A review of national estimates of the number of adoptions reveals that there were 50,000 total adoptions in 1944. The number of adoptions steadily increased, hitting a peak of 175,000 in 1970, then declining to 104,088 domestic adoptions in 1986, according to NCFA data. Based on AIIP data, there were an estimated 118,529 total adoptions in the United States in 1990.

An ever-expanding number of U.S. families are seeking to build their families through international adoption. In 2003, 20,443 families chose to adopt abroad, a significant increase from 6,587 families in 1993 (Office of Children's Issues, n.d.). Despite this increase, not every adoptive parent understands that children coming to this country for adoption have lived under conditions very unlike traditional birth children. These early life experiences influence the developmental needs of internationally-adopted children and how they will be able to integrate into their new families. As a consequence, the child's parenting and therapeutic needs may be different than parents expect.

Unfortunately, common misconceptions or "myths" related to adoption can interfere with parental preparation for the realities of adoption. Pediatric nurses understanding these myths and realities, as well as relevant parenting strategies, can help a prospective adoptive parent both understand their child's background and its impact on development, and develop a unique set of parenting skills distinctly tailored to the needs of their new child. This preparation will help the adoptive parent rebuild the child's emotional and developmental foundation. Preparation will also help a parent integrate the child into the family.

A prospective adoptive family should be informed that children available for international adoption come from "high risk" backgrounds. Poverty is common and increases the risk of birth mothers having had limited or no prenatal care, poor nutrition, poor overall health, communicable diseases, and a history of substance abuse (World Health Organization [WHO], Regional Office for Europe, 2002; WHO, 2002). Children waiting to be adopted typically come from backgrounds of abuse and neglect (Mitchell & Jenista, 1997), and many were unwanted and abandoned.

Most children adopted internationally have lived in "baby homes," hospitals, or orphanages. Although the term "baby home," where many infants less than 3 are housed, may conjure up the idea of a more secure environment than that of the more negative words "orphanage" or "institution," each of these terms usually describes a similar environment that is very problematic for the young child's healthy development. [For purposes of this article, the term "institution" will be used generically to refer to each of these settings.]

Countries that are overburdened with the need to care for large numbers of abandoned children are also often faced with poverty and economic instability, and the needs of abandoned children are usually low priority (WHO, Regional Office for Europe, 2002; Mitchell & Jenista 1997). The institutional environments in which young children are raised are commonly fraught with problems ranging from lack of food, proper shelter, and clothing, to exposure to infectious disease, physical abuse, and sexual predators (Jenista, 2000; Johnson et al., 1992; Miller, 1999a; Miller, Kiernan, Mathers, & Klein-Gitelman, 1995; Mitchell & Jenista, 1997). In addition to physical deficiencies, the most egregious issue of institutional life is the all too common lack of consistent caretakers for young children (Chisholm, 1998; Smyke, Dumitrescu, & Zeanah, 2002). Typically, institutional care of children is provided by a large number of poorly trained adults who are unable to provide consistency or otherwise meet the developmental needs of the children in their care (Johnson et al., 1992; Chisholm, 1998; Chisholm, Carter, Ames, & Morison, 1995; Morison, Ames, & Chisholm, 1995; Rutter, 1998; Vorria, Rutter, Pickles, Wolkind, & Hosbaum, 1998a; Vorria, Rutter, Pickles, Wolkind, & Hosbaum 1998b; O'Connor et al., 2000). This lack of consistent and appropriate care can result in lifelong issues for the adopted child and family, including behavioral, cognitive, emotional, and social problems (Rutter, 1998; O'Connor et al., 2000).

Medical and developmental concerns. An erroneous assumption is often made that children adopted from other countries have received the same type of medical and developmental care they would have if they had been living with a family or staying in a hospital in the U.S. Actually, children raised in institutions often lack sufficient of nutritional food, shelter, and clothing (Frank, Klass, Earls, & Eisenberg, 1996; Gunnar, Bruce, & Grotevant, 2000). Medical problems are treated inadequately or not at all. Due to a multitude of factors, the vast majority of children arriving for adoption will present with significant growth stunting and marked developmental delays (Johnson et al., 1992; Mason & Narad, 2002; Miller & Hendrie, 2000; Morison et al., 1995). Many children will also present with behavioral abnormalities including unusual steriotomies (rocking, head banging, and hand flapping), attachment difficulties, and either aggressive or extremely passive behaviors, including conduct disorders (Chisholm et al., 1995; Chisholm, 1998; O'Connor et al., 2000; Rutter, 1998; Smyke et al., 2002; Zeanah, Smyke, & Dumitrescu, 2002). Many of these behaviors develop as adaptive survival skills in the institutional setting but will often be frustrating and challenging in the home. To better prepare for their new child's arrival, parents need to familiarize themselves with the potential and/or actual medical, developmental, and emotional challenges of their child.

