Promoting a healthy tomorrow here for children adopted from abroad

By Joni Bosch, ARNP, PhD; Shannon Sullivan, MD; Don C. Van Dyke, MD; Hongjun Su, PhD; Lori Klockau, JD; Kelly Nissen, MSW; Karen Blewer, BA, OTR; Ellen Weber, MA, ARNP; and Susan Schoon Eberly, MA

Adoptions of foreign-born children by families in the United States, which more than tripled over the past 25 years, may raise medical, developmental, psychosocial, and legal concerns. Pediatricians who understand those concerns and are familiar with referral resources can better serve international adoptees and their new-found families.

In 1978, families in the United States adopted 5,315 international children. By 2001, that number, as estimated by the US Immigration and Naturalization Service (INS), had risen to 20,000 per year, many being children under 1 year of age.¹ Internationally adopted children, particularly those adopted from institutions, often face medical, behavioral, emotional, and developmental difficulties that can significantly affect their well-being. Pediatricians have always played a key role in the evaluation and health care of adopted children, including children from other countries. Understanding the particular concerns of international adoptees and becoming familiar with a range of referral resources (Table 1)^1,2 can help pediatricians serve these children and their families better.

TABLE 1
Online international adoption resources

Medical evaluation often begins with a preadoption assessment of the child's health.³ Sometimes the parents' excitement about adopting a child overwhelms their ability to be objective about potential problems. Pediatricians need to talk with families about the risks involved.³ They can help parents determine whether they can make the necessary emotional and financial commitment. Table 2 lists items that the pediatrician may want to discuss.^2–5

TABLE 2
What to discuss with families during the preadoption process

Preadoption assessment and initial exam

A family usually receives some sort of medical record for a child they are thinking of adopting. The record may be complete and useful, or it may consist of little more than a name, estimated birth date, and sex.³ The child's health history may include information that is inaccurate or difficult to interpret. A recent review of Russian medical records, for example, found that most contained neurologic diagnoses unfamiliar to American physicians.³ Interpret the results of lab studies cautiously because quality control to guarantee accuracy may have been lacking. Photographs and videos of a child may provide useful information about the child's development, and may also raise new concerns not evident from the medical record.³

International adoption may create health risks for the adoptive family. These risks may include exposure to diseases such as tuberculosis and hepatitis, which may not be detected before a child is placed with the family.⁴

International adoption clinics can help you interpret medical information and assess risks.² They are found in 16 states and the District of Columbia; 22 states offer telephone consultation.² For contact information, visit www.comeunity.com/adoption/health/clinics.html .

When a child joins an adoptive family, the pediatrician should perform a careful initial examination within two weeks of the child's arrival in the US—sooner if the child is acutely ill or has an unstable medical condition.⁵ Review the child's medical record, confirm the history and diagnoses, and repeat lab studies as needed (Table 3).^5–10 Consider referral for early intervention services shortly after a child's arrival. This is especially important for children with such diagnoses as:

• Attachment problems

• Behavior problems

• Cerebral palsy

• Down syndrome

• Fetal alcohol syndrome/exposure

• Head circumference more than two standard deviations below the mean

• History of abuse

• Hypertonia, hypotonia, hyperreflexia, athetoid movement

• Vision, hearing, and other sensory deficits.^7,9

TABLE 3
Health screening for international adoptees

Immunization issues

Some pediatric experts recommend reimmunizing all internationally adopted children, no matter what their immunization status, because of concerns about:

• outdated, poorly stored, or biologically impotent vaccines that may compromise long-term immunity

• malnourished children's poor response to vaccines

• inaccurate or poorly documented immunization records.^11,12

Another way to clarify immune status is to test adoptees—particularly older children and children who may require multidose series— for titers to vaccine-preventable diseases.^5,12

The American Academy of Pediatrics' Red Book recommends that international adoptees follow the immunization schedule recommended for all children in the US.^6,13 You can print out the recommendations from www.cdc.gov/nip/recs/child-schedule.htm#Printable . A useful guide to minimum intervals between vaccine doses in a series can be found at www.cdc.gov/mmwr/preview/mmwrhtml/rr5102a1.htm .

