DANA E. JOHNSON AND JUDITH K. ECKERLETHROUGHOUT HUMAN HISTORY, loss of parental nurture and protection through death or abandonment placed a child’s survival at immediate risk. Standing in stark contrast to other options, the elevation of an abandoned or orphaned child to a position indistinguishable from a birth child within a family through formal or informal adoption was the superior mode of ensuring survival and well-being in a harsh world. Adoption, however, sometimes came with a price: the loss of the child’s cultural, ethnic, and racial ties.
In the twenty-first century, adoption is broadly accepted and an important part of our shared cultural experience in the United States. The U.S. National Foster Care Adoption Attitudes Survey revealed that almost three-fourths of respondents were at least somewhat familiar with adoption and that two-thirds or more had a favorable to extremely favorable opinion of intercountry, private, or foster care adoption. About 40 percent of respondents reported that a family member or close friend had been adopted (Dave Thomas Foundation, 2013). Numerically, adoption is an important way in which families are built in the United States. More than 1.5 million adopted children, about one of every forty children less than 18 years of age, were living in families in 2010. If one includes stepchildren, one in fifteen children have a relationship with an adoptive parent (Kreider & Lofquist, 2014).
EVOLUTION OF TRANSRACIAL DOMESTIC AND INTERCOUNTRY ADOPTION IN THE UNITED STATES
Diversity is a central characteristic of contemporary adoption in the United States. On the basis of the 2007 National Survey of Adoptive Parents, 40 percent of adopted children were involved in a transracial, transethnic, or transcultural adoption (Vandivere, Malm, & Radel, 2009). In 2009–2011, almost 438,000 transracially adopted children, 28 percent of all adopted children under 18 years of age, lived within homes in the United States (Kreider & Lofquist, 2014). Although informal adoption has a centuries-long tradition in the United States and a legal foundation for adoption has existed since 1851 (Herman, 2012f), because of the historical stringent racial boundaries in the United States, transracial domestic and intercountry adoption entered the mainstream only after the humanitarian tragedies of the mid-twentieth century and changes in attitudes toward race following World War II.
Transracial Domestic Adoption
The first recorded transracial adoption of an African American child by a Caucasian family in Minnesota, took place in 1948 (Herman, 2012h). However, organized activity in North America to promote transracial adoption dates to 1960 when the Open Door Society in Montreal, Quebec, attempted to place black children in same-race homes but recruited white families if these efforts failed. A similar organization, Parents to Adopt Minority Youngsters, was founded in Minnesota in 1961. Because children of color always have been disproportionately represented in foster care, additional agencies began transracial placement in situations in which same-race homes were unavailable (Simon, 2006). Further breakdown of racial barriers during the sixties increased interest in transracial adoption and during 1971, 2,574 black children were adopted by white families in the United States (Simon, 2006). In 1972, concerned about a child’s loss of racial and cultural identity, the National Association of Black Social Workers issued a strongly worded response against this growing trend of transracial adoption, affirming “the inviolable position of black children in black families where they belong physically, psychologically and culturally in order that they receive the total sense of themselves and develop a sound projection of their future” (Herman, 2012g, p. 1).
This organized opposition immediately decreased the number of transracial adoption of black children by white families to about 1,000 in 1973, down 71 percent from 1971 (Simon, 2006). Although the number of domestic transracial adoptions slowly increased from the 1973 nadir, the trajectory was to change again in the nineties when Congress enacted the Multiethnic Placement Act of 1994 as amended by the Interethnic Provisions of 1996, a federal civil rights law enacted to speed placement of children in foster care into permanent homes (Hollinger & The ABA Center on Children and the Law, 1998). This legislation prohibits using race, color, or national origin for decisions either delaying or denying a child in foster care of adoptive placement or for denying individuals the opportunity to become a foster or adoptive parent. States must be diligent in recruiting foster and adoptive parents who reflect the racial and ethnic diversity of the children who need homes. Following passage of that legislation, transracial adoptions from the public foster care system increased from 11 percent in 1995 to 15 percent in 2004 (Eschelbach Hansen & Simon, 2004).
Intercountry Adoption
Children adopted internationally constitute 37 percent of transracially adopted children in the United States (Kreider & Lofquist, 2014). Following World War II, thousands of children who were orphaned, abandoned by their soldier-fathers, or separated from parents needed homes. Military personnel in the occupying forces were the first to step forward to bring these children into their families. Between 1948 and 1962, U.S. families adopted 1,845 German, 744 Austrian, and 2,987 Japanese children. Additional waves of adopted children arrived in the United States following subsequent conflicts, including the Greek Civil War (3,116 from 1948 to 1962), the Korean War (4,162 from 1953 to 1962) the Vietnam War (3,267 between 1963 and 1973), and the war in El Salvador (2,083 between 1980 and 1990; Alstein & Simon, 1991; Herman, 2012e).
Because of the growing shortfall of adoptable infants in the United States secondary to increasing availability of support for single parents as well as legal abortion, beginning in 1968, the number of children placed from abroad rose consistently (Alstein & Simon, 1991). Children from Central and South America, India, and the Philippines, as well as an increasing number of children from Korea, boosted the total number of intercountry adopted people to nearly 10,000 year by the mid-eighties. A sharp increase in intercountry adoptions during 1990–1995 accompanied the fall of Communism in Eastern Europe and the dissolution of the United Soviet Socialist Republic. Augmenting this rise was the liberalization of Chinese adoption policy in response to the rise in abandonment of infant girls secondary to strict population control measures. Although rates of adoption from Romania flared briefly in 1991 (2,594), the number of children adopted from Russia and China rose steadily during the ensuing decade. By 1995 Korea had been supplanted as the top-placing country, and in fiscal year (FY) 2003, China and Russia accounted for 56 percent of intercountry adoption placements in the United States. In 2004, a record number of 22,884 orphan visas were issued in the United States (U.S. Department of State, 2014c).
Since that peak, the total number of intercountry adoptions has decreased progressively (7,092 in FY 2013) back to levels comparable to the eighties. The reasons for this decline are complex and include implementation of the Hague Convention on Intercountry Adoption and the Intercountry Adoption Act, the recent recession, political tensions (e.g., Russia), more restrictive requirements for adoption (e.g., China), internal political turmoil (e.g., Ukraine), and emerging domestic adoption programs in many countries that once placed children abroad, as well as perceived or documented fraud and abuse within the system. For these and no doubt other reasons, the most recent U.S. National Foster Care Adoption Attitudes Survey showed that international adoption was not viewed as favorably as it had been in the past (Dave Thomas Foundation, 2013). Nevertheless, internationally adopted people account for a significant component of transracially adopted people in the United States. The U.S. Census Community Survey in 2009–2011 identified 244,869 children who were internationally adopted, a total of 16 percent of adopted children less than 18 years of age (Kreider & Lofquist, 2014).
