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International Adoption: Considerations for Professionals, Parents and a Personal Perspective

27 Dec

International Adoption: Considerations for Professionals, Parents and a Personal Perspective.

International Adoption: Considerations for Professionals, Parents and a Personal Perspective

27 Dec


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Imagine a world in which you have no language.  Can you?  Perhaps the adult who becomes aphasic could experience this… perhaps someone like my father who suffered from Alzheimer’s disease experienced this – but I think that all children regardless of where they are from come into the world as blank slates, computers without any language installed.  All of use start out in life without any language at all.

In an internationally adopted child it is my impression from reading about those who live in orphanages this blank slate may actually continue into their new homes.  In her book, Silent Tears: A Journey of Hope by Kay Bratt this very phenomenon is described.  Ms. Kay lived in China and describes her work in a children’s orphanage and the lives of the children there.  She describes in her diary the daily experiences that she witnessed, the ways in which she was really able to help the children and her own journey of adopting a child internationally.  The impact of the environment that she describes undoubtedly contributes to the blank slate – the child devoid of any language as the result of a lack of stimulation.  It is a wonderful book to read and gives a very interesting perspective of children who come with that life experience in hand.

Sharon Glennen, a well known authority in the field of international adoption is a speech-language pathologist and describes in an article within the book Adoption Parenting: Creating a Toolbox, Building Connections which is edited by Jean MacLeod and Sheena Macrae, PhD some of the developmental issues that may influence the development of language in this group of children.  Her articles are numerous on the subject and searching for additional articles by her may be beneficial if you treat an adopted child in your practice.  As well, this particular text, dealing with developmental issues from Birth through Pre Adolescence, is a wonderful resource for parents as well and covers other aspects of adoption.

Ms. Glennen’s work speaks to me as the parent of an adoptive child; although his adoption was domestic.  Had I known more about the history of my now fifteen year old son at the point that we met his biological mother it would have been so helpful.   I think that I would have been proactive and done a bit more research in terms of the specialized needs with which he came to his adoptive father and I.  After the fact, I found myself delving into literature and consulting with specialists in the areas of difficulty with which he presents.  I still am with the knowledge that children, even teenagers are works in process and have brains that are still in the process of development.  It is this experience that facilitated this review of literature and reading about other experiences of adoptive parents.  The day that we finalized his adoption we met my son’s biological mother.  The one thing that she did share with us was that we would need to be strong as disciplinarians.  I now realize that she was alluding to the fact that her previous ten or eleven children (four in her custody) had issues in terms of behavior management.  Maybe I did not want to face this, or was in denial about this really happening to me.  Regardless, it moves me to think that we as professionals owe it to ourselves and our clients, patients, students and their families to be educated in areas of development of adopted children.

Ms. Glennen notes that non-verbal social interactions may be less affected by the orphanage environment as opposed to spoken language.  She encourages parents of children less than twenty four months to focus on these skills and that unlike non-adopted children, at age thirty months some true words are just beginning to emerge.    Imagine being in a preschool or social group as an internationally adopted child attempting to interact with your peers.  How frustrating that must be!

Adoptive parents often compare their children to those who are not so this seems incredible important to point out to them.  Ms. Glennen  goes on to state that a child who is not talking by thirty months may also have additional factors that influence the development of language in this particular group of children.  So, perhaps parents need to be advised to seek the guidance of other professionals, depending on the particular situation with which they are faced.

Older children are at a disadvantage.  They have to catch up to their peers, having had less exposure to the language of their new homes.  Glennen describes that these are children who may have “Limited English Proficiency”.  This will impact on their development of academic skills. These are the children who may have actually started to learn one language – but then this stopped because they moved away from their initial culture and perhaps into the home of an adoptive family with no fluency in the “language of origin”.  If I were seeing a child with this background, I would advise the adoptive parent to discuss this at the onset of the school year with the teachers who will be working with their children.  Perhaps at the outset, supports can be put into place to help these students as a group

As an adoptive parent I discovered that there are support groups for adoptive parents.  One such group in my New York area is called the Adoptive Parents Committee. Others in a group such as this can share experiences regarding how they have handled educational needs of their children.  On a personal note, I cannot begin to share with all of you how helpful this organization has been over the years.

I could probably go on, but I believe that I have given my readers and colleagues some food for thought which may be of benefit to others.  If this blog is a help to at least one of you, it will have been worth the time and energy put forth in its preparation.

Adoption: Developmental Differences to Consider

27 Nov

Sixteen years ago when I was trying to locate a woman who wanted to plan for the placement of her child in the hands of adoptive parents, “birth parent” was used to refer to the parent who gave birth to the adopted child.  With the increased variety of methods by which families can be created, I guess the term “biological parent” came into vogue.  Adoption is only one way to create a family, after all. 

What Do Biological Parents Do???:   Many biological parents who have to place their child in the hands of adoptive parents do so with significant personal sadness.  The circumstances that brought them to the point of having to do so is often quite unfortunate, leaving a personal scar that may never heal.  Biological parents may have to PLAN an adoption, because they love their child and want the best for them, realizing that they cannot care for them.  It is not necessarily, as i have heard many state, that the child involved was “given away”.  This term in actuality is offensive to many in the adoption community.

Baggage Carried:  I do not think that as a group people who adopt necessarily consider the developmental differences to which these childern may be prone.  Impoverished living conditions, poverty, abuse or genetically carried predispositions may all be contributing factors that are unknown to a prospective adoptive parent and child.  In a professional role, there is a responsibility to both be aware of and appreciate this fact.  I also believe that it is the role for every professional who touches the life of an adopted child to become an educator for both the adoptee and adoptive parent in terms of the differences that are present.  Teaching the adoptee and the adoptive parent how to deal with the problems that may be present, so that functioning is at the highest possible level is extremely important.   Parents need to be empowered to locate professionals who are adoption savvy – aware of the issues. As well, the possibility of screening a child who was adopted in

Birthdays:  From their perspective, the adopted child will always understand that there is a person or people who chose to not care for them after they were born. Children who walk into your office will carry throughout their lives a feeling of having been rejected, on some level. Birthdays will always represent a day of loss for them. They may be exciting, but sad as well. Sometimes adopted children withdraw from their adoptive family on that day, not wanting to confront this aspect of their lives. Instead, they may bury their head into a solitary activity, avoiding others.

