Evaluating Risk Factors in Domestic Adoption

Are you thinking about adopting a baby? Are you worried about what risk factors exist that you should know about? Join us to talk about these issues with Dr. Lindsay Terrell, a pediatrician at Duke University Medical Center and an Assistant Professor in their Department of Pediatrics. And James Fletcher Thompson, a South Carolina attorney with extensive experience in adoption. 

In this episode, we discuss:

• Lack of prenatal care.
  • What is covered in prenatal care and how might a lack of prenatal care impact a baby?
• Prematurity
  • What causes a premature birth?
• Prenatal exposure
  • Alcohol
    • What are some red flags that a mom might have abused alcohol during her pregnancy?
    • Does the degree of impact differ depending on when in the pregnancy alcohol was consumed?
    • What are the long- and short-term impacts of alcohol consumption on a child exposed prenatally?
    • Creating a Family’s Prenatal Substance Exposure Workshop for Parents
  • Opioids 
    • List of opioid drugs in increasing degree of strength
      • Codeine.
      • Hydrocodone (Vicodin, Hycodan)
      • Morphine (MS Contin, Kadian)
      • Oxycodone (Oxycontin, Percoset)
      • Hydromorphone (Dilaudid)
      • Heroin
      • Fentanyl (Duragesic)
      • Methadone, Suboxone
    • Does the degree of impact differ depending on when in the pregnancy the opioid was used?
    • Does the degree of long-term impact differ depending on whether the baby was born dependent or with a diagnosis of Neonatal Abstinence Syndrome (NAS) or Neonatal Opioid Withdrawal Syndrome (NOWS)?
    • What are the long- and short-term impacts of opioid exposure on a child exposed prenatally?
  • Cocaine
  • Marijuana
  • Methamphetamine 
  • Polysubstance abuse 
  • Creating a Family has extensive resources to help parent a child exposed to opioids prenatally. 
• Sexually Transmitted Infections
  • What are the common STIs? 
  • What are the risks of each of them to the unborn child or newly born child?
• Mental Health Issues
  • What is the genetic connection for the following mental health disorders? How heritable are these mental illnesses?
    • Anxiety disorders, including panic disorder, obsessive-compulsive disorder, and phobias. 
    • Mood disorders: Depression, bipolar disorder 
    • Personality disorders (antisocial, borderline, narcissistic)
    • Psychotic disorders, including schizophrenia
    • ADHD
• Legal Risk Factors
  • What are the most common legal risk factors when adopting an infant through private adoption?

Transcript

Please pardon any errors, this is an automated transcript.

Unknown Speaker  0:00  
Welcome to Creating a family. Talk about foster, adoptive and kinship care. I'm Dawn Davenport. I am the host of this show and the director of the nonprofit creating a family.org.

Unknown Speaker  0:12  
Today we're going to be talking about evaluating risk factors common to domestic infant adoption. We will be talking with Dr Lindsay Terrell. She is a pediatrician at Duke University Medical Center and an assistant professor in the Department of Pediatrics. She is the Clinical Director of Duke's Foster Care Clinic, and she and her husband are also licensed foster parents. At the end of this interview, we will also be talking with James Fletcher Thompson, he is a South Carolina Attorney with extensive experience in the legal process of adoption as well as assisted reproductive technology. He's a frequent lecturer throughout the country on adoption as well as child welfare issues, and he is the author of the book published by the South Carolina bar entitled South Carolina adoption law and practice. He has received national and state recognition for his service on behalf of children and adoptive families, and he also serves on the board of creating a family. As I said, we will be discussing the legal risk factors with Jim at the end, but we were going to start with Dr Terrell talking about some of the common risk factors in domestic infant adoption. And when I say this, I mean medical and mental health risk factors. I want to start with the lack of prenatal care. Very often we see that expected women, for a variety of reasons, have not had prenatal care. I think that's something that worries adoptive parents. So. Dr Terrell, what is covered in prenatal care, and how might the lack of prenatal care impact a baby? Right? Thanks, Dawn, thanks for having me today. I'm looking forward to this conversation, and I'm also looking forward to the conversation to follow as well, and all of the legal risk factors. But so let's start with just what's covered in in just general prenatal care for a child or for a mom and a baby, right? So I kind of bring this up into groups, I think about the first step is just general health assessments and monitoring for mom, right? So that includes things like blood pressure checks to make sure that mom doesn't have high blood pressure or gestational hypertension or preeclampsia, right? Those are all things that can really complicate a pregnancy, things like urine tests are done to check for signs of protein or glucose, which would be an indication of gestational diabetes, monitoring for infections. For example, urine infections can be not something that you want during a pregnancy and can lead to complications weight monitoring, blood tests to check for certain infections, as well as anemia and blood type, which can put that baby at risk for some things later on as well. And then General Training for genetic conditions. It's also a routine part of overall kind of monitoring of mom. Then the next step of this prenatal care is really thinking about the growth and development of the baby. And so during some appointments, but not all, ultrasounds are completed to check for fetal growth, monitoring that baby's position, checking for any abnormalities that they may see on the baby. At each appointment, they measure a fetal heart rate, or heartbeat to make sure that that baby's heart is beating in the rate that it should we think about fundal height, which is measuring the how big the uterus is, right, which is an indication of how big the baby is. And so those are kind of the two big categories that we prenatal care would be broken up into. But then you also think about what else goes into those appointments, where that OB would be talking about nutrition and lifestyle counseling, things about how to eat, how to exercise, lifestyle modifications, you know, don't drink alcohol, don't smoke cigarettes, try not to eat raw tuna, all of those things that go into those regular prenatal cares visits. And then you also think about vaccinations, preventative care, as well as monitoring any chronic health condition that mom may have, right? Not all moms coming into pregnancy are healthy, and some medical conditions can complicate or add challenges to pregnancy, and so making sure that that is done well and under good monitoring is an important part of a healthy baby being developed and born. So if a mom hasn't had the advantages of having this prenatal care, how does that impact the fetus and then ultimately, the baby, right? You know, I think in the medical world, we generally say a lack of prenatal care can lead to really significant and serious complications in that baby. And you can imagine that without good prenatal care, it could become difficult to identify or address any complications that may be present or may come.

