QUICK Orphans: Foster Care and Adoption – Global LESSON Perspective ABOUT Description/Etiology Poverty, underdevelopment, natural disasters, epidemics, and war are conditions that produce a staggering number of orphans worldwide. The term orphan has been applied loosely throughout history, often to include children who are homeless, abandoned, or neglected. The United Nations Children’s Fund (UNICEF) defines an orphan as a child who has lost one or both parents. Of the 132 million orphaned children worldwide, only 13 million have lost both parents (UNICEF, 2015). Many of these “true” or “double” orphans have lost both parents to AIDS. It is well established that orphaned children suffer more deficits in education, socialization, and nutrition than do non-orphaned children. Addressing care of children who have been orphaned requires an understanding of interconnected issues concerning local and kinship foster care and adoption; orphanage placements; and international adoption. The largest numbers of orphaned children are in sub-Saharan Africa, Asia, Latin America, and the Caribbean (UNICEF, 2015). In developing countries, especially in Africa, in the traditional system of kinship care, in which children whose biological parents are deceased or unable to care for them are raised by relatives or close family friends. Family members often are too young or too old to adequately care for a child of relatives, however, and many cannot afford an additional child or children. Many children taken in by relatives are treated differently from biological children; they often are subjected to discrimination and experience deprivation and exclusion. Many become ill. Many children in kinship care have inadequate food, clothing, shelter, and education. Some children leave these situations to live on the streets, where they are vulnerable to other forms of abuse. Recruitment to armies and other types of forced labor and recruitment to organized criminality, as well as exposure to sexual and physical abuse, prostitution, sexually transmitted diseases, and substance use, are all common experiences among orphaned children in developing countries. Children for whom kinship care is not an option may be raised in orphanages. Large numbers of orphanages in developing countries lack adequate funding and have inadequate physical facilities and management. Some orphanages are equipped only to meet the basic physical needs of children whereas others provide consistent caregiving that is supportive and can help foster healthy attachment relationships. Some researchers have found that orphanages can be detrimental to the psychosocial and physical development of children, Authors especially children who have been traumatized by war. In contrast, other researchers have Jan Wagstaff, MA, MSW determined that there can be positive outcomes for children living in these institutions. Cinahl Information Systems, Glendale, CA Generalizations about institutional care should be avoided. Some community-based Jessica Therivel, LMSW-IPR Cinahl Information Systems, Glendale, CA orphanages, even those in what are described as low-resource conditions (e.g., lacking clean water, lacking adequate physical facilities, lacking funding), try to mirror a familial Reviewers environment and have the potential to meet children’s developmental needs. It is important Lynn B. Cooper, D. Criminology to note that a quality foster or adopting family environment is always optimal and is Cinahl Information Systems, Glendale, CA described as the best means of addressing childhood traumatization. Laura McLuckey, MSW, LCSW Cinahl Information Systems, Glendale, CA Although Africa in particular has many orphans and faces a crisis in care provision, in general the countries of Africa do not support international adoption; only a small number presently permit it. Community-based solutions, such as kinship foster/adoption February 17, 2017 or familial-type orphanages, are considered preferable, but some scholars are encouraging

Published by Cinahl Information Systems, a division of EBSCO Information Services. Copyright©2017, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206 international adoption in Africa as another option. A majority of the orphaned children adopted from institutions in African countries by families in the United States arrive in the United States with attachment disorders or cognitive, social, or physical deficits from prolonged deprivation. The longer children have spent in poorly resourced orphanages, the more behavioral and other problems adopting parents encounter. The impact of institutionalized care has been measured by the Bucharest Early Intervention Project, which conducted randomized controlled studies of the development of orphaned children in Romania starting in 2000 by comparing subjects of standard intervention (i.e., institutional rearing) to subjects placed in high-quality foster care and to a control group of children reared by their families. Among the findings was the existence of sensitivity periods during which children can “catch up” from delayed development and after which catching up is unlikely. In the children who remained institutionalized the study found lower IQs, deficient attachment skills, delays in language development, higher rates of psychiatric illness by age 4 1/2, delayed brain maturation and smaller brain volume, and shorter telomeres (i.e., areas on chromosomes that provide protection from the stress of cell division) (Nelson et al., 2013). International adoption has been controversial. Concerns have been raised globally about how children become available for adoption, the suitability of the adopting families, and the regulation of the agencies or intermediaries involved in the adoption process. The presence of fraud and corruption in international adoption has social justice implications for social work: social workers involved in global adoptions, including those who work with families utilizing global adoption, need to be aware of the legal and ethical considerations pertaining to adoption and to speak up publicly if they encounter fraudulent or dangerous practices.