Environment:  Children who are adopted may come from homes that are void of adequate nutrition.  Biological parents of adoptees who choose not to raise them may do so because of poor financial circumstances.  They may have need for the money that the legal process invovled in the actual adoption process may be a motivating factor for them to go this route.  

Child trafficking: This is something well documented in China.   The following link provides a detailed definition of this term and after reading this, one can come to appreciate how trafficking can influence a person:  The emotional toll that this takes on a human being cannot be understated.  The article that I reference here gives a very real picture of the very issue. 

Orphanages:  If a child was in one internationally or domestically prior to placement there may be factors that cause delays in the development of communication skills, nutrition and overall growth.  Sharon Glennen, PhD., CCC/SLP has documented this in her articles that are readily available online.  In her article “Orphanage Care and Language” she talks of her own experience in adopting a child from Russia.  Her travels to various orphanages and observations made during her visits are documented.  Amongst the red flags that she notes are a lack of environmental stimulation from adults, delays in language development, low birth weight, limited play opportunities.   Some children are left drinking from bottles or may not be assisted in learning how to eat with utensils.  One can surmise that the need for a multidisciplinary team evaluation and treatment approach in working with these children is essential to help them reach typical developmental milestones.    

In closing, I quote Susan Soon-Keum“ADOPTION is bittersweet,” said Susan Soon-Keum Cox, vice president for public policy and external affairs at Holt International, a Christian adoption agency based in Eugene, Ore., with an extensive program in China.  She states that “The process connects birth parents, child and adoptive parents in an unequal relationship in which each party has different needs and different leverage. It begins in loss”.  *“For Adoptive Parents, Questions without Answers” We all need to be sensitive when we deal with all of these parties.  Families where there is an “open adoption”, where the adoptive parents and child have a relationship especially in domestic ones, where we as professionals have a possibility of gaining more information. In some cases it will not be and you will have no history at all….there will be gaps in our knowledge of that with which we deal.  This is an unfortunate reality with which we all must sadly deal.

Steps for Helping Your Baby Learn to Eat and Drink: surprise fact and first steps to take

2 Nov

Baby eating baby food (blended green beans)

Image via Wikipedia

It has come to my increasing attention that there is a need for parents to know what resources are available to help them in understanding typical development.  In an effort to help offer guidance I am going to just present a few take-aways in this post.                                                                                                                                                                                                                                                                                 Parents need to understand that they are their child‘s first teacher and can offer stimulation at home that will further aid their child in learning how to eat and drink. 
                                                                                                                                                                                                                                                                                                                                Start feeding your baby puree solid foods, as a general rule when they are eight months old. Start with a stage one baby food and give them a small baby sized spoon that are available readily in a drug store. The spoon should have a soft surface, where the food is placed. Typically you will see these marketed as “baby spoons”.  One that the baby above uses is an example.   Bear in mind that you will want to be guided by your child’s pediatrician about the amounts of food that your child eats. 
In terms of giving your child liquids.  A fact not very widely recognized is that your baby will be born knowing how to suck and swallow and have had a great deal of practice at that point.  Your baby in-utero is starting to suck and swallow because they are surrounded in the womb in amniotic fluid.   They need to learn how to  suck and swallow this.  As a result – your child does not need you to teach them this skill, (typically developing children) and can skip the bottle.  Rather than giving them a bottle, be that teacher and teach your child to close their lips so that some of te very first sounds can emerge “m”, “b” and “p”.  How are they produced?  Closing your lips.  So……try to use a honey bear with tubing.  A company by the name  of Talk Tools sells this product.  They can be found at  The product comes with tubing.  You, the person feeding the baby is going to place the tubing  in the baby’s mouth and squeeze the honey bear itself and liquid  will flow into the baby’s mouth.  The person feeding the baby will be the one controlling how much liquid is given.  Straw drinking will develop around fifteen to eighteen months, so do not worry about this for now.   
Pacifiers – my personal pet-peeve.  Do you and your child a favor by avoiding their use from the beginning.  A typically developing child does not need them and the continued use will be to your child’s detriment, if you have already started.  Sorry….  Children need to learn to close their lips – not continue the sucking and swallow that the pacifier promotes.  If your child is using this you can start weaning them by cutting the rubber part of the pacifier down very gradually…snip off a bit by bit.  Gradually there will be not enough to suck on and the pacifier will be gone.    
Thickening agents may be suggested by your doctor if your child or young infant is having difficulty swallowing.  Be careful because some of these have not been tested on this population and there may be better options such as nectars, thichening with rice cereal, smoothies or shakes.
Sarah Rosenfeld Johnson has written a great deal about the connection between speech development and feeding.  Google her name and  you will see more specific information.  As well, the website can tell you more about this speech-language pathologist.                                              

“Autistic Wandering” DSM code added 10/11 and an Organization that Can Actually Help

21 Oct

I have been hearing a number of people within the world of social networking talking about this new code and wondering why??? why is this even being presented now.  What will be the  impact of having a new code like this on those with this illness?. These are questions that have been posed by a number of professionals.  Parents reading this post, I wonder what you think..  It would be interesting to hear your thoughts on this.  Maybe it would make you feel better if this code is in place for your child. I am actually glad that it is being listed.  I also became aware of an organization that might help someone who actually does wander and perhaps this would be a helpful resource for readers.

What LifePROTEKT is doing to help people with special needs

Each week thousands of people connect with LifePROTEKT to find out the latest information on wandering prevention, fall detection and location based GPS products. Some just visit to read the posts that are relevant to the communities we represent, and others look at the various products we offer in the personal location based GPS market as shown in our comparison grid.

Over the past year, it has been our pleasure to have donated hundreds of devices to families in need for their at-risk loved ones that may be prone to wandering. We have also donated our safety products to various healthcare organizations, law enforcement agencies, and charitable foundations including Autism Speaks, TacaNOW, Autism Society of America, Mason Allen Medlam Foundation and the National Autism Association to name a few. That does not include the individual personal families we have helped to secure their loved ones in order to rest a little easier at night.

