Creating a Family: Talk about Adoption & Foster Care

Health, Emotional, and Developmental Issues Common to Children Adopted Internationally

November 29, 2019 Creating a Family Season 13 Episode 45
Creating a Family: Talk about Adoption & Foster Care
Health, Emotional, and Developmental Issues Common to Children Adopted Internationally
Show Notes Transcript

What are the health, emotional, and developmental issues common to children adopted from abroad. What should parents and professionals consider before adopting internationally. Our guest expert is Dr. Dana Johnson, Professor of Pediatrics and one of the founders of the Adoption Medicine Clinic at the University of Minnesota. He is the parent of two birth daughters and an adopted son from India.

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Speaker 1:

* Note that this is an automatic transcription, please forgive the errors.

:

Welcome to creating a family talk about adoption and foster care. Today we're going to be talking about health, emotional and developmental issues, common to children adopted from abroad. We'll be talking with dr Dana Johnson. He is a professor of pediatrics and one of the founders of the adoption medicine clinic at the university of Minnesota. He is also the parent to two birth daughters and an adopted son from India. Welcome Dr. Johnson to creating a family. Thank you so much for talking with us today about what is a very important topic. All right, so we know that children who are adopted internationally come with a host of health, emotional and developmental issues that we want parents to be aware of before they complete the adoption so that they know what they're getting into and also know that they will be prepared to be the best parent for this child.

Speaker 1:

So we're going to start with talking about the general process for inner country or international adoption. And I'm just going to walk through some of the basics that people need to prospective adoptive parents need to know about. The first step is to choose a us accredited or approved adoption service provider and the way you would do that is go to the website for the inner country adoption accreditation and maintenance entity. It's a, the abbreviation is I a M E and people call it, I am me and you would go to their website, which is I a M e.net and they have a list of accredited or approved adoption service providers. Then you would apply to the U S CIS to be found eligible to adopt. Then ultimately, this is a quick perusal, but then you would be matched with a child by the authorities in the country from which you are adopting. Then you would apply to U S CIS for a child to be found eligible to immigrate to the United States and receive us saving us agreement to proceed with the adoption. Then the next step is you would go almost always you traveled to the country. You would go and adopt the child in their country of origin. You would obtain a U S immigration visa for your child and then bring your child home. Now, let me pause and mention that each country has a different process but I just gave you was a general overview and the other thing that you need to know is this is something unique about a inter-country adoption. You have to meet the legal requirements of the country that your child was born in the U S government and your state to get more specific information on the process for the country. You're considering the best place to go to, well first of all your agents, they get information from your agency, but you could also go to the state department website, travel.state.gov and click on inter-country adoption and then you can get specific information. If you don't remember, travel.state.gov you can always use your search browser and just use the term state department, international adoption to find the website. Then once they are, you're going to click on the country information section and you can get specific information about the process in your country. And I should also mention that if you have problems along the way and you need to file complaints against your agency, if you have problems, you can do that at the inter-country adoption, accreditation and maintenance entity website. That is, I am me, I a M E. dot net. All right. So that's the general process that you would go through. So now let's talk about some of the general characteristics and needs of the kids who are available for adoption from abroad. Dr. Johnson, you have been involved in international adoption probably just about longer than most any doctor really. So what are you seeing now about the general characteristics and needs of kids who are waiting to be adopted?

Speaker 2:

Well, Don, when I began in adoption medicine and around the time that I adopted my son, most of the kids that were available for adoption from abroad were very young and they were generally in pretty good health. Uh, we've seen that change dramatically over the last 35 years. And most of the kids that are available now for adoption are children with special needs and their children that are older. And the reason for that is that adoption has really taken off and most of the sending countries so that younger, healthier innocents are adopted in their country of origin. And the ones that are difficult to place internationally are the ones that have disabilities or significant medical problems or have been within institutional, uh, or other types of care for a long period of time.

Speaker 1:

So the factors that lead children to be in state care and need adoptive families are special needs and, and age. Are those the primary factors that you see that lead children to be placed now?

Speaker 2:

Well, I think that if you look throughout the world, the vast majority of kids who are within institutional care or waiting for placement and adoptive families or children who have been placed in care because of poverty, most of them have one parent. Very few are actual double portions or have lost both their mother and father. But being a single parent in many countries puts tremendous financial obligations on individuals and they often can't take care of their children in place. Some of this more than state care, I mentioned a disability. There's also the social stigma of single parent pregnancy, which is also coupled with financial problems. And we have kids from natural disasters or from parental incapacity such as mental illness or parents being placed in jail because of legal problems or mental health issues. Very few were actually placed because of abuse, although many have experienced abuse. But throughout the world, poverty is really the, the motivating factor for kids to be in care.

Speaker 1:

So what are the most frequent medical or psychological problems that you see now in children who are brought to you for evaluation after adoption?

Speaker 2:

Well, they're the problems that we see due to the nature and economic status of the country involved. So because of poverty, we see problems with growth. We also see problems with infectious diseases, especially intestinal parasites and countries that don't have higher standards of care. But we also see a number of, or a great variety of disabling conditions that caused parents to abandon their children to state care. And the, and these can vary from severe cardiac problems. Gastrointestinal just about any organ system can be involved.

