Elaine E. Schulte
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 United States, about 1 million children <18 yr of age are adopted; 2–4% of all American families have adopted. Annually across the globe, approximately 250,000 children are adopted, with 30,000 of these between nations. In the United States, approximately 120,000 children are adopted every year. Of these, 49% are from private agencies, American Indian Tribes, stepparent, or other forms of kinship care. The remaining 51% of adoptions include public and international adoptions. Public adoptions account for the majority of these. Because of changing policies toward adoption and social change in several of the sending countries, the number of international adoptions has decreased dramatically over the last 10 yr. Public agencies support approximately 50% of total annual adoptions in the United States, private agencies facilitate 25% of adoptions, and independent practitioners (e.g., lawyers) handle 15% of adoptions. Compared to 19% of the general population, approximately 39% of adopted children have special healthcare needs.
The Adoption and Safe Families Act (P.L. 105-89) requires children in foster care to be placed with adoptive families if they cannot be safely returned to their families within a reasonable time. In fiscal year (FY) 2014, there were an estimated 415,129 children in foster care, and 107,918 were waiting for adoption. Of the 238,230 children who exited foster care, 51% were reunited with parent(s) or primary caretakers(s), and 21% were adopted (see Chapter 9 ).
Many children awaiting adoption are less likely to be adopted because they are of school age, part of a sibling group, members of historically oppressed racial/ethnic groups, or because they have considerable physical, emotional, or developmental needs. A number of policy efforts are aimed at increasing adoption opportunities for these children, including federal adoption subsidies, tax credits, recruitment efforts to identify ethnically diverse adults willing to adopt, increased preplacement services, and expanding adoption opportunities to single adults, older couples, and gay/lesbian partners.
Although same-sex couple adoption is legal in more than a dozen countries worldwide, it is actively debated in the United States. Although legislation regarding same-sex couple adoption varies by state, increasing numbers of gay and lesbian partners have been able to adopt. Current estimates suggest that almost 2 million children, including 5% of all adopted children, are raised by gay and lesbian parents. Adopted children include those adopted domestically, those from foster care, and internationally adopted children. There is increasing evidence that children raised by same-sex couples are as physically or psychologically healthy, capable, and successful as those raised by opposite-sex couples. Pediatricians can advocate for adopted children by supporting gay and lesbian parents.
Open adoption , usually through an agency or privately, occurs when the birth mother arranges to continue to be involved, although in a limited manner, with the legally adopted family. This may occur through surrogacy or more often in an unplanned pregnancy.
Along with foster care adoptions, international adoptions are a way of providing stable, long-term care to vulnerable children throughout the world. There is concern that in some countries of origin, the rapid growth of international adoption has outpaced regulation and oversight to protect vulnerable children and families. Opportunities for financial gain have led to abuses, including the sale and abduction of children, bribery, and financial coercion of families, but the extent and scope of the potential concern is difficult to ascertain. Increasing global efforts, such as the Hague Convention on Protection of Children and Co-operation in Respect of Intercountry Adoption , have promoted political cooperation between nations and established international law to reduce potential for child abduction and child trafficking and to ensure that the best interests of the child are paramount in decision making. Participating nations, including the United States, are working to address the myriad of sociopolitical conditions that create the need for out-of-family care, and are working to support children within their nation's borders. International adoption is increasingly considered a measure of last resort if the child cannot be cared for within his or her birth family (including extended relatives), the immediate community, or the larger national culture. As a result, children adopted internationally into the United States are more likely to enter their families at older ages or with complex medical, developmental, or social-emotional needs.
Although the vast majority of children adopted internationally enter the United States for purposes of adoption, a small but growing number of children exit the United States for adoption into other countries. For example, in FY 2014, 96 children exited the United States for adoption by families in other countries (e.g., Canada, Netherlands, Ireland, United Kingdom). Little is known about the circumstances surrounding these adoptions and the eventual outcomes of the children who are adopted internationally from the United States.
In 2015, U.S. families adopted 5,647 children from other countries (compared with a peak of 22,884 in 2004). Children from China, Ethiopia, South Korea, Ukraine, Bulgaria, and the Congo represented 65% of children adopted internationally into the United States in 2015; 42% were from China alone. Although individual experiences vary, most children placed for international adoption have some history of poverty and social hardship in their home countries, and most are adopted from orphanages or institutional settings. Many young infants are placed into orphanage care shortly after birth. Some older children have experienced family disruption resulting from parental illness, war, or natural disasters. Still others enter orphanage care after determination of significant abuse or neglect within their biological families. The effects of institutionalization and other life stresses may impact all areas of growth and development. As a result, many children require specialized support and understanding to overcome the impact of stress and early adversity and to reach their full potential.
