by Dana E. Johnson

The most difficult area in adoption medicine is predicting the needs of children adopted from orphanages. We are only beginning to understand how these kids are doing. Studies have been too few to say with certainty what percentage is normal (even if we could define "normal"). Also, the situation changes with time. Some children resolve problems, while others begin to exhibit them as the years pass. Because studies only deal with a two-to-five-year period after adoption, no one can speculate on long-term issues.

The following are issues that should be considered when adopting an institutionalized child. Personally, nothing would please me more than for all institutionalized children to find permanent homes. However, nothing would make me feel worse than a family adopting a child they could not parent.

What are the chances that my child will be normal on arrival?

Essentially, zero. Kids aren't in orphanages because they come from intact families, with good standards of living and ready access to good health care and nutrition. Proposal for adoption by destitute, single mothers with poor prenatal care and inadequate diet, is the most common reason why a child is available. The second most common is termination of parental rights, because of neglect and/or abuse. Over 50 percent are low-birthweight infants, many were born prematurely, and some have been exposed to alcohol or other drugs in utero.

An orphanage is a terrible place for a child. Lack of stimulation and consistent caregivers, poor nutrition, and physical/sexual abuse all interfere with normal development. All institutionalized children fall behind in large and fine motor development, speech acquisition, and social skills. Many never find an individual with whom to complete 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 poor. And group living fosters diseases such as intestinal parasites, tuberculosis, hepatitis B, measles, chickenpox, and ear infections.

Will I be able to determine the nature and severity of my child's needs before arrival?

I have seen few children for whom enough information on prenatal factors, birth weight, and postnatal development was available to say that the child was normal. A more common situation is identifying children who clearly are abnormal. There are children who have the typical characteristics of FAS, children with clear neurological abnormalities, and children with autistic-like behaviour. Have your child evaluated by knowledgeable professionals after arrival. Most institutionalized children, especially those older than two, need rehabilitation after orphanage life.

Even if a child initially appears normal, problems may arise with time. For example, attachment problems may not become apparent until a child feels secure in his or her new environment. And the challenges of school may unmask subtle intellectual and learning disabilities.

If my child isn't normal on arrival, when will she catch up?

No one can answer this with certainty. Most children progress far better with adoptive families than in orphanages. Unless a child is truly neurologically impaired, gross and fine motor skills and strength respond well to good nutrition and a stimulating environment.

Yet many children, especially those who spent considerable time in institutions, continue to show delays in language and social skills, behavioural problems, and abnormalities in attachment behaviour even after several years in adoptive homes. In most situations, they respond to treatment, but this takes time and expert guidance. In some situations, therapy will improve but not correct the problem. For example, with FAS the challenges will be lifelong.

Will I be able to find therapeutic resources within my community?

Your child's most important resource is your family, and your commitment is key to his or her success. However, expert help is often needed to help a child who has suffered neglect and abuse.

One of the most frustrating situations for a parent is having a child with a problem, but no access to help. Hope for the best but prepare for the worst. Before accepting a referral, seek out resources in your community, including a speech and language pathologist, occupational therapist, neuropsychologist, and therapists with experience in post-institutional behaviour problems.

Some of these services may be available for free within your school system, but many will involve significant expense. Check with your school and health plan to see what services are covered, at what level, and for how long. Investigating these areas may determine 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 a child with problems so severe that they disrupt your family is small. Educate yourself by contacting organizations like Parent Network for the Post-Institutionalized Child (PNPIC), then honestly evaluate your own capabilities. The risk, although low, may be too great for your situation.

If you proceed, you can lower the risk by obtaining appropriate information from your agency and having it reviewed by a knowledgeable physician before accepting a referral. An important part of this process is being prepared to say no if a child's needs exceed your capabilities.

But be aware that you will never have all the information you need to eliminate risk. The best decision you can make will be well-reasoned, well-informed, and accompanied by the "leap of faith" that is part of all conscious decisions to parent. If you cannot assume this risk, adopting 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 questionnaire returned by a large number of families who adopted from Romania revealed that 90 percent had a positive view of their adoption. Being satisfied with their decision did not mean that their children were problem free (whose children are?) but less than 10 percent of families were ambivalent about their decision, and only a small percentage were considering disruption of the adoption.

Dana E Johnson, MD, PhD, is co-director of the International Adoption Clinic in Minneapolis, and a professor in the Department of Pediatrics and director of the Division of Neonatalogy at the University of Minnesota Hospital. He is also dad to an internationally adopted daughter. This article is condensed, and reprinted by permission, with thanks to Lois Hannon (Parent Network for the Post-Institutionalized Child, Box 613, Meadow Lands PA 15347, 412-222-1766, e-mail thais1@earthlink.net). The full text of this article is on the web at www.adoption-research.org/research.html