International adoption: Health evaluation of the international adoptee

Introduction

International adoptees new to Canada have unique challenges and needs, and their health issues are often complex. In many cases, they arrive without a prenatal, birth or family history, and their real birth date is often unknown.  Their ‘life story’, including experiences before and during orphanage or foster care, is usually unclear.  Their life trajectory may well include fetal stress, a difficult early life, trauma, malnutrition, recurrent illness and hospitalization. All international adoptees have experienced abandonment and, probably, multiple breaks with an attachment figure.  Some children will have encountered psychological trauma, or physical, sexual or emotional abuse. They may have witnessed violence, especially if they arrive from war-torn countries. Potential risk factors for international adoptees are also discussed on the page Preparing to Adopt.

One-half of international adoptees have an acute illness within a month of arriving in their new home. In about 80% of children with at least one medical illness, the new diagnosis is suggested by screening tests, and was not evident from prior histories or physical examinations.^1,2 Their countries of origin are often endemic for infections that are seldom seen in Canada.

Families may choose to adopt a child with a physical or intellectual disability.  Physicians may need to build awareness—their own and the adopting family’s—around disabilities which may be connected to other, as yet unidentified, congenital defects or malformations or part of an associated genetic syndrome.

Because of multiple risk factors, all international adoptions are “special needs” adoptions.  Infections and malnutrition can usually be treated quickly and effectively, although malnutrition may have longer-term effects (e.g., cognitive and behavioural challenges such as ADHD or problems with school learning). Psychological trauma, disrupted attachment and learning difficulties will require nurturing from adoptive parents, as well as focussed supports and time to improve.

Assessment and screening

Whenever possible, international adoptees should be referred to an international adoption clinic or to a physician with expertise in this area. Their first visit should be planned for 2 to 4 weeks after arrival.  Advise adoptive parents to call earlier if the child shows signs of infection or physical or emotional distress.

Key components in an initial assessment

• Review pre-adoption documents and vaccination records
• Take a history:  Record adoption, transition, travel and initial home experiences in detail
• Conduct a physical exam
• Screening tests
  • Laboratory tests
  • Audiology, dental, vision
  • Developmental
  • Behavioural

Review pre-adoption documents and vaccination records

• The clinician should review all information and supporting materials given to adoptive parents at the point of the adoption, which may (or may not) include recent growth parameters, a description of illnesses or hospitalizations, and vaccination records. In some cases, international adoptees arrive with almost no documentation. Occasionally, records showing daily routines, photos and the names of previous caregivers are provided.
• Clinicians should carefully review immunization records, if available. Be mindful that any newcomer child’s vaccination records may be unreliable and inconsistent with Canadian schedules.² For more information, see the section Immunizations: Bringing Newcomer Children Up-to-date.
• Health care providers should also make sure that all caregivers and family members have been fully immunized before travelling to the child’s country of origin.  For more information, see the section International Adoption: Helping parents prepare for travel. 
• Note that any visitor to the new home within 60 days of the child’s arrival in Canada should receive Hepatitis A vaccine.

The American Academy of Paediatrics has a detailed list of topics to review when taking a medical history of an international adoptee.³

Take a history: Record adoption, transition, travel and initial home experiences in detail

Consider asking adoptive parents the following questions:

• Did the family travel to meet the child? Did both parents travel? Did other children make the trip?
• How did the child make the transition to the parent’s care (e.g., was there preparation or an immediate transfer of care)?
• How long did they stay in the child’s home country?  How many visits and trips?
• How was the first encounter with the child? How was the first 3 days, the first week?
• Did the parents meet any of the child’s caregivers or biological family?
• Was the child ill? Did any family members become ill during the trip?
• Since being in the adoptive home, how is the child doing?
• Is the child exhibiting any behaviours that concern the parents?
• How many caregivers are in the home? Are the parents taking time off work? If so, for how long?
• Are there siblings in the home? Are they adopted?
• Is the child sleeping well? Adapting to the time change? What are the child’s sleeping arrangements?
• Is the child exhibiting self-stimulating behaviours?
• Is the child eating well? Learning to chew? Hoarding food?

