Understanding Infant Adoption
Unified Curriculum One Day
Trainer’s Guide UIA 4
By
Spaulding for Children Southfield, MI
In collaboration with
Arizona’s Children Association Tucson, AZ
Harmony Adoptions Maryville, TN
Latino Family Institute West Covina, CA
Lutheran Social Services of South Dakota Sioux Falls, SD
Funding for this curriculum was provided by Cooperative Agreements numbers 90 CG 2651/01, 90 CG 2651, 90 CG 2652/01, 90 CG 2653/01, 90 CG 2654/01, 90 CG 2655/01, 90 CG 2656/01 from the US Department of Health and Human Services. The contents are solely the responsibility of the authors and do not represent the official views or policies of the funding agency. Publication does not in any way constitute an endorsement by the Department of Health and Human Services.
Published by: Spaulding for Children 16250 Northland Drive, Suite 120 Southfield, Michigan 48075
© copyright 2004 By Arizona’s Children Association, Harmony Adoptions, Latino Family Institute, Lutheran Social Services of South Dakota, and Spaulding for Children. All rights reserved. No part of this material may be reproduced, stored in retrieval systems or transmitted in any form whatever without prior permission of these organizations.
Revised April 2008 Revised August 2010 Revised December 2011
For instructions on how to access special accommodations for disabilities (ADA) statement please visit our web site at www.iaatp.com.
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Table of Contents Trainer’s Guide
Introduction………………………………………………….. vi Who We Are and Why We Developed this Curriculum……… xi Philosophy Underlying the UIA Curriculum ………………… xiii Central Concepts in the UIA Curriculum….…………………. xiii Guidelines…………………………………………………….. xiv Components of the UIA Curriculum………………………….. xvi Preparation and Tips for the Trainer………………………….. xxi TurningPoint Instructions…………………………………...... xxiv
Module 1: Introduction ……………………………………. 1 Introduction: Objectives and Content………………….…….. 5 Pre-test……………………………………………………….. 11 Personal and Professional Values……………………………. 12 Title X………………………………………………………… 13 The Option of Adoption Video 16 Values Exercise……………………………………………….. 18 To Find Out More About It…………………………………… 25 Children’s Health Law………………………………………... 29 Clinical Guidelines for Nondirective Counseling…………….. 34 Legal and Ethical Considerations…………………………….. 36
Module 2: Adoption Practices……………………………… 1 Introduction: Objectives and Content………………………... 3 Historical Perspective of Adoption…………………………… 4 Adoption Then and Now Video ………………………………. 5 Accurate and Neutral Adoption Language……………………. 8 The Relationship Continuum………...... 12 Types of Adoption Activity …………...... 17 To Find Out More About It …………………………………... 23 Issues and Perspectives in Adoption: Then and Now ……….. 27 Ethical Considerations in Adoption…………………………... 33 A Brief Description of Open Adoption……………………….. 35 Remove Barriers and Latino Families Will Adopt…………… 37 Looking Back Over the Landscape of Adoption……………... 41 Grief and the Open Adoption Process………………………… 45
Module 3: Adoption Law and Practice……………………. 1 Introduction: Objectives and Content…………………….…... 3 Federal Adoption Laws……………………………………….. 5 Servicemembers Relief Act of 2003………………………… 7 Adoption Legal Process………………………………………. 9 Adoption Agencies/Attorneys/Pregnancy Counseling……….. 11
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Frequently Asked Questions about Adoption (FAQ’s)……….. 18 Rights of Birth Parents………………………………………... 27 Child Protection Law…………………………………………. 30 To Find Out More About It…………………………………… 34 MEPA/IEP……………………………………………………. 35 ICWA…………………………………………………………. 36
Module 4: Social, Cultural and Personal Influences……... 1 Introduction: Objectives and Content………... 3 Influences of Family, Community and Culture in Pregnancy... 4 Option 1 of 2: Team Activity………………………………… 4 Culturally Responsive Services………………………………. 8 Birth Father Issues and Considerations………………………. 10 Engaging the Birth Father…………………………………….. 11 Special Issues For Teens……………………………………… 13 Option 2 of 2: Lecture………………………………………… 18 Culturally Responsive Services………………………………. 19 Birth Father Issues and Considerations………………………. 21 Engaging the Birth Father…………………………………….. 23 Special Issues For Teens…………………………..………….. 25 Influences Wheel ……………………………………………... 30 Influences Activity…………………………………………… 33 To Find Out More About It…………………………………… 46 Cultural Responsiveness in Providing Options Counseling….. 49 Social, Cultural, and Personal Influences…………………….. 53 Techniques for Engaging the Birth Father……………………. 58 Adolescence and the Adoption Option……………………….. 60 Families in Crisis……………………………………………... 64 Helping Teens with Future Planning…………………………. 68 Special Concerns for Adults and Teens………………………. 71 Domestic Violence Wheel……………………………………. 73 Substance Abuse……………………………………………… 74 Clinical Depression…………………………………………… 75 Pregnant Teens: Discussing Family Involvement……………. 77 Stages of Birth Father Grief………………………………… 78 Cross – Cultural Skills Checklist…………………………… 81 Self Assessment Worksheet ………………………………….. 82
Module 5: Nondirective Techniques for Informed Decision-Making……………………………………………... 1 Introduction: Objectives and Content……………………… 3 Nondirective, Noncoercive Counseling..……………………... 5 Nondirective, Noncoercive Techniques ……………………… 7 Nondirective Client Centered Approach Video…………….. 9 Informed Consent…………………………………………...... 12 Julie Video………………………………………………...... 14
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Kesha Video…………………………………………………... 18 Option 1 of 2: Role Play Exercise……………………………. 22 Option 2 of 2: Role Play Exercise …………………………… 24 Discussing the Adoption Option Video……………………. 26 To Find Out More About It…………………………………… 32 Brief Nondirective, Noncoercive Interventions………………. 37 Legal and Ethical Considerations…………………………….. 41 Checklist for Effective Communication……………………… 46 Giving and Receiving Feedback……………………………… 48 Working with Resistant or Angry Patient/Clients…………….. 49 Birth and Adoption Plan (Sample) …………………………… 53 Introducing Pregnancy Options in Fifteen Minutes or Less …. 56
Module 6: Resources & Community Referrals for Pregnancy Counseling & Adoption ………………………... 1 Introduction: Objectives and Content……………………… 5 Making Successful Referrals…………………………………. 6 Option 1 of 2: Panel Presentation…………………………… 9 Option 2 of 2: Assessing and Making Referrals……………... 13 Closure & Adjourn…………………………………………..... 31 Post-test and Evaluation………………………………………. 32 To Find Out More About It…………………………………… 33 Sample Letter (for Panel Presentation)……………………….. 35 Assessing Community Resources…………………………….. 38 Networking and Collaboration………………………………... 40 Making Successful Referrals Checklist…………………...….. 43 Questions for Health Care Practitioners………………………. 44 Questions for Patient/Clients…………………………………. 45
Glossary………………………………...... 1-14
Helpful Websites…………….……………………………... 15
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Introduction A Note About the Curriculum Development Team...
