International Adoption: A Review and Update.

Abstract

After completing this article, readers should be able to:Although interest in intercountry adoption continues to be high, the numbers of international adoptions have changed dramatically since the peak in 2004 when 45,483 international adoptees (IAs) were placed in families worldwide. By 2017, the number dropped 79% to 9,387. In the United States, the receiving country for 40% to 53% of all IAs during this period, placements reflected this same trend downward from 22,989 to 4,714. The reasons behind this decline are complex and include US and international factors. (1)From 1972 through 1990, more than 50% of IAs were from South Korea. (1) These children were generally relinquished by healthy women stigmatized by single parenthood, were raised in foster families, and were provided a high level of medical care. Most Korean children adopted to the United States were infants. In contrast, adoptees from Eastern Europe, and other countries that used institutional care, arrived in large numbers in the early 1990s. Many of these children were born into low socioeconomic circumstances, were exposed to intrauterine alcohol, were cared for in orphanages, and received inadequate medical care. Considering the profound adversity experienced in institutional care settings in terms of abuse, neglect, and exposure to violence, the findings that these experiences were associated with significant medical problems as well as acute and persistent developmental, emotional, and behavioral disabilities in postinstitutionalized adoptees were not surprising. More recently, children have arrived from African countries and Haiti having lost their parents to infection, including epidemics such as Ebola; armed conflict; and natural disaster. Adopted children arriving in the United States from all over the world stimulated great interest among the membership of the American Academy of Pediatrics, catalyzing the formation of the Section on Foster Care and Adoption in 2000; the establishment of the Council on Foster Care, Adoption, and Kinship Care in 2011; and the publication of Adoption Medicine in 2014.The advent of health-care providers focused on the nuances of international adoption medicine led to research on best practice. Although international adoptions have decreased since 2004, health-care providers still care for thousands of new adoptees every year, as well as the multitude of IA children and young adults adopted in previous years. In addition, adoptions from the US foster care system have increased during the past 20 years. Except for regionally specific infectious diseases, a strong case can be made that most adoptees, whether international or domestic, share the same array of physical, developmental, and mental health challenges. Therefore, it is more important than ever that pediatricians are able to counsel all prospective adoptive families, comprehensively evaluate the physical and mental health of children in foster care and after adoption placement, and support child well-being and successful family formation. This review article summarizes the most recent recommendations for best practice in the comprehensive health-care of the internationally adopted child and his or her family.Examination of the situation in China, the principal country participating in intercountry adoption to the United States since 2004, highlights one reason why international adoptions are decreasing but also exemplifies the increase in significant medical issues. After the gradual relaxation and then termination of the 1-child policy, China has seen a dramatic increase in domestic adoptions of young, healthy children. Of those who remain institutionalized, 98% have disabilities. (2) Now, children adopted from China are older. Because these children experience longer periods of institutionalization, adoptees from China are at greater risk for secondary cognitive, emotional, and behavioral sequalae related to prolonged social deprivation. Similar changes have been observed in most countries participating in intercountry adoption during the past decade. Therefore, due to the high percentage of children in the adoption system with histories of risk factors affecting their health, it is more important than ever for parents and professionals to participate together in thorough preadoption preparation.Thirty years of international adoption medicine experience have shown us that there are no “low-risk” referrals per se given the inherent stress and loss that adoptees experience. Thus, risk to normal growth and development are never completely absent. Review of the medical and social information for a child who not only cannot be physically examined but also is from another country and health-care system is challenging. Key information to consider when doing the review is summarized in Table 1. With rare exception, the initial review of the adoption referral requires follow-up questions of the adoption agency. For example, updated anthropometric measurements, information on current developmental status, and additional laboratory screens are often indicated. Parents are asked to request these through their adoption agency.The goal of the preadoption review is to guide the adopting family in the life-changing decision being made based on expert evaluation of the available data. The review summary ideally gives the family a clear picture of resources (medical, financial, emotional, time) needed to parent a child with particular needs, what life will look like as a family, and the child’s long-term prognosis. However, without the benefits of doing a physical examination oneself and diagnostic screens in one’s own health-care setting, diagnostic and prognostic capabilities are limited. Counseling parents about the range of outcomes and the limits of prognostication is needed to ensure that they are realistic and well prepared to welcome their IA into the family. Encouraging adoptive parents to examine their long-term social, medical, and educational expectations for their adopted child in the