HELPING FOSTER CHILDREN WITH PRENATAL SUBSTANCE EXPOSURE SUCCESSFULLY TRANSITION TO ADOPTION

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HELPING FOSTER CHILDREN WITH PRENATAL SUBSTANCE
EXPOSURE SUCCESSFULLY TRANSITION TO ADOPTION

• Susan Edelstein, LCSW
• Jill Waterman, PhD
• Karen Rathburn, PhD
• UCLA TIES for Adoption

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TIES FOR ADOPTION

• Training, Intervention, Education and Services
• Funding Agencies Los Angeles County Departments
  of Children and Family Services (DCFS) and Mental
  Health (DMH EPSDT) and private foundations

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HISTORY OF PSE AND ADOPTION

• Epidemic of PSE beginning in 1970s
• Early dire predictions about impact of PSE
• Many children with PSE not being adopted
• Current research on outcomes more balanced

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ISSUES ABOUT PRENATAL SUBSTANCE EXPOSURE

• Emotional reactions about birth parent
  information interactions
• Development of empathy for birth parent
• Who and what to tell about substance abuse
  history
• Family and friends
• Professionals
• Child
• Fears of effects on childs behavior
  development
• Fears of childs own future drug use

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CONCEPTUAL BASIS FOR TIES FOR ADOPTION

• Thorough preparation of parents
• Model of cumulative risk
• Intervention during childs transition to
  adoptive home
• Adoption-sensitive interventions
• Interdisciplinary, interagency approach
• De-stigmatization of children with PSE

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DE-STIGMATIZATION OF CHILDREN WITH PSE

• Explaining model of cumulative risk
• Teaching temperament specific strategies
• Reviewing balanced research outcomes
• Using appropriate language in discussing children
• Hearing from seasoned adoptive parents of
  children with PSE
• Thoughtfully deciding who to tell about PSE

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TIES FOR ADOPTION MODEL

• Pre-placement education
• Developmental Assessment Clinic
• Multidisciplinary consultation
• Transition Counseling
• Parent and child therapy/support groups
• Parent, child family intervention
• Infant mental health program
• Specialty groups
• Pediatric, psychiatric, speech/language and
  educational services

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PRE-PLACEMENT EDUCATION

• Session 1 Developing empathy for
  substance-abusing parents
• Examining own attitudes about drug addiction
• Understanding drug addiction
• Talking to children about difficult history

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PRE-PLACEMENT EDUCATION

• Session 2 Prenatal substance exposure medical
  and developmental concerns
• Research on effects of PSE
• Cumulative risk model
• Strategies for childrens challenging behaviors

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PRE-PLACEMENT EDUCATION

• Session 3 Special issues to consider in
  adopting a child with prenatal substance exposure
• Who do you tell about childs history?
• Substance abuse prevention strategies
• Considerations about open adoption with parents
  with substance abuse histories
• Presentation by seasoned TIES adoptive parents

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EVALUATION OF PRE-PLACEMENT EDUCATION

• 559 prospective adoptive parents given
  questionnaire about (1) attitudes toward drug
  addiction children with substance exposure, (2)
  demographics (3) openness to adopting child
  with PSE prior to and at end of training
• 3 attitude subscales
• Attitudes toward children with PSE
• Empathy toward drug abusers
• Negative attitudes toward pregnant drug users

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CHANGE IN ATTITUDES ABOUT PSE

• All scales changed significantly (plt.001)
• More positive about children with PSE, more
  empathic about drug abusers, but also more
  negative about pregnant drug users

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CHANGE IN OPENNESS TO ADOPT PSE CHILDREN

• Most parents initially open to adopting PSE child
• Parents become significantly more open after
  training
• Change in attitudes associated with increased
  openness
• Training destigmatizes children with PSE

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DEVELOPMENTAL ASSESSMENT CLINIC

• Two mornings per month
• Foster adoptive children with multiple
  developmental/psychological/medical concerns
• Prior to and following adoptive placement
• Multidisciplinary
• Psychology, Social Work, Psychiatry, Pediatrics,
• Education, Speech and Language
• Questions about diagnosis, treatment needs and/or
  placement options

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MULTIDISCIPLINARY CONSULTATION

• Occurs when child identified for adoptive
  placement
• Face-to-face meeting of parents, social workers
  and TIES interdisciplinary team members following
  comprehensive assessment
• Identifies childs strengths and needs so parents
  can make informed decision
• Recommendations about needed services

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PARENT AND CHILD SUPPORT GROUPS

