Ask the Adoption Medicine Expert: Assessing a Referral
by Deborah Borchers, M.D.
Q:"We’ve heard from our agency that we’ll be receiving a referral soon. What medical information will it contain, and how should we assess it?"
A:In the best cases, the referral of a child for adoption will include the child’s complete prenatal history, information about the child’s birth, all medical diagnoses and hospitalizations to date, weight, height, and head circumference measurements taken at regular intervals, developmental history, birth family medical history, laboratory test results, and immunization records, all supplemented by photos and videos taken at different points in time.
In reality, however, such a complete picture is rarely available, and the information that’s sent varies greatly, depending upon the child’s age, country of birth, foster care agency or orphanage, and the adoption agency or attorney working on the adoption. Families adopting newborns in the U.S. or from South Korea are likely to receive detailed medical information. In other countries, such as China, Ethiopia, Russia, and Vietnam, parents may receive as little as two sets of data (usually measurements), one from birth and one from the time of the referral, along with information about the child’s sleeping and eating habits, and a photo.
The referral should include details about any specific medical diagnosis, such as cleft lip or palate, heart murmur, or club feet. In the U.S., such information is usually accurate, and medical records from any physicians and hospitalizations are available. This is not always the case in other countries. On occasion, diagnoses appear to be incorrect or incomplete. This is why pictures, videos, and additional medical testing, as needed, may be significant.
Is an adoption medicine specialist needed to review the referral?
Whether you are adopting from the U.S. or abroad, adopting a newborn, toddler, or older child, you’ll want to have a medical professional familiar with adoption review the child’s records. Given the family instability, poverty, or drug or alcohol abuse that all too often lead to an adoption plan, it’s prudent to objectively evaluate any child at the time of his or her adoption, regardless of the presence or lack of medical data. You’ll want an assessment of all of the information received, not just to determine whether the child is right for your family, but also to be sure that you’ll be able to meet the child’s needs.
In addition to an objective perspective, an adoption medicine specialist can offer knowledge of common risks and diagnoses from particular countries, and will know what you can request in terms of further information and testing. If you’re adopting internationally, an expert’s perspective is especially valuable, because the names of medical conditions or laboratory studies vary by country. In the former Soviet republics, for example, the term "perinatal encephalopathy" means that a child is at risk for developmental delay from previous injury (possibly including the birth process).
If you receive photographs and a video, a physician should review them for signs of genetic defects, prenatal alcohol exposure, and other conditions. Videos also give clues as to a child’s social development, based on his interactions with caregivers and other children.
A listing of physician members of the American Academy of Pediatrics Section on Adoption and Foster Care is available at aap.org/sections/adoption.
How should I assess the information?
A child’s growth over time reflects his nutritional status, so growth is one of the first indicators a physician will assess. Many experts believe that, for every three to four months spent in an institution, a child loses one month of growth. Length, weight, and head size should be compared to the Centers for Disease Control and Prevention’s standard growth charts (go to cdc.gov/growthcharts and click on "Clinical Growth Charts"). Measurements showing that a child has ceased to grow, or has significantly slowed in growth, raise a red flag. Similarly, a child with a small head (microcephaly) is at risk for developmental delays.
In addition to slowing a child’s physical growth, the malnutrition and lack of stimulation experienced in an institution can cause developmental delays. If delays are noted, physicians should determine whether a child’s physical and mental growth rates are consistent. For example, a 15-month-old who is about the size of a one-year-old may be at a one-year-old level developmentally, as well.
Some referrals come with checklists of a child’s development, others with a narrative list of skills a child has attained at various ages. It is important to consider all areas of development (speech and language, large motor skills, fine motor skills, personal and social skills), rather than focusing only on skills that are easily documented, such as sitting up and walking. [Find links to developmental indicator charts at adoptivefamilies.com/medical.]
How should I decide?
Ultimately, like becoming a parent by birth, every adoption is a leap of faith. Families adopting a child must be prepared for the unexpected, and committed to meeting their child’s needs. The referral you receive gives you a rudimentary understanding of your child’s past—and the kind of care that will ensure a healthy future.
Finding a Doctor
Now’s the time to find a pediatrician, so you can schedule your child’s first post-adoption checkup as soon as you get the OK to travel. An adoption medicine specialist can review the referral, and provide care as your child grows, but such a specialist isn’t necessary for long-term care. Ask friends, neighbors, adoption support group members, and your adoption agency to recommend pediatricians in your area. Ask any doctors you’re considering the following questions:
- What is your philosophy about antibiotics? About vaccinations and immunizations?
- What is your experience with adoption medicine? How many of your patients were adopted? From my child’s country of birth?
- Describe your medical training and areas of special interest.
- Do you have daily phone-in hours?
- Who covers for you when you are on vacation?
- What is the average wait for well-baby appointments?
- What’s the procedure if my child needs to see a specialist?
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