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

Are you thinking about adopting internationally? Don't miss this interview covering the common health, developmental, and emotional issues found in kids adopted internationally. Our guests are Dr. Kimara Gustafson, M.D., M.P.H., an Assistant Professor in the Department of Pediatrics at the University of Minnesota Medical School, a Faculty Member in the Division of Clinical Behavioral Neuroscience, and a pediatrician at the Adoption Medicine Clinic at the University of Minnesota. We will also talk with Dr. Katie Stone, a postdoctoral fellow in the Department of Pediatrics at The University of Minnesota Medical School. She is part of the Psychology team at the Adoption Medicine Clinic.

In this episode, we cover:
The best place to get information on the country-specific laws and the adoption process is your agency and the US State Department website on intercountry adoption, in the country information section.

Each year the US State Department prepares an Annual Report on Intercountry Adoption that includes the length of time and cost for adoptions from specific countries. The country-specific pages at the US State Department website also has some of this information.

• What are some of the general characteristics and needs of kids waiting for adoption abroad? 
• Generally, what factors across the world lead children to be in state care and to need adoptive families?
• What are the most frequent medical or psychological problems you see in children adopted internationally?
• What are some common environmental toxins currently seen in the primary placing countries to the US and how might they impact children?
• For the main placing countries to the US how common is:
  • Prenatal substance abuse
  • Malnutrition
  • Emotional issues
  • Genetic abnormalities
  • Developmental Delay
  • Other known health risk factors
• What is the impact on a child of leaving familiar ties and surroundings?
• What is the experience of most children leaving their family of origin?
• How does institutional care impact children?
• How does institutionalization affect child development?
• What children are at the greatest risk for attachment disorders?
• What are the psychological issues children who have experienced abuse, neglect, or trauma may face?
• What are some of the acculturation and assimilation issues children may face post international adoption?
• How does adoption itself impact children, adolescents, and adults? Resources for parents and professionals:
  • Being Adopted: The Lifelong Search for Self, co-authored by David Brodzinsky 
  • The Primal Wound by Nancy Verrier are resour

Transcript

Please pardon any errors, this is an automated transcript.
Unknown Speaker  0:00  
Welcome everyone to Creating a Family talk about foster adoptive and kinship care. I'm Dawn Davenport. I am the host of this show as well as director of the nonprofit, creating a family.org. Today we're going to be talking about health, emotional and developmental issues common to children adopted internationally, we'll be talking with Dr. Kimara Gustafson. She is an associate professor in the Department of Pediatrics at the University of Minnesota Medical School, and a faculty member in the Division of clinical behavioral neuroscience, and a pediatrician at the adoption Medicine Clinic at the University of Minnesota. We will also have Dr. Katie Stone. She is a postdoctoral fellow in the Department of Pediatrics at the University of Minnesota Medical School. She is part of the psychology team, and the adoption medicine clinic providing expertise on mental and behavioral health attachment, and social emotional development for PhD in Clinical child psychology. Thank you both for joining us today

Unknown Speaker  1:05  
for having us. All right. What are some of the general characteristics and needs of kids waiting for adoption? Dr. Gustafson? Yeah, so I think that historically, when we thought about international adoption, usually what comes to mind, our young children, often infants, and they're coming for factors that are what we kind of now think of would be similar to social determinants of health. So lack of financial resources, lack of nutritional resources, lack of housing stability in the country of origin. Well, those are still definitely factors that can kind of lead to needs for adoption, and especially kind of international adoption. What we are seeing now, both in terms of numbers, there has been a very significant decrease in the number of eligible children for national adoption, you know, as like in early 2000s, we thought peak around over 20,000 children were adopted in those years, when I looked just recently in the State Department, its legs two years. So 2021, I think the number just put it just over 1000 Children that were adopted internationally, so has dropped very significantly, and then the children that we are seeing are much, much older. So more commonly the youngest, we will see kind of the youngest, and like quotation marks would be 234, early grade school. And then we're seeing children that are well into grade school age, so 910 11 up to teenage years, we're also seeing more sibling sets. And so you're seeing kids that are coming where maybe one of the children is fairly young, but then it can span all the way up to, you know, someone coming and being adopted at 14 1516. And then in terms of the health needs, well, we historically used to see kids that were needing more health care, maybe that was due to lack of opportunity in terms of surgical intervention or medication. Now what we're seeing are much more complex medical, and then social emotional concerns, including prenatal substance exposure experiences of early trauma and stress in those kinds of conditions. Excellent. What you talked about the general characteristics and why children were used to be sent? What were the factors that led children to need international adoption in the past? What are the factors now that across the world that lead children to be in state care and to need adoptive families with these older children that we are seeing and more complex emotional and medical needs? Yeah, so I think that some of it is dependent on their country of origin. So kind of varies country by country, most commonly what we're seeing Currently, our children being adopted from South Korea, India, Southeast Asia, and then kind of a smattering from Eastern Europe. So that has slowed down. And we're really not seeing as many children being adopted from Africa or the African continent as we had historically as well. For example, like with India, we I think, are still seeing children that maybe are in their adoptive situation due to lack of resources, either financial or familial or nutritional. But children coming from Korea, I think it's much more of a oversimplification would be like a kind of governmental policy. They don't necessarily have the kind of the social or Policy Infrastructure right now for a lot of unwed mothers or single parents. And so those children are often placed into a foster care situation and then become eligible for international adoption. And then with Southeast Asia, it's kind of a, I would say maybe a hybrid of the two where we see children that are coming into their kind of welfare

Unknown Speaker  5:00  
system due to lack of financial resources, but also have more prenatal exposure in terms of like substance or alcohol exposure, and would be older. And so kind of a whole spectrum of kind of the either physical or medical or social emotional support that they will eventually need. Dr. Stone what are the most frequent psychological problems you see now in children adopted internationally?

