, the pattern of differences observed depended on the neurophysiological indicator involved: for certain aspects, previously institutionalized children placed in foster families were similar to the group without an institutional experience; for others, they were comparable with those who remained institutionalized. Instead of the expected simple results (children in families doing better than children in institutions), the authors found a “complex constellation of neural processes” (McDermott et al, 2012, p. 63) in the children’s recovery after initial adversity. Page 6 of 22Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 8 The same complexity appears in the limbic system anatomy. Research on PI children has found larger, atypical amygdala volumes, with no size differences in the adjacent hippocampus (Mehta, et al., 2009; Tottenham et al., 2010). These anatomical data are backed by research with young rats: after exposure to stressful immobilization, the hippocampus recovered from the consequent atrophy, while the amygdala continued to present abnormally increased values (Vyas, Pillai, & Chattarji, 2004). Structurally, two elements from the same zone (the limbic system) present differential plasticity in the recovery following adversity. The “complex set of neural processes” (McDermott et al, 2012) is not exclusive to the frontal cortex. Behavioral data from neuropsychological research also speak of differential plasticity. EF (control of impulses, planning, rule learning, spatial memory and various aspects of attention and information processing) has been the main object of study with behavioral techniques. According to Loman et al. (2013), attention regulatory difficulties consistently reported for PI children reflect problems with sustained attention more than with selective attention or the inhibitory control. In another study, Pollack et al. (2010) showed that children with longer institutionalization differed from those with shorter or no institutionalization in certain aspects (visual memory and visually mediated learning, attention, inhibitory control), but not in others (auditory processing, rule acquisition, manipulation, planning). Data from the BEIP also showed that, compared to the foster care and never institutionalized groups, the children who remained institutionalized were overall less accurate on an inhibitory control task. But in the measures assessing attention allocation and response monitoring, the never institutionalized children outperformed the other two groups, highlighting the important role of early experience in shaping the development of neural systems involved in inhibitory control via attention regulation processes. Page 7 of 22 Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 15 References Albers, L.H., Johnson, D.E., Hostetter, M.K., Iverson, S., & Miller, L.C. (1997). Health of children adopted from the former Soviet Union and Eastern Europe. Comparison with preadoptive medical records. Journal of the American Medical Association, 278, 922-924. doi:10.1001/jama.1997.03550110060037. Beijersbergen, M. D., Juffer, F., Bakermans-Kranenburg, M. J., & Van IJzendoorn, M. H. (2012). Remaining or becoming secure: Parental sensitive support predicts attachment continuity from infancy to adolescence in a longitudinal adoption study. Developmental Psychology, 48, 1277-1282. doi:10.1037/a0027442. Belsky, J., Bakermans-Kranenburg, M.J., & Van IJzendoorn, M.H. (2007). For better and for worse: differential susceptibility to environmental influences. Current Directions in Psychological Science, 16, 300-304. doi: 10.1111/j.1467- 8721.2007.00525.x. Bowlby, J. (1969). Attachment and loss: Vol. I. Attachment. New York: Basic Books. Bowlby, J. (1973). Attachment and loss: Vol. II. Separation: Anxiety and anger. New York: Basic Books. Cyr, C., Euser, E.M., Bakermans–Kranenburg, M.J., & Van IJzendoorn, M.H. (2010). Attachment security and disorganization in maltreating and high-risk families: A series of meta-analyses. Development and Psychopathology, 22, 87-108. doi: 10.1017/S0954579409990289. Grotevant, H.D. & McDermott, J.M. (2014). Adoption: Biological and social processes linked to adaptation. Annual Review of Psychology, 65, 235-265. doi: 10.1146/annurev-psych-010213-115020. Hart, H. & Rubia, K. (2012). Neuroimaging of child abuse: a critical review. Frontiers in Human Neuroscience, 6, 1-24. doi: 10.3389/fnhum.2012.00052. Page 14 of 22Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 16 Hodges, J., Steele, M., Hillman, S., Henderson, K., & Kaniuk, J. (2005). Change and continuity in mental representations of attachment after adoption. In D.M. Brodzinsky & J. Palacios (Eds.), Psychological issues in adoption: Research and practice (pp. 93-116). Westport, CT: Praeger. Johnson, D. E. (2000) Medical and developmental sequelae of early childhood institutionalization in Eastern European adoptees. In C.A. Nelson (Ed.), The effects of early adversity on neurobehavioral development. The Minnesota symposia on child psychology, vol. 31 (pp. 113-162). Mahwah, NJ, Erlbaum. Johnson, D. E. & Gunnar, M.E. (2011). Growth failure in institutionalized children. Monographs of the Society for Research in Child Development, 76 (4, Serial No. 301), 92-126. doi: 10.1111/j.1540-5834.2011.00629.x. Juffer, F. & Van IJzendoorn, M.H. (2007). Adoptees do not lack self-esteem: A metaanalysis of studies on self-esteem of transracial, international, and domestic adoptees. Psychological Bulletin, 133, 1067-1083. doi: 10.1037/0033- 2909.133.6.1067. Lerner, R.M. (1984). On the nature of human plasticity. New York: Cambridge University Press. Loman, M.M., Johnson, A.E., Westerlund, A., Pollak, S.D., Nelson, C.A., & Gunnar, M.R. (2013). The effect of early deprivation on executive attention in middle childhood. Journal of Child Psychology and Psychiatry, 54, 37-45. doi: 10.1111/j.1469-7610.2012.02602.x. McCall, R.B., Van IJzendoorn, M.H., Juffer, F., Groark, C.J., & Groza, V.K. (Eds.) (2011). Children without permanent parents: research, practice and policy. Monographs of the Society for Research in Child Development, 76 (4, Serial No. 301). doi: 10.1111/j.1540-5834.2011.00626.x. Page 15 of 22 Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 17 McDermott, J.M., Westerlund, A., Zeanah, C.H., Nelson, C.A., & Fox, N.A. (2012). Early adversity and neural correlates of executive function: Implications for academic adjustment. Developmental Cognitive Neuroscience, 2S, S59-S66. doi: 10.1016/j.dcn.2011.09.008. Mehta, M.A., Golembo, N.I., Nosarti, C., Colvert, E., Mota, A., Williams, S.C.R., Rutter, M., & Sonuga-Barke, E.J.S. (2009). Amygdala, hippocampal and corpus callosum size following severe early institutional deprivation: The English and Romanian Adoptees Study Pilot. Journal of Child Psychology and Psychiatry, 50, 943-951. doi:10.1111/j.1469-7610.2009.02084.x. Miller, B.S., Kroupina, M.G., Iverson, S.L., Mason, P., Narad, Ch., Himes, J.H., Johnson, D.E., & Petryk, A. (2010). Determinants of catch-up growth in international adoptees from Eastern Europe. International Journal of Pediatric Endocrinology, 107252 (Epub 2010 December 29). doi:10.1155/2010/107252. Nelson, C.A. (2007). A neurobiological perspective on early human deprivation. Child Development Perspectives, 1, 13-18. doi: 10.1111/j.1750-8606.2007.00004.x. Nelson, C.A., Bos, K., Gunnar, M.R., & Sonuga-Barke, E.J.S. (2011). The neurobiological toll of early human deprivation. Monographs of the Society for Research in Child Development, 76, pp. 127-146. doi: 10.1111/j.1540- 5834.2011.00630.x. Pace C.S., Zavattini G.C., & D’Alessio M. (2012). Continuity and discontinuity of attachment patterns: A short-term longitudinal pilot-study of late-adopted children and their adoptive mothers. Attachment & Human Development, 14, 45-61. doi: 10.1080/14616734.2012.636658. Page 16 of 22Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 18 Palacios, J., & Brodzinsky, D. M. (2010). Adoption research: Trends, topics, outcomes. International Journal of Behavioural Development, 34, 270-284. doi: 10.1177/0165025410362837. 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 & Development, 37, 282-288. doi: 10.1111/j.1365- 2214.2010.01142.x. Palacios, J., Román, M., Moreno, C., & León, E (2009), Family context for emotional recovery in internationally adopted children. International Social Work, 52, 609- 620 . doi: 10.1177/0020872809337679. Palacios, J., Román, M., Peñarrubia, M., & León, E. (2013, July). Growth recovery in internationally adopted children: a longitudinal study. Paper presented at the Fourth International Conference on Adoption Research, Bilbao, Spain. Pascual-Leone, A., Amedi, A., Fregni, F., & Merabet, L.B. (2005). The plastic human brain cortex. Annual Review of Neurosciences, 28, 377-401. doi: 10.1146/annurev.neuro.27.07.02.03.144216 . Peñarrubia, M., Palacios, J., Moreno, C., Román, M., León, E., & Moreno-Maldonado, M.C. (2013, July). Executive function and early adversity in children adopted internationally. Paper presented at the Fourth International Conference on Adoption Research, Bilbao, Spain. Pollak, S.D., Nelson C.A., Schlaak M., Roeber B., Wewerka S., Wiik K.L., Frenn K.A., Loman M.M., & Gunnar, M.R. (2010). Neurodevelopmental effects of early deprivation in post-institutionalized children. Child Development, 81, 224–236. doi:10.1111/j.1467-624.2009.01391.x. Page 17 of 22 Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 