What parents need to know about speech-language assessment of older internationally adopted children

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This post is based on Elleseff, T (2013) Changing Trends in International Adoption: Implications for Speech-Language Pathologists. Perspectives on Global Issues in Communication Sciences and Related Disorders, 3: 45-53

Changing Trends in International Adoption:

In recent years the changing trends in international adoption revealed a shift in international adoption demographics which includes more preschool and school-aged children being sent for adoption vs. infants and toddlers (Selman, 2012a; 2010) as well as a significant increase in special needs adoptions from Eastern European countries as well as from China (Selman, 2010; 2012a).

After these children arrive to US, many school districts have difficulty determining appropriate school placement for these children (Gindis, 2005).  Similarly, many speech language pathologists continue to struggle with determining whether speech language services need to be provided to these children (Scott & Roberts, 2011).

So what do we know regarding language development of older IA children post-adoption?

Studies have found that age of adoption is strongly connected with language outcomes (Glennen & Masters, 2002; Krakow & Roberts, 2003; Roberts et al, 2008), which means that older IA children (3+years of age) are at greater risk of having worse language outcomes than children adopted at younger ages.

Upon arrival to US, IA children will typically acquire English via the subtractive model of language acquisition (birth language is replaced and eliminated by English), which is a direct contrast to bilingual children, many of whom learn via the additive model (adding English to the birth language (Gindis, 2005). As a result, of subtractive language acquisition IA children experience very rapid birth language attrition (loss) post-adoption (Gindis, 2003; Glennen, 2009).     

Gindis (2005) found that children adopted between 4-7 years of age lose expressive birth language abilities within 2-3 months and receptive abilities within 3-6 months post- adoption. However, this process may be significantly expedited in children under 4, whose language may be delayed or impaired at the time of adoption (Gindis, 2008).

In the first year post arrival, language gains are rapid (Geren, Snedeker & Ax, 2005; Gindis, 2005; Pollak, 2005).  This is because IA children are now starting to receive a lot of language stimulation in their new homes and are now exposed to enriched school and community experiences (e.g., play dates, outings, etc) as compared to their time spent in institutionalization.  Furthermore, since these children are adopted by monolingual parents they “need functional English for survival”, and thus have a powerful incentive to acquire English (Gindis, 2005; p. 299).

Gindis (2005) found that “fully functional communicative fluency is usually achieved by international adoptees of school age within the first 6 to 12 months of their life in their new country” (Gindis, 2005, p. 301).  As impressive as that sounds we must be very careful with how we interpret these children’s language accomplishments post-adoption (Glennen, 2009; Hough & Kaczmarek, 2011; Scott & Roberts, 2011).     

Recognizing the difference between communicative vs. cognitive language gains

The rapid gains of IA children during the first year post adoption are termed “communicative language fluency” (CLF). This means that they had attained the ability to express their needs and interact with parents, teachers and peers in familiar social contexts. (Gindis, 2005).  This is different from “cognitive language mastery” (CLM), which refers to the child’s ability to meet academic demands and appropriately keep up with grade-level curriculum (Gindis, 2003; Gindis, 2005; Scott & Roberts, 2011; Silliman & Scott, 2009).  Presently researchers are uncertain how many years it takes for IA older school-aged children to attain CLM, since we don’t have any studies in this area (Scott & Roberts, 2011). Part of the problem is that we often lack knowledge regarding the foundational language abilities and early literacy skills, of older IA children, pre-adoption.

How do we determine which older IA children will require speech- language services post arrival?

Starting pre-adoption

Parents should try to obtain as much information as possible regarding their perspective child’s prenatal and medical histories, early development, as well as pre-adoption experiences including history of neglect and sexual, physical and emotional trauma (Gordina, 2009; Glennen, 2007; Hwa-Froelich, 2012).  Parents also need to know which questions to ask the orphanage personnel regarding their pre-adoptive child’s birth language and/or academic abilities in order to determine if language delays or deficits are present. Samples of pre-adoption questions are available on Dr. Glennen’s website, here.

For children over 3, speech and language delays in the birth language, may be documented in adoption records and translated for the parents (Miller, 2005). Even though parents may be given only a general statement of child’s delay with no other explanation, know that in some countries (e.g., the Russian Federation), additional records are available and can be requested from the orphanage (Gordina, 2009). Orphanages located in the former Russian republics for example, must keep educational, developmental and behavioral summaries, as well as speech language reports and/or treatment summaries (Gordina, 2009). For school-aged children transcripts, communication books (“dnevnik”) and notebook/workbooks are also available (Gordina, 2009). 

The importance of hearsay:

If parents can’t get any records regarding their child’s speech language abilities, they should try speaking to the orphanage staff to find out anecdotal information regarding whether the child had a language delay/disorder pre-adoption. This information is just as valuable when it comes to qualifying the child for services (Glennen, 2007). Try to videotape the child telling a story, or sharing information with familiar adults, since that video can later be analyzed to determine if deficits are present (Glennen, 2009).

Post-Arrival Recommendations:

After arrival, parents should try to seek a comprehensive speech language assessment, if they can find a speech-language pathologist speaking the child’s birth language.  Please note that due to rapid birth language loss, an evaluation in the birth language for children with delayed and disordered speech-language abilities must be conducted as soon as possible since the results will not be reliable several months post arrival (Gindis, 2008). If the parents are unable to find speech-language pathologist speaking the child’s birth language, the child should be evaluated in English 2-3 months post arrival to see how quickly he/she is acquiring it (Glennen, 2007).

