This is an overview on medical risks from Dr. Dana Johnson's website:
ADOPTING AN INSTITUTIONALIZED CHILD:
WHAT ARE THE RISKS?By Dana Johnson, MD, PhD After reviewing the medical records of nearly 1,000 institutionalized children, I can conclusively state that the most difficult area in adoption medicine is predicting the needs of children adopted from orphanages. Unfortunately, there is no shortage of dogmatic opinion, both positive and negative, on the outcome of these children. Recently I have been quoted as saying that 85% of institutionalized children are normal. If so, why are so many families seeking help for their adopted children through organizations like PNPIC? Confused by what you have heard? I am. The major problem is that we are only beginning to understand how these kids are doing. Studies utilizing appropriately selected and tested institutionalized children have been too few to say with any certainty what percentage are normal (even if we could define what we mean by "normal"). It is also quite clear that the situation changes with time. Some children resolve problems, whereas others begin to exhibit them as the years pass. All contemporary studies of institutionalized adoptees from abroad deal with a rather narrow span of time-within two to five years of placement. Without valid data, we are left with our own opinions-which, of course, are shaped by our personal experience with adoption, by conversations with families we have come into contact with in our practice, and by our own world view.What do we really know, and what can we say about institutionalized children as a group? More importantly, what can we say about the child you have adopted or are considering adopting? Certainly, no one is in a position to provide statistics on what percentage are abnormal or normal. Even if we did have those data, they would address the status of institutionalized children at an early age. Twenty years from now, worries that your child had language delays at four years of age will be replaced by concerns of whether your child has acquired the tools to be successful as an adult; e.g., a positive self-image, a high school diploma and independent living skills. No one is in the position to even speculate on these long-term issues. Following are questions and answers which address issues that I feel should be considered when adopting an institutionalized child. Since I am offering advice in the absence of irrefutable facts, you are entitled to know my personal view on this subject. Nothing would please me more than to have all institutionalized children find permanent homes. However, nothing would make me feel worse than having a family adopt a child they were unprepared to parent. What are the chances that my child will be normal on arrival? Let me be blunt. The chance of an institutionalized child being completely normal on arrival in your home is essentially zero! Here's why:
Kids aren't in orphanages because they come from loving, intact families with a good standard of living and ready access to good health care and nutrition. Abandonment by a destitute, single parent with poor prenatal care and inadequate diet is the most common reason why a child is available for adoption. The second most common reason is termination of parental rights because of neglect and/or physical/sexual abuse (often alcohol related). Over 50% of institutionalized children in Eastern Europe are low birth weight infants, many were born prematurely, and some have been exposed to alcohol in utero. Finally, children with major medical problems or physical handicaps may be placed in orphanages by their parents due to limited access to corrective treatment and rehabilitation services. These kids are a high-risk group by any standard.