The funder required that this curriculum be developed, pilot tested, and submitted to the Department of Health and Human Services for review within four months of grant award. To ensure meeting that time standard, as well as the Guideline standards, Spaulding for Children, Arizona’s Children Association and Harmony Adoptions invited the other grantees to join together to develop the Unified Curriculum.
The Unified Curriculum Development Work Group (UCDWG), comprised of representatives of the six grantees, developed and/or reviewed content materials in existing curricula; provided constructive criticism on content and format outlines and the modules themselves; identified reference materials and articles; and served as field test trainers and observers.
Members of the Unified Curriculum Development Work Group included:
• Marcie Velen, MSW, LCSW, Director of Permanency Planning, Arizona’s Children Association • Jane Ball, MA, National Curriculum and Training Institute • Pam Frye, MS, Adoption Services Director, Harmony Adoptions • Bruce Rappaport, PhD, Executive Director, Independent Adoption Center • Patti Colston, MS, Program Director, Independent Adoption Center • Maria L. Quintanilla, MSW, Executive Director, Latino Family Institute • Frances Marron-Zamarripa, MSW, IAATP Program Director, Latino Family Institute • Julie Klinger, Project Director, Lutheran Social Services of South Dakota • Terry Tompkins, Lutheran Social Services of South Dakota • Jean Niemann, MSW, ACSW, National Coordinator, Spaulding for Children • Ernestine Moore, MSW, JD, Contractual Curriculum Director and Editor, Spaulding for Children • Pam Wolf, LCSW, Executive Director, Harmony Adoptions • Gloria A. Cortez, Community Outreach Coordinator, Latino Family Institute • Ann Avery, RN, MSN, CPNP, Clinical Services Director, Health Services Northwest Michigan • Susan Grough, RN, BSN, President, Priority Health Services, Inc. • Sylvia Sims Gray, Ph.D., Professor, Eastern Michigan University • Daphne Nedd, PhD, Assistant Professor, Wayne State University School of Nursing (also a nurse midwife) • Suzanne Weathers, MSN, RN, Lead Nurse Planner
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Due to the rigorous timelines for completion of the curriculum, a tightly managed process allowing for concurrent development, review, and refinement was developed. This process involved several steps, which are:
• A curriculum content outline was developed based on the Federal Guidelines. • A curriculum writing and video production schedule was established within two weeks of the grant award. • The UCDWG agreed on a training design and proposed content. • A UCDWG member volunteered to lead a team to refine the training design, research and write content, and developed original materials for the six modules. • The UCDWG and other health professionals provided consultation and critique on content outlines, training design, proposed content; reviewed actual drafts of the curriculum modules as they were developed and suggested revisions. • Video treatments were previously researched and written under the previous Infant Adoption Awareness Training Program funding to Arizona’s Children Association, Harmony Adoptions, and Spaulding for Children. They were edited for this curriculum. • The required pilot test was scheduled and held to ensure sufficient time for incorporating the feedback from the pilot trainees prior to submission to the Children's Bureau. • The evaluators for the six grantees worked together to develop comprehensive evaluation tools and collected and analyzed the data from the pilot training so that all findings and recommendations could be used in the final revisions.
The primary task of the unified curriculum development team was to capture the major training concepts on paper, to research and synthesize subject matter, and to organize the content into a clear, instructionally sound document that included educational video vignettes. Most important, the team wanted all of the materials to be “user friendly” and written in clear, concise language, without jargon.