Do not delay immunizations unless a child is acutely ill with more than a mild illness. All immunizations except varicella may be given to children awaiting the results of HIV screening. It may be wise to withhold measles, mumps, and rubella (MMR) vaccine from children with HIV who are severely immunocompromised (CD4+ T-lymphocyte count less than 750 per mL for children under 12 months of age, less than 500 per mL for children between 1 and 5 years, or less than 200 per mL for children 6 years of age and older).¹⁴ Vaccines from different manufacturers are considered interchangeable, although you need to adjust the number of boosters based on the formulation you are using for Haemophilus influenzae type B.⁶

If you are unsure whether a child has been vaccinated, reimmunization is usually considered safe.^5,6 However, the Advisory Committee for Immunization Practices (ACIP) recommends that children not receive more than six doses of diphtheria-pertussis-tetanus toxoid before 7 years of age.⁶

Watch out for TB and hepatitis

Tuberculosis (TB) is common in all 10 countries that provide most of the children offered for international adoption (Figure 1).^5,15 Clearly, it is important to screen all internationally adopted children with the Mantoux (PPD) skin test.^5,6

Many children from Asia and Latin America have been vaccinated against TB with the bacille Calmette-Guérin (BCG) vaccine. Because the vaccine may provide unreliable protection and can also prevent accurate Mantoux assessment, you must screen these children with a PPD test.⁷ If the BCG scar appears to be recent, wait until the scar has healed completely to give the PPD test.⁵ When a child who has received BCG has a PPD test reaction (induration) of 10 mm in diameter or greater, consider a diagnosis of and treatment for infection—especially if the child was born or lived in an environment where the prevalence of TB is high.¹⁶

Children who have TB may test negative for the disease because of recent exposure, malnutrition, or other infection. All international adoptees need a follow-up skin test 12 months after arrival.^5,8 Children do not need a chest radiograph if they have neither symptoms nor a positive PPD test.⁶

Hepatitis B is endemic in many international adoptees' countries of origin.⁵ Perform serologic testing for hepatitis B surface antigen, hepatitis B surface antibody, and hepatitis B core antibody to identify current infection, resolved infection, or chronic carrier status.⁶ Children who test positive for surface antigen should be evaluated by a pediatric gastroenterologist.⁵ Those who test negative for surface antigen should be immunized immediately for hepatitis B unless they show immunity based on lab studies. Retest six months after arrival to detect infection that was in the incubation phase at the time of the first test.⁵

Care of the teeth

Dental examination, preferably by a pediatric dentist, should be part of the evaluation of every adopted child.^7,8,17 Table 4 lists common pediatric dental problems.¹⁷ Children with a craniofacial disorder (particularly cleft lip and palate), genetic syndromes, hematologic disorders, congenital heart disease, neurologic conditions, cancer, infectious disease (HIV), or developmental disorders often require special dental care.^8,17

TABLE 4
Common dental disorders and their causes

Concern about eating well (and well enough)

Children who were institutionalized before adoption often have protein-energy malnutrition and a lack of micronutrients.¹⁸ Rickets is common, as are deficiencies of iron and iodine, which can impair brain development.^5,18 Although malnutrition can affect long-term growth and development, improved nutrition and stimulation can have a significant effect on heading off many potential problems.¹⁸

Institutionalized children who were served only soft foods may not accept foods of different textures.^9,19 Children may also refuse unfamiliar food and flavors. A child who went hungry in an institution may be preoccupied with food, gorge, and hoard food.⁹ You may need to reassure parents that these behaviors are not unusual and should improve gradually.⁹ Providing the child with a lunchbox in which to store snacks in his or her room may help.

