International adoption is a social phenomenon that reached Spain in the late 1990s and peaked in the 2000s, ranking the country second in the world in the number of adoptions, only after the United States of America. At present, this trend has slowed down due to economic, bureaucratic or political circumstances.1

Now that the years have passed, we are able to observe the reality of adoption, or rather, of adopted children, thanks to the perspective given by the passing of time and a more settled situation. And I would like to speak from personal experience.

I work as a primary care paediatrician in a small city in Castile and León in the northwest of Spain. When children from international adoptions started to arrive, I was faced with a situation that was new to me. On one hand, there were children from regions of the world at a higher risk of health problems due to various factors: some were related to the conditions in their countries of origin (poverty, insalubrity, etc.); others, related to the situation of the child prior to being abandoned (pre- and perinatal care, malnutrition, abuse); and finally, some pertained to their time in institutions (in which both the facilities and the care are usually inadequate). On the other hand, they were generally accompanied by mature and knowledgeable adults who had become parents after a long personal quest often rife with obstacles and difficulties. In some cases, I was already acquainted with due to preadoption visits, phone calls from the countries of origin, consultations with photos and videos taken at the orphanages, etc. However, other times it was our first encounter. My immediate concern was to try to meet the needs of these children and their families as best as possible, and to look for information to expand my expertise and skills in this new area as a paediatrician.

Fortunately, right from the beginning we had ready access to documents and guidelines that proved useful in daily practice, and they helped us all to evolve from an intuitive approach to a more comprehensive and protocolised delivery of care.2

The available literature, both here in Spain and worldwide, which is increasingly abundant, evinced the need to focus on aspects related to malnutrition and deficiency diseases, infections and parasites, vaccinations, sensory abnormalities, skin disorders, etc. The information contributed by Martínez Ortiz et al.3 illustrates the reality of adoptions from Ethiopia between 2006 and 2010.

There was also a lot written about the quality of the reports that come with the children from their countries of origin, and about the veracity and reliability of this data.

In the first few months of their arrival to Spain we were in frequent contact, closely monitoring physical health and psychomotor development, and performing various analyses and complementary tests. In health areas like our own, where we lack specialised services for these patients, the collaboration of colleagues in the paediatric department of the hospital was essential in patients who had preexisting diseases or in whom we discovered signs of disease. It was a journey on which we all learned together.

When this first stage after “landing” ended, in which children and families adapted to their new situation, life in most homes settled down into everyday routine.4 With this routine came the checkups and vaccinations, the consultations for the usual reasons in infants and preschoolers (in our experience, their acute infections in the first two years in Spain did not differ in type or frequency from those presented by Spanish children of the same ages), attending daycare and school.

The start of daycare and school is a particularly sensitive time for both children and their parents due to the significant change that it brings to their everyday lives. In these cases, there was the added uncertainty of how the child was going to cope with the separation, which, though only temporary, might be painful and reminiscent of previous separations. Some parents also expressed concern about how others would respond to a “different” child. But the fact is that the increasingly manifest ethnic diversity of our schoolchildren from the earliest grades is an everyday reality that children internalise effortlessly without giving it any thought.

Among the different aspects that are documented in the periodical follow-up reports of adoptions requested by Spain's various Autonomous Communities is school adjustment, which has been satisfactory overall.

Time passes, children grow, and as things progress we encounter a problem that worries families, educators and paediatricians: attention deficit hyperactivity disorder (ADHD), which is the most common chronic psychiatric disease in the paediatric age group. The estimated prevalence in our setting is 6.6%. But in internationally adopted children, especially those from certain countries in Eastern Europe, the incidence is higher than expected.5 The complex aetiopathogenicity of this disorder involves some risk factors that may have been present in previous periods of their lives, unbeknownst to us. There is also the question of whether all diagnosed cases meet the criteria or are excessively severe and the label is applied to other conditions, perhaps related to immaturity or to a different evolution in the learning process, but the facts are striking and warrant giving the issue more thought.

Currently a large number of these adopted children are reaching adolescence, a stage that gets bad press in society and worries families as to how to deal with it. Adolescents are characterised by rebelliousness, independence, self-affirmation and a desire to fit in with their peers. But in adopted children, these issues may be compounded by the issue of identity and belonging, the feelings of loss and abandonment, the rejection of parents with whom they suddenly seem to have nothing in common. They may have conflicting attitudes, ranging from a desire to know their country and culture of origin to an outright rejection of either, to the point of not even being willing to discuss them. It may be a period of tough questions and answers, if these have not been broached before. Based on what they know about their children and respecting their wishes, parents will be able to choose the best course of action.

Finally, I do not wish to ignore the unwelcome situation of failed adoptions. They are a very small percentage, but they represent the breakdown of a process that started out of love, hope and responsibility. After unsuccessfully calling on the help of various professionals to try to tackle the challenges that they were confronted with, the family surrenders and the child ends up once again in the care of another institution, the social services of the autonomous communities, in a new crisis of abandonment and rejection. Everyone involved suffers, and they feel as if they have lost a great opportunity.

And just as these adopted children have grown up, international adoption too has matured. It has now become an everyday fact of life: without idealising it and, like life itself, without perfect children or perfect parents.