Fetal Alcohol Syndrome Research

The overall goal of the IAC research program is to identify risk factors that predict medical and developmental problems in international adoptees and thus develop strategies for intervention and education that maximizes each child's potential. Recently, investigators at the University of Minnesota (Fig 1.) conducted a NIH-funded study of 1,834 Minnesota families who adopted 2291 children from abroad during 1990-98 (International Adoption Project-IAP). This 556-item survey confirmed that alcohol/drug exposure is a common risk factor in international adoptees in Minnesota (Fig. 2).

Figure 1 . International Adoption Project, University of Minnesota

 
Figure 2. Parent Reported Alcohol/Drug exposure in International Adoptees to Minnesota 1990-1998 (n=2291)

The IAP confirmed that alcohol/drug exposure is the most potent risk factors for long-term, parent-reported behavioral and developmental problems (Table 1) and scores on the Child Behavior Checklist in the preclinical and clinical range (Table II).

Note: Tables I and II contain odds ratios based on logistic regression analysis. For example, in Table I, a child who experienced deprivation has 3.41 times the odds of having parent-reported developmental delay than a child who did not experience deprivation and a child who was known or suspected to be alcohol/drug exposed has 12 times the odds of having parent-reported autistic behavior than a child who is not alcohol/drug exposed. In Table II, odds ratios are based on data from Child Behavior Checklists filled in by both parents. Children qualified if one or both parents scored the child in the pre-clinical or clinical range (T score >61)

  Table I. Odds Ratios for Risk Factors and Parent-Reported Long-Term Behavior Problems in International Adoptees (IAP, n=2291). Age=age at arrival (for every 3 mo of age), Orph=Length of orphanage confinement (for every 3mo of age), Dep=History of Deprivation as reported by parents. LBW=Birthweight < 2.5 kg, Alcohol/Drug=Known or suspected alcohol/drug exposure.

Table II. Odds Ratios for Child Behavior Checklist Score in the Preclinical and Clinical Range in the International Adoptees (IAP, n=2,291). Age=age at arrival (for every 3 mo of age), Orph=Length of orphanage confinement (for every 3mo of age), Dep=History of Deprivation as reported by parents. LBW=Birthweight < 2.5 kg., Alcohol/Drug=Known or suspected alcohol/drug exposure.

Adoption Trends and how they affect the Risk of Fetal Alcohol Syndrome in International Adoptees

International adoption is a growing component of adoption in the United States . In 2001, the most recent period for which accurate data are available, international adoptions made up 15 percent of all adoptions (total adoptions=127,407) [1]. This percentage has tripled since 1992. In FY 2004, Americans adopted 22,884 children from abroad [2]. The 2000 U.S. Census reported 199,136 international adoptees younger than 18 years of age living with families in the U.S. (12.5% of adopted children) [3]. In 2001, the rate of children who joined families through international adoption was 4.7 for every 1000 children born in the United States [1]. International adoption is particularly popular in Minnesota , which has one of the highest rates of international adoption in the world 11.3/1000 live births [1].

Over the past 20 years, the origin of children placed in the United States has changed dramatically (Fig 3). In 1986, almost two-thirds on international adoptees came from Korea . During 1990-1995, the fall of Communism in Eastern Europe , the dissolution of the U.S.S.R. and the liberalization of the Chinese adoption policy in response to population control initiatives ushered in the current era of international adoption. The number of children adopted from Russia and China has steadily climbed during the ensuing decade. By 1995 Korea had been supplanted as the top placing country and in FY 2004 China and Russia accounted for 52% of international adoption placements in the U.S [2].

This increase in adoptions heralded not only a change in countries of origin, but also a very different population of children than had been previously placed through international adoption. In the mid-80s, most international adoptees came from Korea . These children were relinquished by healthy women stigmatized by single parenthood, raised in foster families, provided a high level of medical care and adopted as infants. In comparison, international adoptees today are far more likely to: be abandoned by poorly nourished, destitute mothers who have abused alcohol or intravenous drugs, be cared for within orphanages and other institutional care settings, receive inadequate medical care and join their adoptive families as toddlers or older children [4].