Speaker 1:

So another factor that we sometimes see not infrequently see is malnutrition. How does malnutrition affect children and does it depend on the age at which they are malnourished?

Speaker 2:

Well, malnutrition can be devastating for kids, particularly when very young children are malnourished during the early years of life when brain growth occurs or the majority of brain growth occurs, not having enough food to eat really stunts, not only physical growth but also brain growth as well. And that growth inhibition can be permanent in terms of affects the central nervous system. And in terms of of development, uh, as kids get older and growth slows down in brain growth is not going through that tremendous surge that we see in infancy. The effects are less, but they still can be significant. So malnutrition is never good for kids, which is why the world health organization and UNICEF pays so much attention to making sure kids are well nourished.

Speaker 1:

And what about malnourishment in pregnancy? A pregnant woman who is not, doesn't have an adequate diet, how does that impact the fetus and in the baby?

Speaker 2:

Well, babies are pretty good parasites, so they will often take from the mother what they need actually making her health a little bit worse. But in severe cases where we have very bad maternal malnutrition, we see significant growth restriction and the incidence and that can affect longterm linear growth. So these kids are shorter. It can affect cognitive development because they're growing brain growth is not as good. It can also lead to additional problems like for instance, early puberty in kids who've sustained intrauterine growth restriction because of maternal malnutrition.

Speaker 1:

Yeah, it's kind of the opposite of what you might think, right? Yeah. You would think that they would be postponed entering and entering puberty. All right. Now let's talk about environmental toxins. We know that, uh, there are different environmental laws, there are different standards for what, uh, cookware and all sorts of environmental pollutants and toxins. So I want to talk about what are some of the common environmental toxins you're currently seeing and let's talk about, I'm going to go through some of the primary place in countries to the United States. All right, so what are some of the environmental toxins that you know of or see in say China?

Speaker 2:

Well, in China, and this actually is probably the most common one that we know of, uh, around the world. We for a while saw very high incidents of lead toxicity and kids in countries with poor environmental records. Things can get into the environment fairly easily and let us, certainly one of the most common contaminants that we see in the environment. We're seeing less than that than we used to sense a leaded gasoline has been phased out around the world, but it's, it's still a significant issue and we always check for lead toxicity in kids.

Speaker 1:

How does lead affect a child?

Speaker 2:

Well, there are a couple things that happened. One is that development is impaired, let can be toxic to the central nervous system. So that brain growth is altered. Brain development has changed and these kids can wind up with with a lower IQ it gets, they have significant toxicity, they can also develop anemias and other symptoms of lead levels are very, very high, but it's the developmental delay that is the most significant and the longest lasting.

Speaker 1:

All right. Then India is another one of the top place in countries. What are some environmental toxins, uh, is led a continued issue there and are there additional environmental,

Speaker 2:

well, the issue there, um, you know, one of the problems is that there are so many potential toxins that it's very difficult to decide what to, what to check for. I, and to my knowledge, no one really has done a toxicologic survey on children coming from abroad that have been adopted and to this country or European countries to see what might be present. But certainly countries with high environmental standards, the, the risk is going to be low. The countries where very lax environmental standards are present, the possibility of insecticide pollution. There agents that get into the, into the water or the food system is always a possibility.

Speaker 1:

Anything additional that you would add for some of the other top countries? South Korea, Bulgaria, let's see, Colombia, Haiti or certain African countries. Anything that comes to mind from a environmental toxin standpoint that would be present there but not already discussed?

Speaker 2:

Um, no, not, not that I know of to be honest with you. Obviously in, in countries like that with tour environmental records there is the possibility although we're not exactly sure what specific things to look for.

Speaker 1:

All right. And for parents who are wanting more specific information and on the country that they're considering, the world health organization has some information, world health rankings would have some information and you can also check with the world food program which has some information on malnutrition. Alright. And here's a topic that is common in the United States as well. And that is the impact on children of maternal substance abuse. And then let's make sure that we're talking about alcohol as well as drugs. I think so often we think of maternal substance abuse and we don't think of alcohol because it's a, at least in the U S as a legal substance that across most of the world to this. So let's talk about how our fetuses and babies impacted by mom's consumption of alcohol or drugs during pregnancy.

Speaker 2:

Well, the consumption of these agents and not only affects the baby directly, but also affects the mom in the sense of of her ability to take care of herself or ability to get prenatal care or ability and desire to take care of herself during pregnancy, eat a good diet, et cetera. So the significant use of elicit and legal agents like alcohol can alter outcome in pregnancy in a number of different ways. Certainly mothers who are addicted and who parents or children for a period of time before relinquishing them to institutional care often provide a deprived environment for their child as well. So it's a multifactorial thing in terms of the actual effects of agents on children for most of the illicit drugs that are used such as heroin, cocaine, methamphetamine, et cetera. Other two major areas on effects on the baby. One would be actual effects on the pregnancy itself. So for instance, we know that mothers who use cocaine can often have spikes in blood pressure and can have effects on the placental circulation and often deliver babies prematurely. So that can be an effect of the drugs. But also there's the direct effect of the drug on the central nervous system. It's intense and we are all aware of needle and neonatal abstinence syndrome where children are born addicted and have to come off of those drugs over the first weeks or months of life. And that affects their ability to function normally as an infant and to respond in a normal way and be able to be calmed and soothed by their caregivers. Of all the agents that mothers use during pregnancy, the most devastating though is alcohol and that clearly is the number one cause of preventable mental retardation and mental health problems that we are currently aware of. There is no safe amount of alcohol and alcohol consumption varies tremendously around the world. We often think of Eastern Europe, um, alcohol consumption there as being very problematic. And that's true, but we're seeing much more alcohol use during pregnancy and Korea and other countries where westernized standards of living are permeating the culture so that it's not permissible for young women to drink. In fact, in Korea it's looked at as a badge of honor to be able to drink as much as the men companions when you go out to a bar. So we're seeing more problems with, with fetal alcohol spectrum disorder and fetal alcohol syndrome in many countries where we never used to see it.