• Meet monthly for 1½ hours in evening
• Four parent groups with parallel child groups
• Child group part play, part social skills
  training, part discussion about adoption and loss
  issues
• Main issues for parent group
• Understanding placement, transition and loss
• Challenges with systems (e.g., concurrent
  planning)
• Handling difficult child behaviors
• Issues about prenatal substance abuse

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TRANSITION COUNSELING

• Offered when issues arise during visitation and
  placement process
• Usually relatively short-term and intensive
• Parents and children usually seen separately
  after initial joint session
• Family therapy later on in treatment

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TRANSITION COUNSELING PARENT INTERVENTION

• Attachment and loss issues
• Understanding child development
• Using temperament constructs and fit with parent
  temperament to destigmatize child and PSE
• Dealing with particular behavioral issues
• Coping with emotional issues about concurrent
  planning

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VALUE OF TEMPERAMENT CONSTRUCTS

• Parents can
• learn to anticipate issues for their particular
  child
• adjust parenting strategies to childs
  temperament
• avoid making negative judgments about child
• stop blaming selves for inborn traits of child
• feel more effective when understand behavior

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TRANSITION COUNSELING CHILD INTERVENTION

• Grief and loss
• Sense of self and self-esteem
• Emotion regulation skills
• Process of becoming a family
• Attachment issues
• Divided loyalties
• Coping with previous traumatic and abusive
  experiences

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INFANT MENTAL HEALTH

• Transition program for babies and parents
• Components
• Home visiting
• Monthly parent-infant group
• Developmental/socio-emotional assessments
• Major issues
• Concurrent planning legal risk, birth parent
  visits
• Developmental, behavioral and PSE concerns

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SPECIALTY GROUPS

• Adoption process groups (16 wks.)
• Pre-adolescents adolescents/separate parent
  group
• Activity-based
• Incredible Years (Webster-Stratton) 12 weeks
• Empirically supported parenting group
• Parallel Dinosaur School social skills training
  group
• Some adoption-specific modifications
• Grief and loss group
• Group for resource parents whose child returns to
  birth family

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EDUCATIONAL, PSYCHIATRIC AND PEDIATRIC SERVICES

• Educational
• Assistance with school placement
• Advocacy for special education services
• Psychiatric
• Psychiatric consultation and evaluations
• Medication management
• Pediatric
• Understanding implications of childs medical
  history and/or condition
• Assistance with referrals to specialists
• Speech and Language
• Assessments of children
• Consultation to staff
• Assistance with therapy referrals

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TIES FOR ADOPTIONSATELLITE DEVELOPMENT

• University Based Program to
• Community Mental Health Agency

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BENEFITS

• Easier access for families
• Services tailored to particular community
• Cross fertilization of ideas, resources and
  programs
• Ability to refer to alternate site to avoid wait
  lists for families
• Greater research training opportunities
• Enhanced funding possibilities

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CHALLENGES

• Fidelity to the TIES Model while adapting to
  needs of the community Department of Mental
  Health requirements
• Replication of interdisciplinary team model in a
  community mental health setting
• Working out the relationship structure between
  sites
• Preserving TIES model while allowing for own
  innovation
• Maintaining a connection with core site given
  distance, different staffs, administrative
  differences, etc.
• Time commitment for technical assistance

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RESEARCH FOLLOW-UP STUDY

• 82 children and their families followed at 2 and
  12 mos. post-placement, then every year until 5
  years post-placement
• Developmental evaluations, temperament, behavior,
  emotion regulation and family measures,
  parent-child interaction, parent interview
• Findings limited by lack of control group

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WHO PARTICIPATED?

• 54 Boys, 46 Girls
• Child Ethnicity
• 37 Latino/a
• 29 African-American
• 17 Caucasian
• 12 Other/Mixed Ethnicity
• 5 Unknown

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FAMILY CHARACTERISTICS

• Transracial Adoptions 40 match with neither
  parent (parents 65 Caucasian)
• Parent Marital Status
• 52 Married
• 12 Living w/ Domestic Partner
• 32 Single
• 4 Divorced
• Gay Households 27
• More than one child in home 48

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BIOLOGICAL RISK FACTORS

• 91 prenatally exposed to drugs
• 38 born prematurely (lt36 wks gestation)
• 53 had birth complications

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ENVIRONMENTAL RISK FACTORS

• 44 had history of abuse/neglect
• Average age at placement 3 yr. 11 mo.
• 51 lived with birth mother after birth
• 51 had 3 or more prior placements (range 1-15)

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COGNITIVE DEVELOPMENT

• Cognitive scores went up consistently over the 5
  years
• Most in average range after 1st year
• 20 of children gained at least 15 points in 1st
  yr after placement

Average Cognitive scores over 5 years
105
100
Cognitive Score
95
90
0
1
2
3
4
5
Years post-placement
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CHILDRENS EXTERNALIZING BEHAVIOR PROBLEMS

• Externalizing problems attention problems,
  aggression, oppositional behavior, conduct
  problems (acting out)
• Decrease over 1st 3 years, though not
  significantly, then rise at year 4 -- WHY??

