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INTERNATIONAL REFERENCE CENTRE MINISTRY OF FOREIGN FOR THE RIGHTS OF CHILDREN AND EUROPEAN AFFAIRS DEPRIVED OF THEIR FAMILY (ISS/IRC) INTERNATIONAL ADOPTION SERVICE THE PLACE OF CHILD HEALTH IN THE ADOPTION PROCESS The place of child health in the adoption process 1 TABLE OF CONTENTS PREAMBLE 3 1. INTRODUCTION 4 2. THE STATE OF HEALTH OF ADOPTED CHILDREN: AN OVERVIEW 5 A. RESULTS 5 B. ANALYSIS 5 3. PRE-ADOPTION SUPPORT 7 A. RESULTS FOR COLLECTIVE INFORMATION SESSIONS ON MEDICAL SUBJECTS BEFORE THE ADOPTION 7 BRIEF OVERVIEW 7 DETAILED SUMMARY 7 B. RESULTS FOR INDIVIDUAL PRE-ADOPTION CONSULTATIONS 8 BRIEF OVERVIEW 8 DETAILED SUMMARY 8 C. ANALYSIS OF RESULTS FOR PRE-ADOPTION SUPPORT AS A WHOLE 9 4. MEDICAL SUPPORT FOR ADOPTION APPLICANTS AND THE CHILD IN THE COUNTRY OF ORIGIN 11 A. RESULTS 11 BRIEF OVERVIEW 11 DETAILED SUMMARY 11 B. ANALYSIS OF RESULTS 12 5. POST-ADOPTION SUPPORT 14 A. RESULTS FOR CONSULTATIONS ON THE CHILD’S ARRIVAL 14 BRIEF OVERVIEW 14 DETAILED SUMMARY 14 B. RESULTS FOR POST-ADOPTION CONSULTATIONS 15 BRIEF OVERVIEW: 15 DETAILED SUMMARY 15 C. ANALYSIS OF RESULTS FOR POST-ADOPTION MEDICAL FOLLOW-UP AS A WHOLE 16 6. CONCLUSIONS 17 7. ANNEXES 18 A. THE PLACE OF CHILD HEALTH IN THE ADOPTION PROCESS: A SAMPLE GOOD PRACTICE DIAGRAM MONITORED BY AN AAB 18 B. LIST OF PERSONS OR BODIES WHO REPLIED TO THE QUESTIONNAIRE 19 The place of child health in the ...

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THE PLACE OF CHILD HEALTH  NITHE ADOPTI ON PROCESS MINISTRY OF FOREIGN AND EUROPEAN AFFAIRS INTERNATIONAL ADOPTION SERVICE         INTERNATIONAL REFERENCE CENTRE FOR THE RIGHTS OF CHILDREN DEPRIVED OF THEIR FAMILY (ISS/IRC)                   1The place of child health in the adoption process 
 TABLE OF CONTENTS PREAMBLE 3 1. INTRODUCTION 4 2. THE STATE OF HEALTH OF ADOPTED CHILDREN: AN OVERVIEW 5 A.  RESULTS 5 B.  ANALYSIS 5 3.  PRE-ADOPTION SUPPORT 7 A. RESULTS FOR COLLECTIVE INFORMATION SESSIONS ON MEDICAL SUBJECTS BEFORE THE ADOPTION 7 DBERITEAFI LOEVD ESRUVIMEMWA RY 77  B. RESULTS FOR INDIVIDUAL PRE-ADOPTION CONSULTATIONS 8 DBERITEAFI LOEVD ESRUVIMEMWA RY 88  C.  ANALYSIS OF RESULTS FOR PRE-ADOPTION SUPPORT AS A WHOLE 9 4.  MEDICAL SUPPORT FOR ADOPTION APPLICANTS AND THE CHILD IN THE COUNTRY OF ORIGIN 11 A.  RESULTS 11 BRIEF OVERVIEW 11 DETAILED SUMMARY 11 B.  ANALYSIS OF RESULTS 12 5.  POST-ADOPTION SUPPORT 14 A.  RESULTS FOR CONSULTATIONS ON THE CHILDS ARRIVAL 14 BDREITEAFI LOEVD ESRUVIMEMWA RY 1144  B.  RESULTS FOR POST-ADOPTION CONSULTATIONS 15 BDREITEAFI LOEVDE SRUVIMEMWA: RY 1155  C.  ANALYSIS OF RESULTS FOR POST-ADOPTION MEDICAL FOLLOW-UP AS A WHOLE 16 6.  CONCLUSIONS 17 7.  ANNEXES 18 A.  THE PLACE OF CHILD HEALTH IN THE ADOPTION PROCESS: A SAMPLE GOOD PRACTICE DIAGRAM MONITORED BY AN AAB 18 B.  LIST OF PERSONS OR BODIES WHO REPLIED TO THE QUESTIONNAIRE 19 The place of child health in the adoption process 2
 PREAMBLE  Although the health of adopted children is a central and legitimate issue in all adoptions, it is nevertheless not often dealt with in specialised literature and research. Based on this observation, the International Adoption Service (SAI - Service de l’Adoption Internationale) of the French Ministry of Foreign and European Affairs suggested to the ISS/IRC1 that they carry out a joint study on this theme.  It is first of all important to specify that the objective of the study is not to make a list of the different pathologies that may affect adopted children, nor is it to study the way in which children receive medical follow-up after their adoption. Instead, it concerns examining the place given in the adoption process to issues related to child health and to study how healthcare is organised. For example, what information do adoption applicants receive concerning the health of the child that is proposed to them? How is the child’s check-up carried out? What support do families receive before adoption, in the country of origin, on the child’s arrival and afterwards?  In order to do so and to paint as complete a picture as possible of the health aspects of adoption, we have both collected information from the practice itself and analysed the different systems in place throughout the world. As the subject is extremely vast, the study focused on the measures taken by the receiving countries, as they have particular responsibility in this field. The viewpoint of the countries of origin is nevertheless also included, thanks to the contributions that we have received from many of them.  As regards methodology, a questionnaire was sent out in January 2010 to a large range of persons and authorities that were likely to contribute to the research. In total, 32 replies were received from 22 countries, of which 13 were receiving countries, 7 were countries of origin and 2 were “mixed” (both receiving countries and countries of origin at the same time). Among these replies, 20 came from Central Authorities, 4 from Adoption Accredited Bodies (AABs) and 8 from professionals, mainly doctors. Given that some replies were compilations of replies from several intervening parties within the country, the diversity is greater in reality than what it seems.  