The most recent data on the breakdown of transracial adoption in the United States comes from the 2007 National Survey of Adoptive Parents, which found that 27 percent of adoptions from foster care, 21 percent of private domestic adoptions, and 84 percent of intercountry adoptions were transracial. The growing number of transracial adoption over the past half-century appears to parallel the increase in approval of interracial marriages. In 2011, a Gallup poll reported that 86 percent of American (96 percent blacks, 84 percent whites) approved of black–white marriages, an increase from an overall approval rate of 4 percent in 1958. Although only 66 percent of surveyed individuals 65 years old or older sanctioned marriage between blacks and whites, 97 percent of 18- to 29-year-olds approved. If comparisons between approval of interracial marriage and adoption are valid, transracial adoptions likely will increase in the future.
Medical Issues in Adoption
Despite the leadership role of prominent pediatricians at the turn of the twentieth century, such as Dwight Chapin, in supporting adoption as a means to decrease the extraordinarily high rates of infant mortality and morbidity within orphanages (Sherman, Aldrich, Bonar, Carr, & McCulloch, 1938), the discipline of pediatrics, until recently, has failed to appreciate the full range of issues faced by adoptive families and the special medical and development needs of children residing in or adopted from orphanage or foster care. As late as 2000, most standard textbooks on general pediatrics failed to even to mention the topic (Johnson, 2005). In the late eighties, investigators identified a high prevalence of medical problems in children adopted internationally that jeopardized not only the health of the child but also of the adoptive family and greater community (Hostetter, Iverson, Dole, & Johnson, 1989; Hostetter et al., 1991; Jenista, 1993; Jenista & Chapman, 1987; Lange, Kreider, & Warnock-Eckhart, 1987; Lange & Warnock-Eckhart, 1987; Lange, Warnock-Eckhart, & Bean, 1989). Following these reports, the American Academy of Pediatrics (AAP) published specific guidelines for postadoption screening for children from abroad (Committee on Infectious Diseases, 1994).
Over the ensuing 25 years, investigators focused considerable attention on adopted children spurred on not only by the surge in intercountry adoptions and the burgeoning population in foster care but also by rapidly increasing knowledge on the short- and long-term effects of early deprivation on child health and development.
MEDICAL PROBLEMS AND RISK FACTORS IDENTIFIED IN POSTINSTITUTIONALIZED CHILDREN
Growth impairment (Albers, Johnson, Hostetter, Iverson, & Miller, 1997; Johnson et al., 1992; Mason & Narad, 2005; Miller & Hendrie, 2000; Miller, Kiernan, Mathers, & Klein-Gitelman, 1995) High risk of prenatal alcohol exposure (Gronlund, Aring, Hellstrom, Landgren, & Stromland, 2004; Landgren, Svensson, Stromland, & Andersson Gronlund, 2010; Miller et al., 2009; Miller et al., 2006; Robert et al., 2009)
Hearing and vision problems (Eckerle et al., 2014)
Nutrient deficiencies (Fuglestad et al., 2013; Fuglestad et al., 2008; Gustafson, Eckerle, Howard, Andrews, & Polgreen, 2013)
Developmental delays (Albers et al., 1997; Groze & Ileana, 1996; Johnson et al., 1992; Miller et al., 1995; Rutter, 1998)
Sensory processing problems (Cermak & Daunhauer, 1997; Wilbarger, Gunnar, Schneider, & Pollak, 2010)
Emotional and behavioral issues (Ames, 1997; Gunnar & van Dulmen, 2007; O’Connor & Rutter, 2000; O’Connor, Rutter, Beckett, Keaveney, & Kreppner, 2000; Rutter, 1999; Rutter, Kreppner, & O’Connor, 2001; Zeanah et al., 2009)
During the past decade, the AAP has taken a leadership role in educating child care practitioners in this area. Fostering Health: Healthcare for Children and Adolescence in Foster Care was published in 2005 (Task Force on Health Care for Children in Foster Care, 2005). The AAP Council on Foster Care, Adoption, and Kinship Care (COFCAKC) was formed in 2011 by merging the Section on Adoption and Foster Care (founded in 2000); relevant parts of the Committee on Early Childhood, Adoption, and Dependent Care; and the Task Force on Foster Care. This council generates policy, creates educational programming and resources, develops and promotes advocacy initiatives, and supports translation of policy and education into practice. In 2014, the AAP and COFCAKC published the first comprehensive overview of adoption for child health professionals Adoption Medicine: Caring for Children and Families (Mason, Johnson, & Albers Prock, 2014).
Adoption professionals also experienced a steep learning curve about the specific health needs of adopted children. In the mid-eighties, we queried long-standing and highly respected adoption agencies in our community about the wisdom of establishing an adoption medical clinic. One response was particularly illustrative of the prevailing view, “You won’t get much business because all the kids we place from abroad are healthy.” Although this viewpoint was no doubt heavily influenced by the high percentage of truly healthy Korean infants being placed at that time, once the long-term sequelae of severe deprivation were recognized in postinstitutionalized Romanian, Russian, and Chinese children in the early nineties, the notion that love and good food were sufficient for child well-being was discredited. Currently, education on medical and developmental issues is a mandatory component of preadoption education for most parents adopting internationally (U.S. Department of State, 2014b) and is incorporated into most training programs for parents adopting from foster care.
Preadoption Contact with Adoptive Parents: The Preadoption Medical Review
Because health issues and health service utilization are of paramount concern for adoptive parents (Ames, 1997; Le Mare, Audet, & Kurytnik, 2007), families often consult with health care professionals before adoption about general health issues in children adopted from foster care or from abroad or may seek to understand the medical needs of a specific child referred to them for adoption. Discussions at this point in the adoption process prepare parents to more knowledgably ascertain whether their financial and emotional resources, social network, marriage, and family structure are in line with the likely needs of a particular child. The preadoption visit is also an opportunity for a health care provider to establish a relationship with the adoptive family that will ensure appropriate health care and guidance throughout childhood.