Pre-adoptive consultation. A pre-adoptive consultation with an international adoption specialist can be helpful in interpreting information parents may have obtained about the child. At the time of the consultation, the specialist will review growth and developmental information obtained from medical reports as well as any videotapes and pictures. In many circumstances growth parameters, but no accurate developmental assessment, will be provided. These growth measurements often can serve as a proxy for the child's overall health and development, since factors that interfere with the child's growth--ranging from prenatal exposures and malnutrition to underlying medical conditions--can also interfere with the child's cognitive development (Gunnar et al., 2000; Mason, personal communication, 2004; Mason & Narad, 2002; Miller & Hendrie, 2000; Morison et al., 1995). The international adoption specialist can identify potential risk factors and possible long-term implications, as well as discuss potential supportive interventions. Pre-adoptive consultation with an international adoption specialist is one way to ascertain if the referred child will be one that the family feels adequately prepared to parent (see Table 1).

Medical conditions are usually the principle concern of adoptive parents. Internationally adopted children often live in overcrowded conditions with poor nutrition and hygiene, breeding grounds for opportunistic infections. Intestinal parasites, hepatitis B and C, tuberculosis, and scabies can be present (Miller, 1999b; Miller & Hendrie, 2000; Stephenson, 2001). Fortunately, the majority of these conditions are self-limited or treatable. However, other conditions such as fetal alcohol syndrome, fetal alcohol effects, lead poisoning, mental retardation, and genetic diagnoses have long-term and lifetime implications.

Immunizations. Commonly, adopted children present reports of immunizations that demonstrate inaccuracies, such as vaccines given before the child's birth, given at inappropriate times of intervals, or given on the same day of each month. Some research demonstrates that many children adopted from international orphanages have high rates of positive antibodies (Staat, 2002); however, this is not universal (Hostetter & Johnson, 1998). Current recommendations suggest that internationally adopted children should have vaccination records reviewed at their first medical appointment after arrival. Those children with either no records or inadequate immunizations should have their vaccines restarted. All other children should be screened and re-immunized if titers are inadequate.

Nutrition/feeding. The nutritional status and feeding history of the internationally adopted child has implications for growth, development, and behavior (Olness, 2003). The quality and quantity of the food provided in many institutions is often severely limited by economic factors. Foods are often supplemented with sugar to boost calories. Lack of adequate nutrients can impact the child's growth and overall health (Mason & Narad, 2002; Mason, Narad, Jester, & Parks, 2000). Malnutrition, rickets, poor vision, anemia, and other conditions may be present. Fortunately, many of these problems can be minimized or resolved with proper nutritional intervention.

Meal times in institutions are based on necessity and survival rather than nurturing and socialization: feeding is often quick and unpleasant. The child is usually positioned facing away from the caregiver and the food, lacking variation in texture and taste, is rapidly "shoveled" into the child's mouth using a large serving spoon. Minimal time is permitted for swallowing. Children may be required to eat either piping hot or ice cold foods, depending upon where they are in the serving line. Toddlers quickly learn to use utensils or risk going hungry.

Once a child is adopted, these early feeding experiences often manifest as troublesome and challenging behaviors ranging from voracious consumption to food avoidance. For example, infants often have ferocious sucking and quickly finish a bottle. Removing the bottle for burping can be an anxiety producing behavior as the infant is not used to getting the bottle back once it has been taken away. Similarly, when presented with a plate of food the toddler may continue to consume more than needed to satiate hunger. To help combat these behaviors, parents should offer their children food on a regular and predictable basis. Typically, during the first few months, caloric intake should not be limited, and the child should be allowed to consume as much food as desired.

Parents may also have to deal with a child demonstrating significant food aversions. These aversions can take the form of food or texture avoidance. New flavors, odors, and textures of food may be unfamiliar and overwhelming to the recently adopted child. Past forced feeding experiences, underlying medical conditions, or anxiety associated with prior feeding techniques can pose a dilemma for both the parent and the child. Consequently, feeding can be very stressful. Children may refuse the bottle or "spit out" certain textures of food. Often a child will self-limit the type, amount, and consistency of food intake. Further, most internationally adopted children have missed out on the social context and pleasure associated with mealtime (Frank, Klass, Earls, & Eisenberg, 1996). Having the luxury of playing with food and choosing what, when, and how much to eat are likely new experiences (Dietz & Stern, 1999). Parents can help children with food aversions by starting with familiar foods, slowly changing their consistency, and very slowly introducing new foods.

