Children's Doctor

International Adoption and Foster Care - Winter 2014

Taking a Global View of the Child Adopted Internationally

Susan Friedman, MD

A 4-year-old male who was recently adopted presents with a history of abdominal distension and loose, foul-smelling stools. He complains occasionally of abdominal discomfort. He is picky in his food choices but does eat large amounts of preferred foods and likes to carry food around with him at all times, getting upset if this is not allowed. Hyperactivity and some sexualized behaviors are reported. One year prior, his reported weight and height were <5th percentile for age. His weight and height have continued to fall to below the 3rd percentile, while head circumference was tracking on the 50th percentile. Clinical exam revealed a mildly distended abdomen that was soft and non-tender, no HSM or masses. Exam also revealed a prominent forehead, an absent uvula and unusual symmetric linear scars on the temples. No other abnormal features were noted. Developmental delay was noted for speech and visual motor skills. Lab testing revealed microcytic anemia (Hg 9, MCV 69), elevated absolute eosinophils (1100), and a positive PPD.

Further history reveals that this child was left orphaned 3 years previously when his birth mother died, and he lived in an orphanage until his adoption. There was no information about his birth or family history, and his date of birth was estimated. Medical information from the orphanage included a few sets of growth parameters, sparse developmental information, and some laboratory testing: HIV 1/2 antibody, HBsAg, and RPR negative.

Discussion: This child’s presentation of failure to thrive, abdominal distension without HSM/masses, foul-smelling stools, and significant eosinophilia—in the context of adoption from Ethiopia—is typical of a child with a parasitic infection. The most common pathogen associated in this population is Giardia, and a stool for Giardia rapid antigen was positive. He was treated with metronidazole, and the diarrhea resolved. A repeat CBC, however, revealed that the eosinophil count had risen to just over 3000. Moderate to severe eosinophilia (>1500/μL) is not typical of Giardia infection, and further investigation for other parasites endemic in Ethiopia (strongyloides, Toxacara, and schistosomiasis) was positive for strongyloides. Following a 7-day course of albendazole, the eosinophilia resolved and later serologic testing was negative. The abdominal distension resolved, and he demonstrated significant catch-up growth. Lab testing revealed iron and vitamin D deficiency, which responded well to supplementation. The linear scars were consistent with ritual tribal scarring, and, although not proven, his absent uvula was likely due to traditional uvulectomy. His CXR (indicated for evaluation of the positive PPD) was negative, and he was treated for latent TB with a 6-month course of rifampin. Followup developmental evaluation 4 months after arrival showed good developmental catch up. The family was referred for family/child counseling to help with the behavioral issues.

Each year, thousands of children are adopted from foreign countries by U.S. families (see Chart 1). The majority of children are under 4 years and most come from orphanages (see Chart 2). There has been a recent upsurge in the number of children arriving from Ethiopia and other African countries. The medical issues vary somewhat from one country of origin to another, and the trend in recent years has been toward adopting more medically complex children. However, internationally adopted children from all countries constitute a population that is at significant risk for a wide range of medical, developmental, and psychosocial issues that pose unique challenges to the pediatrician (see Table 1).

Chart 1: Country of origin of Children Adopted to U.S., 2012

chart-1-winter14

Chart 2: Age of Internationally Adopted Children, 2012
Age of children Number of adoptions
Under 1 year old 901
1–2 years 3,704
3–4 years 1,303
5–12 years 2,056
13–17 years 664
18 years and older 40
Total international adoptions = 8,668

Source: U.S. Department of State-Bureau of Consular Affairs: Intercountry Adoption. Available at: http://adoption.state.gov/about_us/statistics.php. Accessed October 28, 2013.

 

Table 1: Common Medical Issues in International Adoptees
Growth deficiency/malnutrition/micronutrient deficiencies (anemia, rickets), microcephaly
Intestinal parasites
Other infections: +PPD, hepatitis A/B/C, scabies, lice, tinea, chronic otitis media
Developmental delay: especially speech/language
Fetal alcohol spectrum disorder (mainly Eastern Europe)
Feeding difficulties: texture issues, food anxiety/hoarding
Sleep issues
Dental decay
Birth defects (mainly China): CL/CP, CHD, limb deformities, SB, undiagnosed genetic disorders
Behavior issues: hyperactivity, self-stimulation, sensory aversion, attachment difficulties
Suspected history of physical/sexual abuse
Anemia: iron deficiency, lead, thalassemia

Children adopted from Africa typically have been exposed to psychosocial or physical trauma, and many are true orphans, having seen their relatives die of AIDS or malaria. This child was likely exposed to trauma and lack of consistent care, resulting in impaired infant/toddler attachment that can lead to later impairments in social relationships, attachments, trust, and intimacy. Food anxiety (hoarding, distress at the end of meals) is not uncommon. Sexualized behaviors can be exhibited by children who either frequently witnessed sex or were victims of sexual abuse.