This is the time when a professional trained in adoption medicine plays a unique role. Once limited to guidance regarding common malformations, such as cleft lip and palate, or infectious diseases, such as hepatitis B, areas of knowledge have expanded dramatically over the past two decades to include interpreting medical terminology from various countries, ascertaining the short- and long-term effects of institutional rearing, and highlighting changing regional differences in medical risk. For example, heavy prenatal alcohol use historically has been high in Eastern Europe but is rising in other nations (e.g., South Korea) that are experiencing rapid Westernization (Lee, Shin, Won, Kim, & Oh, 2010).
The accuracy of medical and social information for children in the process of adoption varies widely depending on the quality of the medical system in the country of origin as well as the training, experience, and personal biases of the professionals responsible for collecting and reporting referral information. The experience of a medical professional trained in adoption medicine can help families accurately interpret the often-confusing referral information and realistically gauge whether additional information should or even could be obtained. For example, Korea has a medical system that is similar to the United States with medical information that is typically comprehensive, reliable, and up to date. Follow-up information as well as additional diagnostic testing is readily available. China has the potential for sophisticated medical care but significant regional variations exist in diagnostic capabilities. While procuring follow-up information or additional diagnostic testing is possible, the cost in time and money for the child’s institution is often the limiting factor. Referrals from Eastern Europe frequently list a number of diagnostic terms that are used inaccurately and indiscriminately. In these cases, a provider’s experience in discerning actual conditions from the multiple diagnoses that carry no weight in Western medicine is often critical in setting appropriate expectations for adoptive families.
A health care professional can play an important role in the preadoption process through nonjudgmental discussions regarding the families’ motivations to adopt and by helping them understand whether their resources are sufficient to enable a child to navigate medically and culturally through their life course. It is important during the preadoption process for the family to develop an extended view of possible outcomes of their decision. Most families will research what it means to have a child with HIV before adoption but some might not realize the implications of the child’s culture and race. Considering what it will mean to parent a transracial child, not only as a cute little infant, but also as a young student, a surly adolescent, and an independent young adult, is a parental exercise that health care professionals should support. Faced with sometimes-candid statements by adoptive parents about their comfort level in adopting children of certain racial backgrounds, we may not agree with their view but we need to help them engage in more self-reflection and assist them in knowing how their beliefs will intersect with the reality of raising a child who is transracially and transculturally adopted.
Cultural Sensitivity and Awareness During Preadoption Counseling
Addressing the overall issue of cultural sensitivity and awareness in the delivery of health care, the American College of Obstetrics and Gynecology stated the following:
Culture is defined as the dynamic and multidimensional context of many aspects of the life of an individual (Wells, 2000). It includes gender, faith, sexual orientation, profession, tastes, age, socioeconomic status, disability, ethnicity, and race. Cultural competency, or cultural awareness and sensitivity, is defined as, “the knowledge and interpersonal skills that allow providers to understand, appreciate, and work with individuals from cultures other than their own.” It involves an awareness and acceptance of cultural differences, self awareness, knowledge of a patient’s culture, and adaptation of skills. (ACOG Committee on Health Care for Underserved Women 2011, p. 1)
The cultural sensitivity and awareness checklist, designed to facilitate understanding and communication within health care settings, helps to operationalize the process of determining which cultural aspects surrounding adoption require awareness and sensitivity from health care professionals (Seibert, Stridh-Igo, & Zimmerman, 2002). Several items on this checklist are particularly relevant for providers as they begin relationships with parents choosing to build their family through adoption, including communication method and language barriers, cultural identification, beliefs, and health care provider bias.
CULTURAL SENSITIVITY AND AWARENESS CHECKLIST
1. Communication method: Identify the patient’s preferred method of communication.
2. Language barriers: Identify potential language barriers (verbal and nonverbal).
3. Cultural identification: Identify the patient’s culture.
4. Comprehension: Double-check: Does the patient or family comprehend the situation at hand?
5. Beliefs: Identify religious and spiritual beliefs. Make appropriate support contacts.
6. Trust: Double-check: Does the patient or family appear to trust the caregivers? Remember to watch for both verbal and nonverbal cues.
7. Recovery: Does the patient or family have misconceptions or unrealistic views about the caregiver, treatment, or recovery process? Make necessary adjustments.
8. Diet: Address culture-specific dietary considerations.
9. Assessments: Conduct assessments with cultural sensitivity in mind. Watch for inaccuracies
10. Health care provider bias: We all have biases and prejudices. Examine and recognize yours.
COMMUNICATION METHOD AND LANGUAGE BARRIER
Establishing our clinic in 1986, we chose the name Foreign-Born Adoption Clinic and then distributed promotional literature to adoption agencies in our community. Shortly after opening our doors, the clinic received a call from Marietta Spencer, a social worker at Children’s Home Society of St. Paul, who had authored “The Terminology of Adoption” for The Child Welfare League of America (Herman, 2012b). She patiently explained that “foreign-born” carried negative connotations, whereas the term “international” was neutral. Her Positive Adoption Language, which later evolved into Respectful Adoption Language, included vocabulary that “acknowledges those involved in adoption as thoughtful and responsible people, reassigns them authority and responsibility for their actions, and, by eliminating the emotionally charged words which sometimes lead to a subconscious feeling of competition or conflict, helps to promote understanding among members of the adoption circle” (Johnson, 2001, p. 1).
Spencer’s visit not only prompted a name change to the “International Adoption Clinic” but also a change in the language that we used with our families. Although terms such as illegitimate and legitimate already had been stricken from our lexicon, terms such as “real” or “natural” parent became birth parent and terminology that labeled a child were dropped (e.g., Korean child became simply a child). Rather than memorizing a table of appropriate terms, the following guidelines are helpful (Romanchik, 2013).
GUIDELINES FOR POSITIVE ADOPTION LANGUAGE
Do you or others use the word with a silent, but intended, “only” in front of it?
Does your language honor the connections that exist?
Does your language reflect the reality of the situation, both legally and practically?
Do you ask others involved how they would like to be addressed or referred to?
Do you continue to use language that others find offensive?
Cultural Identification
Clearly, a child adopted transracially or internationally is from a different culture, but an important question is whether the context of adoptive and birth families differ. Is there a culture of adoption that is relevant for medical providers? In the case of birth parents, assuming a pregnancy was planned, the most likely reason a baby is conceived is to expand their family. This is a common reason why parents adopt as well, but other factors enter into the decision-making process, such as wanting to provide a permanent home for a child and infertility (Vandivere et al., 2009).
