Kinship Care and Foster Care: A Comparison of Out-of-Home Placement From the Perspective of Child Abuse Experts in North Carolina.

Kinship Care

Internationally, there is an increasing trend toward placing children in kinship vs. foster care. Prior research suggests that children in kinship care fare better compared to children in foster care; however, the reasons for this remain unclear. We conducted a systematic review and meta-analysis to examine the hypothesis that kinship care better preserves children's connectedness to caregiver, birth family, culture, and community; which, in turn, is associated with more optimal child outcomes. Thirty-one studies were reviewed that compared children aged 0-18years in kinship care vs. foster care on levels of connectedness, three of which had outcomes that permitted meta-analysis. Findings indicated that children in kinship vs. foster care were more likely to feel connected to family in general; however, there was not a clear advantage for kinship vs. foster care for caregiver, birth parent, cultural, and community connectedness. While levels of connectedness were generally associated with more adaptive child outcomes for children in both kinship and foster care, no reviewed studies examined the hypothesis that children's connectedness may mediate the relationship between placement type and child well-being and placement outcomes. Results are discussed with respect to limitations and policy implications of the current evidence-base and the need for more rigorous research to help identify how to improve child well-being in home-based care.

Assessing Quality of Care in Kinship and Foster Family Care

1. Sandra H. Jee, MD, MPH 1. Department of Pediatrics University of Rochester Rochester, NY 1. Mark D. Simms, MD, MPH 1. Department of Pediatrics Medical College of Wisconsin Milwaukee, Wisc Improving the Odds for the Healthy Development of Young Children in Foster Care . Dicker S, Gordon E, Knitzer J. National Center for Children in Poverty: Columbia University Mailman School of Public Health. Promoting the Emotional Well-Being of Children and Families (Policy Paper No. 2). January 2002;1–28 Children and Family Services Reviews, Part V: Most States Fail to Meet the Mental Health Needs for Foster Children . Huber J, Grimm B. Youth Law News . 2004;Oct-Dec:1–36 CWLA Standards for Health Care Services for Children in Out-of-Home Care . Washington, DC: Child Welfare League of America; 1988. Educational Experiences of Children in Out-of-Home Care . Smithgall C, Gladden RM, Howard E, Goerge R, Courtney M. Chicago, Ill: Chapin Hall Center for Children at the University of Chicago; 2004:1–77 Fostering Health: Health Care for Children and Adolescents in Foster Care . 2nd ed. Task Force on Health Care for Children in Foster Care, American Academy of Pediatrics, District II, New York State. Elk Grove Village, Ill: American Academy of Pediatrics: 2005 Healthy Foster Care America . www.aap.org/advocacy/HFCA/ On any given day, more than 500,000 children are living in state-supported foster home care. In the course of a year, more than 800,000 children experience placement in a foster home. Many of these children return home quickly, but for some, placement may extend for years and may involve care in multiple foster homes. Most of the children have experienced serious family dysfunction prior to placement, including exposure to domestic violence and to their parents’ mental health disorders, addiction, or criminal activity. Serious neglect and abuse are the most frequently stated reasons for removing children from their parents’ care. Children entering foster homes have extremely high rates of physical and mental health problems, developmental delays, and educational underachievement. As a group, children in foster care …

To report baseline mental health measures from the Children in Care study, a prospective epidemiological study of children in court-ordered foster and kinship care in New South Wales, Australia. Mental health, socialization and self-esteem were assessed in 347 children in a statewide mail survey, using two carer-report checklists, the Child Behavior Checklist (CBCL) and the Assessment Checklist for Children (ACC). Children in the study had exceptionally poor mental health and socialization, both in absolute terms, and relative to normative and in-care samples. Levels and rates of disturbance for children in foster care exceeded all prior estimates. Rates of disturbance for children in kinship care were high, but within the range of prior estimates. Boys presented with higher scope and severity of mental health problems than girls on the CBCL, while gender-specific patterns of disturbance were shown on the ACC. A moderate age effect was accounted for by children's age at entry into care. Children in care are at high risk of mental health problems. Psychological support for the children and their carers is an essential secondary prevention strategy. Implications for service delivery are discussed.