Unknown Speaker  5:29  
Well, we see a number of different concerns for for some of the kids that are coming to us from international adoption pathways, the most predominant one is a lack of attachment or difficulties attaching and so that can look like a variety of things. And it takes some time for the adoptive family and the adoptee to form that bond. Because oftentimes, the children who are adopted internationally are coming from different home environments, sometimes institutional care still other times in the foster care system in their country of origin. And so it's it takes a while for them to learn how to attach to a caregiver, a consistent caregiver. And we know that that caregiver child relationship, that primary caregiver is kind of the foundation for all other mental health. And so oftentimes, we're gonna see some behavioral concerns. So they might have a lot of high energy, they might be kind of moving all over the room, you might see some aggression or some externalizing behaviors. We also see oftentimes kiddos that have symptoms of anxiety, depression, kind of hyper vigilance, always looking around the room always scanning their environment, checking for dangers, things like that. But you know, one of the things that's most critical for our adoptees is making sure that they have that strong foundation and that parent child relationship, and we work often with parents on how to form that relationship, how to help that child feel safe, because once we know that there's that strong attachment to their adoptive caregivers, we can work on some of those other things like depression and anxiety and some of those externalizing behaviors that that we often see from some of these children.

Unknown Speaker  7:11  
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Unknown Speaker  7:48  
Okay, Dr. Gustafsson? What are the effects of malnutrition? Because we know certainly many of the kids coming over have not had adequate nutrition, either prenatally or postnatally. throughout their life. Yeah. So I would say that we're not necessarily seeing the kids that with like the extreme malnutrition, that maybe historically we've seen, that we're seeing probably more like, for instance, from India, we see kind of the institutional impact of nutrition, where they their growth just isn't quite as robust, they're still kind of growing just at a slower pace. And so sometimes what that will look like kind of clinically, that we're seeing in clinic is more just that it becomes a kind of a complex relationship between caregiver, child and food, and so that they might have behaviors related to that where there's hoarding, or there's over eating, or food refusal or resistance. And again, then when we layer that into kind of the context of if they're coming home at 234, right, in kind of that peak, toddler fees, and food can be a source of connection and attachment that then becomes, you know, confusing for a caregiver, like, do I give them the food, do I not give them the food. So we still will see kind of this phenomena that we call catch up growth, where children, when they come home and kind of are in a permanent and stable and supportive environment, they will have, or can have kind of a very robust appetite, and they seem to kind of outgrow, you know, their clothing size, like shoe size or clothes size pretty quickly, and then it'll kind of level off. But we're not seeing kind of the malnutrition to the point where it may be historically where we would have to do like medical intervention to help catch them up in the same way. Well, that's good. I mean, that's a significant improvement. For sure. Yeah. So our environmental toxins still a concern, and if so, what are some of the common environmental toxins you currently see in the primary placing countries to the Yes. And how do these toxins impact kids? Yeah, I would say probably not so much environmental toxins right now.

Unknown Speaker  10:00  
but the most common kind of external toxin, if we were to call it that would be prenatal substance exposure. So alcohol, we're seeing some methamphetamine opioids, and then there's kind of just a whole variety of substances that, you know, I'm not even like fully familiar with in terms of, you know, like in different parts of the world, they'll do sniffing or kind of inhaling glues, substances, and things that are kind of street drugs of that area that might not be as common or prevalent in the US because we have other substances, but not as much as that we're seeing where there's, like environmental pollutants or something of that nature. And I think one of the things that's when we're thinking about toxins, environmental toxins that are impacting the child, they think it's also kind of related to the malnutrition question, thinking about the prenatal environment. I think that oftentimes, we're always thinking about, you know, what is that child's life like after they've been born. But, you know, one thing that we know is that their brains are developing in utero, and whatever that mom has been exposed to, including that malnutrition, if there is poverty, which oftentimes is the case. And sometimes we don't always know, from our international adoptive children kind of that birth history, there's very little things we know. And so just thinking about how that impacts brain development, and then how that can impact behavior. So kind of related to some of those high energy hyperactivity difficulties focusing, which can then lead to challenges in different environments, like school once they've come to the US and other types of environments at home. So we really tried to take a holistic approach to understanding the child not just from what they were exposed to in the country of origin, but also potential prenatal toxins that could be impacting that that brain development that could help us explain some of those behaviors that we might be seeing, even after they've been adopted. And then in the US for years, you know, we might then see in school, that they're having any challenges with peers or academic work or things like that. I'm so glad you brought that up, especially the point that in international adoption, we very often do not know, South Korea may be the exception, whereas they do a good job. But I think even now, in South Korea, birth moms are not necessarily being totally forthcoming. And in other countries, there's not even in an attempt to find out what was happening prenatally what type of exposures to alcohol or drugs. So, Dr. Stone, how common is from what you can tell, which we just acknowledge, that you may not know, and be paused and also indicate that oftentimes, the impact of prenatal substance exposure to alcohol or drugs is not apparent immediately. It's apparent at times, you know, the ages of around four, or certainly the ages of around eight, when we start expecting different things of kids higher level things, higher level thinking skills. And that's when we will often see this come out. So parents are blindsided. They're like, Oh, I had no idea. But now they're really struggling, the challenge is really struggling. So Dr. Stone, how common in the main placing countries to the US? Is prenatal substance exposure? Well, you know, I do think it depends country by country. And I can let Dr. Gustafson kind of talk specifically about different countries and kind of prevalence within our country. But I just wanted to piggyback off what you had said, we are seeing oftentimes, when we don't know exactly what's what's happening, we are seeing some of those behaviors happening in those environments that when the demands are higher on the child that that's when those questions start to come about. Often clinically, we'll see them in clinic at three, four or five years old. And we know that those that kind of those executive functioning skills, the needing to organize the need to plan that's kind of can look like, oh, I told the child you know, my child to go clean their room, and they didn't do anything, you know, having the difficulty of kind of focusing to go put your shoes on before we leave the house, things like that. Those are the type of day to day challenges that our families are facing. And so we do try to stop and if we know anything prenatally we can help us understand well, maybe it's how that child's brain developed and is growing. But oftentimes, that's when we're going to start seeing those as as challenges get harder, we kind of see these bumps in you know, childcare, but then maybe moving to elementary school where the demands are a little bit higher, they have to sit for circle time and things like that. Or then even into middle school the child might have been able to kind of hold it together or kind of make make it by but then when the demands get higher like there's they have to switch from classes to classes or you know, different things like that those challenges or the peer relationship challenges. Sometimes we'll see social boundaries and things like that. So all you know, prenatal