Unknown Speaker  5:00  
Come up during that pregnancy. Now, is it possible to have a totally healthy, wonderful baby with no prenatal care? Yes, that's possible, hoping and assuming that there are no complications that come up, but that's a gamble, right? And and in our world, and especially in the United States today, we have great prenatal care to offer to try to help and pick up some of these complications. And so without prenatal care, what we know is that babies are at increased risk of preterm birth. You think about, you know, normal deliveries at 40 weeks pre term is before 37 and so in general, research shows that if, if moms are not getting routine medical care, they are more likely to have a baby born preterm that can lead to complications, which may include breathing problems or feeding problems or behavior problems or even long term problems, so kind of a wide range of what could happen from that, also moms with little to no prenatal care more likely to have babies with low birth weight, and we Think about generally, like five and a half pounds or more is kind of in that normal category. Below that, you're thinking low birth weight, and so they're born small, but again, similar complications as to the preterm birth when you think about respiratory problems, feeding problems or ongoing developmental delays later in life. Now I say all these things, that doesn't mean you're guaranteed that, right? We're just talking about general risk. I want to make sure that everyone who hears this doesn't get scared away by saying, Oh no, no. Prenatal care means all of these problems. It doesn't mean that it's just a higher risk. Other things to just think about with little to no prenatal care would be screening for those infections and overall health conditions that might be missed screening for babies health conditions so genetic abnormalities or congenital abnormalities that that baby may have that would normally be picked up in routine prenatal care may not be picked up until birth. And even then, some of those things can be a little tricky to pick up at birth, and so I would want to make sure that you have a good pediatrician and that that baby's getting good care, to make sure that all of the things that should have been screened for early are being checked out well, doesn't mean they're going to screen for everything once baby's born, but just being thoughtful about listening to that baby's heart and doing a good physical exam on that baby and making sure that that baby as developed as normally as possible. And then, you know, I think the biggest risk of, or kind of the scariest of lack of prenatal care, is just this risk of stillbirth, right? It's much higher if, if a mom is not receiving prenatal care. And so, again, that's why I think the medical world would really push that every mom have access to really good prenatal care. And then I think about as a mom in general, you know, it's hard being pregnant, and there are a lot of emotional changes, and you know, especially if you're a mom who's thinking about adoption, that that prenatal care, I hope, would offer you some support for education and mental health support as you're thinking through that. And so for moms who aren't getting that, where could they get that support? In another way, you know, it's just something to be thinking about, right? And as you say, generally speaking, once a mom is making a decision to place her child if she is in contact with an adoption agency or an adoption attorney, at that point, usually she is then beginning to get the prenatal care Right, right. And I think it'd be interesting to just pull the audience and say, you know, do you think that if a baby's being put up for adoption, they'd have limited to no prenatal care. You know, thinking like that, mom doesn't want them. And I think it's important to know it's so individual based on how that mom's doing and what they're thinking, there may be children or babies that are where mom is deciding adoption, and she's had great prenatal care pregnancy, and she cares so deeply for that baby, and so it is usually issues of poverty, yeah, not about caring. It's not about caring. It's not about love. It is about a chaotic life, a busy life, just a lot of different factors, right?

Unknown Speaker  9:16  
Let me take a moment right now to ask a favor of you, we really need you to rate our review this podcast. It really helps us when you do that's how any of the podcasting apps make. Recommendations. Could be a star rating or could be a written review. Either one is really helpful for us. And of course, subscribe to the podcast if you're listening. That goes without saying and recommend it to friends. But in addition to subscribing, which is probably the most important, if you could please rate and review this podcast, it would really help us. And now you can get back to this interview

Unknown Speaker  9:51  
all right. Now I want to talk about another risk factor that can come up with domestic infant adoption is prenatal.

Unknown Speaker  10:00  
Exposure to alcohol and drugs. Again, it is not universal. However, it is also not uncommon. So we're going to start this section by talking about the short and long term impacts for alcohol. Then we're going to move in to talking about opioids, and then we're going to talk about other drugs that are commonly abused in the in the US. All right, so let's start with alcohol. What are some of the red flags that a mom might have abused alcohol during her pregnancy? It's such an interesting question I was I was trying to think again, breaking up into two pieces. One is just trying to understand mom a little bit more. I'm trying to put myself in the perspective of maybe a bio mom has just chosen me as a family, and I'm trying maybe I have a little bit of a relationship with her. I'm getting to know her risk factors I would think about would be right, obviously past use of alcohol, or an alcohol abuse situation that you know, I hope moms would be able to talk about, and free to talk about, if that was true, a history of substance abuse in general, or poly substance abuse, where a mom is using so many substances that you would worry that they're all at risk, right, including alcohol, those would be things I would Think about for mom. But then once that baby is born, there would be certain things that would make you worry that maybe that baby had had alcohol exposure, and that would be things like growth restriction or that baby being smaller than what you would expect. And then there's certain, you know, fetal alcohol syndrome is this big term, and it can be challenging to diagnose but but typically, what we think about with fetal alcohol syndrome, they are facial abnormalities that come along with that as well. And so sometimes, when that baby is born, a physician can can do a physical exam on that baby and have concern for that. As far as I know, there's no real great way to slam dunk diagnose it, we kind of have to watch how that baby does over time. But there are certain things, growth restriction, facial abnormalities, and then as that baby grows up, if there are developmental delays, all of that could at least indicate a concern for exposure to alcohol in utero.

Unknown Speaker  12:20  
And I'll just throw out that the classic facial abnormalities are fairly rare, and therefore the absence of those does not mean that a child has not been exposed Correct. Does the degree of impact differ depending on when in the pregnancy alcohol was consumed? Yeah. So that kind of, as you said, right that it makes sense to me, and what we know from literature is that the earlier on you're exposed to alcohol, the more likely you would be to have those facial abnormalities, right as your face is developing, literally inside a mom and so earlier on during pregnancy, that consumption of alcohol can lead to more of those deformities or changes in facial appearance, but also changes in baby's organs as well. You know, you think about heart defects or other birth defects that can be affected when there's a chemical actually in there that shouldn't be in there. And then when you think about second and third trimester, so later on during pregnancy, that baby's not a face is not developing. The organs are already developed, but the effect of alcohol on the brain and overall body of that baby is still very much a concern. And so alcohol later on in pregnancy, you start thinking about posing a risk on the baby's development, learning difficulties, attention, things later on in school, or even in more short term baby being born small, maybe having trouble feeding, and that kind of thing. And so there's a whole spectrum of this fetal alcohol syndrome. And so as you said, some of them may be more visible, but some, and I would say, even in our clinic, over the past 10 years, we've maybe seen one or two children who have really concerning features of fetal alcohol syndrome, and then we've seen many, many others where we're concerned about exposure to alcohol in utero, but there are no abnormalities or facial abnormalities that would come along with that. Yeah, and for more information on this, creating a family has a terrific workshop that we put on for parents. It's the prenatal substance exposure workshop for parents. Include a link in the outline to that, but it's a three session in depth of what to expect and, most importantly, what works. How do you help these kids? How do you help these kids thrive? Yeah, that's great that y'all do that Don Yeah. All right. Now moving on to opioids. One of the challenges on prenatal substance exposure in general is that alcohol is very difficult to test for at birth. So very often we're guessing we.

