Psychiatrists Often Needed to Ensure Success of International Adoptions

When San Francisco psychologist Juli Fraga, Ph.D., counsels international (also referred to as intercountry) adoptees and their families, she brings with her a personal understanding of the mental health issues that can arise or persist even years after the initial adoption. Fraga was born in Korea, adopted by a white family in Nebraska, and grew up in an environment where there was little diversity.

“I never felt that I fit in,” Fraga told Psychiatric News, adding that it was difficult for her parents to understand what she went through as they had never experienced racism themselves.

“Adoption in general is a form of trauma, and international and transracial adoptions add yet another dynamic to the situation,” said Fraga. She noted that adoptees are often expected to be thankful for their new family while not acknowledging the loss that led them to that point.

“There’s a sense of ‘Look at what you’ve gained,’” said Fraga, which can be interpreted by the adoptee as “be grateful for your loss.”

In “Mental Health in Internationally Adopted Adolescents: A Meta-Analysis,” published in March 2017 in the Journal of the American Academy of Child & Adolescent Psychiatry, lead author Kristin G. Askeland, Ph.D., of the Department of Health Promotion, Norwegian Institute of Public Health, and colleagues reported that as a group internationally adopted youngsters show higher levels of mental health problems than their nonadopted peers. “This difference should be acknowledged, and adequate support services should be made available,” wrote the authors.

Similar results were reported in “Alcohol and Drug Use Among Internationally Adopted Adolescents: Results From a Norwegian Population-Based Study,” published on March 2, 2017, in the American Journal of Orthopsychiatry. Also led by Askeland, this study found that the increased risk of mental health problems among internationally adopted adolescents also led to more alcohol and drug use than among their nonadopted peers.

Mental health problems, such as reactive detachment disorder, disinhibited reactive disorder, posttraumatic stress disorder, developmental delays, and language disability are common among international adoptees, Adiaha Spinks-Franklin, M.D., a developmental-behavioral pediatrician at Texas Children’s Hospital and the Texas Children’s Center for International Adoption, told Psychiatric News.

“The older the child is at adoption, the more risk there is of mental health issues, because there have been so many years of trauma and neglect,” said Spinks-Franklin.

Spinks-Franklin observed that it’s not only adoptees themselves who can experience problems, but also the adoptive parents and other siblings. Issues include sibling jealousy as the adopted child requires more time, energy, and resources; stress and fatigue; and even remorse when the adopted child is not blending into the family as easily as anticipated.

Psychiatrists play a crucial role in working with international adoptees and their families, said Spinks-Franklin. “When seeing a child adopted from another country, consider the strong likelihood of early childhood trauma or neglect, as well as fetal alcohol syndrome or disorder, particularly if the child is from Eastern Europe,” advised Spinks-Franklin. “Also, be aware that the child may be developmentally younger than his chronological age. As the child ages, problems can persist, or new problems—such as depression and anxiety—can present.”

The importance of adoption-competent mental health professionals, including psychiatrists, has received increased attention in recent years. In December 2016, the Donaldson Adoption Institute released a policy perspective titled “A Need to Know: Enhancing Adoption Competency Among Mental Health Professionals.” The report highlighted the difficulty that adoptive families face in finding practitioners who understand and are trained in the areas of permanency and adoption. Identifying practitioners who are adoption-competent is not always clear or easy to determine, the report noted, in part because adoption counseling has not yet been recognized as a professional specialty in health care, with accompanying guidelines for training, practice, and credentialing. Programs such as the National Adoption Competency Mental Health Training Initiative (NTI), however, are being established in the hope of filling that void.

NTI was created in October 2014 through a five-year, $9 million cooperative agreement between the Maryland-based Center for Adoption Support and Education (C.A.S.E.) and the Department of Health and Human Services, Administration for Children and Families, Children’s Bureau. The evidence-informed, standardized web-based training is designed to help child welfare professionals and mental health practitioners better understand and address the mental health and developmental needs of children who are in the process of being adopted or have already been adopted.

Training modules specific to international adoptions include value-based education, such as the importance of racial and cultural identity from both a historical and contemporary perspective and development of skills, such as assisting parents in initiating conversations about race, ethnicity, and culture; supporting the significance and preservation of a child’s connection to his or her ethnic/racial heritage and culture of origin; and assisting a child in integrating his or her racial/ethnic identity with other identities.

Ensuring that an international adoption is a success takes a team of providers, including teachers, pediatricians, psychologists, and psychiatrists as well, said Spinks-Franklin. “We all have to work together.” ■

“Mental Health in Internationally Adopted Adolescents: A Meta-Analysis” can be accessed here. “Alcohol and Drug Use Among Internationally Adopted Adolescents: Results From a Norwegian Population-Based Study” is available here.