Medical Issues in International Adoption
Growth charts information and downloadable, printable charts Article by Dr. Douglass on Medical Issues (below as web page or PDF)

I like for all the families I work with to read this brief overview article. You may already be fully aware of these issues but I want to be sure that all families I interact with are starting on "the same page." Much of this material may seem negative. Remember that I am very "pro" adoption but I do want parents to be aware of the medical issues specific to international adoptions so they can make fully-informed decisions that will result in solid, healthy, forever families.

First of all, it is important to consider some of the reasons why children are in orphanages. Very few children are truly orphans without any living parents. Most children are relinquished due to hardships of birth mothers living in poverty. This raises the odds that the birth mother did not have great prenatal care, may not have had good nutrition, and may have abused substances to relieve the stress of poverty. Other reasons include parental neglect or social pressure (the one child law in China or social predjudice against children with deformities). The bottom line is that the very reasons children are in orphanages often put them at higher risk for developmental, behavioral, and medical problems.

Add to this difficult start any length of stay in an orphanage and the detrimental effects can add up. Most orphanages are at the bottom of the social ladder in terms of government funding so nutrition is often marginal. Study after study in various countries all show predictable weight, height, and sometimes head circumference deficits depending on how long a child has lived in an orphanage.

Rates of infectious diseases are also high. Studies have found gastrointestinal parasites in 7 - 51%, latent tuberculosis in 5-19%, and hepatitis B infection in 5% of international adoptees. Hepatitis C and syphilis rates are less than 1%. Fortunately, there have been very few cases of HIV infection in international adoptees (less than 0.1% in one survey). Experts are watching these numbers closely as many of these diseases appear to be on the rise in many countries.

Another issue, particularly in Russia and the former states of the Soviet Union, is maternal alcohol use during pregnancy. Diagnosing children with fetal alcohol exposure or fetal alcohol syndrome (FAS) is difficult. The criteria include a history of maternal alcohol use, signs of brain injury (developmental delay and/or small head circumference), poor growth (including small size at birth), and several facial features. The facial features of FAS (such as a thin upper lip and no normal groove - called the "philtrum" - between the upper lip and nose) can be subtle and somewhat subjective. The problem with diagnosing FAS in children in orphanages is that a large portion of children in orphanages have no maternal history, are somewhat developmentally delayed, and have poor growth whether they have FAS or not.

Even more concerning than the nutritional, infectious, and substance exposure risks these children face is the lack of emotional attention and cognitive stimulation they receive while in the orphanages. Families who have completed their adoptions routinely respond that they have more issues regarding their adoptive child's emotional/cognitive health than their medical problems. The longer children reside in orphanages the higher their risk for more emotional/cognitive issues. Even in the best of orphanages it is difficult to give adequate affection and language stimulation to individual children. This was underscored when we traveled to adopt: every child in the room at the orphanage (ages 1 to 4) exhibited self-comforting rocking behavior (on their hands and knees) as they went down for their naps. With many different caregivers involved, children often do not learn to attach appropriately to specific adult "parent" figures. Because of this lack of attachment many newly adopted toddlers will go to any stranger without anxiety. This is often misinterpreted as gregariousness when in fact it is an abnormal lack of stranger anxiety. For most children who spend less than 2 years in an orphanage this lack of attachment resolves without major problems. In some children, particularly older children who spend more than 2 years in an orphanage, attachment issues may be more severe and require professional assistance. There are occasional examples of children adopted as infants developing attachment problems but they are uncommon.

Here's the good news! Of the over 20,000 children who are adopted into the U.S. each year, the majority of them have done well and their parents would consider adopting internationally again. Some of these families have had few if any medical or behavior problems with their children. Others have needed special educational services or medical care but since they were prepared and supported they have had an overall positive experience and would consider adopting again. Several factors play into such excellent outcomes from such difficult early infancies. First, most of these kids are survivors and are quite resilient. The majority respond nicely to the nutrition, affection, and attention that their new families lavish on them. Second, more and more pediatricians are screening these children for medical and/or emotional issues and initiating proper therapies such as state-sponsored early intervention services. Lastly, as mentioned above, I think parents are better educating themselves about international adoption and are thus better prepared to deal with the issues that might come up with their child. I hope this brief overview will assist in this education process and allow you to better welcome your child into your home!