To examine the influence of kinship care on behavioral problems after 18 and 36 months in out-of-home care. Growth in placement of children with kin has occurred despite conflicting evidence regarding its benefits compared with foster care. Prospective cohort study. National Survey of Child and Adolescent Well-Being, October 1999 to March 2004. One thousand three hundred nine children entering out-of-home care following a maltreatment report. Kinship vs general foster care. Predicted probabilities of behavioral problems derived from Child Behavior Checklist scores. Fifty percent of children started in kinship care and 17% of children who started in foster care later moved to kinship care. Children in kinship care were at lower risk at baseline and less likely to have unstable placements than children in foster care. Controlling for a child's baseline risk, placement stability, and attempted reunification to birth family, the estimate of behavioral problems at 36 months was 32% (95% confidence interval, 25%-38%) if children in the cohort were assigned to early kinship care and 46% (95% confidence interval, 41%-52%) if children were assigned to foster care only (P = .003). Children who moved to kinship care after a significant time in foster care were more likely to have behavioral problems than children in kinship care from the outset. Children placed into kinship care had fewer behavioral problems 3 years after placement than children who were placed into foster care. This finding supports efforts to maximize placement of children with willing and available kin when they enter out-of-home care.

Health Status and Type of Out-of-Home Placement: Informal Kinship Care in an Investigated Sample

Child abuse and neglect are common problems across the world that result in negative consequences for children, families and communities. Children who have been abused or neglected are often removed from the home and placed in residential care or with other families, including foster families. Foster care was traditionally provided by people that social workers recruited from the community specifically to provide care for children whose parents could not look after them. Typically they were not related to the children placed with them, and did not know them before the placement was arranged. In recent years many societies have introduced policies that favour placing children who cannot live at home with other members of their family or with friends of the family. This is known as ‘kinship care’ or ‘families and friends care’. We do not know what type of out‐of home care (placement) is best for children.This systematic review was designed to help find out if research studies could tell us which kind of placement is best. Sixty two studies met the methodological standards we considered acceptable. Wherever possible we combined the data from studies looking at the same outcome for children, in order to be more confident about what the research was telling us. Current best evidence suggests that children in kinship care may do better than children in traditional foster care in terms of their behavioral development, mental health functioning, and placement stability. Children in traditional foster care placements may do better with regard to achieving some permanency outcomes and accessing services they may need. Implications for practice and future research are discussed.Executive summary/AbstractBACKGROUNDEvery year a large number of children around the world are removed from their homes because they are maltreated. Child welfare agencies are responsible for placing these children in out‐of‐home settings that will facilitate their safety, permanency, and well‐being. However, children in out‐of‐home placements typically display more educational, behavioral, and psychological problems than do their peers, although it is unclear whether this results from the placement itself, the maltreatment that precipitated it, or inadequacies in the child welfare system.OBJECTIVESTo evaluate the effect of kinship care placement on the safety, permanency, and well‐being of children removed from the home for maltreatment.SEARCH STRATEGYThe following databases were searched to February 2007: CENTRAL, MEDLINE, C2‐Spectr, Sociological Abstracts, Social Work Abstracts, SSCI, Family and Society Studies Worldwide, ERIC, PsycINFO, ISI Proceedings, CINAHL, ASSIA, and Dissertation Abstracts International. Relevant social work journals and reference lists of published literature reviews were handsearched, and authors contacted.SELECTION CRITERIARandomized experimental and quasi‐experimental studies, in which children removed from the home for maltreatment and subsequently placed in kinship foster care, were compared with children placed in non‐kinship foster care on child welfare outcomes in the domains of well‐being, permanency, or safety.DATA COLLECTION AND ANALYSISReviewers independently read the titles and abstracts identified in the search and selected appropriate studies. Reviewers assessed the eligibility of each study for the evidence base and then evaluated the methodological quality of the included studies. Lastly, outcome data were extracted and entered into REVMAN for meta‐analysis with the results presented in written and graphical forms.RESULTSSixty two quasi‐experimental studies were included in this review. Data suggest that children in kinship foster care experience better behavioral development, mental health functioning, and placement stability than do children in non‐kinship foster care. Although there was no difference on reunification rates, children in non‐kinship foster care were more likely to be adopted while children in kinship foster care were more likely to be in guardianship. Lastly, children in non‐kinship foster care were more likely to utilize mental health services.AUTHORS’ CONCLUSIONSThis review supports the practice of treating kinship care as a viable out‐of‐home placement option for children removed from the home for maltreatment. However, this conclusion is tempered by the pronounced methodological and design weaknesses of the included studies.