Unknown Speaker  15:00  
Don't know. And honestly, even if a mom comes in to labor drunk, if she says, I I just did this because I was trying to cope with the labor pains, you won't know. And it metabolizes so quickly in our bodies, therefore it's almost impossible to test at birth, so you're not going to know. However, some of the drugs we are now moving to talk about in opioids is one of them it is possible to test so you may know that a child has been exposed. So what I'd like to do is talk about some of the opioid drugs, and I've made a list of drugs that are used at increasing degrees of strength and that a mom may have taken during pregnancy. And I'd like to talk about what we know as far as the the impact, what's research telling as far as the impact, both short term, but really more long term, because we will talk about NASA now in a minute. I don't want to talk about that necessarily now. So codeine is I actually didn't realize it was a lesser strength, but apparently it is codeine, and then some of the Vicodin ones, which are hydrocodone, and then maybe morphine. So let's talk about some of those. What do we know about the impact of these less strong opioids? So I would say for those, like the lower potency opioids that you spoke about, you know, those are all they should be prescribed medications. You can get them prescribed by a doctor. So I typically, when I think about those, I'm thinking about, you know, someone who's having tooth pain or just had a root canal, or maybe they had a arm fracture and they need a little something. So all of these prescription opioids, hopefully are being given under the care of a physician. They still pose some risk, right? But hopefully a physician is monitoring the amount and the duration that that mom is getting and therefore limiting how much that baby is being exposed to. Even with prescribed opioids, such as the one you said, there still can be some risk that can come with that, including, I know you won't talk about NAS yet, but you know abstinence syndrome, depending on when that is during pregnancy and related to delivery, can still have an effect, but overall, in terms of the effect on that baby, it should be relatively low. Okay, excellent, yes, and we can throw in neonatal abstinence syndrome NAS or neonatal opioid withdrawal syndrome now, so it's possible, but because usually these are not being abused as street drugs, although that can happen, but that's not the common one. If it's under prescription from a doctor, what I'm hearing you say is that the the risks of long term impacts is lower, and the risk of Nasr now's are lower as well, correct? And those can also be misused, right? So someone could get a prescription and misuse that, or someone could sell them on the street, and they could be used as street drugs, which would make it more concerning about what it is that you're taking, typically, if they're being used in a street drug kind of fashion, and this is anecdotally, from just being in clinic and having experience with some of these children, is that those drugs are being used with higher potency when they're on the street. So the street drugs are mixing in more of the higher potency one and maybe filling in the lower potency one, just on an as needed basis. And so I'm not minimizing that they can be used in street drugs, but typically the higher potency one are more kind of the heavy hitters in the street drug category. All right, so we'll move to the heavy hitters that would be some of the oxycodones, which would include OxyContin and Percocet, and they would also have Dilaudid, which is hydromorphone. I believe I'm going to hold heroin and fentanyl to talk about in just a minute. So let's talk about some of the again, these are often prescribed, but they're also often used illegally as well. So what do we know about the opioids such as Oxycontin, Percocet and Dilaudid? Yeah, so all of those, right? They're higher potency, so you're at higher risk of that baby having that addicted kind of feeling, right? It's just a little baby, but they still have that. If they're exposed over a long enough time, it's more likely that they're going to have that addiction type level of need for that drug. It's a physical dependency, isn't it? Yeah, the dependency. And so this neonatal abstinence syndrome, NAS or NAS, as you said, is that dependency so that baby is born and prior to being born with getting these hits of these opioid or narcotic drugs, and then once that baby is born and that umbilical cord is separated, they all of a sudden have a beast withdrawal of all of those drugs. And it would be just like an adult going to a rehab program and experiencing the withdrawal of that medication, and it's.

Unknown Speaker  20:00  
It must be miserable. You know, it sounds like it's miserable and awful for adults, and babies can only really do one thing to express that, and that's the incredibly fussy which interrupts feeding. They can have really irritable digestive systems. One of my favorite little places in the NICU is where they keep babies who have been exposed in just this very dark, quiet room, and there are all kinds of protocols to make sure that you don't disturb them. So when I think about those, I guess we'll call them medium potency, but they're still pretty high potency. Most of those are still prescribed. Oh, I think all the ones you said are still prescribed by a physician. So hopefully it's just a short term thing, and they're prescribed by a physician. Maybe a mom has a slip disc or something during pregnancy, and she gets a couple of doses of Dilaudid. That's great, but if it's being misused or overused, then you start to think about, okay, symptoms short term when that baby is born. But then you also have to start thinking about the longer term complications, which can obviously vary on the dosage and the duration, but you start to think about kind of all the ones we mentioned before. I mean, you can have things like birth defects, problems with organs so you know, congenital heart problems or other organ problems. But then you also start to think about just overall growth and development for that baby and behavior concerns and predisposition to certain mental health problems that you know long term, we just need to be thinking about again. It doesn't guarantee it, right, but it's the risk factors are there all right. Now let's talk about heroin, and actually, even more important, fentanyl, because that is replacing, in so many ways, heroin. What do we know about the impact, both short and long term of a mom and these are most often being abused illegally? Yeah? So what do we know about the the risks of NAS and nows, as well as the long term impact of a mom who's abusing heroin or fentanyl. And I would say anecdotally, fentanyl and heroin are are all what we're seeing most of right now in this okay, that's helpful. Thank you. Pandemic of drug exposure and drug addiction that's out there, and so obviously, heroin and fentanyl have the highest risk of all of these things that we had just talked about. And so if a mom has been using fentanyl or heroin throughout her pregnancy or with limited support or limited, you know, access to drug rehab programs, then short term, you could likely expect that that baby is going to be born with dependency type symptoms, or this NAS or now kind of symptoms, and what that looks like to someone who's not medical is an incredibly fussy baby who gets disturbed pretty easily by light or sound, has an upset GI tract. You know, feeding may not be super comforting, things like really watery loose stools or diarrhea can accompany this as well, vomiting, spitting up. And so all of those things are tracked when that baby is born, it's tracked in the NICU. There's a whole scoring system, and if the baby score is too high, then they actually get a little dose of morphine. And so hopefully a baby could make it through that period without needing any additional medication, but sometimes babies who are really experiencing those symptoms actually need a little dose of a medically prescribed opioid to taper down those symptoms over time, in the same way that an adult would receive Suboxone or methadone to help relieve some of their symptoms. And so that that's the short term complication. And I think once that baby makes it through that period, which can last days to weeks, depending on the half life of the substance that was being used, once they make it through that period, they typically, they might be a little more irritable than the average baby, they may have more feeding trouble than the average baby, but typically they make it through that horrible first stretch, and they kind of would look and appear more like a baby who has not been exposed to substances, if that makes sense, then you got to think about the long term consequences from that. And you know, our medical field is still learning so much about this, and unfortunately, we're still in this crisis of substance abuse that I think we will still be learning about this for years. But the typical things to think about for a baby who is exposed to these higher opioids throughout their pregnancy, you think about developmental delays, cognitive impairment, behavioral issues and increased risk of learning disabilities it may affect the child's motor skills or attention or overall, you know, cognitive functioning, and the severity of that can just depend on that amount and duration and when those opioids are used, and the temperament and the genetics of the child itself, right, right? It's so unknown, and I've seen many.