context of the range of outcomes is important as well. The better equipped a family is from the beginning, the higher the odds for a successful placement. Because interpretation of medical information can vary greatly depending on the referring country, the age of the child, and the nuances of interpretation by region, consultation or referral to a clinician who specializes in adoption medicine can be a valuable resource for families.A comprehensive medical assessment of the newly arrived IA is recommended within 2 to 3 weeks of arrival at his or her new home. The initial visit focuses on addressing parents’ immediate concerns; establishing a baseline for growth, development, and mental health; identifying and addressing immediate and long-term medical needs; screening for infectious diseases and nutritional deficiencies; determining the immunization status; and providing support for a healthy transition and strong attachmentIdeally, at least 1 hour of face-to-face time is needed to accomplish these goals. Before the visit, obtaining and reviewing the medical records from the country of birth or from the child’s preadoption review assists the health-care provider in planning the most efficient and valuable visit for the family. A previsit questionnaire is invaluable in understanding the parents’ concerns and planning how to address each one before the clinic visit.An interpreter is recommended for children 18 months and older. An interpreter gives the pediatrician the ability to talk with the young child in his or her native language, incorporating playfulness and reassurance. For the older child, an interpreter can assist the child in telling their own story, asking questions, and understanding the numerous activities of the medical visit. Parents may ask questions of the child through the interpreter to further understand their child’s needs, likes, dislikes, and fears. The interpreter can also assist the pediatrician in understanding the medical and social history, review of systems, and special needs directly from the older child and to assess language skills. An interpreter may at times serve as a translator of the medical record, most commonly the immunization record.Depending on the country of birth, the medical and social history may be either nonexistent or extremely detailed. Accuracy is variable as well. Parents are asked to provide all documents detailing preadoption medical and social information from the country of birth, including the immunization record. Much of this information may have already been reviewed during the period from initial referral to arrival home. However, more information may be discovered by the adoptive parents during their visit to their child’s birth country, in court or other official documents. In addition, the older child typically can add to the medical history with the assistance of an interpreter. Key historical information includes country of birth; birth history, including birthweight and intrauterine drug exposure; maternal history; time with birth family; reason for loss of birth family; time in foster care and/or orphanage; number of transitions between caregivers; developmental screening; and medical history, including laboratory screens for human immunodeficiency virus, syphilis, and hepatitis B and an immunization record. In addition, the child may have received a class B waiver from US State Department physicians before leaving the country of birth, which allows the child to enter the United States but requires follow-up. For example, a child with a positive screen for TB and normal chest radiographic (CXR) findings will receive a class B waiver.For some IAs this may be their first complete physical examination. A full examination including genitalia may be traumatizing, and, if so, the better option is to complete the examination over subsequent appointments. Many IAs have had frightening experiences in medical facilities without the comfort of an adult to buffer the trauma, for example, of a painful procedure. Examining the child while he or she sits on the lap of the parent or for the older child, encouraging his or her parent to stand close by the examination table or hold the child’s hand is not only comforting but may be absolutely necessary to do the examination. Of note, the physical examination of an IA is unique in that a head circumference is measured for all children regardless of age; special attention is given to the evaluation of undernutrition, including stunting; and close attention to facial features suggesting fetal alcohol effects and heightened vigilance for previously undiagnosed medical problems are imperative. In addition, the epidemiology of diseases in the country of birth is important to consider on physical examination. For example, increased attention for splenomegaly in a child from a region endemic for malaria or lymphadenopathy on examination of a child from a region with a high prevalence of tuberculosis (TB). Pediatric audiology and ophthalmology referral is recommended for all IAs due to the high prevalence of hearing and vision problems in this population. (3)A battery of laboratory tests is recommended for the newly arrived child. These are summarized in Table 2. Baseline laboratory screens indicated for all IAs are outlined and updated periodically in the American Academy of Pediatrics Red Book and on the Centers for Disease Control and Prevention (CDC) website. Laboratory screens performed in the country of birth should be repeated in the United States. Specific tests are indicated depending on the country of birth, infectious diseases endemic in that region of the world (see the CDC Yellow Book online), and the prevalence of genetic differences there. Intentional efforts to ensure minimal trauma are important. For example, applying a topical anesthetic to minimize pain with blood draws and, if available, having a child life specialist accompany the child and parents to the laboratory alleviates anxiety and pain.TB infection and intestinal parasites are the most common infections diagnosed in IAs. All IAs