A parent brings her 9-year-old child whom she recently adopted from foster care to your office. The child is on multiple medications for asthma, and mom is concerned about some behavior issues. Later that day, your office partner sees an internationally adopted toddler for the first time. The child had cleft lip surgery at age 4 months but has not yet had her cleft palate repaired. She has had chronic ear infections and is malnourished and developmentally delayed.
These clinical scenarios have become commonplace in the world of adoption, as many adopted children have multiple health care needs. An updated AAP clinical report describes the challenges of caring for this unique patient population and offers pediatricians practical guidance on what the initial health evaluation of these children should include.
The report notes that pediatricians play a vital role in supporting families of adopted children, including counseling parents during the preadoption phase, providing health care for children after adoption and offering resources to help families integrate the adopted child into the family unit.
The report Comprehensive Health Evaluation of the Newly Adopted Child, from the Council on Foster Care, Adoption and Kinship Care, is available at https://doi.org/10.1542/peds.2019-0657 and will be published in the May issue of Pediatrics.
Data from multiple sources indicate that approximately 120,000 children are adopted each year. Most adoptions are domestic or through foster care. Domestic adoptions occur primarily through the national public welfare system or independent adoption agencies.
There has been a marked decrease in international adoptions over the last 10 years, mainly because of changes in the internal policies of several countries and concerns about adoption service provider activities and unregulated practices. China has accounted for the majority of international adoptions.
Challenging histories
Regardless of the method of adoption, children in the foster care system, children adopted through private domestic agencies and those adopted internationally all have an increased incidence of physical, developmental and mental health concerns.
When performing a comprehensive evaluation, it’s critical to keep in mind that all of these children come with a history. Their life prior to adoption may have included prenatal exposure to alcohol or licit or illicit substances, physical or sexual abuse, malnutrition or traumatic events. These issues may be known at the time of adoption or may not become apparent for some time after placement in the adoptive home.
It’s not unusual for parents and other caregivers (child care providers, teachers, grandparents) to want to forget about the pre-placement history because it often is sad or difficult to discuss. Pediatricians can help parents keep the child’s early life experiences in mind, particularly when challenging situations occur.
Thorough exam, screenings
A comprehensive exam should be completed shortly after placement. Ideally, pediatricians should plan for a longer visit than what typically is anticipated for a new well-child visit and could code this as a new patient, problem-based visit.
The exam includes a complete review of the medical history, a thorough unclothed physical examination, laboratory studies to assess for infectious diseases, screenings for hemoglobinopathies and assessment of malnutrition and immunization status. A detailed list of the components of the medical history, physical exam and diagnostic testing can be found in Tables 1-3 of the clinical report. Multiple visits may be necessary to complete all of the components.
Additional screening evaluations to assess hearing, vision, dental health and developmental status should be conducted as well. The pediatrician will want to address any concerns about mental health or behavioral issues.
Lastly, it is important for the family and child to feel supported. Pediatricians should ask about family life, taking into account the feelings of parents, siblings and extended family members. Discussion also should focus on transitions to child care or school. While a newly adopted child brings much joy to a family, the adjustment can be stressful for everyone.
Drs. Schulte and Jones are lead authors of the clinical report. Dr. Jones is a member of the AAP Council on Foster Care, Adoption and Kinship Care Executive Committee, and Dr. Schulte is a former member of the executive committee.