Unknown Speaker  25:00  
Many babies who are exposed to many substances, and they're doing great, right? And I've seen some who are exposed and they struggle more, and maybe feeding is an issue, or, you know, behavior is an issue. Or, I will say too, I think it's important to know that even if a baby didn't experience that really hard newborn time that now they're now, it doesn't mean that they won't have the long term effects. I'm so glad you say that, because I think that's almost a universal misperception of everyone but but in specific to prospective adoptive parents, we hear it all the time. They weren't born dependent, or they didn't have NAS or nows, therefore I think they're not going to have any impact. It actually, it's not connected. You could still have an impact regardless of whether the child was born dependent Exactly. And the same thing is true, you may have a really hard infant period and then no long term complications at all. And it helps me to think about this like naturally during the birth process. Let's just say I'm a mom, and four weeks before my baby is due, I take fentanyl every day for something, maybe I'm having horrible back pain or something, my baby would be born with likely NAS or nap like that. That would be very hard for that baby, but they were just exposed for the last four weeks of pregnancy. The likely long term complications are hopefully not as much. Whereas I could have used fentanyl up until my 36 week of pregnancy and then gone through rehab and detox, and then that baby would be born already detox because I went, he or she went through that with me in my belly, and so at that 40 week mark, when the baby's born,

Unknown Speaker  26:41  
the baby actually looks and seems okay and is not irritable and not fussy. However, they had 36 weeks of fentanyl prior to that during really critical developmental periods. So, you know, trying to think through that logically sometimes helps me understand how that could be. That makes perfectly good sense. Well, the way I think of it, as the baby went through the withdrawal in utero, is what happened, and so we're not seeing it on the outside, all right. Another very common question is moms who are going through medical treatment for substance abuse disorder and are being given methadone, Suboxone, and there may be others now as well, but it's part of a medically prescribed treatment to help them with their substance abuse disorder. What do we know about the impacts of these drugs that are utilized to help moms cope with substance abuse disorder?

Unknown Speaker  27:34  
So you know, I think about methadone and suboxone similarly to like prescribed other opioid medications, if they're being taken well in the way that they're prescribed, and they're limiting all of the other higher, scarier opioids, that sounds really good, right? Right now, are they without all risk? No, right? Suboxone and methadone definitely carry some risk, but I think the risks are relatively low, and overall, compared to the other, opioids, are in a much safer category. Now, a baby who's exposed to suboxone and methadone throughout the length of being in that mom's belly will still likely be born with that Nas and now syndrome, right? Because both of those medications, methadone and suboxones, are long acting opioid medications. And so the way they work is the person takes a dose of it, and it kind of lowers the need for another opioid. It just kind of lowers that threshold. And so it's this long acting opioid, and so the half life is long. And so when a baby is born, exposed to Suboxone or methadone, that period when they're born where they're having these neonatal abstinence syndrome is usually quite longer than a baby who's born exposed to fentanyl, where that half life is quick, because the half life of Suboxone and methadone is so much longer. So in the hospital, when a baby is born exposed to methadone and Suboxone, we had, kind of a general idea. You may not see the symptoms until two to three days after that baby is born, because the half life has to get low enough where that baby is actually missing or needing that depending on that medication. And then typically those symptoms may last a little bit longer, so that risk for the neonatal oxidant syndrome. It's still there with those medications, but the longer term risks are lower if that mom can maintain those medications instead of the other scarier opioids. And does it a degree of long term impact? You've already mentioned that the risk of short term NAS or now does depend on when in the pregnancy the opioid was used if the mom has stopped the baby goes to withdrawal in utero, and so does not have Nasr now. But what about the long term impacts? Does a degree of impact long term depend on when in the pregnancy the opioid was used? If the mom used and then realized that she was pregnant and got into a.

Unknown Speaker  30:00  
Treatment Facility, you know, at when she was four months pregnant, versus a mom who, for whatever reason, either picked up using towards the end of her pregnancy, right? Do we have any information on that? You know, I would say maybe my information is more anecdotal, that the longer that that mom has been clean and using methadone and Suboxone, the better and the the lower risk of kind of bad outcomes later on, or I shouldn't say, bad, longer term outcomes. You may know more than me Don about specifically methadone and suboxone and what research shows just for those medications. You know, in clinic we see it's rarely just those men. Unfortunately, substance abuse is just the disease that people go in and out of, right, depending. And so there might be some use early on, and then Suboxone or methadone, and then some more use and suboxone and methadone. And so in my mind, the more suboxone and methadone that there is with just those medications, the happier I am and the more hopeful I am that that child can go on and have as healthy of long term outcomes as possible given the situation to begin with,

Unknown Speaker  31:11  
let's move off of the opioids. You've also mentioned that cocaine was another drug that you commonly see abused. So what about the short term impacts of cocaine, primarily, we're thinking NAS now or just a fussy baby, and then the long term impacts and and maybe there's more research on this, because cocaine has been around and abused for a longer period of time. Yeah, that's a good question. I typically think about cocaine in the same way that I do heroin or fentanyl, and typically there's quite a bit of overlap there. And so, you know, I think the hardest thing about cocaine, unlike opioids, is there really isn't an antidote to make someone feel better. So if, if I'm addicted to fentanyl, the box and methadone can lower that threshold for me. If I'm a baby born exposed, having been born exposed to fentanyl, morphine can be given to kind of lower that threshold of my fussiness.

Unknown Speaker  32:10  
Cocaine, unfortunately, just doesn't really have an antidote like that, and so babies that are born exposed to cocaine just have a similar and very incredible fussy period, similar stuff, ABS, stomach, all the things, feeding difficulties, low birth weight, all the things I said that apply to opioids, but there, there really isn't anything the health system can provide to help lower those things, right? You You really think about babies born to cocaine, really needing that waddle, quiet, soothing, low stimulation environment for short term and then for long term, all of the things that I mentioned for opioid, the higher, heavier hitting opioids, including long term behavior and cognitive challenges, are also true for cocaine, something that I know is increasing, and I think it's going to increase even more is marijuana usage as legalization. And I also think that pregnant women are sometimes thinking, well, I shouldn't drink, but it's okay for me to vape smoke or eat edibles with THC, so what do we know about the short and long term impacts of kids whose mom have used marijuana during pregnancy in any of its forms?

Unknown Speaker  33:32  
You know, Don I have to say I'm probably not as familiar with this overall infant exposure. We see it a lot. You're right. It's just out there. You know, people are using marijuana a lot more than usual, and there's not the public service campaign about don't drink when you're pregnant. There's not that for don't use pot when you're pregnant, right? What I think about marijuana is that it is interacting with your brain. Is a substance that interacts with your brain. And so it would be understandable that in a developing brain and nervous system that introducing that chemical could cause trouble, right? And we know this with teens and adults who use marijuana long term, their brain actually does change a bit their overall ability. And, you know, desire to do things, and their appetite, all of that can kind of change long term. And actually, people who use too high a dose of marijuana or too much marijuana over a long time can have marijuana induced psychosis, right? We know that marijuana can very negatively affect your brain, or affects some people's brains, and so I think we still have some learning to do about that and and what the long term consequences of marijuana are. Now, when I think about when I'm just going about my regular, regular day, and this is some of my favorite part of my work, is someone will call and say, Hey, I'm I'm thinking about fostering this child, or I'm thinking about.