If a child is not gaining weight after adoption, evaluation by a health care provider and, potentially, a gastroenterologist will be important to evaluate underlying conditions such as helicobacter pylori infection. Behavioral and feeding interventions may also be necessary.

Acquisition of developmental milestones is of paramount concern when assessing the preadoptive child. Before the adoption, parents should obtain the most recent and accurate assessment possible of the child's developmental milestones. This should then be compared to chronotogical age appropriate norms. By determining the deviation in the child's developmental milestones based on chronological age, the prospective parents will gain a better understanding of what problems they may face. For example, a 24-month-old child with developmental milestones of a 6-month-old is far more concerning than a 24-month-old child with developmental milestones of a 20-month-old.

Developmental delays are common among institutionalized children and understandable given the child's early environment. Some of these delays may be remediable with parental support and an improved environment after adoption. However, the reversibility of delays is not assured: an observed delay may in some cases be the early sign of lifelong physical or cognitive impairment.

Speech and language. Speech and language development is one area commonly needing attention. Because children in institutions often lack consistent primary caregivers with whom to have one-on-one interactions (Zeanah et al., 2002), foundational experiences in language development may be missed--the opportunity to observe a caregiver's face, listen to the cooing sounds of the adult, and mimic these sounds for example (Lansdown & Walker, 1991). Often the child has had limited exposure and opportunity to observe and practice language skills. As a result, the majority of internationally adopted children will have what Glennen and Masters (2002) term "stop and restart" language development.

To help with English and general language skills, parents should speak to the child and provide an environment rich in vocalization and language stimulation. Initially, getting down at the child's eye level and allowing him or her to watch the parent's mouth move while listening to the sounds is helpful. Often this is the first time the child will have been exposed to how sound is made. Responding in a consistent manner to the child, with pauses between vocalizations, is helpful. Singing songs and playing noise games are also useful. Initially upon coming to the adoptive home, the young child may have arrested language development and may not be making sounds. Older children may have poorly developed native language skills. Either way, parents should be watching for continued advancement in language. While many internationally adopted children will go on to acquire language at rates similar to those born and raised in the U.S., approximately one third of adopted children will have some speech and language difficulties (Glennen & Masters, 2002). Delays in language also may be a signal of other underlying issues, such as neurological impairment or cognitive delays (Glennen & Masters, 2000; Irwin, Carter, & Briggs-Gowan, 2002). For these reason children who are not progressing within the norm should obtain speech and language evaluations, and intervention as needed.

Motor skills. In many cases, children will gain new motor skills once they are in a family. Many institutionalized infants have been kept in cribs or playpens throughout the day and not given the chance to explore. In some cases the children have been tied to beds or potty-chairs to make keeping track of them easier. These children may become upset with quick changes in position or movements from one surface to another as well as when presented with large open spaces, like a playroom. They may lack understanding of where their body is in space and may not understand that their limbs are able to help them get from one place to another. Given these early experiences, gross and fine motor skill delays are common following adoption. None-the-less, the newly adopted child should be assessed for underlying medical conditions that may contribute to weakness or delay.

Parents can offer activities that allow children to experience motion and mobility. For example, gross motor development can be encouraged by simply allowing the child to roll of roam around a room and even climb over the parent, or if weakness is present, to move with parental assistance. A variety of textured surfaces can be gradually introduced. Incrementally increasing the space a child is allowed to explore and watching for signs of being either overwhelmed or under stimulated are important.

Fine motor skills, such as discovering one's hands and picking up toys, are often novel for the previously institutionalized infant. Young toddlers may never have had the opportunity to actually hold and explore safe objects. Parents can offer materials such as pizza dough or o-shaped cereals to help children practice grasping.

Adoption is a great joy and milestone achievement for families. So, celebrating the adoption of the new child and introducing them to extended family and friends is often of paramount importance for new parents. It is common for parents to want to plan a welcome party or to have many people over to visit in the first weeks. However, most children first coming home are not ready to deal with the barrage of new people, smells, sights, sounds, noise, colors, textures, and activities associated with a celebration. A newly adopted child, yet unattached to parents, lacks a secure base to retreat to when overwhelmed. Parents should be informed that a more supportive way to introduce the child to family members is slowly over time. Contact with friends and families should be minimized until the child has an increased level of comfort with the parents and is ready for new experiences.