The Trainer’s Guide and Participant’s Handbook reflect the work products of the Unified Curriculum Development Work Group (UCDWG) with editing and integration assistance by the staff of Spaulding for Children:
• Kris Henneman, MSW, Project Director • Ernestine Moore, MSW, JD, Curriculum Director • Jean Niemann, LMSW, ACSW, National Coordinator • Tim Hylka, MA, Trainer/Consultant • Pamela Walker, MSW, CSW, Project Specialist • Joanna Naud, MSW, Trainer/Consultant • Kimberly Hairston, MA, LBSW, Trainer/Consultant • Patricia Hannah, LMSW, ACSW, Trainer/Consultant • Adam Jenovai, MA, Project Specialist • Diane Fox, LBSW, Trainer/Consultant • George Miller, BS, Consultant
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The Pilot Test Group included:
• Marsha Gelt, MPH Project Director, Center for Health and Training • Karen Dluhosh, MC Training Manager, Center for Health and Training • Pam McCoy, RN, PHN, Healthy Start Program Coordinator, Contra Costa County • Megan Ashworth, Medical Students 4 Choice • Teresa Enns, Public Health Nurse, California Children’s Services • Ashley Alwood, Medical Students 4 Choice • Kristin Broughton, Medical Students 4 Choice • Jasper Chen, Medical Students 4 Choice • Krista Regan, Medical Students 4 Choice • Teri Greiling, Medical Students 4 Choice • Susan Gamble, Medical Students 4 Choice • Rita Barouch, MSW, Medical Social Worker, Richmond Health Center • Patrice Zink, MA, Project Manager/Trainer, JSI Research and Training Institute • Evelyn Kappeler, Senior Project Analyst OSOPHS • Sue Moskosky, MS, Director, U.S. DHHS, Office of Family Planning
Their role was to offer constructive criticism to improve the content and structure of the curriculum prior to submission for federal review. The additional persons participating in the pilot test were:
• Pam Steele, MA, Training Coordinator, West Coast IAATP • Jennifer Allen, BA, Training Coordinator, West Coast IAATP • Lorene Clark-Lacayo, Training Coordinator, West Coast IAATP • Keri Lake, Training Coordinator, West Coast IAATP • Jennifer Knowlton, JD, Training Coordinator, West Coast IAATP • Susan Romer, Attorney-at-Law, Law Offices of Adams and Romer • Martin Giovannini, MA Training Coordinator, West Coast IAATP • Beth Hall, Executive Director, PACT • Gloria Cortez, Community Outreach Coordinator, Latino Family Institute • Laura Warriner, LCSW, County Liaison, Department of Health, Latino Family Institute • Renee Popona, Mid-wife, Trainer, Arizona’s Children Services • Kathleen Silber, ACSW, Associate Executive Director, Independent Adoption Center • Bruce Rappaport, PhD, Executive Director, Independent Adoption Center • Patti Colston, MS, Project Director, West Coast IAATP • Monica Rumsey, Administrative Assistant, West Coast IAATP • Charles Webb, BS, Logistics Manager, West Coast IAATP • Susan Quash-Mah, MS, Project Manager, West Coast IAATP • Pam Wolf, LCSW, Executive Director, Harmony Adoptions of Tennessee • Jennifer McGhee, MSW, Training Coordinator, Harmony Adoptions of Tennessee
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• Julie Klinger, LBSW, Project Director Adoption Programs, Lutheran Social Services of South Dakota • Sue Grundyson, Trainer, Lutheran Social Services of South Dakota • Kirby Wilcoxson, Senior Vice President for Academic, University of Sioux Falls • Patrice Zink, MA, Project Manager/Trainer, JSI Research and Training Institute • Marcie Velen, MSW, Director of Permanency Planning, Arizona’s Children Association • Jan Cardwell, MSW, Training Director, Arizona’s Children Association • Jean Niemann, MSW, ACSW, National Coordinator, Spaulding for Children • Michelle Schiller, BS, IT Director, West Coast IAATP • Maria Quintanilla, Program Administrator, Latino Family Institute • Maria Garcia Flores, Arizona’s Children Association • Frances Marron, Project Director, Latino Family Institute • Jane Ball, MA, Vice President, Arizona’s Children Services • Robert McKenna, Region 3 Training Director, Office of Family Planning, RTC • Kris Henneman, MSW, Vice President, Spaulding Institute, Spaulding for Children • Ernestine Moore, JD, MSW, Curriculum Director, Spaulding for Children • Sharonlyn Harrison, President/CEO, Public Research and Evaluation Services • Iraj Imam, PhD, Senior Research Manager, Cal Research • DeSondra Ward, Senior Research Assistant, Cal Research • Thida Tan, BAS, Research Assistant, Cal Research • Gabriel Orozco, BA, Research Assistant, Cal Research • Carol Coley, Research Assistant, Cal Research • Diana Leakey, ESQ, Research Assistant, Cal Research • LCDR Nancy Mautone-Smith, M.S.W., L.C.S.W., Regional Program Consultant, U.S. Department of Health and Human Services, Office of Family Planning
All of these persons, in their various roles, were critical to the development of this curriculum, and we thank them.
The following persons were instrumental in revising the curriculum. We thank them for their contribution.
• Jean Niemann, LMSW, ACSW, National Coordinator, Spaulding for Children • Patricia Hannah, LMSW, ACSW, Senior Trainer Consultant, Spaulding for Children • Julie Klinger, LBSW, Project Director Adoption Programs, Lutheran Social Services of South Dakota • Marcie Velen, MSW, LCSW, Director of Permanency Planning, Arizona’s Children Association • Suzanne Weathers, MSN, RN, Lead Nurse Planner • Julie Maleski, MSW, Trainer Consultant, Spaulding for Children
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Acknowledgments
Many individuals have contributed their expertise, vision, creative abilities and support to the development of UIA. All contributors have enriched the curriculum. In addition to those previously named, we owe deep gratitude to the health care providers, health counselors, pregnancy counselors, adult adoptees, birth parents, adoptive parents, and direct practice staff who participated in videos and shared personal and professional insights. As a result, this curriculum is a relevant, empowering, practice-based model for orienting health care workers to share the adoption information and referral to women with unplanned pregnancies.