Unknown Speaker  35:00  
Out maybe a adoption local or in the US, adoption of this baby. And here are the risk factors. Marijuana doesn't worry too much, right? But when I hear heroin, cocaine, fentanyl, I worry a lot more. And so doesn't mean it's no risk at all, but you know, it's in the same category of eating too much sugar, like we're ranking risk has been the lower of the lower of the higher. Yeah. And the last one I always want to ask about, because we used to see it. I'm not sure how much we're seeing it now, and that's methamphetamines. I don't know how common it is right now, but what are the risks that you worry about with meth? Yeah? So meth is similar to cocaine, heroin and fentanyl. You think of general pregnancy complications that can include low birth weight, being born early, being born with feeding problems, irritability, trouble growing right? Meth falls in that same category. In addition to that, when we're talking about things that we're inhaling or injecting, we got to think about concern for other infections too. So just be thinking about that as well. But then you know, with meth similar to cocaine and fentanyl and heroin, those longer term outcomes are very similar, okay? And again, like hard to know, and so much of what we're seeing now is really this poly substance abuse. You know, substance abuse must be so challenging because your body's so dependent on these drugs that you're you're willing to get what you can from who you can get it from. And maybe that's presumptive for me to say, but it seems like the use of multiple substances is more common in the use of just one unless it's being prescribed by a physician. We see that as well. And I throw in alcohol with there as well. And something that I think the general public is not aware of is that from the long term impact, alcohol is by far the worst of all. It's counterintuitive, because it's legal, but the long term impact is the most and for those people listening, let me also say that creating a family has extensive resources to help parents, parenting a child exposed to opioids, alcohol, or really any of the drugs. There are definitely techniques. There are definitely things that that work, especially if parents are aware going in and are looking for and getting help quickly and getting a child diagnosed quickly. So it's not all doom and gloom. There are things that can be done, but part of it, our challenge is making sure prospective adoptive parents or foster parents go in with their eyes wide open, right?

Unknown Speaker  37:43  
Let me interrupt this interview for just a moment to tell you about the free courses we are offering to you through the support of the jockey being Family Foundation. We have 15. They are really terrific courses. If you need a certificate of attendance, you can get it. If you don't, you don't have to, but you could still take the courses and learn the information, and they really are great. So you can jump back now to the interview, but don't forget the talking being family courses at Bitly slash, j, b, f, support.

Unknown Speaker  38:15  
All right, now I want to move to talking about the risks for sexually transmitted infections. So first, what are the common STI sexually transmitted infections that are seen most commonly now with pregnant people, right? So I think that STIs that people are most familiar with are things like gonorrhea, chlamydia, trichomonias, right? Those are the kind of low hanging fruit ones, and then then you think about maybe the more scary ones. I'll put syphilis in its own category, because unfortunately, we're seeing a pretty big increase in syphilis across the United States. It's totally preventable. It's also treatable, and so that's why I put it in its own category. Gonorrhea, Chlamydia, trichomonas also preventable and treatable, and then you have herpes and HIV. Herpes and HIV, right? Are preventable, they're treatable, but not curable. And so typically, there's kind of a stigma that goes along with those which I'm excited to talk about. Probably HIV the most out of everything. But yeah, so those are the STIs that I think about when I think about and I'm going to drop trichomonas out of there, because it carries a little bit of risk, but overall it doesn't carry the risk that the other ones do. All right, so what are the risks? Let's take each of them. Let's start with gonorrhea and chlamydia. What are the risks to the unborn child, or the newly born child, because I, as I understand that some of the risk accrue as the child passes through the birth canal, correct and is exposed, but some of the risk might have to do with the child in utero, right? And so we should think about risk is how long that baby has been exposed, or that mom has had this disease, right? If they have it for a day.

Unknown Speaker  40:00  
Or a week, probably a pretty low risk. And that's why prenatal care is important, and getting medical care when there are problems is important. So when I'm talking about the risk for these, I'm talking about kind of untreated gonorrhea and chlamydia that maybe has gone on for some amount of time. So those infections, particularly, you'll hear me kind of say the risk during pregnancy for a lot of these is the same, the risk for preterm birth goes up low birth weight, or the risk of a baby being born smaller than it should be, also goes up. And then what you really think about for gonorrhea and chlamydia specifically is that when that baby is born through that birth canal, they're exposed to that gonorrhea and chlamydia, and that could lead to a neonatal infection of either gonorrhea and chlamydia. And you know, I think people know that when a baby's born, they get their vitamin K shot, they get their little eye drop or the eye ointment that's actually prevention or treatment of a gonorrhea infection in their eyes. And so in third world countries where prenatal care is not as accessible, babies who are born and not treated for these type of infections can go on to have blindness, pneumonias, blood infections, right? Really, really high risk things for babies, we don't see that a lot here in the US, because most of the times they're treated during prenatal care, and those symptoms are terrible for a mom, so she's usually trying to get care for those and so once the baby makes it through the birth canal and can be treated, overall, that baby should do okay, even though they may have been exposed. Okay. What about herpes? Herpes is one that everyone worries about, right? I feel like I get some calls where people are like, I'm considering fostering or adopting this baby. And the bio mom has herpes. So herpes is an interesting one. If the mom is on treatment for herpes to lower her viral load of herpes, and if she doesn't have an outbreak during the time of delivery, that baby is going to do great, probably, you know, like very, very low risk for anything going on. Now, if that mom is not treated at all for herpes and has an active infection, the medical recommendation is that baby have mom have a C section, right? And then that baby would be closely monitored after birth.

Unknown Speaker  42:14  
If that, let's say the baby is born at home or or it's just a precipitous delivery that comes out too fast and is born through an active herpes infection, then you really do have to worry, right? And the hospital would make sure that that baby got all of the treatment that they needed. The risk of herpes, if a baby acquires herpes is that it can go into the nervous system and cause meningitis and other really horrible and complications. And so that is there. But again, in in our world of good medicine in the United States, those are relatively low. Now, is it possible too, that someone has maybe oral herpes and comes in and gives that baby a big old kiss on the mouth right after they're born? Yes, and that's also really concerning, right? So in general, if someone has an active herpes infection, they should be really careful around a newborn. Which one do you want to tackle next? HIV or syphilis? Let's tackle syphilis. Because syphilis, to me, is a mean beast, and I hate it because you can treat it so quickly, and I hate that the rates of it are going up in the US. But syphilis, to me, is a it scares me. It scares me about the long term complications for that child. I would also assume that most moms, if they're getting any prenatal care, and because it's a relatively quick treatment, is it not? You're right? Yes, if you get good prenatal care, and that's what's great about let's say you get syphilis week one and you're treated week two. Great. That's perfect. Yeah, so it's a quick treatment. It's not like you're going to have to have years, but no, no, it's very quick. And so that's what maybe makes me so frustrated about syphilis, is that as long as you get good treatment, it prevents really challenging outcomes for a baby. However, if you don't know, you have it, and the primary lesion of Syphilis is painless, doesn't hurt, and so it can be kind of a some people may not know what it is. And so if you don't get treatment for syphilis, especially early on during pregnancy, Syphilis is one of these gets can cross through the placenta, and so it can lead to congenital syphilis. And congenital syphilis puts you at extreme high risk of stillbirth, preterm birth, low birth weight, miscarriage, significant birth defects or organ damage. And so if that, let's just say the mom during her entire first trimester, second trimester has syphilis. Even if she gets treatment, there's still these high risks to that baby, okay, and then if the baby's exposed later on, right? Then that lowers your risk of that congenital syphilis kind of syndrome or complications. But most of the time with these, I would say.