Each month we also run a contest through the Autism Women’s Network which gives one family in need the opportunity to win a personal location device which includes a one year free subscription to protect their loved one with autism. If interested, you can enter your story here:

Along with these achievements we wanted to share some of the very relevent information provided by LifePROTEKT’s strategic partners. Over the next few months, major enhancements and improvements will be released on LifePROTEKT’s “Products That Protect” offerings. You can check them out here:

The advancements of the new products being launched will consist of things like two way calling, 30 day battery life, child predator alerts, bread crumbing, destination alerts, one-click geofencing, SOS Alert, temperature alerts, much more significant cell coverage for increased and faster accuracy in location and the list goes on. This does not even include any software advancements being made on these products. Now add the better cell coverage provided by the carriers, extended battery life and multiple choice offerings of which carrier works best in your area, and the solutions that provides, will assist many loved ones being brought back safely to their families or caregivers. They may even prevent them from wandering off in the first place.

LET’S GO ONE STEP FURTHER. Since LifePROTEKT understands the special needs communities we can recommend the best solution that fits the needs of the individuals that may be at-risk. Our products are the best solutions that are in the personal GPS industry as we work very closely with manufacturers such as Lok8u, Securatrac, AmberAlertGPS, Aerotel, Laipac, Pocketinder, Enfora and others. We take into consideration the sensory issues of an autistic child, the technical ability of the caretaker using smartphone or text messaging technology, we even determine coverage zones prior to providing the right solution that fits the needs of the family. For example, AT&T may not have the same coverage in your area as T-Mobile hence we predetermine the best solution to fit the needs of the family. (Please note that this technology relies on the triangulation of both cell phone and GPS technology).

LifePROTEKT is the ONLY company that offers various solutions that fit the needs of the special needs family and we are always looking at for the best scenario for parents and caregivers.

One More Thing We Offer. For every sale that is put through LifePROTEKT a portion of the proceeds is donated back to the autism and Alzheimer’s community. We do care about the communities we represent and make this pledge to help in spreading the awareness of at-risk individuals that may wander.

Finally. We are working very closely with healthcare organizations to help reduce the costs of these devices by covering them through various healthcare insurance programs. We have been lobbying for Center of Disease Control’s ICD-9 coverage to help more families where a wandering loved one may be a concern. CDC’s ICD-9 would provide insurance reimbursement for LifePROTEKT devices. This would be similar to the way a doctor would prescribe a glucometer for a diabetic. In this case, the doctor would prescribe a wandering prevention device for an at-risk individual to be covered by the family healthcare provider.

We ask you to share our website with others and help us promote solutions that have the potential to save many lives as we provide a small piece of technology that gives a great peace of mind!

We also request your help the Mason Medlam Foundation by signing the petition for Mason Alert. This will help so many families that have special needs individuals potentially save their loved ones from the same situation that had happened to Mason Medlam some short weeks ago. May God bless the Medlam family for their compassion and committment to preventing another tragedy from occurring due to wandering.

Sign and pass along the petition here:

LifePROTEKT uses the latest Location Based GPS devices and wandering prevention technologies to help find and care for those that can easily get lost or want to live independent lives.




Update – The New School Year – Helping Your Child

19 Oct

"Teacher Appreciation" featured phot...

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Has Therapy Started?

This is something to confirm right now. You probably assume that your child’s individualized educational plan or invidualized education planis at school.  Maybe not.   Let me be clear – i am not trying to put anybody down – but sometimes there gets to be so much paperwork that these and other  important documents can get misplaced.   If you did not have a chance to bring it down in person; as i discussed last month, please check.  Know that it may take a month to six weeks, depending on the school, to actually start servicing your child on a regular basis because of the fact that schedules take a little bit of time to get put together. New children’s names flow into the hands of therapists all year long.

Is Your Child’s Teacher Informed?

Just because an IEP or an IFSP has been received does not mean that your teacher knows about it.  If you can set up an individual meeting with your teacher now – that would be of tremendous help to BOTH the teacher and your child.  Knowledge is power – so if your teacher understands the type of problem that your child has, he or she will be more likely to be able to work with you.  For example, if she or he needs a hearing aid – or another type of amplification system to use in the classroom at school then they can check that it is there in the morning. 

Informational Hand Outs Related to Disabilities:

These are available and you should come with them to a meeting that you have with your teacher – at a parent-teacher conference.  Try and get some that are specific to your child.  Provide them for and discuss your individual situation with your child’s teacher. (amerrican speech-language hearing association occupational therapy association) physical therapy association) cerebral palsy) (children and adults with add/adhd)

These are a few organizations that may be able to help you locate information about your particular child’s disability.  They may actually have age appropriate material so that you can start a dialogue with your child about their special needs and then have them become advocates for what they need at school!  These organizations may have support groups for families too.  Don’t forget your pediatrician, the school nurse, the special education supervisor and the therapist who treats your child at school.

Great Resource for others interested in early neurologic development!

15 Oct


Understand Typical Developmental Milestones and Tips for Keeping Your Child Safe

10 Oct

We all hope for happy and healthy children. When there is a glitch…when a parent has the unfortunate situation of being told that their child will need help in the very early years, when neuroplasticity is at a peak, emotions may rage.  Cuts to the early intervention program, in many areas of the country have heightened anxiety about the future for disabled children, those receiving services through the early intervention program or those receiving services elsewhere.  Some parents have expressed reticence about enrolling their child in a specialized education program, or having professionals in their home to offer services to their child.   That feeling is respected.  Acceptance of a developmental delay or other type of handicapping condition may take a while to set in.  That said – I have a few suggestions.

I have realized that parents whose children receive early intervention services or those who would like their children considered for program participation are genuinely unsure of the process or they are not educated about what might qualify their child for services in a particular area.  Others are unaware of what they would expect to see in terms of skill development in a variety of areas.  That is unfortunate.  Parents need guidance and there are resources available for you.  Especially of concern is that you learn about when typically developing children acquire specific milestones like crawling, sitting, standing, speaking, eating solid food, drinking from a cup, assisting with dressing.  There are many more that could be mentioned.  Below is information that may be helpful: 

DVD:  A Life to Love: Preventing Accidental Injury to Our Most Precious Resource-available in English, Spanish, Chinese Creole, Arabic and Russian  (produced by the NYC Administration for Children’s Services @ 150 William Street New York, NY 10038.  NYC residents can call 311).

