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Adoption

Adoption
Literature review current through: Jan 2024.
This topic last updated: Oct 23, 2023.

INTRODUCTION — Many couples or individuals create or expand their families through adoption. Families may seek to adopt because of infertility, fetal loss, death of a child, desire for more children, or simply to provide a home to a child in need of a home. Pediatric health care providers may provide preadoption counseling to prospective adoptive parents, evaluate children after adoption, and/or provide ongoing care to adoptees.

This topic provides a general overview of adoption within the United States and describes the potential role of the primary care provider as an advocate for adopted children and their families. The recommendations below are largely consistent with those of the American Academy of Pediatrics Committee on Early Childhood and Council on Foster Care, Adoption, and Kinship Care [1,2]. Specific infectious disease and immunization considerations in children adopted from outside the United States are discussed separately. (See "International adoption: Infectious disease aspects" and "International adoption: Immunization considerations".)

TERMINOLOGY

General terms — General terms that are used commonly in adoption are defined below [3]:

Adoption – A legal (formal) mechanism that allows full family membership and privileges to children who were not born into the family [4].

Informal adoption occurs when the birth mother allows another person to take parental responsibility for her child without obtaining legal approval or recognition of that relationship.

Birth parent or biologic parent – The individuals who conceived the child; referring to these individuals as the "real" or "natural" parents should be avoided.

Adoptive parent(s) – The individual(s) rearing the child.

Adoption constellation – Birth parents, adoptive parents, the adopted child, siblings, extended family members, and adoption professionals.

Adoption plan – An arrangement made by a birth parent to relinquish parental rights, via a legal process, to another individual; referring to the adoption plan as "giving up" the child should be avoided [2].

Kinship adoption – Adoption by a biologic relative of the child.

Referral – The time in the adoption process when the prospective family is given information concerning a prospective adopted child.

Finalization – Completion of the legal process that transfers parental rights to the adoptive parents; it generally occurs two to six months after the child has been placed with the adoptive parent(s).

Dissolution – The legal process of severing the relationship between the adoptive parents and the adopted child after the adoption has been finalized; dissolution may be voluntary or involuntary.

Disruption – An adoption that is terminated before it is legally finalized; disruption often occurs after the child is placed in the adoptive home, which requires a new placement plan for the child.

Adoption medical specialist – A pediatric health care provider who has special interest and expertise in medical issues associated with adoption. An adoption medical specialist can provide preadoption consultation, travel support, postadoption screening, and/or ongoing primary care [5].

Confidentiality — Regulation of confidentiality in adoption seeks to balance the privacy and anonymity of biologic parents with the "right-to-know" interest of the adopted child. Statutes regarding confidentiality vary from state to state; information regarding the statutes in particular states is available through the Child Welfare Information Gateway. There are four general approaches:

Confidential records – The original birth certificate and adoption records are kept sealed by the courts and can be inspected only with court approval. This approach is used in a small and declining number of states.

Open records – Adopted adults are given access to their adoption records or original birth certificate upon request and with no restrictions. This is the policy in an increasing number of states.

The American Academy of Pediatrics endorses the National Adoption Center's policy supporting provision of both the original and amended birth certificate to the adoptive family at the time of adoption (unless specifically denied by the birth parent[s]) and of granting the adopted person access to the original birth certificate at age 18 years [6,7].

Search and consent – An adoption agency or other intermediary investigates the location of one party at the request of another party who would like identifying information. The adopted person may petition the court to open the records if the biologic parent does not consent to release of the identifying information. This approach is used in approximately one-half of states.

Mutual consent – In mutual-consent voluntary adoption registries, information is maintained in a central file where adopted adults, biologic parents, and, in some cases, adoptive parents register their names to give consent to release identifying information if it is requested by one of the other parties. Identifying information can be released only if all parties agree.

Types of adoption

Agency adoption – Adoption services traditionally are provided by licensed public or private agencies that offer services to birth parents, adoptive parents, and children who need families.