Unknown Speaker  45:00  
It's moms who have limited prenatal care, and they come in and they're positive for syphilis, and no one knows how long they've been positive, right, right? And the baby's born, and there are certain tests you can do to see is that baby active, the baby actively have syphilis now, and so the doctors will do that, and it's very easy to treat the baby to clear the infection of syphilis, but it doesn't prevent the long term outcomes that that baby may have already been exposed to. And so when I say Syphilis is scary to me, it's just very unpredictable. And maybe it's the most frustrating for me, because when a family will call and say, there's this baby who was born positive for syphilis, or mom was positive for this amount of time. I really don't have a great answer for them. And so the advice that I would give is those babies are at at high risk of having long term challenges that they may not have any at all, but you would need to go in as you said, Don eyes wide open to what that could be. Okay. The last one we're going to talk about is HIV, and we've come a long way in the treatment of HIV, yeah, but it's still a common STI, right? Yeah, I could talk about HIV all day. To me, it's my favorite. You know, I think there's such a stigma about HIV and how horrible it is, and you should be an outcast in society if you have it, and you people are still like, ooh, even, you know, some day here they're like, oh, but HIV is so treatable now we can't cure it. Nobody's figured out how to cure it yet, but with good medication and following up with an infectious disease team, we can get HIV levels to zero or below a certain level and and you wouldn't even know if you check their blood that they have HIV. And so it's so important for everyone to realize where we have come with this disease. And there are still babies being born to acquire HIV,

Unknown Speaker  46:56  
but they're like long term health outcomes, and how they do in life is pretty good. And so many people would probably say they're the most scared of HIV. But I would say, let's change that, and let's think about HIV in the way that we how treatable it now is. So when I think about HIV, it's fascinating. A mom can have HIV, and my understanding is the high risk of that baby, the highest risk of that baby acquiring HIV, is when the baby is born through the birth canal or through a C section, right? They're exposed to all those body fluids. If they don't receive treatment right away, the appropriate antiviral treatment, their risk of acquiring HIV is somewhere around like 25 to 40% depending on mom's viral loads and when she got it, and all of that kind of stuff. If they receive treatment right away when they're born, and typically that several weeks of treatment with good following up with infectious disease and some blood checks and that kind of stuff, you can decrease that risk to less than 1% Wow. And that to me, it's so fun to follow these babies, and you just hope, right each time they get their blood drawn, you're like, Please don't be positive. Let's break this cycle of HIV for this baby and just let this baby go on and have a normal life. But occasionally, one or two of them, over several years, have come back positive, and they're doing great on their antiretroviral treatment. My infectious disease colleagues would say the hardest thing for them is going to be the stigma that they face during their lifetime. Their disease is not going to be the hardest thing interesting, and so that's just a fascinating thing to think about as an adoptive or foster parent, right? That your biggest support that's going to be needed is just the stigma around that child based on what people assume, which is bad. But I should say, as a mom has HIV and is pregnant, you're still carrying preterm risk, low birth rate, risk, delayed growth and development, long term things, all of those things still fall right. While this baby's being developed, there's a virus actively kind of around and affecting this mom's metabolism and health, and so that can impact the baby. So I don't want to minimize it. There's still challenges that come. But overall, I think there's a misperception about how scary that disease is.

Unknown Speaker  49:22  
All right, now I want to shift to mental health issues, and the main thing, the main thing I want to talk about is, what is the genetic connection, or how heritable are these mental illnesses? Because that is information that often people do know about, sometimes you don't, but usually I mean it's a question that's asked of birth moms or expectant moms, if they know the father of the father. And so the question we get is, what are the chances that the child will inherit this mental illness? So I'm just going to name a few. And if you could just tell me how heritable.

Unknown Speaker  50:00  
Strong of a genetic connection is there. Let's start with anxiety disorders, and that would include panic disorders, obsessive compulsive disorders, phobias, things like that. How common is it for if a parent, one or both parents have this that the child may inherit it as well? Yeah, these are hard questions to answer, especially on a case by case, but I think the understanding in literature about anxiety disorders is that they are inheritable, but it's not 100% and it's not 50% it's something lower than that, that if a closed family member has an anxiety disorder, the relative may also be predisposed to that now, does that person automatically have an anxiety disorder, not necessarily, but are they predisposed that in the right environmental settings with stress or trauma, that that could blossom into something bigger, potentially? So you raise such a good point, what is difficult about this? And the reason it is hard to give a hard and fast answer is that, assuming that the adoptive family doesn't have an anxiety disorder, the child is going to be raised in an environment where that disorder is not influencing the environment. And so it's hard to tease out, because much of the research would be the child is being raised by the parent that is struggling with the anxiety disorder. So that's a complicating thing that you have to take into account. Let's talk about mood disorders, which I would include depression and bipolar. What's the genetic connection there? So for a depressive kind of disorder, I put it in the same category as anxiety, that genetics play a role. You can be predisposed and have a slightly more likelihood depending on your environmental factors. Bipolar disorder is a really interesting one that seems to be much more inheritable than these other types of mental health disorders, and it's fascinating to me, but the literature shows that, like, there's an inheritability of 60 to 85%

Unknown Speaker  52:05  
I've read the same Yes, last thing I just heard was 80% Yeah, right, which is, you know, if one parent has it, my understanding, and I might be wrong on this, on is it doesn't mean the child, then, is guaranteed to have or an 80% chance of bipolar, right? It's just that it seems to be inherited pretty high. The predisposition is high. Yes, it's high. And so you know, that child might look more like 10 to 20% of a chance. And then, you know, one way they look at this is the inheritance across twins. And so if one twin has at its higher risk, that the other twin would also have that. So that's a really interesting one. Yeah, in keeping in mind that if both biological parents have this, then it obviously would increase the chances as well, right, right? Let's talk about personality disorders, anti social, borderline narcissistic. What do we know about those as far as heritability? So they seem to be kind of in between anxiety and depression and bipolar, which is different than I would expect. Right in my mind, my mind, it is different. Go ahead, I think about personality disorders as much more environmental, but it seems that there is kind of a genetic predisposition, and now I don't know, in these studies, are they looking at if one person is raised in one environment that led to a personality disorder, and then the brother or their baby is raised in the same environment, that's that's already a higher risk thing. So I'm not sure if they tease that out, but I was surprised that it does tend to have a bit more of a genetic predisposition than I expected. Okay, what about psychotic disorders? And I guess where I'm really talking about is schizophrenia.