Unknown Speaker  15:00  
exposure is going to impact things long time down the road that we don't often see as challenges until maybe a little bit later. It makes great sense. Okay, Dr. Gupta thing, can you tell us about the prevalence that you see of prenatal substance exposure by the most common place in countries that are sending kids to the US? Yeah, I think to be overly simplified, but I would say right now, in terms of country of origin, where there's probably not a high prevalence of prenatal substance exposure, it would be India. And right now, the other countries that children are coming from, I would just based on kind of what we're seeing, currently probably assumed that there is exposure, unless it's kind of very obviously stated otherwise. And usually, if the medical record says that there was no prenatal exposure for alcohol or substances, then that kind of means that there's some other more serious medical condition or kind of a family history of something that would be kind of a concern. And that has necessitated that the child is thought to be not eligible to be placed in the country of origin. And so usually, I would say, kind of, if we're thinking about international option, again, kind of the way that we have historically, maybe when we thought about it 3040 years ago, that these were kids that were kind of maybe lack of opportunity, and that's why they're needing to be placed. Now we're seeing that it's not so much lack of opportunity, but that their needs are kind of maybe exceeding what's available in the country of origin. So just for overall, kind of, for families to know, if they're looking internationally, the potential needs of the child are going to be greater. And then to kind of piggyback on what Dr. Stone was saying is that, I think, too, that sometimes difficult to know, kind of the chicken or the egg is, you know, we know that within populations of children that have an experience of adoption or foster care that they have higher rates of maybe behavioral issues or kind of mental conditions such as depression, anxiety. And so sometimes I think what happens is it gets kind of dismissed as Oh, well there. That's because they're adopted, and it's not necessarily further evaluated or explored in terms of, well, potentially, yes, they maybe they have risk factors, maybe there's family history of depression, anxiety, or mental conditions, or they had experiences of early life toxic stress. But that also doesn't mean that there aren't things that we can't do. So kind of in general, I think, really, once we know the risk factors, keep those in mind. But it's not kind of a predetermined path that the child has to take, you know, especially like a path to struggle or failure, that there are definitely things we can do and the earlier that we can intervene and better support, the better potentials that that child and family might have going forward. Yes, I'm so glad you said that. Because we don't want to paint the picture here, that these kids are beyond health, because they absolutely are not. Well, I think if I understood you that what we're seeing now is if you see a child who has not been prenatally exposed, they likely have outside of India, you mentioned but they likely have significant health issues that make them a less likely candidate to be adopted in their country of origin, or genetic abnormalities, something that you see much of at this point. And again, I'll direct this to you, Dr. Goossen. Yeah, we can still see it like sort of the example I think of that would be if we're looking at Korea, I just kind of assumed that they heard prenatal alcohol exposure unless stated otherwise, just the prevalence of alcohol use among women of childbearing age in the country is very, very high. So the kids that we are seeing that there is no prenatal alcohol exposure. Those are like for instance, it might be someone who was born many months premature, so that then they have kind of the risk factor of that early prematurity, low birth weight, potentially hospital complications during that early body and brain development. So they might not have the alcohol exposure, but then they have other risk factors that could be similar in terms of ADHD, learning disabilities, behavioral concerns, and just maybe the root causes slightly different. Yeah, that makes good sense. Are you seeing many kids with Down syndrome or other type of genetic issues? Or are they more commonly placed in country now? You know, to be honest, I guess I haven't seen any recently I think the country where we were more commonly seeing kids with genetic conditions had been China. We haven't seen as money just you know, things have been full. I haven't seen as many children coming from China recently. That's because they're not Yeah, yeah. And so like China would be we would see Down syndrome we would see a contra pleasure, which is what we think of is kind of the people who are shortened due to genetic reasons.

Unknown Speaker  20:00  
We will see some more children that had cerebral palsy. And were coming from China.

Unknown Speaker  20:06  
Are there any other health risk factors that have left off that you see with any regularity? Well, we see we just in general, we see children that have a lot of maybe isolated. So like they have eye issues that might need eventually surgical intervention, or they might have some eye issue that would kind of result in partial blindness, we see children that have hearing difficulties or something that would need support in terms of the auditory pathway. So deafness, and then we are seeing more and more kids that they've already are, they have a diagnosis of FASD. Or they're coming with mental health diagnoses already, like depression, anxiety, ADHD, those type of things. Okay, and Dr. Stone, how common are the developmental delays? Are? Is it? Is it almost universal for children? Or is that not the case?

