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Assessing the Risks - Russian Adoptions
by Andrew Adesman, M.D.

Adoption of a child from Russia presents many challenges and opportunities. Although there are many “reasonably healthy” children in Russian orphanages waiting to be adopted, there are also a considerable number of children with significant medical or developmental problems. Unfortunately, the adoption process is an imperfect process with many inherent obstacles and risks, and the media attention in this area has been generally quite negative. Although this unbalanced coverage has “heightened sensitivity” (prompting families to educate themselves about these developmental and medical issues), it has perhaps exaggerated the true risks currently associated with adoption of a very young child from Russia.

Hopeful Trends:
Admittedly, children in Russian orphanages are at increased risk for malnutrition, developmental delay, poor growth, medical illnesses and emotional disorders. Although some orphanages have more resources than others, none could be considered a satisfactory environment for a child of any age. Thus, with each passing month and year, children in these orphanages tend to lag further and further behind in their growth and development.

If this is so, how can one ever feel positively about the process and one’s prospects of adopting a child who will likely have normal growth and development? I believe several factors justify cautious optimism: the availability of younger children for adoption, the availability of pre-adoption videos to assist in the screening process, and the availability of international adoption medical consultants, who can review medical summaries and videos, counsel prospective parents about risks, and identify additional information that may be needed.

Younger Children: Three years ago, it was difficult to adopt a child below 18 months of age, whereas now, many referrals are infants — children under 1 year of age. The ability to adopt infants from Russia means that these children will have spent a much shorter time in the orphanage setting. All of the research to date suggests that the detrimental effects of institutionalization are progressive over time, and that the younger the child at adoption, the greater his or her ability to “bounce back.” Although the factors that determine resilience are not well understood, children under 1-2 years of age are clearly most resilient.

Adopting an infant or young toddler has advantages as well as disadvantages. Although the adverse effects of institutionalization will be minimized if a child is adopted within the first 6-12 months of life, it is somewhat more difficult during infancy to identify certain “biologically-based” developmental and neurological impairments. Fortunately, the “biological” risks are generally quite low compared to the risks of developmental delay associated with institutionalization.

Videos: The overwhelming majority of agencies that refer children from Russian orphanages now provide prospective adoptive parents with a videotape of the child. Although these videos vary considerably in length and quality, they have the potential to provide at least some information about the child’s size, nutritional status, motor skills, social skills, language, personality and overall health. Admittedly, since these videos typically only depict a child for 2-10 minutes and may record minimal activity or interaction, they sometimes fail to provide any meaningful developmental information. Similarly, videos can sometimes raise clinical “red flags” such as “fisting” or “low muscle tone” which later resolve and turn out to be “red herrings.” In spite of their limitations, however, videos make it possible for adoptive parents to have qualified medical consultants review the tapes objectively, looking for signs of serious medical or developmental problems.

Occasionally, an agency is unable to provide clients with a videotape of the child at the time of referral; in these instances, photographs and/or answers to specific questions can often provide adequate assurance that the child is not at high risk for developmental or behavioral problems. Though not essential, videos are often quite helpful. Yes, a movie picture is worth a thousand words!

Adoption Medicine Consultants: Individuals or couples interested in adopting a child from Russia or an Eastern European country should obtain a pre-adoption medical consultation when they get their referral. This consultation will help you understand the child’s medical history and evaluate his or her current nutritional status and developmental functioning. Moreover, the consulting physician should be able to counsel you as to which issues are likely to resolve and which may represent long-term concerns. Although many of the children adopted from Eastern Europe do not have any major health problems or developmental disabilities, these children are at increased risk for many different medical and developmental disorders — some of which may not be apparent at the time of referral and may not be treatable. Thus, the pre- adoption medical consultation will reduce one’s risk of adopting a child with unexpected medical or developmental problems; however, one can never eliminate this risk.

Obstacles to Pre-Adoption Screening:
There are many inherent limitations and obstacles to accurately assessing a child’s current status and future prospects.

• Information regarding the child’s medical history or developmental status may be incomplete or inaccurate.

• There is the potential to over-interpret what may be an otherwise relatively benign or minor condition or finding.

• Even if the complete medical history is available, the specific cause of a child’s developmental delay or disability may never be known.
• The younger the child, the more difficult it may be to detect certain developmental problems. For example, cerebral palsy cannot always be detected in the first 6-8 months of life. Similarly, mental retardation, autism and speech-language disorders cannot reliably be detected in the first 12-18 months of life. Learning disabilities and attention-deficit hyperactivity disorder are generally not recognized before 5-7 years of age.

• Children generally develop in a predictable sequence; however, there is considerable variation in the rate and way in which they develop. In other words, there is a broad range of what constitutes “normal” development.

• Perhaps most importantly, children are often very “resilient.” The younger the child, the less certain one can be of the long term implications of mild develop mental delays or past medical problems.

Children do not thrive in orphanages. The orphanages in Russia and Eastern Europe are deplorable in many regards, and yes, these institutional settings inexorably take their toll on the medical, nutritional, developmental and emotional health of thousands of young lives that reside there. These grim realities notwithstanding, there are many wonderful children to love and adopt. Adoption agencies that place children from Russia can put you in touch with many families who now have wonderfully healthy children at home. The Internet mail lists are also rich with tales from proud and elated parents of children adopted from Russian orphanages who are now thriving in every sense.

With the availability of much younger children, many of the risks previously associated with adopting from Russia have diminished. Consultation with an experienced adoption medicine consultant can substantially further reduce one’s risk of significant medical, developmental or emotional problems. I would estimate that 25 percent of the younger children referred to me for evaluation represent “low risk” referrals (that is, only mild delays in growth or development and no apparent significant medical problems). These children will almost certainly thrive once placed in a nurturing home.

Similarly, 50 percent of the referrals I review I consider “moderate risk” because these children have somewhat greater delays in their growth or development or there are one or more potentially significant medical issues in the medical summary. Although I do not have follow-up data to confirm my clinical impression, I believe that most of these children also do quite well. My “high risk” category (the remaining 25 percent) is reserved for children with more serious medical problems or for children who have significant delays in growth or development which are not likely due to the institutional setting alone.

As with all major decisions and long term commitments, there are elements of risk and uncertainty inherent in the Russian adoption process. To paraphrase a famous physicist, it is very difficult to make predictions, especially about the future. Adoption medicine consultants help families sort out the “red flags” from the “red herrings,” identify the salient and credible medical issues, and place that particular referral into a broader clinical context.

As a board-certified pediatrician specializing in the evaluation of children with developmental problems, I appreciate the many obstacles and limitations that are intrinsic to the adoption process. I know that adopting from Russia and Eastern Europe brings with it additional anxieties and frustrations, and that these risks cannot be dismissed or ignored. However, for those individuals, couples and families who are considering adopting an infant or toddler from this region, I believe there are many wonderful children just hoping for a new life — waiting to laugh and to smile . . . longing to love and be loved.

Dr. Adesman is Director of the Adoption Evaluation Center and Chief of the Division of Developmental & Behavioral Pediatrics at Schneider Children’s Hospital in New Hyde Park, NY. He is also Associate Professor of Pediatrics at the Albert Einstein College of Medicine. Readers wishing to contact Dr. Adesman may reach him at 718-470-4000.

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