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Disabilities Among Foreign-Born Adoptees
Abstract & Commentary
By Elizabeth M. Keating and Philip R. Fischer, MD, DTM&H Ms. Keating is a student at Mayo Medical School, Rochester, MN. Dr. Fischer is Professor of Pediatrics, Department of Pediatric & Adolescent Medicine, Mayo Clinic, Rochester, MN.
Ms. Keating and Dr. Fischer report no financial relationships relevant to this field of study.
Synopsis: At an approximate rate of 12%, disabilities are twice as common among internationally adopted children in the United States compared to the general U.S. population, but the rates of disability are similar between foreign-born and U.S.-born adopted children. Children adopted from China and Korea have much lower risks of disability than do children from eastern Europe.
Source: Kreider RM, Cohen PN. Disability among internationally adopted children in the United States. Pediatrics 2009;124:1311-1318.
Kreider and Cohen studied more than 13,000 internationally adopted children ages 5 to 15 and more than 155,000 domestically adopted children ages 5 to 15; they then extrapolated findings from this sample to the entire U.S. population. (Data are summarized in Table.) Data were collected from the 2000 U.S. Census. Disability rates for internationally adopted children in the United States were estimated by country of origin, adjusting for age at adoption, gender, current age, and parental characteristics. These rates were compared to the disability rates for children adopted domestically. Disabilities identified are sensory (severe vision or hearing impairment), physical (limitation in walking, climbing stairs, reaching, lifting, or carrying), mental (learning, remembering, or concentrating), and self-care (dressing, bathing, or getting around inside the home).
It was correctly predicted that adopted children had higher rates of disability than non-adopted children. Internationally adopted children have disability rates (11.7%) similar to those children adopted domestically (12.2%) and more than twice the rate for non-adopted children in that age range (5.8%). Disability rates among children adopted from China and Korea had lower adjusted disability rates than domestically adopted children, while children adopted from Russia, Romania, and Bulgaria all had higher odds of disability than did domestically adopted U.S. children. Children who were adopted as infants had the lowest disability rates relative to those adopted at ages 2 to 9. Adoptive parents’ education showed no significant effect in the international adoption models. Children who were adopted by non-Hispanic white parents had higher adjusted odds of disability.
Professionals practicing travel medicine often see adopting families for either pre-travel or post-immigration consultation. It behooves them, even as it behooves other child health and education professionals as well as adoptive and prospective adoptive parents, to be aware of the risk for disabilities among internationally adopted children.
Overall, there was no difference in the rate of reported disabilities between domestically and internationally adopted children aged 5 to 15, although both had rates that were more than twice as high as the general population of children. A number of factors potentially could explain the higher rates of disability among adopted children. First, the health statuses and behaviors of birth parents before or during pregnancy may contribute to a child’s higher risk for early health problems and disabilities. A second factor that may contribute is deprivation during the institutional care within orphanages, and longer exposure to these conditions may lead to long-term disabilities. Third, the intentional selection of children with disabilities for placement and acceptance during international adoption, either because domestic families do not choose to raise children already identified as disabled or because some U.S. parents seek disabled adoptions for altruistic reasons, may be a factor that explains the higher rate of disability.
Several studies of internationally adopted children have identified physical, psychosocial, and academic challenges among foreign-born adoptees. One recent study has shown that although international adoptees can adequately catch up to their non-adopted peers in certain areas of development, they often experience difficulties with attention regulation, executive function, and sensory processing. These deficits may increase the risks for later school problems.1 Attention deficit disorders are more common in international adoptees than in native-born Swedes.2 Furthermore, children adopted internationally from institutions have been shown to have even more problems. A recent study showed that 44% of post-institutionalized children had stunted growth and were more likely to fall behind academically in school; adverse outcomes relate to the duration of institutionalization but not to the country of origin.3 Another study showed that post-institutionalized children frequently demonstrate persistent socio-emotional difficulties, such as an unusual lack of social reserve with unfamiliar adults.4
In addition to mental and behavioral effects, institutionalization also has physiological and biological effects. A study of post-institutionalized children showed that early social deprivation in an institution may contribute to long-term regulatory problems of the stress-responsive system.5 Furthermore, it has been shown that institutionalization impairs regulation of the hypothalamic-pituitary-adrenocortical (HPA) axis, potentially increasing vulnerability to stressors throughout life.6
Thus, the risk of identified disability in foreign-born adoptees varies with the country of origin but is similar to the risk of disability in U.S.-born adoptees. Children adopted from institutional settings carry additional risks of social and academic challenges. There are other risks related to international adoption that impact the practice of travel medicine. Hepatitis A has been identified in international adoptees and, subsequently, their direct and indirect contacts.7 Hepatitis A vaccination now is recommended for household members and other close personal contacts of adopted children newly arriving from countries with high or intermediate hepatitis A endemicity.8 Helpful literature to guide physicians caring for international adoptees and their families has recently been reviewed.9