Unknown Speaker  20:57  
I mean, there's a pretty significant variability among children. You know, we'd like to think about it in the context of different areas of domain of development. So it is fairly common that there's going to be some areas of delay in most of the children that we see. But the domains are different per person. There's individual differences with children. So sometimes we're seeing some motor delays. With some kiddos and others, we're seeing speech delays, and that could be related to medical concerns, like hearing difficulties that Dr. Gustafson just mentioned, oftentimes, it's hard to identify some of those executive functioning delays until a little bit later, but a lot of the children that we're seeing are of school age, and so we're seeing some of those difficulties focusing difficulties with academic functioning, I would say, across the board, one area that we're seeing most common is difficulties and self regulation, related to executive functioning in some ways with difficulty attending, but self regulation and oftentimes a lot of irritability, a lot of crying, a lot of kind of emotional tantrums, outbursts, things like that, sometimes aggression. So being able to really regulate themselves in in different contexts, given different demands, I would say that's probably the most common area of concern that we're seeing. Okay.

Unknown Speaker  22:23  
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Unknown Speaker  22:49  
What is the impact on a child leaving their home leaving their country leaving all their familiar ties and their surroundings? Dr. Stan, you know, it has a significant impact on on children, you know, we see it variability with the age and memory development. And so kids that have been in their environments, or the country of origin for longer periods of time might have more challenges adjusting, but for the most part, it can have a pretty significant impact. And it honestly has a lot to do, again, with each child and their their own experiences. So oftentimes, we will have families come in who maybe a child has been in foster care in that country, and had most of their life been with the same caregiver that entire time, and then they are being adopted internationally, but they've really had a strong relationship with that person. And so sometimes we'll see some beautiful connections that are made where the adoptive family continues to maintain contact with that caregiver, in their country through, you know, luckily, we have the internet and through social media and things like that, they're able to kind of continue to maintain contact. Other times we'll have children who maybe were in a group care setting where they have, you know, fond memories of other peers in those settings, and can talk about those relationships that that they had to leave. And so, you know, oftentimes we talk with families about that grief and that loss, that that there's these mixed feelings that are happening for children that they are, you know, happy to be in a place of stability, where, you know, this is their long term family, their forever family, but there's still that feeling of loss because they have these memories and these people that they have been a part of their life for however long they were they were in country for. And so it can be a number of mixed feelings that they are having to grapple with and kind of helping parents navigate, you know, how do we support the child and also grow in our family and our relationship with the child to continue to support them? I would assume that most children do not have an ongoing relationship with

Unknown Speaker  25:00  
their family of origin, their biological family, but leaving the country and coming here would make it extremely difficult for them to reestablish that. So is that an issue that you say? Yeah, you know, I think that, as you said, for the most part they are leaving. You know, it's so interesting to think about and talk about, but they're leaving all of the familiar foods and all of the familiar sounds and all of the familiar smells to a completely new environment that is almost shocking, really, in a lot of ways. Good use of a word. Yes, it is shocking. Yeah, it is. It's like all of your senses are on high alert, because you've never experienced these smells, and these sounds and these different things that you're looking at people that don't look the same as the people you've grown up knowing. And so it can put your your body into kind of the chakra this seat, you know, oftentimes it can be a fight or flight, you know, hypervigilance just trying to make sense of it, especially for our little ones that you know, might be to and still not talking yet, or not being able to really comprehend what's happening. One of the things that we find to be most helpful for families who are adopting internationally is this, the families and I know this can be hard, but if the families the parents can spend time in country prior to leaving to the US, that helps that child have some adjustment to these new people because you know, it can be pretty overwhelming to not just meet your your forever parents, but then all of a sudden get on a plane, what is that I've never seen a plane, and then come to the US and all of you know, new neighborhood, new home new people around, but kind of having that be a little bit slower of a transition where the parents, the adoptive parents are able to be in country and going to either the foster care home or the the group care setting. And, and helping that transition, elongate that transition just a little bit to help with that adjustment for the child. It used to be some countries insisted on that. I'm not seeing it as much now. And it's unfortunate, because I think it is such a it does add to the cost. I'm not naive doesn't but on the other hand, it is better for kids, you talked about some of the typical behaviors of flight or fight the meltdowns, withdrawal would be another one that we might see for some kids. Any other typical behaviors, as children are adjusting to what really is their entire life being turned upside down?

Unknown Speaker  27:30  
Yeah, I mean, a, the ones we talked about already kind of the main ones, the kind of shutting down, just be non responsive, but also then the bigger ones, like the crying incessantly not being able to be sued, and just continuous crying, getting really angry, upset, overwhelmed. All children respond differently. But you know, one thing we always like to make sense is what is the child trying to communicate to us right now? What are they doing to try to tell us that something is wrong. And we, we don't always need to know it. But it's helpful to kind of understand context, that they are leaving everything they've ever known for something completely different. And so just having that in the parents mind can sometimes help.