An orphanage is a terrible place to raise an infant or young child. Lack of stimulation and consistent caregivers, suboptimal nutrition and physical/sexual abuse all conspire to delay and sometimes preclude normal development. All institutionalized children fall behind in large and fine motor development, speech acquisition and attainment of necessary social skills. Many never find a specific individual with whom to complete a cycle of attachment. Physical growth is impaired. Children lose one month of linear growth for every three months in the orphanage. Weight gain and head growth are also depressed. Finally, congregate living conditions foster the spread of multiple infectious agents. Intestinal parasites, tuberculosis, hepatitis B, measles, chickenpox, middle ear infections, etc., are all found more commonly in institutional care settings Will I be able to determine the nature and severity of my child's immediate health needs prior to arrival? I have seen very few children for whom sufficient information on prenatal factors, birth weight, and postnatal growth and development was available to say that the child was normal. A more common situation is identifying children who clearly are very abnormal. These are children who have the typical facial and growth characteristics of fetal alcohol syndrome, children with clear neurologic abnormalities and children with autistic-like behavior. It is impossible to predict the exact needs of most children, which is why you should have your child evaluated by knowledgeable professionals after arrival. Most institutionalized children, especially those older than two years of age, need rehabilitation services to correct deficits imposed by orphanage life. Even if a child initially appears normal, remember that many problems are not apparent at the time of arrival in your home. For example, children with significant attachment issues often do not exhibit these behaviors until they feel secure in their new environment. The challenges of school, particularly the transition between kindergarten and first grade, may unmask subtle intellectual impairments and learning disabilities. If my child isn't normal on arrival, when will he/she catch up? This is a question that no one can answer with certainty. We do know that your child will progress far better in your home than he/she would have in the orphanage, and that most children make tremendous gains in growth and development during the first years with their adoptive families. Unless a child is truly neurologically impaired, gross and fine motor skills as well as strength respond well to improved nutrition and a stimulating environment. However, many children, especially those who spent considerable time within institutional care settings, continue to show delays in language and social skills, behavioral problems, and abnormalities in attachment behavior even after several years in their adoptive home. In most situations, areas of delay respond to appropriate treatment, but resolution of the problem may take time and expert guidance. In some situations, therapy will improve but cannot correct the fundamental problem; e.g., fetal alcohol exposure. In these situations, the challenges will be life-long. Since my child will likely have medical and/or developmental needs, will I be able to locate appropriate therapeutic resources within my community? Your child's most important resource is you and your family. Your commitment to your child's well-being is the single most important factor in success. However, despite what you may have heard, love alone may not be enough. Expert help is frequently needed to rehabilitate a child who has suffered prolonged neglect and abuse within an orphanage. One of the most frustrating situations a parent can face is having a child with a problem, but no access to help. Hope for the best but prepare for the worst. Before you accept a referral, seek out the resources in your community that may be necessary. These include speech and language pathologists; occupational therapists with training in sensory integration therapy; neuropsychologists who have experience evaluating institutionalized children; and therapists with experience in post-institutional behavior problems and attachment disorders. Some of these services may be available for free within your school system, but many will involve significant expense. Be sure to check with your health plan to see what services are covered, at what level, and for how long. Careful investigation of these areas may help you decided if adopting an institutionalized child is an option for your family. What are the chances that our child will have severe problems? The likelihood that you will adopt an institutionalized child with problems so severe that they disrupt the fabric of your family is small. Educate yourself with information available through organizations such as PNPIC, then honestly evaluate your own capabilities as a parent. You may decide that the risk, though low, is too great for your situation. If you decide to proceed, you can lower your chances of adopting such a child by obtaining appropriate information from your agency and having it reviewed by a knowledgeable physician prior to accepting a referral. An important part of this process is being prepared to say no if you recognize that the needs of a certain child exceed your capabilities. Be aware, though, that you will never have all the information you need to eliminate this risk. Don't drive yourself wild in an endless search for that one final piece of information that will guarantee a correct decision. The best decision you can hope to make is one that is well-reasoned, based on the information that is available, accompanied by the "leap of faith" that is a mandatory part of all conscious decisions to parent. If you cannot knowledgeably assume this risk, international adoption-particularly of an institutionalized child-may not be for you. Will we be satisfied that we made the choice to adopt a child from an orphanage? The answer to this question is the reason I remain optimistic about adopting institutionalized children. A study involving a questionnaire returned by a large number of families who adopted from Romania revealed that 90% had a positive view of their adoption. However, being satisfied with their decision to adopt did not mean that their children were problem free (whose children are?). Less than 10% of families were ambivalent about their decision, and only a small percentage were considering disruption of the adoption.
Don't expect your child to emerge from an orphanage unscathed.
Prepare in advance to rehabilitate your child.
Institutionalized children are a high-risk group. Make sure that you are prepared to take on the parenting challenges.
Optimism is appropriate. Most families feel positively about their adoption.
Some composite examples cited in The Connected Child, by Purvis, Cross & Sunshine...