It is common for children who have been internationally adopted to be diagnosed with ADHD. Extra care for this diagnosis is needed, however, as ADHD symptoms may in fact be the hyperarousal of post-traumatic stress disorder (PTSD). The American Academy of Pediatrics recently published an excellent guideline on recognition and management of childhood emotional trauma (see References).

Referral to a therapist who works with young children and has expertise in treatment of emotional trauma is essential in such cases. Developmental delays are common and developmental evaluation is recommended for this population. Many children catch up quickly after adoption, but others have primary developmental disorders that require diagnosis and management.

References and Suggested Readings

American Academy of Pediatrics. Helping foster and adoptive families cope with trauma. Available at: www.aap.org/traumaguide. Accessed November 25, 2013.

Miller LC. Immediate behavioral and developmental considerations for internationally adopted children transitioning to families. Pediatr Clin North Am. 2005;52:1311-1330.

Howard C, John C. International travel with infants & children. Centers for Disease Control and Prevention, Travelers’ Health website. Available at: http://bit.ly/intladopt. Accessed November 25, 2013.

Are We Neglecting the Neglected?

Philip Scribano, DO, MSCE

There are more than 400,000 children in the U.S. foster care system each year—even with national child welfare efforts to reduce the number of children requiring out-of-home care. The medical home, defined as providing “accessible, continuous, comprehensive, family centered, coordinated, compassionate, and culturally effective” medical care, is often not accessible for children placed into substitute care (ie, foster care, kinship care, residential treatment). Yet, it may offer the greatest benefit in fostering wellbeing and stability due to the challenges of out-of-home placement transitions. Despite this benefit, children often lack the significant coordination of care needed to ensure their complex needs are adequately addressed.

Children placed into substitute care have a disproportionate prevalence of medical conditions, behavioral and emotional problems, and developmental problems and disability, compared to the general population, even when adjusting for socioeconomic indicators (see Table 2). These problems can cause significant functional impairment and be a major obstacle to permanency in the foster home. They also hinder the child’s peer relationships and school performance.

Table 2: Healthcare Disparities Among Children in Foster Care
Condition Percent
Chronic medical conditions
i.e., asthma, vision or hearing problems, malnutrition, failure to thrive, anemia, dental caries, chronic sequelae of abuse injury
30-80
Behavioral and emotional problems
i.e., conduct disorder, attentional disorders, attachment disorders, depression, anxiety, aggressive behaviors
50-70
Developmental delay/
significant disability

i.e., global developmental delay, speech and/or language delays, mental retardation, cerebral palsy, prematurity, learning disabilities, hearing/vision impairments
20-60
No routine primary healthcare 12
Delayed/missing routine
immunizations
34

(See Table 2 references below)

The challenge in providing optimal healthcare to children in foster care is compounded by multiple placement changes. When a child is moved, discontinuity of healthcare often occurs due to changes in medical provider. On average in the United States, a median of 3 foster care placements is experienced for each foster child with almost 20% of children experiencing a move in an average of 10 months. Continuity of healthcare has been associated with desirable outcomes such as reduced emergency department and inpatient utilization, earlier and more effective treatment of chronic illnesses, improved immunization rates, and increased patient and caregiver satisfaction. Healthcare coordination is paramount to improve the quality of healthcare and avoid unnecessary repeat testing and evaluation, and over- or undertreatment of chronic conditions, resulting in more cost-efficient care.

The costs associated with healthcare for foster youth are notably higher by 6-fold than for children with similar medical complexity and socioeconomic status. The greatest expenditures are in hospitalization, medical equipment, and outpatient mental healthcare. Utilization of more expensive health services in an emergency department also increases, and rises even more with frequent foster placements as caregivers rely on the emergency departments for outpatient care. Increased utilization of mental health services is also associated with the number of placement changes.

Better access to physical and behavioral health assessment and treatment can lead to less severe manifestations of illness and/or behavioral problems and provide greater placement stability for these children, thus reducing healthcare and other related costs.