Clinical Practice Guidelines Quick Reference Guidelines for Parents and Professionals are available through the NY State Department of Health, Early Intervention Program, Corning Tower Building, Room 208, Albany, NY 12237-0618  These are available free of charge at  and relate to a variety of developmental areas such as vision, communication, hearing, motor function. 

Zero to Three

Scholarly Article Supports That There Is A Point To Early Intervention..Please Share..

26 Sep

For anyone who interacts with others who are questioning the point to early intervention and the effects that it can have on very young children, feel free to pass this article on.  It makes for a very good educational tool…. Thank you.

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Challenges and limitations in early intervention


Article first published online: 21 SEP 2011

DOI: 10.1111/j.1469-8749.2011.04064.x


Developmental Medicine & Child Neurology

Developmental Medicine & Child Neurology

Special Issue: Impact of Intervention: can we affect typical and atypical development of the human brain? Outcome papers from an International Workshop held 22-24 April 2010 in Groningen, the Netherlands

Volume 53, Issue Supplement s4, pages 52–55, September 2011

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How to Cite

HADDERS-ALGRA, M. (2011), Challenges and limitations in early intervention. Developmental Medicine & Child Neurology, 53: 52–55. doi: 10.1111/j.1469-8749.2011.04064.x

Author Information

  1. Department of Pediatrics, Developmental Neurology, University Medical Center Groningen, Groningen, the Netherlands.

*Correspondence: Dr Mijna Hadders-Algra, University Medical Center Groningen, Developmental Neurology, Hanzeplein 1, 9713 GZ Groningen, the Netherlands. E-mail:

Publication History

  1. Issue published online: 21 SEP 2011
  2. Article first published online: 21 SEP 2011
  3. PUBLICATION DATA Accepted for publication 28th February 2011.


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Jump to…Top of pageAbstractParent–Infant InteractionType and Timing of the Lesion of the Developing BrainAge at Which the Intervention is AppliedContents of Early InterventionConclusionAcknowledgementsReferences


  1. Top of page
  2. Abstract
  3. Parent–Infant Interaction
  4. Type and Timing of the Lesion of the Developing Brain
  5. Age at Which the Intervention is Applied
  6. Contents of Early Intervention
  7. Conclusion
  8. Acknowledgements
  9. References

Research over the past three decades has shown that early intervention in infants biologically at risk of developmental disorders, irrespective of the presence of a brain lesion, is associated with improved cognitive development in early childhood without affecting motor development. However, at present it is unknown whether early intervention is also able to improve developmental outcome in infants with a serious lesion of the brain. This paper discusses factors that might play a role in the effect of early intervention. The following picture emerged from the limited evidence available: (1) coaching of parents seems an effective means of intervention; (2) our understanding of the plasticity of the developing human brain is currently too limited to allow a direct practical implementation in early intervention; (3) intervention before term age should primarily focus on stress reduction, intervention after term age on stimulation of infant development; and (4) our knowledge of the best ways to stimulate infant development is scant. Nevertheless, preliminary data suggest that offering the infant ample opportunities to explore by self-produced motor activities the borders of their own abilities might be a good strategy for promoting developmental outcome, including functional mobility.

Infants might be at risk of developmental disorders for a variety of reasons. The risk might consist of social or biological disadvantage or a combination of both.1 Well-known examples of biological disadvantage are prematurity or low birthweight, whether accompanied by a serious lesion of the brain or not.2 The usual care of infants at risk of developmental disorders includes early intervention. This comprises ‘the multidisciplinary services provided to children from birth to 5 years of age to promote child health and well-being, enhance emerging competencies, minimize developmental delays, remediate existing or emerging disabilities, prevent functional deterioration and promote adaptive parenting and overall family functioning’.1 Today a wide variety of early intervention programmes exists.3–6 The programmes have been shown to be effective in promoting developmental outcome, in particular cognitive outcome, in infants socially at risk of disadvantaged development.7 Gradually, evidence is also emerging of the effect of early intervention in infants biologically at risk of developmental disorders, i.e. those with prenatal, perinatal, and neonatal complications. The effect of early intervention in these groups has been studied most often in preterm infants. Recent systematic reviews, including meta-analyses, on the effect of early intervention in infants born preterm indicate that early intervention is associated with improved cognitive development during infancy and preschool age.5,6 Evidence that the effect persists into school age or later is lacking. In addition, the reviews indicate that early intervention in general has little effect on motor development. Interestingly, the beneficial effect of early intervention on cognitive development appears to be relatively independent of the specifics of the intervention programme.5 However, it should be realized that few studies investigated relationships between the contents of the intervention programmes and developmental outcome.

The aim of the present paper is to discuss factors that might play a role in the effect of early intervention in infants biologically at risk of developmental disorders. The following issues will be addressed: (1) the role of parent–infant interaction; (2) the type and timing of an early lesion of the brain; (3) the age at which the intervention is applied; and (4) the contents of intervention.

Jump to…Top of pageAbstractParent–Infant InteractionType and Timing of the Lesion of the Developing BrainAge at Which the Intervention is AppliedContents of Early InterventionConclusionAcknowledgementsReferences

Parent–Infant Interaction

  1. Top of page
  2. Abstract
  3. Parent–Infant Interaction
  4. Type and Timing of the Lesion of the Developing Brain
  5. Age at Which the Intervention is Applied
  6. Contents of Early Intervention
  7. Conclusion
  8. Acknowledgements
  9. References

Parents are the key persons in a child’s life. Awareness of the impact of parents, caregivers, and the family on child development has resulted in the recognition of the importance of family-centred intervention services in health care for infants with or at risk of neurodisability.8,9 However, the role of the family, parents, and caregivers in the various forms of family-centred service varies substantially. The interventions differ for instance in the extent to which family autonomy is respected, in the degree of parental instruction or parental coaching, and in the attention paid to parent–infant interaction.10 The effect of most components of family-centred service on the child’s developmental outcome is unknown. An exception to this rule is the effect of parent–infant interaction on developmental outcome. Various studies have indicated that greater dyadic tuning between parent and infant, and more responsive, positive, warm, and sensitive parenting, is associated with better developmental outcome at preschool and school age.11,12 However, it is important to realize that association does not automatically imply causation. The association between parental behaviour during interaction with the infant and developmental outcome might in part be mediated by the characteristics of the infant. For instance, infants with an early lesion of the brain might show more stereotyped and less adaptive behaviour than typically developing infants.13 This, in turn, might induce less positive parental behaviour and impaired dyadic interaction between parent and infant. Nevertheless, the recent randomized controlled study of Koldewijn et al.14 suggests that parental behaviour also has an independent effect on child outcome. The study indicated that the preterm infants who had received intervention that paid specific attention to the infants’ self-regulation and sensitive parent–infant interactions had a significantly better motor outcome at the age of 2 years than the comparison group of infants. In contrast to most other studies, the intervention was not associated with improved cognitive outcome.

