adoption and behavior - developmental-behavioral pediatrics
TRANSCRIPT
The Epidemiology of Adop0on and Common Developmental &
Behavioral Issues Encountered in Adopted Children
Tiffany Lim Laura Campbell Danielle Shin
3 December 2014
Epidemiology • ~2% of the US popula0on • 3 categories – Domes0c private agency, kinship, tribal adop0on (>50%)
– Domes0c public adop0on (~40%) – Interna0onal adop0on (<10%)
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
The Process: Adop0on through Foster Care
• Mul0-‐step process – Select an agency licensed in the adop0ve parents’ state of residency
– Complete a homestudy [up to 6 months] • Documents, interviews, home visits
– Begin to search for a child and exchange informa0on
Sources: hAp://adopt.org/ten-‐step-‐overview hAp://www.adoptuskids.org/for-‐families/how-‐to-‐adopt
• Mul0-‐step process, con0nued – Selec0on – Mee0ng the child – Receiving an adop0ve placement – Legalizing the adop0on (“intent to adopt” pe00on)
The Process: Adop0on through Foster Care
Sources: hAp://adopt.org/ten-‐step-‐overview hAp://www.adoptuskids.org/for-‐families/how-‐to-‐adopt
Common Myths About Adop0on
• You have to be wealthy and own a house. • You can’t adopt a child that you know professionally.
• If you’re the rela0ve of a child in foster care, you have a lower chance of being successful in adop0on.
• A birth parent or another rela0ve can take an adopted child back.
Source:hAp://www.adoptuskids.org/for-‐families/how-‐to-‐adopt/common-‐myths-‐about-‐adopHon#birth-‐parents
The primary care clinician’s role
• Preadop0on – Obtain medical records through the adop0on agency including family history
– Obtain details about birth parents including educa0on, work, interests and reasons for placing child for adop0on
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
• Post-‐adop0on – Schedule follow-‐up visit soon acer newly adopted child joins the family
– Con0nue to work with parents to address concerns about child’s behavior and adjustment
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
The primary care clinician’s role
When is the right 0me to tell a child that he/she is adopted?
• Open discussion about adop0ve and birth history as soon as a child joins the family – Adopted children should learn about their adop0ve history from adop0ve parents rather than someone else
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
How to tell a child he/she is adopted
• A discussion involving a “history of adop0on” • Several 0mes, over a 0mespan of years • Topics to include – Role of birth parents – Mo0va0on of adop0ve parents to adopt – Reiterate that it is not child’s fault that he/she was placed for adop0on
– Emphasize adop0ve parents’ love for child Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
Understanding Adop0on Across Stages of Development
• Preschool – Where did I come from? – Concrete aspects of adop0on – Interest in their “birth story”
Strategies: – story books
Sources: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011; Jones et al. The pediatrician’s role in supporHng adopHve families, 2012
Understanding Adop0on Across Stages of Development
• Age 7-‐11 years – Beker understanding that they are unique in being adopted
– Self-‐esteem issues, comparison to others
Strategies: – Reassure parents – Coach parents to give honest answers – Okay to share photos or lekers
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011; Jones et al. The pediatrician’s role in supporHng adopHve families, 2012
Understanding Adop0on Across Stages of Development
• Early adolescence – Informa0on seekers – Trying to define own iden0ty and individuality
Strategies: – Honest discussions to avoid idealizing birth parents
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
Understanding Adop0on Across Stages of Development
• Late adolescence – Thinking about own rela0onships – Thinking about own health concerns – Increased interest in family history (of birth parents)
• Strategies: – Honest discussions – Full disclosure – Difficult topics can be facilitated by therapist
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
Why did my birth mother give me up for adop0on?