In order to facilitate the reading and use of the results obtained, we have decided to process the information received by following the classic pattern of an adoption process. The first part addresses the issue of the child’s health during the pre-adoption phase. At this stage, we focused mainly on the way in which adoption applicants are informed and prepared when they launch the procedure. The second part deals with support for applicants during the procedure, when they have been matched to a child and are present in the country of origin, as well as the conditions and the quality of the child's health check-up. The last part focuses on the child’s healthcare on arrival in the receiving country and afterwards, especially post-adoption follow-up phase. Each part is dealt with by following the same pattern and first of all provides a summary of results, the main observations and finally the proposals made in order to consolidate or improve the situation.  We wish to thank very sincerely all the persons and institutions who replied to this questionnaire2. The quality of the replies received has allowed us to draft a study that we hope will be constructive and useful for all the players involved.  Dr Christine Roullière-Le Lidec     Stéphanie Romanens-Pythoud Ministry of Foreign and European Affairs   Childrens Rights Specialist International Adoption Service     ISS/IRC                                                1 International Reference Centre for the Rights of Children Deprived of Their Family/International Social Service: www.iss-ssi.org/2009/index.php?id=131 2 Countries represented: Armenia, Australia, Belgium, Brazil, Cyprus, Czech Republic, Denmark, Dominican Republic, Ecuador, France, Germany, Ireland, Italy, Lithuania, Monaco, New Zealand, Philippines, Portugal, Spain, Sweden, Switzerland and Turkey. For further details, see the list of persons/institutions who replied to the questionnaire in Annex 1. The place of child health in the adoption process 3
 1. INTRODUCTION  Insofar as this study addresses the issue of health in the adoption process at an international level, it is first of all necessary to recall that ‘adoption systems’ vary considerably from one country of origin to another, and that the health specificities of adoptable children can be linked to these systems. For example, the countries of origin that have implemented complete programmes of alternative measures for children deprived of their family, mainly propose special needs children for intercountry adoption. From a purely medical viewpoint, these special needs cover a large range of physical and/or mental pathologies that are more or less reversible, requiring long-term care or specific treatment that is still relatively inaccessible in several countries. This first group of children can be distinguished from the others insofar as by definition, the children have a very specific medical background. This group also includes children who are older and/or with siblings. Conversely, for ‘standard’ intercountry adoptions, the children may suffer from different pathologies such as deficiencies, infections, etc., which are linked to their environment of origin and to their background. In simple terms, the problems they may have can generally be easily treated and should not cause any particular medium- and long-term concerns, on condition, of course, that the medical examinations have been carried out in a complete and thorough manner.  This distinction is important for this study as the adoption process for a child with special needs, if identified as such, is not prepared or managed in the same way as that of a ‘normal’ adoption. For example, the applicants’ approach and their preparation are different, the intervening parties, whether institutional or private (belonging to an AAB) are specialised, the medical information in relation to the child is more thoroughly examined and explained, etc.  Given the current-day evolution of intercountry adoption, which has seen an increase in the proportion of adoptions of special needs children, it is obvious that the health element in the adoption process will occupy a greater place. However, one cannot fail to notice that although the cases clearly identified as being ‘special needs’ well and truly benefit from adequate support in the countries of origin and in the receiving countries, the importance given to health issues is not yet sufficient for the greater majority of intercountry adoptions. In this context, it would be useful to draw inspiration from the efforts made in the placement of special needs children in order to better manage all intercountry adoptions. Such a move is all the more important as children who are officially declared as being ‘healthy’ or as having curable illnesses can later develop all sorts of physical and/or psychological pathologies that are not identified at the time of matching, but which could create major problems for their adoptive family. In other terms, a ‘normal’ adoption could in fact turn out to be an ‘adoption of a special needs child’ and may lead to serious complications.     The place of child health in the adoption process  4