In the Groningen Vroege Interventie Project (VIP project), a study on intervention from 3 to 6 months corrected age in infants at high biological risk of developmental disorders, we recently evaluated the contribution of specific elements of intervention to developmental outcome. The results suggested in particular that coaching of parents was associated with improved developmental outcome at the age of 18 months.15,16 Coaching is defined as professional guidance aiming to empower caregivers so that they can make their own decisions during daily care activities. This implies that coaching differs largely from instruction.17

Jump to…Top of pageAbstractParent–Infant InteractionType and Timing of the Lesion of the Developing BrainAge at Which the Intervention is AppliedContents of Early InterventionConclusionAcknowledgementsReferences

Type and Timing of the Lesion of the Developing Brain

  1. Top of page
  2. Abstract
  3. Parent–Infant Interaction
  4. Type and Timing of the Lesion of the Developing Brain
  5. Age at Which the Intervention is Applied
  6. Contents of Early Intervention
  7. Conclusion
  8. Acknowledgements
  9. References

Over the years, animal data have demonstrated that the effect of a lesion of the developing brain depends on the point in time at which the lesion occurs. Originally, it was thought that ‘the younger the age at insult, the better the outcome’ (the so-called Kennard-principle).18 However, gradually it became clear that the consequences of a lesion of the developing brain depend on developmental stage at insult, the site and the size of the lesion, animal species, exposure to chemical substances before and after the insult, and environmentally induced experience. It transpired that each stage, each neural system, and each species has specific vulnerabilities and resources of resilience to cope with the effects of an early lesion.19

Our knowledge on how this information translates to the human situation is limited. Recent advances in brain imaging and neurophysiological techniques have furnished some insights. It became clear that insults occurring during (the period equivalent to) the early third trimester of pregnancy usually affect the periventricular areas, including the periventricular white matter; those occurring near term more often affect the cortical grey matter.20 Staudt21 demonstrated that the organizational processes in response to an early lesion not only vary with the timing of the lesion but also with the neural system. For instance, in case of a unilateral lesion of the brain, the chance of motor recovery is higher for early third-trimester lesions than for lesions occurring near term. This is because, at early age, recovery might be mediated by persisting ipsilateral corticospinal projections that compensate for the lost ones on the side of the lesion. For the sensory systems the effect of an early third-trimester lesion is different. At that age the ascending thalamo-cortical somatosensory projections have not yet reached the cortex, allowing the system to use local deviations that bypass the lesion in order to reach the cortex.

Little is known, however, about the way in which we might facilitate the processes that mediate functional recovery in the developing human brain. Our knowledge is most advanced in unilateral spastic cerebral palsy (CP). Animal data pointed to the importance of balanced activity in both hemispheres and to the consequences of lesion-induced unbalanced activity during early development.22 The animal data, recent findings on the pathophysiology,23 and the effect of intervention in unilateral spastic CP (constraint-induced movement therapy or stimulation of bimanual activity)24 suggest that bilateral motor activity at early age is an important factor in functional recovery after an unilateral lesion of the brain.

Jump to…Top of pageAbstractParent–Infant InteractionType and Timing of the Lesion of the Developing BrainAge at Which the Intervention is AppliedContents of Early InterventionConclusionAcknowledgementsReferences

Age at Which the Intervention is Applied

  1. Top of page
  2. Abstract
  3. Parent–Infant Interaction
  4. Type and Timing of the Lesion of the Developing Brain
  5. Age at Which the Intervention is Applied
  6. Contents of Early Intervention
  7. Conclusion
  8. Acknowledgements
  9. References

The human nervous system changes and develops throughout life.25 But the way in which it changes varies with age. During prenatal life, focus is on neuron and glial cell proliferation, cell migration, neural apoptosis, and axon and dendrite formation. During infancy, dendrite formation, synapse production, and myelination are most prominent. In later childhood, the major developmental processes consist of synaptic reorganization and myelination. This implies that the nervous system has age-specific forms of plasticity. For specific lesions and functions this plasticity is associated with critical windows during which intervention might have an effect that no longer might be obtained once the window is past. Critical periods have been demonstrated in the treatment of amblyopia and for the effect of cochlear implants on cortical processing of auditory information and speech development.26,27 Interestingly, the critical periods of the two sensory functions share the following characteristics: (1) the earlier the intervention is started, the larger is the functional effect; (2) the critical period of substantial functional effect ends around the age of 7 years; and (3) also beyond the critical period, intervention might still induce functional changes.26,27 It has been hypothesized that in the development of unilateral spastic CP a similar critical period might exist,23 but further research is required to corroborate this suggestion. Extrapolation of some animal data that implied recovery of function after an early lesion of the brain is best during the period of dendritic outgrowth and formation, suggests that the period ranging from the third trimester of pregnancy to the postnatal age of about 1.5 years offers the best opportunities for effective intervention.25,28

Before term age the effect of intervention might also be affected by stress. The stress is related to the difficulties of the preterm infant to adapt to the extrauterine situation owing to immaturity of vital physiological functions.29 The stress might enhance the capacity to cope with extrauterine life and thus promote survival. But stress before term age might also induce ‘developmental programming’.30 Animal data indicate that stress during early life gives rise to changes in serotonergic and noradrenergic activity in the cerebral cortex and alterations in dopaminergic activity in the striatum and prefrontal cortex.31–33 These changes have been associated with impaired development of the maps of body representation in the primary somatosensory cortex, inappropriately developed ocular dominance columns in the visual cortex, and mild motor problems.13 Gradually, evidence is accumulating that stress during early human ontogeny is also associated with long-term modifications of neurobehavioural development.32,34 In addition, animal research has indicated that the hormonal changes induced by stress might modify the effect of a lesion of the developing brain and the effect of early intervention.19 The sensitivity of the young nervous system to stress-related factors implies that reduction of stress is an important goal of early intervention before term age.

