Few experiences in medicine can be more professionally and personally rewarding than a child's first visit to your office. For some parents, however, the route to your practice may not be a traditional or typical one. Last year, over 13,000 children¹ arrived in their physician's examination room through a process that included a home study conducted by a social worker, fingerprints checked by the Federal Bureau of Investigation, mountains of paperwork, the intimidation of a foreign bureaucracy and difficult, indeterminate periods of waiting.

Quarles and Brodie point out in their article in this issue of American Family Physician² that international adoptions are booming. The number of children from abroad who are adopted into American families has more than doubled since 1992.¹ Therefore, it is likely that most family physicians will care for one or more international adoptees. Moreover, international adoptees require different medical care than that needed by children born in the United States. Most international adoptees do not fit the stereotype of a starving orphan. The smiling, chubby appearance of the child you examine offers few visible reminders of the spectrum of problems that may exist. Therefore, before you act, consider how medical care should be modified for these children. Asking the questions “how,” “where,” “why,” “when” and “to what extent” will help you remember how care for a child adopted from abroad should differ from care given to his or her family.

How?

The answer to how a particular child came to be adopted is both simple and complex. Obviously, the child arrived in the family through adoption, but the process of adoption differs significantly from the experience of having a birth child—not necessarily better or worse, just different. Each family has a story; take time to hear it. Was this their way to resolve a problem with infertility? What is their view of the child's country of origin? How do their extended families feel about the adoption, etc.? Acknowledging these differences and valuing their experiences will enhance your standing with the family. More importantly, these details will help you appropriately advise them throughout their adoption experience.

Where?

A child arrives from both a country and a care environment. As a general rule, countries with a high per capita income have good health care for children. Adoptees from these countries typically bring with them accurate medical records, up-to-date vaccinations, and a history of good growth and normal development. However, medical information, immunization records and the general health status of a child are suspect when the child is arriving from a country that has difficulty providing the minimum requirements of health for their people. While the child now resides in a community where tuberculosis, hepatitis B, syphilis and intestinal parasites are uncommon, the child might have been exposed to these problems before his or her arrival. Because disorders that are commonly encountered in international adoptees rarely present with visible manifestations, all of these children—no matter how healthy they appear—require appropriate laboratory evaluation after they have been placed in their adoptive homes.

Before arriving in the United States, a child will usually have been cared for either in a foster home or in an institution (orphanage or hospital). Foster care generally provides a superior environment where growth and development are often on par with that of children in birth homes. Institutions are the worst of all environments for infants and young children and, unfortunately, are the sites where care is provided in countries that place two out of three international adoptees.¹ A low caregiver-to-child ratio and the lack of a consistent caregiver's individualized care lead to delays in speech acquisition, attachment, and the development of social skills and growth.

Why?

Most international adoptees were abandoned at an early age because of the economic strain or social consequences of keeping the child. However, a substantial number of children become eligible for adoption when parental rights are terminated because of neglect or abuse. Emotional and nutritional neglect as well as physical and sexual abuse are the constant companions of poverty, mental illness, alcoholism and drug dependence. Help your families recognize the inevitable emotional consequences of these experiences and obtain appropriate treatment.

When?

While most families prefer to adopt newborns, regulations imposed by placing countries often delay referral of children until after the first or second year of age. Normal brain development requires both an intact genome and appropriate environmental input during early life. We would not expect normal development in a child who has a deletion in their genome, and we would not expect normal development in a child with “environmental deletions.” The greater the deficit in genome or in appropriate environmental stimuli, the more problems we observe.

Consequently, no child who has spent his or her first years in an orphanage or a hospital will be completely normal. While optimism is appropriate because of the tremendous resilience shown by most children, helping parents develop realistic expectations of a child who has been in an institution, ensuring appropriate evaluation of suspected problems, and identifying and coordinating effective therapeutic interventions are of immeasurable aid to families who have adopted these at-risk children.

To What Extent?

Parenting a child from another country is a lifelong commitment. Encourage families to be involved with local and national adoptive parent support groups. Adoptive families benefit from hearing how other parents deal with prejudice in transracial adoption, answer questions from their child regarding their adoption and their birth parents, and handle transitional issues during adolescence. Inform your families about culture camps where adoptees can gain appreciation of their culture and develop pride in their country of origin. Adoptive Families of America (800-372-3300) maintains an extensive listing of local parent support groups and parenting resources. Finally, remember that all members of the family share the benefits and burdens of adoption. Nothing is more troubling than to see relationships disrupt because of unrecognized and untreated psychologic needs brought about by the stresses inherent in adoption or the challenges involved in parenting a child who was institutionalized.

Appropriate medical care for international adoptees involves more than a single visit to a physician's office. It is a partnership between you and the family that extends beyond an initial assurance that a child is free from organic illness. Family physicians are well suited to provide comprehensive family-centered care that is critical for many families who have adopted children from abroad. Counseling adoptive families and caring for their children has been one of the highlights of my career and can be for you as well.