Monday, September 03, 2007

GREAT article..please take the time to read!

The post-institutionalised child
by Karleen Gribble
Each year there are over 10 thousand inter country adoptions worldwide. Many of these children have spent at least some of their life in an orphanage, experiencing institutional care, which has had a far-reaching impact on them. Most of these children will have some interaction with paediatric health or other childcare professionals in the months and years after their adoption. However, because theirs is a relatively rare situation it is understandable that knowledge of their special needs is outside the experience of most professionals.Nevertheless, given information, professionals can use their specialised skills to assist parents and play an important role in the lives of adoptive families.
This article aims to provide a background on the experience of children in institutional care and highlight issues for health or other childcare professionals to consider in caring for a post-institutionalised child. These issues include: developmental delays,over friendliness or "over attachment," sleep issues, peer interaction and language acquisition, food, hospitalisation, over friendliness or "over attachment", developmental delays, "hidden"symptoms, issues of diagnosis, and consideration of the needs of the parents.
The experience of children in institutions.
Institutional neglect
The experience of a child in an institution is very different from that of a child in a family. Though institutions vary widely in the quality of care they provide, they generally have high child to caregiver ratios, which do not allow for individualized attention;they may also be lacking in heating, cooling, space, toys and nutrition. The physical and emotional deprivations of institutionalisation can result in a raft of problems including: a range of health issues, trouble with forming relationships(attachment difficulties), physical and developmental delays and language and sensory integration issues.
The most serious deprivation of institutionalisation is the lack of a consistent and sensitive caregiver with whom the child can trust and form a healthy attachment. Development of trust and a secure attachment normally occurs through interactions in which a primary caregiver meets a child's needs in an appropriate manner resulting in reduction of discomfort and in feelings of relief. This cycle of need-distress-gratification-relief-need is ordinarily repeated many thousands of times in the first years of a child's life but is absent or greatly reduced in the experience of institutionalised children.The absence of this attachment cycle in the early years of a child's life can be incredibly damaging and impact their ability to develop relationships and function in society.
Developmental processes
High child to caregiver ratios also limit the physical experiences of children who may be restricted to a cot/room for extensive periods of time, may spend very little time in interaction with any adult and are unlikely to have treatment for any physical special need they have. As a result, many children will not meet gross or fine motor mile stones during the time they are institutionalised. Nutritional deprivation or contamination of food or water with toxins such as lead or mercury can also impact development and health. Some children will experience sexual or physical abuse and infectious diseases and parasites are easily transmitted in the collective living conditions of an institution.
Health risks
Many of the medical issues that need to be considered post adoption are obvious to medical practitioners who know to routinely test for infectious disease and parasites, reliability of immunization record and to organize developmental, hearing, sight and dental checks within an appropriate time frame. Guidelines for health care professionals are readily available on these topics and references are easily identified via a Med line search for example, however,there are matters that may be less obvious but are nonetheless important to consider.
Different children will be impacted differently by institutionalisation, not just because the quality of care they experience may vary but also because their internal resources for dealing with their environment and care or lack of care will be different. Some children, potentially those adopted at a younger age,will appear to emerge relatively unscathed but others may be profoundly affected. Few children will have all of the problems discussed here and many problems will likely be evident only for a short period of time. Children are remarkably resilient and sensitive caregiving results in incredible healing for a large proportion of children. However, it is vital that appropriate care be given in order for healing rather than exacerbation of problems to occur.Health and other child care professionals have an important function in assisting and supporting parents in their care giving and play an extremely influential role in providing expert advice.
Developmental delays
Children who have spent an extended period of time in institutional care are often developmental delayed and retarded in growth due to physical and emotional deprivation. Children will often have three different "ages," a chronological age, a developmental age and an emotional age, which may vary widely from one another. Their developmental age will depend upon the care they have received prior to adoption. In many institutions, babies are left lying on their backs for extended periods of time and preschool aged children may be restricted to a cot for most of the day and therefore have poor gross motor skills. Even older children are likely to have had a limited opportunities for physical or fine motor activities and thus, will compare poorly to children in families. However, children often experience enormous catch up growth developmentally and physically after placement and can benefit from the assistance of physical therapy and early intervention services. It is also worth considering that although there is often rapid improvement post-placement, some children have permanent damage as a result of their early experiences. Children's emotional age will be related to the quality of relationships the child has had prior to placement. If the child has not had sensitive care from a primary caregiver their emotional growth will be severely retarded. Many suggest that the emotional age of the child is linked to the length of time they have been in a family. Thus, a 5 year old adopted at 3 years will have an emotional age close to those of a 2 year old born into their family and may express this in their needs and behaviour.