Jump to…Top of pageAbstractParent–Infant InteractionType and Timing of the Lesion of the Developing BrainAge at Which the Intervention is AppliedContents of Early InterventionConclusionAcknowledgementsReferences

Contents of Early Intervention

  1. Top of page
  2. Abstract
  3. Parent–Infant Interaction
  4. Type and Timing of the Lesion of the Developing Brain
  5. Age at Which the Intervention is Applied
  6. Contents of Early Intervention
  7. Conclusion
  8. Acknowledgements
  9. References

Recent reviews3–6 have brought the limitations of our understanding on the effectiveness of specific components of early intervention clearly to light. Presumably the multifactorial composition of early intervention in children with or at risk of neurodisability is responsible for the lack of understanding. It is acknowledged that the effect of intervention might not only depend on the nature of the lesion of the brain and on family conditions, but also on the interaction of the intervention with the various personal and environmental factors.35

Still, the body of knowledge on early intervention steadily grows. It suggests that the nature of the most effective intervention before term differs from that applied after term age.3,4 Before term age, stress reduction appears to be essential. The Newborn Individualized Developmental Care and Assessment Program8 is a well-known example of a standardized intervention programme in which stress reduction is a major goal. This programme has been associated with a beneficial effect on developmental outcome in infancy, but the effects on outcome beyond infancy are controversial.3,4,36,37 The study of Guzzetta et al.38,39 suggests that, in addition to stress reduction, the application of infant massage during the preterm period might have a beneficial effect on development. The positive effect was found in low-risk infants. Further studies are required to investigate whether massage will have a similar positive effect on development in infants with a lesion of the brain. Animal data suggest that this might be the case.19

Little is known about the effectiveness of specific components of intervention applied after term age. A large diversity of general developmental programmes has been associated with better developmental outcome, in particular with improved cognition. The interventions presumably consist of a mix of effective, neutral, and counterproductive elements. Future research should aim at unravelling these components. The Groningen VIP project was a first step in this direction. In the VIP project the contents of intervention were systematically quantified and correlated to developmental outcome immediately after the end of intervention (at the corrected age of 6mo) and 1 year later. The data revealed (1) coaching of parents and (2) challenging the infant with a wide variety of self-produced motor activities were associated with better functional outcome at 18 months, in particular with improved functional mobility, (3) the proportion of time of the intervention sessions that was spent with handling techniques (hands-on) showed a negative association with functional outcome at 18 months, and (4) application of sensory and passive experiences was associated with a positive effect on cognition immediately after the end of the intervention, but these components of intervention showed a negative association with outcome at 18 months.15,16 The finding that self-produced activity in a variety of conditions is associated with better outcome is in line with the developmental principles of the neuronal group selection theory: the afferent information associated with self-produced trial-and-error activity guides the process of selection of the best strategy for each situation.13 The data suggest that coaching of parents to solve their own problems and to integrate motor activities in which the infant is allowed to explore the borders of its own abilities into daily routines might be a simple and effective means of promoting infant development.

Jump to…Top of pageAbstractParent–Infant InteractionType and Timing of the Lesion of the Developing BrainAge at Which the Intervention is AppliedContents of Early InterventionConclusionAcknowledgementsReferences


  1. Top of page
  2. Abstract
  3. Parent–Infant Interaction
  4. Type and Timing of the Lesion of the Developing Brain
  5. Age at Which the Intervention is Applied
  6. Contents of Early Intervention
  7. Conclusion
  8. Acknowledgements
  9. References

Research over the past three decades has shown that early intervention in infants biologically at risk of developmental disorders is associated with improved cognitive development in early childhood. The effects have been shown for groups of infants with varying degrees of biological risk of whom only a minority had a serious lesion of the brain. This means that it is currently unknown whether early intervention is able to improve outcome in infants with a serious lesion of the brain. The data of the VIP project suggest, however, that this might be possible: the previously mentioned associations between components of intervention, such as parental coaching and promotion of the exploration of a variety of self-produced motor activities, and functional outcome were found in particular in the small subgroup of children who developed CP.15,16 Additional studies on the effect of early intervention in infants with a lesion of the brain are urgently needed. These studies also should pay attention to the contents of intervention. The LEARN 2 MOVE 0 to 2 years project is a step in the desired direction.40

Jump to…Top of pageAbstractParent–Infant InteractionType and Timing of the Lesion of the Developing BrainAge at Which the Intervention is AppliedContents of Early InterventionConclusionAcknowledgementsReferences


  1. Top of page
  2. Abstract
  3. Parent–Infant Interaction
  4. Type and Timing of the Lesion of the Developing Brain
  5. Age at Which the Intervention is Applied
  6. Contents of Early Intervention
  7. Conclusion
  8. Acknowledgements
  9. References

I gratefully acknowledge Tineke Dirks, Ilse Ebbers-Dekkers, Elisa Hamer, and Tjitske Hielkema, for comments on a previous draft of the manuscript. The early intervention work of Mijna Hadders-Algra is financially supported by the Johanna KinderFonds, Stichting Fonds de Gavere, the Cornelia Stichting, ZonMW, Stichting Rotterdams Kinderrevalidatie Fonds Adriaanstichting, Phelpsstichting, Revalidatiefonds, Revalidatie Nederland, the Nederlandse Vereniging van Revalidatieartsen, and the Graduate School for Behavioural and Cognitive Neurosciences.

Jump to…Top of pageAbstractParent–Infant InteractionType and Timing of the Lesion of the Developing BrainAge at Which the Intervention is AppliedContents of Early InterventionConclusionAcknowledgementsReferences


  1. Top of page
  2. Abstract
  3. Parent–Infant Interaction
  4. Type and Timing of the Lesion of the Developing Brain
  5. Age at Which the Intervention is Applied
  6. Contents of Early Intervention
  7. Conclusion
  8. Acknowledgements
  9. References
  • 1
    Shonkoff JP, Meisels SJ. Handbook of Early Childhood Intervention. Cambridge, UK: Cambridge University Press, 2000.

