Tatyana Elleseff MA CCC-SLP 
Article Title
Orofacial Observations of Internationally Adopted Children: Recommendations for Parents and Non-Medical Adoption Professionals 
Posted Date
Article Text
Portions of this article were originally published in November 17, 2011 Issue of Advance Magazine for Speech Language Pathologists & Audiologists, Online Newsletter, under the title: "Orofacial Assessments: Pediatric Case Studies Illustrate Their Importance".

Several months ago, I've administered speech-language testing to a 3-8 year old boy, adopted from Russia at the age of 3-0. During the course of my assessment I noticed his atypical facial features. He had a very small head, inward set eyes, and widely set ears. At that time, even though this boy had already seen a number of other adoption professionals (including a neurologist, an occupational therapist and another speech language pathologist), I felt that it was very important to record my findings and refer the parent for a second opinion with a pediatrician specializing in working with internationally adopted children. My rationale for seeking a second opinion for this child was further reinforced by a number of additional red flags, which included his significantly decreased play skills, severely impaired language ability, as well as significant social emotional and behavioral manifestations characterized by excessive impulsivity, distractibility, hyperactivity, decreased self-regulation, rapid over-stimulation, as well as anger outbursts and tantrums when others refused to follow his agenda and attempted to set limits on his behavior.

Subsequent, second opinion consultations for this child resulted in a diagnosis of Fetal Alcohol Spectrum Disorder, a term which describes the range of physical, mental, behavioral, and learning disabilities that can occur in children whose prenatal history is remarkable for excessive maternal alcohol consumption.

I use this case to illustrate a point. At the time of adoption this child presented with significant unrecognized deficits, which continued to persist unrecognized and unaddressed post adoption. While I acknowledge that oftentimes little could be done done before a child is adopted, I also want to emphasize that this child could have been receiving relevant and necessary services for 8 months post adoption, but didn't because his deficits were missed!

The above case is not an isolated occurrence by any means. As a speech language pathologist who works exclusively with various at-risk pediatric populations (including internationally adopted children), I have numerous clinical examples I can share with you. In the past I have encountered undiagnosed feeding and swallowing issues, submucous clefts, vocal webs, Cerebral Palsy, Wilson's Syndrome, a number of undiagnosed Fetal Alcohol Spectrum Disorder cases, and even several cases of severe infections due to excessive tooth decay and poor oral hygiene. I can go on for a while but I do believe that I have sufficiently demonstrated my point.

Fact is that oftentimes internationally adopted children arrive to US with a host of undetected disorders and deficits. Lack of detection is further increased in children adopted from economically developing countries or from hard to access insular regional orphanages, where they may fail to receive consistent and appropriate medical care, or where overcrowded conditions coupled with staff shortages may cause for deficits to be missed or unrecognized.

Consequently, oftentimes it is the parent(s) who are the first individuals to observe something different or unusual regarding their child's facial features, oral structures, or any other appearance anomalies.

While many parents, of course, are not professionally trained in recognizing physical signs and symptoms of serious disorders, it is important to note that detection of unusual features is not as difficult as it sounds.

Here are some basic guidelines:

Does your child's face look symmetrical or do you see any obvious signs of weakness (paralysis) on either side of the face (particularly evident when the child smiles and one side of the face droops or doesn't move).

Do you find that your child's features look odd or unusual in any way? Examples may include, but are not limited to: unusually wide or narrow set eyes, unusually set ears, virtual absence of a nose bridge, excessively thin upper lip, flatness of a groove above the lip, and so on (although with respect to facial appearance one needs to be very careful and account for differences in normal facial variation among various ethnic groups).

Do you notice any unusual spots, nodules, or openings on your child's face or body or in his/her mouth?

In what condition is your child's mouth? Is there excessive tooth decay? Do you see an unusual absence of teeth (in older children), or unusual bite (open bite, cross bite, etc)? Is there excessive drooling?

Does your child have a usual voice or unusual cough in the absence of a documented illness?

If you do, then it would be a good reason to consult with a pediatrician specializing in international adoptions, to see whether your observations merit a referral to a specialist (e.g., neurologist, orthodontist, etc).

I realize of course that parents are not trained professionals, but they are observant individuals! Moreover, there is a great likelihood that they are actually the first people to spend a prolonged period of time with the child. There's an even greater likelihood that they are the first people to actually "see" the child vs. the orphanage staff who may have fulfilled the child's basic needs (feeding, diapering, etc) but who in reality may have actually spent very little face to face time with the child.

Furthermore, parents should not worry whether something that may see may not be a cause of concern. What if it is and is not addressed? That is why it is so important to share your concerns with relevant medical professionals. It is up to them to investigate further whether your observations merit additional follow ups. If you are concerned, bring it up! You never know! You may paving the way to timely diagnosis and relevant intervention provision for your adopted child.

To be continued…

In this article parents were given suggestions of how to initiate the medical referral process if they are concerned with their internationally adopted child's orofacial appearance or functioning. In the next article (currently in development) parents will be given suggestions of how to initiate the process of appropriate remediation services for their adopted child after the receipt of a specific medical diagnosis (e.g., FASD).


  • Golper, L (2009) Medical Speech Language Pathology: A Desk Reference. Clifton Park, NY: Delmar Cengage Learning
  • Shipley, K, & McAfee, J (2008) Assessment in Speech Language Pathology: A Resource Manual. 4th Ed. Clifton Park, NY: Delmar Cengage Learning
Tatyana Elleseff MA CCC-SLP is a bilingual speech pathologist with a private practice (Smart Speech Therapy LLC) and a full-time hospital affiliation (UMDNJ) in Central, NJ. She received her MA from NYU and her Bilingual Extension Certification from Columbia University. She is licensed by the state of NJ and holds a Certificate of Clinical Competence from ASHA. She specializes in working with bilingual, multicultural, internationally and domestically adopted as well as at-risk children with complex medical, psychiatric, developmental, neurogenic, and acquired communication disorders. For more information see Tatyana’s blog and website: or call her at 917-916-7487 
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