This curriculum was supported throughout its development by Spaulding for Children’s Training and Resource Center support staff. Particular thanks are extended to:
• Tamekia Smith • LaShaun Smiley • LaTanya Reese • Saro Buettner • Kathleen La Rosa • Jacqueline Dziadosz
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Understanding Infant Adoption Introduction
Who We Are and Why We Developed this Curriculum
Spaulding for Children was founded in 1968. Its founders had a dream that all children are adoptable, without regard to their age, race, or disability. Acting upon that dream, Spaulding has become internationally acclaimed on its pioneering work in the field of special needs adoption. Since its inception, Spaulding has provided adoption and related services to hundreds of children and their families. The Agency has also provided training and consultation to professionals in England, Scotland, South Africa and throughout the United States and Canada. Since Spaulding was designated as the National Resource Center for Child Welfare Adoption in 1985, 67,000 professionals and parents have been trained in best practices in adoption and post adoption services. Spaulding continuously develops and disseminates new training curricula, publications, and training videos to improve adoption methods and practices.
Spaulding’s mission is: “In collaboration with families, communities, and local, state, and national organizations, Spaulding will assure that all children grow up in permanent families and have the help they need to be successful in life.” The Understanding Infant Adoption (UIA) curriculum is consistent with the mission of Spaulding and the role of its Institute for Family and Community Development, which was created in 2000 to expand outreach services to communities, including faith-based communities. The Institute’s purpose is to provide high quality, accessible training to parents and their “helpers” to empower parents with all of the information they need to provide good care and make good decisions for themselves and their families.
Much support was gathered from others along the way, both within Spaulding for Children and throughout the State of Michigan. The solid, interagency collaborative relationships that developed will be a long-lasting benefit of this curriculum project.
Arizona’s Children Association, founded in 1912 with the establishment of an orphanage in Tucson, is the oldest adoption agency in the state. For more than 92 years, the agency has developed an array of 85 quality child welfare and behavioral health programs whose purpose is to address the needs of children and their families in all 15 counties of the state. The mission’s motto “protecting children and preserving families” reflects the ongoing commitment towards permanency for children and family-centered practice. Arizona’s Children is a private, not-for-profit organization, licensed by the State of Arizona Department of Economic Security, the Arizona Department of Behavioral Health Services, the North Central Association of Schools and Colleges, and accredited by the Joint Commission on Accreditation of Health Care Organizations (JCAHO). Arizona’s Children Association (AzCA) is a member of several organizations including the Child Welfare League of America, North American Council for Adoptable Children, Voices for Adoption, and the National Foster Parents Association.
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Arizona's Children Association has a long history of developing methods and materials to facilitate best practice in child welfare. We are proud to participate in this national collaboration to benefit the health care field as well as the child welfare field. We would like to thank those who participated in the development of the original Arizona IAATP curriculum of 2002, as much of that material has been successfully evaluated and is included in the new Unified Curriculum of 2005.
Harmony Adoptions of Tennessee, Inc. is a full-service, non-profit, licensed adoption agency in the State of Tennessee. In addition to the traditional adoption services, home study assessment, placement of children and post placement supervision, Harmony Adoptions offers a complete array of educational and supportive services to adoptive families, pregnant women and the community. In addition to the IAA grant, Harmony’s ASAP (Adoption Support and Preservation) is a program funded by the State of Tennessee Department of Children’s Services which provides crisis intervention, family and individual counseling, support groups and family mentors to families who have adopted a child or children from the Department of Children’s Services.
Adoption Services of Lutheran Social Services of South Dakota (LSS) are based on a tradition of concern for children. For more than 80 years, LSS has provided services for children in need of families, counseled birth parents, and offered services for those adopted. In 1939, LSS became the first child placement agency licensed in South Dakota. Through the years, services have changed to keep pace with the changing needs of adoptive parents, birth parents, and most importantly, children. LSS is honored to have been awarded the Infant Adoption Awareness Training Grant for South Dakota, North Dakota, Wyoming, Montana, Colorado, and Utah. We look forward to training health care providers over this region during the next two years and are committed to a continued relationship with the other grantees in providing a nationwide unified curriculum to all training participants.
Latino Family Institute, Inc. (LFI) is the only private Latino non-profit, full service adoption and foster care agency that serves the southern California Latino community. LFI is committed to preserving the Latino family by providing culturally sensitive comprehensive bilingual (English and Spanish) services. LFI is also dedicated to our children and families in producing effective changes in the areas of adoption and foster care at the local, state and national levels.
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Philosophy Underlying the UIA Curriculum
The Understanding Infant Adoption (UIA) curriculum is based on the belief that in the situation of an unplanned pregnancy, women should be provided equal information and counseling regarding all options in a nondirective, noncoercive manner in order to make an informed decision.
UIA is based on a set of values and beliefs that coincide with Title X family planning regulations that include:
• Recognize that health care providers are partners in the process of disseminating information on options counseling and the adoption option.
• Providing neutral, factual information and nondirective counseling on each of the options and referral on any option the woman chooses.
• Providing services without subjecting individuals to any coercion to accept any specific method, and in a manner that protects individual dignity and respect.
Central Concepts in the UIA Curriculum
UIA is designed to train staff at federally funded health centers and clinics to provide adoption information and referral to pregnant women on an equal basis with other options. UIA provides opportunities for participants to assess their own strengths and resources and to determine their own needs for further information.
UIA recognizes that adults learn differently from children and provides information in a number of different ways to help trainees integrate the information they are learning. This curriculum also acknowledges the strengths these participants have to offer clients to assist them in making an informed decision.
Cultural competence is a central concept in UIA. By this, we mean recognizing and celebrating diversity, treating others with respect and working to understand differences rather than to make judgments about them.
UIA also is based on a series of competencies, or skills, that participants will develop over the course of the training. Competencies focus on the nature of nondirective, noncoercive options counseling and informed consent in adoption.
The Department of Health and Human Services (HHS) published specific guidelines for the curriculum. They are printed here in their entirety to provide insight to the rationale of the content and structure of the curriculum.
