Linda Tirella

Health of Children Adopted From Guatemala: Comparison of Orphanage and Foster Care

Objective. Since 1986, American parents have adopted >17300 children from Guatemala. This study assessed the health, growth, and developmental status of 103 Guatemalan adopted children (48 girls; 55 boys) after arrival in the United States. Physical evidence suggestive of prenatal alcohol exposure and adequacy of vaccinations administered were also reviewed. Methods. Retrospective chart review was conducted of 103 children who were evaluated after arrival in the United States in an international adoption specialty clinic, and a case-matched study was conducted of a subgroup of 50 children who resided in either an orphanage or foster care before adoption. Mean age at arrival was 16 ± 19 months. Before adoption, 25 children resided in orphanages, 56 resided in foster care, and 22 resided in mixed-care settings. The 25 children who had resided in orphanages before adoption were matched for age at arrival, interval from arrival to clinic visit, and gender with a child adopted from foster care. Health and developmental status of these matched pairs were compared, allowing the first direct comparison of children raised in orphanages or foster care before adoption. Results. Mild growth delays were frequent among the children. Mean z scores for weight, height, and head circumference were, respectively, −1.00, −1.04, and −1.08. Children from foster care had significantly better z scores for height, weight, and head circumference than those from orphanage or mixed care. Among children who were younger than 2 years at arrival, growth measurements correlated inversely with age at arrival. Infectious diseases included intestinal parasites (8%) and latent tuberculosis infection (7%). Other medical conditions included anemia (30%), elevated lead levels (3%), and (using strict criteria) phenotypic facial features suggestive of prenatal alcohol exposure (28%). Adequacy of vaccine records from Guatemala was assessed: 28% met American Academy of Pediatrics standards for vaccine administration. Unsuspected significant medical diagnoses, including congenital anomalies and ocular, neurologic, and orthopedic problems, were found in 14%. Most children were doing well developmentally (80–92% of expected performance), but 14% had global developmental delays. Cognition, expressive and receptive language, and activities of daily living skills correlated inversely with age at arrival for children who were younger than 2 years at adoption. Among the 50 matched children, those who resided in foster care before adoption had better measurements for height, weight, and head circumference at arrival to the United States. Moreover, those who resided in foster care scored significantly better for cognitive skills than those who had previously resided in orphanages (96.3% of age-expected compared with 88.3% of age-expected); other skills did not differ between the 2 groups. No differences were found between the 2 groups of children related to prevalence of medical diagnoses or phenotypic evidence suggesting prenatal alcohol exposure. Conclusions. Guatemalan adoptees display similar overall patterns of growth and developmental delays as seen in other groups of internationally adopted children, although not as severe. Younger children had better growth and development (cognition, language, and activities of daily living skills) than older children, regardless of location of residence before adoption. Among children who were matched for age, gender, and interval from adoption to evaluation, those who had resided in foster care had better growth and cognitive scores than children who had resided in orphanages before adoption. These findings support the need for timely adoptive placement of young infants and support the placement of children in attentive foster care rather than orphanages when feasible.

Outcomes of children adopted from Eastern Europe

Behavioral problems are frequent among post-institutionalized Eastern European adoptees. However, risk factors related to outcomes have not been fully delineated. We evaluated 50 Eastern European adoptees, age 8—10 years, with their adoptive families for more than five years. Cognitive and behavioral outcomes and parenting stress were evaluated in relation to pre-adoptive risk factors, including arrival age, growth, and facial phenotype related to prenatal alcohol exposure. At follow-up, IQ and achievement scores were ≥ average in most children (≥74%). Behavioral and school problems were common (externalizing 44%, internalizing 18%, behavioral symptoms 50%, attention deficit hyperactivity disorder (ADHD) 46%, learning disabilities 40%, mental health disorders 28%); 38% had multiple problems. Behavioral problems correlated inversely with IQ. Parent stress was high and correlated with child externalizing behaviors and inversely to child full scale IQ. Children with “severe behavioral disturbances” (24%) were more likely to have had smaller head circumferences at arrival. Childs age at adoption related inversely to parent stress, possibly due to the longer duration of time that children resided with their families. “High/intermediate risk” phenotypic facial scores for prenatal alcohol exposure (58%) correlated with head circumference z scores at arrival and follow-up. Otherwise, arrival age, growth, and facial phenotype did not correlate with these specific outcome measures.

Time use in Russian Baby Homes.