What professionals can do:Arrange for developmental assessments shortly after placement,understanding that they can assist in tracking the child's progress but may not be a good indication of the long-term prospects for the child.Refer to early intervention services and do not assume that delays will be transient or be ameliorated without assistance.Consider the emotional age of the child in determining how tests might be administered, matching testing procedure with emotional maturity rather than chronological age (e.g. hearing or sight tests).Provide practical suggestions that may assist a child in overcoming delays.
Over friendliness or "over attachment"Over friendliness to strangers (called indiscriminate affection in the literature) is a common behaviour in post-institutionalised children. In institutions, where there are few carers, children learnto be cute and engaging in order to maximize adult attention. This is a survival mechanism since children who receive no human touch are at increased risk of morbidity and death. Post-placement, children sometimes seek to be attractive to strangers, seeing every adult as a potential new caregiver. Perhaps because most caretakers in institutions are women and have failed them, many children show a definite preference for men (alternatively they may be scared of men). Children presenting indiscriminate affection need to learn that there are different types of relationships with adults and that family is something special. Parents have had success in teaching their children this by limiting the opportunity for contact with other adults and instructing those adults that they interact with of the boundaries they have set with their child. Younger children maybe easily confined to their parent's arms. Older children may be told with whom they may cuddle (initially it is advisable that this is only mum and dad) or hold hands or talk and specific instruction on relationships provided. Emphasis can be placed on how parents care for their children and that children in families do not need to look after themselves.Explaining to children the concept of "circle of care" is often helpful in aiding children to understand the inner sanctum of family and how extended family, friends and acquaintances are spread out like ripples on a pond; the distance from the centre indicating the closeness of the relationship.At the same time that children are seeking the attention of strangers (or sometimes apart from this behaviour), children may strive to distance themselves from their parents, particularly their mother and may appear to be very independent. Thus, children may avoid making eye contact, avoid physical contact, be stiff while being held or act in such a way as to attempt to make themselves undesirable to their parents. Fear of intimacy is behind this behaviour as post-institutionalised childrenhave experienced multiple caregiver loss and learnt that they canrely only on themselves. This can be very difficult for parents,particularly the mother who is often the primary caregiver and the focus of the child's rejection (many children will be somewhat accepting of their father while vehemently rejecting their mother).It can also be easy for parents to come to consider that their child is naturally independent and to allow them to maintain emotional distance. This however, is not in the child's best interest as healthy independence can only grow from healthy dependence on a primary caregiver and the long-term consequences of accepting distancing are serious. Families may need to be supported by family,friends and professionals if they are not to take the rejection of their child personally.Parents often find that they are able to assist their child to trust and build attachment with them by being responsive to their needs and gently persisting with closeness, not accepting the rejection at face value. It is not a case of forcing closeness on a child but providing closeness in ways that the child finds acceptable and gently increasing their tolerance over time. If a child rejects comfort from a parent, the parent should remain with the child and continue to attempt to comfort them. Activities that build trust and maximize close physical contact can also assist; for example, carrying the child in a sling (note: since children are rarely carried in institutions, many do not initially know how to hold on when beingcarried), cosleeping, cobathing, swimming together, playing gamesthat initiate eye contact, dancing together, massage and handfeeding. These activities can be a beginning for reinstating theattachment cycle that was disrupted by institutionalisation.Assisting the child to develop a secure attachment with a primarycaregiver may be the most difficult part of parenting a child withpast hurts. There is a continuum of attachment from securely attachedto severely attachment disordered. As children with severe attachmentdisorder may exhibit extremely antisocial behaviour as they grow(including aggression, lying, cruelty and self destructive action)and find it difficult to function in society, early intervention onbuilding attachment is vital.Some children rather than rejecting parental care become what someview as "over attached," usually to the mother, and cannot toleratebeing out of her sight. In fact, such children are insecurelyattached and, fearing loss of another mother, determine to neverleave her side. This can be wearing for mothers, however, resolutioncan only be achieved if the mother gives her child the closenessneeded, allowing separation only when the child is ready to do so,moving from short periods of separation to longer and emphasizing thepermanence of the relationship. Forcing separation will have theopposite affect of what is desired and will prolong insecurity ofattachment.Over friendliness, premature independence and "over attachment" canbe challenging for parents not just because they may be difficult todeal with but also because Western culture values independence inchildren.