  • 2
    Allen MC. Neurodevelopmental outcomes of preterm infants. Curr Opin Neurol 2008; 21: 123–8.

  • 3
    Blauw-Hospers CH, Hadders-Algra M. A systematic review on the effects of early intervention on motor development. Dev Med Child Neurol 2005; 47: 421–32.

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    Blauw-Hospers CH, De Graaf-Peters VB, Dirks T, Bos AF, Hadders-Algra M. Does early intervention in infants at high risk for a developmental motor disorder improve motor and cognitive development? Neurosci Biobehav Rev 2007; 31: 1201–12.

  • 5
    Spittle AJ, Orton J, Doyle LW, Boyd R. Early developmental intervention programs post hospital discharge to prevent motor and cognitive impairments in preterm infants. Cochrane Database Syst Rev 2007; 18: CD005495.
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    Orton J, Spittle A, Doyle L, Anderson P, Boyd R. Do early intervention programmes improve cognitive and motor outcomes for preterm infants after discharge? A systematic review Dev Med Child Neurol 2009; 51: 851–9.

  • 7
    Halpern R. Early intervention in low-income children and families. In: Shonkoff JP, Meisels SJ, editors. Handbook of Early Childhood Intervention, 2nd edn. Cambridge, UK: Cambridge University Press, 2000, p 361–86.

  • 8
    McAnulty G, Duffy FH, Butler S, et al. Individualized developmental care for a large sample of very preterm infants: health, neurobehaviour and neurophysiology. Acta Paediatr 2009; 98: 1920–6.

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    Rosenbaum P. Family and quality of life: key elements in intervention in children with cerebral palsy. Dev Med Child Neurol 2011; 53 (Suppl. 4): 68–70.
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    Dirks T, Hadders-Algra M. The role of the family in intervention of infants at high risk for cerebral palsy: a systematic analysis. Dev Med Child Neurol 2011; 53 (Suppl. 4): 62–67.
  • 11
    Smith KE, Landry SH, Swank PR. The role of early maternal responsiveness in supporting school-aged cognitive development for children who vary in birth status. Pediatrics 2006; 117: 1608–17.

  • 12
    Treyvaud K, Anderson VA, Howard K, et al. Parenting behavior is associated with the early neurobehavioral development of very preterm children. Pediatrics 2009; 123: 555–61.

  • 13
    Hadders-Algra M. Variation and variability: keywords in human motor development. Phys Ther 2010; 90: 1823–37.

  • 14
    Koldewijn K, van Wassenaer A, Wolf MJ, et al. A neurobehavioral intervention and assessment program in very low birth weight infants: outcome at 24 months. J Pediatr 2010; 156: 359–65.

  • 15
    Hielkema T, Blauw-Hospers CH, Dirks T, Drijver-Messelink M, Bos AF, Hadders-Algra M. Does physiotherapeutic intervention affect motor outcome in high-risk infants? An approach combining a randomized controlled trial and process evaluation. Dev Med Child Neurol 2011; 53: e8–15.

  • 16
    Blauw-Hospers CH, Dirks T, Hulshof LJ, Bos AF, Hadders-Algra M. Pediatric physical therapy in infancy: from nightmare to dream? A two arm randomized trial. Phys Ther 2011. In press.

  • 17
    Dirks T, Blauw-Hospers C, Hulshof H, Hadders-Algra M. Differences between the family-centered program ‘Coping and caring for infants with special needs’ and infant treatment based on principles of neurodevelopmental treatment. Phys Ther 2011. In press.

  • 18
    Kennard MA. Reactions of monkeys of various ages to partial and complete decortication. J Neuropathol Exp Neurol 1944; 3: 289–310.

  • 19
    Kolb B, Mychasiuk R, Williams P, Gibb R. Brain plasticity and recovery from early cortical injury. Dev Med Child Neurol 2011; 53 (Suppl. 4): 2–3.
  • 20
    Krägeloh-Mann I, Horber V. The role of magnetic resonance imaging in elucidating the pathogenesis of cerebral palsy: a systematic review. Dev Med Child Neurol 2007; 49: 144–51.

  • 21
    Staudt M. Reorganization after pre- and perinatal brain lesions. J Anat 2010; 217: 469–74.

  • 22
    Martin JH, Chakrabarty S, Friel KM. Harnessing activity-dependent plasticity to repair the damaged corticospinal tract in an animal model of cerebral palsy. Dev Med Child Neurol 2011; 53 (Suppl. 4): 9–13.
  • 23
    Eyre JA, Smith M, Dabydeen L, et al. Is hemiplegic cerebral palsy equivalent to amblyopia of the corticospinal system? Ann Neurol 2007; 62: 493–503.

  • 24
    Gordon AM. To constrain or not to constrain, and other stories of intensive upper extremity training for children with unilateral cerebral palsy. Dev Med Child Neurol 2011; 53 (Suppl. 4): 56–61.
  • 25
    De Graaf-Peters VB, Hadders-Algra M. Ontogeny of the human central nervous system: what is happening when? Early Hum Dev 2006; 82: 257–66.

  • 26
    Holmes JM, Clarke MP. Amblyopia. Lancet 2006; 367: 1343–51.

  • 27
    Sharma A, Nash AA, Dorman M. Cortical development, plasticity and re-organization in children with cochlear implants. J Commun Disord 2009; 42: 272–9.

  • 28
    Kolb B, Brown R, Witt-Lajeunesse A, Gibb R. Neural compensations after lesion of the cerebral cortex. Neural Plast 2001; 8: 1–16.

  • 29
    Klaus MH, Fanaroff AA. Care of the High Risk Neonate, 5th edn. Philadelphia: WB Saunders, 2001.
  • 30
    McEwen BS. Physiology and neurobiology of stress and adaptation: central role of the brain. Physiol Rev 2007; 87: 873–904.

  • 31
    Van den Bergh BR, Mulder EJ, Mennes M, Glover V. Antenatal maternal anxiety and stress and the neurobehavioural development of the fetus and child: links and possible mechanisms. Neurosci Biobehav Rev 2005; 29: 237–58.

