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The health and well-being of adopted children.

Article Excerpt
THE AMERICAN ACADEMY of Pediatrics (AAP) has recognized that adopted children may have particular vulnerabilities and health conditions for which pediatricians should be alert and has made recommendations regarding the content of initial medical examinations of children at the time of adoption. (1) The AAP has also recognized a role for pediatricians in facilitating communication about adoption-related health issues with adoptive families. (2) Pediatricians may need to evaluate preexisting health conditions in children whom families are considering adopting or who have been adopted, and specialty health clinics on adoption now exist in most large cities. (3)

The literature on the health of adopted children is primarily limited to clinical or volunteer samples or studies of small populations. Of 101 studies included in a recent meta-analysis, only 7 involved sample sizes of >500 children. (4) There are clear advantages to using large, nationally representative samples to examine issues specific to adopted children, (5) yet few national surveys have sufficient sample sizes to permit reliable analyses of adopted children. The National Survey of Children's Health (NSCH), with a sample of nearly 3000 adopted children, is an exception. In this article, we take advantage of this resource to examine the health and well-being of adopted children relative to biological children.

THE HEALTH OF ADOPTED CHILDREN

Adoption is a legal action in which parental rights and responsibilities are transferred from one person to another, creating a parent-child relationship where one did not exist at birth. Approximately 2.5% of US children (1.6 million) joined their families through adoption. Analyses of census data have shown that adopted children differ demographically from children living with biological parents: adopted children are less likely to be <6 years of age and are more likely to be girls and to live in families with higher incomes. (6)

Review articles have described the literature regarding the health and development of adopted children. (7,8) Although most adopted children are healthy, adopted children have been shown to be at elevated risk for adjustment problems, externalizing behaviors, conduct disorders, and attachment disorders, A recent meta-analysis of studies regarding behavioral problems and mental health referrals suggested that adopted children had somewhat more behavior problems but were substantially overrepresented beyond their higher levels of need in their use of mental health services. (4) This phenomenon may reveal both higher problem prevalence and higher levels of service seeking by adoptive families. (9-11) In addition to mental health concerns, adopted children are also more likely to have at least 1 disability.

Representative survey data have provided some information about the prevalence of health problems and health care issues for adopted children. Miller and colleagues (5) found that although the vast majority of adopted adolescents were well within the normal range of functioning, adopted children were at higher risk across a broad array of domains, including school achievement, physical health, and psychological well-being. Sharma et a1 (12) examined data on nearly 5000 adoptees and matched controls selected from a large survey of youth in schools and found that adopted children experienced consistently higher levels of drug use, negative emotionality, and antisocial behavior. These surveys, however, focused on issues of adolescents and, although large, were not representative of the national population of adopted children.

We present and compare estimates of the health and well-being of adopted children and biological children. Recognizing that there are differences in demographic characteristics between these 2 populations, characteristics that may be related to health and well-being outcomes, we adjust estimates to control for differences in demographics. Because we expect that adopted and biological children will differ on health status, we also adjust estimates of health care access and use and child well-being to control for special health care needs status to examine whether these indicators show differences above and beyond differences in need. Our analyses allow us to make inferences about the health and well-being of adopted children relative to biological children, independent of preexisting differences in demographic characteristics and the prevalence of special health care needs.

METHODS

The data are from the 2003 NSCH, which is described in the article by Kogan and Newacheck (13,14) in this issue; more in-depth information can be found elsewhere." Human subjects review was not required for this study.

In the NSCH, there were a total of 2903 adopted children, 2.8% of the total sample. Respondents were asked their relationship to the child, and if the respondent was the mother (or father), the respondent was asked whether she (he) was a biological, adoptive, step, or foster mother (or father). If the respondent was not the mother (or father), then the respondent was asked whether the mother (and/or father) in the household was a biological, adoptive, step, or foster mother (or father). This enabled us to identify, for any household with a mother (and/or father) present, whether that mother (father) was the adoptive mother (father) to the child. We identified any child with an adoptive mother...

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