Growth concerns

Growth retardation is the most common medical finding associated with internationally adopted children who have been institutionalized.⁸ Such children may have about one month's loss of growth for every two to three months in the institution.²⁰ Expect catch-up growth in the first six to 12 months after adoption.^8,18 If growth is slow or no catch-up growth occurs, immediate consultation and further evaluation are warranted.^8,18 Some girls with significant growth retardation who experience dramatic catch-up growth are at risk for precocious puberty.⁸

Plot height, weight, and head circumference on growth curves that reflect the child's ethnic background; you can find these growth charts at www.comeunity.com/adoption/health/growth.html . You may want to reassure parents that, although height and weight may increase slowly, short stature or underweight do not correlate with ongoing developmental delay (extremes of growth failure are always cause for concern).⁸ The risk of developmental delays or disability increases as rate of head growth and head circumference decreases^8,18,21 (Table 5).

TABLE 5
Troubling relationship: The risk of cognitive deficit increases as head circumference decreases

Developmental issues

An interpreter should participate in the developmental assessment of children whose native language is not English, particularly if the child is older than 3 years. Information about the child's functional abilities, and changes in abilities since arrival, is useful.⁹ Standardized tests may be of reduced value because of language barriers, rapid changes in skill level, and possible lack of normative values for the child's cultural background.⁹

A stimulus-rich environment is the foundation of neural development in infancy; children in an institution may not experience such an environment.¹⁹ Children adopted before they are 6 months old typically have fewer problems, but as many as 90% of children who spend more than a year in an institution have delay in at least one area of development.⁹ In children institutionalized longer than six months, mean IQ is 15 to 20 points lower than that of children adopted before 4 to 6 months of age.⁹

Even children who are developing normally may show some rigidity, concentration problems, and excessively concrete (rather than analytical or abstract) thinking.²⁰ If a family is adopting a child who has been institutionalized, early referral to a child psychologist or other mental health professional with experience in adoption and attachment issues may be helpful.^9,19

Studies suggest that for approximately 35% of internationally adopted children, developmental/behavioral concerns resolve andthe children become "normal." For another 35%, developmental/behavioral concerns, usually related to attachment disorder or cognitive development, persist. The remaining 30%, continue to exhibit ongoing, serious concerns three years after adoption.⁹

Adoption records describe risks resulting from intrauterine exposure to toxic substances (maternal alcohol use, for example) in as many as 17% of children from the Russian Federation and other Eastern European countries.⁸ Other studies report a 1.6% incidence of diagnosed fetal alcohol syndrome.⁸ Children who become available for adoption may be from difficult family and social environments that can place them at risk. Figure 2 in the print issue (Adapted From Johnson D, Dole K: International adoptions: Implications for early intervention. Infants and Young Children 1999;11(4):34) shows some of these concerns.⁹

Some "relative delays" in development may have a cultural basis. Children can appear to have a motor delay if, for example, they come from a culture in which doting foster parents or siblings constantly carried them. Poor gross motor skills or clumsiness may improve with opportunities to use these skills. Children raised in a bilingual environment can present special challenges for accurate developmental assessment. [For more on this topic, see "Language development in bilingual children: A primer for pediatricians" in the July 2001 issue.]

Sensory defensiveness

Children need a range of sensory experiences to develop fully. Some children, such as those reared in an institution, may not have such experiences.¹⁹ They may develop sensory defensiveness as a result—an overreaction or defensive response to ordinary sensations or experiences.²² Such children often dislike:

• everyday grooming, such as hair combing

• hugging and cuddling

• handling materials such as finger paints, paste, and sand

• common noises (vacuum cleaner, toilet flushing)

• bright lights.

Referral to a therapist trained in sensory-motor problems in children may be helpful.

Detachment: Feeling unsafe and unnurtured

The attachment cycle begins when an infant experiences a need such as hunger, thirst, loneliness, or fear. The infant expresses the need by crying, smiling, or some other signal, and an adult intervenes. Once the need has been met, the child relaxes. This cycle, repeated throughout infancy, is crucial to a child's sense of safety and trust, to development of a healthy personality, and to higher level functioning.