The documented growth of kinship care has boldly thrust this topic into the forefront of child welfare practice. This study compares the permanency, safety, and stability outcomes for a matched group of children placed in kinship care and foster care. After controlling for demographic and placement characteristics, children in kinship care had significantly fewer placements than did children in foster care, and they were less likely to still be in care, have a new allegation of institutional abuse or neglect, be involved with the juvenile justice system, and achieve reunification. These findings call for a greater commitment by child welfare professionals, policy makers, and researchers to make kinship care a viable out-of-home placement option for children and families.

This study examined socioemotional problems among children age 0 to 5 years in formal kinship and foster care across a northeastern state. Findings revealed that more than one third of children in both types of care showed socioemotional problems. More children were placed in kinship care when they lived in rural settings, were biracial, or spent time in the neonatal intensive care (NICU) after birth. Unique child and maltreatment characteristics predicted socioemotional problems scores for each placement type. Among children in kinship care, being biracial, spending time in the NICU, and being referred to child welfare for either caregiver substance abuse or neglect were related to socioemotional problems. When children were in foster care, spending time in the NICU, being referred to child welfare for child neglect, or being referred for intimate partner violence were all related to socioemotional problems. The results have implications for child welfare policy and practice, especially in light of increased efforts to place children with kin.

Studying the subjective well-being (SWB) of children in out-of-home care is becoming important. However, there is a lack of results on the subjective well-being of children in kinship care. The aim of this study was to analyse and compare the subjective well-being of children at the age of 12 years old in kinship and residential care and in the general population, taking into account gender differences. We administered the questionnaire used in the International Survey of Children's Well-Being (ISCWeB) including two psychometric scales (OLS and PWI-SC). The results showed differences in overall SWB scores (using PWI-SC as a SWB indicator) and in its components among the three groups: children in kinship care scores were more similar to those from the general population. The PWI-SC displayed good fit statistics with the pooled sample and good comparability with the Multi-group SEM with constrained loadings and intercepts, suggesting it was acceptable for comparing correlation, regressions and mean scores of the items. Gender appeared to have statistically significant effects on the OLS scale, showing lower scores for girls in residential care. Supporting kinship appropriately and taking into account gender issues are the challenges facing public policies for children in care.

