Search

Non-adherence to treatments for chronic diseases may jeopardize patients' health, increase costs of care, and cause unnecessary clinic appointments and diagnostic studies, as well as additional treatments with potentially serious side effects. Little is known about adherence to methotrexate in pediatric rheumatology. Because this medication is commonly used in JIA, we assessed adherence among children receiving methotrexate in two countries. A total of 76 outpatients (M:F 21:55) with JIA seen in Rio de Janeiro (Brazil) and in Boston (US) taking methotrexate for >2 months were enrolled. Questionnaires were completed by the parents from both centers. Non-adherence was defined as omission of ≥3 prescribed doses in the previous 8 weeks. Patients' ages ranged from 1 to 17 years. Mean time on methotrexate was 20.5 months (±25). Overall rate of non-adherence was 18%. The rate of reported non-adherence was 8% in Boston and 24% in Rio de Janeiro (P = 0.012). The main reason for non-adherence in Boston was "child refused"; in Rio de Janeiro, the main reason was inability to obtain medication. Age had a negative association with adherence (P < 0.0001). Sex, time on methotrexate, route of administration, or concomitant use of other medications were not associated with adherence. Eighteen percent of children with JIA prescribed methotrexate were non-compliant. The difference in reasons for poor adherence between patients in Rio de Janeiro and Boston suggests that different strategies may be needed to improve adherence in these 2 settings. The rate of non-adherence warrants further investigation.

Most international adoptees (IA) have rapid catch-up of the delays common at arrival. However, it is not known whether development at arrival predicts later abilities or school readiness. Therefore, we comprehensively evaluated language, fine motor, visual reception (VR), executive function (EF), attention (ATT), and sensory skills (SS) in IA preschoolers. We hypothesized that pre-adoptive risk factors, development at arrival, and the post-adoptive environment (time in day care) would predict developmental and behavioral outcomes and school readiness. 37 IA (12M:25F), currently age 4-5 years and previously seen in our clinic (mean arrival age 12 months), were evaluated with standardized tests of development, language, EF, ATT, and SS, along with demographic information, parent interview, and review of arrival clinic records. Fine motor and VR skills at arrival ranged from average to very below average. At followup, most IA were average or above average in fine motor, VR, and language skills, but many had concerning scores for ATT (42%), EF (11%) and SS (48%). Arrival expressive language T scores (Mullen) predicted follow-up scores for expressive language (PLS-4, r = .44, p = .005). Arrival fine motor scores (Mullen) correlated with follow-up auditory comprehension scores (PLS-4, r = .47, p = .002) and inversely with inattention scores (Conners', r = -.48, p = .003). Arrival visual reception scores correlated inversely with global measures of attention (Conners' opposition r = -.45, p = .005, ADHD scores r = -.49, p = .002, and to a lesser extent hyperactivity r = -.35, p = .03). Age at arrival was a very strong predictor of many of the outcome measures tested, including language performance, attention regulation, executive function, and sensory processing. Children who spent more time in daycare had significantly more difficulty with emotional control (p = .005). Although IA have good catch-up in specific areas of development, difficulties with ATT regulation, EF, and sensory processing may increase the risk of later school problems.

Objectives: Since 2000, American families have adopted 1,700 children from Ethiopia. Little is known about the health and development of these children., Patients and Methods: Retrospective chart review of the arrival health status of all 50 (26F:24M) children from Ethiopia/Eritrea seen in the International Adoption Clinic., Results: Prior to adoption, most children resided with relatives; 36% were >18 months old prior to entry into care. More than 50% were true orphans, often due to HIV. Arrival age ranged from 3 months to 15 years (mean +/- SD 4 years +/- 43.8 months). At arrival, growth z scores were near-average (weight -.59, height -.64, head circumference -.09); significantly better than adopted children Guatemala, China, or Russia seen in our clinic. However, some Ethiopian children were significantly growth delayed (WAZ < or =-2, 8%, HAZ 12%, HCZ 18%). Age at adoption did not relate to growth delays. Medical issues on arrival included intestinal parasites (53%, [14% with > or =3 types]), skin infections (45%), dental caries (25%), elevated liver transaminases (20%), latent tuberculosis (18%), and hepatitis B (2%). Age-appropriate vaccines had been administered in 15-77% of children (depending on specific vaccine). Behavior problems were uncommon. Gross/fine motor and cognitive skills were approximately 86% of expected for age. Age correlated inversely with developmental scores for cognition (r = -.49, P = .003). Five children had age reassignments., Conclusions: Ethiopian/Eritean adoptees differ from other groups of internationally adopted children: they reside for relatively long periods of time with relatives prior to institutionalization, often have uncertain ages, exhibit few behavioral problems at arrival, have better growth, and may have less severe developmental delays. Whether these differences at arrival predict better outcomes for the Ethiopian/Eritrean children is unknown.

Nearly 220,000 children have been adopted from other countries by American parents since 1986. Approximately 65,000 children have arrived from China and Russia, mostly in the past 6 years. Most of these children reside in orphanages before adoption, where they may experience malnutrition, environmental deprivation, neglect, and exposure to infectious diseases. After arrival to the United States, international adoptees should undergo specialized screening evaluation for infectious diseases and other conditions. Infectious conditions of special concern include hepatitis B and C, syphilis, human immunodeficiency virus infection, tuberculosis, and presence of intestinal parasites. Before the adoption occurs, the infectious disease consultant may be asked to assist the primary care provider and the adoptive family with advice about travel and review of preadoptive medical records. After the adoption, the infectious diseases consultant may be asked to assess the adequacy of the child's vaccination record from the birth country and to assist in screening, evaluation, and management of infectious diseases.