Medical Resources :: Common Diseases :: Developmental Issues :: Age in Chinese Children

After reading this, please read The Conundrum of Age Assignment for Children Adopted from Abroad (2007.10.28), an updated verion of this article.

Chinese children who are abandoned in infancy and childhood may not have an exact date of birth. If an infant has a belly button with some remains of the umbilical cord from birth, the child was probably born within a few weeks of the abandonment. Date of birth is usually assigned based on the date of arrival in the orphanage. The Chinese adoption administration and institute staff estimate the year of the birth according to the child's appearance. Occasionally the date of birth is written on a note pinned on the child at the time of abandonment.

To accurately determine the age of a child who may have an inaccurate date of birth is challenging, but feasible. If the child is less than one year of age, a difference of weeks or even a few months is not critical to the long-term development and health of the infant. Children who are pre-school age or beyond require a more intensive investigation for the assessment of age for appropriate placement in school. Placement in the proper class in pre-school and beyond is important for the success of the child socially and academically. Assignment of an appropriate age is also essential for the child's sense of self and identity.

It has been my experience that establishing age involves a team approach involving the parents, the pediatrician, a radiologist, a dentist, teachers, a lawyer, and developmental specialists in certain cases. It is essential to allow a transition period after the adoption of about 6-12 months before beginning a formal assessment of age. Children can be somewhat malnourished when they first arrive in the U.S. and this can account for failure to thrive physically and developmentally. Malnutrition is by far the most common cause of growth failure. Chronic illness, family dysfunction, and institutionalized living are other obvious causes of growth failure. Catch-up is swift, but it may take up to a year for a consistent pattern of linear growth and weight gain.

Pediatricians evaluate children developmentally using the Denver Developmental Screening Test (DDST) which assesses children from birth to six years of age. The DDST uses personal-social, fine motor-adaptive, language, and gross motor milestones to establish the developmental level of an infant or a child. It is probably advisable to do the DDST with each well-child visit and to allow a child 6 months to a year to adapt and adjust to her new environment. If the child has delays on the DDST, then early intervention is usually appropriate and a more comprehensive evaluation is performed by qualified experts such as language and speech specialists and physical therapists. Under the age of three years, children in New York State are provided with free early intervention services in each borough. After the age of three years each school district provides services.

I usually recommend a "bone age" X-ray between 6-12 months after the adoption. This involves an X-ray of the left hand and wrist. The radiation exposure is minimal. A radiologist, a physician who specializes in the interpretation of X-rays, compares your child's X-rays to the X-rays of children with established ages in a textbook called "Radiographic Atlas of Skeletal Development of the Hand and Wrist" by Greulich and Pyle. The X-ray plates in this atlas are representative of thousands of healthy children relating the child's bone development to chronological age. There is alot of variability even in children who are not malnourished. Statistical tables which include standard deviations are part of the bone age assessment and it must be understood that the accuracy of the test is limited in children less than 4 years of age. Children can have delayed bone age and it doesn't necessarily mean that this is their age. Some children who have never lived in an orphanage and who have been healthy all their lives, may have a delayed bone age. There are familial/genetic factors which cause the children in a family to have delayed bone age and delayed puberty. Most children with delayed bone age catch up later in childhood or adolescence. They have the potential to grow. It is very important to remember that people from cultures with a smaller stature do not have delayed bone age. Their bone age is normal, but they are just smaller.

Next I recommend a set of dental X-rays. It is preferable to go to a pediatric dentist or at least to a dentist who has alot of experience with children and enjoys working with kids. There is an amazing variability in the numbers of teeth children have in infancy. Well-nourished children can have no teeth at one year of age. The average one year old has 4 upper and 4 lower teeth. Teething usually begins by 5-6 months of age and children teeth for about 2-2 1/2 years until the 20 primary teeth are all erupted in the mouth. I had an incredible experience recently when I traveled with six families adopting their daughters from Hefei and Tongling. One baby who was eight months old had no teeth, but she was actively teething. Within two weeks of her arrival in the U.S., she had five teeth. I am sure that her recent nutritional improvement led to swift eruption of her teeth. Dentists are able to consult charts which depict the appearance of the primary and permanent teeth in the jaw bone at particular ages. The position of the permanent teeth in the bone is correlated with age and the disappearance of the root of the primary teeth is very telling.

I am presently working with a family who have a pre-school aged little girl. She arrived from China last year and we did a bone age just recently. Her birth date gives her a chronologic age of about five, but for me developmentally, she appears more like a 3 1/2 -4 years of age. Her bone age was 3 1/2 to 4 1/2 years. Her dental X-rays are consistent with 4 years of age. She has no evidence of the resorption of the roots of her primary teeth and this is a particularly useful way to assess dental age in a young child. Speaking with the dentist was very helpful because we could work together and discuss this child's developmental assessment, her bone age, and her dental age.

Input from the teacher was also very helpful. The teacher can pinpoint a child's age from school performance and social maturity. The mother and I have been working on establishing an age for her daughter for the past year and now we have collected enough information and we know the child well enough to make a determination. As a team, we have settled on an age and now the family will consult with their lawyer. Documentation of her bone age, dental age, developmental age, and her school performance will allow a legal change of her date of birth.