• Not the child’s fault! • Honest, plausible explana0ons • Suppor0ve statements if known history of birth parent mental health issues or substance abuse
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
Addressing Nosy Neighbors & Chaky Children
• Outsiders’ ques0ons – Give honest answers, but respect child’s privacy
• Responding to teasing – Posi0ve statements
• Children over-‐sharing informa0on – Give bits and pieces of info appropriate to child’s developmental age
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
“The Search”
• Common occurrence • No consensus on op0mal 0me to reunite • Generally leads to posi0ve outcomes with adop0ve family
Source: The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care, 2011
The Well-‐Child Check
• Immuniza0ons • Growth • Screenings
Sources: hkp://www.healthychildren.org; Jones et al. The pediatrician’s role in supporHng adopHve families, 2012
Developmental and Behavioral Issues
• Transi0onal issues – Anxiety, depression, misbehaving
• Discipline • Sibling Rivalry • ADHD & learning issues • Risky adolescent behavior
Sources: hkp://www.healthychildren.org; Jones et al. The pediatrician’s role in supporHng adopHve families, 2012
Effect of Nurture on Nature
• The anatomic brain structures that govern personality traits, learning processes, emo0onal regula0on, and reac0ons to stress are established and strengthened during the first few years of life
• The forma0on of these neural networks is influenced by nega0ve environmental condi0ons, including lack of s0mula0on, abuse, and violence within the family
Children in Foster Care • Many children in foster care have been the vic0ms of abuse
and neglect during the early years of life, when brain growth and development are most ac0ve
• Intrauterine alcohol and drug exposures also leave many in
the foster care system with cogni0ve, sensory, and emo0onal impairments
• As a result, children in foster care suffer a high incidence of developmental delays (up to 25% in some age groups), PTSD (up to 25%), and other psychiatric diagnoses (up to 80% of children aging out of foster care)
Pathophysiology: Toxic Stress
AAP: Helping Foster and AdopHve Families Cope with Trauma. 2013.
Signs and Symptoms
AAP: Helping Foster and AdopHve Families Cope with Trauma. 2013.
AAP: “Helping Foster and AdopHve Families Cope with Trauma. 2013
Foster Care Clinic (FCC) Increases Detec0on of Developmental Delay
Horwitz, SM et al. Pediatrics. 2000; 106; 59.
Targeted Screening Increases Detec0on of Developmental Delays
Jee SH et al. Pediatrics. 2010; 125; 282.
AAP. The Medical Home Approach to IdenHfying and Responding to Exposure to Trauma. 2014.
Conclusions • Emo0onal and cogni0ve disrup0ons early in life have the poten0al to impair brain development
• Children in foster care have dispropor0onately high rates of physical, developmental, and mental health problems
• Pediatricians have a special responsibility, as advocates for these children and their families, to help evaluate and help address these needs
References • hAp://adopt.org/ • hAp://www.adoptuskids.org/ • Jones VF, Schulte EE. Commikee on Early Childhood; Council on Foster Care,
Adop0on, and Kinship Care. The pediatrician's role in suppor0ng adop0ve families.Pediatrics. 2012 Oct;130(4):e1040-‐9
• The Zuckerman Parker Handbook of Developmental and Behavioral Pediatrics for Primary Care Third EdiHon. Eds. Augustyn, Marilyn, and Barry Zuckerman, and Elizabeth Caronna. Philadelphia: Lippincok Williams and Wilkins, 2011.
• Healthychildren.org. “Family life: Adop0on & Sibling Rivalry.” 3 Oct. 2013. Web. 1 Dec. 2014. hkp://www.healthychildren.org/English/family-‐life/family-‐dynamics/adop0on-‐and-‐foster-‐care/Pages/Adop0on-‐and-‐Sibling-‐Rivalry.aspx
• Healthychildren.org. “Family life: Adopted Children & Discipline.” 29 April 2014. Web. 1 Dec. 2014. hkp://www.healthychildren.org/English/family-‐life/family-‐dynamics/adop0on-‐and-‐foster-‐care/Pages/Adopted-‐Children-‐and-‐Discipline.aspx
• Healthychildren.org. “Family life: Interna0onally Adopted Children: Important Informa0on for Parents.” 28 Feb. 2014. Web. 1 Dec. 2014. hkp://www.healthychildren.org/English/family-‐life/family-‐dynamics/adop0on-‐and-‐foster-‐care/Pages/Interna0onally-‐Adopted-‐Children-‐Important-‐Informa0on-‐for-‐Parents.aspx
References • American Academy of Pediatrics. Helping Foster and AdopHve
Families Cope with Trauma. 2013. hkp://www.aap.org/en-‐us/advocacy-‐and-‐policy/aap-‐health-‐ini0a0ves/healthy-‐foster-‐care-‐america/Documents/Guide.pdf
• Commikee on Early Childhood, Adop0on and Dependent Care. “Developmental Issues for Young Children in Foster Care.” Pediatrics. 2000; 106; 1145
• Horwitz, SM et al. “Specialized Assessments for Children in Foster Care.” Pediatrics. 2000; 106; 59.
• Jee SH et al. “Improved Detec0on of Developmental Delays Among Young Children in Foster Care.” Pediatrics. 2010; 125; 282.
• AAP. The Medical Home Approach to IdenHfying and Responding to Exposure to Trauma. 2014. www.aap.org/traumaguide