Medical Evaluation of Internationally Adopted Children for Infectious Diseases. American Academy of Pediatrics. In: Pickering LK, Baker CJ, Long SS, McMillan JA, eds. Red Book: 2006 Report of the Committee on Infectious Diseases. 27th ed. Elk Grove Village, Ill: American Academy of Pediatrics; 2006:182– 183Health Care in the First Year after International Adoption. Schulte EE, Springer SH. Pediatr Clin North Am. 2005;52 :1331– 1350OpenUrlCrossRefPubMedWeb of ScienceImmediate Behavioral and Developmental Considerations for Internationally Adopted Children Transitioning to Families. Miller LC. Pediatr Clin North Am. 2005;52 :1311– 1330OpenUrlCrossRefPubMedWeb of SciencePreadoption Opportunities for Pediatric Providers. Chambers J. Pediatr Clin North Am. 2005;52 :1247– 1270OpenUrlCrossRefPubMed
The number of children adopted from foreign countries into the United States has tripled over the last 15 years, with approximately 7,000 and 21,000 adoptees entering the United States in 1990 and 2006, respectively. The demographics of international adoptions during this time also have shifted. In 1990, Korea sent the largest number of children to the United States. Most of these Korean children were born to single, young mothers and put up for adoption, accompanied by at least some information about family and prenatal health. In addition, many of these children were cared for in American-style foster homes prior to adoption. By 2006, most international adoptees came from China, Russia, and Guatemala. In contrast to the Korean adoptees of the early 1990s, children adopted from China and Russia are more likely to have been abandoned or removed from the home. In China, the adoptees more commonly are girls because of the one-child policy and cultural preference for males. Russian adoptees are more likely to have been removed from the home because of concerns about child abuse and neglect, maternal mental illness, or maternal substance abuse. In instances of abandonment, often little is known about the child's pre- and postnatal health history or family health history.
The circumstances leading to international adoption suggest some of the unique challenges facing pediatricians who care for this patient population. Some children may be adopted with little or no information about their medical histories, including their immunization status. When medical records are available, they may be written in a foreign language; when translated, they still may contain medical terminology that has no clear analogous English term or may be used in a context that is unfamiliar to American clinicians.
The circumstances under which international adoptees are born as well as the conditions in which they live prior to their adoption may place them at risk for certain medical problems. In general, international adoptees are more at risk than the general American pediatric population for poor growth, developmental delay, fetal alcohol syndrome, autism, and anemia. In addition, depending on their country of origin, international adoptees may be at risk for certain infectious diseases, particularly parasitic infections. Many studies have demonstrated that children who have resided in institutional or orphanage care prior to their adoptions are more at risk for such medical and developmental problems than are their counterparts who have resided in foster care.
Pediatricians play an important role in helping families who are considering international adoption to prepare for the adoption as well as in caring for children once they have been adopted. In the preadoption phase, the pediatrician may assist families by helping to review and interpret any available medical information about the child and the child's biologic family while keeping in mind that available information may be inaccurate. In addition, the pediatrician should discuss common health problems for which international adoptees may be at risk and provide appropriate anticipatory guidance, paying particular attention to how families can ease the transition of the newly adopted child into the new home. The pediatrician also should advise families who are considering adoption that the period of transition and the formation of attachment between the child and the adoptive parents may take a few months to more than a year.
Once a child has been adopted, the pediatrician should see him or her as soon after arrival in the United States as possible, ideally within 1 week. If the child is verbal, a translator who speaks the child's language should be present at the initial visit. At this visit, the pediatrician should assess the child's developmental age, remembering that the child's developmental age should be reassessed every 3 to 4 months during the first year because many variables, including transition to a new environment, may complicate the initial assessment. The pediatrician also should make prompt referrals to community resources, assist parents with obtaining an Individualized Education Plan and special education resources through the child's school if the child is of school age, and provide parents with information about available local adoption support groups and international adoption clinics.
At the first visit, the pediatrician also should review any available information about the child's medical history and immunization status. Current Red Book guidelines recommend that if no immunization records are available for the child or if records do not comply with the United States or World Health Organization schedules, the child should be treated as if he or she were unimmunized and started on an appropriate catch-up immunization schedule. The Red Book also recommends that all internationally adopted children undergo hearing and vision screening and that clinicians obtain blood specimens for a complete blood count and assessment of serum lead concentrations, hepatitis B, human immunodeficiency virus, and syphilis infection status. All children also should have stool sent for examination for ova and parasites, Giardia lamblia, and Cryptosporidium and have a tuberculin skin test placed regardless of bacille Calmette Guérin status. In addition, the Red Book recommends that children emigrating from areas where hepatitis C is endemic be tested for hepatitis C serologies. For infants, consideration also should be given to metabolic screening.
International adoptees represent a special population of pediatric patients who are at risk for certain medical problems. The pediatrician must be aware of this risk when caring for such patients. At the same time, the pediatrician must keep in mind his or her role in helping to ease the transition of adoptees and their adoptive families so adopted children might flourish and achieve their full potential.
Drs Dawood and Serwint have disclosed no financial relationships relevant to this In Brief. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.
- Janet R. Serwint, MD, Consulting Editor
Comment. International adoption is an emotional journey for a family. Pediatricians can play a pivotal role in preparing expectant parents, helping them to navigate the adoption process, and assisting them with their adopted child through the necessary transitions. International adoptions pair some of the most vulnerable children with the lowest-risk parent groups. Most adoptive parents are financially stable, are well educated, have been screened by social workers and agencies, and are enthusiastic about assuming their long-awaited role as parents or adding to their families. It is crucial that pediatricians inform parents about the evident problems but also about the possibility that additional problems may exist. This disclosure is essential to assure the best permanent placement for these children and to have the parents enter the relationship with realistic expectations.
Adoptive parents need to provide sufficient time, security, and love when the adopted child arrives. Therefore, family or parental leaves are recommended to provide consistent caregivers for the child and allow bonding to occur. Although parents may undertake considerable preparation prior to the adoption, little usually is done to prepare the child. If the agency allows, adoptive parents may want to send photos of the adoptive family members and their house, labeled in the child's language, so the child has some visual images ahead of time. Also, sending pictures of the child's caretakers and where they live in their country may help with the transition once the child arrives in the United States. Although a child is entering a very loving environment, he or she may experience a grieving period, mourning the loss of relationships, friendships, and the accustomed culture. Respecting the child's culture and allowing opportunities for re-exposure to and exploration of that culture after the move is essential. All of these recommendations help to make as smooth a transition as possible and set the stage for the development of a strong family unit.
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