 2. THE STATE OF HEALTH OF ADOPTED CHILDREN: AN OVERVIEW  A.  Results  Although it is difficult to establish a precise overview of the state of health of adopted children (as quantitative data are extremely scarce on this subject), the replies received nevertheless indicate that adopted children have often complex health problems, among which the most common ones enumerated are digestive and cutaneous parasitosis, infectious diseases (hepatitides B and C, tuberculosis, etc.), problems linked to malnutrition, growth retardation, attachment disorders, etc. More atypical pathologies such as asthma or various allergies are also often referred to. In addition, when the countries of origin implement specific programmes for special needs children, the pathologies are of course different. This is the case for example in Lithuania, where 80% of children proposed are part of this category.   B.  Analysis  Observation 1: In general, we have observed that the main health problems of adopted children can be effectively taken care of in the receiving country, barring cases where the pathologies appear later. In fact, the health problems encountered by professionals (see above) remain, on the whole, relatively easy to treat in a Western health system.  This first observation must nevertheless be put into perspective: at the current time, children with more serious pathologies more often than not remain in institutions in the countries of origin, either because their biological family is not in a position to pay for their care, or because they have not found any alternative family solution, precisely because of their handicap. We have also observed that for cultural reasons, these same children are only rarely proposed for intercountry adoption, as their country of origin declares them as unadoptable.  ISS/IRC missions in several countries of origin3 have clearly shown that the ‘non-adoptability’ of these children depended more on structural factors than on reasons purely related to their individual characteristics. Several scenarios have thus been identified:   If the administrative organisation of a country decides that a child with a mild handicap (i.e. loss of an eye, developmental retardation, etc.) is referred to a medical organisation rather than an institution such as an orphanage, the fact that the authorities who will take care of him or her (a health ministry for example) are not competent in the field of adoption will mean that this measure is not considered, even if it could totally fulfil the child’s needs.  If the decision relative to the psycho-social adoptability of the child (as opposed to the legal adoptability) lies with nursery personnel, we observe that the appraisal of adoptability is often distorted by cultural prejudice, meaning that only children who are apparently healthy are proposed to foreign applicants.  Lastly, certain legislative frameworks explicitly exclude the adoption of children with certain types of pathology, thus preventing any individual assessment of the relevance of an adoption.  Proposal 1: Healthcare systems still need to be developed and improved in several countries of origin by including all alternative care measures in order to avoid children remaining institutionalised for the simple reason that they are ill and that their family does not have the means to look after them. If the States of origin do not have the necessary resources to take charge of these developments alone, exchanges of experience and of good practices between countries of                                                3 For example: in 2007: Kazakhstan, Kyrgyzstan, Azerbaijan; in 2009: Vietnam; in 2010: Côte d’Ivoire, Guatemala. The place of child health in the adoption process  5
 origin should be encouraged4 and, if necessary, the intervention of external specialists should also be supported.                                                4 Such exchanges have taken place in Latin America for example between Guatemala and Peru, Chile and Colombia. The place of child health in the adoption process  6