What professionals can do:
Support parents in their measures to deal with overfriendlinessor "over attachment" and parenting in a way that promotes attachment.Encourage parents whose child is rejecting them not to take itpersonally and to persist in striving for closeness with their child.Refer families of children with severe attachment issues toprofessional assistance.Listen as parents describe their concerns, understanding that somechildren with a disordered attachment will present very well inpublic and save their troublesome behaviour for home.
Sleep Issues
Sleep problems are very common in newly adopted, post-institutionalised children and can be the most challenging aspect ofparenting in the first year post-adoption. Both difficulty in gettingto sleep and night waking may occur and last for months to years. Itis not unusual for a newly adopted child to take several hours to goto sleep at night and to wake a dozen times per night or more indistress. However, sleep difficulties are not the problem that needsto be solved, rather they are a symptom of an underlying issue.Possible reasons for sleep difficulties may be a result of trauma, aninability to feel safe, or that night has been an unsafe time forthem in the past.For most post-institutionalised children, adoption is a traumaticevent. Their placement is often abrupt, with little or no preparationgiven to the child who experiences a change in caregivers and adrastic change in environment. Communicating to the child what ishappening to them is often difficult because of language differences.Children may be able to consciously control their reaction to thestress of the new environment during their waking hours but in a morerelaxed state during sleep their anxiety and or anger is exposed.Night is also a time when grief can more easily surface and thelosses that a child has experienced are revealed.Children may also have difficulty sleeping because they do not feelsafe and to sleep well a feeling of safety is required. The upheavalin the child's life means that they know that any change is possible.They may fear what changes may happen while they are asleep and fightsleep, sleep with their eyes open or wake in fear during the night.Night can also be an unsafe time in an institution as are theregenerally few caregivers at night (one per 20 children is common).Thus, if children are being abused, it is likely to happen at night,resulting in feelings of unsafety at night.Since sleep difficulties are a symptom of a deeper problem, sleeptraining techniques such as controlled crying/comforting are notsuitable for children who have lived in an orphanage. Such techniquescan cause further damage to an already hurt child as they learn thatthey cannot trust their parents to respond to their cries. However,in responding sensitively to children's cries at night, parents mayassist the child in working through the trauma of placement, or otherpast traumas, and in feeling safe in their new environment. Beingwith the child as s/he goes to sleep is advisable. Some families findthat co-sleeping, placing the child's bed next to or in the same roomas the parents' bed alleviates symptoms. Co-sleeping in particular ismentioned by many parents as being pivotal not just in improvingsleep for everyone (note: it can take a couple of weeks for parentsto become accustomed to cosleeping) but also in promoting trust andattachment. Remaining close to the child during the day andmaximising physical contact at every opportunity (for example;avoiding the use of prams and baby chairs but instead using arms,sling or lap) will also assist in building trust, attachment andimproving sleep. It is important to realise however, that nointervention is likely to result in immediate alleviation of sleepdifficulties but that time is required. Parents whose child hassevere sleep difficulties will need to find strategies to assist themin coping with the situation. This may include catching up on sleepduring the day or on weekends, sleeping whenever the child sleeps,suspending non-essential activities and garnering assistance fromfamily or friends to maintain the household.