Agencies work with prospective adoptive families to assess whether adoption is appropriate. A home study is conducted to educate families about adoption and to determine their suitability to adopt [8]. The home study includes information regarding the adoptive parents' motivation for adoption, financial status, religious beliefs, employment, education, relationship stability, childrearing practices, and housing. The adoptive parents must provide copies of birth and marriage certificates, financial statements, letters of recommendation, and reports of physical and mental health from a health care provider. They also must undergo a criminal background check.

In addition to performing the home study, agencies share medical and social information with the adoptive families and provide services to various members of the adoption constellation through the adjustment period and beyond [8]. Agencies may have a consulting clinician available to offer advice if children manifest physical, emotional, or developmental problems. In addition, the agency can receive and relay new medical information from the birth parents to the adoptive parents (eg, regarding inherited disease).

Independent adoption – Adoptions can be arranged privately through clinicians, attorneys, or other facilitators [8]. Approximately 65 percent of states allow facilitators to work with prospective adoptive parents to find an expectant birth mother.

Subsidized adoption – In subsidized adoption, also called adoption assistance, adoptive families receive financial support (eg, monthly cash payments and Medicaid coverage) from the federal and state governments to assist in caring for an adopted child with special health care needs [3]. Support may include access to medical care, counseling/therapy, special equipment, and tutoring services [2]. Subsidized adoption has facilitated the adoption of children with special needs, whose medical and special educational expenses might otherwise deter an adoptive family. Most families that adopt children from foster care receive adoption subsidies.

Open adoption – Openness in adoption refers to an agreement between the birth and adoptive parents to maintain some amount of communication. The degree of openness varies and usually is agreed upon by all of the involved parties, including the adoption agency and the adopted child if they are of appropriate age. Approximately 68 percent of domestic adoptions are open adoptions [9]. Openness arrangements vary and can change over time based upon the wishes of the birth and adoptive families. (See 'Confidentiality' above.)

Most adoption professionals believe that adoptive families should have information about the health of their adopted child's birth relatives. Some degree of ongoing openness is helpful if birth relatives develop medical conditions after the child's placement [10].

Legal-risk placement – In legal-risk placement, the child is placed in foster care with caregivers who are interested in adopting the child if reunification with the birth parents is not possible [3]. The legal adoption of the child cannot be guaranteed to the foster parents because of the continuing rights of the birth parents. (See "Epidemiology of foster care placement and overview of the foster care system in the United States", section on 'Birth parents'.)

EPIDEMIOLOGY — Approximately 120,000 children are waiting to be adopted in the United States each year and approximately 60,000 are adopted with public health agency involvement [11]. Among children adopted with public health agency involvement, approximately one-half are adopted by a foster parent and one-third by a relative.

Trends in adoption include increasing numbers of transracial, same-sex-parents, and single-parent adoptions and increasing numbers of adoption of children with special health care needs, as well as increasing openness in adoption [2,12]. These trends result from the shortage of healthy newborns available for placement, cultural changes, and increasing attempts to find permanent families for children with special health care needs in foster care.

Trends in domestic adoption – Most domestic adoptions occur through the national public welfare system (ie, foster care) or through independent agencies [1].

Public welfare adoptions – The numbers of children adopted from the foster care system increased between 2016 and 2019 (from approximately 55,500 to approximately 66,000), but declined in 2020 (to approximately 58,000) [11,12]. In fiscal year 2020, the mean age of children adopted from foster care was 6.5 years.

Between 25 and 30 percent of the children in foster care in the United States are eligible for adoption [11,13]. Among those who were adopted in 2020, 54 percent were adopted by foster parents, 35 percent by relatives, and 11 percent by nonrelatives [11]. However, many of the children in the foster care system who are available for adoption are difficult to place in permanent homes because of certain characteristics (eg, older children; children with physical, mental, or emotional problems; and children who are part of a sibling group) [14,15]. (See "Comprehensive health care for children in foster care".)

Other types of adoption – In 2012, approximately 49 percent of all United States adoptions were from sources other than foster care or intercountry [16]. These included private agencies, tribes, and step-parent or other forms of kinship care.

Trends in adoption of children with special health care needs – Adoptions of children with special health care needs has increased since the mid-1990s. Many adopted children have complex medical, developmental, behavioral, educational, and psychological challenges [17-20]. The special health care needs often are identified and managed before adoption but may not be apparent until months or years after adoption. (See 'Children with special health care needs' below.)

