Adoption

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Chapter 34 Adoption

Mark D. Simms, Samantha L. Wilson

Adoption is a social, emotional, and legal process that provides a new family for a child when the birth family is unable or unwilling to parent. In the USA, about 1 million children are adopted; 2-4% of all American families have adopted. In 2007, approximately 135,000 children were adopted. Of these, approximately 40% were stepparent or relative adoptions. Of nonstepparent adoptions, approximately 60% were from the child welfare system, 25% were international, and 15% were voluntarily adoption-placed domestic infants. Private agencies or independent practitioners, such as lawyers, handle approximately one third of adoptions.

The Adoption and Safe Families Act (P.L. 105-89) requires that children in foster care who cannot be safely returned to their families within a reasonable period of time should be placed with adoptive families. As a result, adoptions of children in foster care increased from about 18,000 per yr to a peak of 53,000 in 2002. Nonetheless, approximately 130,000 children are “waiting to be adopted” from foster care, a number that has remained stable since 2003. Many children awaiting adoption have “special needs” because they are of school age, part of a sibling group, members of ethnic or racial minority groups, or because they have physical, emotional, or developmental needs. Federal adoption subsidies, tax credits, special minority recruitment efforts, increased preplacement services, and approval of adoptions by “nontraditional” families (particularly single adults and older couples) are aimed at increasing the adoption opportunities for these children.

Over the past quarter century, the number of families wanting to adopt children from other countries has grown dramatically. Between the late 1960s and the early 2000s, Sweden received well over 40,000 foreign children. In France, 3 out of 4 children adopted are foreign, from over 75 countries. The number of children adopted into the USA from other countries varies each year as a result of political and social changes across the globe. In 2008, U.S. families adopted 17,438 children from other countries (compared with 7,093 in 1990). In 2008, Guatemala, China, Russia, Ethiopia, and South Korea were the 5 primary sending countries for children to the USA. Most children placed for international adoption have histories of poverty and social hardship in their home countries, and approximately 65% are adopted from orphanage/institutional settings. Although many young infants are abandoned shortly after birth, some older children have experienced family disruption resulting from parental illness, war, or natural disasters. The effects of institutionalization and other life stresses impact all areas of early development, creating distinctive risk factors for these children.

Worldwide, according to UNICEF, there are 50 prospective adopters for every available child. There is concern that in some countries of origin the demand for adoptive children from other countries outstrips regulation and oversight to protect these children. Opportunities for financial gain have lead to abuses including the sale and abduction of children, bribery, and financial coercion of families.

Role of Pediatricians

Preadoption Medical Record Reviews

Adoption agencies are making increased efforts to obtain biological family health information and genetic histories to share with adoptive families prior to adoption. Pediatricians can help prospective adoptive parents evaluate the health and developmental history of a child and available background information from birth families in order to assess actual and potential problems or risks that children may have. Under the Hague Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption (implemented in the USA on April 1, 2008), agencies in the USA that arrange international adoptions must make efforts to obtain accurate and complete health histories on children awaiting adoption.

The nature and quality of preadoption medical records of children living outside of the USA vary widely. Poor translation and use of medical terminology and medications that are unfamiliar to U.S. trained physicians are quite common. Results of specific diagnostic studies and laboratory tests performed in the child’s home country should not be relied on and should be repeated once the child arrives in the USA. Paradoxically, review of the child’s medical records may raise more questions than provide answers. Each medical diagnosis should be considered carefully before being rejected or accepted. Country-specific growth curves should be avoided as they may be inaccurate or reflect a general level of poor health and nutrition in the country of origin. Instead, serial growth data should be plotted on U.S. standard growth curves; they may reveal a pattern of poor growth due to malnutrition or other chronic illness. Photographs or videotapes/DVDs may provide the only objective data regarding a child’s health status. The quality of this information, however, is often of questionable value. Nonetheless, full-face photographs may reveal dysmorphic features consistent with fetal alcohol syndrome (Chapter 100.2) or findings suggestive of other congenital disorders.

Frank interpretations of available information should be shared with the prospective adoptive parents. As noted by the American Academy of Pediatrics Committee on Early Childhood, Adoption and Dependent Care (1991), “It is not the pediatrician’s role to judge the advisability of a proposed adoption, but it is appropriate and necessary that the prospective parents and any involved agency be apprised clearly and honestly of any special health needs detected now or anticipated in the future.”