Speaker 1:

Yeah. And there's not as much of a public awareness campaign and certain countries, South Korea again comes to mind about the dangers. Uh, we have been, you know, for the last what 20 years, uh, has been drummed into probably more maybe 30 years. It's been a lot of, uh, public service announcements about the dangers of alcohol consumption, but other countries don't have that. So there's less social stigma and at land, quite frankly, just less knowledge about the impact of, of maternal alcohol consumption. Let me mention two things. One oftentimes, and this is the case with, uh, more often the case with a drug exposure, the opioids, the heroines, the meth, Coke, things such as that the impacts are such that very often parents don't see them until the child is an early school age because it's impacting higher level thinking and, and skills that come into effect then. So one of the things to consider if you are a parent who is adopting a child who may have been exposed to some of these drugs, is to be aware of early intervention services and to be cognizant of your child and in the beginning and how they're doing academically and get them support early on. Another point is that we have a mini courses at creating a family that go into great detail on the topic of the impact of prenatal exposure on children. All right, so we've talked about, uh, you've mentioned, uh, South Korea. Are there any other countries that come to mind that have a higher, when I say countries, I mean those that are placing internationally to the U S that have a higher incident of prenatal exposure.

Speaker 2:

Well, we see it in every country. It's probably you alcohol use, Korea, Eastern Europe would be the more common countries, but we, we've seen it in kids from Ethiopia and South Africa and many places where you wouldn't necessarily think that alcohol use would be high in pregnant women. So I think it's universal around the world that risk exists. And the more you can find about the mother's history, the better off we are in terms of being able to able to integrate that into our evaluation of the child.

Speaker 1:

What about malnutrition? What are the countries that you see where malnutrition is more of a problem?

Speaker 2:

I think malnutrition is going to be directly related to the economic standard of each particular country. So it would be extremely unlikely to see a malnourished child coming from Korea much more likely to see a malnourished child coming from, for instance, India, Africa, et cetera, would be a place where food insecurity is a, is a major problem. And not only are mothers malnourished, but children often with an institutional care settings, uh, where they don't have the resources to adequately feed their children are going to be malnourished as well.

Speaker 1:

[inaudible] that's a good point that it's not just a their home environment, but once they are in state care, a malnutrition can also continue or even begin at that point. Well we assume that that mental health is fairly universal throughout the human population, but perhaps it's not. So are there countries that you see that are placing to the U S where you see a greater incident of emotional issues or emotional issues dependent on other factors that can be at any country?

Speaker 2:

Well, any child who spends any time within an institution is going to be at risk of a variety of emotional and behavioral disorders. So countries that use primarily institutional care settings rather than foster care are going to be those problems. They're going to be more common. We also see, because you know, children with disabilities are being placed for an inter country adoption because they can't be placed domestically. We're going to see, Hey, a skewing of the population, international adoptees as kids who are identified in their country of origin is having mental health issues. But I don't think there's a specific country where that's more common than, than other places,

Speaker 1:

you know, genetic abnormalities or something we get questions about. And again, I, I'm not sure that they're, that doesn't, I would assume that uh, the percentage of children born with a genetic issues or genetic abnormalities would be again, following population. However, if the ability to have a country to handle it's a medical issue to handle it in country or the stigma in the country of, of having a child, um, or there's the ability of the parents might vary. So do you see any disproportionate representation for kids with genetic issues coming from different countries?

Speaker 2:

No, not necessarily. I think part of the problem of, of saying there are more or less in various countries is the population that we see that are, that are actually placed for an a country adoption. So, for instance, in China, it's dependent upon the orphanage director to initiate placement of a child from one of their government institutions. So the orphanage director has to feel that that child might be adopted if they see a child with a genetic issue that they don't think anyone would accept, they're not going to place that child. So we may or may not see that child get into the, uh, the group of kids that are actually being placed. You know, I would say that genetic abnormalities are pretty common around the world and I don't think that they're going to vary tremendously like country of origin. But whether or not that country feels that those children are placeable may vary. So we may see more coming from one country versus the other.

Speaker 1:

Yeah, that's what I would assume as well. And developmental delays. There are so many reasons for develop developmental delays, including institutionalization or prenatal exposure. You've already mentioned that alcohol exposure is a, is a significant one. So would we assume that developmental delays would be more common in countries that favor institutional care over foster care?

Speaker 2:

Oh yes, absolutely. You know, kids in foster care by and large look like kids in a family situation and so they'll, they're more often be normal than kids who are growing up with an institutional care settings.