Unknown Speaker  28:14  
Sometimes it doesn't always make the behavior stop or go away. But it can help how we respond how parents respond and regulate ourselves in those moments. We don't take it personally, we realize that the child is not rejecting me, the child is shutting down as the only way they can cope. Yeah. And you know, I was glad you raised the issue. We don't see that many super little ones coming over. But you know, we think that oh, a toddler, they're very young, they will have far less impact. But those kids that toddler, that toddler age, they don't have they don't have the words that you can you can't give them they don't have the understanding either. So that's a tough age for kids to be moved in. Those behaviors would be an exacerbation. That could be exacerbation of tantruming. But it could also be those kids to shut down and withdraw. Yeah, certainly, I think of it as fight flight or freeze. And I think sometimes to just to make sure that families know, another common response might be the freeze. And essentially, the child doesn't necessarily feel safe, and so that we not uncommonly will hear where parents are like, Oh, they're so easy. But then the question is, like, are they really easy? Or are they just not? They don't feel safe, because they're not going to make their needs known. Right? So they don't feel safe enough to make their needs know. Yeah. Right. And then also, similarly, we have kids where the parents sometimes feel like, what am I doing wrong? Because they're only dysregulated in the home. And then kind of reframing that context. Well, home is where they feel safe, so they can kind of let everything out. school might be where they don't feel safe yet, or they're able to kind of hold it together long enough through school. They're kind of like white knuckling it through school. Like they're getting reports from the school. They're doing great. They're like, you know, they're good listener, they're good follower. And then when you get

Unknown Speaker  30:00  
then the car is like everything kind of explodes. And, again, trying to help the film needs to know, not necessarily that you're doing something wrong or take it personally. But it might be that this is where they feel safe, and then also helping them to recognize if they're kind of very compliant, that's also not necessarily a good thing. It might mean that they're still kind of in that freeze mode. Yeah, that's a good point, even though you think it's good, because it's not they're not causing you trouble. That's not good for the child necessarily, emotionally.

Unknown Speaker  30:33  
Dr. Gustafson, let's talk about institutional care, and how that impacts children and child development. Yeah, well, and so this will probably actually fall back into Dr. Stones area of expertise a little bit more, too. But, you know, what we know, historically from studies, is that institutional care can very significantly impact a child's ability to form a healthy attachment, you know, when you're kind of cycling through caregivers, and you don't really know who the kind of your primary caregiver might be, or who to identify, you know, one of the questions that the psychology team always asks is like, who's there? Who's their go to person? Who is the person that they if they were hurt, or if they needed something, who are they going to go to right, and if you're in a group care studying where you aren't able to identify that, then that can have significant impacts. And I think we thankfully hopefully have learned over many, many decades of time that we have to be able to provide children more than just protection, like physical protection in terms of a building and nutrition, right, like we think we used to think of we just had them somewhere, they can physically be safe, and we give them enough calories, they'll be okay. And now we know that even if we give them a physical space, and we give them technically enough calories, they're still lacking. And it can get to the point where they will actually stop growing because of lack of attachment and social emotional support. And so, in general, we think that institutional care if we can find an alternative is probably better, because it helps kids to more quickly identify who their primary caregivers. That being said, we have seen kids coming from institutions where we kind of say, they're probably the favorite, because they're clearly doing really well, they probably have someone I mean, we we've had ones where they're in technically in an orphanage, and then we find out or someone was actually taking them home at night, from the orphanage. And so they had kind of like a nanny that would take them home at night. And so they were kind of in a unofficial foster care setting. And then there has been work done, specifically in China and Dr. Dina Johnson, who founded our clinic here in Minnesota has been instrumental in that work, where they've created what they call villages, where it is technically still an orphanage, but they kind of group them as like a family cohort. And so it just helps the kids have more of that family experience, even in a group care setting. And we've seen with those organizations just a big improvement in terms of the overall kind of health and wellness of those kids. That makes sense. And you said, Well, we used to think that if we could just put a roof over their heads, and food in their bellies that they would be safe. But another thing we know about institutional care, is that it's a place that's ripe for abuse, both from adults, because children need caring adults who are watching out for them and without that other adults can be attracted to those settings who are abusive, but also older children. If there's not adults who are there to supervise that can be problematic to doctor. So what type of care are we seeing now in the various countries placing kids for adoption to the US, as foster care common? For some countries? It is? Yeah, I think it varies. So Korea, like I said, is almost 100% foster care for children who are being placed for international adoption. India right now is still institutionalized care. And then places like Southeast Asia in China, it's it's a little bit of a hybrid. Gotcha. Yeah. Not that many countries have the foster care system similar to like the US. Yeah. Do we see a direct correlation between the degree of impact the longer the child has been in the orphanage or child welfare institution? Dr. Stone? Yeah, we certainly do. We know that the longer the child is in care, the more challenges they have with forming that attachment relationship. And so oftentimes, children coming from orphanage care will have diagnoses of reactive attachment disorder, meaning that they have not been able to or learn how to establish a relationship with a primary caregiver, either through lack of opportunity being an institutional care through changes in foster care.