After completing this article, readers should be able to:Although interest in intercountry adoption continues to be high, the numbers of international adoptions have changed dramatically since the peak in 2004 when 45,483 international adoptees (IAs) were placed in families worldwide. By 2017, the number dropped 79% to 9,387. In the United States, the receiving country for 40% to 53% of all IAs during this period, placements reflected this same trend downward from 22,989 to 4,714. The reasons behind this decline are complex and include US and international factors. (1)From 1972 through 1990, more than 50% of IAs were from South Korea. (1) These children were generally relinquished by healthy women stigmatized by single parenthood, were raised in foster families, and were provided a high level of medical care. Most Korean children adopted to the United States were infants. In contrast, adoptees from Eastern Europe, and other countries that used institutional care, arrived in large numbers in the early 1990s. Many of these children were born into low socioeconomic circumstances, were exposed to intrauterine alcohol, were cared for in orphanages, and received inadequate medical care. Considering the profound adversity experienced in institutional care settings in terms of abuse, neglect, and exposure to violence, the findings that these experiences were associated with significant medical problems as well as acute and persistent developmental, emotional, and behavioral disabilities in postinstitutionalized adoptees were not surprising. More recently, children have arrived from African countries and Haiti having lost their parents to infection, including epidemics such as Ebola; armed conflict; and natural disaster. Adopted children arriving in the United States from all over the world stimulated great interest among the membership of the American Academy of Pediatrics, catalyzing the formation of the Section on Foster Care and Adoption in 2000; the establishment of the Council on Foster Care, Adoption, and Kinship Care in 2011; and the publication of Adoption Medicine in 2014.The advent of health-care providers focused on the nuances of international adoption medicine led to research on best practice. Although international adoptions have decreased since 2004, health-care providers still care for thousands of new adoptees every year, as well as the multitude of IA children and young adults adopted in previous years. In addition, adoptions from the US foster care system have increased during the past 20 years. Except for regionally specific infectious diseases, a strong case can be made that most adoptees, whether international or domestic, share the same array of physical, developmental, and mental health challenges. Therefore, it is more important than ever that pediatricians are able to counsel all prospective adoptive families, comprehensively evaluate the physical and mental health of children in foster care and after adoption placement, and support child well-being and successful family formation. This review article summarizes the most recent recommendations for best practice in the comprehensive health-care of the internationally adopted child and his or her family.Examination of the situation in China, the principal country participating in intercountry adoption to the United States since 2004, highlights one reason why international adoptions are decreasing but also exemplifies the increase in significant medical issues. After the gradual relaxation and then termination of the 1-child policy, China has seen a dramatic increase in domestic adoptions of young, healthy children. Of those who remain institutionalized, 98% have disabilities. (2) Now, children adopted from China are older. Because these children experience longer periods of institutionalization, adoptees from China are at greater risk for secondary cognitive, emotional, and behavioral sequalae related to prolonged social deprivation. Similar changes have been observed in most countries participating in intercountry adoption during the past decade. Therefore, due to the high percentage of children in the adoption system with histories of risk factors affecting their health, it is more important than ever for parents and professionals to participate together in thorough preadoption preparation.Thirty years of international adoption medicine experience have shown us that there are no “low-risk” referrals per se given the inherent stress and loss that adoptees experience. Thus, risk to normal growth and development are never completely absent. Review of the medical and social information for a child who not only cannot be physically examined but also is from another country and health-care system is challenging. Key information to consider when doing the review is summarized in Table 1. With rare exception, the initial review of the adoption referral requires follow-up questions of the adoption agency. For example, updated anthropometric measurements, information on current developmental status, and additional laboratory screens are often indicated. Parents are asked to request these through their adoption agency.The goal of the preadoption review is to guide the adopting family in the life-changing decision being made based on expert evaluation of the available data. The review summary ideally gives the family a clear picture of resources (medical, financial, emotional, time) needed to parent a child with particular needs, what life will look like as a family, and the child’s long-term prognosis. However, without the benefits of doing a physical examination oneself and diagnostic screens in one’s own health-care setting, diagnostic and prognostic capabilities are limited. Counseling parents about the range of outcomes and the limits of prognostication is needed to ensure that they are realistic and well prepared to welcome their IA into the family. Encouraging adoptive parents to examine their long-term social, medical, and educational expectations for their adopted child in the context of the range of outcomes is important as well. The better equipped a family is from the beginning, the higher the odds for a successful placement. Because interpretation of medical information can vary