When expecting a baby, couples often say they do not care whether they have a boy or a girl so long as the baby is healthy. The reality is some children are born with or develop medical issues because of genetics or the environment to which they are have been exposed. Having a pre-placement medical assessment conducted is an excellent way for those seeking to adopt to gather information allowing them to make a truly informed decision about pursuing the adoption of a specific child.
It is essential for prospective adoptive parents to consider a child’s current medical problems and the risks of developing problems in the future before accepting a placement. Are they up for the challenge of parenting a child with these health issues? If not, then passing on the match is prudent so the child can receive the best care.
History of Pre-Placement Medical Assessments
Evaluating medical issues of a waiting child is a more recent concern in adoption history here in the United States. Initially, adoptions were focused on placing healthy infants for adoption; in fact, some even believed only “normal” children were appropriate for adoptive placement.1 Children who had experienced some type of abuse or who suffered from a disability that could not be corrected were usually deemed unavailable for adoption.2
Societal changes, however, shifted perspectives on the ability to adopt children with special needs. Birth control and abortions became readily available, and society became more tolerant of single mothers, even going so far as to provide financial support for them. These developments reduced the pool of children available for adoption. With couples still desiring to adopt, foreign adoptions and adoptions of children with special needs, particularly those in foster care, became alternative sources for adoptive placements. The need for prospective adoptive families to be counseled about medical needs, however, was recognized and is still observed.
Over time, understanding of the long-term impact of a child’s prenatal and post-birth environment on his development grew. Entities placing children for adoption have to take into account the present and future needs of the child being placed, as well as the capabilities of families who might take a placement to handle those needs. Children with issues that will affect their future, whether physical, mental, or emotional, will do best in adoptive homes prepared to meet the challenges those issues present.
Nevertheless, for adopting families to make a truly informed decision on whether to pursue the adoption of a specific child, input from a medical professional about known or potential health problems is required. Accordingly, pre-placement medical assessments have become an important resource for prospective adoptive parents during the decision-making process.
When to Do a Pre-Placement Medical Assessment
Input from a medical professional about a child’s current disabilities and risks of future health problems is helpful at any time. But the crucial point for that input is at the very beginning of the adoption process before the final decision is made by prospective adoptive parents. The time for a couple to determine they are not equipped to deal with a child’s needs is before—and not after—the child is placed in the home. A disruption merely adds to the issues the child may already be facing, and it would be emotionally taxing on the adoptive parents as well.
At the outset of the adoption process, placing entities typically ask a prospective adoptive couple to identify medical conditions they are willing to consider. While a couple might accept a premature infant, they may not feel prepared to handle a drug-exposed infant. Just as each child is unique and has different needs, each adoptive couple will have different capabilities to offer. In order to determine what they might be able to handle, the adoptive couple must have information on the risks and expected outcomes of medical conditions.
A consultation with a medical professional allows them the opportunity to ask questions and honestly address what they can expect in a child and from themselves. With this information in hand, the couple can narrow down the types of situations for which they desire to be considered.
Get All the Details from an Assessment
Of course, general information on a medical condition is not adequate when a specific opportunity is offered to prospective adoptive parents. The most common situation where a medical professional provides counsel to adoptive parents is after they receive a referral for an identified child. The couple needs to know what to expect in that particular case, and not in a hypothetical one. Providing medical records about an identified child and his birth parents for review allows a doctor to address the expectations and reality of a living, breathing child.
Who should prospective adoptive parents consult for a pre-placement medical assessment? If the adoptee is a child, a pediatrician is the most appropriate starting point. A pediatrician who has experience in the adoption and foster care area is an even better resource.
According to Dr. Veronnie F. Jones, adoption and foster care are evolving subspecialties in the pediatric field.3 The American Academy of Pediatrics has a section of its organization specifically focused on adoption and foster care issues; members of that section are available for consultation before couples take physical custody of a child (including before traveling for international cases).4
Depending on the child’s issues, a specialist in a practice area may need to be consulted. If the child’s country of origin has problems with a certain infectious disease to which the child may have been exposed, for example, an infectious disease specialist’s input would be beneficial and important. If the child has suffered abuse or other trauma, consultation with a mental health professional may be advisable.
Where Assessments Are Done and Records Are Stored
The pre-placement medical assessment to be undertaken will vary depending on where the child is being adopted. The source of the placement will affect the type and extent of medical records available and how reliable those records are.
Medical information on a child to be adopted can be divided into different categories and can come in different forms. The most informative type of medical information is objective information.5 This information includes measurements, such as height, weight, and head circumference; reports from laboratory, radiology, or pathology tests; and photographs of disabilities, facial features, etc.
Subjective information can be helpful, but it may be biased or incomplete. This type of information might include narrative descriptions or reports on the child by caregivers, such as a foster parent, or opinions on whether the child is developmentally delayed or normal.
Domestic Infant Placement
The reasons why a birth parent is choosing to make an adoptive placement are good places to start an evaluation when a newborn is being adopted in the U.S. Such reasons impact a child’s psychological, medical, and developmental future. If a birth mother cannot parent due to drug addictions, alcohol abuse, or mental illnesses, that background must be addressed. Can the child inherit the parent’s mental health issue? Was the child exposed to drugs and/or alcohol while in utero? Children available for adoption are at a high risk of prenatal exposure to illegal drugs or alcohol; thus, such exposure should routinely be considered a possible scenario.
