Intercountry Adoption and Child Welfare: Who Are the Children? The Changing Challenges in...
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Transcript of Intercountry Adoption and Child Welfare: Who Are the Children? The Changing Challenges in...
Intercountry Adoption and Child Intercountry Adoption and Child Welfare: Who Are the Children?Welfare: Who Are the Children?
The Changing Challenges in International The Changing Challenges in International
AdoptionAdoption
Dr. Judith K. Eckerle and Dr. Judith K. Eckerle and
Dr. Dana E. JohnsonDr. Dana E. Johnson
University of MinnesotaUniversity of Minnesota
GoalsGoals Describe trends in international adoption over the past 10 Describe trends in international adoption over the past 10
yearsyears Highlight major changes in the demographics of children who Highlight major changes in the demographics of children who
are being considered for adoption are being considered for adoption Discuss new ways of thinking to:Discuss new ways of thinking to:
1)provide for intercountry adoptees and their needs 1)provide for intercountry adoptees and their needs 2) prepare families considering intercountry adoption.2) prepare families considering intercountry adoption.
Opportunity to familiarize ourselves with medical, Opportunity to familiarize ourselves with medical, developmental and behavioral conditions that we may developmental and behavioral conditions that we may encounterencounter Alcohol Exposure- FASD spectrumAlcohol Exposure- FASD spectrum Syndromes, Birthmarks, Complicated Medical HistorySyndromes, Birthmarks, Complicated Medical History
How can current knowledge on the outcome of How can current knowledge on the outcome of institutionalized children and international adoptees inform institutionalized children and international adoptees inform our response to the current orphan crisis?our response to the current orphan crisis?
The Trends:The Trends: Korea reducing the number of children available- In 2008, the
Minister (MOHFW) and other government officials at the Blue House have discussed a plan to end ICA in 3 years by reducing the quota by 300 every year.
China, Ethiopia and the countries of Eastern Europe have become the source of the majority of children (54%) placed in American families. http://adoption.state.gov/news/total_chart.html
Ethiopia recently announced a 90% decrease in the number of adoptions that they will participate in starting Mar 9. 2011
Level of care received by international adoptees prior to arrival in the United States. (Institutional versus Foster Care)
U of MN IA 10 Year U of MN IA 10 Year Comparison ProjectComparison Project
40 children were randomly selected from 40 children were randomly selected from paper records kept from 1998 of children paper records kept from 1998 of children referred from referred from S.KoreaS.Korea and reviewed at the and reviewed at the IAC, U of MN.IAC, U of MN.
40 children were randomly selected from the 40 children were randomly selected from the computerized database from 2008 of children computerized database from 2008 of children referred from S. Korea and reviewed at the referred from S. Korea and reviewed at the IAC, U of MN. IAC, U of MN.
IAC 10 Year Comparison ProjectIAC 10 Year Comparison Project
The goal of this study was to The goal of this study was to 1) Examine trends in the type of child referred 10 1) Examine trends in the type of child referred 10
years ago versus todayyears ago versus today 2) Look at risk factors that had decreased or 2) Look at risk factors that had decreased or
increased in the past 10 yearsincreased in the past 10 years 3) Examine the risks that parents, social workers 3) Examine the risks that parents, social workers
and adoption professionals should be made aware and adoption professionals should be made aware of in order to prepare parents for their potential of in order to prepare parents for their potential childs’ needs.childs’ needs.
Mean age at time of referralMean age at time of referral
3.93
6.27
0
1
2
3
4
5
6
7
1998 2008
Age atTime ofReferral(mo)
1998 3.93 months1998 3.93 months 2008 mean age 6.27 mo 2008 mean age 6.27 mo
Effective January 1, 2007, Effective January 1, 2007, Korean law required a five-Korean law required a five-month waiting period before month waiting period before an infant orphan can be an infant orphan can be considered for intercountry considered for intercountry adoption. adoption.