"In the orphanage, Donnie is in the farthest crib from the nursery door. He lies in soiled diapers for hours at a time and is the last baby fed by the attendant. Left untouched and underfed, he does little but stare at the walls and ceilings. The back of his head has become flattened from remaining in that position so long."
How will Donnie react to an interested adoptive parent? Probably with alarm, fending himself off from physical contact and avoiding eye contact. Perhaps by crying, too, but we can guess that Donnie did not get much response to crying in the nursery, so he may have no use for crying any more.
This child will probably not grow and thrive and develop in any fashion akin to that of a child in a US family. The lack of attention as much as the lack of food will stunt his growth. Deprived of a caregiver who responds to cries and reassures Donnie lovingly that he will be cared for, that someone cares about him, Donnie has no chance to learn to trust or "to bond with other people or to even process sights, sounds, and sensations." Short of being spoken to, Donnie cannot learn language and without exposure to color and texture, his brain does not develop the neural pathways needed for vision and touch. Short of being cuddled, Donnie's brain cannot learn to synchronize his emotions and reactions with a sensitive and caring parent. "Isolation is more damaging to an infant than early mistreatment."
This is why I feel appalled at the idea that children should be left in orphanages for months in honor of cultural preservation, as some countries interpret the Hague Convention on adoption choose to do. No orphan should be left in an orphanage for a minute longer than necessary to find a family somewhere who will love that child. Culture is secondary to family. It is a crime against humanity that any nation holds children back from having families.
Children who have been in orphanages are all special needs children. Yes, you might observe that the child looks chubby and has bright eyes and clear skin; but, if that child has been in an orphanage, the child has been short of key nutrients for growth -- love and a mother. And, there are a host of other impediments that can affect development.
Medical risks can be obvious, like scabies, or oblique, like many forms of brain dysfunction. Children in orphanages are susceptible to parasites, hepatitis, TB, growth disorders relating to malnutrition or mal-absorption, and developmental delays. Children with medical issues that are not treated, as they may not be while in an orphanage, are at risk for the problem being compounded by lack of treatment.
The rule of thumb for developmental delay due to institutionalization is a loss of one month development to every three months for a child reared in a family. Your orphanage child at 12 months will be about the equivalent in development to a family child of 9 months. Many children are resilient are rebound from orphanage life. Others present issues that will challenge them and their families for the rest of their lives.
Another example from The Connected Child is that of a five year old girl, Gloria, who is "pretty with wide brown eyes, a pouting mouth and long dark hair. She catches the attention of two orphanage attendants, who... lure the little girl with kindness and teach her how to gratify them sexually. Gloria learns that flirting and stimulating an adult's private parts is the way to earn attention, affection and food."
Gloria's experience with molestation will shape many of her behaviors and confuse, even alarm, her adoptive parents. Her identity is now charged with sexuality, and she has learned that sexuality is a ticket to affection and security. It is a difficult behavior to unlearn; in fact, I would consider the problem of sexualized behaviors one the most distressing that adoptive families can face. In addition, it can come as a complete surprise. Obviously, orphanage attendants do not list a child's sexual attributes on their profiles. It is a secret, one that may emerge months after an adoption is completed.
In some countries, orphanages and foster care are regulated enough to give reasonable assurance that a child will have been treated well and kindly. But let's look at some history... in China, it is not uncommon for babies to lie unattended for hours, nor is it terribly unusual for a child to come home with the back of their head rather flat. In Russia, babies are often left with bottles propped along side their heads, with the nipples on the bottles deliberately enlarged, to speed up the feeding. As a result, the children do not learn that extremely important exercise of sucking; they virtually drown, choking in formula, the formula they do not get down spills down their cheeks and into their ears, causing virulent ear infections and potential hearing damage. In fact, the above happens in many, many countries. In Kazakhstan, and Kyrgyzstan, there may be only two or three caregivers for a room full of ten or more infants. At night, there may only be one. In Guatemala, which has in the past been the epitome of excellent foster care for orphans, the children are now in orphanages, where they receive the same kind of care that most children in orphanages receive: not enough. The excellent book There is No Me without You tells the story of a wonderful woman and her care for orphans in Ethiopia, in which there is a case of a caregiver sexually molesting a child. It can happen anywhere; I know of very young children who arrived in their new homes sexualized from both Russia and Guatemala. In many countries it is also possible that, as girls and sometimes boys reach puberty, they are trafficked into prostitution.