Facts and Figures In fiscal year 2013, there were 7,092 adoptions in the United States of children from other nations, a decrease from 8,668 in 2012 and 22,734 in 2005 (U.S. Department of State, 2015). The top five countries of origin of children adopted in the United States in 2013 were China, Ethiopia, Russia, South Korea, and Ukraine (U.S. Department of State, 2015). Of these adoptions, 7.6% were children under 12 months of age, 37.8% were children between 1 and 2 years old, 16% were children between 3 and 4 years old, 28.6% were children between 5 and 12 years old, 9.3% were children between 13 and 17 years old, and 0.6% were young adults 18 years old or older (U.S. Department of State, 2015). In Zimbabwe researchers found that in a sample of orphans the parents of 40% of the children had both died from HIV-related illnesses, whereas the parents of 17% of the children had both died as a result of other causes (Mhaka-Mutepfa et al., 2014). In Nepal, 70% of orphans living with HIV/AIDS were in kinship care settings whereas 30% were in institutional care homes. The Nepalese children who were in kinship care had more positive and optimistic outlooks on life and had more friends when compared to the children in institutional care (Acharya et al., 2013). Of internationally adopted children living in the United States, 51% are from Asia, 25% from Europe, and 20% from Latin America (Kreider & Lofquist, 2014).

Risk Factors Diseases such as HIV/AIDS or, more recently, Ebola have created large numbers of orphans in some countries. Disease, civil war, and inadequate welfare support for families are pressing issues in many countries. Poverty and its resulting challenges can also increase the risk that a child will be orphaned. Children in kinship care or orphanages are themselves vulnerable to developmental issues, human trafficking, and abuse. Prospective adopters are at risk of becoming engaged in fraudulent adoption practices. In addition, prospective adopters are vulnerable to emotional difficulties that can result from the stresses related to foreign adoption. These stresses may include extended timeframes for the adoption to be finalized, foreign countries changing policies on foreign adoption while families are in the midst of the process, or countries shutting down all foreign adoptions even after a prospective family has been matched with a child.

Signs and Symptoms/Clinical Presentation Prospective adopters of orphaned children from overseas can anticipate signs and symptoms of developmental difficulties (e.g., developmental delays, attachment issues, health problems), particularly when a child has spent an extended period in an orphanage that lacked resources or that provided limited caregiving. There may be physical symptoms present, such as cleft lip and palate, stunted growth, heart disease, orthopedic issues, malnutrition, and infections. Social Work Assessment › Client History • Conduct a biopsychosocialspiritual assessment to include information on any physical, mental, environmental, social, spiritual, or medical factors relating to the child • Initiate efforts to identify/locate parent/family members • Obtain as much family history as possible to aid in the treatment of the orphaned child. Depending on the age of the child, family history may be unattainable • A home/family study will be conducted during the foster or adoption application process. As well as information gathering, this process includes the education and preparation of prospective parents and can take between 2 and 10 months › Relevant Diagnostic Assessments and Screening Tools • A challenge of using screening and assessment tools with orphaned children is that many tools require input from parents, teachers, or other adults with knowledge of the child, who may not be present to provide the needed information • The Achenbach System of Empirically Based Assessment (ASEBA) includes a range of assessments that could be used depending on the social worker’s initial impression of area(s) that require further information › Laboratory and Diagnostic Tests of Interest to the Social Worker • Any screenings for infectious diseases, hematologic issues, metabolic disorders, nutritional status, delayed development, and lead exposure • Prospective parents may be subject to a toxicology screen for drug and/or alcohol use or there may be a medical history of drug and/or alcohol use by the biological parents