Environment. Because many institutionalized children have been confined to cribs and deprived of early sensory stimulation, coming into a normal home environment can in itself be overwhelming. By keeping the environment low key and integrating the child slowly, parents can minimize sensory overload and provide the child with the opportunity to gradually learn to master the sights, sounds, smells, and textures of his or her new world (Federici, 1998; Morison et al., 1995). Initially room colors should be muted and only minimal toys available.

Interactions. Most importantly, a child needs to spend time with the new parents. The luxury of having one or two people provide individualized attention is far more exciting and important than the television or the latest toys. Parents may need to be informed that institutionalized children do not automatically know how to play. A helpful approach is for the parent to present the child with a toy, demonstrate what to do with it, and then gradually offer challenges to help the child move to the next level of mastery. The best way for children to learn is when they are excited about and engaged in an activity (Greenspan, 1992).

Toys. In choosing toys, those that promote a rich opportunity for imaginative play and child- induced noise are ideal for integrating socio-emotional and developmental skills. While playing and having fun with quality toys, children are also learning about persistence, cooperation, leadership, tolerance, empathy, turn taking, ordering, and sequencing (Singer, 1996). Furthermore, they are playing different roles and emotions and thus learn to discriminate between what is pretend and what is reality (Greenspan, 1992; Singer, 1996). The combination of all these play-related skills helps the child learn to better negotiate their world while advancing milestone development.

Because the child's development is often delayed, parents need to adjust their parenting expectations to the child's developmental, rather than chronological age.

Identification of delays in development, behavior, and social-emotional skills, as well as early treatment have been found to be beneficial for both the child and the parent (First & Palfrey, 1994; Sices, Feudtner, McLaughlin, Drotar, & Williams, 2003).

Love is a very valuable and important part of the adoption process. However, love alone is often not able to make up for the deprived past environment the child has likely experienced.

Attachment. Since many internationally-adopted children have not been exposed to a consistent caregiver, the child may never have developed healthy attachments, and the new family may face some challenges developing relationships (Zeanah et al., 2002). Although attachment is a complex process that changes over time, affection, reliance on caregivers, and exploratory behavior are three aspects of attachment adoptive parents should be attuned to (Boris, Fueyo, & Zeanah, 1997). First, in an institution, the one way for a child to receive extra attention or food is to seek out strangers. In an adoptive family, parents need to help a child integrate the concept that the parent is consistently available and reliable in both giving and receiving affection. For healthy attachment, the child should learn to discriminate parent from stranger in this regard. Second, a young child needs a balance between reliance on the parent and the development of a sense of independence. Children who are either overly compliant or have defiant behavior that does not allow for reliance on a parent are demonstrating attachment problems that need intervention. Third, a developmentally healthy child has an ability to explore an unfamiliar environment by starting out near the parent, moving further away, and then returning to the parent for a reunion and emotional recharging (Bowlby, 1988). Difficulty separating or separating but not checking-in with parents are signs of concern (Boris et al., 1997). When attachment problems are noted, parents should seek an assessment and guidance or intervention as early as possible from a health care professional familiar with internationally adopted children and attachment problems.

Having an understanding of normal growth and development will help the family identify needs the child may have soon after their adoption. Additionally, by understanding the early life events of an adopted child, parents can recognize the need for special parenting approaches. Educated and informed parents can put a plan in place that will help the child learn the new behaviors that are appropriate to the family environment while minimizing those that were necessary for survival in the institution. Well-informed parents can also recognize when, despite all their planning and preparation, they may need to locate and advocate for professional help for the child and/or family. Understanding these realities of international adoption can help families promote optimal development of their new child and optimal development of the family unit as a whole.

Table 1. Resources for International Adoption Information American Academy www.aap.org Provides general information on of Pediatrics adoption links to the sub specialists with experience in international adoption. Centers for www.cdc.gov Provides information on the Disease Control treatment of infectious disease and current international health issues. Joint Council www.jcics.org A national organization of adoption of International agencies. Children's Services University www.peds.umn. Provides links to adoption health of Minnesota edu/iac/ care professionals throughout the United States. U.S. State www.state.gov Current international travel advisory Department information.

The Family Matters section focuses on issues, information, and strategies relevant to working with families of pediatric patients, To suggest topics, obtain author guidelines, or to submit queries of manuscripts, contact Elizabeth Ahmann, ScD, RN; Section Editor; Pediatric Nursing; East Holly Avenue Box 56; Pitman, NJ 08071-0056; (856) 256-2300 or FAX (856) 256-2345,