  • 32
    Van den Bergh BRH. Developmental programming of early brain and behaviour development and mental health: a conceptual framework. Dev Med Child Neurol 2011; 53 (Suppl. 4): 19–23.
  • 33
    Braun K, Bock J. The experience-dependent maturation of prefronto-limbic circuits and the origin of developmental psychopathology: implications for the pathogenesis and mental disorders. Dev Med Child Neurol 2011; 53 (Suppl. 4): 14–18.
  • 34
    Kikkert HK, Middelburg KJ, Hadders-Algra M. Maternal anxiety is related to infant neurological condition, paternal anxiety is not. Early Hum Dev 2010; 86: 171–7.

  • 35
    Bartlett DJ, Chiarello LA, McCoy SW, et al. The Move and Play study: an example of comprehensive rehabilitation outcomes research. Phys Ther 2010; 90: 1–13.

  • 36
    Symington A, Pinelli J. Developmental care for promoting development and preventing morbidity in preterm infants. Cochrane Database Syst Rev 2006; 19: CD001814.

  • 37
    Wielenga JM, Smit BJ, Merkus MP, Wolf MJ, van Sonderen L, Kok JH. Development and growth in very preterm infants in relation to NIDCAP in a Dutch NICU: two years of follow-up. Acta Paediatr 2009; 98: 291–7.

  • 38
    Guzzetta A, Baldini S, Bancale A, et al. Massage accelerates brain development and the maturation of visual function. J Neurosci 2009; 29: 6042–51.

  • 39
    Guzzetta A, D’Acuto MG, Carotenuto M et al. The effects of preterm infant massage on brain electrical activity. Dev Med Child Neurol 2011; 53 (Suppl. 4): 46–51.
  • 40
    Hielkema T, Hamer EG, Reinders-Messelink HA, et al. Learn 2 move 0–2 years: effects of a new intervention program in infants at very high risk for cerebral palsy – a randomized controlled trial. BMC Pediatr 2010; 10: 76.


Communicating About Disabilities With Your Child

24 Sep

The attraction to disability may be nothing mo...

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So – your child has received an IFSP (individualized family service plan) or the IEP (individualized education plan).  They are now going to start receiving services.  You receive copies of reports and now have to absorb in black and white what your child’s difficulties entail.  These are very hard for a parent to read.  Maybe you need some support in understanding the disability, learning how to help your child.  Does this sound familiar?  This is now your life and your child’s life. You have to look the problem right in the face, just as the people in the picture above are doing to something that is unknown to us, but in the distance. You are not sure really what it is but as the figure moves closer,  a new reality takes place for you and your child. 

Good news is that those who work with infants, toddlers, older children and adults with disabilities or learning differences can act as invaluable supports.  They can help advocate for your child and aid you as a parent in understanding the nature of the problems with which he or she lives.  Professionals can help you learn how to teach your child about compensating for the difficulty that they have so that they develop into functional and safe adults. 

There  is an important key here – we are talking about your CHILD.  Parents do a disservice to your child if this is not something that is not openly discuss at home,  from the time that your child is young.  You may readthis and wonder how in the world do you talk to a child about the problem that they have and at what age?. 

Preschool aged children with disabilities are in classrooms with typically developing classmates, depending on the severity of the problem.  At younger and younger ages children are consequently becoming aware of differences in others.  This concept mayy already be discussed at school before you have gotten around to it.  Your child deserves to hear about their personal situation from their parent or other primary caregiver first.  So – here are a few jumping off  points for you.

With a child as young as preschool age, you might start very simply at pointing out things that a child may see around him or her.  Perhaps you pass by a person who is blind and walks with a seeing eye dog.  Talk about what the dog does.  A family member wears glasses, a person is in a wheelchair, the universal symbol for handicap accessibility.  Discuss theese situations.  

Your child’s teacher, school director, religious leader and/or the pediatrician might able to guide you in recommending books that describe the disability specific to your child.  They may also know about books that describe children in general, who may have disabilities or difficulties in learning.

Television shows such as “Dora the Explorer“, “SpongeBob Square Pants“, “Little Bear” and “Sesame Street” have episodes  in which the children have disabilities.  You may choose to watch these shows with your child and discuss this if the situation presents itself. 

Talking to your child, especially as they are young adults of what they have to do to keep themselves safe. For example, if they take medication then perhaps they should not be drinking alcohol. If they have a physical disability and want to drive a car, they may need to be guided in terms of adapting the vehicle.  Again – be guided by professionals treating your child for especial significant points to discuss with them. 

 Part of maturing as a person is understanding who we are.   If we do not truly do so, then how can we take care of ourselves as we grow.  Consider this true story.  A young man who lives with ADHD at his Bar Mitzvah (a right  of passage into adulthood; typically at the age of thirteen, within the Jewish religion) prepared a discussion about the Torah portion for that week.  He presented it to his family and friends.  The discussion was striking.  The young man said that he thought that the Biblical character, Moses, had difficulty controlling his anger and had an impulsive side to him.   He illustrated that within the Torah reading for that week.  Further, he related this to himself.  He was able to openly discuss his own disability, having recognized it in someone else. 

The next day, the same teen-ager left for school and by the end of a year demonstrated some ability to calm himself down in moments of anger more efficiently so that he was not physically hurting  other people. In this particular case, it is an ongoing process – but his awareness of the problem is ultimately what is enabling him to compensate for it.  He has taken ownership for this particular aspect  of his personality. 

Resources  are out there to help parents as well as adults.   Here is a sample of a few that might be meaningful for others reading this post but you can generally find this information by just typing into a search bar the name of the disability, illness, problem and information for parents, children and adults generally are found. 

CHADD (children and adults with ADHD) has a link that is designed to give parents information

Sensory Processing Disorder Foundation

Autism Society of America

Stuttering Foundation: tips for parents

American Speech-Language Hearing Association: has a link for “self-help groups for speech-language and swallowing disorders” and “resources” which links you to ways to help a child  or adult understand a hearing disorder

American Psychiatric Association www.ParentsMed.Org provides resources about medication for children as well as adults

Epilepsy Foundation

If you go into either or and type in a search for information, programming related to children with disabilities a number of resources are loaded and provide assistance for both parents and caregivers.

If anyone reading this has more information that they think would be useful for others, please comment so that others can benefit.  Thanks.