ADOPTING FROM ABROAD

As she adopted a 15-month-old girl from India, Jerri Ann Jenista was told that the child had cerebral palsy, severe developmental delays and was thought to be having seizures.

Jenista, a University of Michigan pediatrician who specializes in the health problems of children adopted from other countries, took her new daughter Rohina right off to a neurologist. In those initial screenings six years ago, the doctors ruled out cerebral palsy and the seizures, Jenista recalled, and friends and colleagues assured her that Rohina's developmental delay would improve with time. And it did. So did her hepatitis, her intestinal parasites, her tuberculosis, her asthma, her malaria, her malnutrition.

When Rohina was 3, Jenista took her in for a routine checkup. Her pediatrician was on vacation, and they saw a new one.

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"What are you doing about the blind eye?" the new doctor asked a flabbergasted Jenista.

"In retrospect," said Jenista, "almost everything {neurological symptoms and developmental delays} could be explained by that eye. I was so focused on what I thought she should have, as were her other doctors, that we missed the real problem."

This story has a happy ending, as do most of the stories of foreign adoptions. Rohina, now 8, is healthy and doing well in school.

Babies from abroad may come with health problems, but they are often minor. Even when they are not, most of the problems can be addressed medically. Certainly, say parents and pediatricians, they do not lessen the joy the children bring or the love they receive.

"The vast majority of children adopted from other countries have some problems," said Jenista, "but they can be taken care of if you think about them."

Yet if Jenista, who is one of the leading specialists in her field, could miss such a significant problem in her own child, she wondered, what must be happening in the rest of the country?

In fact, parents and the doctors who work with children being adopted from abroad are concerned about exactly that. International adoptions have accounted for 7,000 to 10,000 placements a year in this country over the past five years. As the number of children from underdeveloped countries rises, so do concerns about their health.

"Most of the kids adopted from abroad come in pretty good shape," said Dana Johnson, a Minnesota neonatologist who is director of the International Adoption clinic at the University of Minnesota in Minneapolis. They come "with problems that by and large you can either cure or at least deal with in an intelligent fashion."

There are no statistics or demographic studies on how many children come with health problems and what types of problems they may have. Yet a pattern of medical problems is beginning to emerge. These ailments often reflect the health conditions of the country and may not be easily recognized by U.S. doctors.

One of the most common, yet potentially dangerous, ailments is the presence of intestinal parasites -- giardia, various types of amoeba and worms. If left untreated, parasites can lead to chronic diarrhea and a failure to thrive. Children also frequently have scabies, lice, skin diseases and ear infections. All of these conditions can be cleared up with appropriate drug treatments.

A smaller number of adopted children come with more serious problems, including hepatitis B and tuberculosis. There have even been a handful of cases of AIDS, according to pediatric specialists.

These illnesses pose serious risks for the child and the parents if the infection goes untreated. A child may harbor the hepatitis B virus for years with no symptoms, but can pass the virus to others. Untreated, hepatitis B can cause potentially lethal liver problems, including cancer.

Tuberculosis is another concern. It can usually be promptly cleared up in young children with drug treatment. In infants, the disease is rarely contagious to members of the family.

What concerns specialists like Jenista and Johnson is that many U.S. physicians are so unfamiliar with some of these illnesses that they may go undetected -- and untreated.

"One of the problems," said Johnson, "is that these children look good. They're not the starving orphans that have been stereotyped in the media."

Most pediatricians who see these children are mainly used to upper middle class families and are unprepared for the more unusual problems that may be present. "They are simply not doing appropriate screening tests," said Johnson, whose clinic has seen more than 500 children in the past five years who have been adopted from abroad, and had phone consultations on more than 1,000.

Pediatricians who have studied adopted children point out that every child's condition is different and there is little way to say with certainty beforehand which children will have serious conditions to deal with or which will have mild problems.

In addition, these experts caution that adoptive parents and the children's primary doctors must be aware of special behavioral and developmental problems the children might face.

Marlene Cimons, a Los Angeles Times reporter who adopted a daughter from Calcutta almost five years ago, sought help from Johnson's clinic about the baby's small size. Barra, her child, turned out not to have any medical problem; she was just petite. But it was frightening for a time, Cimons said.

"You love these kids so much, and they really are your children, you do whatever you have to to ensure their health," she said.

