A pediatrician noticed that a 5-year-old male was coming for an initial visit later in the week. The scheduling notes said that he was recently adopted from Africa. The pediatrician has no other information available but wanted to review what evaluation should be completed during the visit. A search of the American Academy of Pediatrics website for policies and guidelines revealed several regarding international adoption. The search also brought up several references for evaluation for children in foster care. The pediatrician planned to also review the Centers for Disease Control website for traveler’s health information once the country or area of Africa was known.
There is much overlap between immigrant children and children in foster care – particularly around adoption. Immigrant children are defined as those who are legal and undocumented immigrants, refugees and international adoptees. Children in domestic foster care if not reunified with their parents may be adopted by relatives (kinship permanency) or with non-relatives (national adoptees). Additionally, international adoptees and children initially or recently placed into foster care need similar medical evaluations.
Children that are adopted, including those who had been in foster care, have higher rates of asthma, moderate or severe health problems, developmental delays, psychosocial problems (problems with emotion, concentration, behavior, getting along with others, etc. ), learning disabilities and school difficulties and are more likely to have special health care needs. Fifty percent or more of international immigrants have at least 1 health problem. Eighty percent of the health problems may not be evident by history or physical examination and 60% of the health problems are infectious disease related.
Health care evaluations for immigrant and foster care children are similar as both groups need good general care and screening for appropriate problems and treatment. International adoptees have a higher risk for tropical infectious diseases, while children in domestic foster care may have higher risks for physical and sexual abuse. Obviously a thorough review of all medical records available and a thorough history and physical examination should alert the health care provider to specific concerns for a child that need to be specifically addressed (e.g. immigration to South East Asia, exposure to substance abuse, etc.).
An evaluation for international adoptees and children in foster care could include:
- Review of all medical records *^+
- Complete history and physical examination *^
- Growth parameters ^
- Development *^+
- Signs of trauma or abuse ^
- Genital and anal examination ^
- Dental examination *^
- Vision and hearing *
- Psychosocial evaluation *^+
- Adaptation to new home +
- Posttraumatic stress disorder
- School problems and learning disabilities +
- Infectious Disease
- Hepatitis A
- Hepatitis B *+
- HIV as appropriate *^+
- Sexually transmitted infections, as appropriate ^+
- Syphilis, congenital
- Tuberculosis *
- Preventive Health
- CBC *
- Urinalysis *
- Lead *
- Neonatal screening
- Infectious Disease
- Treatment, as appropriate but usually treated presumptively
- Malaria *
- Intestinal parasites * including amebiasis, schistosomiasis
- Immunizations *+
* Recommended by the Centers for Disease Control for new immigrants and refugees within 3 months of arrival into the United States.
^ Recommended for initial health screening for foster care placement.
+ Recommended for comprehensive health screening for foster care placement (within 1 month of placement)
Routine screening for Hepatitis A, B, D and E is not indicated. Many immigrant children are behind the normal growth parameters for US born children but have significant catch-up growth in 1 year. As many as 75% of immigrant children have dental disease upon entry to the US. Immunization records that are incomplete or suspicious should be considered underimmunized and catch-up vaccination begun.
Many adoptive families have concerns about communicating with their children and others about the adoption or foster care and its circumstances. The American Academy of Pediatrics has recommendations regarding the developmental understanding and communication about adoption. See the To Learn More section.
Questions for Further Discussion
1. What mental health services are offered in my community for international adoptees and children in foster care?
2. What school related services are offered in my community for international adoptees and children in foster care?
- Symptom/Presentation: Health Maintenance and Disease Prevention
- Specialty: General Pediatrics | Preventive Medicine and Health Maintenance | Social Services | Travel Medicine
- Age: School Ager
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American Academy of Pediatrics. Initial Medical Evaluation of an Adopted Child. Pediatrics. 1991:88.
American Academy of Pediatrics. Health Care for Children of Immigrant Families. Pediatrics. 1997:199;153-156.
American Academy of Pediatrics. Health Care of Young Children in Foster Care. Pediatrics. 2002:109: 536-541.
American Academy of Pediatrics Policy Statement. Familes and Adoption: The Pediatrician’s Role in Supporting Communication. Pediatrics. 2003:112;1437-1441.
Bramlett MD, Radell LF, Blumberg SJ. The Health and Well-being of Adopted Children. Pediatrics. 2007:119;s54-s60.
Walker PF, Stauffer WM, Barnett ED. Centers for Disease Control. Traveler’s Health Yellow Book. Chapter 9. Health Consideration for Newly Arrived Immigrants and Refugees. Available from the Internet at: http://wwwnc.cdc.gov/travel/yellowbook/2010/chapter-9/after-arrival-in-the-us.aspx (rev. 7/29/2009, cited 9/15/09)
ACGME Competencies Highlighted by Case
3. Informed decisions about diagnostic and therapeutic interventions based on patient information and preferences, up-to-date scientific evidence, and clinical judgment is made.
4. Patient management plans are developed and carried out.
6. Information technology to support patient care decisions and patient education is used.
7. All medical and invasive procedures considered essential for the area of practice are competently performed.
8. Health care services aimed at preventing health problems or maintaining health are provided.
10. An investigatory and analytic thinking approach to the clinical situation is demonstrated.
11. Basic and clinically supportive sciences appropriate to their discipline are known and applied.
12. Evidence from scientific studies related to the patients’ health problems is located, appraised and assimilated.
13. Information about other populations of patients, especially the larger population from which this patient is drawn, is obtained and used.
15. Information technology to manage information, access on-line medical information and support the healthcare professional’s own education is used.
24. Cost-effective health care and resource allocation that does not compromise quality of care is practiced.
25. Quality patient care and assisting patients in dealing with system complexities is advocated.
Donna M. D’Alessandro, MD
Professor of Pediatrics, University of Iowa Children’s Hospital