International adoption:
Concerns for pediatric providers
Lisa
Albers, MD, MPH
How common is international adoption today?
The number of children from foreign countries adopted in the United
States has increased by five to 10 percent annually over the past
decade. In 2002 there were over 20,000 such adoptions. The largest
numbers came from China and Russia, with about 5,000 adoptions each,
and from Guatemala, with over 2,000 adoptions.
Today, three-quarters of internationally adopted children arrive
from countries that rely on institutional care, have low per capita
income and difficulty providing adequate nutrition and health care.
Children from orphanages are also spending more time in those institutions
prior to adoption. These changing conditions have significant medical
and developmental implications for children and their families after
adoption.
When are healthcare providers involved in the
adoption process?
Prior to adoption, families may seek assistance in reviewing medical
records or reviewing videotapes of a prospective adoptee. At that
point, families generally have agreed to adopt a particular child
and may be seeking reassurance or help in planning for that child’s
future needs. Immediately after adoption, children need a thorough
medical review and screening process. Respiratory, gastrointestinal
and skin infections are common.
Developmental, behavioral and emotional concerns—such as sleeping
or eating difficulties, attachment issues and developmental delays—may
also be apparent at this point. Many issues resolve spontaneously
while others require intervention. Long-term medical, developmental,
behavioral and emotional issues may be the result of pre-adoptive
experiences. Examples include chronic hepatitis B infection, speech-language
difficulties, learning difficulties and adjustment difficulties.
What immediate post-adoption issues should providers evaluate?
Immediate health concerns may include treatable, acute or chronic
infections, growth issues and developmental delays. During an
initial post-adoption visit, any scars, bruises, birth marks or
evidence of past physical or sexual abuse should be documented.
Country-specific issues may include toxic exposures (e.g., lead),
iodine deficiency (common in China) or fetal alcohol exposure
(a particular concern in Eastern Europe). Another common concern
for families is determining the child’s “real” age, as birth dates
may be estimates.
Are growth delays a significant issue in international
adoption?
Research suggests that children typically “lose” about one month
of growth for every three months of institutional care. Most children
with psychosocial short stature, a predominant cause for growth
failure within institutionalized care settings, demonstrate an
immediate and dramatic surge in growth when they move to a new
environment, probably due to improved nutrition, improved growth
hormone secretion and decreased cortisol secretion. Further evaluation
is warranted for adopted children whose growth does not accelerate
in the months following adoption. Also, early puberty has been
reported in many international adoptees and may be associated
with diminished final short stature.
Should immunizations from the child’s home country be
accepted?
A significant percentage of children from foreign countries lack
adequate immunity, despite satisfactory vac- cination records.
As a result, international adoptees should either be re-immunized
or tested for titers to vaccine-preventable diseases to ascertain
their immune status and to guide decisions about revaccination.
If checking titers is not feasible, re-immunization of international
adoptees is recommended.
Are developmental delays to be expected?
Yes, especially in children who have been institutionalized, neglected
or abused, severely malnourished or generally lacking in developmental
stimulation. Nutrition and developmental stimulation do help a
great deal, but children may continue to present with delayed
or atypical development.
As a rule of thumb, most infants who are delayed make two months
of developmental progress (at least) in one month. Although some
international adoptees do achieve typical development, some do
not. My approach is to discuss early intervention programs on
the first visit and to strongly recommend such a program if a
child is severely delayed or if parental support seems indicated.
Most parents welcome the option of a developmental assessment,
ongoing monitoring and therapy, if indicated.
How do you assess language delays in a child who has been
removed from his or her first language environment?
Language delays are particularly difficult to assess in international
adoptees. Unlike other immigrant children who continue to speak
their primary language, international adoptees lose their first
language in parallel with gaining a second one. It is helpful
to understand the proficiency of a child’s language in their primary
language before adoption, but this is rarely feasible. Functional
receptive language is relatively easily acquired at most ages,
but more robust language in the school-age child may take up to
four years to fully develop. While English as a Second Language
(ESL) services may be helpful, such measures are often insufficient
for older adoptees who may have a primary language disorder.
What emotional and behavioral concerns are parents facing?
A child’s emotional health post-adoption is related to a number
of factors, including the child’s temperament, parental temperament,
pre-adoption environment, trauma history and health status, as
well as post-adoptive adjustment. It is very difficult to determine
true concerns vs. “within the range of normal” during a single
office visit.
Some common behaviors of concern to parents include self-stimulatory
behaviors, such as head banging or rocking, which can be expected
to diminish with time. Gorging on food and refusal to eat are
relatively common, and sleeping patterns may be erratic. Parents
appreciate an explanation of goals for eating and sleeping behaviors,
but should be encouraged to provide this structure for their children
with some flexibility.
In general, younger adoptees typically form a strong relationship
with their new parents within a week of meeting them. Indiscriminate
friendliness is common in older international adoptees, but is
both disturbing to families and a safety risk for the child. Depression
is not uncommon and manifests at an age-appropriate level.
Some of the most common parental concerns include “attachment
disorders” and “sensory integration disorders.” Health professionals
may also have concerns about developmental delays, failure to
thrive, language delays, pervasive developmental delays (PDD/autism),
post-traumatic disorders (PTSD) or mental retardation. Sadly,
emotional neglect, physical abuse and sexual abuse are not uncommon
in orphanages around the world. These are not diagnoses to be
made on an initial visit, but require continued monitoring and
often the assistance of other professionals.
Lisa Albers, MD, MPH, director of the Adoption Program at
Children’s Hospital Boston will speak on the issue of international
adoption at the Pediatric Health Care Summit at South Shore Hospital
on June 19. For more information visit www.childrenshospital.org/resources/cme/courses.cfm
or call (617) 355-2454.
