1. CECILIA BAXTER, MD, FRCP(C) EDMONTON ADOPTION CLINIC PROFESSOR EMERITUS, UNIVERSITY OF ALBERTA

2. 1. Describe the changing complexity of international adoption 2. Discuss identified risks of international adoption 3. Discuss through the use of case studies the medical and social issues for international adoptees and the potential impact on both the child and the family’s welfare

3. 2012 China2697 Ethiopia1568 Russia748 Republic of Korea627 Ukraine395 Democratic Republic of Congo 240 Uganda238 Nigeria197 Columbia195 Taiwan177 Ghana171 India159 Total:8668

8. a) Children:  Developing countries/economically burdened  Little or no prenatal care  Prenatal toxin exposures ◦ Congenital infections ◦ Alcohol ◦ Drugs  Social circumstances leading to loss of birth family ◦ Poverty ◦ llness or death  Physical, emotional, sexual abuse

9.  Changes in eligibility rules  Increased waiting times  Countries changing  Programs such as: ◦ Waiting Child Program ◦ Special Focus Program

10. b) Institutions ( orphanage or foster care):

11.  Underfunded  Understaffed  Environmental challenges  Developmental delays  Emotional delays  Attachment challenges

12.  Brief narrative  Physical exam ◦ May only be weight, height, not head circumference  Basic lab ◦ Hepatitis B ◦ HIV ◦ Syphilis

13. Information:  Often incomplete  More than six months old  Inaccurate/contradictions  Different medical terminology

14. One day old male from China  Cleft lip and palate  Mosquito/insect bites  Eczema buttocks  Needed nutrition  Choking on milk  Cleft lip repair at three months of age Two week hospitalization

15. Nine months:  Slow eater  Head circumference 25 th percentile  Height 25 th percentile  Weight below 5 th percentile  Suggest palate repair at two years of age  Lab normal  Development normal

17. Issues:  Failure to thrive  Lip, palate repair  Additional surgeries  Hearing, recurrent otitis media  Speech delay

18.  Aspiration  Orthodontic  Risk of syndrome, other anomalies  Infectious disease, developmental delays, attachment  Midline defects

19. Arrived 18 months (transferred foster care 15 months): Development:  Language 12 months  Gross motor 15 months  Fine motor skills 12 months  Social skills 15 months Outcome:  Three surgeries on palate/nose  Cosmetic nose surgery  Speech delay  Growing well  Self esteem

20. Learning points:  Access to multidisciplinary team  Surgical repair not of same quality  Multiple surgeries  Long term: ◦ Speech ◦ Cosmetic ◦ Self esteem

21. 12 day old boy from China:  Congenital imperforate anus  Urethral rectal fistula  ‘State of illness dangerous’  Emergency colostomy  Impetigo  Neonatal pneumonia

22. Two weeks:  Weight 25 th percentile Eight months:  Anoplasty  Rectourethral fistula repair  Poor growth  Daily anal dilation  Lab normal  Ultrasound of kidney normal

23. 18 months:  Developmental delay (10 – 12 months)  Bladder/bowel function normal  Info discrepancy

24. Issues:  Birth to placement ◦ Hypoglycemia ◦ Hypothermia ◦ Dehydration  Poor weight gain  Sphincter control  Kidney  Urinary tract infection, incontinence  1/3 associated lumbosacral deformity

25. Arrived 27 months:  Height 55 th percentile  Weight 70 th percentile  Head circumference 10 th percentile  Occasional vomiting  Loose stools, oozing  Keloid formation  Prolapsing rectum  Excoriated buttocks

26. Development: Gross motor 18 months Fine motor 18 months Language 12 months Social 12 months Other: Required lots of care Grieving loss of normal family life Initial impact on attachment Significant language delay Urinary tract infection

27.  MRI of spine normal  Ultrasound of kidneys normal  Surgery  Anorectoplasty ◦ Stricture small bowel ◦ Ileostomy (five months) ◦ Three additional surgeries ◦ Weekly dilation ◦ Skin care issues