One common question posed by professionals unacquainted with adoption is why adopt a child from abroad when thousands of children are waiting in domestic foster care for a permanent home? Most individuals who pursue intercountry adoption desire the entire spectrum of parenting experience and therefore seek as young a child as possible. At the end of FY 2012, only 22 percent of children awaiting adoption from foster care through public agencies were less than 3 years old (U.S. Department of Health and Human Services, 2013). During the same interval, 53 percent of children adopted internationally were less than 3 years of age (U.S. Department of State, 2014c). Adoptive parents also choose intercountry adoption because of concerns about the child’s relationship with her or his birthparents and about potential health issues in fostered children. In the 2002 National Adoption Attitudes Survey, a majority of respondents stated that if they were thinking about adopting, a major concern would be making sure that the birthparents would not later decide to reclaim their parental rights (Dave Thomas Foundation for Adoption, 2002). Other families are concerned about open adoption and wish to avoid ongoing interactions with their child’s birthparent(s). In addition, medical problems and mental health issues were identified as major worries when adopting from foster care. Intercountry adoption does provide some degree of security that birthparents will not contact or reclaim their adopted child. However, excluding domestic adoption in hopes of avoiding medical or behavioral problems is flawed reasoning as the children currently available for adoption from abroad share many of the same risk factors and medical and behavioral problems as children in domestic foster care (Chernoff, Combs-Orme, Risley-Curtiss, & Heisler, 1994; Garwood & Close, 2001; Halfon, Mendonca, & Berkowitz, 1995; Simms, Dubowitz, & Szilagyi, 2000; Takayama, Wolfe, & Coulter, 1998).
Humanitarian disaster triggers a resolve to adopt in many people, as was evident following the depiction of the plight of children in Romanian orphanages in 1990–1991 (Hunt, 1991), selective abandonment of infant girls in China (Evans, 2000), the Southeast Asian (Brown, 2005) and Japanese tsunamis (Doukopil, n.d.), and the Haitian earthquake (Seabrook, 2010). Family origins or an affinity with the child’s country of origin also may weigh heavily in this choice. Finally, some families seek special needs children with correctible handicaps who otherwise would not be treated, or parents may wish to share skills they acquired dealing with long-term disabilities in children with similar problems (e.g., blindness or deafness). In these situations, health care professionals should help families focus on the primary goal of identifying and parenting a child whose needs they can meet rather than “saving” a child or expecting gratitude for a child’s so-called rescue.
Finally, for optimal communication, professionals must be aware that while taxing events lead up to the arrival of a child in both birth and adoptive families, the stresses experienced are often quite different. Adoptive parents have little to no control and often no knowledge of the gestational milieu in which their child develops or the caregiving environment that surrounds their child after birth. Adoptive parents endure intense scrutiny during their home study and approval process, a waiting period often far longer than 9 months, extensive out-of-pocket fees not covered by health insurance, travel to unfamiliar countries, and the ever-frustrating necessity of dealing with government bureaucracy and legal systems both at home and abroad. These events shape an identity with similarities as well as clear differences from the experiences of a birth parent.
Beliefs
Religious beliefs play a powerful, central role in many adoption decisions. Judeo-Christian tradition holds individuals who adopt in high esteem, and in Islam, taking custody of a foundling is deemed an act of piety (Pollack, Bleich, Reid, & Fadel, 2004). Two pioneering families in transracial and intercountry adoption were motivated in large part by their religious beliefs. The “One-Family United Nations” of Helen Doss and her Methodist-minister husband Carl that graced the pages of Reader’s Digest and the cover of Life in the mid-twentieth century was the first intercountry adoption “poster family” (Doss, 1949, 1954; Herman, 2012d). Because the couple was infertile but desiring children, the Doss family ultimately adopted twelve children, some with special needs, who were considered unadoptable because of their mixed-race parentage. The children represented Korea, Japan, Philippines, Spain, France, Malaysia, Burma, Mexico, Hawaii, and three Native American Chippewa, Blackfoot, and Cheyenne tribes. Two of the most prominent figures in the early history of intercountry adoption in the United States, Bertha and Harry Holt, shared the same roots and motivations (Herman, 2012a). Already birthparents of six, the Holt’s eventually made the decision to adopt eight Korean orphans after hearing a presentation from the director of World Vision at a Sunday evening service at their church. They would later go on to help shape the adoption landscape on a global level.
Although the evangelical community has a long-standing commitment to orphan care (Joyce, 2013), increasing involvement is being catalyzed through the Christian Alliance for Orphans (2014). One of the core principles of this organization follows: “To act upon God’s call to care for orphans is not merely a matter of duty or reaction to need. It is first a response to Gospel: the loving Father who sought us, adopted us, and invites us to live as His sons and daughters” (Christian Alliance for Orphans, 2014, p. 1). Thus, it is not uncommon for individuals with a strong faith-based approach to adoption to view a child’s referral as divinely ordained and therefore unquestionable. Rather than directly challenging parents to consider whether this child is a correct fit for the family, it is appropriate for a health care professional to approach the consultation process as an opportunity to inform the family about the likely spectrum of services the child will require, explore what options might be available in their community, and discuss what the long-term care of the child might entail.
Health Care Professional Bias
Our closely held beliefs emerge not only through decades of our own experiences but attitudes also are transmitted vertically to us through our parents and extended family. Consequently, we all have biases, some of which are inconsequential in our professional lives, but others that interfere with our ability to optimally relate to our patients. Socrates stated that an unexamined life is not worth living, which should remind professionals that biases have the most destructive power when unacknowledged. In terms of adoption, child health providers have strong feelings that may extend beyond the transracial or transcultural aspects of adoption. Adoption is a common method for lesbian, gay, bisexual, and transgender people to form families (Mallon, 2008). When the American Academy of Pediatrics promulgated a policy that supported adoption by same-sex parents (Committee on Psychosocial Aspects of Child and Family Health, 2002), a group of pediatricians broke away to form the American College of Pediatricians (n.d.) as they felt that any child-rearing situation aside from a heterosexual, two-parent family was not in the best interest of children. Others have challenged the wisdom of allowing children with special needs from abroad to be adopted by families in the United States through the feeling that it adds to our shared economic burden. Whether such views are right or wrong, some providers will feel conflicted with elements of the culture surrounding transracial or intercountry adoption. Acknowledging our biases and exploring their roots is the most important step in providing competent and sensitive care to individuals who differ physically, culturally, or socially.