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Guidelines Specific to the Infant Adoption Awareness Training Program (HHS Publication)
Training Goals The Training will:
• Impart up-to-date and accurate information about adoption, including the various types of adoptions, such as closed adoptions and adoptions involving varying levels of “openness” with respect to the amount of contact or information exchanged between adoptive parents and birth parents. • Be consistent with applicable State law, imparting information on the legal issues pertaining to adoption, including the rights of the birth mother and father. • Impart information to the trainees about the Multiethnic Placement Act/Interethnic Placement Act (MEPA/IEP), particularly as it relates to the circumstances under which a birth parent may or may not choose adoptive parents for the child. • Impart information to the trainees about the Indian Child Welfare Act (ICWA). It will particularly explain that organizations that work with birth parents on adoption should ascertain as soon as possible whether a child is or will be subject to ICWA prior to proceeding with the adoption process. • Impart information about how family members and the birth mother’s community may impact her pregnancy decision process. • Impart information about the role of the birth father in the pregnancy decision. • Impart information about various adoptions services available within the community and how to assess the quality of those services and their appropriateness for a particular woman. • Impart information on adolescent development and the differences between counseling adolescents at varying ages and counseling older women. • Impart information about the psychological and emotional reactions, such as shame, grief, loss, guilt, and depression that the birth mother is likely to experience throughout the decision-making process as she considers various pregnancy options, as well as the emotions the birth father is likely to experience.
Basic Skills Learned
• Trainees will increase their awareness of their attitudes and biases pertaining to adoption so that they are able to present the adoption option in an objective, non- biased manner. • Trainees will increase their sensitivity, understanding and skills regarding the influences that both a birth mother and birth father may experience from family, peers, and community. • Trainees will improve their basic counseling skills, including cultural competence, listening, building rapport, recognizing someone in crisis, being empathetic and treating clients with respect.
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• Training participants who will counsel pregnant women will learn skills in nondirective counseling to ensure that adoption, and information about other pregnancy options, is presented objectively, without bias or judgment. • Consistent with State and Federal laws, trainees will increase their knowledge of adoption and adoption procedures so that they are able to present accurate and up- to-date information during options counseling. • Training participants will increase their knowledge of available adoption-related referral resources and how to assess the quality and/or appropriateness of these resources. • Trainees who will counsel pregnant women will have basic case management skills including the ability to assess service needs and make appropriate referrals.
Curriculum The curriculum will include:
• Interactive exercises that promote skills development, such as role playing and discussions of potential responses to various scenarios. • Exercises such as attitude awareness activities that promote awareness of personal biases, prejudices, and negative attitudes and how they impact the provision of adoption information, as well as information on other pregnancy options. • A component in which birth parents, adoptive parents, and/or adult adoptees present their experiences with adoption. • Resource materials that trainees can take with them to refer to when they are providing counseling on pregnancy options and to disseminate to the women they are counseling.
Training Structure The training should:
• Involve no more than two (6-hour) days. • Be conducted by experienced trainers. • Include presentations and opportunities for interaction with professionals from both the health and adoption fields.
Special Features of the UIA Curriculum
UIA includes written and video materials that are easily used by the trainers and training participants. Icons and print variations are used in the Trainer’s Guide to denote training exercises and video segments. The trainer’s preparation pages are printed on blue paper; materials used in training are printed on white paper, and materials referenced but not trained during the session are printed on pink paper. In the Self Study Workbook all pages are white. Participant pages also are assembled in a separate Participant’s Handbook, which participants may use readily throughout the training and refer to afterwards.
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Consistent with the nature of adult learning patterns, UIA uses video segments to highlight, model and reinforce training concepts. Dramatic case scenarios and documentary video facilitate interactive and experiential activities during each module.
UIA also provides participants with opportunities for self-reflection and open discussion of issues facing women with unplanned pregnancies, as well as the different service providers available in their areas. Understanding the different resources available for pregnancy counseling and adoption services is a key characteristic necessary to make informed referrals consistent with client/patient needs and preferences.
Components of the UIA Curriculum
The Trainer’s Guide has been designed to inform prospective trainers how to teach health care providers to present the adoption option to women with unplanned pregnancies who request options counseling or options information. The curriculum is divided into six modules. Each module has three sections: trainer’s preparation instructions; training materials, including Participant Handbook materials; and a reference materials section that has Participant Handbook materials that are not trained in the module but are referenced during the training of that module. In the Trainer’s Guide, the trainer is given potential answers, which appear in italics, to all questions posed.
The trainer’s preparation section, copied in blue, includes:
• Preparing to Train provides directions on unique features of the specific module. • Required Materials/Equipment and Room Set Up lists the items specifically needed for training this module.
The training materials section includes the actual training content with instructions on what to do and say. Within the Trainer’s Guide, each type of activity and instruction is designated by a labeled icon. They are as follows:
Time Allotted This clock icon lets the trainers know how long a particular segment will take. It can be found at the beginning and throughout each module of UIA.
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Directions Directions tell the trainers what needs to be done during a particular segment. It is up to individual trainers to decide how to accomplish these tasks during their preparation for training. Trainers are to read and understand the direction prior to training. They are not written to be read verbatim.
Trainer's Comments This section is content for mini-lectures. The factual information to be shared with participants is contained here and is written so that the trainers can read or paraphrase each point until they become familiar enough with the material to internalize the curriculum content.
Large Group Discussion This section offers proven triggers for stimulating exchanges in the large group setting. It includes suggestions for managing the large group discussion to keep it lively, informative and on track.
Team Activity The team activities provide the opportunity for open discussion of attitudes, feelings and reactions to information presented throughout the training. Activities also provide a forum for group members to get to know one another and to develop a supportive network.
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Individual Activity Individual activities emphasize self-assessment and personal discovery. The Trainer’s Guide provides clear instructions, hints and rationales to help make these activities meaningful and productive.
Video Description The Trainer’s Guide provides a brief synopsis of each video vignette, followed by the key points to be covered in the discussion following the Video/DVD.
