International Adoption: Preparing to adopt a child from overseas
- All international adoptions are “special needs” adoptions.
- Parent education and anticipatory guidance are essential.
- Health professionals can help prospective parents to review and interpret pre-adoptive medical information and to anticipate inaccuracies.
- Pre-adoption risk factors include prenatal exposures, inadequate prenatal care, malnutrition, neglect, abuse, being adopted at an older age, prolonged hospitalization or institutionalization before adoption.
- Parents must update their own vaccinations and be advised about disease risks and precautions before travelling.
- Attachment between a newly adopted child and adoptive parents can take anywhere from a few months to more than a year, depending on pre-adoption risk factors and parental commitment.
- Developmental delays are common but most newly arrived children catch up rapidly; language delay may persist longer.
- While most adopted children do well, a subset have complex emotional and neurobehavioural needs.
Countries of origin
Since 2000, 1500 to 2000 children have been adopted every year in Canada.1 The countries Canadians adopt from have changed somewhat over this period, and the needs of the international adoptee are becoming more complex. China continues to be the leading country of origin, while the number of children adopted from the U.S., Haiti, Russia and Southeast Asian countries, including Vietnam and South Korea, have fluctuated. Since 2007, more children are coming from Ethiopia and other African countries (see Table 1). The ‘profile’ of prospective international adoptees (IAs) is also changing: older children, children with known complex medical or surgical needs, and birth siblings being adopted together are increasing in number. Children adopted from countries other than the U.S. are the focus of this discussion.
|Country of origin||2008||2009||2010|
Source: Source: Citizenship and Immigration Canada, RDM at March 2011, and GCMS on May 31, 2011. Transmitted Oct. 26, 2011. Summations by Robin Hilborn. From Family Helper, www.familyhelper.net
Risk factors for IAs
All international adoptees are considered “special needs” adoptions because of multiple potential risk factors, including:
- Coming from a resource-poor or developing country
- Receiving little or no prenatal care
- Prenatal exposure to alcohol, drugs and congenital infections
- A traumatic birth-family history (e.g., the illness or death of a parent, poverty, or physical, emotional or sexual abuse)2
- Coming from an institution which is underfunded and understaffed, burdens which increase the risks of disease and malnutrition
- Environmental issues, such as the lack of a nurturing or stimulating environment and inconsistent caregiving, which can impair development, lead to emotional delay and challenge attachment3-5
- Early life stress (ELS), with neurodevelopmental and psychosocial effects
- Identity-formation challenges, such as a confusing family story, loyalty conflict, searching for racial identity or searching for birth family.
Unlike an immigrant or refugee child, an international adoptee is not accompanied by a caregiver who is familiar with her personal health, culture or family history. Even if adoptive parents have travelled to their child’s home country, they are often unfamiliar with her first language or details of her past.6
Pre-adoption medical information
Prospective parents typically receive pre-adoption information that may include:
- A brief narrative of how the child came into care
- A physical examination (often with weight and height measurements only, not always head circumference)
- Basic laboratory screening (commonly, though not always, for hepatitis B, C, HIV, syphilis, hemoglobin electrophoresis)
- Limited developmental information
- Photos, possibly a video
This information is often incomplete, out of date by at least 6 months, and either inaccurate or contradictory (e.g., recorded vaccines being given before a child was born or conflicting physical measures noted for the same time period).
Translation difficulties and the variant use of certain medical terms can be challenging. Russian proposals often include diagnoses such as “perinatal encephalopathy” and “hydrocephalic syndrome”, which appear to suggest pathology. However, Russian doctors see the birth process as a form of a neurological insult or as a trauma from which the child recovers.3 Such terminology needs to be reviewed in context with the other information provided to corroborate evidence of a neurological deficit.
Some parents receive no advance information but instead travel first to a child’s country of origin to meet him, gather information and make the decision to adopt on site. This process occurs in Russia, the Ukraine and Kazakhstan.