Disruptions in the attachment cycle leave a child feeling unsafe and unnurtured. If basic survival needs are not met, the child won't attain normal developmental milestones. Functions of the brain stem (respiration, heart rate, reflexes), mid-brain (hunger, sleep), limbic system (attention, self-regulation, and attachment behaviors), and cortex (learning, memory, and cause-and-effect thinking) are all affected.

Symptoms of attachment disorders may continue throughout a person's lifetime.^23,24 In addition to sensory defensiveness, children with attachment issues may exhibit the following symptoms:

• inability to give or accept affection from parents (although they are affectionate and charming with strangers)

• abnormal speech patterns, incessant chatter, nonsense questions

• need to control interactions with others

• poor peer relationships

• poor impulse control (may appear hyperactive, inattentive)

• low tolerance for frustration and change

• lack of cause-and-effect thinking

• lack of conscience

• obvious or "crazy" lying

• stealing

• destructiveness toward self, others, animals, and property

• fecal smearing, urinating in unusual places

• preoccupation with fire, blood, and gore.²⁵

A child's attachment issues result from emotional loss. Parents may be able to help by providing "regressive" care that the child was denied earlier, such as holding, rocking, and singing. Children who have been abandoned may assume that if they are "bad enough," the adults in their lives will leave them again. To prevent the pain of reabandonment, these children may distance themselves from anyone with an interest in establishing a relationship. For this reason, parents need to use "time ins" rather than "time outs" for discipline. During a "time in," the child and parent resolve the problem together.

Adopting children with special needs

An increasing number of international adoptions involve children who have special needs, such as medical problems, a history of abuse, emotional disorders, HIV, or prenatal drug or alcohol exposure.²⁶ Pediatricians can help parents evaluate their own skills, resources, and level of confidence in dealing with concerns that they may face.³ Local parent support groups may be a good resource. When parents discover that their adopted child has an unanticipated or severe medical, developmental, or behavioral condition, they may need to mourn the loss of their dream of an ideal family life, just as birth parents of a child with special needs do.

Prompt referral to early intervention services is critical for children with special needs. Your state's University Center for Excellence in Developmental Disabilities (UCEDD) can be a useful resource. UCEDDs are a network of interdisciplinary resource programs, including health-care programs, for children with disabilities and their families. Located in every state and US territory, they have been linking families with the services and supports they need for more than 40 years. For information about the UCEDD in your state, visit www.aucd.org (see Table 1).

Adolescent adoptees

In addition to the usual developmental struggles of adolescence, internationally adopted teenagers face some special concerns:

• attachment issues, including fear of abandonment

• difficulty with identity formation

• control issues

• lack of a sense of belonging

• lack of a sense of authenticity in their cultural role. ²

Although clinical studies indicate that adopted children may need mental health treatment, cohort studies show that adoption has a fairly minor impact on development.²⁷ In the presence of identical concerns, adopted children are more likely to be referred for mental health care than children who live with their biologic parents. Children with traumatic memories of life before adoption may need counseling.

Issues of language and culture

It is important for internationally adopted children, particularly older children and teens, to learn about and celebrate their cultural background.²⁸ Parents of adopted children—especially children of a transracial or transethnic adoption—need to help their children develop a positive sense of their cultural, racial, and ethnic identity, beginning in early childhood.²⁸ By about 3 years of age, children begin to identify differences in skin color; by 4 years, they start to become aware of racial groups.²⁸

Children born into a non-English-speaking environment should have a developmental assessment by professionals experienced with bilingual children, particularly if the child is older than 3 years.²⁹ Internationally adopted children—even those adopted in early infancy—typically show some expressive language delay.³⁰ Children younger than 3 years adjust rapidly to a new language and environment³¹; for older children, native language significantly affects cultural identity, educational experience, and communication skills.