  3. PRE-ADOPTION SUPPORT  In the pre-adoptive phase, adoption applicants can be informed and/or prepared as regards health issues linked to adoption in two ways: as part of collective information sessions and/or with individual consultations.   A. Results for collective information sessions on medical subjects before the adoption Brief overview   IF YES Conditions of the Number of Availability of information session Providers (who, replies information (compulsory nature or training, etc.) Session content sessions  not, price, duration, frequency, framework) 32 replies for Yes: 18 - compulsory in 15 All sessions are Variable but the 22 countries No: 10 cases always provided by information provided is Varies in relation - free in 13 cases, --professionals usually general to the region charged in 5 cases, specialised in and/or the body - variable price in 2 adoption in charge: 3 cases  - variable frequency - variable duration but 1 hour minimum - public or private framework Detailed summary  As the above table indicates, the majority of receiving countries provide adoption applicants with information sessions in one form or another, and more often than not in a compulsory manner (15 out of 22, i.e. 68%). The form, conditions (duration, frequency, etc.) and the content of these sessions nonetheless varies a lot from one country to another. Thus, in some cases, these sessions are like real courses or pre-adoption preparation classes. In other cases, the structure is less rigid. Certain countries such as Portugal, Sweden or French-speaking Belgium provide very structured content, with a precise programme and number of hours. In other States, such as in Australia or Switzerland, session content is more v5ariable and adjustable in relation to the region and/or the body in charge of the information session.   Collective information sessions often take place at the very beginning of the adoption process, or even before applicants have really begun the process. They do not usually focus on medical problems, but deal with these issues as part of more global information. At this stage, these sessions usually provide a form of introduction to adoption and aim to explain to applicants the current adoption situation, the profile of adoptable children, what such a process implies, etc. Sometimes, more specific country information is already given at this stage, as in Australia for example, to applicants who have already chosen the country of origin of their future child. But in any case, medical issues are addressed in general terms, especially during discussions on special needs children, or on the most common medical problems encountered among adopted children.                                                 5 In this regard, in federal States the organisation of these sessions often varies in relation to the jurisdiction. The place of child health in the adoption process 7
 B. Results for individual pre-adoption consultations Brief overview   IF YES Availability of Conditions (organisation, Number of individual duration, frequency, price, Providers (who, replies  pre-adoption funding, compulsory nature, training, etc.)  Content  sessions etc.)  32 replies Yes: 24 - compulsory in 9 cases Generally Very varied content for 20 No: 5 - charged in 7 countries by paediatricians, countries Varies in this information must be sometimes relation to the interpreted in relation to the accompanied by a jurisdiction type of funding of the nurse and/or with the and/or the healthcare system in place in participation of a body in the country (see below) psychologist or a charge: 3 - variable frequency psychiatrist. - lasts 1 to 2 hours   Detailed summary  Individual pre-adoption consultations are available in most countries. These are only compulsory in 9 countries that replied to our questionnaire, but they are strongly recommended in almost all the others.  These consultations are organised in two ways: - Consultations that are similar to medical consultations and are part of the standard healthcare system; - Information sessions based on the collective session model, but which are individualised. In this case, the sessions are often funded by the State or a public organisation.  Sometimes the two models coexist, as in France, where adoption-related medical consultations are very specific and can take place at various stages of the procedure.  Financial coverage of these consultations depends on the funding structure of the healthcare system in place in the country. In this regard, we can distinguish countries known as ‘Beveridgian’ with tax-based funding (i.e. Great Britain and Spain) and countries known as ‘Bismarckian’ with a social insurance-based structure (i.e. France and Germany)6. In the case of an individual medical consultation, its payment comes under the same rules as a practitioner’s other consultations. Concerning collective consultations on the other hand, their cost is borne either by the applicants or by a public or private organisation.   The content of individual consultations or sessions is however extremely varied and covers one, several or all of the following subjects:                                                6 Social welfare systems in Europe are of two different origins. In ‘Beveridgian’ systems (from the name of Lord Beveridge, founder of the British model), rights to basic social welfare protection are given to all citizens and are funded by taxes. ‘Bismarckian’ systems (from the model of the German system, founded by Chancellor Bismarck) are based on social insurance and funded by employee contributions, with an extension to those who are eligible. This health insurance cover is extended to other persons irrespective of their professional status.  The place of child health in the adoption process 8