Social Work Treatment Summary When a child is orphaned, early intervention and treatment are essential for the child’s well-being. The social worker should first attempt to locate and contact a parent or guardian. If contact with a parent is made, services should be offered to help the parent reunite with the child, if deemed appropriate. These services include mental health and substance abuse treatment for the parent or child, family or individual counseling for the parent or child, financial assistance, and referrals for medical insurance. Child protective service agencies often intervene if a parent or guardian cannot be located. It is important for the child to be placed in a permanent, safe environment in which he or she can develop normally. Trauma-informed care models often are used for children who have been exposed to trauma (e.g., child maltreatment, unstable home environment, exposure to violence, abandonment). This child-focused collaborative approach utilizes individualized assessment and recognizes the profound impact trauma can have on the child and family. Treatment goals include establishing a therapeutic relationship, improving immediate safety (e.g., health, relationships, environment), identifying how the trauma impacts the child’s current functioning, and helping the child develop adaptive ways of coping (e.g., relaxation, meditation, exercise). Social workers should be aware of their own cultural values, beliefs, and biases and develop specialized knowledge about the histories, traditions, and values of their clients. Social workers should adopt treatment methodologies that reflect their knowledge of the cultural diversity of the communities in which they practice. Social workers should practice with awareness of and adherence to the NASW Code of Ethics core values of service, social justice, dignity and worth of the person, importance of human relationships, integrity, and competence; and become knowledgeable of the NASW ethical standards as they apply to providing culturally competent care to orphaned children and their caretakers and practice accordingly. Clients interested in international adoption typically proceed through the following steps: › Step 1: Client/s must become educated on international adoption › Step 2: Client/s must have an understanding of the laws pertaining to adoption in the child’s country and their own country › Step 3: An agency is selected through which the client explores options. The social worker may be employed by this adoption agency or may be working with the client in another capacity and be providing support as the client pursues adoption › Step 4: Completion of a detailed home/family study through a state adoption agency › Step 5: A child is chosen › Step 6: Client/s files the legal documents

. Problem Goal Intervention Child is orphaned Provide the child with a safe Assess family history for any and nurturing environment possible placement; refer to individual therapy; arrange mental health evaluation; ensure that medical needs are met; provide emotional support; coordinate services with school system if child is of school age Client wishes to adopt Client will begin the Provide U.S. adopters internationally but has adoption process and have with information from concerns about the process increased level of comfort the Child Welfare Information Gateway, https:// www.childwelfare.gov/ pubPDFs/f_inter.pdf _ Help client in finding support and advice on foreign adoption; ensure client has engaged a reputable adoption agency and is not being taken advantage of; provide the client with emotional support and counseling to cope with the stresses related to foreign adoptions

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Applicable Laws and Regulations Each country has its own standards for cultural competence and diversity in social work practice. Social workers must be aware of the standards of practice set forth by their governing body (National Association of Social Workers, British Association of Social Workers, etc.) and practice accordingly. The United Nations Convention on the Rights of the Child is an international human rights treaty that recognizes that every child is entitled to certain basic rights, including the child’s best interests being the primary concern in making decisions that affect him or her, the right to be raised by his or her parent(s) or cultural grouping, and the right to have a relationship with his or her parent(s), even if the child is separated from them. (UNICEF, n.d.) In international adoption, the laws of both the country in which the child lives and those of the country in which the adoptive parents live govern the process. In addition to these laws, countries may be party to the Hague Convention on Intercountry Adoption (HCIA) of 1993, which acts as an international law and imposes additional requirements. The Hague adoption convention is an international agreement that establishes procedural safeguards for intercountry adoption. The United States ratified the Hague adoption convention in 2008. One requirement of the convention is that prospective adopters be trained in the issues surrounding transracial adoption. (HCCH, 1995) › There are two processes for adopting internationally, depending on whether the country of origin is participating or not participating in the Hague treaty. A fact sheet on legal requirements can be found at https://www.childwelfare.gov/pubs/ factsheets/hague.pdf › A child should not be considered legally available for adoption until three conditions are met: the child meets the legal qualifications of his or her country of origin to be eligible for adoption and the receiving country; the adoption is determined to be in the best interest of the child; and a valid consent process has taken place with the biological family. There is no standard for what constitutes “best interest” and as a result this step can be overlooked In South Africa the Children’s Act 38 of 2005 includes legislation that governs orphaned children. The main objectives of the act are to provide for structures, services, and means for promoting and monitoring the sound physical, psychological, intellectual, emotional, and social development of children; provide care and protection for children in need; promote the protection, development, and well-beingof children; recognize the special needs that children with disabilities may have; and give effect to constitutional rights of children. (Blackie, 2014)