There is no where safe to be an orphan. Most children are safe in families; although not all. No children are safe in orphanages. There is simply not enough care -- there is simply not enough adults who care. The Connected Child notes that from their research on Russian and Romanian adoptees, the children remained smaller that their home-reared children or those adopted at birth, that the presence of cortisol, a potentially cell-damaging hormone was present in higher levels, proportionate to the time they resided in an orphanage, that 23% of the 86 families involved in the study reports their children had been sexually abused prior to adoption, and 47% were physically abused. More than half were deemed neglected and none had been held during infant feeding. One-third of the children presented developmental learning delays, social or academic impairments and were smaller in height and weight as compared to their peers.
Most orphanages do their best with the resources they have to feed and nurture children. Nowadays, many are clean, well organized, have adequate food and warmth, have play areas with toys the children can actually play with, have outdoor areas for children to run, have rudimentary education for toddlers and pre-schoolers, have doctors available and administrators or social workers who really do look out for their welfare. But, it is still an orphanage. I am concerned that the current world economic crisis will reduce resources available to orphanages to provide care -- including nutritional food and caregivers.
No one can promise that a child will "catch up." Simple developmental delays can be caught up but frequently an adopted child will present issues later on. These may not differ much from the challenges that families with biological children face; she is "shy" or he is "anxious" or she is "hyper" or he is "belligerent." These descriptors fit children from everywhere. The difference is that child born into families are probably exhibiting these behaviors for different reasons than an adopted child. It is easier to trace the behavior patterns of a biological child. She may act "just like Aunt Margaret" or he may "have a temper like his father." Adoptive parents do not have these markers. We are in the dark with respect to heredity.
The approach recommended for dealing with behavior issues or developmental deficits in an adopted child may differ from methods one might use with a family-born child. Do not, for instance, use a time-out that involves separating your mischievous adopted child from you. Forget sitting your child in the corner in the family room while you are in the kitchen. Adopted children need time-ins, not time-outs. Your child needs to be close to you and able to see you, not separated. Don't send an adopted child to their room, either. Young children will simply feel abandoned if you punish them with separation and thus you will undo all the trust your family has been working so hard to build. Older children may feel like they have "won" if you punish them with separation, because that is what they wanted anyway -- to avoid family intimacy because it raises their anxiety.
I don't know of any child therapist who recommends spanking. Avoid it. With an adopted child, it may get their attention, but it will also damage whatever trust you are trying to achieve. Don't jeopardize the long term goal -- a positive and healthy relationship -- for a short term solution. Any kind of threatening physical behavior on the part of the parent will cause the child to emotionally withdraw. This is definitely not the goal. There are many occasions when physical intercession is called for; holding a child gently, looking seriously but kindly into their eyes. sitting down with them closely on the sofa, asking them to take deep breaths with you, are some strategies. For those who wish more, I suggest talking with a local adoption social worker or child psychologist and reading Martha Welch's book, Holding Time.
This is a review from Amazon on the book...
"My sister introduced me to this book. She found it at the local library. It was an answer to our prayers! PLEASE read this book, and try it on your children! It has made an incredible difference in my life and the lives of my four children. This idea of "Holding Time" is so incredibly much better than the other forms of discipline out there--time out, spanking, etc. It is a great way to get "angries" out in a safe way. It not only helps the child learn to communicate their feelings, it helps moms learn patience and self discipline too. I love it and would VERY HIGHLY recommend it to you. I plan to buy a copy for myself for future reference, one for our church, and for several of my close friends. My little girl (age 3) is a totally different child after starting holding. She expresses her feelings much better (instead of screaming or throwing a tantrum) and has fantastic eye contact. She actually ASKS for Holding Time! My 7 year old son has also opened up verbally, and doesn't demand attention through bad behavior (stealing, lying, etc). "Holding Time" is very much worth the $. I thank God for it, and also Martha G. Welch, M.D.!"