What professionals can do:
Support parents as they deal with sleep deprivation and parenting ina way that is outside the cultural norm.Assist in developing strategies for dealing with sleepproblems/deprivation.Encourage parents by assuring them that they are doing somethingimportant by being there for their child at night and pointing outthat every time their child exhibits distress is an opportunity toprovide comfort and thus strengthen attachment.Provide advice on ways to help the child to feel safer (some elementsof "protective behaviours" programs can assist with older children).Peer interaction and language acquisitionIt is conventional wisdom that children need to socialize with otherchildren in a group environment in order to develop socialcompetence. However, group childcare environments are not appropriatefor the post-institutionalised child in the immediate post-adoptionperiod. If children are placed in a group care environment they maybecome stressed because it reminds them of the institution they camefrom and they fear abandonment. Alternatively, they may seem to fitright in and wish to spend more time there, finding the closeness offamily life stressful and wishing to avoid the intimacy there.Neither of these situations are in the child's best interests. Somefamilies of post-institutionalised children find that the needs oftheir child may necessitate delaying schooling or homeschooling. Ifentry into daycare or school is necessary, the introduction should bemade gradually. Each child needs to be considered individually asresponses to alternative care varies widely and thus, it is notpossible to give absolute timeframes or protocols that are applicableto all.It is often suggested to migrant families that daycare or school maybe helpful in language acquisition. However, as mentioned, groupchildcare environments are problematic for post-institutionalisedchildren and since their adoptive families speak English, it is ininteractions with parents and siblings that the new language is bestacquired. It also needs to be recognized that issues associated withlanguage acquisition for post-institutionalised children may bedifferent from migrant children learning English as a secondlanguage. This is because migrant children are generally learningEnglish within the context of speaking their first language at homeand often after having obtained competence in their first language.However, post-institutionalised children most often do not haveparents who speak their first language. In addition, children may nothave developed age appropriate language competency prior to placementbecause the low child to caregiver ratio in institutions means thatchildren associate primarily with same aged peers with similarlanguage deficiencies. Thus, the building blocks of language may havebeen missed, presenting special issues for language acquisition.
What professionals can do:
Support parents in any requests they make with regards making entryto daycare or school easier for their child.Take care not to inadvertently usurp the parental role and be sure toassist the child to distinguish between themselves as temporary part-time caregivers and the parents as permanent family.Not accept inappropriate affection from the child and discuss anyconcerns you have with the parents.Observe language acquisition carefully and refer to speech therapy ifnecessary.
There are several situations in which food can be an issue for thepost-institutional child. Because many children have experienced foodscarcity in institutional care they may hoard or overeat. Thisproblem is usually mitigated with time and allowing the child to havefree access to food (placing nutritious snacks where the child canreach them or packing a lunch box for the child to carry around).Restricting access to food may make the problem worse. Children mayalso not have developed the capacity to recognise the feeling ofsatiety or hunger since they have been given food on a schedule andregardless of individual need. Parents may need to encourage theirchild to make a connection between body signals of hunger or fullnessand their relationship to food.Some children may not have experienced much variety in food and mayneed a gradual transition to other foods. In some cases, children mayhave been sustained solely on bottle feeds well past the age at whichsolid food would normally have been introduced and may refuse solidfood. Problems with different textures may be a sensory integrationissue, children may also have an overactive gag reflex or may belacking muscle development to chew food.It is also common for children to regress in eating habits at thetime they are adopted. Regression is a frequently observed responseto trauma and, as discussed previously, placement is traumatic.Children may also seek to regress in order to experience some of thenurturing that they missed out on earlier in life. Thus, childrencapable of feeding themselves may wish to be fed, children longweaned may request bottle feeding and some children pursuebreastfeeding with their new mother. Regression should not be viewedas a problem but as an opportunity for nurturing. Adoptive familiesare encouraged to provide times where their child can be 'babied' andto bottle feed even if the child is well beyond the normal age ofweaning.
What professionals can do:
Refer eating problems to specialist speech pathology if necessary.Support parents in "babying" their child.If concerned about dental caries, suggest preventative measures thatdo not involve weaning from the bottle.
Hospitals and the procedures that happen there can be frightening forany child but for post-institutionalised children there areadditional reasons why they might be anxious. The hospitalenvironment, for many children, is reminiscent of the institution inwhich they once lived and this can create great fear, as they maybelieve they will be abandoned at the hospital. In the short termthey may react to this stress by shutting down, disassociating,talking incessantly, becoming hyperactive, or uncooperative (note:these symptoms may be seen in any stressful situation and some post-institutionalised children suffer from post-traumatic stressdisorder). Some parents have found that even a day visit to ahospital can disrupt the child for several weeks. Thus, time in ahospital should be minimised and for example it may be helpful toarrange for the child's history to be discussed with health careprofessionals via telephone and for waiting before an appointment tobe minimised (parents may suggest that they wait outside the hospitalbuilding and be called by mobile phone when their child is to beseen).In addition, post-institutionalised children who are hospitalised mayneed to have their parents with them at all times, regardless oftheir age. The potential seriousness of the long-term consequences ofnot doing this cannot be understated. If the child feels that theyhave been abandoned in the hospital because their parents have notbeen allowed to remain with them the attachment relationship that hasbeen developed since adoption may be severely damaged. If the primarycaregiver of a child is ill or requires hospitalisation this can beextremely scary for children who may regress or otherwise expresstheir anxiety.
