CHAPTER 39

Health Care for International Adoptees

ChrisAnna M. Mink, MD, FAAP

Although internationally adopted children come from a wide range of birth countries, many of their health-related issues are similar. Many of the children have lived in orphanages in impoverished areas of the developing world and have incurred the maladies associated with poverty and deprivation.

Epidemiology

From 1999 to 2012, 242,602 children were adopted internationally into the United States; this is nearly the same number as the previous 30 years combined. Through the first decade of the 21st century, 90% of such children were from Asia, most commonly China and South Korea; Eastern Europe; and South America (Guatemala and Colombia). From 2009 to 2012, China, Ethiopia, and Russia were the 3 leading countries of origin for children adopted into the United States. The number of international adoptions has been declining since 2009, with a nadir in 2017 of only 4,714 adoptees entering the United States. This decline is the result of multiple factors, including economic uncertainty in the United States; changing geopolitical landscapes in birth countries; and stricter policies governing adoption in an attempt to curb corruption, including The Hague Convention on the Protection of Children and Co-operation in Respect of Intercountry Adoption, which is an international agreement for standardizing intercountry practices to promote protection of children available for adoption.

Many factors influence the choice of international adoption. In the United States, delays in childbearing and associated infertility have increased the demand for adoptable children. Simultaneously, more readily available birth control and growing acceptance of single motherhood have resulted in a decreased number of infants available for adoption. In addition to the shortage of adoptable children in the United States, other factors in the decision to pursue international adoption include real and perceived risks of domestic adoption (eg, failure of birth parents to relinquish rights), reluctance to adopt a child with special needs or with in utero drug exposure, and limited availability of children with desired traits (eg, specific age and ethnicity [often white infants]). The prompt termination of rights of birth parents in international adoption is also cited as a factor in this decision.

The advent of intercountry adoption in the United States occurred in conjunction with World War II and the large number of orphaned children in Europe, many of whom were fathered by American soldiers. The second—and more formalized—wave of intercountry adoption occurred with the Korean War. Because of the need to care for unwanted orphans, primarily of mixed ethnicities and fathered by American soldiers, South Korea established a foster care system and the children became available for adoption to Americans. War and political turmoil remain factors in the availability of children for adoption. For example, the fall of communism was a significant factor in Russia and other states of the former Soviet Union becoming common birth countries for adoptees in the 1990s and the early part of the 21st century. Following a diplomatic rift, however, in 2013 the Russian government outlawed adoptions to the United States. Early in the 21st century, because of poverty and political strife, more children were being adopted from African countries, especially Ethiopia. Recently, adoptions from Ethiopia have been stopped, however, in part because of cultural pride, as well as a highly publicized death resulting from abuse of an Ethiopian child adopted into the United States.

Societal values also influence adoption practices. China was among the leading birth countries for adoptees because of the population control initiatives of the government mandating that families have only 1 child. With this practice and the desire for a male heir, some newborn girls were abandoned and became available for adoption. With the 2008 Summer Olympic Games, China had a surge in national pride and a realization that their future population may not include enough girls for the boys to marry. Subsequently, fewer infant girls became available for adoption. Currently, China mainly permits international adoption of children of both sexes with special medical or developmental needs.

Until 2016, most internationally adopted children were female (approximately 56%), in part reflecting the adoption of girls from China, as well as a preference among some adoptive parents (especially single women) to adopt a girl. Currently, most are male, mainly reflecting the changes in China’s policies. International adoptees are young, with approximately 55% between the ages of 1 and 5 years.

The United States is the birth country of approximately 100 children annually adopted into other countries. Absolute statistics for US children adopted into other countries are not available because the US government does not routinely report the number of exit visas issued for adopted children. These adoptees are often males of African American or mixed ethnicity and are adopted by families in Canada and Western Europe. They are available purportedly because of the low desire for these infants by adoptive parents in the United States.

The status of the country of origin (eg, war, turmoil, poverty, societal values) aside, significant overlap exists in the reasons that children from foreign countries and from the United States become available for adoption. The common reasons include parental substance use, abandonment, chronic neglect, abuse, and domestic violence, all of which often are associated with underlying poverty.

Until the 1990s, most international adoptees were from South Korea, which had in place an excellent foster care system and health care. Since the 1990s, most adoptees come from institutions in poor nations without a developed foster care system, resulting in a significant decline in the health and well-being of adoptees.

