MON July 9, 2018 MON July 9, 2018
10:30 am 10:30 am
Cartier I Cartier I

Dana Johnson

Professor of Pediatrics, University of Minnesota

Judith Eckerle

Associate Professor, Department of Pediatrics, University of Minnesota

Megan Bresnahan

Occupational Therapist, Masonic Childen's Hospital, University of Minnesota Health

Maria Kroupina

Associate Professor, Department of Pediatrics, University of Minnesota

Symposium: Evidence-based multidisciplinary approach to supporting the medical and mental health needs of adoptive and foster families from referral through family formation

Preadoption medical evaluation of a child

The interaction between a health care professional and a potential adoptive family at the time of a child’s referral is not only an opportunity for education on the medical condition of a child but also the best chance for influencing parental expectations about their future adoption experience. However, without a different set of lenses than used to evaluate a child raised by a competent family, evaluating a child who experienced early adversity may not accurately communicate potential risks and benefits to the parents. The goal of this first part of the symposium to lay the groundwork for knowledgeably and productively discussing medical risks with parents as well as facilitating a dialog about appropriate expectations when future challenges are anticipated. Based on experience of over 25,000 preadoption medical reviews as well as a survey involving 2,300 international adoptees from Minnesota, the following topics will be addressed:
1. Common prenatal risks
2. Short and long-term effects of institutional care.
3. Quality of foster care
4. Structure, capacity and quality of medical care systems.
5. Idiosyncratic medical terminology.
6. Routine screening tests that should be expected
7. Additional tests that might be available and those that likely aren’t.
8. Interpretation of growth information from different caregiving environments.
9. Interpretation of developmental information for children living in different caregiving environments.
10. Spectrum of diagnoses in specific countries.
11. Benefits to the family of medical review.
12. Counseling families about living with uncertainty.
13. Setting appropriate expectations for children with complex medical/developmental problems.
14. “Red Flags” in the history that portent great stress or adoption/family disruption.
15. How accurate are predictions?

Post-Placement Medical and Developmental Evaluation of Child

Part 1. Medical Screening
Many children from the US and international adoption and foster care system come from backgrounds of prenatal and early childhood trauma, prenatal exposures, under or non-diagnosed health conditions and multiple transitions. Many of these children have unique medical, behavioral and educational needs. Post-arrival medical assessment begins within the first few weeks after arrival and includes assessment of exposure to infectious diseases, evaluation of immunization status, baseline growth, assessment of common nutritional deficiencies, toxin exposures (lead and alcohol) and hearing and vision screening. Three to six months after arrival the child is seen again to again evaluate exposure to infectious diseases and evaluate progress in growth and nutritional recovery. Additional visits take place as needed to reevaluate cognitive recovery, growth, risks for early puberty and harbingers of chronic disease such as hypertension. We will also discuss specialist input from endocrinology, genetics and neuropsychology.

Part 2: Developmental Screening
Children from a background of multiple transitions, prenatal exposures, early neglect or abuse, orphanage care or current foster care are at risk for developmental delays. Their backgrounds are often significant for limited handling in infancy, lack of developmental skill opportunities and sensory experience. These factors may also be combined with other unaddressed medical and mental health diagnoses, nutritional deficiencies and genetic influences. A child’s early experiences impact the progression of development skills and without them it can impair these skills. A thorough assessment of a child’s global development skill level can help a parent understand the child’s current level of function and what they can do to help their child. With specific expertise from a provider trained in normal and institutional developmental milestones, it is possible to assess a child’s current level of function using a variety of functional and standardized activities, while also taking into consideration the child’s history. By doing so, we can help the family, professionals and educators recognize the strengths and weaknesses to build that child’s potential and make home and school recommendations for specific interventions. It is through this team approach to comprehensive recognition and treatment of a spectrum of medical and developmental issues, we can optimize the health of children in adoption and foster care and increase the chance of a successful long-term placement and growth of the family unit.

Post-placement mental health support for foster and adoptive families

Adopted children carry a unique risk of exposure to a variety of negative factors due to the multifaceted adversity they face from birth. Unfortunately, many adopted children experience self-regulation, and can be at greater risk for experiencing toxic stress, even many years after adoption. The main focus of this presentation is to explore how research on early brain development, toxic stress and the buffering role of parent-child relationships, can help us build an effective program for these high-risk children.

We will present a summary of previous research and data from our work with adopted children seen in our Early Childhood Mental Health Clinic. Due to the adversity they face, adopted children are uniquely at risk for experiencing compromised attachment relationships. Our study explored the prevalence of Reactive Attachment Disorder (RAD) in a group of 114 children aging from 1 to 5, who were referred to our clinical program. As in the previous studies we found a very small number of children (N=1) met the full RAD diagnostic criteria. However, it was found that even children who do not meet the full diagnostic criteria present with symptoms that will alter developmental trajectory. More than 60% of our clinic sample demonstrated difficulties in signaling distress, putting them at risk to experience toxic stress long term after adoption. Our results highlight the importance of viewing these clinical disorders as existing on a spectrum in order to adequately provide care to children who need it. If left unaddressed, stress experiences that occur without buffering relationships can have long term detrimental effects on brain anatomy and chemical balances, compromise the immune system and create a plethora of maladaptive internalizing and externalizing behaviors.

To translate our research findings into practice, we have developed a two-step program aimed at addressing the needs and concerns of families of newly adopted children. Initially, families go through a screening process aimed at understanding the experiences of both the caregiver and child to help create a preventative intervention program. Based on the results from this preliminary screening, children and families deemed high-risk for increased stress are referred to our Early Mental Health Program and undergo further developmental assessments. Based on the results of these assessments, families are directed towards evidence-based intervention programs that best fit their presenting problems and family systems. Working with adopted children of school age, regardless of years since their adoption, we were able to identify an important gap in mental health services. As a result, we developed a new step for our mental health program with a focus on promoting self-regulation. In this presentation, we will also discuss our collaborative work with our medical team in developing a comprehensive assessment and intervention for an adopted child.