Unknown Speaker  53:51  
Yeah, so schizophrenia is one that definitely has a genetic predisposition. It's similar to this bipolar category of pretty high heritability across of schizophrenia. So it's high. I think the studies show it's about 80% and then again, if the parent has it, that child then is at a, you know, 10 to 15% so. And then again, if both parents have it, that puts that at higher risk. And I think we're understanding more in schizophrenia some actual genetic where they're actually ears and in the genes that make you more predisposed to a kind of schizophrenia type diagnosis. And the last one I want to talk about, I actually don't think of as a mental health issue. Maybe it's because I'm the parent of two students who have it. But ADHD, it's very common in the adoptive population. How heritable is that ADHD is quite heritable, which is fascinating. ADHD is hard for me, because I think when we talk about the foster and adoption world, these children have been exposed to all the things that we've talked about today. You know, there's some amount of in utero something or.

Unknown Speaker  55:00  
Maybe preterm birth or maybe low birth weight, all these things that predispose to possible behavior concerns later on, and then you add in possible trauma, if you're in the foster care system,

Unknown Speaker  55:10  
all of those things look like ADHD, which complicates it. Yeah, so we're diagnosing ADHD, but, but what is truly genetically ADHD, and what's environmental predisposed. Something happened and you ended up with ADHD. It's very hard to to tease out, but, but all that to say that if a parent, or both parents, have ADHD, it's very likely, or that child is at a much higher risk, of having an ADHD diagnosis sometime later on too.

Unknown Speaker  55:40  
Before we continue, I need to shout out a huge thanks to hopscotch adoptions. They are a Hague accredited international adoption agency placing children from Armenia, Bulgaria, Croatia, Georgia, Ghana, Guyana, Morocco, Pakistan, Serbia and Ukraine. We have had them as a sponsor for the podcast for a very long time, and we are so appreciative of their support. They specialize in the placement of kids with special needs, in particular Down syndrome. And they also do a lot of kinship adoptions, and they can place kiddos throughout the US. And they offer home study services as well as post adoption services to residents of North Carolina and New York. So check them out, hopscotch adoptions, and now back to the interview.

Unknown Speaker  56:26  
Okay, now we're going to switch to talking about the legal risk factors. It is required that adopt, I think, in all 50 states that adoptive parents have a home study and background check requirements. Who does that process?

Unknown Speaker  56:41  
Yes, you have to add that pre placement home investigation and post placement report usually done by the agency. Or there are, can be private, certified home study providers in the states that can do that. It's not just any social worker that can do an adoption home study. It's unique. And so families often say, Well, I've got a friend who's a social worker who works for Department of Social Services, I'll have them do my home study. An adoption home study is very different from a foster care license or from any other thing that's called home study. This is an adoption pre placement home investigation with unique criteria that's statutorily driven, all right, another legal issue that can come up, and this goes back to what we were discussing about, where the adoptive parents identify or find a expectant parent on their own. Can adoptive parents advertise to find expectant parents who are considering placing their baby. It's a state by state requirement. South Carolina allows it, so long as they have a home study and different states have that rule, but it can be a criminal violation to advertise in some states, and criminal violation if you are not home study approved. So you have to be mindful of that for sure. How does that work on social media? Is that considered advertising? If you are posting on social media, look, we are looking to adopt. If you know of someone, or if you yourself are considering, please let me know. Is that a risk for adoptive parents? I think if they have a home study and they are approved, I think that that's a safe bet. Those laws went primarily went into effect where there were yellow pages, if we, any of us, remember those days when non licensed agencies facilitators were advertising adoption services and they were not licensed or accredited or in any way accountable, and those were those groups primarily. But as long as a family has that licensed home study and they're doing that on their own social media, I think that's appropriate. All right, you have alluded to this earlier. Can you restate the what we call a legal risk adoption. Can you restate the think you said there were three issues that could come up that make an adoption risky going forward?

Unknown Speaker  59:10  
Yeah, the three things that I think are the most significant legal risk issues are one, the federal law, the Indian Child Welfare Act, ICWA, if the child is a Native American, child is a member of a federally recognized tribe, the rules are just different there. And so that's an important hallmark of legal risk, is ICWA. The second is making sure that the requirements of the interstate compact on the placement of children the ICPC are adhered to, which is this compact among the 50 states that says that both states have to agree before a child can move from state A to state B, as a preliminary to a possible adoption. And honestly, that happens a lot.

Unknown Speaker  59:58  
What are some of the issues under?

Unknown Speaker  1:00:00  
For the ICPC interstate compact for the placement of children. What are some of the issues that would come up that parents need to be aware of, that they wouldn't automatically think of, that they need to make certain that they are adhering to?

Unknown Speaker  1:00:14  
Well, it's largely procedural. It requires the sending state to look at the medical and social history, look at the home study, look at all of the documents that freed this child for adoption, to make sure that they're done under state law, and then they're also reviewed by the receiving state to make sure, for instance, that this child has special needs, that that adoptive parents have a home study that approves them for the placement of a child similar to that child. So that sometimes takes time, and it might be a week, sometimes more, before the adoptive parents are free to return to the home state. So it's a legal risk, technically, but as long as you're following the process which is well laid out, yes, right. All right. Honestly, the biggest legal risk of ICPC cases is working with an attorney who dabbles in adoption and did not recognize the ICP C's applicability. Okay, that makes good sense. All right. And what is the third legal risk that you were referring to, birth father issues, okay, recognizing that birth fathers have a legally recognized, constitutionally protected right so long as they have done certain things, and those things usually are defined by state law. But if that man has seized the opportunity that the biological connection afforded him. His consent to the adoption is required, just like a birth mom's, but if he hasn't, the adoption can go forward without his consent. That is very state specific. So in South Carolina, he has to have done certain things. He has to have stepped up, if you will, have been an earnest father as he lived with her, has he offered to? Has he contributed financially? And then the next question is, did he, if you will, raise his hand as the father. Did he register with the putative father registry, which 34 states have, that allows there to be this database where a man who is not named, meaning a John Doe. He's not on the birth certificate. He wasn't named by the birth mother and the consent document, but he can name himself by virtue of registering with this database under the name of the birth mom. And then we check the birth mom's name, and again, it's a confidential database. Not everyone can just go on here and and to search these records, but an adoption agency can, an attorney can to see if a man has claimed paternity. If he's claimed paternity, he's given notice and an opportunity to be heard as to whether he's done those things necessary if he hasn't signed up. That's usually in most states, an implied, irrevocable waiver of his right to receive that notice. All right, so there's no more publication than newspapers and things of that nature. So the legal risk issue is, have we dealt with the birth father in an appropriate way, given him an opportunity to be heard? And if he has done those things, given him the right to be a participant in the adoption, and if he hasn't, it gives us a way to move towards permanency for that child more promptly.

