Approximately 50% of adopted infants born in the United States are adopted without agency assistance. Most of these are open adoptions to some degree, with varying degrees of contact maintained among the birth parent(s), adopted child, and adoptive parents. Fewer than 50% of domestic adoptions are infants; the rest are older children and children with so-called special needs (Stolley, 1993). Children with special needs make up about 25% of domestic adoptions. These children may have disabilities, serious medical conditions, or psychological problems. They also may be older (over age 5), part of a sibling group, or members of a minority group (National Committee for Adoption, 1989).

At any one time, approximately 500,000 children are in foster care in the United States. Many more children are available for adoption than actually are placed. Children in foster care generally are more difficult to place than infants. Reasons for this include older age, race, the presence of sibling groups, a history of maternal substance abuse and neglect, or a history of long placement in foster or multiple homes. The average length of stay in foster care before adoption is 4 to 5 years. Approximately 90% of children adopted from foster care are adopted by their foster parents, a few of whom are biologic relatives. Thus, these children may have had long relationships with their adoptive families (Adoption Medical News, 1996).

About 15,000 children are adopted from other countries each year. Most are infants, with very few of them younger than 4 to 6 months old. Despite constant challenges due to changing economic and political factors and abrupt closings and openings of adoption programs, the number of international adoptions has risen every year and probably will continue to increase. At the same time, the countries of origin for most of these children have changed almost completely. In 1989, the most common country of origin was Korea, followed distantly by Colombia, India, the Philippines, and Chile. In 1998, the two most common countries of origin were Russia and China, followed by Korea and more distantly by Guatemala and Romania (Personal Communication, Immigration and Naturalization Service and U.S. Department of Justice, 1999). In general, children now are most likely to come from Eastern Europe and the former Soviet Union, East Asia, and Central and South America, with smaller numbers from Southeast Asia, India, and Africa. This mix probably will continue to change. On the whole, children adopted from abroad are more likely to come from very poor developing countries than they were a decade ago. They often have experienced prolonged institutional care, with limited access to good nutrition and medical care.

The number of children adopted from Russia and Eastern Europe was small until 1992, but increased steadily over the next several years. This region has now become the most popular area for adoption. These children are more likely to be older infants or toddlers. Virtually all have been in institutions for some time (often for long periods) before placement. These youngsters may be part of sibling groups. One of the most challenging aspects of adopting children from Russia and Eastern Europe is the frequency of abandonment
and maternal alcohol abuse. In one study of children adopted from Eastern European orphanages, maternal alcoholism was listed in 17% of referral documents, while fetal alcohol syndrome (FAS) was found in 2.4% of referrals (Johnson et al., 1996).

The number of children adopted from China was small until 1993 to 1994. Since then, adoptions have increased rapidly, largely because of abandonment resulting from China’s one-child policy, rather than social or medical issues. Almost all Chinese children available for adoption are girls. Their health usually is quite good, largely because of early placement with adoptive families. Since reorganization of the Chinese adoption system in 1997, however, children have been slightly older on arrival and may have more problems related to longer periods in large orphanages. These problems may include developmental delay (generally transient, with resolution seen sometime after placement) and attachment disorders due to institutionalization. Parents must be older than 30. They may be single (although single men must be over 40). Older parents must be willing to accept older infants and toddlers.

Adopted children have come from Korea for many years and generally have been healthy. The number of children available from Korea, while higher prior to the early 1990s, has remained in the range of 1600 to 1800 per year (U.S. Immigrations and Naturalization Service). Korea has a high standard of living and excellent medical care, and the children often have quite complete accompanying medical records. Children are cared for in foster homes or orphanages and may be normal developmentally except for some gross motor delay from being carried on the backs of caretakers. This “piggybacking” is a cultural norm for Korean child raising.

If the parents are considering adoption because of infertility, acceptance of their infertility and the loss of a biologic relationship with their child is essential. Usually this means that they have stopped fertility treatments. Some adoption agencies require that parents have not just stopped treatment, but also are using birth control.

Some parents express an interest in adopting a child with a medical problem or fall into a group likely to be offered a child with special needs (eg, older parental age or single marital status). Such individuals must consider carefully the lifelong implications of such a placement and their ability to meet that child’s needs. Parents should evaluate honestly their feelings and abilities, recognizing that adoption involves a great deal of uncertainty and that problems may be either better or worse than described in referral documents. The clinician should be as objective and supportive as possible and prepared to describe the range of problems that parents may encounter.

Parents who want a healthy child should never feel pressured to adopt a child who has a problem that they cannot handle. Having the parents review a special needs checklist (Display 6-1) may be an extremely useful starting point for discussion about children with special needs. This checklist also can assist the provider in gauging the parents’ understanding of the risks of adoption.

Most children from abroad are of a different racial or ethnic background than parents who are adopting. Parents need to consider carefully such differences. If parents are planning an interracial or international adoption, unresolved feelings about infertility may come painfully to the foreground after the adoption is complete. The parents may be the recipients of many embarrassing, intrusive, and even offensive questions if the child obviously is not biologically related (eg, of a different skin color). Complete strangers may feel entitled to discuss the parents’ infertility without invitation and to question the parents’ relationship to their child.

For many reasons, adoptive parents frequently express a distinct preference for adopting a boy or a girl. This may
limit their options to some degree, and the provider may need to discuss gender and race preferences.

