Children’s International Adoption Clinic Helps Children Thrive

from Caring For Our Future, Fall 2005

By Karen Z. Dodd, MS, PNP-C

Did you know that The Children’s Hospital has an International Adoption Clinic?

The clinic, which began in 1999, is staffed by a multidisciplinary team of professionals. Team members include physician Matthew Daley, MD, nurse practitioner Karen Dodd, clinical psychologist Kristin Vaver, MD, physical therapist Michelle Thornhill and occupational therapist Nancy Corson.

The International Adoption Clinic (or IAC), located in the Child Health Clinic on the second floor of the hospital, provides consultation to families and primary-care providers prior to a child’s adoption and after adoption if needed. Services include:

• Pre-adoption consultation and review of medical records and videotapes
• Consultation to prepare for foreign adoption
• Post-adoption medical evaluation
• Growth assessment
• Comprehensive developmental assessment
• Evaluation of psychological, social and attachment issues
• Testing for various infectious conditions as needed
• Referrals to community resources or other specialists as needed and in consultation with the child’s primary-care provider

There has been a dramatic rise in number of international adoptions in the past decade. Since its inception, the IAC has performed more than 250 pre-adoption evaluations and more than 300 post-adoption team evaluations.

In the United States, the rate of international adoptions has risen dramatically, with nearly 20,000 foreign-born adoptees entering this country each year (Bledsoe, Johnston, 2004). In the 1960s, many children were adopted from Asia as a result of the Korean War, while in the 1970s and 1980s there was a predominance of children from both Korea and several Latin American countries (Jenista, 2000).

Due to a variety of rapid political changes in both the former Soviet Union and Asia in the 1990s, these countries have provided a new group of children for adoption. In 2004, immigrant visas were issued to orphans coming to the U.S. from various countries as noted in table 1. A vast majority of children from Russia and China have spent much of their lives in orphanages or institutions, often under circumstances of severe deprivation, before they are adopted.

As a result of their often neglectful and deprived backgrounds, children adopted internationally may be faced with a host of medical, developmental and social-emotional challenges. About 60 percent of the children seen in the IAC have some degree of developmental delay. On average, parents can expect to see about one month of delay of developmental mil estones for every three months a child has spent in an orphanage.

Medical conditions may include:

• Infectious diseases (such as tuberculosis, intestinal parasites and scabies)
• Poor nutrition and growth
• Fetal alcohol syndrome or its effects
• Early puberty
• Environmental exposures (such as lead exposure and intrauterine exposure to alcohol or drugs)
• Hepatitis B, Hepatitis C and HIV exposure

For children who spend time in an orphanage, the effects of institutionalization can be profound. Developmentally, these children may have gross and fine motor delays. In a typical orphanage, the children lie in cribs or sit in walkers for long periods without toys or adult interaction. They frequently are over-bundled in clothing and sometimes tied into their walkers. Most have minimal opportunities to explore or use their bodies. Poor nutrition further impairs their muscle development.

Sensory processing disorders can result from “negative” sensory input such as constant noise, poor temperature regulation from over-swaddling, poor lighting, uncleanliness and sometimes even the use of restraints. Feeding problems are not uncommon in institutionalized children as a result of little variety in food type, temperature and texture. Most feeding problems are related to sensory issues and a lack of experience. Although the big-bottle nipples used in many orphanages allow for rapid ingestion of liquids, they don’t allow children to swallow properly. Typically the children are discouraged from mouthing or touching their food.

Additionally, there can be significant risks to the social and emotional development of children in orphanages, including a lack of individualized care. Children in orphanages often have multiple, rotating caregivers who tend to focus on their physical needs rather than their emotional needs. There also is a higher incidence of abuse. These children may have impaired cognitive development, although the majority of children catch up considerably in their first year post-adoption (Judge, 2003).

The services offered by the International Adoption Clinic are tailored to address these multiple and sometimes complex issues. With pre-adoption consultations, prospective parents provide whatever medical records, pictures or videos that they are given of the child, which is often very limited. In China , for example, it is illegal for parents to relinquish a child, so babies (most often girls) are abandoned without any information about the family, pregnancy or birth history, although subsequent records are kept in the orphanage about medical history, examinations and lab work. Conversely, South Korea commonly has good prenatal, birth and family histories available to prospective parents for their review.

The IAC team helps to interpret the pre-adoption medical information and give an estimate of the child’s risk for medical or developmental problems compared to other internationally adopted children. This task can prove challenging since the medical terminology from different countries tends to vary significantly. Medical records from Russia commonly contain medical diagnoses that would appear alarming to a pediatrician in the United States . Frequently we see the diagnosis of “perinatal encephalopathy,” which suggests brain damage. In the IAC, 60 percent of the records we review from Russia contain this diagnosis (see table 2). Interestingly, physicians in Russia use the term for any child who has social risk factors that could potentially increase their risk for neurologic injury or effects. In this context, the IAC looks at all of the objective information and can often reassure parents when there is a lack of any objective findings to support the likelihood of brain damage. Ultimately, the decision of whether to adopt a child or not is always the prospective parents’ decision. The role of the IAC is to help the parents determine whether they are comfortable with whatever diagnoses or potential challenges the child may have.

The IAC recommends that a newly adopted child receive a complete physical examination by his or her primary pediatrician or provider soon after arrival in the United States . Once the child has been home for at least 6 to 8 weeks, he or she can be seen for a post-adoption multidisciplinary evaluation in the IAC if needed. We recommend not evaluating these children prior to a couple months from when they were adopted because it takes some time for them to transition into their new family and environment as well as to a new language. Developmental testing prior to this time may not be accurate.

Through its multidisciplinary evaluation, the IAC strives to address the multi-faceted challenges these children face. An early and comprehensive evaluation will:

• Identify areas of delay
• Allow interventions to be focused on areas of need
• Help parents understand their child
• Provide a baseline for measuring progress over time
• Assure parents that “catch up” will not always occur spontaneously

The post-adoption evaluation is a comprehensive visit that takes about an hour and a half. It includes a thorough medical evaluation, growth and developmental testing, and an evaluation of psychological, social and attachment issues. Testing for various infectious diseases also is covered. The IAC makes referrals to community resources or other specialists as needed. Despite the risks and challenges, the majority of the children we see in the IAC end up doing quite well, and the families appear to value being seen by a group of professionals with particular expertise in international adoption.

A recent review of literature looked at the rate of behavioral problems and mental-health referrals of international adoptees compared to domestic adoptees. (Juffer, Van Ijzendoorn, 2005). Results were encouraging, showing that most international adoptees are well-adjusted. International adoptees show fewer total behavior problems than domestic adoptees and were referred to mental-health services less often. With international adoption, ultimately, “the risks are many, but the joys are great.” (Jenista, 2000).

References

Bledsoe, J., and Johnston, B. (2004). Preparing families for international adoption. Pediatrics in Review, 25, (7), 242-249.

Jenista, J. (2000). The risks are many but the joys are great. Pediatric Annals, 29, (4), 208.

Judge, S. (2003) Developmental recovery and deficit in children adopted from eastern European orphanages. Child Psychiatry and Human Development, 34(1), 49-62

Juffer, F., and Van Ijzendoorn, M.H. (2005). Behavioral problems and mental-health referrals of international adoptees: a meta-analysis. JAMA, (20), 2501-15.