Postadoption Care

Arrival Visit

After the child is settled in the new home, pediatricians should encourage adoptive parents to seek a comprehensive assessment of the child’s health and development. The unique medical and developmental needs of internationally adopted children have led to the creation of specialty clinics throughout the USA. A significant number of internationally adopted children have acute or chronic medical problems, including growth deficiencies, anemia, elevated blood lead, dental decay, strabismus, birth defects, developmental delay, feeding and sensory difficulty, and social-emotional concerns (Chapter 34.1). All children with symptoms of an acute illness should receive immediate medical care. The American Academy of Pediatrics recommends that all children who are adopted from other countries undergo routine screening for infectious diseases and disorders of growth, development, vision, and hearing (Tables 34-1 and 34-2). Additional tests (e.g., malaria) should be ordered depending on the prevalence of disease in the child’s country of origin. If the child’s PPD is negative, a repeat skin test should be performed in 4-6 mo, since children may have false negative tests due to poor nutrition. A positive PPD should be followed by a QuantiFERON-TB Gold test to determine if the response is the result of prior BCG vaccination (Chapter 207). If they have not received hepatitis A vaccine prior to leaving the USA, parents and other household contacts (siblings, grandparents, etc.) should also be immunized. In 1 survey, 65% of internationally adopted children had no written records of overseas immunizations; however, those with records appeared to have valid records, although doses were not necessarily acceptable according to the U.S. schedule (Chapter 165).

Table 34-1 RECOMMENDED SCREENING TESTS FOR NEWLY ARRIVING ADOPTEES

Screening tests

• Complete blood cell count
• Hemoglobin identification
• Blood lead level
• Urinalysis
• Newborn screening (children <12 mo)
• Vision and hearing screening
• Developmental testing

Other screening tests to consider based on clinical findings and age of the child

• Detection of Helicobacter pylori antibody or 13C-urea breath test
• Stool cultures for bacterial pathogens
• Glucose-6-phosphate dehydrogenase deficiency screening
• Sickle cell
• Urine pregnancy test

Infectious disease screening (see Table 34-2)

Table 34-2 SCREENING TESTS FOR INFECTIOUS DISEASES IN IMMIGRANT CHILDREN

RECOMMENDED TESTS

Hepatitis B virus serologic testing*

• Hepatitis B surface antigen (HBsAg)
• Antibody to hepatitis B surface antigen (anti-HBs)
Hepatitis C virus serologic testing*†
Hepatitis A virus serologic testing†
Varicella virus serologic testing†
Syphilis serologic testing

• Nontreponemal test (RPR, VDRL, or ART)
• Treponemal test (MHA-TP or FTA-ABS)

Human immunodeficiency virus 1 and 2 testing (ELISA if >18 mo, PCR if <18 mo)*
Complete blood cell count with red blood cell indices and differential (if eosinophilia, see text)
Stool examination for ova and parasites (2-3 specimens)†
Stool examination for Giardia lamblia and Cryptosporidium antigen (1 specimen)†
Tuberculin skin test (with CXR if >5 mm induration)*†

OPTIONAL TESTS (FOR SPECIAL POPULATIONS OR CIRCUMSTANCES)

GC/Chlamydia
Malaria thick and thin smears
Urine for O&P for schistosomiasis, if hematuria present

ART, automated reagin test; FTA-ABS, fluorescent treponemal antibody absorption; MHA-TP, microhemagglutination test for Treponema pallidum; RPR, rapid plasma reagin; VDRL, Venereal Disease Research Laboratories.

* Repeat 3-6 mo after arrival.

† See text.

Developmental Delays

At the time of international adoption, many children exhibit delays in at least 1 area of development, but most exhibit significant gains within the 1st 12 mo after adoption. Those adopted before 6 mo of age usually demonstrate typical development, whereas those adopted at older ages have more variable outcomes.

Growth Delays

Physical growth delays are common among internationally adopted children and may represent the combined result of many factors, including unknown/untreated medical conditions, malnutrition, and psychological deprivation. Weight and height at the time of adoption have been negatively correlated with the amount of time spent in institutional settings. Though most children experience a significant catch-up in physical growth following adoption, many remain shorter than their U.S. peers.

Language Development

The majority of internationally adopted children have had little exposure to English. Within 24 mo postadoption, most preschool-age children attain English language skills equal to those of born in the USA. In older children, delays in native language skills often predict delays in English acquisition.

Eating Concerns

Initial concerns about eating, sleep regulation, and repetitive (e.g., self-stimulating or self-soothing) behaviors are common, especially among children adopted from institutional settings. Feeding concerns are often linked to limited exposure to textured or solid foods. Also, children may not have developed an awareness of satiation cues, leading to hoarding or frequent vomiting. Feeding concerns often subside gradually with introduction of age-appropriate foods and parental limits to portion sizes. Occasionally, additional support from a speech pathologist or feeding specialist is warranted to address possible physical concerns that could impede proper feeding.

Sleep Concerns

Sleep is often disrupted as the child reacts to changes in routines and environments. Efforts to create continuity between the preadoption and postadoption environment can be helpful. Within the first few months, as the child’s emotional self-regulation improves, many sleep concerns subside. Similarly, stereotypic behaviors, such as rocking or head banging, often diminish within the first few months following adoption.

Social and Emotional Development

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