Medical and Video Reviews from Russia
Medical and Video Reviews from Russia Guidelines in understanding and interpretingMedical and Video reviews from Russia
When I review a video, I first rate the quality of the video. What is the length of the video? If the video is less than 1 or 2 minutes, I really can't make a very complete assessment of the child's development because the child may not display enough behavior for evaluation. A good video is usually at least 5 minutes in duration and it shows the child with and without clothes. Video of a child being bathed can be very useful because we see the child's body and we see how the child reacts to stimuli like temperature. It is very essential to be able to view the child's skin and extremities without clothes for birth marks and possible deformities. Muscle tone can be better assessed if we look at the extremities as they are moving. The symmetry of movement can be observed. If the movement of limbs is asymmetric, we might diagnose a neurologic abnormality. The quality of the child's nutrition can be assessed by looking at the child without clothes. The developmental age of the child can be determined to some extent by looking at a good quality video. I use the standard Denver Screening Test: this screening tool helps pediatricians evaluate the child from birth to 6 years of age. It assesses language, fine-motor adaptive, gross motor, and personal-social development. Children who are living in orphanages may be delayed just because they have been living in an institutionalized setting and their nutrition has been sub-optimal. There is a belief among adoption professionals which is supported by some limited medial data, that for every 3 months a child resides in an orphanage there may be loss of one month of development. This is probably an over-simplification of the effect of orphanage life on the development of a child, but I find it to be a useful tool.
It would probably be very easy for adoption professional/facilitators to use the Denver Developmental Screening Test as a guide in making the video. Some age appropriate skills could be assessed and filmed. For example, a four-month-old infant is capable of reaching for toys or objects slightly out of reach. This could be easily filmed. A child can sit on his own between 6-8 months, but we need to show this and then we need to show the sitting when it does occur. Children follow past the midline at 2-3 months of age. Kids rake a raisin or a cheerio at 6-8 months and they have a neat pincer at 8-10 months. These are very easy tasks to set up and observe with video. Families who travel to an orphanage to adopt a child can be instructed to carry out the same tasks so that a video can be prepared for waiting families. Filming a child eating is a terrific way to assess sucking and swallowing and interaction with the caretaker.
It is essential to know the date that the video was done to correlate the developmental age with the chronological age. Vocalizations are a very key aspect of my evaluation. Unfortunately, most of the children in orphanages do not vocalize. They have little one-on-one connection with their caretakers. The caretakers usually do not speak to the children as they change their clothes or feed the child. When I hear vocalizations in a video, I am pleasantly surprised and I consider this very encouraging for this child's future development. If a child is not doing much on a video, this does not necessarily mean that there is something seriously wrong with the child. A child may have just awakened from a nap or the child may have an acute illness, like a cold. This can alter a child's mood.
Video should depict the child interacting with adults and age appropriate toys should be offered to the child to see how the child handles toys. Filming children with other children is also enlightening; how they interact gives us information about the child's ability to socialize. This is especially valuable for older children. Are both hands symmetrically touching or grabbing toys? Does one arm or leg seem to be less in use than the other arm or leg? Are all four extremities moving? These are some of the questions that should be answered. There should be close-ups of the face so that the reviewer can comment on features consistent with Fetal Alcohol Syndrome. FAS is a difficult diagnosis to make when the video is not clear. If the child is less than one year of age the bones and muscles are changing so rapidly that he features of the face may not reveal features consistent with FAS. It should be understood that children known to have been exposed to alcohol during pregnancy may not have FAS, but they may develop characteristics consistent with Fetal Alcohol Effect (FAE) which may not be so obvious until the child enters school and displays problems with memory, learning, and behavior.
Sequential videos are very helpful in the assessment of a child. I am seeing more and more tapes of children taken in early infancy with follow-up tapes every few months. This really is enlightening. If the child has established a consistent pattern of development even with some delay, this is encouraging. If the child seems to display a substantial decrease in the developmental growth with each new video, then this is discouraging and may reveal some underlying neurological or metabolic problems. It is exceedingly difficult to assess an infant less than six months of age by a video. The limited array of behaviors makes it difficult for me to assess very young infants.
Video taken by other families who are traveling to adopt their child may be very useful. American families have an understanding of development that is often not appreciated by staff in Russia orphanages. The family can also consult with a pediatrician before the trip and guidelines can be sent with the family who is doing the video so that the video can be focused. Of course, this can be also done for the videos produced by adoption agency facilitators. A prospective family can provide video guidelines to their agency and these can be used to produce that video.
Video of older children should depict them eating, drinking, playing with friends preferably outside where the child can run around. Observing children drawing pictures, identifying pictures that are on cards or in picture books is especially helpful as long as there is accompanying English translation. This helps the viewer assess the child's receptive and expressive language which is really the key to a child's cognitive development.
Growth Parameters
Plotting the height, weight, and head circumference that appear on the medical abstract is a key facet of the medical evaluation. How the child looks on a standard growth curve is very important. Most children in orphanages are undernourished and even if they start out at birth at an average weight and height, they generally do not maintain that growth velocity due to poor nutrition and institutionalization. Psychosocial dwarfism is a well-understood medical consequence of poor nutrition and institutionalization. If a child is adopted under the age of two years, there is usually good rebound and weight gain and linear growth improves. It should also be understood that the birth weights of children in Russia are well below the average weight of a newborn in the U.S. Poor prenatal care, smoking, and drinking during pregnancy are quite common in Russia and are in major causes for low birth weight in newborns. Parents need to understand that measurements can be unreliable. The staff who measures children in orphanages are well-meaning individuals who have little medical training. It is not unusual for scales to be old and measuring tapes to stretch. Babies are notorious for squirming and measuring lengths is problematic even in the good U.S.A. Videoing a staff member or better, yet, the orphanage doctor measuring the child is of particular benefit. We can hear the measurements stated in the video and assess their reliability. If the child is failing to thrive by the weight and height parameters. I am still optimistic since the vast majority of these children under two years of age catch up.
Head circumference is obviously the most important growth parameter in the child's medical profile. The growth of the head correlates with brain growth. Heads grow fast and furiously in the first year of life. The average head circumference of a newborn is 35 cm and in the first year of life the head grows about 12 cm. If you look at a standard growth curve there is a 5th% and a 95th% line for each age. If the child is somewhere at or between these percentiles, this is considered normal growth. This growth curve allows for the small, medium, and large head. Head size is universal. Except, for the difference in the shape of the head of some cultures like Asia the back of the head may have a flat appearance, heads should fit on a standard growth curve.
Reasons for small head circumference are varied. Some heads are small due to poor nutrition during the pregnancy, smoking, drinking, intrauterine infections, and in some rare cases craniosynostosis (premature closure of the soft spots of the cranium). Some kids are born with normal heads, but due to malnutrition their heads don't grow. It is not clear yet what percentage of children coming from Russia have heads less than the 5th%. In the summer of 1998, I sent a student to work in three Russian orphanages in the Udmurtia republic; she evaluated 154 children ages ranging from 4 months to 55 months in Izhevsk, Glazov, and Votkinsk. 38% of the children had microcephaly.
In my practice, the majority of the children adopted from Russia have head circumferences above the 5th%. Those children with head circumferences below the 5th%, adopted less than two years of age, have had some rebound growth. More time is needed to present useful statistics. When a head circumference is
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