Preadoption medical record reviews are important for both domestic and international adoptions. Adoption agencies are making increased efforts to obtain biological family health information and genetic histories to share with adoptive families prior to adoption. Such information is often becomes increasingly relevant as the child ages. Pediatricians can help prospective adoptive parents understand the health and developmental history of a child and available background information from birth families in order to assess actual and potential medical risk factors to support adult decision-making about the family's ability to parent the waiting child.
Under the Hague Convention, U.S. agencies that arrange international adoptions must make efforts to obtain accurate and complete health histories on children awaiting adoption. The nature and quality of medical and genetic information, when available, vary greatly. Poor translation and use of medical terminology and medications that are unfamiliar to U.S.-trained physicians are common. Results of specific diagnostic studies and laboratory tests performed outside the United States should not be relied on and should be repeated once the child arrives in the United States. 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 because they may be inaccurate or may 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; this may reveal a pattern of poor growth because of malnutrition or other chronic illness. Photographs or video files may provide the only objective information from which medical status can be determined. Full-face photographs may reveal dysmorphic features consistent with fetal alcohol syndrome (see Chapter 126.3 ) or findings suggestive of other congenital disorders.
Frank interpretations of available information should be shared with the prospective adoptive parents. The role of the healthcare provider is not to comment on the advisability of an adoption, but to inform the prospective parents of any significant health needs identified now or anticipated in the future.
All internationally adopted children should have a thorough medical evaluation shortly after arriving in the United States. Many children may have acute or chronic medical problems that are not always immediately evident, including malnutrition, growth deficiencies; stool pathogens, anemia, elevated blood lead, dental decay, strabismus, birth defects, developmental delay, feeding and sensory difficulty, and social-emotional concerns. All children who are adopted from other countries undergo comprehensive screening for infectious diseases and disorders of growth, development, vision, and hearing (Tables 8.1 and 8.2 ). Regardless of test results before arrival, all children should be screened for tuberculosis with either a tuberculin skin test (TST) or interferon-γ release assays (IGRA). If the child's purified protein derivative (PPD) skin test is negative, it should be repeated in 4-6 mo; children may have false-negative tests because of poor nutrition. Additional tests (e.g., malaria) should be ordered depending on the prevalence of disease in the child's country of origin (see Chapter 10 ). Immunization records should be carefully reviewed. Internationally adopted children frequently have incomplete records or have been vaccinated using alternative schedules. Pediatricians may choose to check titers to determine which vaccines need to be given, or they can choose to reimmunize the child. The unique medical and developmental needs of internationally adopted children have led to the creation of specialty clinics throughout the United States, which may be a valuable resource for adoptive families at all stages in the adoption process and throughout the adopted child's life.
Physical growth delays are common in internationally adopted children and may represent the combined result of many factors, such as unknown/untreated medical conditions, malnutrition, and psychological deprivation. It is more important to monitor growth over time, including preplacement measurements, since trend data may provide a more objective assessment of the child's nutritional and medical status. Children who present with low height-for-age (growth stunting ) may have a history of inadequate nutrition as well as chronic adversity. Although most children experience a significant catch-up in physical growth following adoption, many remain shorter than their U.S. peers.
Many children adopted internationally exhibit delays in at least 1 area of development, but most exhibit significant gains within the 1st 12 mo after adoption. Children adopted at older ages are likely to have more variable outcomes. In the immediate post-adoption period, it may be impossible to determine with any certainty whether developmental delays will be transient or long-lasting. Careful monitoring of development within the first years of adoption can identify a developmental trend over time that may be more predictive of long-term functioning than assessment at any specific point in time. When in doubt, it is better to refer early for developmental intervention, rather than wait to see if the children will catch up.
For both domestic and international adoptees, genetic or biologic risk factors for poor language development may be identified preadoptively, but it is unlikely that international adoptees will have had these delays identified before adoption. These children typically have not had an assessment in their native language and have had little exposure to English. It may not be possible to fully assess their language abilities until they have had a chance to learn English. Regardless of the age at adoption, most internationally adopted children will reach age-expected language skills over time.
If a child has language delays, referral to early intervention or the school district should be made. Clinicians may need to work with these groups to help them understand the unique circumstances surrounding an adopted child's language development. For example, English language acquisition in internationally adopted children depends on the age of adoption and native language skills. Placing the recently adopted, school-age child in an English as a Second Language class may not be sufficient if the child's language development in the primary language has been atypical.