Trends in international adoption – Trends in international adoption are discussed separately. (See "International adoption: Infectious disease aspects", section on 'Epidemiology'.)

MEDICAL EVALUATION

Preadoption

Preadoption visit information gathering – Before adoption, pediatric health care providers may be asked to review the prospective adoptive child's health information. Prospective adoptive families generally seek information about potential long-term care needs, prognosis for specific medical problems, and availability of community resources. Clinicians who lack expertise in preadoption evaluation may refer families to an adoption medical specialist.

Families should obtain as much information as possible about their prospective child before the preadoption evaluation; the clinician (or clinician's office personnel) can advise the family regarding the type of information necessary to assess the child's health. Although most referrals are incomplete, it is useful to obtain the following information about the child and the birth family [1,2,4]:

Health history of birth parents, siblings, and extended family of origin members – Ages, medical issues, developmental or cognitive delays, mental health conditions or diagnoses, history of smoking, alcohol or drug use, genetic conditions, medications.

Social history of birth parents, siblings, and extended family of origin members – Educational attainment, history of incarcerations, domestic violence, previous foster care placement, religious preferences, etc.

Circumstances of the adoption – Why was the child placed for adoption? Was the termination of parental rights voluntary or involuntary? Placement of siblings (especially if close in age or cohabited previously).

Child's birth history – Pregnancy history, including the use of nicotine, alcohol, and licit or illicit drugs; prenatal care; maternal nutrition; gestational age; labor and delivery; type of delivery; weight, length, and head circumference; Apgar scores; complications.

Child's past medical history – Medications, hospitalizations or surgeries, developmental milestones, growth parameters, physical examinations, well-child care, dental care, immunizations, all laboratory reports.

Child's behavioral and mental health history – Aggressive behaviors (violence, cruelty to animals); hyperactive or impulsive behaviors; internalizing behaviors (eg, withdrawn, anxious); feeding issues; sleep issues; enuresis; sexualized behaviors (eg, promiscuity, excessive/inappropriate masturbation).

Child's past social history – Previous placements, school performance, religious preferences, special education needs, history of abuse, neglect, early childhood trauma, significant relationships (eg, teacher, extended family member), food insecurity, homelessness, etc.

Children who have lived in an orphanage or foster care or have current or past involvement with child protective services are at increased risk for fetal alcohol spectrum disorder. (See "Fetal alcohol spectrum disorder: Clinical features and diagnosis", section on 'Risk factors'.)

Child's current medical and social issues, strengths, special interests, and abilities.

Preadoption visit – During the preadoption evaluation, the clinician should review all available medical records; determine whether additional information should be sought by the family; discuss the medical, developmental, and behavioral issues that can be anticipated for the child based upon the information that is available; and provide guidance regarding the timing of the first appointment for the adopted child. Options for feeding adopted newborns should be discussed so that adoptive mothers who wish to breastfeed can be referred to a lactation consultant and have adequate time to prepare for induced lactation [21,22].

The clinician also may discuss the upcoming transitions for the adoptive family and the child. Adoptive parents should be encouraged to educate themselves about ways they can ease the adjustment for everyone and set realistic expectations for the changes to their family. Information for parents is available from the Child Welfare Information Gateway and the AAP (table 1). (See 'Resources' below.)

Adoptive parents may expect the guarantee of a "healthy child," request unnecessary tests, or expect the pediatric health care provider to provide unrealistic predictions. Such requests require thoughtful responses and appropriate anticipatory guidance. The role of the pediatric health care provider is not to judge the advisability of a proposed adoption but to clearly and realistically apprise the prospective adoptive parents of any physical or mental health needs detected now or anticipated in the future [1]. Pediatric health care providers should define and explain the risks to the family so that potential problems can be anticipated and addressed appropriately. The pediatric health care provider can also assist with making sure that the proper social support systems are in place to help the family cope with externalizing behaviors or other adjustment issues as they arise. (See 'Early adjustment issues' below.)