Lois Ruskai Melina's notes in Raising Adopted Children that both the child and the parents in an adoptive families have suffered losses; both may be suffering unresolved grief and anger. The child has lost birth mother, caregiver and all familiar ties. The adoptive parents may have lost pregnancies due to fertility issues. These losses can cause both child and parents to be anxious, grieving, defensive or hyper-sensitive. While we cannot expect the child to sort out their feelings prior to the adoption, it is essential that adoptive parents enter into the new relationship with a child without superimposing their fears and losses onto the relationship. The emotionality of an adoption can throw a new mother into post-adoption depression; be aware that this is not unusual but needs to be treated before it impedes ability to attach to a little one who needs you desperately, no matter what his or her behavior suggests.
There are terrific post-adoption resources on a variety of techniques to stimulate development, trust and affection. Sensory integration is a kind of a catch-all term that includes many of these techniques; it has become a standard topic in pre-adoption education. It has proven time and again to be a family-oriented easy to learn method of helping your child learn developmental steps that may not have been addressed while in an orphanage. Some of these are hard to identify with a young child. It is useful to engage in sensory integration playtime whether or not you can "see" missing pieces, because whether you can or cannot see them, they are there.
Most families ask for a "healthy" child. Adoption agencies can hope to match you with a child who appears in good health, contextually; one who appears nourished and alert. But no one can guarantee any child's physical or psychological health and every child who has spent time in an orphanage has suffered some form of neglect, in comparison to being a treasured child in a family. Every adopted child is a special needs child, to some degree. Even those adopted at birth, because gestation cannot be overlooked; the birth mother may not have had the energy or resources to make her body a safe and nurturing environment for the child during those critical first months of life.
Sometimes families say "Why is this all so complicated and scary?" It has to be -- so that parents understand the risks and prepare for a child who will need extra help. It is very important to adjust expectations in accordance with what your child may have experienced prior to and after being placed in the orphanage. There are other risks: a child may be the result of rape or incest and this may be unreported. The birth mother or father may have undiagnosed psychiatric conditions. All families are concerned about whether the child was exposed to drugs or alcohol in utero. Sometimes this is known or reported; sometimes it is unknown or undeclared by the birth mother. The risks need to be weighed carefully. While some research indicates that the majority of adopted children do "catch up" and become loving and attached, succeed at school and develop healthy friendships, that may not be your child. Risk is always present. The child who appears chubby and bright eyed may present attachment issues. The child who appears skinny and scared may become a rocket scientist.
Understanding the general backdrop of what causes children to become orphans is an important part of pre-adoptive education. Many adoptive families have not encountered an orphanage or witnessed endemic poverty; some have. In our world poverty is real and widespread and often part of the reason a woman will choose to relinquish a child; another reason may be shame. An unwed mother may be shunned by family and community and endure cultural condemnation. The woman who longs to keep her child may face a social predicament that makes it impossible to raise her child -- to feed and clothe that child, or provide an education. The child may present a barrier to the woman's chance to be wed, later on. It was not so long ago that children born out of wedlock were called "bastards" in the US -- a term of derision and shame. The children were victimized as a result. A woman's decision to relinquish her child may be include many motives, none of them happy. She may hope that her child will have a better chance at life through adoption.
Every child needs a family, however that child came to be born, whatever their path to a family. Where countries can assist to preserve families and protect children from being orphaned, that is ideal; presuming the birth family is not cruel or neglectful. Unfortunately, the population crisis, famine, cultural mores, AIDS, desertion or incapacitation of a parent, laws that fail to protect, educate and employ women -- all contribute to children being orphaned.
We cannot change the world overnight. But adoption can change the world for a child. .