Available Services and Resources › Center for Adoption Support and Education, http://adoptionsupport.org/ › British Association for Adoption and Fostering, http://corambaaf.org.uk/ › Adopt Abroad, http://adopt-abroad.com/ › Bureau of Consular Affairs, U.S. Department of State, “Intercountry Adoption,” https://travel.state.gov/content/ adoptionsabroad/en.html › Holt International Children’s Services, http://www.holtinternational.org/ › National Council for Adoption, http://www.adoptioncouncil.org/

Food for Thought › Motivations of persons wishing to adopt a child from another country vary, but reasons commonly given are wanting to give a home to a disadvantaged child; general love for children; wanting to start a family; wanting to help with a refugee situation; or a desire to add to one’s family › There are countries that have shut down intercountry adoption programs either voluntarily or as a result of pressure from receiving countries and international organizations. Receiving countries may refuse to authorize intercountry adoptions if corruption or fraud is suspected to be present in the adoption process in the originating country. Guatemala discontinued intercountry adoption in 2008 when it was attempting to be in compliance with the Hague treaty. Nepal suspended adoptions to make changes in adoption laws, but once it was ostensibly compliant with the Hague treaty many receiving countries continued to receive reports that the necessary changes had not been made. These included a lack of clarity on who gains financially from the adoptions, an insufficient legal adoption framework, and lack of clarity regarding whether the best interests of the child standard was being met. Most receiving nations have chosen to continue their moratoriums on adoptions from Nepal, effectively closing Nepal to intercountry adoptions again (Breuning, 2013) › Children in institutions that focus on strong caregiver-child interactions and attachments have improved socioemotional, mental, and physical development. In countries in which deinstitutionalization cannot take place, efforts to improve the existing institutions can improve child outcomes. These improvements may include lower caregiver to child ratios, improved physical facilities, and increased screening for any developmental issues (McCall, 2013) › Social workers should be knowledgeable of their country’s or state’s legal mandates regarding disclosure of information to prospective adoptive parents. Full disclosure of non-identifying information regarding the child’s social, medical, and mental health background is generally considered to be best practice, and courts have held agencies liable for “wrongful adoption” when pertinent information is misrepresented or withheld › Some countries that rely heavily on kinship care for orphans are attempting to formulate official community-based orphan care programs which provide supplementary care and schooling for these children and funding for their caregivers (Maundeni & Malinga-Musamba, 2013)

Red Flags › Since intercountry adoption is driven by demand, families in some countries may be coerced into allowing their children to be adopted rather than being informed of social services that may offer support and assistance that would allow the child to remain in the home (Roby et al., 2013) › Kinship and other alternative forms of care are practiced in many countries; both social workers and adoptive families need to recognize that a child who is orphaned or who is not living with both parents may not be in need of adoption (Roby et al., 2013) › Social workers need to recognize that in many countries where kinship care is utilized, such arrangements may not be subject to the legal requirements, reimbursements, or formal oversight that is present in more developed countries (Maundeni & Malinga-Musamba, 2013) › For younger children, failure to establish a parent/child bond has a negative impact on self-esteem, emotional attachment, and confidence later in life › As a result of the Ebola crisis in West Africa in 2014, almost 4,000 children lost one or both parents. Stigma surrounding the disease has complicated kinship care for these children (UNICEF, 2014) Discharge Planning › Ensure that the child has suitable placement and that his or her basic needs are met › Provide linkage to community resources such as developmental screening, medical, financial, and educational assistance programs, and counseling services as appropriate › Follow up with available family members

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