Postadoption

Medical evaluation — The initial medical evaluation of an adopted child should be a comprehensive assessment of medical, developmental, and psychosocial issues. The timing of the first postadoption visit is determined by the age of the child and the circumstances related to the adoption. A newborn or a child adopted from foster care should be seen as soon as possible, while an internationally adopted child should be evaluated within two weeks of arrival to the United States. (See "International adoption: Infectious disease aspects", section on 'Post-arrival evaluation'.)

At the initial postadoption visit, the primary care provider should assess the completeness of records and acute and chronic medical problems if they have not already done so [1]. (See 'Preadoption' above.)

The provider should plan to spend additional time to review the physical, nutritional, safety, developmental, social, and emotional needs of the adopted child [23]. This information is particularly important for first-time adoptive parents who have not received the anticipatory guidance, caregiver, and safety advice that is provided at regularly scheduled health maintenance visits.

All adopted children – All adopted children should have a complete medical evaluation that includes:

Assessment of growth and growth trajectory. (See "The pediatric physical examination: General principles and standard measurements".)

Assessment of development. (See "Developmental-behavioral surveillance and screening in primary care".)

Physical examination – Aspects of the physical examination that are particularly important in adopted children include [1]:

-General appearance – Clinical features suggestive of a genetic disorder, syndrome (eg, fetal alcohol spectrum disorders), or congenital infection (see "Fetal alcohol spectrum disorder: Clinical features and diagnosis" and "Overview of TORCH infections")

-Eye examination – Findings associated with strabismus (eg, limited extraocular muscle function), other abnormalities of the extraocular muscles, or abnormalities of the fundus (eg, chorioretinitis) (see "Evaluation and management of strabismus in children")

-Skin – Signs of infectious diseases (eg, impetigo (picture 1A-B)); infestations (scabies (picture 2A-D), lice (picture 3)); congenital abnormalities (eg, hemangiomas, nevi); trauma (eg, bruises in characteristic patterns); scars related to trauma or immunization (eg, Bacille Calmette-Guérin (picture 4)); or sexual abuse (see "Evaluation of sexual abuse in children and adolescents", section on 'Physical examination' and "Physical child abuse: Recognition", section on 'Red flag physical findings')

-Developmental and neurologic abnormalities (see "Detailed neurologic assessment of infants and children")

Age-appropriate screening tests. (See "Screening tests in children and adolescents", section on 'Common screening tests in pediatrics'.)

For domestically adopted newborns, newborn screening (including hearing screen) may need to be repeated if the results of the original screens are not available. (See "Overview of newborn screening" and "Screening the newborn for hearing loss".)

For older children adopted domestically, screening and laboratory studies performed before adoption need not be repeated if results are available, unless the child has had additional environmental (eg, lead) or infectious disease (eg, hepatitis B) exposures [1].

Assessment of immunization status – The child's immunization status should be updated as necessary to be complete according to the recommendations of the Centers for Disease Control and Prevention Advisory Committee on Immunization Practices (figure 1A-B). For children who are behind, or who lack complete immunization records, immunizations should be updated as necessary (table 2A-B). It is not necessary to measure antibody titers in domestically adopted children with written documentation of immunizations [1]. (See "Standard immunizations for children and adolescents: Overview", section on 'Routine schedule'.)

Children adopted from foster care – In addition to the evaluation, all children adopted from foster care should also have a [24]:

Mental health evaluation (see 'Other mental health issues' below)

Developmental health evaluation (if <6 years of age), as recommended for all children (see "Developmental-behavioral surveillance and screening in primary care")

Educational evaluation (if >5 years of age)

Dental evaluation

These evaluations can be conducted as part of the comprehensive health assessment by a multidisciplinary team or through referral to specialists. It is important that they be conducted in a timely manner and that information is shared among all the professionals caring for the child or teen and the adoptive parents.

Internationally adopted children – Additional evaluation for internationally adopted children is discussed separately (see "International adoption: Infectious disease aspects" and "International adoption: Immunization considerations")

Early adjustment issues — After placement, newly adopted children undergo an adjustment period, whether they were adopted from foster care or from an institution. Children of all ages must feel safe in their new environment. They need time to create a trusting bond with their caregivers. Adoption agencies often encourage a period of "cocooning," during which the family remains within the home to promote bonding. However, a cocooning period may not be realistic for many families, as adoptive parents have to tend to other children or need to return to work and rely on other adults to help provide childcare. Clinicians can help adoptive parents recognize, understand, and respond to their newly adopted child's adjustment issues. Recognizing and addressing differences in culture (eg, religious preference, race, ethnicity) can play an important role in early adjustment.