Unknown Speaker  35:00  
Homes and things like that caregiver or placement disruptions and stuff like that, are they coming with the diagnosis are being diagnosed what here what's in the US, it's variable, usually, it's once they're in the US, you know, it's possible that they'll have that diagnosis there. But often rarely, usually, once they've come here, and they've been seen by specialists and gotten into support, that's when they're receiving that diagnosis. There's research done through the Bucharest study, which was looking at institutional care in Romania. And what they found is that once the child was adopted internationally and able to kind of form that relationship, they were able to reduce the rate of children meeting criteria for that diagnosis. And what they found through that research is that the longer time they were in institutional care, the higher their rates of retaining that diagnosis over time, so there was a relationship between the length of time and care briefly, what are the symptoms that parents would look for, for attachment disorders? And then what can parents do to help their children develop attachment and emotional ties to their family? Yeah, there's a couple of key components to look for. One is if they're seeking out caregivers for emotional support. So one thing we always ask about is what happens if their child fell and hurt their knee, they're riding their bike, they fell down, what did they do? You know, some, sometimes parents will say they got right back up, brush themselves off and went along with their way. And, you know, at times, if, if that happens with children who are not adopted internationally or domestically, in the US, we call that individualism or independence, you know, they were able to kind of brush their knee off, and we support and encourage that behavior. For kiddos that have been adopted and had multiple changes in caregivers, that's actually a sign that they have learned that they have to rely on themselves, and that they are not using caregivers in the way that typically they would be to maybe like two, three years old, they're they've learned that their needs were not getting met. And so they had to kind of rely on themselves. So that's one area is are they seeking support from primary caregivers, when they need help with something when they get fall and get hurt when they are emotionally distressed? Are they turning to their caregiver, maybe putting their arms in the air to be held or going to seek out emotional and physical connection with their caregiver. Another sign to kind of look out for is their friendliness with strangers. So if they're oftentimes going up to strangers than sitting on their laps, or giving hugs to strangers giving kisses to people that they just met, that can be another warning sign that they again have had so many different caregivers in their life, that they're not able to discriminate? Who is their primary caregiver from another stranger person. And so that will be one thing that we would want to look out for another thing that to kind of check on or watches when you are playing in at the park or in public? Are they checking back with you as their primary caregiver? Do they know that you're their person that you're going to keep them safe? Or are they just running off and going to play? Those are a couple of additional things that you want to pay attention to note, how are they using you as their kind of safe person, they're their special person. And if they're not, there's interventions we can do to kind of help support building and fostering that parent child relationship helping oftentimes it involves re teaching the child that you're their person, you're their primary caregiver, helping them learn that, you know, they can go to you and they need you. Having a relationship with a caregiver is a biological predisposition for our children. And unfortunately, for some of the children that are internationally adopted, and even domestically adopted, they haven't had the opportunity to learn that. And so they've kind of gone against that biological predisposition of needing that caregiver. So we're really having to reteach those children. How do you use a primary caregiver? How do you go to them and you know, learn that they can keep you safe? Well, we talked about when kids first come home, the fight or flight fight or freeze. So during that phase, it seems like you wouldn't be expecting a child to know who their person is and know to who to go back to at all times. So it seems like making a diagnosis of of attachment issues, and certainly a diagnosis of reactive attachment disorder would not be warranted within the very short time after they arrive home. So when should when should we start expecting to see the development because it doesn't have to be instantaneous, does it Dr. Stone? Yeah. You know, one of the things that we recommend for children who are adopted internationally is to do something called kakuni. But basically, it's like a much like if you were on maternity leave for having a baby, you know, having time with that child, you know, in that amount of time.

Unknown Speaker  40:00  
It can vary, but if possible, more than a month, you know, sometimes it's hard to with work and things like that. But oftentimes, even certain employers will be able to, when you adopt, be able to offer kind of that maternity or paternity parental leave, during that time really focusing on that parent child relationship, really spending time in the home setting, building that relationship through play, when the child falls and gets hurt, because they're too and they're inevitable that they're going to fall and get hurt, going to that child physically going there and helping them up. And doing that repeatedly will help rewire their brain functioning to learn that, oh, this is what's supposed to happen when I fall, mom is always there and going to come get me and support me. And kind of reestablishing that over time. The other thing you know, we talked about in clinic with Dr. Gustafson all the time is one thing to help that child learn that you're the primary caregiver, is to make you the sole person that cares for their emotional and physical needs. You know, oftentimes, when a child is adopted, we have all these other family members and friends that want to meet the child and get to know them, and hold them because there's probably super cute and lovable and excited to see you. And, you know, we know that with that indiscriminate behavior, they're going to maybe go up and give hugs to aunts and uncles and grandmas and things like that. And so we encourage parents to really try to limit some of that, that they can kind of, at least for a period of time, we usually say at least six months to spend, really focusing on that parent being the one who gets them food, takes them to the bathroom, if they want hugs or cuddles or they fall and get hurt, the parent is the one who addresses those needs just to kind of reinforce those, that if that person for you, if after that period of time, we're still seeing a lot of those emotional responses and challenges, you know, seeking out mental health services, that can be an important time to kind of check in oftentimes, it's not just the child shuts down and as you know, is super compliant. Oftentimes, we've seen other coexisting behaviors that are happening. And so that would be a time when you'd want to maybe seek out some mental health support from mental health providers and see if is this an attachment based Is this a trauma exposure, a response to some sort of trauma that they experienced is this grief still from from leaving their family of origin, or their home of origin, there's a lot of different factors that can play a role.

Unknown Speaker  42:28  
And they just to piggyback on what Dr. Stone was saying, too, I think oftentimes, when we think about reactive attachment, the person in the system that's getting the diagnosis is the child. But I think just to keep in mind that it based on the premise that they're attaching or not attaching to someone else. And so we want to make sure that the other person or the other people, the adults in their life, are open and available to receive attachment. And that's not always easy for some of these kids. And they always want to save for the families. Like it's one thing when you have a newborn, and you bring them home, and they cry, and they try to make their needs known. And that can be frustrating in a different way. But when you have a three year old and like I have a four year old, you know, they're not always easy. Sometimes they're kind of snarky and demanding little suckers, aren't they? Yeah, yeah. And depending on your previous experience, if you've had any, as a parent or a caregiver, it might be very different than what you previously went through. And then similarly, we have this conversation about siblings that, you know, it's one thing when you bring a newborn home, it's another thing when you bring like a mobile, kind of demanding three year old into the house, and now they're taking all your stuff in there. And so, I think that one of the things too, is trying to help kind of the parents to know that attachment kind of goes both ways. And so sometimes, the parent might need support in that attachment process just as much if not more so than the child because it might not feel quote unquote, natural or organic, because they're gonna, you know, some kids will kind of freeze or not make their needs known. Other kids are going to be like overly needy or demanding and that's also can be very exhausting. And so if you're kind of you're like Tasha not sleeping, now I have this new kid in my house. They're needing all my time. And I before this, this isn't what I thought Parenthood was gonna look like. That can be difficult and so thing to families like it's okay to ask for support for that as well. Yeah, attachment is absolutely a two way street. And sometimes, you know, our life that's also been turned a topsy turvy, and depending on our temperament as parents, some of us handle that better than others, and some of us handle what it feels like rejection from a child better than others and, and, and we all have our own triggers. We just do that's just, we're humans and

