Summary

With the growing numbers of internationally adopted children, pediatricians must be prepared to address a myriad of medical and psychological special needs these patients present. In 2003, over 21 000 children from oversees were adopted by American families, a sizable increase from over 8000 just a decade earlier.[1] Issues encountered during evaluation of children adopted from abroad are very similar to the ones seen in the U.S. foster children. Even a healthy-appearing international adoptee will need comprehensive screening tests, since immunization status often is uncertain, and orphanage life is a Petri dish of infectious diseases, as well as an impediment to emotional and physical development.

Educational objectives

At the conclusion of this activity, participants will be able to:

• Identify potential medical problems expected in post-institutionalized children from various countries
• Recognize the psychological problems seen in adoptees
• Conduct the appropriate medical, developmental, and other evaluations needed for children adopted from abroad.

CME credit

This is an article from The Child's Doctor, Fall 2004 issue. You may take the quiz for learning purposes, but credits are no longer valid.

Author disclosures

Dr. Ochs has no industry relationships to disclose and does not refer to products that are still investigational or not labeled for the use in discussion.

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Potential medical conditions

Orphans from Asia, Eastern Europe, Africa, and the Americas tend to be from the lowest socio­economic stratum and suffer from all the diseases of poverty. International adoptees may have intestinal parasites, tuberculosis, HIV, syphilis, hepatitis A, B, and C, hypothyroidism, metabolic disorders, malnutrition, lead poisoning, anemia, and fetal alcohol syndrome.

Medical problems in adoptees vary with the children's countries of origin. Hepatitis B, C, and HIV infections, although rare, [2] are more common in children adopted from Asia, Eastern Europe, and Africa, and are encountered less often in children from the Americas. [3] Lead poisoning can be expected in all adoptees, but it is found most frequently in children from Asia. [3] Fetal alcohol syndrome is most prevalent in children adopted from Eastern Europe. [3]

Developmental, psychological, and behavioral issues

International adoptees also can be expected to exhibit developmental delays, since the developing brain is sensitive to early insults, such as severe maternal malnutrition and neglect in the first year of life. Alcohol, in particular, is a direct toxin to the fetal brain. Children may look normal, without features of fetal alcohol syndrome, but still be profoundly compromised. Also, life in an orphanage causes 20%-33% developmental delay, especially in speech (T. Ochs, MD, unpublished data, 2004).

Furthermore, the longer a child lives in an orphanage, the more likely he or she is to suffer developmental, emotional, and behavioral problems that can be especially challenging for new families. Creating and maintaining emotional attachments can be difficult for previously neglected children who have been forced to turn inward for comfort. Reactive attachment disorder may occur after severe emotional neglect and multiple caretakers, without one becoming a surrogate parent. These children may act like angels outside the home and like demons with their adoptive families, and consequently, nobody believes the parents' horror stories. Also, autistic spectrum disorders are not uncommon in this population. Children with self-stimulating behaviors (eg, rocking or head-banging) need immediate evaluation. In addition, all adoptees may have symptoms of post-traumatic stress disorder when they are removed from familiar surroundings.

Remarkably, the vast majority of international adoptees do quite well in their new families within a few months, despite initially demonstrating developmental and relational deficits. In some children, however, difficulties may remain over longer periods or worsen.

Internationally adopted children also may suffer from inherited psychiatric disorders that typically are unknown to the adoptive parents, who are given little or no medical and psychiatric history of the child's biological family.

Immunization concerns

Immunizations may or may not have been given, even if appropriately recorded. Also, efficacy of administered vaccines is debatable due to host and storage concerns. These factors make orphanage vaccine records unreliable, although South Korean and Central and South American records are the most likely to be valid. If the immunizations noted in the record look valid, and 2 doses of a specific vaccine were given, the last at least 6 months ago, immunization titers may save repeated vaccines.

Repeating immunizations is also a reasonable choice. Pneumococcal conjugate vaccine (PCV7), Haemophilus influenzae type b (Hib) vaccine, and varicella vaccine are not commonly listed on adoptees'  immunization records, and rubeola vaccine is often given at less than 12 months of age. Also, a rubeola vaccine may not include rubella. Even in children with positive immunization titers, a booster dose of vaccine may be indicated.

BCG vaccine is almost always given to orphanage children, but is, unfortunately, not completely effective in preventing tuberculosis infection. However, the PPD (purified protein derivative) relies upon an appropriate cellular-mediated immune response, which may be adversely affected by malnutrition. For this reason, placing the PPD may be delayed for a couple of months, or, if given at the initial exam, should be repeated in 6 months. A fresh BCG scar means that the PPD can be delayed for 6 to 12 months. A positive result is greater than 10 mm of induration, in which case the previous history of BCG vaccination must be disregarded. [4] A chest x-ray and appropriate treatment must follow.

Recommended screening tests

Laboratory results included in adoption referrals vary in reliability, since laboratories in developing countries are not regulated as tightly as those in the U.S. Multiple patients getting stuck with the same needle may test negative for hepatitis B or HIV in the country of origin, but yield a positive serology in the U.S. It is recommended that these tests be repeated 6 months after initial testing in the U.S. See Table 1 for a complete list of recommended screening tests for international adoptees. [4]

For adopted children who may have developmental delays and are under 3 years of age, a referral can be made to the Early Intervention program for free evaluations and free or low-cost therapy. For older children, the public school system is obligated to do educational evaluations and interventions. Private therapy is often indicated as supplemental or complementary to school services. Resources related to international adoption services are listed in Table 2.

Conclusion

Upon arrival to the U.S., internationally adopted children must be screened for a number of infectious diseases. This is important for the health of the adopted child, the new family, and the community. Pediatricians also need to appreciate the complex physical and emotional challenges faced by these children. Then, it is possible to arrange appropriate evaluations and care for the potential medical, developmental, psychological, and behavioral concerns specific to international adoptees.

REFERENCES

[1.] U.S. Department of State: Immigrant visas issued to orphans coming to the U.S. Available at: http://travel.state.gov/orphan_numbers.html. Accessed June 11, 2004.

[2.] Aronson J. Update on HIV in internationally adopted children. Presented at: Annual Conference of the Joint Council on International Children's Services; 2002; Washington, DC.

[3.] Johnson D. Data presented at: Annual Conference of the Joint Council on International Children's Services; 2003; Washington, DC. Also presented at: North American Council on Adoptable Children; 2004; Minneapolis, MN.

[4.] American Academy of Pediatrics. Report of the Committee on Infectious Diseases. 2003 Red Book. 26th ed. Elk Grove Village, IL: AAP; 2003.