What professionals can do:
Assist in modifying hospital procedures in order to minimise timespent in the hospital environment and to allow parents to remain withtheir hospitalised child at all times, including at night.Be understanding if the child is difficult or uncooperative becauseof fear/anxiety.Explore delaying procedures that require hospitalisation to allow thechild time to adjust to life in their new family and forstrengthening of relationships prior to another stressful event.Make accommodations to minimise the impact of parentalhospitalisation on the child.
"Hidden" symptoms
Some unusual behaviours may present in post-institutionalisedchildren that may not at first appear to be connected to a child'shistory but are indeed related.Children who have been institutionalised may have difficulty inrecognizing the signals their body is sending them. Such abnormalphysical responses have already been discussed in relation to feedingbut can also present in relation to pain responses and wasteelimination. Thus, children may have an abnormally high tolerance topain and may not recognize the need to go to the toilet (for example,physical discomfort may be expressed as emotional discomfort or asanger). The lack of recognition of body signals in relation to foodand waste elimination is a direct result of the regimented life of aninstitution where eating, sleeping and toileting are on a schedule,regardless of body signals. A separation of body signals and actionresults in the quenching of normal response in some children. Highpain thresholds can result, as caregivers are consistently unable torespond to a child's pain or discomfort. Parents of newly adoptedchildren who exhibit an inability to recognize body signals may needto assist their child to make a connection between what their body isexperiencing and why they are experiencing it.Lack of a responsive primary caregiver can also result in a child notdeveloping normal object constancy (since the primary caregiver isthe first 'object') and they may have difficulty inrecognising/recalling the existence of something they cannot see orin distinguishing their own boundaries. An example that illustrateshow this is revealed is a school aged child who stands in front of aparent with eyes covered saying, "you can't see me". This "realspace" conceptual incapacity fuels its emotional counterpart and achild seen to commit a naughty deed may deny responsibilityexpressing the same emotional lack of objectivity (sometimes referredto as "crazy lying"). Underdeveloped object constancy is anotherreason why children may find separations from parents difficult.Responsive caregiving and playing baby games that involve breakingand regaining contact (eg peek-a-boo) and reliability in returningafter separations can assist children in developing this vitaldevelopmental milestone.In addition, since primary caregivers act as regulators of infantphysiology and emotion, children who have lacked this externalregulator do not develop normal self-regulation and have difficultydealing with stress. Thus, post-institutionalised children may appearloud or hyperactive, be disorganised in their behaviour and havedifficulty managing and recognising emotions. Parents sometimesdescribe how their child oscillates from being in control to beingout of balance. In situations where the child is out of balance theyfind that bringing the child physically closer to them, limitingchoice (essentially acting as an external regulator) and reducingstress is of assistance.Another impact of non-responsive care in institutions is that post-adoption some children expect that their parents will be similarlyunresponsive and so do not cry when they are hurt or in need. Forinstance, children have been known to be sick during the night butwill not call out to awaken their parents but will lie in their vomitand waste until morning. A baby who does not cry when upset, hurt orin need because they do not think their parent will respond is nota "good" baby but a badly hurt child who is internally distressed butunable to express it. Such children need to be taught that parentscare for their children and want them to ask for help. Parents canassist their child by watching them carefully for any signs ofdiscomfort, intervening to provide what is needed as early as theycan. Children may also appear very happy after only a few days post-placement, laughing, joking and being engaging. However, thisresponse has a similar root as "over friendliness" in childrenbelieving that they need to be attractive to adults in order tosurvive and families and professionals should not be fooled that thechild has "settled in."Self-soothing is common in post-institutionalised children, usingsuch methods as finger sucking, rocking, head banging ormasturbation. It is unwise for parents to seek to forcibly removeself-comforting behaviours from their children. However, self-soothing is a sign that a child is in need of comfort and suchbehaviours should be gently discouraged with the parent attempting tobe a source of comfort to the child. It is important that the childnot be made to