The primary care provider is in a crucial position to provide coordinated, comprehensive care for children in foster care. Recognition that removal from a family is a traumatic event and often results in removal from most of the child’s social anchors such as her community, school, and sometimes her siblings, is an important first step in providing care to these children. The American Academy of Pediatrics has recently released an excellent tool to strengthen the pediatrician’s ability to address this reality in children placed into adoptive and foster care (Helping Foster and Adoptive Families Cope with Trauma, accessible at www.aap.org/traumaguide).

Second, as the data show, children in foster care are children with special healthcare needs and should receive a coordinated healthcare response to address these complex physical, behavioral, and developmental challenges.

Third, significant barriers exist to improving health outcomes, given the high complexity of the foster care system. Creating a clear communication link with the child’s foster parent and caseworker can reduce common barriers such as: obtaining timely and accurate health information; obtaining appropriate consents for treatment and verification of health insurance coverage; and sharing relevant information across the health and child protection systems. Helpful information for healthcare professionals, including initial health assessment and ongoing health supervision recommendations, can be found at www.aap.org/fostercare.

As healthcare reform efforts continue to evolve, the medical home, care coordination, and accountable care with benchmarks to demonstrate clinically effective, cost-efficient care are on the horizon. Federal, state, and local efforts to improve physical and behavioral health outcomes for children in substitute care would contribute significantly in achieving those goals.

References and Suggested Readings

Landers G, Snyder A, Zhou M. Comparing preventive visits of children in foster care with other children in Medicaid. J Health Care Poor Underserved. 2013;24:802-812.

Woods SB, Farineau HM, McWey LM. Physical health, mental health, and behaviour problems among early adolescents in foster care. Child Care Health Dev. 2013;39:220-227.

Rubin DM, Alessandrini EA, Feudtner C, Mandell DS, Localio R, Hadley T. Placement stability and mental health costs for children in foster care. Pediatrics. 2004;113:1136-1141.

Jaudes KP, Champagne V, Harden A, Masterson J, Bilaver LA. Expanded medical home model works for children in foster care. Child Welfare. 2012;91:9-33.

Stahmer AC, Leslie LK, Hurlburt M, et al. Developmental and behavioral needs and service use for young children in child welfare. Pediatrics. 2005;116:891-900.

Table 2 references

Jee SH, Barth RP, Szilagyi MA, Szilagyi PG, Aida M, Davis MM. Factors associated with chronic conditions among children in foster care. J Health Care Poor Underserved. 2006;17:328-341.

Simms MD, Dubowitz H, Szilagyi MA. Health care needs of children in the foster care system. Pediatrics. 2000;106:909-918.

Hansen RL, Mawjee FL, Barton K, Metcalf MB, Joye NR. Comparing the health status of low-income children in and out of foster care. Child Welfare. 2004;83:367-380.

Stahmer AC, Leslie LK, Hurlburt M, et al. Developmental and behavioral needs and service use for young children in child welfare. Pediatrics. 2005;116:891-900.

Leslie L, Gordon J, Granger W, Gist K. Developmental delay in young children in child welfare by initial placement type. Infant Ment Health J. 2002; 23: 496-516.

Rubin DM, Alessandrini EA, Feudtner C, Mandell DS, Localio R, Hadley T. Placement stability and mental health costs for children in foster care. Pediatrics. 2004;113:1136-1141.

Leslie LK, Hurlburt MS, Landsverk J, Rolls JA, Wood PA, Kelleher KJ. Comprehensive assessments for children entering foster care: a national perspective. Pediatrics. 2003;112:134-142.

Confronting the Epidemic of Psychotropics for High-risk Children

David Rubin, MD, MSCE

A 4-year-old boy is seen for his first periodic screening examination since transferring into the practice. He is accompanied by his new foster care parent and his two siblings, aged 16 months and 6 years. He and his siblings were placed into foster care just over a year ago after a long history of physical abuse and neglect (and an allegation of sexual abuse in his 6-year-old sibling). He and his siblings have remained together, but have been moved 4 times, most recently 2 months ago, after he was burned on his scalp in uncertain circumstances in the last foster care home. There is very little past medical history available for the children, but the foster parent describes that he has already been expelled from one preschool in which he threw a toy truck at his teacher and was difficult to control. He is under psychiatric care at a local program that provides services to Medicaid-enrolled children. He has been prescribed Adderall and clonidine, which he has been taking consistently for the last 6 weeks. After an escalation of disruptive and aggressive behavior at the current preschool, he has been suspended pending further psychiatric evaluation. The current psychiatrist has now asked the foster parent to start risperidone 0.25 mg twice daily, in addition to his current medications. The foster parent is asking for advice on next steps and wonders whether she will be able to continue caring for the 3 children, even though she had hoped to provide a permanent home for them.