Speaker 1:

So of the, of the primary countries that we've talked about, which ones are the tr? Where are the children? Institutionalized? China. Yes, India. What about India?

Speaker 2:

I would say that almost all countries other than Korea, institutional care, China does have some programs where where children are being cared for within families. They may not be placed there initially, but they may be placed there after a while and really have, have a good chance of recovering while they're still in the country of origin. But I think that most of the countries that are currently placing are using institutional care.

Speaker 1:

So we've talked about some of the general impact of children just from malnutrition, environmental toxins, institutionalization, things such as that. But then we, if we, if we look at international adoption, that itself, the act of taking a child from everything that they know, turning their life totally topsy turvy, bringing them to a country where things don't look the same. People don't look the same. They don't talk in a way that they can understand. They don't even smell the same. The smells are different. The food is different. So how does the actual act of taking a child and removing them from anything that's familiar and putting them in a totally different place, how does that impact children?

Speaker 2:

Well, it can impact them tremendously. So if you, if you look at various ages of children, if you're taking that, if you take an infant home from the hospital, they're not gonna really care. I mean they, they really haven't known that environment and they're, they're not acclimated to that place. But if you take an infant who's been with their mother for three or four months and then put them back into a hospital, what will happen to that incident is that they will be just totally regress and not care about anything. And when we, they started having pediatric hospitals around the turn of the of the 20th century, they started noticing this condition where children who had been separated from their mothers and put in the hospital, stopped eating, refused to interact and literally died because they wouldn't take any nourishment and they termed this hospital and eventually this became known through the work of Bowlby is a very severe form of attachment problem so children can actually die when separated from the individuals that they know and love the environment in which they're used to being in older children have have a different response. They may shut down and regress as well, but they can also have other types of behavior. Those much more disruptive, but basically it's a noxious experience for them to go through that. It's a very stressful experience to be put into a new environment with no one around that, you know, no one that you can rely on and that can have longterm consequences for adherence.

Speaker 1:

What type of behaviors might you see initially and then after a short period of time in children who are trying to cope and adjust with so much change happening all at once?

Speaker 2:

Well, I do think that being just shutting down and not not being able to interact during speak or show any emotion at all is is a very common one. You know, unfortunately we're seeing this in the kids in the border that are being separated. You know where you have kids that cry continually, the kids that won't respond to any kind of interaction just because it's so difficult for them to be separated.

Speaker 1:

Yeah, exactly. Just want to remind everybody that this show is underwritten by the being family foundation. Talking. Being family wants you to know that post permanency adoption support programs are vital to help preserve families. However, the availability of these programs is not always community. Katie clearly during the adoption process. In fact, often it's not legal professionals and judges are essential to encourage the use of these services as permissible by law judges, court clerks and adoption agencies can order backpacks through the jockey being family website to ship to the courthouse for adoption day to find out how to get your free backpack. Please visit jockey being family.com. Click on their backpack program and you can get it into your agency. Germany has to apply, although judges and court clerks can also apply. So thank you. Jockey being family for your support of creating a family. All right. We have talked about, uh, we've circled around talking about institutional care and as you said earlier in every country really with the exception of South Korea, children who are placed in international adoption are in institutional care. Sometimes they're called orphanages, sometimes they're called child welfare institutions. I should add that the children who are not eligible for international adoption in South Korea are also in child welfare institutions for the most part. But, uh, those that are being placed for international adoption are generally in pretty high quality foster care. But other countries, not so much. So let's talk about how institutional care can impact children. And does it vary by age?

Speaker 2:

It does vary by age. And I think whenever you're looking at potential factors that may damage child's future, uh, you do have to look at the age when that occurs. And any child who is very young, who is rapidly growing and developing dependent on others for care and we're experiences are having the disproportionate effect on development, those are the kids we have to worry about the most. So shaking a child as an infant and putting them in an institution for the first three years of life is much more devastating than taking a child who is 14 or 15 and putting them in an institutional care settings because the older child has much of their growth and development accomplished by that point in time, and much of their emotional tone already established, a young child doesn't. And that's where we can see the greatest effects.

Speaker 1:

Does it affect their physical growth, their emotional growth, their intellectual growth, or all of the above?

Speaker 2:

It affects everything. In fact, if you look at a vast array of domains in terms of development, which goes from physical development or emotional development, there are very, very few areas to not that are not affected by institutional care. I always say it's institutional cares, the three P's, it's prompt as it incurs very quickly. It's pervasive because it acts across all domains of development and the third P is permanent, in which case not all things can be improved by being placed in a family after a child has been in an orphanage.

Speaker 1:

Yeah, and something else that parents are often not aware of. It's not necessarily just the fact that there may be a low adult to child or caregiver to child ratio or inadequate food or inadequate education or something along those lines. It's also the fact that there's often not enough adult supervision and it is not uncommon to see abuse amongst the children and then that's also a, an issue that parents need to think about.

Speaker 2:

Yes, that's very true. And in fact, any older child that's adopted out of an institution, I always talk to families about the fact that they have experienced abuse, not only from caregivers, as you said from other children, and they've also been exposed at least exposed to inappropriate sexual situations or have been sexually abused by again, the adults taking care of them or by other older children within the institution.