Where there is the domestic adoption of a newborn, the birth mother’s prenatal care records are a crucial tool in assessing the child’s health and future risks. Adoption attorneys and agencies routinely obtain a medical release from a birth mother so those records can be requested and obtained from her obstetrician. These records should include not only information about her prenatal care, but also the medical history of both her and her family.
Blood test results are also contained in prenatal care records such as testing to determine blood type and testing for HIV, Hepatitis B, and sexually transmitted diseases. Drug tests can reveal what substances the child was exposed to in utero.
In some instances, a birth mother will have begun prenatal care late or did not obtain it at all. Regardless of how much or how little care she obtained, records obtained from medical care providers or hospitals in the United States are generally reliable and accurate. Thus, if a pre-placement medical assessment is conducted, at least the basis for that assessment is a solid foundation.
Adoption from Foster Care
According to a January 2012 article in Pediatrics, numerous studies establish that many of the children entering the foster care system have physical, developmental, and mental health concerns.6 These results are not surprising since children are usually brought into the system due to abuse or neglect by a parent. Thus, children adopted from foster care are at higher risk of mental health disorders.7
Medical records for children adopted from foster care in the United States can be viewed as containing reliable information. The problem, however, is that the medical care they do receive is often fragmented with limited continuity.8 When a child is moved from foster home to foster home prior to adoption, a different medical care provider may have seen the child while in each home. When the child was with the birth parent, the circumstances which led to the child’s removal from the home (such as drug addiction) may have resulted in the child not receiving regular or any medical care.
Medical records are generally the sparsest and least reliable in international adoptions; the quality of medical record translation from the child’s native tongue may play a role in this.9 Sometimes the age of the child is not even certain, and there are no accurate tests for age determination.10 Thus, despite having a pre-placement medical assessment, the prospective adoptive parents are still going to walk away with unanswered questions.
A specific concern in international adoption arises if the child comes from an institutional setting like an orphanage. Children who have resided in institutional care are at increased risk of growth delay since growth is impacted by the quality of care provided through the food and nurture offered there.11 According to Dr. Deborah Borchers, adoption physicians agree that a child typically loses one month of growth for every three months in an orphanage.12 For older children, growth measurements from preventive health care records offer insight into developmental progress.
Medical records containing information about the size of a child’s head need careful attention. A small head may suggest a birth defect, fetal alcohol exposure, or malnutrition.13
Pictures and videos of the child may be especially helpful. Entries in medical records may not convey all that should be considered. Seeing what the child looks like rather than simply reading facts about him or her allows a medical professional a broader view; what is observed in pictures and videos might suggest possible medical issues, such as fetal alcohol syndrome, based on things like facial features that are not otherwise addressed.
Assessments in China
A pre-placement medical assessment is especially critical when the child to be adopted is from China. Following the elimination of the one-child policy, the number of healthy children in Chinese orphanages plummeted. According to reports, 98% of the children remaining in institutions in that country have disabilities.14 In addition, the institutionalized children are now older, meaning they have spent long periods of time in an institutional setting. This history puts them at greater risk for behavioral and emotional effects related to extended deprivations.
Beyond actual physical issues, a child in an institutional setting is prone to experience abnormal development in language skills.15 Lack of one on one time with a caregiver impedes language development and causes language delays.16
Value of Pre-Placement Medical Assessments
The value of a pre-placement medical assessment is incalculable. Unfortunately, love will not be able to conquer all an adoptee’s problems; professional intervention and medical treatment may be required. Once a prospective adoptive couple is made aware of current medical problems, possible future risks, and the care and treatment required, an informed decision can then be made on whether they should agree take a specific referral or accept a specific match.
Armed with the knowledge such an assessment provides, an investigation can be made into critical questions. Do the prospective adoptive parents have appropriate and sufficient insurance coverage to provide the care needed? Even if effective drug treatments are available, they could be extremely expensive. Are the services the child would require (i.e., speech, physical, or occupational therapy) available in the prospective adoptive family’s local area? Does their school district provide accommodations the child might need in the classroom?
Without a pre-placement medical assessment, prospective adoptive parents are missing a crucial piece of the adoption puzzle. With the majority of children being placed for adoption having either an identified medical problem or risk factors for mental or physical health challenges, those seeking to adopt are ill-advised to forge ahead with adoption without detailed awareness of what lies ahead. Being prepared for the challenges placement of that child will bring is a prudent way to avoid disruption and dissatisfaction. If the expectation is that the placement of a child will automatically result in a happily ever after, a prospective adoptive couple is going to hit a harsh wall of reality. While knowledge obtained from a pre-placement medical assessment is no guarantee of adoption success, it certainly increases the odds that the couple will take on a situation with their eyes open providing greater likelihood they can create a viable forever family.
1“The Role of Pre-Placement Medical Review in Contemporary Adoption: Setting Expectations, Assessing a Child’s Needs, and Supporting Successful Family Formation,” Dana Johnson, M.D., PhD., “Adoption Advocate No. 131,” May 1, 2019.
3“Comprehensive Health Evaluations of the Newly Adopted Child,” Veronnie F. Jones, M.D., Pediatrics, Jan. 2012.
4“Ask the Doctor: Pre-Adoption Medical Assessment,” Deborah Borchers, M.D., Adoptive Families, May 30, 2020.