28. Learning issues:  Suboptimal surgery  Multiple ◦ Hospitalizations ◦ Interventions ◦ Family  Hospitalizations ◦ Delays attachment  Care giving  Complex issues plus other health issues  Advocacy

29. 10 day old female from Ethiopia 2 years of age:  Microphthalmia  Orthopedic anomalies  Height 10 th percentile  Weight 40 th percentile  Head circumference 5 th percentile

30. Issues:  Abandoned ◦ Hypoglycemia ◦ Hypothermia ◦ Dehydration  Microphthalmia ◦ Little or no vision ◦ 1/3 associated malformation ◦ Can be secondary to prenatal infection, toxins

31. Eye:  An extension of brain  Abnormalities of brain  Developmental disability  Cataracts  Glaucoma  Syndrome

32. Will need:  Peds ophtho/plastics/ortho  Vision/hearing screening  MRI of brain/eye  Chromosome/genetic testing  Developmental assessment

33. Two year old girl from Haiti: Two months:  7 lbs into care  Hospitalized ◦ Pneumonia at six months ◦ Sickle cell trait ◦ Labs negative ◦ Development normal

35. 15 months:  2010 earthquake 2 years :  Weight 20 th percentile  Height 50 th percentile

36. Issues:  Pre-existing malnutrition  Earthquake ◦ Lack of infrastructure ◦ Lack of food ◦ Lack of sanitation  Post Traumatic Stress Disorder  Attachment Parents:  Children often unsupervised  Temporary shelter

37. Arrived home 3 years of age:  Resistant to early attachment  Behavioral struggles  Giardia persistent  Development at 2 – 2 ½ years

38. Learning issues:  Effects of malnutrition  Unstable, unstructured environment ◦ Attachment ◦ Post traumatic Stress Disorder  Emotional toll  Resilience  Patience

39. PTSD: Trauma and stress related disorder Exposure to:  Actual or threatened death  Serious injury or sexual violation ◦ Direct ◦ Witness

40. Young child:  Abuse  Witness violence  Motor vehicle accident  Natural disaster  Conditions of war  Dog bites  Invasive medical procedures

41. Symptoms:  Anxiety  Impulsivity  Aggression  Hypervigilant

42.  Hyperactivity  Apathy/depression  Sleep  Dissociation  School avoidance/failure

43. VulnerabilityResilience Event Individual Family and social Post Traumatic Stress Disorder/trauma:  Increased risk of attachment difficulties

44. 5 year old brother and 3 year old sister from Ethiopia  Birth mom brought into care  Birth father deceased  Lab negative  Both mild iron deficiency  Limited developmental information given

45. Boy:  Weight 50 th percentile  Height 75 th percentile  Head circumference 15 th percentile Girl:  Weight 3 rd percentile  Height 3 rd percentile  Head circumference 15 th percentile

46. Issues:  General infectious disease  Attachment  Developmental Delay  No school readiness  Older child parentified  Possible trauma  Grief

47. Brother upon arrival after 16 months in care:  Dental caries  Tuberculosis treatment  Giardia  Social/academic struggles  Disclosed abuse  Survivor guilt  Attention deficit hyperactivity disorder  Reactive attachment disorder

48. Sister upon arrival after 16 months in care:  Dental caries  Giardia  Molluscum contagiosum  Perforation of right eardrum

49.  Insecure attachment  Academic struggles  Sleep apnea  50% hearing loss  Referral Trauma attachment group

50. Learning issues:  Each child own temperament/life experience  Each child medical issues  Parentification  Sibling rivalry  Mental/emotional health impact  Adaptability/resilience  Team work as a family

51. Adoption disruptions:  Domestic 10 – 20%  Intercountry Holland 1991: 2.8 - 5.7% Spain 2003: 1.5% Spain 2004: 0.88%

52. Understand the risks involved:  Unadvertised issues  Is child’s profile significantly different  Are you and your partner in agreement  If single, be realistic about support  Access to medical services  Access to mental health services experienced with adoption  Financial issues  Impact on siblings, self, family