Clinical Presentation

Preadoption

Some adoptees become known to the US health professional “only on paper” during the preadoption stage. The adoptive parent or parents may ask their physician for help in assessing the child’s medical status. Often a parent receives a written health report (varying in the quantity and quality of information) and photos or videos of the child under consideration for adopting. The written documents may be in a foreign language or not translated by an experienced medical translator. Because some countries prohibit international adoption of healthy children, diagnoses may be embellished to improve the child’s chances for adoption. Additionally, some medical records contain diagnoses that are nonsensical in US medicine but represent standard terms used in the country of origin. These inconsistencies are quite challenging when trying to evaluate the medical records of potential adoptees. Many physicians may not feel comfortable with reviewing medical records given so many limitations; however, even with all the caveats, review of the records may provide valuable insight into the health status of the adoptee.

During this stage, the physician may provide information for parents and families for preventive health measures to prepare for travel to a developing area of the world. The Centers for Disease Control and Prevention (CDC) Traveler’s Health website (www.cdc.gov/travel) is a good resource for physicians and parents. Up-to-date information may also be obtained from the World Health Organization (WHO) and the US Department of State (Table 39.1). Prospective parents should be informed about the infections that may occur in international adoptees, and they should receive appropriate education and preventive measures, including vaccinations (eg, measles, hepatitis A, hepatitis B).

During the Adoption Trip

All internationally adopted children are required by the US Department of State to undergo a physical examination before admission into the country; however, this examination is limited in scope and performed mainly to rule out severe impairments or certain communicable diseases that may pose a public health threat (eg, active tuberculosis [TB]). This examination should not be considered a complete medical evaluation for an individual child.

Some health professionals can provide support for families during travel via e-mail, telephone, and the internet, similar to telephone consultations performed in general practice.

Postadoption

After the adoption, the health status of children on presentation to the US physician may be quite variable, ranging from well to severely ill with acute infections or chronic diseases (eg, malnutrition, TB). The adopted child should be seen by the physician within 2 to 3 weeks of arrival in the United States, or sooner if the child has an acute illness. This 2-week period allows for the child (and parent or parents) to recover from jet lag and become more familiar with each other, permitting a better assessment at the visit. If an acute illness visit is required, a separate appointment for a comprehensive evaluation should be scheduled at a later time.

Health Care Issues

In addition to problems commonly related to poverty and deprivation, many health issues are specific to the country or region of origin (eg, increased risk of malaria and other parasites in children from the continent of Africa). Adoptees from South Korea have the lowest risk for infectious diseases.

Generally, health care issues for adoptees are extensive, including acute illness (eg, respiratory infections), chronic illness (eg, anemia, malnutrition, poor dental hygiene, TB, asthma, parasite infestation), delayed or unknown immunizations, psychosocial challenges, and impaired growth and development.

Some children have assigned birth dates (eg, abandoned infants and street children for whom birth dates are not known), and they may have small growth parameters, making it difficult to know their true age and expected development. Developmental delays, most commonly language delay, are frequently identified. Assessment of development may be even more difficult in infants and young children who are nonverbal and older children who speak their native language.

Growth delay is common for adoptees. Many children are malnourished or exhibit failure to thrive, and these conditions are often multifactorial in origin, including poor prenatal environment (eg, maternal stress, malnutrition, substance abuse), inadequate calories, inadequate nurturing, unrecognized genetic or congenital disorders (eg, fetal alcohol spectrum disorder; see Chapter 147), and untreated chronic illness (eg, TB, rickets). Institutionalized children may exhibit psychosocial dwarfism and may lose 1 month of linear growth for every 3 to 4 months spent in the orphanage. Delay in puberty may be observed in adolescents from deprived environments, such as orphanages. Precocious puberty may also be seen among international adoptees.

Immunization records may not be available, may be incomplete, or may be in a foreign language, which hinders assessment of the vaccination status of adoptees. Many vaccines available in the United States are not available in the developing world (eg, Haemophilus influenzae type b, pneumococcal conjugates) and, thus, children will not have had them. Adopted children immigrating to the United States who are younger than 10 years are exempt from the Immigration and Nationality Act regulations requiring proof of immunizations before arrival; however, adoptive parents are required to sign a waiver that they will comply with US recommended immunizations after arrival.

Psychosocial, emotional, and mental health disorders are some of the more challenging problems to assess. The spectrum of mental health problems is related to age and previous life experiences of the child. Children may have experienced physical or sexual abuse before placement in an institution, and they may also be subject to abuse by older children or adult caregivers while in institutional placement. Attachment disorders are among the most concerning abnormalities for adoptive parents, adoption professionals, and health professionals. The fundamentals for learning healthy attachments are greatly influenced by early infant-caregiver relationships. Thus, many international adoptees have difficulties bonding, in part because they have not had secure caregiver relationships. Issues of attachment and bonding may be especially problematic for children who have resided in an orphanage or had multiple caregivers from an early age. Children who have had multiple caregivers may be indiscriminately friendly, which may pose risks for their safety. Other common mental health problems include depression, attention-deficit/hyperactivity disorder, posttraumatic stress disorder, abnormal behaviors (eg, self-stimulating behaviors, hoarding food, sleep disturbances), and oppositional defiant disorder. As mentioned previously, communication with the child may be difficult because of language barriers, causing another obstacle to assessing the child’s mental health.