Legal issues

Information on many aspects of international adoption can be found on the "Inter-Country Adoptions" page of the Immigration and Naturalization Service Web site at ww.ins.usdoj.gov/graphics/services/ index2.htm. Only a simple medical examination in the country of origin is required for an adoptive child to enter the US.⁴ Assessing the detailed health care and other needs of a child from another country accurately can be complicated. Health standards and the detail and accuracy of medical records from foreign countries often vary from those in the US.^3,4 Some countries permit only special needs children to be placed for adoption, and medical records may include inaccurate information to facilitate adoption.³⁰

Children from birth to 10 years are permitted to enter the US without having been immunized if immunization will take place within 30 days.³² Adoptees older than 10 years must show proof of having received the vaccines required by ACIP, or undergo vaccination with at least the first vaccine of each required series before entering the US.³²

The Child Citizenship Act of 2000 confers US citizenship on an internationally adopted child if:

• he (or she) is younger than 18 years or at least one adoptive parent is a US citizen and the other is a lawful immigrant to the US, and

• the child was admitted to the country legally.

Citizenship provides eligible international adoptees with insurance coverage under Title XIX, PL 106-395, Child Citizenship Act of 2000.

A momentous and complex time

The entry of a child into a family, whether through birth or adoption, is a momentous and complex event. This is especially true with an internationally adopted child. Pediatricians may need to help the family sort through medical, developmental, psychosocial, and legal ramifications before, during, and after adoption. Many resources exist to help you promote a healthier child and family.

ACKNOWLEDGMENT

The authors thank LaVonne Kahler for technical and editorial support and Jody Murph, MD, MS, for reviewing the manuscript before submission.

REFERENCES

1. Child Citizenship Act Information for Adoptive Parents: http://www.ins.usdoj.gov/graphics/publicaffairs/backgrounds/cbground.htm

2. National Adoption Information Clearinghouse Transracial and transcultural adoption. http://www.adoption.com/library/articles/tranrace.shtml ; International Adoption Clinics, links to other physicians. http://www.peds.umn.edu/IAC/Otherdocs.html

3. Jenista JA: Preadoption review of medical records. Pediatr Ann 2002;29(4):212

4. Jeffreys DP: Intercountry adoption: A need for mandatory medical screening. Journal of Law and Health 1996–1997;11(1-2):244

5. Aronson J: Medical evaluation and infectious considerations on arrival. Pediatr Ann 2000;29(4):218

6. American Academy of Pediatrics: 2000 Red Book: Report of the Committee on Infectious Diseases, 25th ed. Elk Grove Village, IL, 2000

7. Quarles CS, Brodie JH: Primary care of international adoptees. Am Fam Physician 1998;9(9):2025

8. Johnson D: Long-term medical issues in international adoptees. Pediatr Ann 2000;29(4):234

9. Johnson D, Dole K: International adoptions: Implications for early intervention. Infants and Young Children 1999; 11(4):34

10. Swagerty DL, Walling AD, Klein RM: Lactose Intolerance. Am Fam Physician 2002;65(9):1845 http://www.aafp.org/afp/20020501/1845.html

11. Schulte JM, Maloney S, Aronson J, et al: Evaluating acceptability and completeness of overseas immunization records of internationally adopted children. Pediatrics 2002;109(2):E22

12. Miller LC, Comfort K, Kely N: Immunization status of internationally adopted children. Pediatrics 2001;108(4):1050

13. Mitchell MA, Jenista JA: Health care of the internationally adopted child, Part 1: Before and at arrival into the adoptive home. Journal of Pediatric Health Care 1997;11(2):51

14. Measles pneumonitis following measles-mumps-rubella vaccination of a patient with HIV infection, 1993. MMWR Morbid Mortal Wkly Rep 1996;45:603 http://www.cdc.gov/mmwr/preview/mmwrhtml/00043110 htm .