Some adoptive parents describe a "honeymoon" period, during which the child is compliant and seemingly quite happy. Others describe children who are withdrawn, hypervigilant, easily overstimulated, aggressive, or defiant. Any of these observations can be typical transitional behaviors and often worrisome to adoptive parents, who may not have anticipated the behaviors or may have concerns that they will persist.

Some children struggle with sleep issues or regulation of their eating patterns. These behaviors can be best understood by considering the child's circumstances before adoption: Was the sleep environment safe? Was the child potentially always hungry or never learned to recognize satiety?

At some point, most children will enter a period of "testing," during which their behavior suggests that they are seeking information about the permanency of their new home environment. Adoptive parents should be patient and reassuring and, at the same time, provide appropriate structure and consistency in their messaging and discipline. Adoption therapists or adoption medical specialists often can assist pediatric health care providers with specific adjustment concerns [5].

Other mental health issues — The risk of mental health disorders (eg, socioemotional problems, attention deficit hyperactivity disorder, autism spectrum disorder) is increased in children adopted from foster care or institutions [1,17,25-27]. Early placement in foster care may mitigate some of the increased risk associated with institutionalization [27]. Factors that contribute to mental health disorders include prenatal exposures (eg, drugs, alcohol), previous abuse/neglect, multiple placements, and prolonged institutionalization [28]. Mental health diagnoses in members of the birth family also may play a role, but this history is not always available. (See "Comprehensive health care for children in foster care", section on 'Mental health issues'.)

Referral to a mental health provider is indicated for adopted children with preplacement risk factors for mental health disorders. Such referrals often are made at the time of placement.

For adopted children who have not already been referred to a mental health provider, screening for mental health disorders is recommended at all medical visits, particularly at regular health assessments [2]. Pediatric clinicians can screen adopted children for mental health issues in the office using validated screening tests such as the Pediatric Symptom Checklist [29], Brief Infant-Toddler Social Emotional Assessment [30], or Ages and Stages Questionnaire: Social-Emotional [31]. (See "Developmental-behavioral surveillance and screening in primary care", section on 'Choice of screening test'.)

Developmental delay — Assessment of the adopted child's development soon after placement or arrival permits early recognition and treatment of developmental delay and/or learning problems. (See "Specific learning disorders in children: Clinical features" and "Specific learning disorders in children: Evaluation" and "Developmental-behavioral surveillance and screening in primary care", section on 'Approach to surveillance'.)

Most children adopted from foster care or internationally have some type of developmental delay [20]. Although many such children make developmental gains after adoption, it is impossible to predict which children will catch up quickly and which will have ongoing needs. Preadoption and postadoption factors both contribute to a child's developmental trajectory [4]. (See "Comprehensive health care for children in foster care", section on 'Development and education'.)

Early referral to developmental or educational specialists is preferred to a "wait and see" approach for adopted children with developmental delay. Clinicians may need to work with school districts to help educators understand the unique circumstances surrounding an adopted child's development. As an example, English language acquisition in internationally adopted children depends upon the age of adoption and native language skills [4]; for the school-age child, English as a Second Language classes may not be helpful if the child's language development in the primary language is atypical. For internationally adopted children, native language skills should be assessed near the time of adoption.

Children with special health care needs — Adopted children who have previously identified physical and mental challenges may have experienced multiple traumas and frustrations. They may have limited coping skills to deal with their feelings of rejection or deprivation. The pediatric health care provider can help the child and the adoptive family address these issues by making appropriate referrals for counseling, support groups, special education, and financial aid. (See "Children and youth with special health care needs".)

Families who adopt children with special health care needs through state social service agencies may be eligible for financial assistance from the federal Title IV-E adoption assistance program and additional subsidy programs that vary from state to state [2]. Families should be encouraged to discuss these programs with their case workers and to apply for financial assistance even if no perceived need exists at the time of adoption because children with special health care needs may require long-term therapy for problems that were not anticipated based upon the initial evaluations.