feel that they are doing something shameful in self-soothing.Some post-institutionalised children self-mutilate by scratching orbiting/hitting themselves or pulling off fingernails. In some casesthey are hurting themselves because they have the poor physicalboundaries and abnormal physical responses described earlier andcausing pain is a way of feeling something. In other cases, neglecthas left children feeling unlovable and deeply shameful and theirself-harm is in response (this sense of shame is also seen in out ofproportion responses to correction, lack of confidence, performanceanxiety or perfectionism). In still further cases, self-mutilationoccurs in response to stress and as a distraction from emotionalpain. In order for self-mutilation to be extinguished, the root causeof the behaviour needs to be addressed. Sensory integration therapy,reducing stress and assisting the child to develop a secureattachment are helpful in reducing self-mutilation.Post-institutionalised children are often bossy and controlling inrelationships having been used to needing to look after themselves.Post adoption they seek to control their world because being incontrol equals safety. This is an artefact of anxiety and one thatneeds to be resolved so that the child can learn to trust theirparents to care for them. Parents may need to constantly remindchildren that it is their job to look after them and that they do notneed to look after themselves. Providing preparation forchanges/transitions can also assist the child to feel safer. Allowingthe child to control everything will be counterproductive in the longterm.It is tempting to think that a child from deprived conditions shouldbe given as much stimulation as possible in order to help them tocatch up. However, this is not a good idea as children are under anincredible amount of stress post-placement as they learn to survivein a new world. This stress has been measured in high cortisol levelsand is evident in some of their behaviours. For instance, it iscommon for children to be hypervigilant meaning that they never relaxbut watch everything very carefully, seeking patterns andunderstanding of what is required of them. This often results inchildren picking up new things very quickly. However, minimisation ofstress should be something that parents aim for and since post-institutionalised children have been used to a very small,predictable world it is advisable for parents to also restrict theflow of new things so there is not too much for the child to have toprocess.The stress that children are under and the limited world in whichthey have lived, leads to other problems. Many children havedifficulty with any transition (e.g. from wake to sleep, from home toout etc) and may take a long time to be comfortable in a newenvironment or with new people. Routine is often very important tochildren, as predictability helps them to feel safer. When meeting anew person, it may take months of interaction before the realpersonality of the child is revealed (many children are very good atmasking their real selves/putting on a brave face). In addition, manyexperiences normal to children in families are foreign to them andextreme reactions to situations such as seeing a dog or walking ongrass are to be expected. Older children may not know how to playwith toys and need to be taught how to play.Many children exhibit great grief at the loss of previous caregivers.Exhibition of grief is a sign that the child had been attached totheir caregiver and this is a good thing as the child can transferthis attachment to their new parents. A child who does not grieve aprevious caregiver may not have been attached to anyone and may havedifficulty building attachment without prior experience of anattachment figure. Thus, allowing the child to grieve is importantand if possible, it is helpful to maintain contact with previouscaregivers.
What professionals can do:
Support families as they deal with these "hidden" symptoms andvalidate their concerns (especially important because family andfriends may discount the reality of these issues).Encourage parents in providing sensitive caregiving and a structured,limited environment.Understand that it can take a long time for a child to be comfortablein a new situation or with new people, including professionals, andSupport families as they deal with the distressing manifestations oftheir child's hurt.
Issues of diagnosis
Issues associated with trauma, abuse or neglect can make diagnosisand treatment of other problems difficult. Thus, a holistic,multidisciplinary approach is required. Although the effects ofinstitutionalisation on children can be devastating and long lasting,not all of the problems that a child presents with may be a result ofinstitutionalisation.It is also easy to forget where post-institutionalised children havecome from when they present well groomed and looked after with theircaring adoptive family. Thus, it is easy to make assumptions aboutwhat to look for based on the child's current environment and nottheir previous one and miss opportunities for early diagnosis andtreatment.