http://www.koreanfocus.org/http://www.koreanfocus.org/koreanadoptionrequirements.htmlkoreanadoptionrequirements.html
(p<0.0005)(p<0.0005)
Tobacco Tobacco (p<0.0005)(p<0.0005)
TobaccoTobacco
Low birth weight and long-term cognitive and behavioral problems including lower intelligence and attention deficit disorder with or without hyperactivity.
http://aappolicy.aappublications.org/cgi/reprint/pediatrics;107/4/794
Medical Problems (Child)Medical Problems (Child)
Known Medical Problems (Child)Known Medical Problems (Child)
Defined as medical problems that would likely Defined as medical problems that would likely require long term follow up or had significant require long term follow up or had significant potential for long term ongoing medical needs:potential for long term ongoing medical needs:
Increased from 5% to 30%Increased from 5% to 30%
(p=0.003)(p=0.003)
Syphilis Syphilis
-Active Syphilis infection** Independently was significant- 0 in 1998, 2 -Active Syphilis infection** Independently was significant- 0 in 1998, 2 in 2008.in 2008. 0.2% 1998, 0.2% 1998,
Syphilis prevalence has rapidly decreased in South. Y-H Cho, H O Kim, J-B Lee and M-G Lee. Sex Transm Inf 2003;79;323-324
China has been experiencing a rapidly growing syphilis China has been experiencing a rapidly growing syphilis epidemic since the early 1990s, with the reported incidence epidemic since the early 1990s, with the reported incidence of congenital syphilis increasing from 0.01 cases per 100 of congenital syphilis increasing from 0.01 cases per 100 000 live births in 1991 to 19.7 cases per 100 000 live births 000 live births in 1991 to 19.7 cases per 100 000 live births in 2005 (Zhou et al)in 2005 (Zhou et al)
Alcohol ExposureAlcohol Exposure
19981998
Of the children that Of the children that were alcohol exposed: were alcohol exposed:
2.5% (1) <1/mo2.5% (1) <1/mo 2.5% (1) >1/mo2.5% (1) >1/mo 5% (2) binge or 5% (2) binge or
multiple times/weekmultiple times/week
Total: 10%Total: 10%
20082008
Of the children alcohol Of the children alcohol exposed in 2008:exposed in 2008:
22.5% (9) <1/mo22.5% (9) <1/mo 20.0% (8) >1/mo20.0% (8) >1/mo 17.5% (7) binge or 17.5% (7) binge or
multiple times/weekmultiple times/week
Total: 60%Total: 60%
Becoming part of Becoming part of corporate culture as well corporate culture as well as teenage and as teenage and socializing for women. socializing for women.
““Alcohol damages for Seoul woman." Alcohol damages for Seoul woman." The woman said she had to drink The woman said she had to drink until early in the morning. A South until early in the morning. A South Korean woman pressured by her Korean woman pressured by her former boss to drink alcohol at former boss to drink alcohol at company dinners has been awarded company dinners has been awarded damages by a court (approx 25K). damages by a court (approx 25K). http://news.bbc.co.uk/2/hi/asia-pacifichttp://news.bbc.co.uk/2/hi/asia-pacific/6631615.stm/6631615.stm
Besides the trends and Besides the trends and theoretical risks, who are the theoretical risks, who are the children, really??children, really??
Celebrity JeopardyCelebrity Jeopardy
Celebrity daughter- Celebrity daughter- What country and who What country and who is the celebrity?is the celebrity?
Mercy JamesMercy James
MalawiMalawi MadonnaMadonna
Celebrity JeopardyCelebrity Jeopardy
Who? Country? Star in Who? Country? Star in what show?what show?
Jenna UshkowitzJenna Ushkowitz KoreaKorea GLEE!GLEE!
Celebrity JeopardyCelebrity Jeopardy
Country? Parent? Who? Country? Parent? Who?
KoreaKorea Marv and Marilyn Marv and Marilyn
EckerleEckerle Judith K. EckerleJudith K. Eckerle
XM, 12mo female, XM, 12mo female, China China ““On admission, her skin On admission, her skin
on right leg has diabrosis on right leg has diabrosis and scar with part of and scar with part of blood”blood”
Development normalDevelopment normal Skin: Right leg of skin has Skin: Right leg of skin has
scar, part of (illegible) for scar, part of (illegible) for 5X5 cm. 5X5 cm.