 - General information on the country of adoption chosen by the applicants as well as its health environment. Often, this is a repeat of the information given during the collective pre-adoption sessions while at the same time it is individualised. - Preparation of and psychological support for the parents in welcoming the child, including in looking after its medical care. In this respect, the practice of the Swiss Adoption Accredited Body Terre des Hommes is interesting: the session leaders deal with the profile of the child with the help of fact sheets presenting the real situation of children with their photograph (which is not that of the child being described), a description of the health and developmental problems, necessary treatment, prospects, etc. The applicants therefore come face to face with the reality of adoptable children and can tackle the issue of their openness in relation to a health problem with the session leader. - Information such as travel advice (vaccinations, hygiene tips, etc.) - Help in deciphering the childs medical records after matching.  This information is generally given by a paediatrician, sometimes accompanied by a nurse and/or with the participation of a psychologist and/or a psychiatrist. In three cases, these consultations are carried out by persons with mainly psychosocial training, with the possibility of applicants being referred to a specialised health service for the medical understanding of the child’s file, if necessary.  In all cases, these consultations are generally considered as a complement to the first collective information sessions. The two phases form a progressive and coherent approach.   C.  Analysis of results for pre-adoption support as a whole  Observation 1: General information sessions exist in several countries, but their form is quite varied. Health and medical information is generally touched upon in a global context and there are no collective sessions specifically dedicated to this single subject. Proposal 1: This first stage should be compulsory for anyone wishing to undergo the adoption process. Sessions should remain quite general and should, for the medical aspect, deal with issues such as the most common health problems among adopted children, special needs children, the health reality in the countries of origin, etc. At this stage, it concerns presenting the realities of adoption to applicants and breaking away from existing myths, dreams, stereotypes or even fantasies, so that the adoption project becomes feasible and realistic.  Observation 2: Individual sessions also exist in numerous countries. They are either organised as individual information sessions, or in the form of medical consultations. Sometimes the two models coexist, as in France. In any case, this individualised stage constitutes an extension of the first general informative phase by proposing more targeted and personalised information. Proposal 2: Whatever form is chosen, this stage should also be compulsory as it allows further support for and preparation of the adoption applicants. It also means that they receive personalised attention and are given the opportunity to express their possible fears and concerns in relation to certain types of medical problems, and to receive answers on this subject, especially concerning the treatment possibilities, the type of care, the prospects, etc. These sessions or consultations also allow session leaders to work with the adoption applicants in order to clarify or if necessary adapt their adoption project.  Observation 3: Deciphering of the medical records is often proposed at the time of matching proposal. Proposal 3: Strict ethics must be respected to ensure that this practice is not perceived as help in selecting the ‘best child possible’. This point is all the more important since, in principle, if the procedure is correctly carried out, the profile of the child that the applicants are ready to adopt is referred to beforehand, including their ‘openness’ concerning the health problems that the child may have. The child proposed should therefore correspond to their expectations, thus reducing The place of child health in the adoption process 9 
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