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