Speaker 1:

[inaudible] so go in with your eyes open as parents on how phone, preparing to integrate that child and help that child. And again, creating a family has a number of really excellent courses on parenting and helping a child healed through sexual abuse. Is the impact of institutionalization worse the longer the child is in an orphanage or a child welfare institution?

Speaker 2:

Yes, it seems to be that way. There have been several very good studies looking at an outcome of adoptees who had been institutionalized and then before they joined their adoptive families and by and large, if, if kids join their families within the first few months of life, maybe up to six months of life, their development is indistinguishable from that of a normal child. Those kids who have been institutionalized for longer than two years tend to have more problems and between six months and 24 months is an area where it's variable as to what is affected.

Speaker 1:

All right. Another impact both of institutionalization as well as prior abuse or neglect is attachment issues and I think it's important to note that attachment issues are along a spectrum and we hear a lot about rad reactive attachment disorder and that is at one extreme, but there are other varying degrees of of attachment issues that we might see in children adopted internationally. So first of all, let's start by saying what children are at the greatest risk for attachment? Well,

Speaker 2:

kids who are in situations where they are not getting individualized care, you know human beings going to have normal development and a wide variety of environments, but each one of those environments must have a, a caregiver who is interested and providing the nurture and individual attention that that child needs. Where we see attachment go off the rails is in situations where they don't have individual caregivers who are interested in responding to the individual needs of that particular child. And the example is institutional care, especially in institutional care where we don't have the appropriate number of caregivers. So we're designed for one-to-one, one adult for two children type of caregiving. And there are, that allows the caregiver to really be able to respond to what that child needs. When you're dealing with caregivers who have a nine 10 incense to take care of, there's no way besides providing the basics of life that those children are going to get what they need. In fact, a number of studies have looked at interaction between children and caregivers in institutional care setting and the amount of interaction that occurs is incredibly low, a very small percent single digits of time spent actually interacting with the caregiver. Most of the time the caregivers attending to other children or trying to get some, some rest from all the duties that they have

Speaker 1:

[inaudible] exactly. And another thing is that there and it depending on the country and of course on the institution there can be high turnover. So you may have a caregiver that has gotten to know a child but then is either fired or at least for another job or for whatever reason. So you've got turnover. And so the child is constantly being exposed to new caretaker even given the fact that they don't have a lot of interaction.

Speaker 2:

Well and, and you know, if you look at a normal situation, you're going to have a handful of caregivers across a year of age or an absence, you know, mom and dad, grandma, a few other relatives, et cetera. If you look in an institutional care setting, um, but it has kind of a normal work schedule, those kids are exposed to 90 to 120 different caregivers over the course of that year. You know, how can any child develop a specific attachment and have consistent caregiving within that kind of an environment

Speaker 1:

and that that turnover and not turnover, I mean, that set up may will function better for the adults. And that's why they're doing it, you know, work hours, vacation, but it's not good for children. Exactly. So what are some of the symptoms of a child with a Hatchmott disorder? And again, knowing that attachment disorders fall along a spectrum. So what are, what's your parents look like?

Speaker 2:

Well, kids with with attachment problems will often have be colicky babies or have feeding difficulties. They have a hard time gaining weight. You know, I think in emotionally and the interaction wise, they're detached and unresponsive. They have very difficult time being consistently comforted. Older kids will have preoccupied or defined behaviors or they won't even want to interact socially with other individuals

Speaker 1:

or even being sometimes indiscriminately affectionate. It doesn't matter who it is. A survival technique for them has been to quickly ingratiate theirselves, ingratiate themselves into any of the adults that walk in a room. And that survival technique carries on. So you might see that type of behavior in a child.

Speaker 2:

Right, exactly. This inhibited social engagement disorder is just called now is a very interesting phenomenon because it's very compelling for parents. They see their child who's very, very friendly, always wants to go make friends with, with other people in the room. And I remember seeing a set of brothers who were adopted by a family who brought the younger one to me because they were just engaged and they thought that that child had a problem, which he did, but the other child was equally dysfunctional in terms of attachment, who was going around and, and being friendly with everyone. And they thought that that child was, was absolutely normal.

Speaker 1:

Yeah, exactly. So what is the, the, and this is a, if you could take an entire class in graduate school on this. So, and I'm not asking for that level of detail, but what is the general process of developing attachment and emotional ties for children and when they come into their adoptive family?

Speaker 2:

Right. Well, you know, parents often ask me, you know, well my, well my child had an attachment disorder and I'll say, of course they will, you know, they've grown up in an orphanage where they have no chance to attach it all. So they have really no meaningful attachment behavior. So what your job is to do is to go back and look at what the attachment cycle is. So your child has a need. Your child cries out or otherwise has some behavior that says that they have a need. You go in and and you feed them, you change their diapers, your kiss, their booboo, whatever. And that child develops a feeling of comfort and security that the world is a good place. And this happened, this happens when you think of an infant tens of thousands of times, that first year of life. And it reinforces the idea that the world is a good place and that there are people around that are interested in you and that you can make your needs be known and have the met. So a family adopting a child who has not had this type of environment has to look for cues to respond to. They have to look for things their kids need. They have to make a deal about this and they have to do it repeatedly and over a long period of time and told that[inaudible] cycles since sinks in to that specific, that child. And it takes a while. But I would say that, you know, we did a survey of 1700 families with 3000 kids that were adopted internationally and most families say that within a short period of time they felt attached to their kids. So this is an issue. Parents need to pay attention to it. But with the exception of a few children who have severe problems, attachment comes along. If parents are responsive to their child's needs

Speaker 1:

[inaudible] we tell people slow down, simplify your life and just be, just be with the child, respond to their needs. Notice them. And children generally will develop an attachment. But the one question we will often get is this one drives me a little nuts. A child, a family will contact that we have a large support group and they will post and say, you know, we've been home for three weeks. I think my child has reactive attachment disorder. They get it because they don't come to me when they need things are or they don't like to be hugged or whatever. So how long post adoption should you wait until you begin to truly worry about a full blown attachment disorder versus a child who is learning to attack?