Participant Handbook Materials Participant Handbook materials are reproduced in the Trainer’s Guide exactly as they appear in the Participant’s Handbook. They are immediately following the trainer’s reference to them, always beginning on a new page of the Trainer’s Guide. "White space" may appear before these materials.
Transition This icon lets the trainer know that we are transitioning to a new content subject or new module.
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Panel Discussion This icon denotes a panel presentation.
Assumptions about the Training Process
UIA advances the concept of empowerment and applies it to providing options counseling to women. This perspective requires that the training process itself be based on the principles of empowerment.
Also inherent in the curriculum design are the assumptions that the UIA program:
• Builds on the integrity and experience of the participants. • Encourages active participation, integration and investment by the participants. • Educates participants by engaging them in learning activities that help them to gain knowledge and build skills through an accumulation of experiences. • Recognizes and addresses the realities and constraints of the systems charged with providing options counseling for women. • Serves as an impetus for further learning, not as the completion of the learning process. • Builds upon the principles of the adult learning model.
Recommendations for Use of the UIA Curriculum
The UIA training is developmental and sequential. Each module lays a foundation of concepts that are applied in the following sessions. To achieve the curriculum’s goals and objectives, and to develop competencies among the participants, the sequence and flow of the modules are critical.
Participants are expected to attend all modules. If any participants must miss a module, they should be given opportunities to “make up” the missed information. Perhaps inviting them to join another orientation group or collaborating with another agency also using UIA could accommodate absentees. Attendance expectations need to be made clear at the beginning.
Who can benefit from the curriculum?
UIA is designed to educate health care professionals interested in providing optimal options counseling to their patient/clients. Materials are written in clear, straightforward language. The language of other professions is used when necessary to provide the
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participant with the ability to communicate effectively with those professionals. All such language was defined, to the extent possible, in commonly-used language.
Who should serve as trainers for UIA?
This curriculum is designed to be trained by social workers or pregnancy counselors, who have experience in providing pregnancy counseling and adoption services with women and teens. This curriculum can be trained using 1 or 2 trainers. Ideally trainers will be from the geographic areas serviced by the trainers. Experiences and insights validate the content of the training. This partnership provides the foundation for empowerment-based practice and for helping participants begin to see themselves as resources for women and teens who face unplanned pregnancies.
How should UIA be presented?
The curriculum should be presented as written. Several sections have options for the activities or team exercises. These options are designed to teach the same point in the same period of time but for different participant needs. Knowing where your participants are coming from and their prior knowledge helps considerably in selecting the appropriate activity.
Requirements related to providing contact hours for nurses
This educational activity has been approved for contact hours by the Michigan Nurses Association (MNA), which was an accredited approver of continuing education for nurses by the American Nurses Credentialing Center (ANCC). Although the MNA is no longer an accredited approver unit, contact hours remain valid through this date. Spaulding for Children has submitted an application to the ANCC to be an accredited provider of continuing education for nurses, and an accreditation decision will be made prior to the date when contact hours approved by the MNA expire.
Individual Boards of Nursing establish licensure renewal requirements for nurses, and some nurses are licensed in more than one state. According to National Council of State Boards of Nursing (2009), the following states and territories have continuing education requirements for nurses: Alabama, Alaska, Arkansas, California-RN, California-VN, Delaware, District of Columbia, Florida, Guam, Hawaii, Idaho, Illinois, Iowa, Kansas, Kentucky, Louisiana-RN, Massachusetts, Michigan, Minnesota, Nebraska, Nevada, New Hampshire, New Jersey, New Mexico, North Dakota, Northern Mariana Islands, Ohio, Pennsylvania, South Carolina, Tennessee, Texas, Utah, Virgin Islands, West Virginia- PN, and West Virginia-RN.
All RN licensing boards nationwide acknowledge and accept contact hours from accredited providers, though the licensing boards of California and Iowa have additional requirements related to approval of the state’s board of nursing if the contact hours will be used for renewal of licensure.
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All participants (including participants who are not nurses) receive contact hours if they sign in, are present for the entire program, complete the pre-test and the post test, complete the “Training Reflection Feedback Form”, and submit the documents to the trainer. The completion certificate, given to participants when the final documents are turned in, documents the contact hours. Certificates are never given out early, or set out during a break. These requirements must be shared with participants at the outset of the training.
Certain procedures and disclosures are required when an educational activity has ANCC approved contact hours: • Sponsorship and commercial support guidelines must be adhered to. If you are not providing the pens with “Understanding Infant Adoption” by Spaulding for Children, it is acceptable to use brand products (like BIC) without any advertisement, or pens with information from the adoption agency or pregnancy counseling center. It would be inappropriate and wrong to provide pens or any other item that advertise pharmaceutical products, candidates, or anything else. There should not be any sponsorship or commercial support for any training session. The grant supports the training. No commercial products can be displayed. • It is appropriate for trainers to disclose which adoption agency or pregnancy counseling center the trainers work for, and it is acceptable to provide pamphlets about the agency/center. It is appropriate for trainers to state there are no conflicts of interest related to the training. • If there is anything that could be considered “conflict of interest” related to the training, this has to be discussed with lead agency personnel, and cleared with representatives from Spaulding for Children.
Preparation and Tips for the Trainers
Talk with co-trainers about how to train as a team. Set ground rules for working together and delineate roles. Make the group feel comfortable and welcome by:
• Making arrangements for refreshments. • Letting people know they are welcome to move about during the session as needs arise. • Letting the group know that breaks are built into each session.
Validate participant responses:
• Verbally, by rephrasing, reinforcing or repeating later during training. Never say, “Yes, but...” • Nonverbally, by smiling, making eye contact, nodding, and gesturing. • By being nonjudgmental. • By using language that refers to the person, not to his or her special need. • Take some risks in sharing information about your personal experiences and feelings.