Unknown Speaker  45:00  
Recognizing that is an important thing. I do also just want to note that reactive attachment disorder is incredibly rare. I'm glad you said that it really is, it really is it would require that child to have many, many different caregivers from very early in development, infancy, in fact, so lots of placement changes if they're in foster care or even long term period of time and institutional care. So it's, it's really rare, we like to think about attachment as like quality of the relationship. And I think we can all agree that there's always ways that we as caregivers can continue to grow in our relationship with our children, and it changes in ebbs and flows. And so when we're thinking about parents and children who are adopted, it's like, has this child ever been attached to anyone? Because if they have if they've had a foster care placement, or they've had that kind of pseudo nanny, who, you know, is kind of really focused on that child, is there maybe the favorite in the group care setting? Those skills can be transferred to new caregivers, we know because they learned that they had this attachment figure, at some point, they know what it feels like to have someone a parent like figure. And so we always kind of try to understand the child from that perspective, have they ever had this relationship? Or what is this parent child relationship look like? It may not be perfect, but and there's, you know, they're continuing to grow in that area. And so I just I just thought it'd be important to kind of note that that is not just everyone coming from international adoptions are going to meet criteria for this diagnosis, right? Absolutely not. In fact,

Unknown Speaker  46:41  
let me stop for just a minute to tell you about a resource that we have at creating a family. It is a resource to provide training, interactive training, our curriculum for support groups, either one, it can be used for support groups or for training. It is a really great resource, we have a library of pick, we have 24. Now we'll be having 25 shortly. By the time you're listening to this, you will probably have 2525 topics that are directly relevant to foster adoptive or kinship families. Each curriculum comes with a video, a facilitator guide, a handout, an additional resource sheet, and if you need it, we have certificates of attendance as well. It is designed to be a turn key resource that allows you to quickly without very much prep, run a high quality support group or training. And you can find this at parent support groups.org. Or you can go directly to our website, creating a family.org. Hover over training and click on Support Group curriculum.

Unknown Speaker  47:49  
Okay, now I want to turn to post traumatic stress disorder, Dr. Gustafsson? First of all, what is it? And what are the symptoms of PTSD, Post Traumatic Stress Disorder? Yeah, and again, probably foreign in Dr. Stone is different. But so I think when we think about PTSD, it usually is in reaction to like a very acute kind of finite event, you know, that there was like the an earthquake or tornado or something, you know, it originated during kind of military experiences for soldiers. And so what it means is that then kind of the body struggles to kind of shut off that, that they're always in a state of threat, you know, that fight or flight. And so it's getting triggered in times when they are physically are kind of objectively in a safe space. But for whatever reason, it kind of turns back on that system, that they're under threat again. And we usually think diagnostically that PTSD is kind of a short lived that the traumatic event occurs, and then they can go through this PTSD period. And then usually through intervention and support, they would kind of process through it or kind of recover from it. I know like Dr. Stone kind of touched on this a little bit, I think what we see in our clinic, and now whatever kind of the psychology can be starting to think is kind of a trauma response experience where there wasn't maybe a finite, you know, earthquake or military event, but that they're experiencing trauma, you know, over time, and then what does that look like in terms of their behaviors, and their interaction with the environment going forward, even if that ongoing trauma is no longer present? Dr. Stone what children are most at risk for PTSD, international adoption, you know, really any child who has been exposed to a traumatic experience and traumatic experience can be something that is life threatening, so witnessing something life threatening or having something life threatening happen to them. And then what happens? I'm just gonna kind of piggyback off of what Dr. Gustafson said, what happens is that their body goes