15. The Adoption Guide—Advocacy for Adopting Families: http://www.theadoptionguide.com/

16. Centers for Disease Control: Core Curriculum on Tuberculosis, Chapter 9: BCG vaccination http://www.cdc.gov/nchstp/tb/pubs/corecurr/Chapter_9_Interpretation.htm

17. Pinkham JR, Casamassimo PS, Fields HW, Jr, et al: Pediatric Dentistry, Infancy through Adolescence, ed 2. Philadelphia, WB Saunders, 1994

18. Miller LC: Initial assessment of growth, development, and the effects of institutionalization in internationally adopted children. Pediatr Ann 2000;29(4):224

19. Faber S: Behavioral sequelae of orphanage life. Pediatr Ann 2000;29(4):242

20. Gunnar M, Burce J, Grotevant H: International adoption of institutionally reared children: Research and policy. Dev Psychopathol 2000;12:677

21. Johnson DE: Does size matter, or is bigger better? The use of head circumference in preadoption medical evaluations and its predictive value for cognitive outcome in institutionalized children. Minneapolis, International Adoption Clinic, University of Minnesota, pp 1–16

22. Wilbarger P, Wilbarger J, Trunell S: Sensory Defensiveness and Related Social, Emotional, and Neurological Problems. Minneapolis, Lecture packet notes, Professional Development Programs, 1998, p 3

23. Perry B: Childhood trauma, the neurobiology of adaptation, and "use-dependant" development of the brain: How "states" become "traits." Infant Mental Health Journal 1995;16:271

24. Terr L: Unchained Memories. New York, Basic Books, 1994

25. The Attachment Center at Evergreen http://www.attachmentcenter.org/main.htm

26. National Adoption Information Clearinghouse: Adopting a child with special needs http://www.calib.com/naic/pubs/f_specne.htm

27. Haugaard J: Is adoption a risk factor for the development of adjustment problems? Clin Psychol Rev 1998;18(1):47

28. Rozien N: Adoption, in Parker S, Zuckerman B: Behavioral and Developmental Pediatrics. Boston, Little, Brown & Co, 1995, pp 339–342

29. Chiocca EM: Language development in bilingual children. Pediatric Nursing 1998;24(1):43

30. Lears MK, Guth KJ, Lewandowski L: International adoption: A primer for pediatric nurses. Pediatric Nursing 1998;24(6):578

31. Bosch L, Sebastian-Galles N: Native-language recognition abilities in 4-month-old infants from monolingual and bilingual environments. Cognition 1997;65:33

32. Vaccination requirements for immigrant visa applicants and adjustment of status applicants. http://www.ins.usdoj.gov/graphics/generalvac.pdf

DR. BOSCH is a pediatric and family nurse practitioner at the Center for Disabilities and Development, University of Iowa Hospitals and Clinics, Iowa City.

DR. SULLIVAN is assistant professor of clinical pediatrics in the Division of General Pediatrics and Adolescent Medicine, Children's Hospital of Iowa, Iowa City.

DR. VAN DYKE is professor of pediatrics in the Divisions of Developmental Disabilities and Medical Genetics at the Children's Hospital of Iowa, Iowa City.

DR. SU is a research fellow at the International Center, Program for Asian Pacific Studies, University of Iowa, Iowa City.

MS. KLOCKAU is in private law practice in Iowa City.

MS. NISSEN is a social worker in the Social Work Service at the Center for Disabilities and Development, University of Iowa Hospitals and Clinics, Iowa City.

MS. BLEWER is an occupational therapist in the Occupational Therapy Department at the Center for Disabilities and Development, University of Iowa Hospitals and Clinics, Iowa City.

MS. WEBER is a pediatric nurse practitioner at the Center for Disabilities and Development, University of Iowa Hospitals and Clinics, Iowa City.

MS. EBERLY is supervisor of Information Resource Services at the Center for Disabilities and Development, University of Iowa Hospitals and Clinics, Iowa City.

The authors have nothing to disclose in regard to affiliations with, or financial interest in, any organization that may have an interest in any part of this article.

Don Van Dyke, Joni Bosch, Shannon Sullivan. Promoting a healthy tomorrow here for children adopted from abroad.

Contemporary Pediatrics

2003;2:69.