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 timewithin two to five years of placement. Without valid data, we are left with our own opinionswhich, 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:
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.
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 adoptionparticularly of an institutionalized childmay 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.
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