greatly depending on the referring country, the age of the child, and the nuances of interpretation by region, consultation or referral to a clinician who specializes in adoption medicine can be a valuable resource for families.A comprehensive medical assessment of the newly arrived IA is recommended within 2 to 3 weeks of arrival at his or her new home. The initial visit focuses on addressing parents’ immediate concerns; establishing a baseline for growth, development, and mental health; identifying and addressing immediate and long-term medical needs; screening for infectious diseases and nutritional deficiencies; determining the immunization status; and providing support for a healthy transition and strong attachmentIdeally, at least 1 hour of face-to-face time is needed to accomplish these goals. Before the visit, obtaining and reviewing the medical records from the country of birth or from the child’s preadoption review assists the health-care provider in planning the most efficient and valuable visit for the family. A previsit questionnaire is invaluable in understanding the parents’ concerns and planning how to address each one before the clinic visit.An interpreter is recommended for children 18 months and older. An interpreter gives the pediatrician the ability to talk with the young child in his or her native language, incorporating playfulness and reassurance. For the older child, an interpreter can assist the child in telling their own story, asking questions, and understanding the numerous activities of the medical visit. Parents may ask questions of the child through the interpreter to further understand their child’s needs, likes, dislikes, and fears. The interpreter can also assist the pediatrician in understanding the medical and social history, review of systems, and special needs directly from the older child and to assess language skills. An interpreter may at times serve as a translator of the medical record, most commonly the immunization record.Depending on the country of birth, the medical and social history may be either nonexistent or extremely detailed. Accuracy is variable as well. Parents are asked to provide all documents detailing preadoption medical and social information from the country of birth, including the immunization record. Much of this information may have already been reviewed during the period from initial referral to arrival home. However, more information may be discovered by the adoptive parents during their visit to their child’s birth country, in court or other official documents. In addition, the older child typically can add to the medical history with the assistance of an interpreter. Key historical information includes country of birth; birth history, including birthweight and intrauterine drug exposure; maternal history; time with birth family; reason for loss of birth family; time in foster care and/or orphanage; number of transitions between caregivers; developmental screening; and medical history, including laboratory screens for human immunodeficiency virus, syphilis, and hepatitis B and an immunization record. In addition, the child may have received a class B waiver from US State Department physicians before leaving the country of birth, which allows the child to enter the United States but requires follow-up. For example, a child with a positive screen for TB and normal chest radiographic (CXR) findings will receive a class B waiver.For some IAs this may be their first complete physical examination. A full examination including genitalia may be traumatizing, and, if so, the better option is to complete the examination over subsequent appointments. Many IAs have had frightening experiences in medical facilities without the comfort of an adult to buffer the trauma, for example, of a painful procedure. Examining the child while he or she sits on the lap of the parent or for the older child, encouraging his or her parent to stand close by the examination table or hold the child’s hand is not only comforting but may be absolutely necessary to do the examination. Of note, the physical examination of an IA is unique in that a head circumference is measured for all children regardless of age; special attention is given to the evaluation of undernutrition, including stunting; and close attention to facial features suggesting fetal alcohol effects and heightened vigilance for previously undiagnosed medical problems are imperative. In addition, the epidemiology of diseases in the country of birth is important to consider on physical examination. For example, increased attention for splenomegaly in a child from a region endemic for malaria or lymphadenopathy on examination of a child from a region with a high prevalence of tuberculosis (TB). Pediatric audiology and ophthalmology referral is recommended for all IAs due to the high prevalence of hearing and vision problems in this population. (3)A battery of laboratory tests is recommended for the newly arrived child. These are summarized in Table 2. Baseline laboratory screens indicated for all IAs are outlined and updated periodically in the American Academy of Pediatrics Red Book and on the Centers for Disease Control and Prevention (CDC) website. Laboratory screens performed in the country of birth should be repeated in the United States. Specific tests are indicated depending on the country of birth, infectious diseases endemic in that region of the world (see the CDC Yellow Book online), and the prevalence of genetic differences there. Intentional efforts to ensure minimal trauma are important. For example, applying a topical anesthetic to minimize pain with blood draws and, if available, having a child life specialist accompany the child and parents to the laboratory alleviates anxiety and pain.TB infection and intestinal parasites are the most common infections diagnosed in IAs. All IAs who are at least 2 years old are screened for TB before traveling to the United States. Further evaluation is performed in the country of birth if the screen is positive. However, repeated screening on arrival in the United States should be performed. The prevalence of latent TB infection among IAs is as high as 27%. (4) BCG vaccine does not prevent infection, and