Discussion: Although caring for youth in foster care has always been fraught with many challenges, this case is illustrative of a trend in recent years toward increasing use of psychotropic medications, both singly and in combination, to control disruptive behaviors in children. Of particular concern has been the use of antipsychotics, which has grown at a pace among children in foster care far beyond that of other Medicaid-enrolled children. By 2008, 13% of children in foster care nationally were using antipsychotics, despite growing concerns about metabolic side effects including significant weight gain and increased risk for early adult onset diabetes. Increased use has been evident across all age groups despite an insufficient evidence base to support their use in noncognitively impaired children.

It would be easy to discount the use of psychotropic medications, and particularly antipsychotics, as emblematic of poor quality of care for children in the community, but such a critique is often unfounded. There have certainly been many situations in which youth have been cared for in facilities of questionable quality, but such an observation ignores the reality that stories like this have become the norm for most children in foster care, regardless of the provider. Rather, the more pressing issue is that the current publicly funded behavioral health system has to date been unprepared to respond to the critical needs of children whose disruptive behaviors are a manifestation of untreated trauma and attachment failure. Although many promising nonpharmacologic interventions have been developed and tested to alleviate the symptoms of repeated emotional trauma, they are often lacking in most publicly funded systems. Such interventions require a larger up-front investment as compared to the “med check” that can be provided on monthly or bimonthly intervals, and the extra work of maintaining engagement in therapeutic models over many weeks and months can be difficult to provide within agencies that are overwhelmed with waiting lists and need.

So what is this clinician to do when encountering this case? It would be easy to write off the psychiatric care as “not my business” and instead focus on verifying the immunization history, but in truth the psychiatric needs are the essence of the care for this child. Although there are no evidence-based rules on how to respond to such a child’s needs, here is guidance:

Although none of these interventions is a panacea in and of itself, and don’t address the cocktail of medications at this moment, they are the basis for a strong therapeutic relationship with the child.

Inevitably, taking these steps will allow you to play a stronger role in reducing the use of multiple medications, and particularly in the youngest children, to eliminate the use of antipsychotics entirely over time.

References and Suggested Readings

Government Accountabilty Office. Children’s Mental Health: Concerns Remain about Appropriate Services for Children in Medicaid and Foster Care. 2012; GAO-13-15. Washington, DC: Government Accountabilty Office; 2012. Available at: http://www.gao.gov/assets/660/650716.pdf. Accessed November 25, 2013.

Kavanagh J, Brooks E, Dougherty S, Gerdes M, Guevara J, Rubin D. Meeting the mental health needs of children. Philadelphia: PolicyLab at The Children’s Hospital of Philadelphia; 2010. Available at: http://www.policylab.us/index.php/publications/evidence-to-action/150-meeting-the-mental-health-needs-ofchildren.html. Accessed November 25, 2013.

Rubin D, Matone M, Huang Y-S, dosReis S, Feudtner C, Localio R. Interstate variation in trends of psychotropic medication use among Medicaid-enrolled children in foster care. Children and Youth Services Review. 2012;34:1492-1499.

Matone M, Localio R, Huang Y-S, dosReis S, Feudtner C, Rubin D. The Relationship between mental health diagnosis and treatment with second-generation antipsychotics over time: a national study of U.S. medicaid-enrolled children. Health Serv Res. 2012;47:1836-1860.

Garland A, Haine-Schlagel R, Brookman-Frazee L, Baker-Ericzen M, Trask E, Fawley-King K. Improving community-based mental healthcare for children: translating knowledge into action. Adm Policy Ment Health. 2013;40:6-22.

Committee on Early Childhood, Adoption and Dependent Care; AAP. Health care of young children in foster care. Pediatrics. 2002;109:536-541.

Referral information

The CHOP International Adoption Health Program provides a comprehensive evaluation and management of children adopted internationallly, beginning with a detailed preadoption evaluation, support during the adoption process, and multi-disciplinary evaluation post-adoption. The program also works with families adopting domestically, whether through private adoption or the adoption of foster children.

To refer a patient or prospective adoptive parents requesting a pre-adoption review to the program, call 267-426-5005 or email CHOPADOPT@email.chop.edu. To learn more about Safe Place: The Center for Child Protection and Health, visit www.chop.edu/safeplace or call 267-426-3111.

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