Reviewing the risk factors:

Get in touch with international adoption professionals such as pediatrician, psychologist, etc to review the child’s adoption records and assess the child post-arrival. Find out if all pre-adoption diagnoses are valid. Are there any other medical diagnoses impacting speech, language and cognition? (Gindis, 2004; Miller, 2005) Please know that some IA children may arrive to US with undetected disorders and diseases such as infections, visual and hearing impairments as well as alcohol-related deficits (Jenista & Chapman, 1987; Johnson, 2000; Miller et al, 2007) especially if they are coming from economically developing countries or hard to access regional orphanages.  There’s a chance they failed to receive appropriate medical care there, so their deficits may be missed or unrecognized (Ladage, 2009).

What you need to know about alcohol-related deficits

Alcohol related deficits are a significant concern for children adopted from former Russian republics as well as from Eastern Europe in general (Davies & Bledsoe, 2005; Johnson, 2000; Ladage, 2009). Prior to adoption, parents should try to obtain access to a court order giving reasons why parental/maternal rights were terminated (e.g., if it was due to alcohol abuse) as well as to ask as many questions as possible to receive any anecdotal information regarding possible maternal alcohol use during pregnancy. Russian physicians’ knowledge regarding Fetal Alcohol Spectrum Disorder (FASD) is still highly limited, so in many cases information regarding maternal alcohol consumption and/or child’s alcohol-related diagnosis may not be included in the pre-adoption records because it was undetected, overlooked, or was deemed unimportant (Balachova et al, 2010; Varavikova & Balachova, 2010).

Some studies of children in Russian orphanages found high numbers of children with FAS (Miller et al, 2006). However, since FAS is the diagnosis made with heavy reliance on the child’s facial features, other alcohol related diagnoses, not affecting facial features, such as Static Encephalopathy (SE) and Neurobehavioral Disorder (ND) are just as noteworthy since they can cause  damage and dysfunction as severe as in individuals diagnosed with FAS.  

Finally, even though some studies report greater delays and worse outcomes for children adopted from Eastern Europe, it is important to understand that “significant developmental concerns can be seen in children from any country” (Ladage, 2009, p. 9).

Birth-language delay is in the records:

If the child’s pre-adoption records specifically state that s/he has birth language delay then it should be taken seriously (Gindis, 1999) since language delays in the birth language transfer and affect the new language (McLaughlin, Gesi, & Osani, 1995). These delays will not “go away” without appropriate interventions.  “Any child with a known history of speech and language delays in the sending country should be considered to have true delays or disorders and should receive speech and language services after adoption.” (Glennen, 2009, p.52)  If a child arrives to US with medical diagnoses, which affect their speech and language, they should receive speech language assessment as well (Ladage, 2009).     

Performing first assessments:

First year post arrival children should be showing quick language increase in the areas of listening comprehension, word knowledge and use as well as pronunciation (Glennen 2007, 2009). During the first year, speech language pathologists (SLPs) can’t report standardized scores since any potential tests that they could use are not standardized on internationally adopted children, so they should instead use their clinical judgment in order to determine whether these children are showing adequate gains.

For children adopted between 3-4 years of age, SLPs can start using standardized tests to report scores for receptive language, vocabulary, and articulation, 1 year post arrival (Glennen, 2009) but not expressive language.  To assess expressive language 1 year post arrival, Glennen (2009) recommends comparing IA children’s performance to peers or using “peer-based local norms” [to] “provide insights into who is doing well and who has a true language-learning disorder” (p. 60). SLPs should also use language samples and dynamic assessment (test-teach-reteach) measures to create a more accurate picture of the child’s abilities (Gindis, 2005; Hough & Kaczmarek, 2011).

Follow-Up Monitoring:

As older IA children attain communicative language fluency parents and professionals must be vigilant to ensure that they continue to improve in the areas of language which contribute to academic success. These include: verbal memory and sentence comprehension, sentence repetition, conversational skills and storytelling, reading and writing, problem solving, social skills and executive functioning. This is very important because past studies found that older IA children present with deficits in these areas (Beverly, McGuinness, & Blanton, 2008; Croft et al. 2007; Dalen, 2001; Dalen, 1995; Desmarais, et al 2012; Gindis, 2005; Glennen & Bright, 2005; Hough & Kaczmarek, 2011; Jacobs, Miller, & Tirella, 2010; Loman et al 2009; Tarullo, Bruce & Gunnar, 2007; Welsh & Viana 2012).

What is still needed?

Presently we urgently need more studies regarding language acquisition and language gains of IA children adopted at older ages. Based on clinical experience of numerous SLPs and ancillary professionals (e.g., psychologists, social workers, etc.) we also need to know more information regarding social pragmatic language development of both older and younger IA post-institutionalized children.

Conclusion:

When we review the pre-adoption risk factors and combine that information with knowledge regarding the child’s pre-adoption development and post adoption progress as well as parental and teacher input we often develop a clear picture regarding appropriate service delivery for older IA children. We must make clinical recommendations based on individual case basis. Children, who struggle academically, after years of adequate schooling exposure, do not deserve a “wait and see” approach. They should start receiving appropriate intervention as soon as possible (Hough & Kaczmarek, 2011; Scott & Roberts, 2007) with services focused on improving their communicative language fluency as well as cognitive language mastery.  

References:

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