The internationally adopted child: overview of challenging issues

Abstract

Many international adoptees join families in industrialised countries every year proposing difficult new challenges to paediatricians. Many children have spent a portion of their life in orphanages, other institutions or foster care (with consequent affective deprivations) and/or came from countries where several infections are endemic. These factors determine a wide series of problems ranging from mental health disorders to language difficulties and infectious diseases. Noninfectious disorders are not outdone as compared to infectious problems (1). Eleven studies investigated mental health problems in almost 18 000 internationally adopted adolescents and compared results with that obtained in more than one million age-matched not adopted controls. As a group, internationally adopted children do not manifest significant defects, but among them, the proportion of subjects with difficulties is larger than among controls. Interestingly, the difference is somewhat larger when parent reports are considered as compared with selfreports. It must be the task of paediatric centres devoted to the cure and the care of internationally adopted children to take the responsibility for managing these mental health problems. Not adopted age-matched controls and internationally adopted children at about four years of life are similar with respect to socioemotional and intellectual abilities, but the adopted children up to 66 months of age manifest defective expressive and receptive language skills (2). In addition, at age three years, adopted children manifest less physically challenging behaviour and are less active. These findings are crucial as communication skills early in life are fundamental mechanisms to achieve normal outcome in social, language and cognitive development (3). Behaviourally, a large proportion, internationally adopted children, regardless of language ability, have more parent-reported hyperactivity and impulsivity in comparison with controls. A portion of adopted children has some language difficulties. These children have a worse performance in academic skills, working and verbal memory as well as reasoning. Functional magnetic resonance imaging shows a reduced activation in traditional language areas (4). Let’s go to organicistic items. There are not sound studies on haemoglobinopathies in internationally adopted children. However, data obtained in immigrant children in Italy can be used by analogy obviously with some degree of approximation. About 5% of human beings carry a gene for haemoglobinopathies: sickle cell disease is frequent in India, Middle-East and sub-saharan geographical range; haemoglobin E, haemoglobin C, haemoglobin D, alpha and beta thalassaemia. To a lesser extent, compound haemoglobins are common in some Mediterranean areas, southern China and India. Screening for haemoglobinopathies should be included for internationally adoptive children who arrive from these areas (5). Early childhood affective as well as nutritional deprivation may cause endocrine modifications. Internationally adopted children are at up to 20-fold of precocious puberty, particularly in children from Africa and India. Poor standard of care and stressors in orphanages can lead to alterations in cortisol regulation and consequent suppression of diurnal cortisol variation (6). Endocrinological items cannot be overlooked when the adoptive child is evaluated at arrival. In their preadoptive life, many children were greeted in orphanages or other institutional care centres, which represent a risk for infectious disease. Many came from areas endemic for a number of infectious diseases. Looking for infectious disease is essential to ensure the health of the child, of his or her new family and the new community in which they now live (7,8). Adoptive parents should take a pretravel medical examination. All family members, not only those who pick the child but also the enlarged family which remains at home, should be investigated as to a history of disease of or immunisation against measles, varicella, rubella, hepatitis A and B, hepatitis. When appropriate, immunisation should be ensured for everyone. Ideally, the child adopted internationally should undergo in his or her country of origin a medical examination and laboratory tests. Sometimes, these last may be unreliable. In addition, just as ideally, adopting parents should obtain the documentation of immunisations, equally unreliable in many instances (7–9). Anyhow, children should be screened shortly after arrival at a paediatric centre specialised in international adoption (9). A fast track should be contemplated if the child develops a febrile illness during or shortly after his or her trip (10). Medical history should be accurately collected and physical examination must be carefully made. History should include the evaluation of possible abuse and consequent sexually transmitted diseases. In addition, the