ASSESSING THE CULTURE OF AN ADOPTED CHILD
Irrespective of whether an adoption is transracial, it would outwardly appear that that each adopted person is born into a rich and diverse culture. The intrauterine environment provides even the youngest infant the sounds of language and music, the tastes of food through the surrounding amniotic fluid as well as the daily rhythms of her mother. These earliest experiences are reinforced throughout the first years of life during the most critical period of brain development. In the situation of the developing child, the definition of culture by Hoebel as an “integrated system of learned behavior patterns which are characteristic of the members of a society and which are not a result of biological inheritance” is particularly helpful (Hoebel, 1966, p. 52). The critical question in terms of adopted children is whether they developed within an environment in which they were able to integrate these experiences into developmental gains, behaviors, and memories that would be typical in their birth culture.
Until the late-eighties, most children adopted internationally were from Korea. Relinquished by healthy women stigmatized by single parenthood, these children were raised in foster families, provided a high level of medical care, and adopted as infants. In contrast, in the twenty-first century, many internationally adopted children are far more likely to be abandoned by poorly nourished, destitute mothers many of whom have abused alcohol or intravenous drugs, be cared for within grossly inadequate institutional care settings, receive inadequate medical care and nutrition, and join their adoptive families as toddlers or older children (Johnson, 2000, 2002). Normal enculturation of children within the foster care system is likewise compromised by neglect and abuse before placement and multiple placement changes in families and schools after entering the foster care system (Casey Family Programs, 2011). In other words, the developmental contexts of children adopted from domestic foster care and from abroad are qualitatively indistinguishable. As a group, it is difficult to argue that these children are ever fully able to benefit from the culture in which they appear to reside without the benefit of permanency.
We contend that the most pervasive influence for most people adopted transracially or internationally is a developmental environment (culture) characterized by prenatal risk and postnatal social, nutritional, and medical deprivation. Within this environment, children experience unbuffered periods of stress, generally referred to as “toxic stress,” which exacts an extreme and often lifelong toll in most developmental areas (Danese & McEwen, 2012; Shonkoff et al., 2012). In institutionalized children who were randomized to foster care, sensitive periods can be identified during early childhood beyond which recovery is less optimal even if children enter a more nurturing environment. For example, children raised in institutions since birth have fewer mental health problems if placed in foster care before 6 months of age and grow best if placed before 12 months of age. Language outcomes are best if placed before 18 month, social skills before 20 months, and cognition and attachment before 24 months (Nelson, Fox, & Zeanah, 2014). This information reveals not only the prompt, pervasive, and profound effects of adversity on early development but also provides guidance about the developmental status of adopted children at the time they enter their families and the areas in which intervention might be necessary.
Medical Assessment After Arrival
One of the benefits of specialty care in a clinic focused on adopted children is the comprehensive team approach to a neglected child coming from a “culture” of deprivation. In determining the effects of neglect and assuring a successful transition into the adoptive family, providers must consider all realms of socioemotional, nutritional, and medical deprivation experienced by the child. An initial examination is recommended 2–3 weeks after a child arrives in his or her adoptive home. Assuming the child is not acutely ill, this brief hiatus between arrival and first visit allows the family to recover from jetlag, improves child cooperation during the initial assessment, and permits the family to formulate specific questions.
An optimal first visit includes testing for major infectious diseases, vaccination status, growth delays, and nutritional deficiencies. Arrangements should be made for vision and hearing testing by specialized pediatric providers. A mental health professional should be available to explore attachment and family adjustment and a pediatric occupational therapist should assess developmental and sensory integration skills to plan for a home program and initiate referrals when appropriate, to early intervention programs. Finally, specific referrals are made to address known or discovered medical problems.
We recommend that all children are rescreened 6 months postplacement. At this time, the growth trajectory is assessed and necessary infectious disease and health screening tests are finalized. Catch-up growth is usually so robust that most children are now within the normal range in height, weight, and head circumference. If not, further diagnostic work-up is warranted, including screening for Helicobacter pylori or other sources of inflammation (Miller, Kelly, Tannemaat, & Grand, 2003). Calorie intake is an important factor in catch-up growth and feeding problems are common in children with sensory-motor problems or a history of adverse early feeding experiences (Rowell, 2012). Referral to a dietician or feeding specialist may be helpful in these cases. Referral to a pediatric endocrinologist also may be appropriate as growth hormone therapy may be indicated (Miller et al., 2010). This is a good time to evaluate family adjustment as the “honeymoon period” may be waning and issues with sleep, eating, attachment, tantrums, and rocking or other self-stimulating behaviors may be emerging. Parents know much more about their child at this time point and are better able to integrate discussions on further medical referrals, developmental and behavioral interventions, and other parenting practices.
INFECTIOUS DISEASE AND GENERAL HEALTH LABORATORY SCREENING
The following tests are performed at the University of Minnesota International Adoption Clinic for all newly arrived international adoptees:
Viral
○ Hepatitis A total Ig (with reflex testing for IgM if total Ig positive)
○ Hepatitis B (SAg, SAb, Core Ab)**
○ Hepatitis C Ab*
○ HIV 1 and 2 Ab*
Bacterial
○ Syphilis screening (antitreponemal Ab, RPR or VDRL)
○ Tuberculin skin test (TST) if less than 5 years old*
○ TST or QuantiFERON blood test if 5 years old or older*
Parasitic
○ Stool examination for ova and parasites (x 3)
○ Giardia Stool antigen
Vaccine Preventable Infection Titers (if documentation of prior immunization)
○ Measles, Mumps, and Rubella Ab
○ Diphtheria and Tetanus Ab
○ Haemophilus influenza type b Ab
○ Polio Types 1 and 2 neutralizing Ab
○ Varicella Ab
○ Alternative approach is revaccination according to current guidelines
General Health Screening
○ Complete blood count with differential, including a peripheral eosinophil count and red blood cell indices*
○ Vitamin D total*
○ Iron panel including C-reactive protein*
○ Thyroid stimulating hormone (TSH) and free thyroxine (free T4)
○ Lead
○ Haiti specific: G6PD, hemoglobin electrophoresis, malaria thick/thin smear if coming from a malaria-endemic area
Note: Ig, immunoglobulin; IgM, immunoglobulin M, Ab, antibody; SAg, surface antigen, SAb, surface antibody; RPR, Rapid Plasma Reagin test.