DEVELOPMENTAL STAGES OF ADOPTION — Adoption is a lifelong process; particular questions, concerns, and emotional issues related to adoption emerge for the adoptive parents and the adopted child at various developmental stages or at the time of "anniversaries" (eg, their birthday, the day they left foster care) [2]. Pediatric health care providers can help the families anticipate and prepare for these specific adoption-related issues, particularly as the adopted child becomes curious about their biologic identity (table 1). Extending the duration of appointments to address these special concerns may be warranted. (See 'Resources' below.)

Before the adoption, adoptive parents may experience a mixture of emotions, including grief and loss related to fertility issues or the loss of a child, happiness, and anxiety regarding their ability to care for the adopted child. They also must decide how to integrate the child into their existing family structure and prepare answers to the questions that the child or other family members will ask about the adoption:

Preschool children – Preschool children will begin to ask questions about their histories. They may begin to have magical thoughts about people or places in their past and may notice ethnic differences. Racial and ethnic differences should be discussed openly and regarded as a source of family enrichment. The child's need to identify with their ethnic group should be respected and facilitated as the child grows [2].

School-age children – Children between 6 and 12 years of age undergo many changes in cognitive and socioemotional development that have significant implications for their understanding of and adjustment to adoption (eg, recognition of the loss of the biologic family; feeling responsible for their biologic parents making an adoption plan) [2,4].

Adolescents – Issues of identity develop during adolescence. Adolescents may idealize the birth family and begin to express a need to search for birth relatives. This search for biologic identity is not a rejection of the adoptive family but a normal developmental stage. Addressing the child's wishes may improve the child's sense of identity, long-term adjustment, and relationship with the adoptive parents [4].

COMMUNICATING ABOUT ADOPTION — The American Academy of Pediatrics Committee on Early Childhood, Adoption, and Dependent Care recommends that pediatric health care providers encourage open discussion of adoption and use of appropriate adoption language beginning at the time of adoption [2]. Adoptive parents should use the words "adoption" and "adopted" in a warm and positive manner, even before the child understands what they mean; they also should refer to the birth family's having made an "adoption plan" rather than having "given the child up" for adoption. Developmentally appropriate information should be provided to the child with love and respect in an open, matter-of-fact manner, so that the child has an understanding of their adoption story, which begins at the time of their birth.

Adoptive parents should be prepared to share developmentally appropriate information about the child's birth family (table 3). They should be guided by the child's questions, answering truthfully and expanding their explanations if the child indicates that they want to hear more [2]. Adoptive parents should be alert for opportunities for open discussion about the child's birth, birth parents, and adoption. Older children, who may be reluctant to discuss their concerns, may need to be encouraged through direct questions or statements.

Children who are in elementary school may ask specific questions about their birth or adoption. Their questions should be answered honestly, emphasizing that the decision was made in their best interest. It is particularly important to assure children between 8 and 10 years of age that their adoption is permanent [2]; such children frequently have concerns about permanency (even those who live with their birth parents) [32-34].

All members of the adoptive family may need help in responding to questions or statements about the status of the adopted child. Being able to discuss these questions openly with their pediatric health care provider helps children understand and accept their adoptive status [2]. Pediatric health care providers may encourage adoptive parents to seek counseling through the adoption agency or a community support group.

LONG-TERM DEVELOPMENTAL AND BEHAVIORAL OUTCOMES — There are no long-term, prospective studies looking at developmental and behavioral outcomes of adopted children as a group. Most individuals with a history of adoption in infancy are well-adjusted and psychologically healthy in childhood, adolescence, and adulthood. Children are at greater risk for a range of developmental and behavioral problems when they have multiple adverse risk factors before adoption and when they are adopted at an increased age; the older they are at the time of adoption, the greater the risk of developmental and behavioral problems [4].