Children from Latin America and India often come into this country with clearly wrong health information provided by care givers in the originating country, said Laurie Miller, chief of the International Adoption Center at Tufts New England Medical Center in Boston. "Sometimes, they come billed as healthy and turn up with major problems, such as heart lesions," she said. "Sometimes, kids who come billed with serious health problems turn out to be great."

Everything has to be interpreted very carefully, she said.

Yet such an experience can be daunting for parents, even when the child is quite healthy. WJLA Anchor Susan King said she and her husband Michael had heard all the horror stories about health problems but were determined to press ahead with plans to adopt a child from Paraguay.

"There were about six of us who learned we'd been assigned babies at about the same time," she said recently. "Then other people who already had adopted would tell us" about specific difficulties they had encountered.

King said she began to wonder what she would do if her child had big problems: "All of a sudden, you have stuff you have to think through. I decided there would be very little that would be a medical barrier for me -- modern medicine can do wonders."

King said that when they received the initial reports about their baby, the only problem Maria Suzanne (known as "Mia") had turned out to be a skin rash. A Paraguayan doctor said it might be scabies -- caused by a skin parasite. Mia was treated and quickly recovered. At the age of 4 1/2 months, she came home to Washington from Paraguay.

The number of foreign adoptions is small compared to those arranged in this country. About 25,000 American-born infants a year are adopted. In addition, another 25,000 older American children or children with certain "special needs" -- handicaps, birth defects, illnesses and genetic problems -- are placed in U.S. families every year.

Until recent years, the majority of children adopted into the United States came from South Korea -- an estimated 83,000 placed in U.S. homes since the end of the Korean War in 1953. But South Korea has begun to restrict the number of children available for out-of-country adoptions.

As adoptions became harder to arrange in South Korea, the focus turned to India and Latin America. Most recently, as the Iron Curtain crumbled, Americans began adopting in Eastern Europe.

Following the overthrow of dictator Nicolae Ceausescu, Americans rushed to Romania seeking babies. In the peak year, October 1990 to September 1991, about 2,300 Romanian children entered the country, according to the Immigration and Naturalization Service. However, amid charges of black-marketeering in babies and other abuses, Romanian officials suspended all out-of-country adoptions last summer. Today, the breakup of the Soviet Union is again shifting adoption attention, now to the newly independent Russian Commonwealth states.

There are no U.S. health regulations that apply to children in foreign countries who are being adopted by American parents. Most adoption agencies require that children be examined by a physician or nurse before they come to this country.

Nonetheless, a study published last August by Johnson, his co-director at the Minnesota clinic Margaret Hostetter, and other members of the clinic staff in the New England Journal of Medicine, reported that one or more serious medical problems, including intestinal parasites, were found in 168 of 293 children adopted from 15 countries who were examined at the clinic. The children, ranging in age from one month to 13 years, had all been seen by pediatricians in this country who had failed to screen for many of the ailments, including hepatitis B and tuberculosis.

Hepatitis testing was positive in 61 of 287 children, and 10 of the 293 youngsters had positive tuberculosis tests; four of these had active disease. Those four were also found to have other infections, including cytomegalovirus, a herpes-related virus, and evidence of earlier polio.

Hepatitis B in this country is primarily a sexually transmitted disease, but it is endemic in some Third World countries, where a child can be infected not only by a carrier mother but also by the reuse of needles in hospitals and orphanages, by blood transfusions routinely used in some Eastern European hospitals to strengthen anemic infants and by poor hygiene.

Robert Lange, an internist in the Medical Adviser's Office at Johns Hopkins Medical Center in Baltimore, who also is a volunteer consultant to international adoption agencies, said that vaccines are now available to protect families and other care givers against infection. For the child with asymptomatic hepatitis, routine monitoring can detect liver problems early.

In addition, the possibility of the AIDS infection in internationally adopted infants is something Jerri Jenista fears might become a major problem in the next decade. Experts estimate that perhaps half a dozen babies have tested positive for the human immunodeficiency virus that causes AIDS after they have been brought here.

"Although the chance of infection is remote" in all but a few high-risk prevalence areas including the U.S., Jenista wrote in an article for adoptive parents, "HIV infection should be considered as an increasing health risk."

When the social worker called from India and told Sheri and James Daugherty in Connecticut about Avinanth, an Indian boy, the couple was undaunted by the report that he had a heart defect. The boy had a ventricular septal defect, known as a hole in the heart, which is actually an opening in the partition that separates the ventricles. It is not uncommon and often closes spontaneously.