* Retest at 6 months.
** Retest at 6 months if test results are negative on initial testing.
Source: Adapted from Jones et al. (2012).
ONGOING ASSESSMENTS
Although preadoption counseling and the initial homecoming health assessment are important, additional time points for further evaluation are worth consideration. Entry into kindergarten is a time when expectations for academics, attention, and behavior increase for any child, and children who exhibit difficulties in these areas may benefit from further medical evaluation.
Neuropsychological testing is especially important at this time as it identifies areas of strength and weakness, which can assist the school system in focusing on a child’s actual needs. Further screening should be done at several time points for signs of fetal alcohol spectrum disorder (FASD) as children in the adoption system are at higher risk (Astley, Stachowiak, Clarren, & Clausen, 2002; Landgren et al., 2010).
Medical providers also can encourage families to access appropriate mental health professionals when the experience of early adversity is likely interfering in attachment or family dynamics. Other problems that frequently require intervention include sensory processing problems, speech and language issues (table 8.1) (Glennen & Masters, 2002), and developmental delays. Early referral to appropriate specialists is critical for optimal outcome.
Another important time point is late childhood when we encounter premature or accelerated puberty. A national survey on central precocious puberty (onset in girls less than 8 years and in boys less than 9 years) from thirty-four pediatric endocrinology clinics in Spain found that the risk of this condition in internationally and domestically adopted children was more than 27-fold greater than birth children. The risk of early puberty was particularly high in girls (Soriano-Guillen et al., 2010). Data from Denmark confirmed the increased risk in internationally adopted girls and showed that the average age of both breast development (9.5 years) and menarche (12.1 years) were approximately 1.3 years earlier than girls born in Denmark. Overall, 16 percent of girls adopted internationally entered puberty before 8 years of age (Teilmann, Main, & Skakkebaek, 2005; Teilmann, Pedersen, Jensen, Skakkebaek, & Juul, 2005; Teilmann et al., 2009). This is an issue in which health care providers should not take a “wait and see” approach for children who have experienced early adversity. Effects on emotional development and final adult stature can be significant and referral to a pediatric endocrinologist familiar with this problem is prudent.
TABLE 8.1 Suggestions for Referral to a Speech and Language Pathologist
| AGE AT ADOPTION |
SUGGESTED REFERRAL CRITERIA |
| 0–12 months |
Refer as if primary English speaker |
| 13–18 months |
Refer if not producing fifty words or two-word phrases at 24 months |
| 19–24 months |
Refer if not using English by 24 months, fifty words at 28 months, or two-word phrases at 28–30 months |
| 25–30 months |
Refer if not using English within several weeks at home or not speaking fifty English words or two-word phrases by 31 months |
Mid- to late adolescence is a time when health care visits are infrequent. Providers, however, should maintain contact with the adoptive family and child as questions regarding identity and relationships often arise. It is also a time to address issues of independence and future educational and vocational prospects if the child has struggled with learning. Screening for chronic adult diseases should also begin at this time (see the following discussion).
U.S. Adoption and Citizenship
The administrative process of intercountry adoption may seem beyond the scope of health care professionals, but providers can play an important role in ensuring maximum legal protection for newly adopted children. Although most U.S. state courts do recognize the legitimacy of a foreign adoption decree, it is not a requirement, and one can only imagine the scenarios in contested divorces or in dissolutions of parental partnerships where unions lack formal recognition. Formal adoption of the child in the United States guarantees that the courts of all fifty states will recognize the adoption. Once a child is adopted or readopted in state court, parents can request that a state birth certificate be issued. Having this document on file guarantees that a child can always obtain a certified copy simply by contacting the appropriate state agency. Birth certificates from abroad, once lost or destroyed, are extremely difficult to replace.
The issue of U.S. citizenship is likewise important when registering to vote or applying for college financial aid, jobs, or a U.S. passport. More ominous is the specter of conviction for a crime and, as a noncitizen, facing deportation. Because of the Child Citizenship Act of 2000, many parents no longer need apply separately for a child’s naturalization but for those who do, health care professionals should stress the importance of citizenship and encourage parents to complete the necessary paperwork to achieve this goal (U.S. Department of State, 2014a).
Horizontal and Vertical Identity
In the first chapter of his superb book, Far from the Tree, about raising children who differ significantly from their parents, Andrew Solomon explores the concept of vertical and horizontal identity (Solomon, 2012). Vertical identity such as ethnicity and skin color is transmissible from one generation to the next, and as such, the presence of these elements is an expectation in birth children. In the case of transracially or transculturally adopted children, these traits may not be shared with their adoptive parents, which forces children to acquire identity from a peer group who share these similarities. Health care professional can help parents promote this identification process and accept it as a normal and necessary part of establishing their child’s identity particularly during the critical years of adolescence. As one adopted person stated, “Children adopted from China don’t want to eat Chinese food with their parents. They want to eat it with their Chinese friends.”
Establishing Horizontal Identity
Observant individuals are continuously reminded that we live in a racist society with wide-ranging discrimination against individuals who do not share the same skin color, ethnicity, or language with the white majority. Such discrimination clearly affect all facets of life, including health. Given the undeniable fact that we do not live in a colorblind society, the following assertion in the 1972 Position Statement Against Transracial Adoption, by the National Association of Black Social Workers is truthful, at least in part, for all people adopted transracially (Herman, 2012g, p. 1):
In our society, the developmental needs of black children are significantly different from those of white children. Black children are taught, from an early age, highly sophisticated coping techniques to deal with racist practices perpetrated by individuals and institutions. These coping techniques become successfully integrated into ego functions and can be incorporated only through the process of developing positive identification with significant black others. Only a black family can transmit the emotional and sensitive subtleties of perception and reaction essential for a black child’s survival in a racist society.