Studies examining the predictive accuracy of pre-adoption information are limited. One study from the former USSR and Eastern Europe showed that while many diagnoses were in children’s records (e.g., congenital adrenal hyperplasia, cleft palate and fetal alcohol syndrome) and confirmed post-adoption, many other unsuspected but significant diagnoses (e.g., optic nerve hypoplasia, cerebral palsy, hearing loss and orthopedic anomalies) were found during post-adoption examinations. Infectious diseases were especially underdiagnosed.7
When pre-adoption videos were viewed to see if they supported children’s medical records, they did so only 30% of the time. Video footage showed new developmental skills 38% of the time and raised new concerns in 33% of cases.8
When videos and post-adoption assessments were compared for agreement on developmental status, a reasonably high specificity was found for 85% of children with mild or moderate delays. However, sensitivity in detecting severe delays was only 45%.9
IA-specific health issues
Anticipatory guidance around potential health risks is an important step in the international adoption process. The more clinicians know about an IA child’s country of origin, the better this advice can be. Also, if the child has a significant disability, being aware in advance of supportive community resources, potential financial impacts, and a family’s readiness and ability to parent a child with complex needs, becomes essential.
Numerous reports on the health of IAs have appeared since the 1990s. They tend to reflect a more complex IA profile overall, which may also contribute to developmental delay:
- About 50% of IAs have at least one important medical condition, usually an infectious disease, though the need to hospitalize for treatment is rare.10-12
- Microcephaly has been found upon initial assessment in 30% of IAs.13
- Developmental delay is common, due to lack of appropriate stimulation, substandard caregiving practices and limited developmental experiences.13,14
- Language is typically the most delayed aspect of development.
- Generally, for every 3 months spent in care, a child loses 1 month of linear growth.15,16 That means that a 4-year-old child who is the size of a 3-year-old may be expected to function, developmentally, at a 3-year-old’s level (at least).3
- The longer an IA child lives in a state of emotional deprivation, the less likely she is to show ‘catch up’ growth within the normal range.17
- Mild-to-moderate growth delays can be overcome, but severe malnutrition (defined as weight <2 SDs for a child half the measured child’s chronologic age [e.g., a 2-year-old child’s weight is 2 SD below the weight of a 1-year-old]) has long-term effects on growth, cognitive development and behaviour.
- Pre-adoptive records reflect prematurity, at 25% , and low birth weight, at 40%.8
- Parasitic infections are common and reported in the range of 15% to 50% of IAs.10,12,15,16 Lower rates have been noted in Southeast Asia and higher rates in Eastern Europe7 and in African countries.12
- The hepatitis B ‘chronic carrier’ state is generally reported in 0% to 6% of cases.10,12,16 Hepatitis B vaccine programs in many Asian countries may reduce this number, but not all children develop protective antibodies, despite vaccination.12
The International Adoption Project, in partnership with the University of Minnesota’s International Adoption Clinic, reported survey results for 2500 families on pre-adoption risk factors and post-adoption outcomes for both school success and adjustment issues over a 9-year period. They used the following pre-adoption risk factors:
- Prenatal alcohol or drug exposure
- Prenatal malnutrition
- Premature birth
- Physical neglect
- Social neglect
- Physical abuse
- 6 months or more in an orphanage, baby home or hospital.
Most children did well:
- 78% of adoptees with ≤3 risk factors were doing well in school
- 50% of children with 4 to 5 risk factors were having difficulties
- ≥4 risk factors were related to post-adoption emotional or behavioural adjustment issues
- Age at placement and the number of risk factors were also highly correlated. Children placed in their adoptive home after 24 months of age had the highest number of risk factors.18
Emotional and neurobehavioural issues
- Neurodevelopmental or learning disorders which are more prevalent among IAs than in the general population include sensory integrative disorder, dyspraxia, and language, attention and executive function disorders.
- Emotional insecurity is also more prevalent than in the general population and can present with externalizing or internalizing behavioural challenges.