who are at least 2 years old are screened for TB before traveling to the United States. Further evaluation is performed in the country of birth if the screen is positive. However, repeated screening on arrival in the United States should be performed. The prevalence of latent TB infection among IAs is as high as 27%. (4) BCG vaccine does not prevent infection, and neither is it a contradiction to doing a tuberculin skin test. The CDC recommends that children younger than 2 years should be screened for TB with a tuberculin skin test. Children 2 years and older, may be screened with an interferon-γ release assay, either T-Spot.TB® (Oxford Immunotec Ltd, Abingdon, United Kingdom) or QuantiFERON® (Qiagen Inc, Germantown, MD). (5) If either the tuberculin skin test or the interferon-g release assay is positive, a CXR must be performed. If the CXR is negative and the physical examination reveals no sign of TB disease, the diagnosis is latent TB infection. Treatment is indicated with daily isoniazid for 9 months for children younger than 2 years. Children 2 years and older may be treated with either isoniazid daily for 9 months or once-weekly, directly observed isoniazid and rifapentine for 12 weeks. (6) Monthly appointments with the primary care team are recommended to check for compliance, dosage adjustment for weight gain, and activation to disease. If CXR is positive or signs of TB on examination are found, referral to or consultation with a pediatric infectious disease specialist is indicated. If the initial screen is negative, a repeated screen is recommended 3 to 6 months after arrival home. (7)Giardia intestinalis is the most common intestinal parasite, followed by Blastocystis hominis. Infected children may have no symptoms predictive of infection. Examination of 3 stool samples for ova and parasites and 1 stool sample for Giardia antigen is recommended. Early-morning collection of stool with 24 hours between specimens is ideal for accurate assessment of the parasite load. (8) Screening serologic testing for schistosome species, Strongyloides stercolis, and filarial species are indicated for all children arriving from countries endemic for these invasive parasites. In addition, all children with eosinophilia (absolute eosinophil count, >450 cells/mm3) should be tested for invasive tissue parasites based on the epidemiology of invasive tissue parasites in their country of birth, as noted previously herein. Toxocara canis, which can cause extremely high eosinophilia, should be considered. Ascaris lumbricoides, identified on stool screen for ova and parasites, may cause eosinophilia as it travels through the body. Both T canis and A lumbricoides are widespread and invasive parasites.Children from malaria-endemic regions may be infected without symptoms. For asymptomatic children, malaria polymerase chain reaction is recommended, if available. Polymerase chain reaction can detect all 5 species of Plasmodium: Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae, and Plasmodium knowlesi. (4) Thick and thin blood smears every 12 hours to look for malaria parasites are indicated for all febrile, newly arrived IAs from an area endemic for malaria. For severe cases of malaria, the CDC Malaria Hotline (770-488-7788) is available for consultation.Toddlers arriving from regions with a high prevalence of hepatitis A may be acutely infected, completely asymptomatic, yet shedding hepatitis A virus. The CDC recommends that all household members and other close contacts (eg, regular babysitters) of children arriving from countries highly prevalent for hepatitis A should be immunized before the child arrives home. (9)Internationally adopted children younger than 10 years are not required to receive immunizations before arrival in the United States; however, adoptive parents must sign an affidavit that their adopted child will be immunized according to requirements within 30 days of arrival in the United States. More than 90% of IAs arriving in the United States have not been immunized per Advisory Committee on Immunization Practices guidelines. Many vaccines recommended in the United States, for example, measles, mumps, and rubella, varicella, and 13-valent pneumococcal conjugate vaccine, are not available in resource-limited countries. Measles vaccine is given as a single antigen. Screening antibody levels are recommended for infants and children 6 months or older with documentation of immunizations with 2 caveats. First, repeated immunization with inactivated polio vaccine rather than testing antibodies is recommended per the CDC catch-up schedule unless there is documentation that the child received the US- or World Health Organization–approved inactivated polio vaccine series. (10) Second, screens for pertussis antibody level do not correlate with immunity to whooping cough. Seroprotective diphtheria and tetanus antibody levels may correlate with Bordetella pertussis immunity if the child received vaccinations containing the pertussis antigen.Common parental concerns at their first medical visit with their child have to do with eating, sleeping, growth, developmental milestones, medical issues identified in the country of birth, and school placement for a school-age child. Other questions can surface regarding the actual age of the child, effects of possible intrauterine exposure drugs and alcohol, known traumatic events, or a history of physical or sexual abuse. Parents are typically seeking advice to make their child’s transition to a new culture minimally traumatic and to lay a solid foundation for attachment. Primary care professionals can help by first maximizing physical health. In addition, referral to pediatric rehabilitation experts may be indicated when there are signs of developmental delays beyond those expected for orphanage care. Referral to mental health services should be considered when issues such as indiscriminate friendliness, anxiety, or distress are identified, especially when symptoms continue beyond the first few months after arrival. Close follow-up by the primary care physician is