Speaker 2:

Right. Well, you know attachment is a two way street so you have to have the child attached to you, but you also have to have yourself attached to the child. So I think if, if people feel that there are difficulties and I wouldn't look at three weeks as a time period where I would expect wonderful attachment to occur, you know, if if you're out two or three months and you're, you're concerned about that, then it's time to see a mental health professional who was expert in looking at attachment behavior and seeing whether it's an issue of a child or an issue of the parents because both can be a factor.

Speaker 1:

That's exactly. I'm so glad you taught. You said we, we often will say attachment is a two way street and parents feel great shame if they are the ones who are not feeling a bond or an attachment to their child. But that could absolutely be part of the problems. And the good news is that with working with, usually with a dedicated therapist who understands attachment and adoption, you can get past this. But I'm really glad you pointed that out.

Speaker 2:

Exactly. You know, it's, some of us is just not intuitive. I mean you, you people really need to have expert help in how to do this the right way. And luckily, you know, we have mental health professionals that see all of her patients the first time when they assess, you know, briefly looking at the parent's ability to understand cues from your child and the child's ability to give cues to their parents. And if that's not happening, you know, there, there can be advice given at the, even initially, very shortly after arrival on how to improve.

Speaker 1:

Yeah. Thanks. Excellent. And let me also mention that, um, as I said before, creating a family does have many courses on attachment, how to help establish attachment. Working within the first six months to create attachment attaching to different ages of child parental attachment. We have a lot of different courses for families to access. Also me remind you that this show is brought to you not only through our underwriting, through the jockey being family foundation, but also our partner agencies and our partner agencies are those that believe in our mission of providing unbiased, accurate information both pre and post adoption. And they not only believe it, but they're putting their money behind it, into support of this show. And this show truly well this show as well as all the resources we provide would not happen without their support. Let me tell you about two of them. One is children's house international and they have some very exciting news. They had been chosen by the CCC WEA, but that is the responsible authority in China. So it's a China adoption authority to participate in a new program that will allow home study ready families so you don't have to have a home study, um, home study ready families to travel to China to meet the child they are matched with and meeting your child and getting a better idea of what their particular needs are, will hopefully decrease adoption. Dissolutions our struggles, uh, post permanency post-placement to get more information. You can go to their website at children's house international and we also have children's connection. They are an adoption agency providing services for domestic infant adoption, embryo donation and adoption throughout the United States as well as home studies and post-adoption support to families, Texas. Alright, now we've talked about the uh, abuse and neglect and trauma that children face just from the act of, of being institutionalized. And some children come into state care because of abuse or neglect and neglect is often a symptom of poverty. So we know that. And then once in the institution we've talked a great deal about how neglect are a, certainly a lack of attention is common and then we there it's possible to have abuse and just the act of being placed in an institution is traumatic. So I wanted to talk a bit about some of the psychological issues children may face who have experienced abuse, neglect or trauma.

Speaker 2:

Well, there are a wide variety of things that can happen to kids depending on the, on the, on the situation that they're in. Certainly children who have experienced specific physical or sexual abuse in their family of origin are going to be very reactive to those types of situations when they get into their foster family, to their family. And those are the kids who we see with, with uh, you know, clear post traumatic stress disorder when they're in situations that remind them of where they had been before. Those children require a lot of understanding from their adoptive parents and especially children who have been sexually abused. You need to start out immediately and therapeutic situation with their adoptive family to try and work through these issues. I've seen a lot of kids who have been traumatized, but no child has been more traumatized and kids who have experienced sexual abuse, it really is, is a horrible situation for them to go through and there is no family they can get through this by themselves without professional assistance. The kids that are have been neglected actually may have more emotional and behavioral problems simply because of the fact that they have not had any stimulation at all in their environments. So they're the kids that we see with, with anxiety, with depression. These are the kids who appear to have attention problems because they're always looking for what's happened to them in the past. And it can be very, very difficult for families who are not aware of these kinds of things, who are not in a therapeutic situation to be able to parent these kids effectively. So I always tell families who are adopting kids out of these particular situations that they really need to establish a therapeutic relationship with a knowledgeable individual before they bring the child into the family and then continue that afterwards. Not only for the child's benefit, but also to support themselves because it's a difficult time taking care of these kids.