Unknown Speaker  1:03:34  
So what rights do adoptive parents have after a match? They have been matched with an expected parent. Parents are mom. They've met with this person, they have had a baby shower. They have started dreaming about this child, but the expected parent, child has not been born, and the expected parents have not relinquished their rights. What rights do the adoptive parents have none, and that's a hard pill. That's really why I don't like the term failed adoption, because a failed adoption looks at the adoption from the adoptive parent's point of view and not the child's point of view. It may very well have been the appropriate decision that that expected mom came to, even though she thought about adoption for a while and maybe even committed to it, but she has complete agency. She has the right of making her own decision all the way through to the time that she signs and through the time of the revocation period. And so the adoptive parents cannot assume that that child is theirs or assume many rights until the law bestows those on them. All right, so what is allowed pre birth? Prior to birth, can adoptive parents and expected parents meet in person? Is it required? How much medical history is shared between them? Is there anything in that process?

Unknown Speaker  1:05:00  
That after there has been a match, or after a expected parent has been identified, is there anything legal that we need to know and that we need to be careful of during that period, there are many times when prospective adoptive parents meet with the birth parents, have a rapport that's built, have an understanding, perhaps even discussing what things look like post adoption. But that does not transform the case to any kind of rights for the adoptive parent. It continues to be completely in the birth moms, really the birth parents decision up until the child is placed and the consent is signed. All right. Now post birth, let's talk about open adoption. Sometimes it is just a verbal agreement between the adoptive parent or parents and the expect or at this point the birth parent or parents, it's what they've talked about, what they verbally agree but sometime they have a written document. Is that written document enforceable?

Unknown Speaker  1:06:06  
So these written documents often refer to packas, post adoption, contact agreements. There's a growing trend in states to recognize a PACA. A PACA is, I think last I looked in about 30 states that would allow enforceable agreements, post adoption contact agreements. South Carolina, for instance, is one of the states that does not have that, but it's been introduced in our legislature this year for those states that don't have a PACA where you can actually enforce post adoption contact, it's really kind of a good faith understanding or an agreement. They're often done where the birth parent says, May I have some pictures? May I have some updates, perhaps a meeting once a year, when people who are first coming into adoption, they may think that that open adoption is driven by birth parents, not so much the more that adoptive parents learn about the impact of some connection, some bridge to the birth family, and how important that can be to a child. I'm seeing more and more adoptive parents be the one that reach out and say, Can we have a relationship? Can we have a mutual respect and understanding over the years, because at age six or age or 12, we may be reaching out to you to gather information for that child. Interesting, yeah, things have changed. The child is often placed with the adoptive parents right at birth or right after birth, released from the hospital to the parents. But when is the adoption usually finalized? Six months or less for an infant adoption, I would say. And again, that's state by state. Some states have certain waiting periods before an adoption can be finalized, but six months or less is a good rule of thumb. During that period of time, who makes medical decisions for the newborn, or for this case, you know, a five month old or four month old, right? So during the pendency of the case, waiting for the adoption to finalize, the adoptive parents still have custody and then post adoption, they are the adopted parents, so they're still making all the medical decisions for the child. They can place the child on their medical insurance. For instance, federal law treats a child to adoption the same as a child by birth. Those protocols, if you will, are pretty straightforward. Does the birth parent have to show up in court for the finalization, or does anybody have to? Is it handled in court, and if so, do the birth parents have to show up? It's funny, these the court hearings. Birth parents typically do not show up. Their waiver that they signed the consent document waived notice of a final hearing. If their rights have been terminated, that they're not given notice of a final adoption hearing. Once in a while, things are so cordial that the birth parents come to a final hearing, but not usual, and then state by state, really different. One of my colleagues is an attorney in California, sometimes it's done virtually or even over the telephone. South Carolina, it's very formal where you come to court dress for court, get sworn in, take the stand, and are asked very difficult questions, like, Do you love this child? And they do understand adoption is forever, but it's a beautiful moment to be able to kind of a public expression of your love for the child. And oftentimes the whole family comes and yes, you get the picture of the baby, you holding the baby, and the judge gets to smile in your picture, and it's a part of your family photo album. Yeah, absolutely, it's sometimes it's the only time that judges smile.

Unknown Speaker  1:09:53  
So an interesting thing that some people don't realize is that the original birth certificate.

Unknown Speaker  1:10:00  
Has the biological parents? If the birth father has been identified, has both parents listed, but then it is amended at some point and the adoptive parents are listed on the birth certificate. So two questions, when does the birth certificate get changed so that the adoptive parents are listed, and how can adoptive parents get a copy of the original birth certificate for their child? Adults or teens often would like a copy of that one? Yeah, absolutely. So the amended birth certificate, if you will, the adoption birth certificate is after the adoption is finalized, but there's no mention of adoption on that document. It simply has the mom and dad listed there as the adoptive parents, without mention that it had never been amended. The original birth certificate is a valuable thing, and then an open adoption where everybody knows everybody, and there's a free flow of information. There are times where that birth parent will supply that to the adoptive parents as a keepsake, something that is kind of put aside for later to be able to have that sense of the beginning stage of life. There's a connection to that for a family, but not so in many states. I, for instance, could not give an original birth certificate to a client, because it's protected under the confidentiality statutes. So unless the birth parents and the adoptive parents have that understanding and do that themselves, I can't facilitate that. And last I looked, only three states have a complete open records to allow an adoptee after age 18 to go back and have that original birth certificate.

Unknown Speaker  1:11:44  
So I guess the bottom line here is that if you want to be able to give that to your child, the time to do that is after, obviously, after birth, but by working directly with the child's birth parents. Yes, all right, and as boring as it might be, we do have to have a social security number. All of us do. Can adoptive parents get that for their child, and do they have to wait till after the adoption is finalized? Or can they do it when they have custody of the child, but they're waiting for that, oh, four to six month period before they go to court or appear and have the adoption finalized? John, perhaps I'm not the best person to ask, because I happen to know that my wife went to Social Security three different times before they finally gave us the social security number, because they wanted all sorts of proof. So I've learned from that experience, and now for my clients, I explain that you wait for the adoption to be finalized, you wait for you to have your your birth certificate, and you go to social security with all sorts of proof of where you live and how long you live there. That's when you would get that done. That's when the social security card would be issued. But prior to that, you know, our babies are not born based on the IRS timeline. And so sometimes we have taxes to take care of, and so there's an adoption identification number. There's a way of being able to claim a child for your taxes before you have that social security number. You can actually use that over a couple of years. Well, thank you so much. Jim Thompson and Dr Lindsay Terrell for talking with us today about evaluating the risk factors common to domestic infant adoption, I truly appreciate your expertise. You.