BACKGROUND We investigated time use of Russian children residing in Baby Homes to document their opportunities and experiences during institutional care. METHODS Time use of 138 non-special needs, randomly selected children (65 female vs. 73 male, age 1 month to 4 years) in Baby Homes in Murmansk, Russia, was analysed. Baby Home specialists were trained in time-use spot observation methodology. Each child was observed every 10 min for 5 h (31 observations/child; >4000 data points). At each observation, we coded: who the child was with, adult role, what the child was doing, location and vocalizations. RESULTS Children spent 50% of their time alone, 27% with a caregiver, 15% with another adult, and 7% with another child. Infants spent significantly more time alone (65%) than toddlers (43%) or pre-schoolers (46%) [F(2,133) = 13.05, P < 0.0001]. Caregivers supervised children (58%), led group activities (16%), cared for individuals (14%), or were absent from the room (12%). Children spent the most time (32%) in activities of daily living; remaining time was spent in meaningful play (27%), non-purposeful activity (16%) or sleep (18%). The percentage of time spent in meaningful play significantly increased across age groups [infants 10%, toddlers 25%, pre-schoolers 36%, F(2,133) = 26.9, P < 0.001]. Infants (23%) and toddlers (20%) spent significantly more time than the older group (10%) in non-purposeful activity [F(2,133) = 26.9, P < 0.001]. In 12% of observations, an adult was speaking to the child, in 10% to the group, and <1% to another adult. Child vocalizations varied by age: infants 42% of observations, toddlers 56%, and pre-schoolers 59%. Older children directed more vocalizations to adults than younger children [F(2,133) = 24.47, P < 0.001]. CONCLUSION Time use of children residing in Baby Homes is limited by routinized schedules and care, at the expense of child-directed or interactive play with adults. Despite close proximity and living in group care, childrens vocalizations and interactions with others are limited.

Medical diagnoses and growth of children residing in Russian orphanages

Aims: Survey the health of young children residing in Russian orphanages.

Child Abuse Fatalities Among Internationally Adopted Children

More than 250,000 boys and girls have been adopted from other countries by American parents since 1989 (Immigrant Visas Issued, 2006). Most of these children have experienced prenatal risk factors (low birth weight, prematurity, lack of medical care and/or exposure to drugs, alcohol, tobacco), as well as risk factors associated with institutional care (growth and developmental delays, medical problems and/or lack of individualized attention) (Gunnar, Bruce, & Grotevant, 2000; Jenista, 2000; Johnson, 2002; Miller, 2005a). As a consequence, internationally adopted children frequently experience a complex array of developmental, medical, and behavioral issues (Hjern, Lindblad, & Vinnerljung, 2002; Miller, 2005b; Rutter et al., 1999; Tizard, Cooperman, Joseph, & Tizard, 1972; Tizard & Hodges, 1978; Tizard & Joseph, 1970; Verhulst, Althaus, & Versluis-den Bieman, 1990a, 1990b, 1992; Verhulst, Versluis-den Bieman, van der Ende, Berden, & Sanders-Woudstra, 1990; Versluis-den Bieman & Verhulst, 1995). Nevertheless, most of them exhibit remarkable catch-up growth and development within months after arriving home. Parents who adopt internationally are generally recognized as an extremely devoted and committed group, who literally “go to the ends of the earth” to form their families. As with other types of adoptions, prospective parents frequently wait for months or even years to complete their international adoptions. Procedural delays and setbacks are common in international adoptions, due in part to the complex requirements of U.S. and foreign government bureaucracies. Throughout the process, significantly, there are multiple opportunities for agencies to appraise and educate the prospective parents. Parents who adopt in any way, for instance, must undergo a “home study” by a licensed adoption agency to meet legal requirements. Home studies are conducted by trained social workers, in part to obtain comprehensive information about the personal lives, child-rearing beliefs, and psychological preparedness of prospective adoptive parents. Because international adoption is a long and intensive process, agencies often have the opportunity to assess prospective parents under diverse and stressful conditions. Thus, it has been shocking and horrific to realize that, since 1996, there have been 18 fatalities (in 17 families) of internationally adopted children because of suspected or proven cases of abuse and/or neglect by their adoptive parents. Adoption officials and child welfare professionals in the United States and the children’s countries of origin are understandably concerned, in some cases alarmed (Correspondent, 2005; Child Abuse Fatalities Among Internationally Adopted Children

Parent Strategies for Addressing the Needs of Their Newly Adopted Child

ABSTRACT The purpose of this study was to describe reflections of nine American parents on the strengths, challenges, and strategies in parenting young children newly adopted from another country. Eight mothers and one father with an adopted child aged <3 years and home for <3 months completed standardized assessments measuring the childs social emotional development, sensory processing, and parental stress. Each parent participated in qualitative interview to discuss challenges and strategies helpful in addressing their childrens needs. All parents reported challenges addressing their childs needs in the areas of sleep, feeding, attachment and self-regulation, and soothing. Parents reported similar strategies to address their childs behavioral concerns. Parents also reported on family factors and community resources that supported the success of the adoption. Although many families described their adoptive child as having challenges with multiple daily life activities, parents reported being able to create effective strategies to address many of these challenging behaviors.

