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Behavioral Outcomes in Internationally Adopted Children
Abstract & Commentary
By Chad Lowe, MD, and Philip Fischer, MD, DTM&H
Dr. Chad Lowe is a resident in the Department of Family Medicine at the Mayo Clinic in Rochester, MN. Dr. Fischer is Professor of Pediatrics, Division of Pediatric and Adolescent Medicine, Mayo Clinic, Rochester, MN.
Drs. Lowe and Fischer report no financial relationship relevant to this field of study.
Synopsis: International adoption is increasingly popular, but there are still concerns about behavioral outcomes in foreign-born adoptees. In a study of 1,948 such children, behavioral problems were more often seen in boys, in children who had been institutionalized, in those who were adopted after 2 years of age, and in children originating from Eastern Europe and Russia.
Source: Gunnar MR, van Dulmen MH, International Adoption Project Team. Behavior problems in postinstitutionalized internationally adopted children. Dev Psychopathol 2007. 19(1):129-148.
While international adoption increases in popularity, many people remain concerned about potential long-term developmental problems in adopted children. Gunnar and colleagues studied nearly 2,000 institutionalized foreign children (defined as having spent at least 75% of their lives in an institution) who were adopted into the State of Minnesota over a 9-year period, and compared their behavior to that of foreign, adopted children who spent little or no time in institutions prior to adoption (less than 4 months). Data were collected from parents who completed a Child Behavior Checklist (CBCL). It was correctly predicted that institutionalization would be associated with increased risk of attention problems, and not with internalizing (withdrawn, somatic complaints, anxiety or depression) or externalizing (delinquency or aggression) behaviors. Data were further analyzed by age of adoption and location of adoption (Russia or Eastern Europe, in comparison to other areas).
Barely half (51%) of institutionalized children were "problem free" (not scoring in any clinically abnormal range) vs 65% of the control (non-institutionalized) group (P < 0.001), and previously institutionalized children were more likely (11% vs 5% respectively, P < 0.001) to show pervasive problems (scoring in the clinically diagnostic range across 5 or more domains). Institutionalization did not predict an increased rate of internalizing or externalizing problems per se; however, older age at adoption (greater than 24 months) was universally associated with increased problems across all domains assessed with the CBCL. A gender difference was noted with boys expressing higher rates of behavior problems than girls. Children from Eastern Europe and Russia also had higher rates of behavior problems than children adopted from other countries.
International adoption is an ever increasing means of creating a family, and thousands of American families do so each year. Media reports depicting the plight of children in poor, developing countries evoke strong emotions, and celebrities publicly discuss their international adoptions in the context of social and political problems of specific countries.
Anecdotal accounts exist of adopted children who, in multiple developmental and behavioral domains, fall significantly behind their peers.It has been estimated that over 80% of the nearly 23,000 children who were adopted into the United States in the year 2003 spent some time in an institutional setting prior to adoption. Gunnar's study shows that slightly more than half of adopted children did not have significant behavioral problems.
Given press reports of deplorable conditions and horrific circumstances some internationally adopted children experience, one might have predicted an even greater number of behavioral problems in institutionalized children. Gunnar's study underscores the resiliency and plasticity of young children, especially under the age of 24 months. Other research has shown that adoption leads to incredible improvements in multiple domains, including physical growth, cognitive development and school performance, and attachment security.1
Counterintuitively, Gunnar's study found that time spent with the adoptive family was associated with increasing behavior problems. It was hypothesized that behavior problems may increase as these children grow older secondary to other factors, such as discrimination associated with race and minority status or lack of coping mechanisms to negotiate increasingly complex peer and social interactions. In addition, adoptive parents may be less likely to believe that problematic behavior is normal as the child grows older. While it is possible that an adoptive family environment may contribute to behavioral problems, many known familial factors that lead to behavior problems, such as poverty and divorce, were not present in the group studied. Other investigations have shown that, in general, parental responsiveness and sensitivity to adoptive children improve over time.
After the Vietnam war, Korean conflict, and the fall of Communism, we were made aware of children who otherwise fell victim to disease and neglect. With the current AIDS epidemic in Africa, adoption has again been proposed as an option to help curb the number of abandoned orphans when other options (such as kinship and intracountry adoptions) have been exhausted.2
International adoption often creates mixed-race families, which can add unique and unanticipated challenges to the post-adoptive adjustment period. A recent study showed that many adoptive parents with "color-blind" racial attitudes actively spoke to their children and others, such as school teachers, about racism and discrimination and pursued cultural activities.3
Adopting children from third world nations with substandard health care adds an additional dimension to caring for newly adopted children. Parents and families who travel to escort their new children home are at risk for contracting infectious diseases and require pre-travel medical counseling.4, 5 A small study of children who had been hospitalized prior to adoption in Sweden showed MRSA carriage of 54% and subsequent transmission of MRSA to adoptive family members occurred.6 Many children arrive in their adoptive families with little or no medical records or with illnesses rarely seen in industrialized nations.5 A recent study of adoptive children who presented to a travel clinic in Nepal had common medical conditions, but were rarely up to date with immunizations or did not have valid documentation of immunizations.4
As international adoption increases in popularity, travel medicine practitioners will continue to provide pre-travel consultation to families traveling overseas to pick up children. At the same time, they might be called on to provide counsel about expectations for developmental outcomes in adopted children. While most foreign-born adoptees do very well, behavioral and developmental difficulties are more common in children who were institutionalized prior to adoption, in those who were adopted after 2 years of age, in boys, and in children from Eastern Europe and Russia.