- Identity formation is complicated by issues of grief and loss. For IAs adopted transracially, issues with racial and cultural identity can be present as well.
Catching up on the basics
Samra is adopted from Ethiopia. She arrived in Canada at 16 months of age, having been in orphanage care since she was 3 months old. The first examination in Canada showed that her height and weight were on the 5% and her head circumference was on the 25%. Her developmental scores ranged from 10 to 12 months, with expressive language her biggest area of delay. Two-month follow-up showed skills at 15 months, with language still the lowest score. By age 24 months, however, all development was age-appropriate: height and weight were on the 25% and head circumference was on the 40%.
- Growth and developmental delays are common in IAs first arriving in Canada.
- Catch-up growth often includes crossing all percentiles.
- When a child is adopted before 18 months of age, most gross and fine motor skills are recovered within a few months to a year if the child is otherwise healthy. A small number of adoptees will have long-term motor and cognitive disorders.
- Language delays take longer to normalize with functional communication catching up quickly. Achieving language mastery can take longer.
Approximately 10% of IAs are adopted after 5 years of age. Their life experiences vary widely. Some children come from a caring birth family while others have coped with abuse and neglect. Older children may have spent a prolonged period in institutional care and may have experienced many, potentially adverse effects on physical and emotional health. They may not be ready for school and are at risk for significant cultural deprivation. School life makes social as well as academic demands that older IAs may not be ready for. Institutional care and the absence of a parental figure limit opportunities to socialize. Such widely variant cognitive and social abilities differentiate older IAs from their immigrant peers.4
Some long-term challenges become apparent in the teen years, when behavioural struggles (e.g., difficulties with executive function and adaptive skills) can impact independence. These effects can result from prenatal alcohol exposure, severe neglect or an attachment disorder.
Information by country of origin
It is illegal to relinquish a child for adoption in China. Most prospective adoptees have been abandoned by a parent, have no birth or family information, and are infants when they come into care. Children are typically in orphanage care but the number transitioning from foster care is increasing. In the last 6 to 8 years, more IAs have been coming through the “Waiting Child Program” for children with an identified medical or surgical disability. Conditions may range from a simple hemangioma to complex medical or surgical problems such as cerebral palsy, a cleft lip or palate, and myelomeningocele. These children may or may not have had surgery already. Parents often choose these programs to shorten their wait time for adopting a child.
Russia, Ukraine, Kazakhstan
In these countries, social and birth histories are often available. Children may have entered institutional care at birth, when their birth mother surrendered them voluntarily or when parental rights were terminated by the state. Pre-adoption proposals show a higher risk of prenatal exposure to alcohol,7 and alcohol consumption by birth mothers may be under-reported in Eastern Europe. Although FASD may not be suggested in pre-adoption information, prospective parents should be aware of higher risk. Children may also have experienced abuse and neglect before entering orphanage care.
Children born in Haiti may or may not have been brought into care by their birth family, which means their social and medical histories are not always available or complete. The death of a birth parent and significant economic and social hardship are often the predisposing factors for coming into care. Since the earthquake of 2010, the burdens on birth families and orphanage caregivers have increased. Children live in small orphanages called “foster homes”.
Ethiopia and other African nations
Economic and social hardship or the death of birth family members are common reasons for a child’s coming into care in Ethiopia. Some children are found abandoned, with no personal information. As in Haiti, children live in small orphanages known as foster or “baby homes”. Minimal information on a child’s background or medical status is provided.
South Korea, East and Southeast Asia
South Korean foster homes often provide the children living in them with Western-style health services. Fairly detailed social and birth histories are available. In Vietnamese orphanages, social and medical information is provided but is less detailed than in Korean proposals. In both countries, children enter care as infants. In recent years, IAs from Vietnam are often children with a disability. Institutions in Thailand, Taiwan and the Philippines can usually provide detailed medical and social information on children in care.