Otherwise, PE normal at Otherwise, PE normal at 12 mo old. 12 mo old.
Epidermolysis bullosa (EB)Epidermolysis bullosa (EB)
Group of inherited Group of inherited bullous disorders bullous disorders characterized by characterized by
blister formation in blister formation in response to response to
mechanical trauma. mechanical trauma.
http://emedicine.medscape.com/article/1062939-overviewhttp://emedicine.medscape.com/article/1062939-overview
Today Today
W.G 10 yo female, HaitiW.G 10 yo female, Haiti
10 yo female adopted from Haiti with unrelated male 10 yo female adopted from Haiti with unrelated male from same orphanage. from same orphanage.
Adoptive family with 6 bio children, stay at home Adoptive family with 6 bio children, stay at home mom and full time employed fathermom and full time employed father
W.G. raised in orphanage care since infancy which W.G. raised in orphanage care since infancy which collapsed around her during earthquake (2010), collapsed around her during earthquake (2010), moved to temporary shelter, then coastal orphanage, moved to temporary shelter, then coastal orphanage, then orphanage care at functioning hospice center then orphanage care at functioning hospice center until she joined her family in the USA. until she joined her family in the USA.
W.G.W.G. WG had history of severe malnutrition when she entered WG had history of severe malnutrition when she entered
orphanage careorphanage care No functional language in Haiti, had never been to school No functional language in Haiti, had never been to school Congenitally totally deaf. Congenitally totally deaf.
Number of minor medical issues but main issues were severe Number of minor medical issues but main issues were severe behavioral outbursts. behavioral outbursts.
LTBILTBI Microcytic anemiaMicrocytic anemia Vit D deficiencyVit D deficiency Parasites (B Hominis, Giardia)Parasites (B Hominis, Giardia) Global developmental delaysGlobal developmental delays Precocious/Accelerated PubertyPrecocious/Accelerated Puberty
W.G.W.G. After a number of emergency discussions with After a number of emergency discussions with
parents, it was decided that inpatient care was best parents, it was decided that inpatient care was best solution after she assaulted one of the other children solution after she assaulted one of the other children in the homein the home
Inpatient stay went extremely well, communication Inpatient stay went extremely well, communication with sign language interpreters and teacherswith sign language interpreters and teachers
Mother refused placement back into home after Mother refused placement back into home after inpatient stayinpatient stay
Family in church community (4 bio children, 3 Family in church community (4 bio children, 3 adopted including one child with severe spina bifida) adopted including one child with severe spina bifida) offered to adopt offered to adopt
JSJS
27 mo male from 27 mo male from
Korea who is Korea who is
developmentally developmentally
doing very well.doing very well.
Missing R thumb Missing R thumb and rudimentary L and rudimentary L thumb.thumb.
Dysmorphic facial Dysmorphic facial features with low set features with low set earsears
R facial palsyR facial palsy R hydronephrosisR hydronephrosis Very small- FTTVery small- FTT Café au lait on L legCafé au lait on L leg
Fanconi AnemiaFanconi Anemia
Leukemia in ~10% of patients (700-fold), Leukemia in ~10% of patients (700-fold), myelodysplastic syndromemyelodysplastic syndrome ~ 6% of patients ~ 6% of patients Solid tumors have been reported in close to 10% of patients,- Solid tumors have been reported in close to 10% of patients,-
most common tumors are liver adenomas and hepatomas (400-most common tumors are liver adenomas and hepatomas (400-fold)fold)
Other types of solid tumors occur in young adults (30%) and Other types of solid tumors occur in young adults (30%) and primarily involve the head and neck, esophagus, and primarily involve the head and neck, esophagus, and gynecologic areas (4000-fold) gynecologic areas (4000-fold)
Oral cancers have been reported in patients with Fanconi Oral cancers have been reported in patients with Fanconi anemia who have received bone marrow transplantationanemia who have received bone marrow transplantation
.. Median diagnosis 7yoMedian diagnosis 7yo
Dr. Dana E. JohnsonDr. Dana E. Johnson
University of Minnesota University of Minnesota
““How have your child’s How have your child’s medical and/or medical and/or
behavioral problems behavioral problems affected your family?”affected your family?”
