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Each year thousands of children immigrate to the United States to begin a new life through international adoption. While internationally adopted children are immigrants who are classified as orphans, most children are not truly orphaned, but have been abandoned by or separated from their parents.1 Children available for international adoption generally have resided all or most of their lives in orphanages before coming to the United States. The exception is South Korea and Guatemala, where nearly all children were placed in foster care until their adoption. In more recent years, some children from China have also been placed with foster families until adopted.

Internationally adopted children generally will be given United States citizenship as they arrive or shortly after they arrive in the United States to join their new families.

From 1999 through 2016, 267,098 children have been internationally adopted to families in the United States2 (Figure 72-1). During this 18-year period, 75% of children came from just six countries: China (29%), Russia (17%), Guatemala (11%), South Korea (8%), Ethiopia (6%), and the Ukraine (4%). In 2004, the largest number of children arrived to the United States at 22,990, with 83% of children coming from just five countries: China (31%), Russia (26%), Guatemala (14%), South Korea (8%), and Kazakhstan (4%).2 However, since 2004, there has been a dramatic decline in the number of adoptions each year and changes in the countries where children are adopted from as well. In 2015, there were only 5648 children adopted internationally, with 81% of children coming from 11 countries: China (42%), Ethiopia (6%), South Korea (6%), the Ukraine (5%), Uganda (4%), Bulgaria (3%), Latvia (3%), the Democratic Republic of the Congo (3%), Colombia (3%), Nigeria (3%), and the Philippines (3%).2 Several countries that once allowed adoption, such as Russia, Romania, Vietnam, Cambodia, and Guatemala, are no longer open to adoption. Other demographic features have changed in international adoption as well with a higher proportion of boys and older children being adopted. In 2004, 65% of adopted children were girls, which was predominantly due to the large number of children adopted from China who were nearly all girls. In 2004, children were also adopted at young ages; 86% of children were younger than 5 years of age and 41% were younger than a 1 year of age.2 In contrast, in 2015, 50% of internationally adopted children were female, 54% of children were younger than 5 years of age, and only 1% were younger than 1 year of age at the time of adoption.2 With the arrival of older children, healthcare providers need to be prepared for increased rates of malnutrition, infectious disease exposures, unmet medical needs, and psychological trauma, which often results in a more difficult transition for these children and their families. In addition to the demographic changes, there has been an overall shift from referring relatively healthy children to children with ...

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