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Bringing Home Baby
On February 12, at John F. Kennedy International Airport in New York, John and Marianna Rivers became parents for the first time. No, she did not go into labor in the terminal, although the couple did experience a delivery of sorts. On that day, they waited anxiously for a seven-month-old Korean baby and his escort to pass through customs, only to discover that there were seven Korean babies on board the incoming flight. They had seen photos of baby Jack before, but on this day he was wearing a hat, which threw them. But John picked his son out of the lineup, and they left the airport as proud parents.
Jack Rivers is one of some 15,000 children from other countries who will be adopted by Americans this year, as part of an unprecedented boom in international adoption. The number of such adoptions has risen by 50 percent since the early 1980s as would-be parents have looked abroad to start or complete their families. The reason is a mixture of altruism and self-interest: Some parents are moved by the plight of unwanted girls in China, where sons are valued more highly and single-child families are the law; others want to avoid the relationships with birth parents that sometimes complicate domestic adoptions; still others are single people who are more likely to be able to adopt a healthy baby in China or India than in the U.S.
But whatever the reason, international adoption is becoming a familiar part of American life. And while until recently 70 percent of international adoptees came from Korea, which has a well-regarded system of foster homes, much of the new growth in adoptions has come from China, Russia, and Eastern Europe, where overtaxed orphanages are the rule. What kinds of problems do these children bring along with the joy they bring their parents? A new clinic run by a research pediatrician at the Yale School of Medicine is trying to find out, and to help parents negotiate solutions.
One of the first stops for the Rivers family after they brought Jack home to Norwalk, Connecticut, was the Yale International Adoption Clinic, a year-old project brought to the University by Dr. Margaret Hostetter, who came to the School of Medicine last year from the University of Minnesota to become director of its Child Health Research Center. Hostetter, whose main field of research is infectious diseases, founded a similar clinic, the first of its kind, at Minnesota in 1986.
“One afternoon I was heading down the hall and was stopped by a colleague,” recalls Hostetter. “He and his wife were going to adopt a baby from India, and he had questions about the medical implications. I said, 'No problem, I’ll do a literature search and get back to you tomorrow.' But there was nothing anywhere about how to evaluate children adopted internationally.”
That dearth of information led Hostetter and her colleague to the idea of a clinic that would examine newly adopted children from foreign countries and give them uniform tests for infectious diseases and other potentially worrisome conditions. As they collected data, they would analyze and disseminate the results, helping parents and other physicians learn what diseases are prevalent among adoptees from various countries. Since Minnesota then led the nation in international adoption, the clinic found itself with no shortage of subjects. Hostetter says she has examined more than 1,400 children over the past 13 years. And as international adoption has spread, so has the idea of “adoption medicine”: There are now more than a dozen such clinics around the country, patterned largely after Minnesota's.
Hostetter’s findings have helped to clear the air about some of the medical risks involved in adopting abroad, a subject that has sometimes received ill-informed, sensational attention from the media. Her data indicate that such life-threatening or lifelong problems as HIV, fetal alcohol syndrome, syphilis, and hepatitis are sometimes seen in adoptees, but that more common are less serious problems such as intestinal parasites. Mary-Ellen Warner of Woodbury, Connecticut, says the Yale clinic discovered that her 22-month-old son Alexander, whom she and her husband Lee had brought home from a Russian orphanage, was infected with Giardia, a parasite that is normally contracted in this country only when beavers get into a water supply. The Warners' own pediatrician, understandably, had not discovered the problem. (It was cleared up, and Warner says Alexi is healthy now.)
Even though some problems tend to be more common in some countries than others, Hostetter gives every child the same battery of tests. “There is no problem that is geographically isolated, except that there seem to be no intestinal parasites in children from Korean foster homes,” she says.
Another common problem Hostetter has documented is a result of understaffed Russian and Eastern European orphanages. Many children who have spent time in those orphanages have significant delays in development, including fine and gross motor skills, language acquisition, and social and emotional development. “The longer a child spends in an orphanage,” she says, “the more likely he or she is to have some developmental delay.” Some children will lose as much as three to four months of development for every year in an orphanage. Hostetter attributes these delays—along with a corresponding delay in linear growth—to a lack of regular attention from caregivers. “It doesn’t take much individual attention to avoid these delays,” says Hostetter. “Just half a day a week, as far as we can determine. The caregivers work six-and-a-half-day weeks, and I saw one case where a caregiver took a child home with her on Sunday afternoon. That child was just fine.” Similarly, in India, orphanages are staffed by women known as “ayahs” who on average care for about four children each. There, too, developmental delays are less common. Whatever delays may occur as a result of time in an orphanage, the chances are good that they will be overcome, especially, says Hostetter, if the child is adopted before the age of 2.
Parents often see an immediate improvement when the children are brought into an environment where they receive such increased attention. “There’s frequently a 'magic month' where the children accrue developmental activities like mad,” says Hostetter. “We often ask to see a child again after that time to see how they’re doing when they’re fully acclimated.”
Assessing the condition of newly adopted children is obviously of great benefit, but most would-be parents would like to know something about a child’s health before they adopt. Medical records from some countries are often spotty or unreliable, and the less reputable adoption agencies may minimize or fail to disclose problems that might slow down or block the adoption. “The best way to tell a responsible agency is by how much information they give you,” says Hostetter. “We’ve heard from potential parents who were told by agencies that they were ‘asking too many questions.’”
Still, some parents are willing to take a chance on a child with a sketchy medical history. “It’s a risk you take,” says Jeff Seymour, who with his wife Barbara adopted baby Catherine last year from Hangzhou, China. “You’ve got to have a little faith and hope it works out. You can’t do the kind of investigation you can in this country.”