Speaker 1:

Exactly. And the time to do that. And just to reiterate what you just said is before you bring the child home and finding a therapist that has adoption, competent your agency, it can help you find such a therapist. And that could be your placing agency or your home study agency. Sometimes if you're placing agency is located somewhere else, um, your home study agency may be in a better situation to help you find such a person. And then I was glad you brought up PTSD, post traumatic stress disorder. What are some of the symptoms that parents would look for for a child who is experiencing PTSD so that they know

Speaker 2:

to get help sooner rather than later? Well, it sometimes it depends on the age of the child. Um, you know, if it happens very, very early for a child, they may not have explicit memories of, of what happened to them, but they may have sub-cortical synapses that will remind them emotionally of kind of what happened. So they may make breakdown in situations where it doesn't make a lot of sense to the adoptive parents as to what might going on.

Speaker 1:

Kids may have much more explicit memories of things and may respond to things like we would normally expect. You know, when they're afraid someone's going to hit them or when they are in a situation where they've been previously abused. Those are the kinds of things that parents need to look for. And I think that, you know, knowing as much as you can about about the, the background of the child and where that child has been in the experiences that they've had will help you really understand why children respond the way they do when they get into specific situations. And it can be pre memory and that's it, or a post the post memory, but the child has blocked it out. So you can look at their symptoms and see if they're responding in a way that seems not appropriate for the, the stimulus that they're over responding or under responding when that would be something yes. And to pay attention on. All right. Something that when parents are adopting internationally, we mentioned at the beginning is that they need to understand the laws and the adoption process of the, uh, their child's country of origin and understand what delays may be happening or anything that might hinder the finalization of the adoption, the best place to get information on the country-specific laws and the adoption process. First is your agency and second would be the us state department website on inter-country adoption. And they have a, uh, country information section. Again, that is travel.state.gov and you go there and you, you click on country specific information and uh, you would then go to the country that you're interested in. Um, and if you forget travel.state.gov just search for state department international adoption and it will take you there. And also note that each year the state department is required to do an annual report on inter-country adoption and it includes length of time it took to complete an adoption in the last year from specific countries. And it also includes some cost information. And to get the, to find out about that, you can go to the country-specific pages at, let's say it again, travel.state.gov to get that information. All right, so we know that children coming to the U S uh, we've talked about it, that they are coming from the, everything is totally new. It's also, it seems like it's really important to understand that they're also coming from a different culture, both the culture of the country as well as the culture of perhaps their, if there were fortunate to be in a foster family or the culture of the institution. So what are some of the acculturation or assimilation issues children may face once here in the United States? When you look at where children

Speaker 2:

are coming from, almost every family who adopts internationally are going to become a multiracial and a multicultural family. So believing that you are going to maintain your family as it was before you're white, you're Swedish. And in the case of my family is just not going to be the case. Suddenly we have a Brown boy in the family and the Brown boys from India and that child needs to know that they are a valid, important or worthwhile individual. And the place that they came from is a wonderful place filled with people just like him who were also wonderful people with interesting culture, interesting foods, and a place to be proud of. I am unfortunately run into families who have a very negative impression of the country that the child is from or have members of the family who aren't particularly happy that it's now a multiracial family and people. And that's unfortunate for the child because that's going to impact their self esteem later on in life. So I think it's very, very important for families to integrate their family life as much as possible into the culture and into the racial, uh, balance that that child is from.

Speaker 1:

I agree wholeheartedly. And not only is the family and extended family adjusting, but the child, depending on the age of the child, the child, him or herself is adjusting. You know, they've come from a place where everybody looked like them and behave like them because there were certain cultural things that were the norm where they were at. And so the child also is having to adjust to the fact that all of a sudden people don't look the same. They, they obviously are going to be talking different but they, you know, even a child old enough to have had any religious practice would be experiencing differences in religious culture as well. So all of that are issues that the family has to adjust to. But the child is also having to adjust how does age or the temperament of the child impact how quickly they assimilate and then are there certain ages where the child simply is going to always feel as if they have immigrated, which of course they have to and not fully a part of this culture?

Speaker 2:

Well I think, you know, as children get older and more used to the culture that they grew up in, that can be more problematic when they, when they Colombian come to a different country. We've had, we've had many families who have adopted older children where the children initially at least were not very happy that they were taken away from their country of origin and people that they felt very, very comfortable with. You know, there, there are some care environments where children really do feel that they have been part of a family there. And separating them from that family is going to bring a period of time where they're going to be very uncomfortable with their new surroundings. People can get over that, but I think that family is said to be very sensitive to that fact. As you mentioned, it's, it's, it's going to be very different. Um, over here. I remember when my son was very, very young, I was just astonished at how, you know, and this was just months of age, how differently he reacted to an individual with dark skin as versus white skin because they clearly recognized that those are the people that look like him. So it's very important to recognize that the kids are going to feel a little discombobulated when they arrive here

Speaker 1:

and for parents what they need. They, if you are adopting trans racially or trans culturally, you have to be prepared ahead of time to become a transracial family. And that means learning things that you need to do to help your child grow into, to grow to an adult of the race that they are. And we want our kids to have a healthy, strong identity as a, uh, an African woman in the United States, our as an Indian man or as an Asian girl or young woman in the U S so there are definitely things that parents can do both before but also after their child is here. And uh, it will be outside the purveyors of this course. But creating a family has a lot of courses on becoming a transracial transcultural family through international adoption. And we have handouts. We've got, uh, tip sheets, things that you can do as parents both before the adoption and after the adoption to help your child and help your family both. So something to be planning on beforehand.