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• Modeling that it is all right to do this. • Making the group more comfortable and willing to take risks. • Keeping the training experiences lively.
Make clear transitions between segments of each session:
• Wrap-up or bring each segment to closure before starting the next one. • Introduce new segments by tying in concepts and ideas from previous materials.
Be conscious of time:
• Many key concepts are discussed in more than one session of UIA. Each subject need not be exhausted before you move on. • Move the group along without making participants feel rushed. • Use participant comments as transitions whenever possible. • Try to start and end each session on time. Never keep participants for more than the time allotted for each module.
To present the training materials successfully, trainers need to be sure to arrange and complete the following before each orientation session: Arrange for:
• Equipment and materials that are needed • Meeting room and room setup • Participant Handbook – one for each participant (be sure that sufficient copies are available) • Video monitor and video player compatible with the format of the 1/2" VHS tapes included in the curriculum • DVD player and DVDs • Flip charts and markers, pens, pencils • Masking tape
Read and review the Trainer’s Guide as many times as needed to become knowledgeable:
• The Introduction: Objectives and Content for each session offer specific preparation instructions. • Trainers may use the white space in the Trainer’s Guide for taking notes. • Trainers may find it helpful to underscore or highlight concepts and key points that you wish to emphasize, adding personal comments and anecdotes where appropriate.
Become familiar with the video equipment to be used. The following pointers apply to most video equipment:
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VCR • Many times during the orientation session, trainers may want to “stop” or “pause” the videotape in order to discuss what has just been seen or to proceed with the session. Practice pausing and stopping the videotape. • Press PAUSE to stop the videotape for two minutes or less. • Press STOP to stop the videotape for more than two minutes. • Learn how to move the tape backward and forward by pressing the REWIND and FAST FORWARD buttons. • Another function of many VHS players is the SEARCH or SCAN or SHUTTLE control. This control allows the tape to be moved backward or forward while the picture is seen on the screen. Learn how to use this function, if the player has it. • To correct any distortion while playing the videotape, adjust the TRACKING knob on the video player. • Prior to each session, test the equipment. Check the monitor and VCR to be sure that they are properly connected. Ensure that electrical outlets and a power cord are nearby. Play portions of the actual videotape that will be used, to make sure it is in good working order. If possible, walk around the room to view (and hear) the video from several of the positions that participants will occupy. Adjust the picture (color, contrast, brightness, etc.) and volume accordingly. • After checking the videotape, be sure to rewind it to the beginning or to cue it to the appropriate place (i.e., shuttle the tape forward or backward to the section of tape that will be shown). Press EJECT to remove the tape from the machine; then turn off the equipment. • Immediately prior to the orientation session, play the beginning of the videotape again to double check that it is the correct one. Be sure to rewind the tape. • Review the video vignettes to become familiar with their content. Review the agenda for each training session. • Field tests have demonstrated that the amount of time allowed for each segment of the session is accurate. DVD • Ensure that both the TV and DVD player are plugged into the electrical socket as well as to each other. • The wiring between the TV and DVD player are typically color coordinated and should be plugged in accordingly. • Turn on TV and DVD player. • The TV needs to be in the appropriate “mode” to play the DVD rather than the television input. Typically, this is accomplished by pushing the menu button on the TV to find the “mode” menu and choosing DVD if possible or other input, i.e. video 2. • Press the arrow or eject button on the DVD player to open the DVD tray. Place DVD on the disc tray with the title side up. • Typically a menu page will appear. There will be thumbprints (small photo showing opening scene and titles) of the various curriculum videos. • Using the remote control - the arrow buttons allow you to toggle through the video choices to highlight the needed video.
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• If no remote control is available, attempt to use the arrow buttons and or the forward buttons on the DVD player to toggle through the Menu items. • When the video has ended, use the stop button or allow the screen to return to the menu page.
Trouble Shooting:
• If there is no picture - check that the connections are plugged into both the DVD player and TV. Check that the colors of the plugs and the input holes match. Make sure you select the video input on the TV so that you can view the picture from the player. • If there is no sound - check the volume on the TV. Check the connections between the DVD player and the TV.
TURNINGPOINT
TurningPoint is used in conjunction with PowerPoint but is not mandatory. With TurningPoint you will click once for the question, and a second time for the answer. This second slide will also show the groups responses as a whole as their answers will be computed by the system. Without TurningPoint the question will appear first and the answer will appear second but the groups answers will not be tabulated or appear.
The TurningPoint Toolbar
• On the TurningPoint toolbar, choose the type of hardware you are using, which is “Response Devices.”
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Checking the Hardware • To run the Hardware Wizard, select Tools and choose “setting.” • Click the “Polling Test” tab at the upper left side of the screen. • You can now test your hardware by clicking on “start test” in the lower right hand corner. • Test the Key pads by pushing any button on each of the Response Cards in turn. • When finished, click “end test.” • Then click “done” to end the Hardware Wizard. • There is no need to check the equipment prior to each training.
Participant List • For our purposes, we do not need to create specific participant lists for each of the trainings. • From the Participant List Drop Down Menu, there are three choices: o Anonymous- responses are confidential o Auto- Polling will grab the devices identification number, but with no official list loaded o Lists- Polling will observe the individual participant list selected. • Click “anonymous.”
Running a TurningPoint Presentation • Plug the receiver into the USB port. • Launch TurningPoint. • Open the PowerPoint presentation. • Check that the participant list is “anonymous.” • To prepare your presentation for the training, Click “reset” on the TurningPoint Toolbar, choose “session.”
• Choose type of responses you would like to receive. Click “Response Devices.” • Start your presentation in “slide show” mode. Note: TurningPoint won’t work unless the PowerPoint presentation is in “Slide Mode.” • Distribute the Response Devices.