indicated to monitor the child’s transition to his or her new culture and family, attachment, and growth and development as well as to follow up on any acute or chronic medical concerns. In addition, increased vigilance for future concerns, such as precocious and/or accelerated puberty (11)(12) or academic challenges, is prudent.Numerous risk factors may impact any area of an IA’s development. For example, multiple transitions impact a child’s ability to learn routines or identify an adult caregiver as an “anchor” for developmental exploration. Acquisition of gross and fine motor skills can be delayed due to lack of opportunity and resources to address neurologic and orthopedic needs. Institutional care negatively affects cognitive development, as does deficiency of micronutrients such as iron and iodine. (13) Sensorineural problems such as hearing or vision loss can affect other sensory systems, as does prenatal exposure to drugs, alcohol, or infection. Institutional care, particularly if prolonged (>6 months), is associated with developmental delay and poor brain growth. (14) Sensory deprivation is a common risk factor for a child in institutional care, resulting in symptoms consistent with overresponsivity or underresponsivity to sensory inputs such as tactile, auditory, and visual input. For example, if an infant is not held, rocked, and/or provided with eye contact, the sensory system may not learn how to process sensory input or how to respond appropriately.Within the first 6 months after arriving home, most IAs make progress developmentally with stimulation and a supportive environment. The parent may promote acquisition of skills by intentionally providing opportunities for developmental stimulation with patience and sensitivity to their child’s needs and by encouraging progression toward age-appropriate developmental skills. Establishing structure and routine in the home environment and daily activities can support all areas of development. For most IAs, initial monitoring of mild developmental delays in the first 3 months rather than immediate referral to physical, occupational, or speech therapy is recommended. Attachment to parents is best supported by limiting frequent visits with another “hands on” adult such as a clinician. If delays are significant, however, earlier intervention may be warranted. Seeking professional evaluation is recommended if delays persist beyond 3 to 6 months after arrival.Discussing all aspects of development is beyond the scope of this article, but highlighting delays in processing sensory input may be helpful in that the symptoms may be more subtle and assessment more nuanced than assessment of other areas of development with standardized parent developmental questionnaires. We experience many types of sensory input every day (tactile, visual, auditory, proprioceptive). Difficulty appropriately responding to ordinary sensory experiences is a hallmark of numerous disorders, including autism, attention-deficit disorder, and sensory processing disorder. The latter was not included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, and the American Academy of Pediatrics has recommended caution in using this term; however, we have found it useful to address sensory processing difficulty with occupational therapy given the widespread neglect and trauma that this population has encountered. With the use of sensory-based therapies, occupational therapy may be acceptable as one of the components of a comprehensive treatment plan. (15) The therapeutic plan typically consists of daily home and school programming and accommodations as well as regular appointments for occupational therapy intervention, which may be home based. Sensory processing challenges can impact sleeping, eating, transitioning to a new home, bonding, attention, self-care skills, school, and community relationships and activities.Examples of inability to tolerate and/or integrate sensory input include the following:Children may have a combination of signs and symptoms from multiple categories with significant variability from child to child and should be examined with a team approach to ensure that medical and psychological needs are being addressed concurrently.Challenges with sensory processing skills affect behavior, which may manifest as acting out or shutting down. New or unfamiliar information can be scary for children whose sensory systems are not processing well. If a child is having a difficult time interpreting information, the result can be poor regulation leading to unwanted behaviors. Recommendations for efficiently screening for common developmental concerns and planning a home “catch-up” program are summarized in Table 3. In addition, questionnaires helpful in assessing a child’s sensory processing skills in the pediatrician’s office are available online. (16)If significant developmental differences persist, they should be investigated as per usual guidelines for children with developmental disorders, including further evaluation by a pediatric geneticist.Given the multiple risk factors that have been discussed, supporting mental health is a key component to helping adoptive families successfully come together. In addition, early adverse psychological and social experiences, exposure to a natural disaster or armed conflict, and lack of educational opportunities negatively affect emotional and cognitive development. Socioemotional adversities include long-term institutional care often with a high child-to-caregiver ratio in an underresourced facility, multiple placements, sexual and/or physical abuse, neglect, and repeated loss of caregivers. The adoption process itself is traumatic. Not only are each of these risk factors individually capable of derailing a child’s neurodevelopmental trajectory, in combination they produce a unique pattern of risk for this vulnerable population. Furthermore, various patterns of trauma differentially affect mental health and neurodevelopment at different stages of a child’s life. As a result, the prevention of long-term mental health and neurodevelopmental