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CHILDRENS EXTERNALIZING BEHAVIOR PROBLEMS (2)

• Externalizing behavior problems generally in
  borderline/clinical range for about 30 of
  children
• In normative sample, about 2.5 in clinical range
  
• Average over time for our sample was 14

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CHILDRENS EXTERNALIZING BEHAVIOR PROBLEMS (3)

• Over 1st 3 years, abused/neglected children and
  those placed after age 4 showed significantly
  more externalizing behaviors
• By years 4 5, these differences no longer
  significant

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CHILDRENS INTERNALIZING BEHAVIOR PROBLEMS

• Internalizing problems anxiety, depression,
  withdrawal (acting in)
• Scores generally lower than externalizing
  (average 6 in clinical range)
• Internalizing behaviors drop significantly in the
  first 3 years after placement

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CHILDRENS INTERNALIZING BEHAVIOR PROBLEMS (2)

• Internalizing problems also more common among
  those abused/neglected, and those placed after
  age 4
• Differences disappear for abused/neglected after
  1st 2 years

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TEMPERAMENT

• Temperament measured at 1st 3 time points
• Quite stable over time expected
• Effects of risk factors Abused children and
  those placed for adoption at older age start out
  with more difficult temperament traits at
  placement
• Largest effect on adaptability and mood
• Differences mostly disappear by 2 yrs.
  post-placement
• Abused children continue to be less persistent
• Conclude that positive home environment offsets
  effect of risk factors over time

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TEMPERAMENT - ADAPTABILITY
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PARENTING STRESS

• Parenting stress decreases significantly over the
  1st 3 years, then rises somewhat again
• Parallels rise at 4 years after placement in
  externalizing behaviors

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PARENTING STRESS (2)

• Abused/neglected children significantly more
  stressful for parents over 1st 2 years then
  differences disappear
• Children placed after age 4 significantly more
  stressful for parents at all times except 5 years
  post-placement

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PARENT SATISFACTION WITH ADOPTION

• Significant increase in satisfaction with
  adoption over 1st 2 years
• Ceiling effect
• Low disruption rate (5), no dissolutions

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PARENT SATISFACTION WITH ADOPTION (2)

• Parents across time felt that parenting was more
  or much more rewarding than they expected
• But many also found parenting more or much more
  difficult than expected

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USE OF TIES SERVICES IN 1ST YEAR AFTER PLACEMENT

• 52 used at least 3 services in 1st year
• Support group and parent counseling each used for
  at least 1 year by 45
• TIES resources rated as most helpful in adapting
  to parenting the child

Percent using each type of service in 1st year
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RESEARCH SUMMARY

• Childrens cognitive scores increase
  significantly
• Internalizing behavior problems decrease, while
  many families continue to struggle with
  externalizing problems
• Impact of risk factors diminishes over time
  most disappear by 3 to 5 years after placement
• Families generally quite satisfied with the
  adoption found parenting harder but more
  rewarding than they thought
• Parents report TIES services very helpful

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CHALLENGES OF IMPLEMENTING MODEL WITH EXISTING
FUNDING STREAMS

• High-risk infants do not fit into EPSDT criteria
• Prevention services not funded
• Conflict between project goal to destigmatize
  children and need to give DSM-included diagnosis
• Cannot treat family under stress due to high-risk
  adoption issues
• Need to focus on larger issues than individual
  symptoms for child transracial adoption,
  divided loyalties between birth and adoptive
  parents, loss and grief, integrating
  difficult/traumatic backgrounds

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LESSONS LEARNED FROM TIES

• Prenatal substance exposure does not doom
  children
• Environmental factors at least as harmful as PSE
• Preparation of parents essential
• Transition to adoptive placement critical period
  for successful family formation
• Many children thrive in non-traditional families
• Well-controlled research sorely needed

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FUTURE DIRECTIONS

• Increase services to Spanish-speaking children
  and families
• Increase adoption-sensitive services for
  adolescents
• Seek funding for prevention (infant mental
  health/concurrent planning)
• Disseminate written materials
• Seek funding to study adoption-specific therapy,
  including control group