neither is it a contradiction to doing a tuberculin skin test. The CDC recommends that children younger than 2 years should be screened for TB with a tuberculin skin test. Children 2 years and older, may be screened with an interferon-γ release assay, either T-Spot.TB® (Oxford Immunotec Ltd, Abingdon, United Kingdom) or QuantiFERON® (Qiagen Inc, Germantown, MD). (5) If either the tuberculin skin test or the interferon-g release assay is positive, a CXR must be performed. If the CXR is negative and the physical examination reveals no sign of TB disease, the diagnosis is latent TB infection. Treatment is indicated with daily isoniazid for 9 months for children younger than 2 years. Children 2 years and older may be treated with either isoniazid daily for 9 months or once-weekly, directly observed isoniazid and rifapentine for 12 weeks. (6) Monthly appointments with the primary care team are recommended to check for compliance, dosage adjustment for weight gain, and activation to disease. If CXR is positive or signs of TB on examination are found, referral to or consultation with a pediatric infectious disease specialist is indicated. If the initial screen is negative, a repeated screen is recommended 3 to 6 months after arrival home. (7)Giardia intestinalis is the most common intestinal parasite, followed by Blastocystis hominis. Infected children may have no symptoms predictive of infection. Examination of 3 stool samples for ova and parasites and 1 stool sample for Giardia antigen is recommended. Early-morning collection of stool with 24 hours between specimens is ideal for accurate assessment of the parasite load. (8) Screening serologic testing for schistosome species, Strongyloides stercolis, and filarial species are indicated for all children arriving from countries endemic for these invasive parasites. In addition, all children with eosinophilia (absolute eosinophil count, >450 cells/mm3) should be tested for invasive tissue parasites based on the epidemiology of invasive tissue parasites in their country of birth, as noted previously herein. Toxocara canis, which can cause extremely high eosinophilia, should be considered. Ascaris lumbricoides, identified on stool screen for ova and parasites, may cause eosinophilia as it travels through the body. Both T canis and A lumbricoides are widespread and invasive parasites.Children from malaria-endemic regions may be infected without symptoms. For asymptomatic children, malaria polymerase chain reaction is recommended, if available. Polymerase chain reaction can detect all 5 species of Plasmodium: Plasmodium falciparum, Plasmodium ovale, Plasmodium vivax, Plasmodium malariae, and Plasmodium knowlesi. (4) Thick and thin blood smears every 12 hours to look for malaria parasites are indicated for all febrile, newly arrived IAs from an area endemic for malaria. For severe cases of malaria, the CDC Malaria Hotline (770-488-7788) is available for consultation.Toddlers arriving from regions with a high prevalence of hepatitis A may be acutely infected, completely asymptomatic, yet shedding hepatitis A virus. The CDC recommends that all household members and other close contacts (eg, regular babysitters) of children arriving from countries highly prevalent for hepatitis A should be immunized before the child arrives home. (9)Internationally adopted children younger than 10 years are not required to receive immunizations before arrival in the United States; however, adoptive parents must sign an affidavit that their adopted child will be immunized according to requirements within 30 days of arrival in the United States. More than 90% of IAs arriving in the United States have not been immunized per Advisory Committee on Immunization Practices guidelines. Many vaccines recommended in the United States, for example, measles, mumps, and rubella, varicella, and 13-valent pneumococcal conjugate vaccine, are not available in resource-limited countries. Measles vaccine is given as a single antigen. Screening antibody levels are recommended for infants and children 6 months or older with documentation of immunizations with 2 caveats. First, repeated immunization with inactivated polio vaccine rather than testing antibodies is recommended per the CDC catch-up schedule unless there is documentation that the child received the US- or World Health Organization–approved inactivated polio vaccine series. (10) Second, screens for pertussis antibody level do not correlate with immunity to whooping cough. Seroprotective diphtheria and tetanus antibody levels may correlate with Bordetella pertussis immunity if the child received vaccinations containing the pertussis antigen.Common parental concerns at their first medical visit with their child have to do with eating, sleeping, growth, developmental milestones, medical issues identified in the country of birth, and school placement for a school-age child. Other questions can surface regarding the actual age of the child, effects of possible intrauterine exposure drugs and alcohol, known traumatic events, or a history of physical or sexual abuse. Parents are typically seeking advice to make their child’s transition to a new culture minimally traumatic and to lay a solid foundation for attachment. Primary care professionals can help by first maximizing physical health. In addition, referral to pediatric rehabilitation experts may be indicated when there are signs of developmental delays beyond those expected for orphanage care. Referral to mental health services should be considered when issues such as indiscriminate friendliness, anxiety, or distress are identified, especially when symptoms continue beyond the first few months after arrival. Close follow-up by the primary care physician is indicated to monitor the child’s transition to his or her new culture and family, attachment, and growth and development as well as to follow up on any acute or chronic medical concerns. In addition, increased vigilance for future concerns, such as precocious and/or accelerated puberty (11)(12) or academic challenges, is prudent.Numerous risk factors may impact any area of an IA’s development. For example, multiple transitions impact a child’s ability to learn routines or identify an adult caregiver