Figure 3 International Adoptions in the United States 1963-2004

The popularity of international adoption in Minnesota coupled with this dramatic increase in the number of children placed from countries once part of the former Soviet Union over the past decade has direct bearing on the incidence of FAS and FASD in this State. Eastern Europeans and Russians in particular have the world's highest per capita alcohol consumption [5] and the risk to the fetus during pregnancy is not widely appreciated particularly among impoverished and/or chemically dependent women who are the most likely to voluntarily or involuntarily loose parental rights. Consequently, many if not most of orphans placed from these countries are at-risk of intrauterine alcohol exposure.

A recent review of patients seen in the IAC at the University of Minnesota during calendar years 2003-4 substantiates this concern about FASD. Of the 483 new children seen, only children from Eastern Europe and the countries of the former Soviet Union had classifiable FASD. Of these, Russia alone accounted for 79% of the children and 85% of the FASD diagnoses.

  Table III . FASD Diagnoses in 222 Eastern European International Adoptees Evaluated in IAC 2003-04.

ARBD = Alcohol Related Birth Defects

ARND = Alcohol Related Neurodevelopmental Disorders

Partial FAS = Partial Fetal Alcohol Syndrome

FAS = Fetal Alcohol Syndrome

Scope of the Problem

During 2003-04, Minnesota families adopted approximately 403 children from Russia [based on the percentage of US international adoption from Russia (25.6%) in FY 2004 and the number of international adoptions in Minnesota in 2003-04 (11.3/1000 live births, total of 138,096 live births in Minnesota in 2003-04)]. The study above predicts 18 children with FAS from this population of Russian adoptees alone. Using an incidence of 1/1000 live birth for FAS in Minnesota , we would predict that 138 children would be born with FAS in Minnesota . Simply stated, during 2003-2004, 12% of new cases of FAS in Minnesota were likely due to placement of affected Russian orphans within Minnesota families.

While this figure is frightening, it may only be the harbinger of additional problems in the future. During the past decade, deterioration of traditional societal values in Korea led to increased alcohol consumption in women during pregnancy (31% in Korean adoptees evaluated in adoption clinic 2003-04). While documented FAS remains unusual in Korean adoptees, it is only a matter of time before we start seeing FASD in this population as well.

c) Identifying Children with FASD After Adoption

Background

One of the challenges of evaluating children with FASD is that current diagnostic criteria may actually over diagnose FASD in International Adoptees. Children with classic Face 4 features, pose fewer diagnostic problems, but many of Institute of Medicine 's diagnostic indicators for growth failure, head size and neurologic sequlae do not take into account the overall high incidences of these findings in international adoptees due to deprivation alone (Table III).

Table III Presence of IOM Feature Indicators in International Adoptees from Eastern Europe/Central Asia (IAC 2003-2004, n=222).

1 = n=218 due to 4 children with cleft lip and palate

2 = Diagnosed based upon medical observation and parental reports only.

3 = Could not be diagnosed at time of initial visit.

4 = Indicators used as confirmation of alcohol exposure due to variable and unreliable medical/social history from child's country of origin.

In our group of Eastern European adoptees, the following findings were significantly correlated with the presence of characteristic facial features of fetal alcohol syndrome - the “gold standard” for diagnosing FAS. The presence of the findings would increase the odds that a particular child could have FAS.

Bibliography

•  How many children were adopted in 2000 and 2001? U.S. Department of Health and Human Services, Administration for Children & Families National Adoption Information Clearinghouse page. August 2004. Available at: http://naic.acf.hhs.gov/pubs/s_adoptedhighlights.cfm . Accessed March 4, 2005.

•  Immigrant visas issued to orphans coming to the U.S. , 2004. U.S. Department of State; Bureau of Consular Affairs. Overseas Citizens Services; Office of Children's Issues. Available at:    http://travel.state.gov/family/adoption/stats/stats_451.html . Accessed March 1, 2005.

•  Kreider R. Adopted children and stepchildren: 2000. U.S. Department of Commerce , U.S. Census Bureau. October 2003. Available at: http://www.census.gov/prod/2003pubs/censr-6.pdf . Accessed February 18, 2005.

•  Johnson DE . Medical and developmental sequelae of early childhood institutionalization in international adoptees from Romania and the Russian Federation . In: Nelson C, editor. The effects of early adversity on neurobehavioral development. Mahwah , NJ : Lawrence Erlbaum Associates, Inc.; 2000:113-162.

•  White S. Russia Goes Dry , Cambridge University Press, Cambridge , 1996.

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