Conduct a physical exam

Approaching the newly adopted child needs time, care and patience. If there is a language barrier, the help of an interpreter can be enlisted with older children. Examination of the genitalia may have to be done during a subsequent visit.  If the child seems very frightened or reluctant, a history of abuse or mutilation should be suspected.

Screening tests

Children are sometimes asymptomatic when carrying an important infection. For example, a child with hepatitis A may not be jaundiced or have only flu-like symptoms, or may have no symptoms at all, yet be very contagious.⁴ Cases of transmission from infected international adoptees to their adoptive families have been reported for hepatitis A, hepatitis B, tuberculosis and measles. It is very important that all immediate family members and prospective caretakers be immunized appropriately before the child arrives. Visitors to the home within the first 60 days should also be immunized against Hepatitis A.

The newcomer child who is adopted may appear quite well at arrival.  However, up to 50% of international adoptees have a medical condition, and about 80% of these conditions will only be identified by screening. All international adoptees should have, at a minimum, the tests listed below.

Laboratory tests

• Complete blood count
• Hemoglobin electrophoresis (any child with microcytic anemia or risk of sickle cell disease)
• G6PD (especially if the child comes from Asia or  Africa)
• TSH
• Creatinine
• AST, calcium, phosphate, alkaline phosphate
• Na, K, glucose
• Vitamin D level
• Lead level (read more about screening for lead in children new to Canada)
• HIV * (read more about HIV/Aids and children new to Canada)
• Hepatitis A IgM/IgG
• Hepatitis B * HBAg, anti-HBsAg
• Hepatitis C *
• Syphilis (VDRL/RPR)
• Strongyloides serology (children from Africa, South East Asia)
• Schistosomiasis serology (children from Africa)
• Urinalysis
• Stool O & P x3
• Quantiferon Gold* test (over 2 years) or Mantoux* testing (read more about tuberculosis and children new to Canada).
• Chest x-ray if clinically indicated

* Repeat 6 months after arrival

Initial findings from a screening test, such as eosinophilia, will require more specialized testing.² Referral to a paediatric infectious disease specialist may be required.

Testing for tuberculosis is recommended for all international adoptees, and should be done at arrival and again after 6 months to capture infection status just before emigration.  See the section on Tuberculosis for details.

Children with a disability should be referred to a multidisciplinary clinic for comprehensive evaluation (e.g., a specialized cleft palate, cardiology or neurology clinic). The family’s physician should also evaluate the parents’ support network, to ensure that they have access to and can seek help as needed.

Determining a child’s age

Questions may arise with respect to an adopted child’s actual date of birth. In children <1 year, a difference of a few weeks or a few months will not be critical in the long term. For older children, age determination is more important, especially with respect to placement in school and eligibility for special education services. Uncertainty about a child’s age may also lead to mistaken attribution of precocious puberty.

There are no accurate or reliable tests for age determination.  A history of malnutrition and deprivation can skew standard measurements, including radiographic bone age and dental eruption. There are also differences in pubertal development among ethnicities.

It is usually best to delay revising a birth date until at least 12 months after adoption, to allow for catch-up growth as well as longer observation of a child’s physical and emotional development.⁵

Developmental assessment

While developmental delays are common in newly arrived children, most catch up rapidly. Language delays may persist for a longer period.  More information about language acquisition is available in this resource. Most adopted children do well, but a subset of IAs arrive with complex emotional and neurobehavioural needs.

Neurodevelopmental or learning disorders are more prevalent in international adoptees than in the general population, particularly sensory integration disorder, dyspraxia, as well as language, attention, and executive function disorders. Attention-deficit and hyperactivity disorder (ADHD) is present in 10% of children adopted from China.