19 Román, M., Moreno, C., Peñarrubia, M., & Palacios, J. (2013, July). Longitudinal continuity and discontinuity in attachment representations of internationally adopted children. Paper presented at Fourth International Conference on Adoption Research, Bilbao, Spain. Román, M., Palacios, J., Moreno, C., & López, A. (2012). Attachment representations in internationally adopted children. Attachment and Human Development, 14, 585-600. doi: 10.1080/14616734.2012.727257. Rutter, M.L., Kreppner, J.M., O’Connor, T.G., & the ERA Study Team (2001). Specificity and heterogeneity in children's responses to profound institutional privation. British Journal of Psychiatry, 179, 97-103. doi: 10.1192/bjp.179.2.97. Smyke, A.T., Zeanah, C.H., Gleason, M.M., Drury, S.S., Fox, N.A., Nelson, C.A., & Guthrie, D. (2012). A randomized controlled trial comparing foster care and institutional care for children with signs of reactive attachment disorder. American Journal of Psychiatry, 169, 508-514. doi:10.1176/appi.ajp.2011.11050748. Sonuga-Barke, E.J.S., Schlotz, W., & Kreppner, J. (2010). Differentiating developmental trajectories for conduct, emotion, and peer problems following early deprivation. Monographs of the Society for Research in Child Development , 75 (1), pp. 102-124. doi: 10.1111/j.1540-5834.2010.00552.x. Steele, M., Hodges, J., Kaniuk, J., Steele, H., Hillman, S., & Asquith, K. (2008). Forecasting outcomes in previously maltreated children; the use of the AAI in a longitudinal adoption study. In H. Steele and M. Steele (Eds.), Clinical applications of the Adult Attachment Interview (pp. 427-451). New York: Guilford. Stronach, E. P., Toth, S. L., Rogosch, F. A., Oshri, A., Manly J. T., & Cicchetti, D. (2011). Child maltreatment, attachment organization, and internal Page 18 of 22Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 20 representations of mother and mother-child relationships. Child Maltreatment,16,137-145. doi: 10.1177/1077559511398294. Tabone, J.K., Guterman, N.B., Litrownik, A.J., Dubowitz, H., Isbell, P., English, D.J., Runyan, D.K., & Thompson, R. (2011). Developmental trajectories of behavior problems among children who have experienced maltreatment. Journal of Emotional and Behavioral Disorders, 19, 204-216. doi:10.1177/1063426610383861. Teilmann, G., Pedersen, C.B., Skakkebaek, N.E., & Jensen, T.K. (2006). Increased risk of precocious puberty in internationally adopted children in Denmark. Pediatrics, 118, e391-399 . doi: 10.1542/peds.2005-2939. Tottenham, N., Hare, T.A., Quinn, B.T., McCarry, T.W., Nurse, M., Gilhooly, T., Millner, A., Galvan, A., Davidson, M.C., Eigsti, I.M., Thomas, K.M., Freed, P.J., Booma, E.S., Gunnar, M.R., Altemus, M., Aronson, J., & Casey, B.J. (2010). Prolonged institutional rearing is associated with atypically large amygdala volume and difficulties in emotion regulation. Developmental Science, 13, 46–61. doi: 10.1111/j.1467-7687.2009.00852.x. 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. doi: 10.1097/DBP.0b013e31811320aa. Van IJzendoorn, M.H. & Juffer, F. (2006). Adoption as intervention: Meta-analytic evidence for massive catch-up and plasticity in physical, socio-emotional and cognitive development. The Emanuel Miller Memorial Lecture 2006. Journal of Child Psychology and Psychiatry, 47, 1128-1245. doi:10.1111/j.1469- 7610.2006.01675.x. Page 19 of 22 Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 21 Vorria, P., Papaligoura, Z., Sarafidou, J., Kopakaki, M., Dunn, J., Van IJzendoorn, M. H., & Kontopoulou, A. (2006).The development of adopted children after institutional care: A follow-up study. Journal of Child Psychology and Psychiatry, 47, 1246-1253. doi:10.1111/j.1469-7610.2006.01666.x. Vyas, A., Pillai, A.G., & Chattarji, S. (2004). Recovery after chronic stress fails to reverse amygdaloid neuronal hypertrophy and enhanced anxiety-like behavior. Neuroscience, 2004, 667-673. doi:10.1016/j.neuroscience.2004.07.013. Page 20 of 22Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 22 Acknowledgement The authors’ data reported in this article come from a longitudinal study funded by the Spain’s Ministry of Science and Innovation, grants SEJ2006-12216 and PSI2010- 19287. Page 21 of 22 Child Development Perspectives For Review Only Running head: DEVELOPMENTAL PLASTICITY IN ADOPTED CHILDREN 23 Table 1. Weight, height and head circumference at the time of adoption and then 3 and 7 post-adoption years (z scores compared against the normative values of a control group) Arrival +3 years +4 years Weight - 1.54*** - .73*** - .52 Height -2.21*** -1** -.46 Head circumference -3.28*** -1.02*** -1.35** *p < .05, **p < .01, ***p < .001 Page 22 of 22Child Development Perspectives