Reviewing a pre-adoption proposal
Prospective parents seek your medical advice on an IA proposal from China. The 18-month-old boy is institutionalized and has a cleft lip and palate. Only the cleft lip has been surgically repaired in China. Additional information shows the child’s weight is just below the 3%, his height on the 10% and his head circumference on the 10%. Laboratory screening for HIV, hepatitis B and syphilis is negative. Developmental information is limited and suggests skills globally at 12 months.
You review the complications of cleft lip and palate with the parents, including the need for surgery to repair the palate in Canada, and tell the parents that a small percentage of children are at risk of other anomalies, such as corpus callosum defects, and renal or cardiac anomalies. Causes of the child’s low weight and developmental delays, including his surgical condition and institutionalization, are discussed. You remind them that you are basing your assessment on the limited information provided. Next steps: to access a multidisciplinary cleft lip and palate team, to ensure medical and developmental follow-up, and to consider impact on the family, are highlighted.
- Review potential medical and developmental issues with parents as a key step in their decision-making process.
- Remind parents of potential limits on the information they have been given.
- Discuss resources that the family may need to support their child’s health care.
- Counsel on the emotional challenges of adoption, including adaptation, attachment and, where appropriate, a possible history of trauma.
- Citizen and Immigration Canada and Robin Hilborn, Canadians go abroad to adopt 1,946 children in 2010 (December 4, 2011). Family Helper: www.familyhelper.net/news/111027stats.html
- Jones VF, AAP Committee on Early Childhood, Adoption, and Dependent Care. Comprehensive health evaluation of the newly adopted child. Pediatrics 2012;129(1):e214-23.
- Bledsoe JM, Johnston BD. Preparing families for international adoption. Pediatr Rev 2004;25(7):242-50.
- Chambers J. Preadoption opportunities for pediatric providers. Pediatr Clin North Am 2005;52(5):1247-69.
- Johnson D. Adopting an institutionalized child: What are the risks? Adoptive Families 1997;30(3):26-30.
- Mitchell MA, Jenista JA. Health care of the internationally adopted child part 1: Before and at arrival into the adoptive home. J Pediatr Health Care 1997;11(2):51-60.
- Albers LH, Johnson DE, Hostetter MK, et al. Health of children adopted from the former Soviet Union and Eastern Europe. Comparison with preadoptive medical records. JAMA 1997;278(11):922-4.
- Jenista JA. Preadoption review of medical records. Pediatric Ann 2000;29 (4):212-5.
- Boone JL, Hostetter MK, Weitzman CC. The predictive accuracy of pre-adoption video review in adoptees from Russian and Eastern European orphanages. Clin Pediatr (Phila.) 2003;42(7):585-90.
- Hostetter MK. Iverson S, Thomas W, et al. Medical evaluation of internationally adopted children. N Eng J Med 1991;325(7):479-85.
- Jenista JA. Infectious disease and the internationally adopted child. Current Opinion in Infectious Diseases 1993;6:576-84: www.comeunity.com/adoption/health/infectious-disease.html
- Saiman L, Aronson J, Zhou J, et al. Prevalence of infectious diseases among internationally adopted children. Pediatr 2011;108(3):608-12.
- Miller LC. Initial assessment of growth, development, and the effects of institutionalization in internationally adopted children. Pediatr Ann 2000;29(4):224-32.
- Miller LC. The Handbook of International Adoption Medicine: A Guide for Physicians, Parents, and Providers. New York, NY: Oxford University Press, 2005.
- Johnson DE, Miller LC, Iverson S, et al. The health of children adopted from Romania. JAMA 1992;268(24):3446-51.
- Miller LC, Hendrie NW. Health of children adopted from China. Pediatrics 2000;105(6):E76.
- Ames EW. The development of Romanian orphanage children adopted to Canada: Final Report, Romanian Adoption Project. Burnaby, B.C.: Simon Fraser University, 1997:1-138.
- University of Minnesota. International Adoption Project: www.cehd.umn.edu/ICD/research/IAP.
- Cecilia Baxter, MD
Last updated: June, 2014