As providers of primary care for children, we are highly knowledgeable about how families are created-or are we? Although most caregivers with whom we interact become parents in the old-fashioned way, in North America and Western Europe, adoption plays a significant role in the formation of kinships. Neither domestic nor international adoption is well addressed during medical training. Inspection of five major pediatrics texts revealed from none to six pages (0%0.2% of total pages) devoted to the topic [1-5], despite the fact that among children less than 18 years of age living with families in the United States, 1 of 40 children is adopted [6]. Adoption is a broadly accepted method of building a family and is part of our shared experience in the United States. The 2002 National Adoption Attitudes Survey [7] revealed that more than 90% of Americans had "very favorable" or "somewhat favorable" opinions about adoption, and 64% of respondents reported that a family member or close friend had been adopted. Thirty-nine percent of Americans had quite seriously or somewhat seriously considered adopting at some point in their lives, and 86% believed that adoptive parents derive the same amount or more satisfaction from raising an adopted child as they derive from raising a birth child. In addition to society's approval, adoption advocates have powerful bipartisan political allies, because 160 members of the US House of Representatives and Senate (30%) belong to the Congressional Coalition on Adoption [8]. International adoption is a growing component of adoption in the United States. In 2001, the most recent period for which accurate data are available, international adoptions made up 15% of all adoptions (127,407 total adoptions) [9]. This percentage has tripled since 1992. The 2000 US Census reported 199,136 international adoptees younger than 18 years of age living with families in the United States (12.5% of adopted children) [6]. In 2001, the rate of children who joined families through international adoption was 4.7 for every 1000 children born in the United States and 5.6 for every 1000 children born in Canada [9-12]. In some US states, Canadian provinces, and Western European countries, the rates were twice that high ( Figs. 1 and 2) [9-13]. Therefore, it is virtually inevitable that providers of primary pediatric care are going to come into contact with families in their practice who are considering or who have adopted internationally. On the surface, international adoption seems to be a win-win situation. On first encounter, you see elated parents with their newly arrived, scrubbed, well-fed, and immaculately dressed child. Parents with room for a child in their hearts matched with a needy orphan-what could be better? On closer examination, however, international adoption is a series of juxtapositions: separation and loss with dreams fulfilled, poverty with wealth, colonialism with self-determination, exploitation with altruism, religious law with secular law, and best interest of the group with best interest of the individual to mention but a few. The polar viewpoints of two contemporary figures in this debate illustrate this best. Mother children is not widely accepted in many countries. In addition, children who are older, have mental or physical handicaps, or are members of ethnic or racial minorities are likely to be difficult to place in permanent homes. Placement abroad must, and thankfully does, remain an option for these children if timely permanent placement cannot be achieved in the child's birth country [97]. Finally, developing appropriate expectations is a recurring theme for families who adopt internationally and should apply to the international community as well. A screening system has never been developed that can predict human behavior with absolute certainty. Clearly, we must focus on placing children in the best possible environment, but no amount of preadoption scrutiny or postadoption follow-up can ever prevent the isolated cases of abuse that are trumpeted in the media. Policy must be based on evidence and not on tabloids, and the data available leave no doubt regarding the positive effects of adoption. Out of calamity and loss, children recover and progress to become functionally and emotionally competent adults [40]. As stated by the distinguished adoption researcher Richard Barth [98]:.
