to the editor: The recent article by Drs. Quarles and Brodie¹ provides an excellent overview of the issues that the families of internationally adopted children must face. Dr. Johnson's editorial,² appearing in the same issue, sheds further light on the trends in international adoption. He notes that 13,000 children were adopted from overseas in 1997. This year, the United States has become home to nearly 16,000 additional international adoptees.³ Family physicians will be called on to contend with some of the significant issues presented by these children.

We recently concluded a study that examined the behavior and emotional issues of 105 children who were adopted from the former Soviet Union. Our community-based study recruited subjects from adoption agency placements, as opposed to a clinic population, to depict the integration of these children into their adoptive families at least two years after placement.

A major issue encountered by the majority of families is that of speech and language problems. Drs. Quarles and Brodie propose that the children be referred to English as second language (ESL) services at subsequent visits. ESL is based on the assumption that first language ability is intact. In our study, 56 percent of the children had speech and language difficulties; other studies support similar findings.⁴ Our research suggests that, rather than ESL services, these children need speech evaluation in their native language, if possible. The availability of such evaluation is variable and seems to depend on the number of internationally adopted children in a given area.

Many factors contribute to the high incidence of speech and language problems in these children. Although a genetic predisposition to speech and language problems may exist, family histories of adopted children are typically unknown. Poor prenatal care and substandard perinatal conditions are common in the countries of the former Soviet Union and contribute to speech and language difficulties. Indeed, the most frequently cited reason for children to be placed in an Eastern European orphanage is abandonment by a single parent who is unable to provide for herself or an infant. Another contributing factor to speech and language disorders is fetal alcohol exposure.⁵ In our sample group of internationally adopted children, the adoptive parents reported (based on information from orphanage records) that 41 percent of the children had birth mothers with histories of alcohol abuse.

Normal language development also requires environmental input to flourish. The orphanages of Eastern Europe have been described as colorless and quiet, with little visual or auditory stimulation.⁶ With child-to-caregiver ratios as high as 30 to 1, the orphanage represents an environment of auditory deprivation, further increasing the risk of speech and language disorders.

Internationally adopted children are often unskilled in their native languages. A child arriving in the United States from Russia is typically monolingual, speaking only in Russian. After several months, the child is monolingual again, this time speaking in English. A child between four and eight years of age will lose the majority of expressive Russian speaking skills within the first few months of living in the United States. Eventually, receptive language will disappear. Thus, the primary language is rapidly extinguished and replaced by English. This initial success in the acquisition of a new language may lead to a false sense of security. Unfortunately, a seemingly smooth mastery of conversational English does not automatically guarantee proficiency in the cognitive and academic aspects of language; these aspects of language become increasingly important as the child enters school. In short, family physicians should not hesitate to refer internationally adopted children for speech and language evaluation.

Multiple resources are available on the Internet to assist adoptive parents in facing the challenges they may encounter. A good place to start would be our Web site, which is devoted to research in international adoption (http://www.adoption-research.org).

in reply: We would like to thank Drs. McGuinness and McGuinness for their response to our article¹ regarding the importance of vigilance in the evaluation of international adoptees for speech and language abnormalities. Information collected from adoption clinics evaluating children from Romania, Eastern Europe and the former Soviet Union indicate that up to 85 percent of these children will have some form of developmental abnormality, and this is especially profound in very young children who come from institutions.^2,3 Family physicians are likely to have the opportunity to care for such childern as more immigrate to the United States. We agree that developmental problems, including speech and language difficulties, are frequent challenges for adopting parents, the children and their physicians.

The impact of institutionalization, environmental deprivation and toxic exposures on the development of speech and language cannot be minimized. However, records from orphanages in these countries frequently depict ominous diagnoses and histories that are sometimes inaccurate.³ We agree with the recommendations of Albers and colleagues³ to consider children who come from such environments as children with “special needs” and to aggressively work to help them meet their developmental potential.

We did not mean to imply that training in English as a second language (ESL) is the answer to identification or treatment of speech and language challenges in these children. For most adoptive parents, gaining access to speech evaluation in the child's native language is difficult, but if available, identification and treatment of language challenges may occur earlier. Many adoptive parents want their children to learn English, and for children without suspected or identified speech and language deficits, ESL services can be invaluable. Early intervention programs for very young children and early identification of older children who lack proficiency in “cognitive and academic aspects of language” are key to the future of these children. Clearly, country of origin is a risk factor, and certain countries should mandate rallying whatever resources are available to ensure optimal speech and language development for these children and their families. Thanks to Drs. McGuinness and McGuinness for underscoring these points.