What professionals can do:
Take the child's history into account when diagnosing and devisingtreatment plans.Not assume that all the problems that the child presents with are aresult of institutionalisation.Consideration for the parentsWhen a family adopts a child from an institution they are taking astep into the unknown. Often little is known about the child they areadopting and there is no way for them to predict how the child willadjust to being in their family and what problems will arise. Theinitial adjustment of a child post-adoption can last for a very longtime, at least a year, sometimes longer. The best-prepared family mayfind themselves surprised by what they encounter, thus, the parentsof a post-institutionalised child also have special needs. A parentor a 4 year old who has been with them since birth is not in the sameposition as a parent of a 4 year old who has only been in the family6 months. Society considers that the birth of a child into a family,though a joyful event, is also difficult and support is oftenforthcoming at this time, however, adoption of a child, particularlyan older child is often not similarly supported. Lack of support andunderstanding from those around them can add to the isolation thatnew parents feel. Parents can find it especially difficult to explainto others the special needs of their children, for example if theirchild has age appropriate cognitive development but is emotionallydelayed. In many cases, the initial period of caring for their childwill be physically exhausting but also emotionally exhausting as theyinvest their energies in seeking to help their child. Further, thedevelopment of relationship between parent and child is a two wayprocess in which both the child and parent must participate.Depending upon their history this will be easier for some parentsthan others. Parenting can bring to the surface previouslyunrecognised personal difficulties that should be dealt with, as itis through self-awareness that problems in this area can be overcome.Although this article presents a quite extensive list of potentialissues that families might face, it is far from exhaustive andfamilies may have other concerns not mentioned here.
What professionals can do:
"Prescribe" rest and avoidance of outside activities if parents areoverdoing it and seeking to get back to normal too quickly.Support parents by providing a listening ear and not dismissingconcerns expressed about their children.Recognise that you may not be able to materially change the situationfor the family but your support, caring and encouragement can make abig difference to the parents' ability to cope.Understand that some parents may not have a basis for comparison ofnormal child development and will need assistance in identifyingwhere their child is in need of help.If appropriate, explore with parents how their history and how theywere parented may impact difficulties they have in providingsensitive caregiving to their child.Be aware that families may be dealing with a multitude of issues andif they do not follow a course of treatment immediately this does notmean that they are not serious about helping their child but thatthey may have more urgent priorities.Ask parents "what can I do to help?"Provide parents with positive reinforcement for the hard work theyare doing with their children.Retain the lines of communication open with parents, understandingthat you are all seeking to care for the child, but in different waysand each must be able to hear and respect the others viewpoint.Adopted and foster children who have not been institutionalisedA significant proportion of children adopted via intercountryadoption have not experienced institutionalisation but resided infoster care prior to adoption. This is generally a much bettersituation for children and means that many of the issues describedhere are less likely to occur. However, even children who have beenin excellent foster care since shortly after birth have stillexperienced multiple loss of caregivers and a dramatic change inenvironment at adoption. Thus, they may still grieve post-adoptionand for example have sleep difficulties that have a root in feelingunsafe. Generally the more moves a child has experienced the greaterthe impact and, as with every new placement, the cycle of attachmentneeds to be reinstated. The approaches for building attachment withpost-institutionalised children also apply here. Foster children withhistories of abuse, neglect and/or multiple placements will presentwith many of the same issues as post-institutionalised adoptedchildren and similar care strategies may be helpful.
This article presents a summary of the issues with which post-institutionalised adopted children may present and ways in whichhealth and other child care professionals may assist them and theirfamilies. It is very important that it be kept in mind that not allchildren present with these issues and that for many children theproblems they have a relatively short lived. Post-institutionalisedchildren are not abnormal and to pathologise them because of theirhistory does them and their families a great disservice. Rather, theresponses described here are normal reactions to an abnormalenvironment. Children are not meant to live in institutional care butin families and for many children growth in a family after adoptionprovides them the opportunity to heal from past hurts. Although theimmediate post-placement period can be challenging for familiesseeing their child grow and heal is something that parents and thosewho have assisted them find particularly rewarding.
This version dated 2/04
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* Recommended reading
Karleen Gribble is the mother of two children, one born to her andthe other adopted as an older child from institutional care in China.Her adopted child came home with a physical disability anddevelopmental delays that have necessitated consultation with andtreatment by a wide range of health and other child careprofessionals. This article has arisen out of her experience as shefound that providing information to professionals about the affectsof institutionalisation helped facilitate communication, optimisedindividualization of care and provided her with the assistance sheneeded to help her daughter. Karleen is also a scientist (BRurSc,PhD) and is Adjunct Research Fellow in the School of Nursing, Familyand Community Health at the University of Western Sydney, NSW,Australia where her research focuses on adoptive breastfeeding andthe non-nutritional impact of breastfeeding.

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