The decision to adopt seemed easy for the Daughertys -- he's a vice president at a large bank, and she's a director of organizational development for a diagnostics firm. They already had one adopted son, Jacob, who had open heart surgery at 3 months.

"We thought about it for all of about 15 minutes," Sheri Daugherty said, "and we both decided, how could we not? We knew we could get the resources to give him the best health care possible, and we felt sure we had the emotional reserve to handle it."

Avinanth came last fall and was examined at Yale Medical Center. He had many of the conditions usual for children coming from a developing country -- scabies, impetigo, parasites -- and he also tested positive for inactive tuberculosis. He did not have the heart defect they expected; it was something more serious. Doctors said he had a patent ductus arteriosis, a duct that normally closes after birth but in his case did not.

When he was operated on, the cardiologists at Yale found more heart problems, which suggested that his birth mother had had prenatal rubella -- German measles. He will need more surgery at Yale. Sheri Daugherty admits to being "a little scared" because the possibility of prenatal rubella could mean a host of other serious problems down the line, including blindness.

Meanwhile, Avinanth, who has gained three pounds since his arrival, is in kindergarten, learning English quickly and "adjusting extremely well," his mother said.

Kathy Sreedhar, who has two children adopted from India and one natural child, has become an unofficial ombudsman to help couples wade through the layers of Indian bureaucracy that can delay adoption for months. She also provided a written guide to help prepare adoptive parents for some of the physical and emotional problems they might encounter.

She adopted her first child in 1972, shortly after the death of her Indian husband. Anita, as Sreedhar named the baby, was 11 months old and weighed 13 pounds. She had intestinal parasites and was seriously malnourished, said Sreedhar. Her diarrhea lasted for months after Sreedhar came home with her because none of the doctors could do anything about it. Sreedhar was working for the Peace Corps here and recalled that she finally took Anita to a State Department doctor. The doctor found and treated the parasites that were sapping the child's strength. Today Anita is 20, a junior at Sarah Lawrence College.

Sreedhar's youngest child, Dev, came nine years ago at about age 3 with a 50 percent hearing loss. He had been abandoned to the sisters working with Mother Theresa, "and they thought he was so cute because he never stopped running," Sreedhar said. But "it was because he was hyperactive."

After being in this country for about five years, Dev was found to have some learning disabilities. But now, Sreedhar said, he is in a special school and "doing great."

The developmental problems that internationally adopted children come with are often among the hardest things to spot. For one thing, said Katherine Smith, a Washington, D.C., pediatrician, "these children from around the world don't fit into the physical growth and development charts that have been developed for U.S. babies." Smith recalled recently that she'd had a parent come in who was worried about the small size of her baby from India.

"I put in half a dozen phone calls to find out if there were any growth curves appropriate to him," she said. "I called the Department of Health and Human Services, the American Academy of Pediatrics and the World Health Organization and blanked out everywhere." Finally, she was referred to Johnson's Minneapolis clinic, which sent her charts for Korean and Indian babies.

For years, while most of the babies came from South Korea, the pediatricians were, as Jerri Jenista puts it, "lulled into a false sense of security." By and large, the Korean children were in excellent health. Many had been cared for in relatively affluent foster homes. Of course, as Dana Johnson said at a conference of adoptive parents last summer, "Korean children come in excellent shape, but they're carried around by their foster parents almost the entire time. When they get here, they're way on the top of the American growth curves and they're kind of lying there doing nothing. They don't roll over. They don't sit up. They have lousy gross motor skills, and if you're not used to looking at those kids you think, my God, that kid's brain damaged."

But "after the child has a chance to lie on the floor and roll around and then crawl around, they'll catch up pretty quickly," he said.

Susan Frievalds, a Minnesota woman who 25 years ago founded and still directs an adoptive parents' support organization with about 15,000 members called Adoptive Families of America, said that when her daughter arrived from South Korea almost 16 years ago at the age of about 9 months -- they never got an exact birth date -- she couldn't sit up but did within three weeks.

It may not be the same with the large number of the babies that came from Romania. Some of the Romanian babies come with only minor problems, especially the youngest ones. Others had been kept for months, sometimes years in orphanages where only the barest health needs were addressed. In addition to being exposed to diseases such as tuberculosis, hepatitis and AIDS, according to press reports from Romania, some of these children were virtually caged in cribs and had little human contact. Johnson suspects that problems will persist indefinitely in some of these children, although others are "spectacular successes," he said.