Initial concerns about eating, sleep regulation, and repetitive (e.g., self-stimulating or self-soothing) behaviors are common, especially among children adopted following a high degree of neglect or developmental trauma. Feeding behaviors of international adoptees may be linked to orphanage feeding practices, or limited exposure to textured or solid foods during later infancy/toddlerhood. Children who have experienced chronic lack of food 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 support for positive feeding practices. Many children who were adopted after significant malnutrition may eat an excessive amount of food. Unless the child is eating to the point of vomiting (which would indicate little awareness of satiation cues), it is generally best to allow them to eat until satiation. Typically, within several months, the child will regulate food intake appropriately. Occasionally, additional support from a speech pathologist or feeding specialist is warranted to address possible sensory, physical, or psychological issues around proper feeding.
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 1st 3-6 mo, as the child's emotional self-regulation improves, many sleep concerns subside. Similarly, stereotypical behaviors, such as rocking or head banging, often diminish within the 1st few mo after adoption.
Dyadic interactions between child and caretaker are a critical component to later regulatory functioning and social-emotional development. The amount and quality of individualized caretaking that children have received before their adoption, whether international, domestic, or through the foster care system, is usually unknown. In many cases, entry into a secure, stable home setting with consistent childcare routines is sufficient to support the child's emerging social-emotional development. Pediatricians can help parents remember that adoption is part of a child's history. Throughout one's childhood, prior experiences or biologic disposition may result in behavior that is confusing to the adoptive parents. The child's reactions may be subtle or difficult to interpret, interfering with the parents’ ability to respond in a sensitive manner. In these circumstances, additional support may be helpful to foster the emerging relationships and behavioral regulation in the newly formed family.
Transracial adoption (where the racial background of the child differs from that of the parent/parents) accounts for a significant percentage of adoptions each year in the United States. In most of these adoptive placements, children of color have been adopted by white parents. Racial identity development, including ways to understand and respond to discrimination, is increasingly recognized as important in the overall development of children. Surveys of adults adopted transracially indicate that racial identity is of central importance at many ages and tends to increase in significance during young adulthood. Integrating race/ethnicity into identity can be a complex process for all children, but it may be especially complicated when they are raised in a family where racial differences are noted. Adults raised within interracial families have noted the value of attending racially diverse schools and of having adult role models (e.g., teachers, doctors, coaches) who share their racial background. Parents who adopt transracially are often encouraged to support interactions within diverse communities and to discuss race (and associated discrimination) often within the family. Black children raised by white families in white communities may have been sheltered from overt racism but need to be taught that many others (including law enforcement officers) will regard them as black with all the intense biases associated with race (see Chapter 2.1 ).
The cumulative amount of early adversity (e.g., numerous years within international orphanage care, extensive abuse/neglect prior to removal from biological family, or multiple foster care placements) experienced by a child before adoption, referred to as toxic stress , can impact both immediate placement stability and long-term functioning (see Chapter 2 ). The degree of presumed toxic stress may be helpful in interpreting a child's behavior and supporting family functioning.*
The unique aspects to adoptive family formation can create familial stress and impact child and family functioning. Some adoptive families may have to address infertility, creation of a multiracial family, disclosure of adoptive status, concerns and questions the child may have about their biologic origins, and ongoing scrutiny by adoption agencies. With gay/lesbian parents, there are often additional psychosocial stressors, including continued barriers to legal recognition of both parents in a gay/lesbian partnership that can negatively impact family functioning. Although most families acclimate well to adoption-related stressors, some parents experience postadoption depression and may benefit from additional support to ease the family's transition.
Families are encouraged to speak openly and repeatedly about adoption with their child, beginning in the toddler years and continuing through adolescence. Creating a Lifebook for the adopted child provides a way to support family communication about the child's history and significant relationships (including birth family members) and to document the child's important life transitions (e.g., through foster care or immigration to the United States). It is common, and normal, for children to have questions about adoption and their biological family throughout their development. An increase in cognitive understanding between ages 7 and 10 yr can sometimes increase adoption-related questions and distress. Youth who have questions about biological family members are increasingly able to access information via social media and web-based searching, raising the importance of ongoing open communication about adoption. Pediatricians may need to respond to increased concerns/questions when the adoptee's health and genetic history is incomplete or unknown. At any time, concerns about development, behavior, and social-emotional functioning may or may not be related to the child's adoption history.
The vast majority of adopted children and families adjust well and lead healthy, productive lives. Adoptions infrequently disrupt; disruption rates are higher among children adopted from foster care, which research associates with their age at adoption and a history of multiple placements before adoption. With increased understanding of the needs of families who adopt children from foster care, agencies are placing greater emphasis on the preparation of adoptive parents and ensuring the availability of a full range of postadoption services, including physical health, mental health, and developmental services for their adopted children.