as an “anchor” for developmental exploration. Acquisition of gross and fine motor skills can be delayed due to lack of opportunity and resources to address neurologic and orthopedic needs. care development, as does of such as and problems such as hearing or vision loss can other systems, as does exposure to alcohol, or infection. care, if prolonged is associated with developmental and is a common risk for a child in institutional care, in symptoms with or to such as and For example, if an is not and/or provided with the system may not learn how to or how to the first 6 months after arriving most IAs make with and a The parent may of skills by providing for developmental with and to their child’s needs and by encouraging developmental skills. and in the and daily activities can support all of development. For most initial of developmental delays in the first 3 months rather than immediate referral to physical, or is recommended. to parents is best by with another adult such as a If delays are however, may be evaluation is recommended if delays beyond 3 to 6 months after all of development is beyond the of this article, but delays in may be in that the symptoms may be more and assessment more than assessment of other of development with parent developmental experience of every to experiences is a of numerous including and The not in the and of and the American Academy of Pediatrics has recommended in this however, have it to address with given the widespread and trauma that this has With the of may be as one of the of a comprehensive The typically of daily and school and as well as regular appointments for which may be can impact sleeping, eating, to a new and and of to and/or include the may have a of signs and symptoms from multiple with significant from child to child and should be examined with a team to ensure that medical and needs are being with skills which may as or or information can be for children are not well. If a child is having a time the can be to for screening for common developmental concerns and planning a are summarized in Table In addition, in a child’s skills in the are available significant developmental differences they should be as per for children with developmental including further evaluation by a pediatric the multiple risk factors that have been mental health is a to adoptive families In addition, early and social exposure to a natural or armed and lack of educational and development. include long-term institutional care often with a high in an multiple sexual and/or physical abuse, neglect, and repeated loss of The adoption is only are each of these risk factors of a child’s in they a unique of risk for this population. of trauma mental health and at of a child’s a the of long-term mental health and issues in adopted children must a and have that the examination of an IA as a team is the most to help the IA the medical in such as or or can clear the for mental health providers to do their best with the child and family. this to that and long-term support to adoptive a comprehensive requires that the initial evaluation within 2 to 3 weeks of arrival must be performed with the that will address the full of risk factors. However, comprehensive mental health services are often not available. The pediatrician an in address this complex of issues a The first is a mental health screen during the initial medical examination to whether a referral is The of this initial screen is of how a child is and with the parent during times of distress and how the parent these for the first in screening are outlined in Table is important for parents to understand that the factors they provide in a and are to the child’s developmental These adoptive parents to an important in the high levels of stress experienced by a child before and during the of is in the negative outcomes associated with stress levels early in only is a with adoptive parents important in stress in the this of also a for the child to their own stress skills. These in are to long-term outcomes as the children of their adoptive parents and to on their this however, from a lack of early in adopted children may not have had the to learn how to their needs. a these children may have a with their parents and, lack the ability to a for comfort when they are in In a of more than adopted children to that This is the that only 1 child in the sample the full for a adoptive parents often to what may like from their child. these in early is to the of necessary to the developmental of adopted research has also to other factors that may the and of a including an adoptive such as their own history of trauma, mental health status, or current of the Thus, in to identifying the of the adopted child, any must include in initial on parental risk factors that may the to address early risk factors from either the child’s or the of the can in negative developmental Referral to a mental health specialist after the child arrives should be considered for the child with multiple risk factors affecting his or her mental health and/or a at risk for a child is to a pediatric mental health the of the a full evaluation with developmental testing cognitive, and motor parental and assessment of the of The that mental health services for adopted children must provide support that includes and for the child and for the follow-up 12 months after arrival with mental health and developmental is recommended for all IAs regardless of their initial of and research with internationally adopted children have that can to a of children. physical and mental health developmental and are indicated for every as indicated based on these ideally address immediate and long-term needs in a A diagnosis of health should be the child has had time to learn a new language, have an and school and as indicated. support for the child and family through each developmental is and as Adoption for Children and American Academy of The of The and the Council on Adoption and Kinship Care CDC Yellow Book Health for Centers for Disease Control and Adoption Medicine of Council for Health of the Adopted from the Council on Foster Care, Adoption, and Kinship that accompany this article, visit

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