Tufts' Miller is more optimistic about the Romanian babies. She believes that with a lot of love, stimulation and good food, most of these children "will blossom."

Daniel Greene, adopted from Romania last March at about 10 1/2 months, is one of the "spectacular successes." But "when we first saw him, I just went 'gulp,' " said his mother, Joanne Albert. "He was extremely malnourished and fairly behind developmentally."

Family members and friends were sure he was not just sick, but retarded, she said, "Nobody really said anything, but you could just see that people were really, really concerned."

At 11 months, Daniel couldn't sit up unassisted. He couldn't crawl. He had no exposure to eating solid food.

Albert and her pediatrician at Kaiser Permanente found a Montgomery County program that had been initially designed for "crack babies," where he went for a couple of months until the program was closed. Now, at 20 months, in a preschool program for developmentally delayed children in the county school system, Daniel gets speech, physical and occupational therapy. In the first six months he was here, Albert said, "he crammed in nine months of development." By and large, he now does almost anything any 20-month-old can do, according to his mother.

In her letter of advice to would-be adoptive parents, Kathy Sreedhar took pains to warn them about the emotional toll children adopted from other lands would have. She wrote, "They suffer from being shifted, separated and having to learn to adjust to new people, new ways of being treated and a new language. Your child may behave in any one or more of the following ways: she may be passive, withdrawn, unresponsive, rejecting or {overly clinging}; test you to make sure he won't be sent back if he's 'bad'; have temper tantrums, disobey, be destructive, bedwet, refuse to eat or sleep or have terrifying nightmares." She wrote that more than a decade ago, but today's experts confirm the message.

Emotional and developmental problems can occur in many adopted children, whether they are adopted from here or abroad. When delays are caused by malnutrition, they can be quickly rectified.

But even the smallest children face some trauma in the radical changes an adoption, especially an adoption to a new culture, can entail. Pediatrician T. Berry Brazelton writes in his book, "On Becoming a Family," that even a 4-month-old has adapted to the environment he or she has been in and "even when the previous placement has been relatively empty and depriving, the baby will have made an adaptation and the baby will have to 'grieve' over the lost environment in order to adapt to the new."

If the new parents understand this grieving may mean a withdrawal and an apparent rejection of "nurturing cues" that is only temporary, they will be less likely to feel they have done something wrong, that they are failures as parents, experts say. The baby will adjust at his or her own pace.

According to David Brodzinsky, a behavioral psychologist at Rutgers University who specializes in the issues involving adopted children, "major complications can come in when kids come from foreign countries and are placed in families where they cannot communicate. The sense of helplessness they must feel must be something we can scarcely conceive," he said.

But even those adopted as newborns may experience a sense of loss at around age 6 when what it means to be adopted begins to penetrate. "You see grief-related reactions and children responding in different ways to what it means to be adopted. The families need to be supportive and understanding because these are things that are not necessarily resolved and put away. It has to be an ongoing dialogue," he said.

Many of the international adoption agencies urge the new parents to participate in cultural activities relating to the child's homeland. Lisa Swenson, who, with her husband, has adopted two Korean children, is about to send her 5-year-old daughter Schuyler to a Korean culture club in Chevy Chase. Her 20-month-old son will go later.

"The children need to have some link to the countries they came from," she said. "They will be growing up with multiple identities and should be knowledgeable about and feel comfortable with both."

Schuyler is "already asking questions about Korea . . . The club where she will get a smattering of language, of history, of culture will help answer her questions," Swenson said.

"She knows she's an American, and we're her parents. She'll someday want to relate to Korea, too."

The three major health centers for internationally adopted children are:

Tufts New England Medical Center adoption clinic: 617-956-7285.

University of Minnesota adoption clinic: 612-626-6777.

University of Michigan adoption clinic: 313-763-2440.

Other sources on international adoption:

Adoptive Families of America, a parents group with 15,000 members and about 275 affiliated local groups. The national organization publishes "Ours," a magazine containing information about cultural, medical and psychological issues associated with international adoptions, as well as information about where and how to adopt. For a free information packet, write: 3333 Hwy. 100 North; Minneapolis, Minn. 55422 (612-535-4829).

The Report on Foreign Adoption, available from International Concerns Committee; 911 Cypress Dr., Boulder, Colo. 80303. (303-494-8333). Listing of all U.S adoption agencies that work in intercountry adoption, the kinds of children they place and requirements for parents. -- Sandy Rovner

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