Because a large percentage of adoptive parents are white and unfamiliar or totally ignorant of the strategies needed, can health care professionals provide such guidance? Although professionals from several disciplines provide competent care for children, at least in the case of children adopted internationally, 92 percent received care from a pediatrician or pediatric nurse practitioner (Eckerle et al., 2014). Are pediatricians or pediatric nurse practitioners likely to be familiar with the particular challenges of transracial adoption within a racist society? If racial demographics of pediatric health care providers are any indication of competency in this area, the answer is “not likely.” A 2013 survey of fellows of the American Academy of Pediatrics revealed that 75 percent were white. Only 15 percent were Asian, 4.1 percent were black/African American, and 6 percent were Hispanic (American Academy of Pediatrics, 2013). White pediatricians were far less likely to have minority patients than their Asian, Hispanic, and black colleagues (Basco, Cull, O’Connor, & Shipman, 2010). The situation is likely even more extreme for pediatric nurse practitioners. In a 2007 survey of nurse practitioners and clinical nurse specialists from many disciplines, 94% of respondents were white (Kenward, 2007).
At the time, concerns expressed by the National Association of Black Social Workers were at least partially warranted as studies in the era following this statement showed that many white parents who adopted African American children at that time tended to exhibit colorblind racial attitudes and were ambivalent about enculturation and racialization (McRoy & Zurcher, 1983). A more recent study of parents who adopted internationally, however, found relatively low mean scores on colorblind racial attitudes and relatively high mean scores on enculturation and racialization parenting beliefs (Lee, Grotevant, Hellerstedt, Gunnar, & Minnesota International Adaption Project, 2006). Thus, health care professionals likely will encounter families who are aware of the issues that must be addressed as their child matures and who are interested in whatever guidance and reminders that can be provided by professionals who are willing to be educated about the subject. The Children’s Bureau offers the following counsel for those considering transracial and transcultural adoption (U.S. Department of Health and Human Services, n.d.).
REFLECTION ON TRANSRACIAL/TRANSCULTURAL ADOPTION BY A COLORBLIND PARENT
The first time I held my infant son in my arms he smiled. Only weeks earlier he lay critically ill in his Calcutta orphanage near death from the monsoon-related enterovirus epidemic that was ravaging the nursery. Rather than mourning, however, I stood at the arrival gate transfixed by joy at his first smile ever—the word had indeed become flesh. At that time, the fact that I was adopting a child of color was the last thought on my mind and therein laid the problem. Of course, our social worker had addressed this issue and encouraged us to explore own beliefs and attitudes about race and ethnicity, but I was blindly confident that our family was up to the challenge. As my 10-year-old daughter definitively stated when asked about having a brown brother, “I wouldn’t care if he’s green or purple. I’d love him anyway” I should have taken our social worker’s advice more seriously.
The father returning Gabriel’s smile was tall, blond, blue-eyed, highly educated, and professionally successful. Not only had I never been personally exposed to racial discrimination, I had lived an essentially insular life in white neighborhoods and schools and had no friends of color until college. Raised in an evangelical religious tradition, I planned on becoming a medical missionary and lived for a year during medical school in the Democratic Republic of Congo. Spending time as a member of a distinct racial minority, however, imparted few lessons as missionaries were accorded an elevated status as medical providers. Not only were my personal experiences woefully inadequate to teach my son to live in a racist society, but the choices we made in terms of neighborhood, schooling, and family friends during my son’s childhood minimized rather than celebrated diversity.
I was a member of a generation of adoptive parents who grew up enthusiastically singing:
“Jesus loves the little children
All the children of the world
Red & yellow, black & white
They are precious in his sight
Jesus loves the little children of the world”
Clare Herbert Woolston (1856–1927)
Emergence from this colorblind innocence began only when I witnessed or was told of racial microaggressions my son experienced, such as the distinct surprise on the faces the parents of his white prom date when they greeted him at the front door. Then came the overt racism. First, in high school while riding in the back seat of his friend’s car with a group of white friends, he was singled out by police officers and questioned about drugs and guns. On another occasion, he was arrested for a trivial traffic violation by police officers in a predominately white suburb.
A further personal revelation came during my attempt to reconcile the song I sang in Sunday school with the unease I felt when boys or men of color approached me on an empty sidewalk—individuals who were the same color as my son. I was troubled to realize that while raised by an exceptionally loving and nurturing family, their attitudes, which reflected the pervasive racism and anti-Semitism of the fifties, had been instilled in me as well.
Although I can’t universalize my own experience and acknowledged short comings in this area to other adoptive parents, I now understand the concern of the National Association of Black Social Workers regarding how ill-equipped most white parents are to “teach from an early age, highly sophisticated coping techniques to deal with racist practices perpetrated by individuals and institutions” (Herman, 2012g, p. 1). But how does this existential anxiety translate into health care advice for parents who adopt children from another race or culture? Certainly many issues, such as identity formation and the development of positive self-esteem, are important and have a major bearing on the future of a child, but my epiphany as both parent and pediatrician was a talk given by a black social worker from Los Angeles about risks faced by children adopted transracially. He related stories of young men of color raised by white parents in white neighborhoods who were unschooled in dealing with law enforcement officers. Stopped in their own communities and being unaware of either the raciest attitudes of the police or appropriate coping strategies, they refused to follow instructions or exhibited emotional outrage at being profiled on their own streets. Not only did this result in arrest but also raised the possibility of having such actions perceived as aggression and met with deadly force.
When I recently apologized to my son for failing to provide appropriate education in this area, he was gracious and stated that he “was a fast learner.” Indeed, he is an intelligent man with good self-awareness, which no doubt helped in his adaptation to the harsh racial realities in our society. The fact, however, that my child or any child in his situation could be killed or seriously injured certainly emphasizes the importance of this area of education. Although the necessity for racialization goes far beyond this issue, this scenario provides health care professionals a powerful entrée to the subject material, particularly for parents, like me, who exhibit colorblind attitudes.