92%
8%
Adjusting Well orAdequatelyStruggling
Most Families Do Well
How can current knowledge on the How can current knowledge on the outcome of institutionalized children outcome of institutionalized children
and international adoptees inform and international adoptees inform our response to the current orphan our response to the current orphan
crisis?crisis?
0
5000
10000
15000
20000
25000
84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 0 1 2 3 4
Other
Ethiopia
Ukraine
Kazakhstan
Cambodia
Paraguay
Colombia
Guatemala
Mexico
Vietnam
Philippines
Korea
India
Haiti
Russia
China
Romania
AAP Redbook Screening Guidelines
Increased Risk of Infectious Diseases
Lead, Growth, FAS andDevelopmental Delays
USA International Adoptions1984-2004
Early Deprivation
Bayley Scales of Infant Development Bayley Scales of Infant Development (MDI-at baseline)(MDI-at baseline)
64
103
0
20
40
60
80
100
120
Menta
l D
evelo
pm
ent
Index
InstitutionCommunity
History of InstitutionalizationHistory of Institutionalization
IG/FCGIG/FCG NIGNIG OROR
Any axis I Any axis I disorderdisorder
45.5%45.5%(N=56)(N=56)
13.6% 13.6% (N=8)(N=8)
5.3 (2.3,12) 5.3 (2.3,12) (p<.0001)(p<.0001)
Any emotional Any emotional disorderdisorder
35.0% 35.0% (N=43)(N=43)
8.5% 8.5% (N=5)(N=5)
5.8 (2.2,16) 5.8 (2.2,16) (p=0.0005)(p=0.0005)
Any Any behavioral behavioral disorderdisorder
28.5% 28.5% (N=35)(N=35)
6.8% 6.8% (N=4)(N=4)
5.5 (1.8,16) 5.5 (1.8,16) (p=0.002)(p=0.002)
Axis I includes all the mental health conditions except personality disorders and mental retardation.
Sensitive Periods—0-3 YearsSensitive Periods—0-3 Years
Mental Health
Growth
Speech
CognitionAttachment
24 3612
Age at Intervention
???
Age of Orphans in Sub- Saharan Africa, Age of Orphans in Sub- Saharan Africa, Asia, and Latin America/CaribbeanAsia, and Latin America/Caribbean
0-5 years12%
6-11 years33%
12-17 years55%
Children on the Brink 2004
Parental DeathParental DeathWar and Natural DisastersWar and Natural Disasters
Indian Ocean Tsunami
150,000 Deaths, 12/26/06
Haitian Earthquake230,000 Deaths, 1/12/10
Trafficking
Child Soldiers
Care for OrphansCare for Orphans Birth FamilyBirth Family Kinship CareKinship Care Adoptive FamilyAdoptive Family Foster CareFoster Care Child-Headed HouseholdsChild-Headed Households Institutional CareInstitutional Care Homeless/Street KidsHomeless/Street Kids TraffickingTrafficking
Child LaborersChild Laborers Child SoldiersChild Soldiers Sex IndustrySex Industry
Well Being
Exploitation
Evidence-Based Orphan PolicyEvidence-Based Orphan Policy
All children coming into care have been socially, All children coming into care have been socially, nutritionally or medically deprived and/or have nutritionally or medically deprived and/or have experienced severe emotional trauma. experienced severe emotional trauma.
All “orphans” are not equal in terms of their needs.All “orphans” are not equal in terms of their needs. The response must include a triage plan.The response must include a triage plan.
AgeAge Medical and psychological needsMedical and psychological needs
PermanentPermanent placement in a placement in a nurturing familynurturing family who can who can meet their needs is right of every child.meet their needs is right of every child. Family supportFamily support