New Kids, New Challenges

International Adoption--Why and from Where?
The number of international adoptions in the United States has increased by 10% each year since 1992¹. Reasons for this include: a shortage of adoptable children in the U.S. with the most desired characteristics (race and age); real or perceived uncertainties inherent in domestic adoption (failure of birthparents to relinquish rights); and, ironically, fear of adopting a “special needs” child. With increased interest in adopting internationally and traditional placement countries such as Korea decreasing the number of children available, new countries such as China and Russia have become the source of the majority of children placed with American families.

Change in the Child Care Environment
Along with changes in countries of origin, a dramatic change has occurred in the level of care received by international adoptees prior to arrival in the U.S. Ten years ago, two-thirds of adoptees came from Korea, a country with a high standard of living where children were cared for in foster homes and had access to excellent health care. Now, more than two-thirds of the children come from institutional care settings in countries where per capita income is low and appropriate levels of health care and nutrition are difficult to provide. Consequently, the overall health and well being of international adoptees has deteriorated significantly.

Assessing the Health Needs of a Child from Afar
International adoption is an expensive, emotionally draining and time-consuming process. By the time a family receives a referral, they are desperate to complete the process and have a child in their arms. Adoptive families need to choose children they are capable of parenting. They need to make well-reasoned decisions at a point in their lives when it is difficult to be dispassionate. No one’s best interests will be served if a family accepts the referral of a child whose needs are greater than the family’s ability to provide.²

Evaluation After Arrival
A newly adopted child should visit a physician within the first few weeks after arrival—sooner if there appear to be problems. While a medical history, physical examination and laboratory tests are all part of the initial evaluation, in international adoptees the history may be limited or fabricated, and the physical examination rarely identifies the problems common to these children. A battery of screening tests is absolutely necessary to fully evaluate the health of the newly adopted child. Below are the tests recommended by the American Academy of Pediatrics and our suggested additions to the list^3-6. For further details, consult the 1997 Red Book: Report of the Committee on Infectious Diseases, American Academy of Pediatrics.

Initial Physical Examination: Special Considerations

Growth.  Institutionalized children suffer from psychosocial growth retardation (abuse dwarfism), falling behind one month of linear growth for each three to four months spent in the orphanage irrespective of country of origin^7-11. After placement in adoptive families, linear growth velocity increases dramatically in almost all children¹². In fact, if rapid linear growth is not observed during the first 12, months further investigation is warranted. Despite this growth spurt, three years after arrival, 31% of Romanian orphans who had spent eight months or more within institutional care remained below the tenth percentile in height and were an average of two inches shorter than children raised in their birth families¹³. Ultimately, final height may be shortened in these children via a combination of prenatal growth deficiency, psychosocial growth retardation and precocious puberty.

Physical and Sexual Abuse.  Unfortunately, institutional care settings are a magnet for adults who prey upon children. If physical or sexual abuse of the child within the orphanage is suspected, it is in the child’s and family’s best interests to seek the advise of physicians and therapists who have expertise in this area. Indications for an evaluation may include unexplained scars or bruises, a positive history or x-ray evidence of fractures, genital/rectal scarring or tears, and sexual behavior that is not age appropriate.

Bony Fractures, Physical Abuse and Rickets.  Related to the question of physical abuse, it is our observation that a number of Chinese children have arrived with bony fractures. Rickets is a common diagnosis on Chinese medical forms. Our studies have confirmed that the older a Chinese child is on arrival, the greater the risk of rickets⁸. Thus, fractures may be due to this nutritional disorder as well as abuse. Any child who arrives with bony deformities, swelling or tenderness should be evaluated for fractures and rickets. Not only is this important in terms of the child's well-being, it is important for the adoptive family's safety to document that these fractures occurred prior to the child's arrival in their home.

Immunizations.  We have recently found that approximately 60% of children who were reported to have received three or more DPT/OPV vaccines in China, Russia or Eastern Europe have no antibodies to these diseases. This means that either the vaccines used were outdated or improperly stored, the child lacked an appropriate immunologic response after vaccination, or the vaccination certificate is fraudulent.

We recommend testing for diphtheria and tetanus antibodies in any child who has reportedly received three or more DPT vaccines. If antibodies are absent or low, or if the child has received fewer than three DPT vaccines, we would advocate starting the immunization sequence over again according to the recommendations of the American Academy of Pediatrics for children not immunized in the first year of life (1997 Red Book, Report of the Committee on Infectious Diseases, American Academy of Pediatrics, Elk Grove Village, IL, 1997, p. 22).

Common Post-arrival Issues

Transitional Problems

• Feeding (gorging, hoarding, preoccupation with going to the grocery store or with what is in the refrigerator)
• Sleeping (not used to sleeping alone, fear of sexual abuse, fear of abandonment)
• Emotional decompensation when faced with situations that mimic terrifying events from the past

Attachment
Indiscrimate friendliness may pose safety issues.

Sensory Integration Difficulties

• Touch (adverse response to clothing and food [particularly meat] textures, bathing, hugging/kissing)
• Hearing, vision, taste and smell (hyper- or hyposensitive)
• Self-stimulation (rocking, head banging, masturbation)
• Pain (usually hyposensitive to pain, unaware they are injured)
• Kinesthetic (clumsy, injury prone)

• Structure, structure, structure: institutionalized children respond adversely to uncertainty
• Maximize parent-child interactions, especially reading and holding; activities should be adjusted to fit the developmental state--not chronologic age--of the child
• Limit contact with individuals outside family
• Encourage structured interactions with other children when parent is present
• Avoid overstimulation
• Tolerate bizarre behaviors as long as they pose no safety risks--they usually diminish with time
• Seek help early--avoid making excuses to explain delays
  

Outcome in Institutionalized Children

Intellectual development.  By one year of age, virtually all institutionalized children are behind in at least one, if not all, areas of development. However, most children make rapid progress during the first years after arrival, with average increases of two developmental quotient points per month. After three years of age, the length of time in the orphanage and delays at 11 months correlate negatively with IQ scores. In children who spent at least eight months within institutional care, mean overall IQ was 90, with a range from 65 to 127 (n=31). In children who spent two years or more within institutional care, mean overall IQ was 69, with a range from 52 to 98 (n=12).

Attachment

• Low attachment scores were seen on arrival and fewer children formed secure attachment relationships; one-third displayed atypical, insecure attachment patterns, particularly those children with lower IQ's, more behavior problems and families with lower socioeconomic status
• More indiscriminately friendly

• Initially internalizing behavior--failure to make needs known, stereotyped behavior
• Evolves into externalizing behavior--aggressive, antisocial, under-controlled, rageful, oppositional

• Hostile and aggressive
• Distractible
• Poorly controlled
• Hyperactive
• Poor attention span

• Thirty percent have several serious problems (IQ is less than or equal to 85, atypical insecure attachment, severe behavior problems, ongoing stereotyped behavior)
• Thirty-five percent have a few serious problems but are making progress
• Thirty-five percent have made wonderful progress

• Length of time in the orphanage
• Number of children adopted
• Younger adoptive mother
• Lower socioeconomic status of mother
• Father alone selected child