What parents can do is ask a doctor like Hostetter to screen videotape footage of the child for signs of health or developmental problems. Russian and Eastern European orphanages frequently provide videotapes of children to prospective parents, and Hostetter says they can be surprisingly useful. “If you can see them for five minutes you can get the gestalt of the child,” she says. “You can see if they’re moving all their extremities; you can see gross motor and fine motor skills, socialization and language. Sometimes there’s too much delay to ascribe to the orphanage—it may be fetal alcohol syndrome or another organic cause, especially in Russia and Eastern Europe.”
Before they adopted Alexander, Lee and Mary-Ellen Warner were sent videotapes of two other Russian children. “We were pretty excited when we got the video of the first child,” says Mary Ellen. “We sent the video to two doctors. Both were really negative and said there were a lot of possible problems, including fetal alcohol syndrome. With the second child, we sent the video and pictures to Dr. Hostetter and another doctor. Again, they were both very negative and said there were definitely signs of fetal alcohol syndrome: the thin upper lip, the eyes far apart. It just broke our hearts.” But when Alexi’s tape arrived, Hostetter gave a positive evaluation of his motor skills and sociability, and the Warners made plans to go to Russia.
Hostetter says she’s not always comfortable with having such a dramatic role in a child’s future. “When the video shows cause for concern, then the parents are probably not going to adopt that child,” she says. “But my role is not to say 'don’t take this baby.' I lay out the facts and let them decide if the situation fits their resources.”
An experienced eye can sometimes allay parental fears. Cristina Benedetto and Rob Laplaca were concerned about the medical history of the mother of the Korean baby they were considering adopting last fall. They showed pictures and the medical history to a pediatrician who came back with an “alarming” report, Benedetto says. But Hostetter said she didn’t think anything was wrong, and the couple adopted the boy in January.
A week after Laplaca brought their son William home from Korea, they took him to the clinic for his evaluation, which confirmed Hostetter’s assessment. William went through a thorough exam given by Hostetter, the developmental specialist Dr. Carol Cohen Weitzman, and nurse practitioner Betsy Groth (who is herself the adoptive mother of two Korean girls).
The exam begins with Groth getting the child’s medical history from the parents. She then discusses with them any concerns they might have—often, as with any new parents, they are about sleeping and eating—and conducts a physical exam. Then Weitzman, a pediatrician who has done a fellowship in developmental and behavioral pediatrics, evaluates the child’s development level using standardized assessments. Hostetter also spends some time with the child before the visit ends with every parent’s (and child's) least favorite part: the drawing of blood for the extensive battery of tests the clinic performs on each child. In addition to testing for an array of diseases, the bloodwork can in some cases verify the accuracy of the foreign vaccination records that accompany the children.
Usually, the children are fine, and the problems are minor. At Yale, Hostetter has yet to see any serious health problems, but the numbers are still small at this clinic—three or four a week, as opposed to about four a day in Minnesota. There, she had occasion to tell parents their children were infected with syphilis, tuberculosis, or hepatitis B or C. “For the most part, I’ve found the parents very compassionate and very understanding,” she says. “We’ve never had an adoption disrupted as a result of medical factors.”
Developmental delays are more common, but parents are usually able to accept those, too. Betsy Groth tells of a couple who brought in a Vietnamese girl who had serious developmental problems. “When we told them about the situation, they just shrugged and said, 'We’re ready to meet her where she’s coming from.' That really made an impression on me.”
It is Groth who, as an adoptive parent herself, often helps parents grapple with some of the nonmedical issues they might be facing. “I made a mother laugh the other day,” she says. “She was telling me about how tired and jet-lagged she was, and I said 'Yeah, and where are the turkey casseroles?' When you give birth, everyone’s ready to pitch in. But when you bring home an adopted child, people come over and expect you to serve them snacks!”
Some apparent problems may be the result of cultural differences. While children from orphanages may be affected by lack of attention, Korean children sometimes have the opposite problem: They have not learned to sit up because they’ve never been put down long enough to try. “They carry babies all the time over there,” says Cristina Benedetto. “At first, William didn’t do a lot for himself. He didn’t hold a bottle or sit up well. But within a week or two even our big dog couldn’t knock him over.” (Benedetto also learned quickly that Korean babies are unaccustomed to sleeping alone in cribs, having slept on floor mats with their foster parents in Korea.)
In addition to helping adoptive parents and children one family at a time, Hostetter, Weitzman, and Groth hope the data collected at the clinic will lead to improved care for all internationally adopted children. Already, Hostetter’s published data on the incidence of diseases has proven essential to the development of recommendations by the American Academy of Pediatrics as to what tests should be done by pediatricians. “We hope to put ourselves out of business as the medical profession gets more familiar with international adoption,” says Groth. “But I don’t see that happening for a while.”
Weitzman hopes that when the clinic starts to see a critical mass of patients, she can begin a research project that will enable the clinic to see the children again and learn more about their health, growth, and development over time. “It’s not always clear what developmental delay means,” she says. “Some arrive with delays and go on to do fine, while others have long-term difficulties. We want to learn what the predictors of healthy adaptation and development are.”
Weitzman thinks there may be differences among children in similar environments that make some better able to cope with institutional settings (and better able to adapt to their new homes). “The question is to sort out which features in these children are protective and which features heighten the risk of developmental problems,” she says. “Those kinds of questions are applicable to other kinds of environmental risks; this is an opportunity to study the effect of adverse care.”
In the meantime, adoptive parents like Jeff and Barbara Seymour will continue to seek out children from abroad, most of them well aware of the potential pitfalls, but willing to try it anyway in order to build a family. “Every adoption has risks,” says Jeff Seymour. “But the rewards tend to outweigh them. It’s amazing how happy we are.”
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