Sensory integration difficulties are increasingly recognized in adoptees. The children may have adverse responses to touch (eg, new clothing, hugs and kisses, bathing) or textures (eg, new foods). Individual senses or all of them (ie, hearing, vision, taste, smell) may be notably increased or decreased, and some children have decreased sensation to physical pain, resulting in an increased risk for injuries. Dyskinesia in the form of clumsiness or being prone to injury has also been observed.

The most common identified medical issues are infectious diseases, including acute illness (eg, upper respiratory infection, bronchitis, otitis, infectious diarrhea) and chronic infection (eg, TB, parasite infestations, with scabies and Giardia lamblia common manifestations of the latter. Because of the lifestyle of their biological mother and the children’s time residing in institutions, many adoptees are at increased risk of exposure to infectious diseases, such as syphilis, HIV, and hepatitis B and C.

Preventive care that is considered routine in the United States is unlikely to have been part of the child’s care and must be performed as appropriate for age. This includes newborn screening laboratory studies and assessments of hearing, vision, dental, and mental health. Anticipatory guidance for new parents should be incorporated into preadoption encounters and all subsequent visits.

Evaluation

The initial office visit with the physician should be scheduled for an extended period because of the complexity of the evaluation and additional time needed for parental education. If the physician’s schedule does not permit extended visits, ancillary staff (eg, nurses, dietitians, therapists) may perform parts of the evaluation and education.

Observation of the child’s behavior, development, and interactions with the adoptive parent or parents and physician is a critical element of the evaluation. Most physicians routinely include such observations in their visits, but particular attention to these factors is necessary for new adoptees. Items to notice include the child’s demeanor and behavior, such as determining whether the child is easily engaged or is withdrawn, makes eye contact with the parent or physician, makes any vocalizations or words (depending on the child’s age), plays with toys, is too friendly or is afraid of strangers, and seeks comfort from the new parent or parents.

History

Limited medical information is available from most birth countries, although some exceptions exist (eg, from foster care in South Korea). Family and birth history are rarely obtainable for adoptees. Immunization histories are becoming increasingly available. Previously, vaccine records were considered unreliable; however, in recent years, data have emerged to suggest that well-documented immunizations may be considered valid. Written records showing the age of the child when vaccinated, date of administration, dose given, and proper intervals between dosing that are consistent with WHO schedules or are comparable to US schedules may be considered acceptable for proof of immunization. (Guidelines for care in the absence of vaccine records is discussed in the Management section of this chapter.)

Dietary history is important for assessing the child’s nutritional status. Questions to ask are listed in Box 39.1.

An interim medical history may be available, because many children are selected by their adoptive parent or parents several months before immigrating to the United States. The interim medical history may be provided from the orphanage or foster care provider through the adoption agency. Parents should be encouraged to solicit as much information as possible from the child’s caregivers. At a minimum, this history should include serial growth parameters, known illnesses, hospitalizations, surgeries, allergies, and immunizations given while the child was under their care. Parents should also ask caregivers about any food preferences, special fears, toys, or friends from the placement prior to adoption. If the child has a special “lovey,” the parent or parents should request to bring it with the child as a transitional object.

Physical Examination

A complete unclothed physical examination should be performed on infants and children of all ages. Because of previous trauma (eg, sexual abuse), however, it may be necessary to perform some parts of the examination over a series of visits to minimize the possibility of inflicting additional trauma from an examination. All aspects of the physical examination are essential. Accurate measurements of height, weight, and, depending on age and size, head circumference should be obtained. Plotting of parameters on the growth curves from WHO or the CDC (compared with birth country) should be used, with few exceptions. The child should be closely inspected for unusual scars or bruises, evidence of fractures (old or recent), rachitic changes, and genital or rectal scarring. The skin should be examined for rashes, lesions, and a bacille Calmette-Guérin (BCG) scar (typically on the upper deltoid). Developmental screening should be performed, and a more complete developmental assessment should be scheduled at a separate visit (when the child is not distressed or acutely ill). A dental examination should be included, and referral for a formal dental evaluation likely will be necessary. Screening evaluations of hearing and vision should be performed; formal testing may be necessary, depending on the age of the child and ability to cooperate.

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