issues in adopted children must take a comprehensive, multidimensional, and longitudinal approach. We have found that approaching the examination of an IA as a team is the most effective way to help the IA thrive. From the medical side, correcting deficits in micronutrients such as iron or vitamin D or ensuring adequate thyroid function can clear the path for mental health providers to do their best work with the child and family. Ideally, this approach involves access to clinical programs that offer multidisciplinary and long-term support to adoptive families. Such a comprehensive approach requires that even the initial evaluation within 2 to 3 weeks of arrival home must be performed with the assumption that ongoing intervention will address the full spectrum of potential risk factors. However, comprehensive mental health services are often not locally available. The pediatrician plays an essential role in evaluation.To address this complex set of issues we developed a 2-step clinical model. The first step is a mental health screen during the initial medical examination to determine whether a referral is needed. The main focus of this initial screen is observation of how a child is signaling and communicating with the parent during times of distress and how the parent reads these signals. Recommendations for the first step in screening are outlined in Table 4.It is critically important for parents to understand that the protective factors they provide in building a safe and secure emotional relationship are likely to determine the child’s developmental outcome. These relationships allow adoptive parents to play an important role in buffering the inevitably high levels of stress experienced by a child before and during the process of adoption. Buffering is critical in preventing the negative outcomes associated with excessive stress levels early in life. Not only is a buffering relationship with adoptive parents important in preventing toxic stress in the moment, this kind of interaction also provides a scaffold for the child to develop their own stress regulation skills. These skills, in turn, are central to long-term outcomes as the children grow independent of their adoptive parents and begin to encounter stressors on their own. (17)Providing this crucial buffering relationship is, however, far from easy. Given a lack of stable relationships early in life, adopted children may not have had the chance to learn how to effectively signal their emotional needs. As a result, these children may have difficulty developing a connection with their parents and, thus, lack the ability to signal a need for comfort when they are in distress. (18) In a clinical study of more than 100 adopted children referred to our clinic, we found that 60% demonstrated difficulties signaling distress. (19) This is despite the fact that only 1 child in the sample met the full criteria for reactive attachment disorder. As a result, adoptive parents often struggle to interpret what may seem like chaotic behavior from their child. Addressing these difficulties in early parent-child communication is critical to establish the kind of relationship necessary to normalize the developmental trajectory of adopted children.Previous research has also pointed to other factors that may affect the emergence and quality of a buffering relationship, including an adoptive parent’s experience, such as their own history of trauma, mental health status, or current stressors of the parent(s). Thus, in addition to identifying the communication difficulties of the adopted child, any intervention program must include in its initial screenings data on parental risk factors that may affect the parent-child relationship. Failure to address early risk factors from either the child’s or the parent’s side of the relationship can result in negative developmental outcomes. Referral to a mental health specialist soon after the child arrives home should be considered for the child with multiple risk factors negatively affecting his or her mental health and/or a parent-child relationship at risk for poor attachment.Once a child is referred to a pediatric mental health specialist, the second step of the model involves a full evaluation with several components: developmental testing (social-communication, cognitive, and motor capacities) parental interview, and assessment of the quality of parent-child interactions. The existing evidence demonstrates that mental health services for adopted children must necessarily provide multidimensional, longitudinal support that includes screening, evaluation, and interventions for the child and for the parent-child relationship. Additional follow-up 12 months after arrival home with mental health and developmental assessments is strongly recommended for all IAs regardless of their initial status.Decades of clinical observation and research studies with internationally adopted children have created lessons that can apply to a broader population of vulnerable children. Comprehensive physical and mental health evaluations, developmental assessment, and intervention are indicated for every IA. Interventions as indicated based on these assessments ideally address immediate and long-term needs in a timely manner. A definitive diagnosis of developmental/mental health disorders should be reserved until the child has had adequate time to learn a new language, form secure attachments, have an optimized home and school environment, and interventions as indicated. Ongoing support for the child and family through each developmental stage is both our responsibility and our joy as pediatricians.1. 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National Council for Adoption. Available at: https://adoptioncouncil.org/9. Comprehensive Health Evaluation of the Newly Adopted Child. (Clinical Report from the AAP Council on Foster Care, Adoption, and Kinship Care) Jones, V., Schulte E. Pediatrics. 2019;143(5):e20190657To view teaching slides that accompany this article, visit http://pedsinreview.aappublications.org/content/42/5/245.