The International Adoption Project, a partnership with the University of Minnesota’s International Adoption Clinic, reported survey results for 2500 families on pre-adoption risk factors and post-adoption outcomes. The study assessed school success and adjustment issues over a 9-year period, using the following pre-adoption risk factors:

• Prenatal alcohol or drug exposure
• Prenatal malnutrition
• Premature birth
• Physical neglect
• Social neglect
• Physical abuse
• 6 months or more in an orphanage, baby home or hospital.

Most children did well:

• 78% of adoptees with ≤3 risk factors were doing well in school
• 50% of children with 4 to 5 risk factors were having difficulties
• ≥4 risk factors were related to post-adoption emotional or behavioural adjustment issues
• Age at placement and the number of risk factors were also highly correlated. Children placed in their adoptive home after 24 months of age had the highest number of risk factors.

It is important to screen for developmental delays from the time of adoption, using a validated tool that the health care professional is familiar with.  Screening with the ASQ (Age Screening Questionnaire) or the DDST (Denver developmental screening test) should be done soon after  arrival, repeated at 6 months and again one year after arrival.

Initial testing may be hampered by language difficulties or the clinician’s own unfamiliarity with the test. Early scores should not be used as predictors of later function but rather, as a starting point for later comparison. Providing a timely referral for age-appropriate therapy, such as physio or a speech and language pathologist, can be critical for building skills and confidence.

Behavioural assessment

While transitioning to their new life, adopted children often exhibit behaviours related to adjustment, such as grieving, sleep disturbances and feeding issues.  Health professionals can provide anticipatory guidance and support to families concerning these and other behaviours. See also:
International Adoption: Enhancing Attachment Between Adoptive Parents and Children
International Adoption: Tools and Resources.

Most children thrive in the nurturing environment of their adoptive home. However, it is important for families and health care providers to remember that all AIs have experienced some measure of trauma and abandonment.  Many children have had to cope with multiple breaks with caregivers or  with emotional, physical or sexual abuse. Some have difficulty recovering from these experiences.  Children may also have witnessed violence.  Whether these experiences occur in early childhood or later, they are likely to disrupt attachment to some degree. Over time, some children must wrestle with low self-esteem, school problems and oppositional behaviour, difficulties that may compound in adolescence. Remember too, that adoptive parents may have their own grief and losses, which sometimes include their initial expectations or motivations for adopting a child. This will impact their parenting and may need to be further explored.

Identifying trauma

When taking an early history for an IA child, the American Academy of Pediatrics recommends assessing for trauma:⁶

 Characteristics of attachment disorder

Adoptive parents are often reluctant to mention concerns about attachment, or they may not be able to verbalize their feeling that “something is awry in the post adoption process”.⁷ It is therefore up to the health professional to ask specifically about the behaviours listed below, and to arrange counselling for both child and family as appropriate.⁷

• Superficially engaging and charming behaviour
• Indiscriminate affection toward strangers
• Lack of affection with parents on their terms (not cuddly)
• Little eye contact with parents
• Persistent nonsense questions and incessant chatter
• Inappropriately demanding and clinging behaviour
• Lying about the obvious
• Stealing
• Low self-esteem
• Destructive behaviour toward self, others or material things
• Abnormal eating patterns
• No impulse control (may be misdiagnosed as ADHD)
• Lags in learning
• Abnormal speech pattern
• Poor peer relationship
• Lack of conscience
• Cruelty to animals

A minority of children have a severe reactive attachment disorder (RAD), with symptoms listed below. The impact of this disorder on both child and family should not be underestimated and appropriate supports and counselling must be put in place as soon as possible.