Self-regulation in newly arrived international adoptees.

ABSTRACT Many newly arrived international adoptees (IA) have difficulties with eating, sleeping, and self-soothing/self-stimulating (SS) behaviors. However, to date the prevalence of these problems and associated risk factors have not been clearly identified. Therefore, we proposed to evaluate 387 IA for the presence of these self-regulation and behavioral difficulties, and examined the relationships between these behaviors and pre-adoptive risk factors including growth measures, orphanage care, age at arrival and presence of medical complications. Data on participants were collected in a retrospective chart review and entered into a standardized data collection sheet by a trained research assistant. This exploratory study included 133 M and 254 F with an average age (M = 16) months at the time of the study. Children in the study represented adoptees from seventeen countries. Forty-nine per cent (49%) of the retrospective sample exhibited SS behaviors, 48% had sleep disturbances, and 34% had eating issues. Many had difficulties in more than one area. Country of origin, pre-adoption residence, and arrival nutritional status all related to the presence of these problems. Hence, self-regulation difficulties are common but both the course and influence of those behaviors on family functioning remains unknown.

Children's drawings: self-perception and family function in international adoption

ABSTRACT No comprehensive studies have examined the utility of family drawings within the context of international adoption. We examined the relationship of Kinetic Family Drawings by 54 internationally adopted children in the USA (65% female; M age = 8.57 years, SD = 2.1) to demographics, child competencies (Child Behavior Checklist: CBCL/6–18) and parental adoption satisfaction (Adoption Satisfaction Questionnaire: ASQ). Two raters independently scored drawings for: emotion (positive, neutral and negative), boundaries (unifying and dividing), family composition (inclusion of family members), interactivity (active or passive) and self-emphasis. Drawing features moderately correlated with CBCL subscales (emotion, boundaries, drawing composite: r range = −.43 to 0.31, all p < .05) and parental adoption satisfaction (boundaries: r = .42, p < .01). Significant drawing differences were also observed by gender, time since adoption, orphanage care and adoption visibility. These findings support the utility of family drawings as an informative, supplemental tool highlighting concerns related to childrens pre- and post-adoption experiences, and their impact on family function.

Family and research context of internationally adopted child abuse fatalities.

insightful commentaries of Drs. Gunnar and Pollak (this issue) and Barnett (this issue). We welcome further discussion of the important points that have been raised. Space limitations in our original letter precluded full presentation of the many complex aspects of the tragic (but fortunately, infrequent) problem of child abuse fatalities of international adoptees. We agree with Gunnar and Pollak that support for the adoptive families of troubled children is sadly lacking—not only in less-populated areas but also in urban areas with many professionals trained in adoption-related issues. Such children—and their families—require significant therapy and other interventions from experienced providers; many professionals with the requisite skills, expertise, and experience are overbooked and unable to handle the volume of demands for their services. Furthermore, the complex mental health and educational needs of many of the children do not usually fit neatly into the knowledge base of a single provider and, as stated by both commentators, many barriers exist to needed care coordination. Furthermore, billing and reimbursement issues can complicate or even prevent needed treatments for children with complicated, chronic conditions, especially mental health disorders. Pediatricians, teachers, and other professionals clearly must receive education—in their academic training and on an ongoing basis—about the issues involved because too few currently are competent to provide the support required for the families of children with specific, intricate emotional and behavioral needs related to adoption and complicated early lives. The systemic strengthening of support by adoption practitioners, school personnel, and other relevant professionals would indeed reduce stress for many of these families. It is important to note that, even with the current deficiencies, the vast majority of adoptive families facing such challenging situations display phenomenal dedication to and advocacy for their children. Although defense attorneys have claimed that several of the fatally injured children had severe behavioral issues, the evidence suggests that such boys and girls are not generally the targets for such cruelty. Rather, as in other cases of child abuse fatalities, parental isolation, inexperience, and emotional problems are more closely linked to this horrid outcome (Crittenden, 1985; Egeland, Breitenbucher, & Rosenberg, 1980). Indeed, children with severe behavioral disorders often have some level of community support services (albeit inadequate) that can mitigate against fatal abuse. It is striking that the children described in our letter were so young (67% were younger than age 3 years). Although challenging behaviors can certainly Family and Research Context of Internationally Adopted Child Abuse Fatalities