Unknown Speaker  50:00  
into this physiological reaction that does not allow their cognitive processes to make sense of what happened. So my body thinks I'm in this state of threat. And so I'm kind of going to shut down all of those like processing components. And then that sticks with me that inability to kind of process and make sense of that environment. And so you see a lot of re experiencing happening through nightmares. Oftentimes, children will have nightmares, they might be replaying through the play that they're having. They might be replaying that experience, if there was some sort of abuse that happened physical, emotional, sexual abuse, or tornado or car accident, things like that domestic violence exposure, they might be replaying that they might be avoiding people that look like that perpetrator. And then you know, you're also going to see a lot of physical symptoms, sleep difficulties, concentration, difficulties, hyper vigilance, always kind of scanning their environment for dangerous things like that. So any child that has kind of been exposed to any of those traumatic experiences, are likely going to have some sort of trauma response. I think what we're seeing now is that Polly victimization, or having been a victim of multiple experiences is really the norm at this point. And so kind of that cumulative trauma that's happening, having been exposed to multiple incidents of abuse, multiple instances of violence, or some other type of traumatic experience is going to continue to have that negative effect on children and have long term effects, not just right now in the immediate moments of having difficulties concentrating at school or sleeping, but can have long lasting health consequences later in life. Yeah, that makes sense. Now, I'd like to turn to what happens to these kids when they come to the United States, we want them and expect them to acculturate and assimilate. So what are some of the issues that children face in acculturating and assimilating? And does the age and the temperament of the child impact this assimilation? Dr. Stone, push this one to you? Yeah, you know, it does. And I think it really is dependent on kind of the age, their past experiences again, and then the age that they are arriving in the US, oftentimes, there's going to be language differences, and so that can have a significant impact on their comprehension and understanding. So if they're learning a completely new language, that's gonna have some communication difficulties, I think what we're seeing, you know, in those early periods, is just trying to adjust trying to build that parent child relationship, trying to adjust to new customers, new experiences, new foods, new language, there's that adjustment period that's happening, and then trying to, you know, work their way through school, we see lots of children with just different school challenges for a variety of reasons, whether it's just how their brain is functioning, or kind of their early experiences, and that's impacted their coping strategies, you know, what we typically will see in kind of what we call middle childhood age range, when their self awareness, self consciousness is coming online a little bit more, they're more aware of themselves and the others. That's when identity development is starting to take place. So kind of that middle childhood, who am I? And how do I classify myself with the other people in this world, in this room in this environment? So we oftentimes talk with parents of older children, as they're moving into kind of preteen pre adolescence and hormones start raging, helping the child kind of make sense of who they are as a person. And that that is continuing to develop even into young adulthood that Who am I as an adoptee? Who am I as a Korean adoptee, who am I as someone who's, I don't know, prenatally exposed or, or something like that, what's my racial identity, and trying to make sense of what's my gender identity and who they are as a person. And that adoption story in that adoption history is very much a part of that identity development, and that acculturation to make sense of them as a person and how they kind of fit in with their world and kind of make sense of their home of origin and their culture and their ethnicity, and also their current family environment and their current community and school and things like that. So that's a good point. And so how does adoption itself the fact of that the child or the young adult, or the adolescent has been adopted? How does adoption itself impact these children or adolescents? Well, you know, I think historically, we always thought that once the child arrives in our home, they're part of our family and that's the end of it and everything is happy and you know, we're we're there and we love and care for them and everything is That's enough and and I think that what we have found is that oftentimes when parents and children openly talk about their adoption history and who they are their birth family, and try to make sense of that that children are able to adjust a bit better able to

Unknown Speaker  55:00  
kind of make sense of that their family is just a constellation of different people that make me who I am. And so we're seeing better abilities to adjust. But that adoption history is always there, whether it comes out when they're 234 and developmentally appropriate discussions, or whether they find out when they're a teenager, eventually it comes out. And so usually what we recommend is for families to really start those conversations early, because it's who that person is that you know, they were born into a family and or into by someone, and then they were adopted by by another family and, and trying to make sense of that history is really important for that individual. And in the written material. We will include links to three books that I think are particularly good to help with this, and help parents understand what is being adopted the lifelong search for self co authored by David Brzezinski. The next is the primal wound by Nancy Vermeer. And the last one is the seven core issues and adoption by Rosia and Maxon. So we'll have links to all of those Dr. Gustafsson the last question for you. Just generally speaking, we've talked about a lot of issues associated with kids who have been internationally adopted a lot of risk factors. But how are the kids once they've been adopted? Generally speaking, how are they doing? I think, in general, that they have the potential to do really well, and they have potential to meet their maximal potential as a person. We know that by studies, you know, like the Bucharest study is a perfect example. We know that by studies that children overall will do better, and they will reach their highest potential when they are in a loving, supportive, permanent kind of home environment, you know, and if that is not possible with their family of origin, then we need to continue to be creative in terms of how we meet the needs of the child. I think that some of what we've talked about today may have been because of wrong assumptions that grownups kind of during that time and with, you know, previous historical policies, kind of think, Oh, well, if we put them in a new family pre verbally, that also means that they're pre experiential, right? When we know that that's not true. We know that toddlers, even if they can't communicate, they have had experiences, they have their own thoughts and their own personalities. So I hope that over the many decades of the work that we've been doing, that we've learned as a community, that there are things that we can do better as a grown up around these kids, and that the potential for the kids is still very great. And you know, to the point of just to back up a little bit in that topic of discussions about racial identity support and identity, adoption, identity support, and that kids are, I think, I mean, obviously, I'm biased. I'm a pediatrician. I think kids are amazing, right? Every kid has the potential to be even more amazing. A lot of times we as the grownups just have to figure out how do we best support them? And when it comes to kind of the racial identity, stepping away from kind of this colorblind mentality, right that, oh, I don't see them as being different than me. They're just my child. Well, we know we live in a racialized society. So they're going to be viewed as different. Let's figure out how to help support them in that identity about, you know, if they're coming to their family through adoption. Well, they're just like my other kids that are biologically connected to me. That might be the case in certain ways. But there are other ways in which the adoption is very much important to their own personal identity and growth and development. And so how do we support them? And so things like I say that being a parent is hard. Being a parent of an adopted child is uniquely difficult in certain ways. But also there are things that I think are uniquely amazing and beautiful in that situation. And both the child can reach their greatest potential and then the parents this opportunity to just become a better version of the parenting self that they can be. That was a perfect ending. Thank you so much, Dr. Kamara Gustafson and Dr. Katie stone for being with us to talk about healthy emotional and developmental issues common to children adopted internationally. I truly appreciate it. Thank you. Thank you.

Unknown Speaker  59:24  
Before you go, let me have just one more, maybe 20 seconds of your time to tell you about one of our partners. It is children's house International. They are a Hague accredited international adoption agency currently placing kids from 14 countries with families throughout the US. children's house also provides consulting for international surrogacy

Transcribed by https://otter.ai