PREPARING FOR A TRANSCULTURAL OR TRANSRACIAL ADOPTION
Examine your beliefs and attitudes about race and adoption and ethnicity
Think about your lifestyle
Consider adopting siblings
Become intensely invested in parenting
Tolerate no racially or ethnically biased remarks
Surround yourselves with supportive family and friends
Celebrate all cultures
Talk about race and culture
Expose your child to a variety of experiences so that he or she develops physical and intellectual skills that build self-esteem
Take your child to places where most of the people present are from his or her race and ethnic group
VERTICAL IDENTITY FOR CHILDREN ADOPTED TRANSRACIALLY AND TRANSCULTURALLY
Despite the fact that it may appear inaccessible, all adopted children have a vertical or personal identity tied to their birth family that should be explored. In terms of domestic adoption, U.S. adoption records were open to adopted persons, birth parents, and adoptive parents before World War II. During the next three decades, however, state laws were enacted to deny easy access to birth records by birth parents and then by adopted adults (Carp, 2006a; Herman, 2012c; Norris 2006). The reasons behind this change centered on the perceived benefits of confidentiality for members of the triad. The effect of this change, however, permitted perpetuation of attitudes and myths about adoption that were prevalent at time: that birth outside of marriage was shameful and should be hidden, that parents need not confront the fact that adoptive families are inherently different, and that contact with other members of the adoption triad inevitably would lead to emotional trauma. In response to this change, adopted individuals banded together and attempted to influence policy on sealed records through such organizations as the Life History and Study Center (1953), Orphan Voyage (1962) and the American Adoption Congress (1978) all founded by Jean Paton and Adopted Persons’ Liberty Movement Association founded by Florence Fisher in 1971. Although these groups had little success overturning confidentiality laws in state and federal courts, their arguments did persuade social work professionals, agencies, and state legislatures to pass statutes and alter policy to enable searches that maintained privacy of triad members through such instruments as mutual-consent voluntary adoption registries or confidential intermediaries (Carp, 2006a).
For many adopted individuals, however, access to information on parentage and culture is considered a fundamental human right. For these individuals, any strategy short of complete access to information was unacceptable. Bastard Nation, an outspoken adoption activist organization founded in 1996, has achieved some success in restoring the rights of adopted individuals to receive their original birth certificate. Although a small number of states permit unconditional access, court orders are still required in most states (Carp, 2006a, 2006b). To further complicate this field, the issue of open records has entered the turmoil of the abortion debate as some feel that removing the option of privacy would lead to more abortions.
Concurrent with the growing desire to identify and contact birth parents, a cadre of amateur and professional identity investigators, adoptee support groups, and access to the Internet permit many individuals adopted both domestically or internationally access to their birth histories (Pertman, 2000). Concerns about this loss of personal identity are being addressed proactively through open adoptions in which birth parents, adoptive parents, and the child remain in contact. Contemporary studies indicate improved outcomes for children when avenues of communication remain open among adoption triad members (Barth & Berry, 1988; Berry, 1991; Grotevant, 1997; Grotevant & McRoy, 1998; Grotevant, McRoy, Wrobel, & Ayers-Lopez, 2013; Grotevant et al., 2008; Von Korff, Grotevant, & McRoy, 2006).
The exponential growth of DNA analysis and commercial DNA databases over the past decade now permits low-cost, conclusive parent, sibling, half-sibling, and first cousin matches. As advancing technology permits cost-effective analysis of even more genomic variations, the identification of ever-more-distant relatives will be possible. A shared interest in one’s forbearers undoubtedly will expand the use of these genomic databases in other countries continuing to revolutionize this search process. Now one need only submit a simple saliva sample through the mail and then await notification of possible family matches through services that integrate extensive crowd-sourced family pedigrees with DNA analysis (e.g., Ancestry.com). These developments may soon render moot the debate about birth record confidentiality and permit contact or closure in situations such as international adoption for which resolution was once thought impossible. Health care professionals counseling adopted individuals exploring these mechanisms to establish family ties should strongly encourage consideration of the benefits and burdens of sharing genetic information as well as the ability of different DNA analytic techniques to provide the answers desired (Lucassen, Hill, & Wheeler, 2010; Research-China.Org, 2011).
TRANSITION TO ADULTHOOD
Most children adopted from foster care or internationally have experienced significant periods of deprivation; thus, an important question is whether these adverse experiences will have an effect on their future health. The Adverse Childhood Experiences (ACE) study is based on more than 17,000 Kaiser Permanente Health Maintenance Organization members who, when undergoing a comprehensive physical examination in 1995–1997, chose to answer ten questions about their childhood experience of abuse (emotional, physical and sexual), neglect (emotional, physical), and family dysfunction (mother treated violently, household substance abuse, household mental illness, parental separation or divorce). The ACE score was determined by adding up the affirmative answers (0–10). The outcome of the study was that the risk for many major health problems (e.g., ischemic heart disease, diabetes, stroke, chronic obstructive pulmonary disease, depression, alcoholism, liver disease) increases in a strong and graded fashion as the ACE score increases (Centers for Disease Control and Prevention, 2014).
Another indicator of the adverse effects of early deprivation is shortening of the specialized nucleoprotein complexes on chromosomes (telomeres) that promote chromosomal stability. Telomere length shortens with each successive cellular division and when length reaches a critical point, cell division ceases and the cell dies. Without regenerative abilities, tissues and organs deteriorate and malfunction. Accelerated telomere length shortening has been associated with normal aging as well as cigarette smoking, radiation exposure, oxidative stress, and psychological stress, including a history of early maltreatment. The Bucharest Early Intervention Project, the first randomized controlled study of foster versus institutional care, recently studied telomere length in their subjects at 8 years of age finding it inversely related to the length of time children were institutionalized (Drury et al., 2012). Thus, early deprivation makes children old before their time.
Adoption is a lifelong journey and medical professionals should orient their practice with adopted individuals in this fashion. First, preadoption counseling and advice is key to address challenges that should be anticipated so families are prepared to meet a child’s likely needs. Second, health care professionals should comprehensively assess a child’s status after arrival. This involves attention not only to medical issues but also the psychological processes involved in incorporating a child successfully into the family. Third, parents must be informed of the necessity to enculturate and racialize their children. Finally, ongoing vigilance will help identify problems that may appear at key developmental horizons or advancing age. As key contacts to children and families throughout their lifetimes, health care providers have the opportunity and obligation to inform individuals with a history of adversity that they are at increased risk of developing a variety of chronic adult diseases, which could affect their quality of life and longevity if unrecognized and untreated. Screening should start during childhood and adolescence and continue throughout adulthood. A healthy lifestyle and regular health check-up will substantially improve prospects for good health.
Although challenges are faced by all transracially and internationally adopted individuals, this chapter ends with an optimistic note. Data accumulated over the past half-century leave no doubt regarding the positive effects of adoption on children’s development. Out of calamity and loss, adoption is by far the most effective means to help children recover and become functionally and emotionally competent adults within the environment of a permanent family (Johnson, 2002).
DISCUSSION QUESTIONS
1. What is the makeup (racial, international versus domestic) of adopted persons in the United States?
2. What are the initial major medical concerns in internationally adopted children especially those coming from institutional care environments?
3. Besides the initial postarrival evaluation, at what ages and time points should medical or developmental reevaluation be considered and what issues should be addressed?
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