Because these adoptions usually are open to some degree, substantial information may be available about biologic and family history, pregnancy, and delivery. The birth mother usually (but not always) has received adequate prenatal care. Medical problems typically have been identified. A western-trained clinician almost certainly will have examined the child, and the results of that examination are known. If the placement occurs at birth, however, congenital anomalies may not yet have been detected.

These children are likely to have been in some kind of temporary placement and tend to be older, because toddlers rarely are available for adoption. Their basic nutritional needs probably have been met, and they most likely have had some past medical care. Medical records frequently are available, although they may be incomplete. Any handicaps probably are being treated. Most North American-born adoptees either are healthy or have defined diagnoses with accompanying information.

These children may have had some level of comfort and affection if they only had one or two placements in foster homes. Some children, however, have been in many foster homes or are isolated from biologic family members, including siblings. They may have a history of abuse or neglect and may be quite emotionally troubled.

These infants rarely are newborns. They may be younger than 6 months but usually are closer to 1 year old. They may have medical problems, such as poor nutrition, restricted growth, parasite infestation, lack of medical care, and incomplete or absent immunizations, as well as adjustment problems resulting from institutional care. They may have experienced extreme poverty, only slightly improved by orphanage care, or may come from a background of abandonment and significant alcohol or other substance abuse. These children usually have no available family history or medical records.

In addition to the problems infants from abroad may experience, these children may have endured more prolonged periods of abuse, neglect, and institutionalization. They may have had little or no schooling and some period of street life. On the other hand, they may have received relatively good care. Living conditions can range from small foster homes (or the child’s own family) to crowded, poor orphanages.

The following are some medical and social issues that may be encountered in U.S.-born adopted children, with which the provider should be very familiar:

The problems parents can anticipate in children from other countries differ in many ways from those of children born in the United States. Although the number of internationally adopted children is fairly small, these children often have medical problems that are unfamiliar and challenging to western providers.

Parents who seek their clinician’s opinion about a child just placed with them may have few records or brief videotapes to view. They rarely have enough information to make truly informed decisions. Medical information provided may be difficult to interpret or wrong, but the provider should advise parents never to ignore a diagnosis made in a foreign country. The provider should look carefully for clues in the referral papers or videos to substantiate any listed diagnoses. It is especially important to look for objective findings that cannot be attributed to prolonged institutional care.

Parents have the right to obtain as complete information as possible and should not immediately accept a referral without further inquiry. Minimally, they should get a date of birth (or estimate), current measurements (height, weight, and head circumference), the results of a recent physical examination, and an estimation of the child’s developmental progress.

A child adopted from abroad may have an assigned birth date estimated by the adoption workers in that country. If the child is an infant, the assigned date usually is accurate enough for evaluation of growth and development. Occasionally, an older child will have a birth date that appears suspicious because the child is small for age. The opposite also may occur; a child may appear to be of appropriate size for age, but is in fact older and small. Such problems occur because of a deliberate underestimation or under-reporting of age to facilitate placement.

The provider should review what information was used to estimate age, including pregnancy history, measurements at birth, or other physical findings. A short delay in growth in an infant may be due to incorrect gestational age rather than true growth failure. Subsequent measurements can be plotted on standardized growth charts for initial comparison. Korean and Chinese children follow growth curves in infancy similar to U.S. children, even in institutional care; children from the Indian subcontinent tend to be somewhat smaller. Growth charts specific for Korean, Chinese, and Indian children are available from the University of Minnesota International Adoption Clinic, identified in the Community Resources section at the end of this chapter.

Not only do these children come from high-risk backgrounds (abandonment, poverty, alcohol abuse, neglect, physical and sexual abuse, inadequate medical and prenatal care, prematurity, or physical handicaps), but they also may have significant health problems due to prolonged orphanage life. Both parents and provider should look for specific clues from the documents and videos that suggest diagnoses (such as FAS) that will make catch-up unlikely after placement with the family.

Children from abroad may come with specific medical diagnoses that are difficult for the provider to understand because of obscure, unfamiliar terms or use of familiar terms that differ from western practice. This is especially true for children from Eastern Europe and the former Soviet Union. For example, children from Russia may have the diagnosis of perinatal encephalopathy, a term with ominous connotations to western providers. Russian physicians use this term much more loosely to describe a child at risk for neurologic impairment. Likewise, a Russian child may come with findings unfamiliar to western providers, such as oligophrenia or intracranial hypertension syndrome.

One of the most difficult situations in which adoptive parents find themselves is the referral of a child with an obscure, frightening diagnosis accompanied by incomplete information. If the child has a serious or frightening diagnosis, the report should include the physical findings or laboratory results leading to the diagnosis. It also should include a description of what the child can do and how the child compares with other children of the same age. It may be helpful to send the referring agency a list of developmentally related questions that can be answered with “yes” or “no.” The parents should take time to investigate, obtain consultations, and talk with other families with similar referrals. If they still have substantial worries after adequate time to reflect and research or if they feel pressured to accept a placement that they think they cannot handle, they should consider saying no.

Adoptive parents dread this event above all else. They probably have waited a long time for this referral and already feel a bond with the child in the tiny photograph or brief video. They feel guilty about “rejecting” this child and worry that it will jeopardize their chances for another referral. The provider can help the parents by reframing the discussion in terms of what is best for this child, including the possibility that another family may have more resources to handle this problem.

Parents may be offered the opportunity to test the child for specific medical conditions, such as hepatitis B and human immunodeficiency virus (HIV), before placement. They may ask the provider for advice about the interpretation or desirability of such testing, as well as the long-term implications of these conditions.