For children adopted domestically, long-term developmental and behavioral outcomes are difficult to predict, given the heterogeneity of adoption circumstances (prenatal history, postnatal history, birth home environment, age at foster home placement, number of foster homes, etc). In general, children placed in a permanent home at a younger age have fewer long-term developmental and psychological needs [35]. Little is known about how adverse childhood experiences before adoption (eg, child maltreatment, prenatal substance exposure) affect outcomes for adopted children or how the effects of these experiences are mediated by the quality of postadoption caregiver-child relationships and/or ongoing special health care needs [36].

For children adopted internationally at >1 year of age, long-term, prospective studies have demonstrated higher rates of poor attention, hyperactivity, difficulty with emotional regulation, and elevated levels of anxiety as well as difficulties later in life with intimate social attachments and emotional regulation [4].

INDICATIONS FOR REFERRAL — Pediatric health care providers should make appropriate social service or mental health referrals as indicated for any member of the adoption constellation.

Potential indications for referral to a mental health provider with expertise in adoption include:

Mood disorders (anxiety, depression, etc)

Attachment concerns

Trauma/grief

Potential indications for referral to an Adoption Medical Specialist include:

Postadoption screening, for example:

The provider is not comfortable or familiar with postadoption screening

The provider has questions about screening labs or catch-up immunization

Concerns about struggles with feeding, sleeping, timing of school placement, age-approximation, developmental delay, learning, attention or behavior

RESOURCES — Pediatric health care providers should be familiar with local support groups and resources for adoptive families (table 1) and clinicians [2]:

American Academy of Pediatrics (AAP), Council on Foster Care, Adoption, & Kinship Care

AAP Mental Health Toolkit (Addressing Mental Health Concerns in Primary Care: A Clinician's Toolkit; some materials are available to the public; others require purchase or subscription)

AAP policy statement on health care issues for children and adolescents in foster care and kinship care

AAP policy statement on promoting the well-being of children whose parents are gay or lesbian

Child Welfare Information Gateway

National Center on Adoption and Permanency

SUMMARY

Terminology – Adoption is a legal mechanism that allows full family membership and privileges to children who were not born into the family. (See 'Terminology' above.)

Preadoption visit – The preadoption visit allows pediatric health care providers to review available information about the prospective adopted child, apprise the prospective adoptive parents of any current or anticipated special health needs, and help prepare the adoptive family for the upcoming transitions. (See 'Preadoption' above.)

Initial postadoption visit – The initial postadoption visit should include a comprehensive assessment of medical, developmental, and psychosocial issues. The health care provider also should educate the adoptive family about the physical, nutritional, safety, developmental, social, and emotional needs of their child. (See 'Postadoption' above.)

Early adjustment issues – Newly adopted children undergo an adjustment period before they can create a trusting bond with their adoptive families. Clinicians can help adoptive parents recognize, understand, and respond to their child's adjustment issues. (See 'Early adjustment issues' above.)

Other mental health issues – Screening older infants and children who have been adopted for behavioral and mental health problems is recommended. The adoptive parents should be counseled regarding the special needs of adopted children related to the adverse life experiences that may have influenced the adoption placement. (See 'Other mental health issues' above.)

Indications for referral – For families who adopt children with special health care needs, referrals for counseling, support groups, special education services, and financial aid should be provided as necessary. (See 'Children with special health care needs' above and 'Indications for referral' above.)

Developmental stages of adoption – Adoption is a lifelong process; particular questions, concerns, and emotional issues related to adoption emerge for the adopted child and adoptive parents at various developmental stages or at the time of "anniversaries." Pediatric health care providers can help the families anticipate and prepare for these specific adoption-related issues. (See 'Developmental stages of adoption' above.)

Communicating about adoption – Open discussion of adoption is encouraged. Developmentally appropriate information should be provided to the child with love and respect in an open, matter-of-fact manner (table 3). The information may need to be repeated and modified depending upon the child's emotional reaction. (See 'Communicating about adoption' above.)

Resources – Pediatric health care providers should be familiar with local support groups and referral resources that address adoption issues (table 1). (See 'Resources' above.)

ACKNOWLEDGMENT — The editorial staff at UpToDate acknowledge Heidi Schwarzwald, MD, MPH, who contributed to earlier versions of this topic review.

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Topic 2854 Version 27.0

References

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