Speaker 2:

Well, I think that that's an extremely important point on, and I was pretty naive when I adopted Gabriel and I came to realize that there are things that individuals of color need to do in our society in order to survive. And especially if you're a young, muscular teenager or a young male, those are the things that only that make life better, but it actually will save your child's life. What to teach them.

Speaker 1:

Yeah. And I, and I hear you and completely agree about the male part, but I would also say that girls coming into this country, I mean there's no, I know you weren't. I was, no, I know you were not saying that that girls, but I mean there are things that from a black woman's perspective or from an Asian woman's perspective that is simply different in our culture and parents. And it's interesting because those of a, and I am white and you are white and those of us who have grown up who are widen, have grown up wide and have grown up in this culture are often simply not aware of it because number one, we haven't faced it. And number two, you know, they, they, we talk about white privilege, but it's real that we don't see and notice things cause we don't have to because it hasn't affected us. Our children will be impacted by it. And the other thing I always tell parents is that when your children are little, you are, you become a, know they, they're a part of, of you. They're apart, they're under your umbrella. And we don't really go that far outside of our community. So people get to know us, people in the grocery store after a while, we're no longer as a transracial family. We no longer stand out. But that changes when your child is not under your umbrella, your child will be viewed as a, uh, an Indian man or as a black woman or as an Asian college student. And it's our job to prepare them to be an Asian, black or Indian person in this country. So yeah. All right. And now we're coming to a topic that is a, a, it's one I feel so passionately about and it's, uh, it's the whole idea of post-adoption or post-placement reports. They are very often required. Again, you can go to the state department sites, state travel.state.gov and find out exactly what the country from your, your child's country is going to require. But it's become a big problem in international adoption with families not completing their post-adoption reports as required. And the problem is for the family, but it's also for the future of all international adoption. And because there are countries that are shutting down because they have not received these reports. And I would go so far as a, do you have a moral obligation? You have agreed prior to the adoption to fill out these reports and even if for whatever reason you're irritated with your agency are, you're really busy and you just don't have the time you need to make the time. So I will get off my soapbox here, but you can get information about exactly what is required from your agency of course, or at the state department website, travel.state.gov click on international adoption or in a country adoption and then click on country information. All right, so now we've talked about, it feels like a lot of the negatives of all the problems kids might have, but let's talk about some of, and this is, you guys are certainly, and at university of Minnesota is certainly on the forefront of doing a lot of this research. So how do kids who are adopted internationally fair once they are brought here and are raised, uh, in a, hopefully well-prepared us family?

Speaker 2:

Well, I, I continue to be in this business

Speaker 1:

and have a great deal of enthusiasm about it

Speaker 2:

because what I do see is the

Speaker 1:

and are transformed their adoptive families

Speaker 2:

into individuals, self esteem, great capacity and able to function well with an adult society. You know, there are exceptions and you know, we can't fix everything. Not all the quality of institutional care can go away. Certainly we see effects of alcohol over the long term, but by and large the vast majority of families are very happy that they adopted and their children are doing well.

Speaker 1:

Yeah, I think that's really important to remember. The act of adoption in and of itself can function as a, as a healing factor from a lot that children have experienced and that happens better when parents are well prepared in advance. Yeah, and adoption itself does have lifelong impacts on children. Just the act of adoption. It's not oftentimes not negative, not positive, but it is. It does impact children, adolescents, and even into adults. Let me recommend two resources. One is a book by Dr. David Brodsky. He, it used to be on our board. He is wonderful and the book is being adopted. The lifelong search for self. I was actually coauthored by dr Brazinski, that's a wonderful book that talks about the lifelong impact of adoption. Another one that you might want to consider is the primal wound by Nancy barrier and those are good resources. You can also find our, you can just type in a search for a the primal wound and you can read articles on it if you would like. And as well. Uh, I should also add to creating a family has courses as well as free resources on the lifelong impact on development from the effect of being adopted. So I would recommend that you, that you consider and go there. Well, any other positive or negative things that you would like to just sum us up on Dr. Johnson?

Speaker 2:

Well, all I would say is that when I came into the field of adoption, I didn't appreciate how important families were. You know, and I'm a pediatrician know, I know that kids are supposed to be in families and that's, that's a good thing and blah, blah, blah. But I didn't understand how devastating it was for kids that develop an environment that didn't include a family until I want it to have Romanian orphanage and saw the kids. It's an enormous benefit for a child who grew up in the family. It, it changes everything in that child's life. And I look back on my own life and my parents and all what they gave me and I'm, I'm just amazed that the gift that a family is for a child and I strongly encourage families who are interested in adopting to pursue it. Um, because I think the outcome is such a wonderful situation in most cases.

Speaker 1:

Well, thank you. That's a perfect to end on. Thank you so much. Dr Dana Johnson, professor of pediatrics and the founder of, or one of the founders of the adoption medicine clinic at the university of Minnesota. The views expressed in this show are those of the guests and do not necessarily reflect the position of creating a family. Our partners are our underwriters. And keep in mind that the information given in this interview is general advice to understand how it applies to your specific situation. You need to work with your adoption professional. Thank you everyone, and we will see you next week.

Speaker 3:

[inaudible].