The specific DSM-5 diagnostic criteria for RAD are as follows:

• A consistent pattern of inhibited, emotionally withdrawn behaviour toward adult caregivers
• A persistent social and emotional disturbance
• A pattern of extremes of insufficient care
• The care described in the third criterion is presumed to be responsible for the disturbed behaviour described in the first criterion
• The criteria for autism spectrum disorder are not met
• The disturbance is evident before age 5 years
• The child has a developmental age of at least 9 months

Another form of attachment disorder is known as disinhibited social engagement disorder (DSED).

The specific DSM-5 diagnostic criteria for DSED are as follows:

• A pattern of behaviour in which a child actively approaches and interacts with unfamiliar adults in an impulsive, incautious and overfamiliar way
• The behaviours described in the first criterion are not limited to impulsivity but also include socially disinhibited behaviour
• A pattern of extremes of insufficient care
• The care described in the third criterion is presumed to be responsible for the disturbed behaviour described in the first criterion
• The child has a developmental age of at least 9 months

Approaches to treatment for both these disorders are complex and should be done by a qualified team. Family support is essential.

Long- term follow-up

International adoptees are usually highly resilient and will, over 1 to 2 years, show significant catch-up growth. They learn the language of their adoptive parents and adapt to the environment and eating practices of their new community.

Health care professionals working with these children and their families need to be aware of common vulnerabilities and to support families by listening to, recognizing, understanding, and empathizing with their ownand their child’s needs. The health care professional can help families learn that parenting an international adoptee often requires uniquely personal approaches.⁸

During primary care visits, monitor a newcomer child’s development and behaviour, as well as assess parent stress and parent–child interactions routinely and systematically. Be sure to access appropriate services for both child and family if needed.

Selected resources

• American Academy of Pediatrics and the Dave Thomas Foundation for Adoption. 2013. Helping foster and adoptive families cope with trauma:
  www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Guide.pdf
• American Academy of Pediatrics. Red Book: 2012 Report of the Committee on Infectious Diseases. Pickering LK, ed. 29th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2012.
• Canadian Paediatric Society. Caring for Kids New to Canada: International Adoption: Tools and Resources.
• Public Health Agency of Canada. Committee to Advise on Tropical Medicine and Travel (CATMAT). Statement on international adoption. CCDR 2010;36(ACS-15):1-17.
• Canadian Collaboration for Immigrant and Refugee Health. Evidence-based Preventative Care Checklist for New Immigrants and Refugees:
  www.ccirhken.ca/ccirh/checklist_website/index.html
• Rutter M, English and Romanian Adoptees (ERA) Study Team. Developmental catch-up, and deficit, following adoption after severe global early privation. J Child Psychol Psychiatry 1998;39(4):465-76.

References

1. Hostetter MK, Iverson, S, Thomas W, et al. Medical evaluation of internationally adopted children. NEJM 1991; 325: 479-485.
2. Public Health Agency of Canada. Committee to Advise on Tropical Medicine and Travel (CATMAT). Statement on international adoption. CCDR 2010;36(ACS-15):1-17.
3. Jones VF, Committee on Early Childhood, Adoption and Dependent Care. Comprehensive health evaluation of the internationally adopted child. Pediatrics 2012;129(1): e214-23.
4. Eckerle JK, Howard CR, John CC. Infections in internationally adopted children. Pediatr Clin North Am 2013;60(2):487-505.
5. Chicoine JF, Germain P, Lemieux J. L’enfant adopté dans le monde en quinze chapitres et demi. Éditions de l’hôpital Sainte-Justine, Québec 2003.
6. American Academy of Pediatrics and the Dave Thomas Foundation for Adoption. 2013. Helping foster and adoptive families cope with trauma:
   www.aap.org/en-us/advocacy-and-policy/aap-health-initiatives/healthy-foster-care-america/Documents/Guide.pdf
7. Miller L. The Handbook of International Adoption Medicine. London, New York: Oxford University Press, 2004.
8. Weitzman C, Albers L. Long-term developmental, behavioral, and attachment outcomes after international adoption. Pediatr Clin North Am 2005;52(5):1395-419.