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• Toggle through your presentation as you would with any other PowerPoint Presentation, using the arrow keys, mouse clicks or remote. • When a TurningPoint slide appears, polling will open, meaning a show bar will appear in the top right corner of the screen.
• The far right “green” display indicates that polling is open and will count as the participants answer the TurningPoint Question. • By clicking the mouse or using the arrow key, polling will close and the participant will no longer be able to provide a response. • Click again and the computer will automatically poll the participant’s responses and show the percentage of the participant’s answers. • Click again and a “correct response” indicator will appear showing the audience which is the correct answer. • Click again to move to the next slide.
At the end of the presentation, a TurningPoint window will appear asking you if you would like to save the session. There is no need to save the training sessions.
Remember, that the UIA PowerPoint Presentation with TurningPoint will need to be “reset” prior to the next training.
How to use with a large group • The TurningPoint hardware consists of a number of response devices. If you do not have enough response devices for each participant you, as the trainer, will need to “group” the participants to share the response device. • Typically, audience members are grouped in twos to discuss their answer and respond for both.
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• The larger the audience is, the larger the grouping to share one device. You will need to be mindful of the room set-up when grouping your audience, e.g. classroom verses large tables. • These factors will determine how you group.
Troubleshooting • Make sure that the receiver is fully inserted into the USB port. • Make sure that the TurningPoint software is launched before opening up the UIA PowerPoint presentation. • If TurningPoint is not operating properly, shut down all programs and computer and restart process from the beginning. • If an error occurs while “resetting the session,” there maybe an issue with updating the software on the laptop. Please refer to system requirements on Page 1 of this document. • TurningPoint technical assistance is available by calling 1-866-746-3015, press #2 for a Training Specialist and #1 if you are currently training. If there is a wait, call again and press 0 for an operator who will put you in touch with a Training Specialist.
Participant Number An ideal size for a session is 20 participants. U shape room set up is preferable as this tends to work best for discussion and group participation. Two flip charts and two television monitors (or one large-screen monitor) are needed for the maximum group size of 30. It is helpful for the trainers to move around the room while speaking and not stand behind a podium or table.
Refreshments should be provided to help the participants be comfortable. If a training session takes place over a standard meal hour, meal arrangements need to be made.
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xxviii DRAFT UIA4 – 1 Day – Module 1 12/11/2011
Module 1: Introduction (60 minutes)
Trainer’s Preparation
Module Contents and Training Process • Introduce yourself. Identify your employer and role in adoption or options counseling. Also inform group that today you are representing Spaulding for Children, the agency that received this federal grant and developed this curriculum. • Welcome participants to the training site. • Share any necessary “housekeeping” details such as break times, restroom locations, lunch arrangements, etc. • Share requirements to receive nursing contact hours. All participants receive contact hours if they sign in, are present for the entire program, complete the pre-test and the post test, complete the “Training Reflection Feedback Form”, and submit the documents to the trainer. The Certificate of Completion, which provides documentation of contact hours, is given to participants when the final documents are turned in. • Post “Parking Lot” poster in rear of room or off to the side so participants have easy access to it. Do not hang it near the trainer or at the front of the room. Make sure that participants have post-it notes to write their questions on. Explain that the post-it notes are for participants to ask questions they choose not to ask out loud, for questions that come up but will be covered in a later module, or for questions the trainer needs to get answers to before the end of the day. All questions on the parking lot will be addressed by the trainer before the end of the day. • Review Turningpoint – what it is and how it will be used during the training.
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• Review agenda for the day.
Preparing to Train - Activities • The pre-test is administered as explained in Module 1, page 11. • Review the following 2 options for the icebreaker and decide which one you will be using today. Option 1 – “Something about you” This ice breaker typically flows with participants sharing their expectations for the day (which you will write on the flip chart). Inform the participants to give some thought as to what they want to learn or accomplish during the day. Then instruct participants to think of something about themselves that no one would know just by looking at them and be prepared to share it with the rest of the group. For the actual activity invite them to share their name, the name of their employer, their position, how long they have worked in this area, the expectations for the day, and something about them that no one would know just by looking at them. Share that sometimes we make assumptions based on someone’s age, manner of dress, or some other outwardly evident characteristic but that might mean we are missing something that could be important. Watch biases and preconceived expectations as well as being routine. Option 2 – The “f” Test Distribute the “f” slip for the exercise and have participants leave it face down until everyone has received a copy. The “f” slip can be found in Module 1, Page 29. When all have a copy, have them turn it face-up and give them about 6 seconds to count the number of “f’s” in the sentence. Have them turn it face-down. Ask them how many “f’s” there were. They will answer anything from 3 to 6. The correct number is 6. They probably missed the “f” in of. Ask how many “s’s” were in the sentence. They probably will have no idea because that wasn’t what they were focused on knowing. There are 7. Now ask what the sentence was about. They will probably know something about “scientific files.” Again, it wasn’t what they were focused on knowing. Share that the point is if they are focused on knowing some particular information from or about their patient/client they may be missing
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something else that could be important. Watch biases and preconceived expectations as well as being routine.
• There are two options for the Title X section of the curriculum, depending upon the background of the participants. Choose one of the following options to use during the training. Option 1 of 2 – Lecture Title X materials Use this option if the attendees are predominantly from Title X clinics.
Option 2 of 2 –The Option of Adoption Video/DVD Use this option if the attendees are not predominantly from the Title X clinics. This 17-minute video provides a foundation to nurses and other health care providers about the importance of their interactions with women faced with unintended pregnancies. There are first person testimonials from birth mothers explaining how their interactions with health care providers have affected them. • The values clarification exercise has two options. Select one before you begin training.
Option 1 of 2: Values Exercise, Personalized Adoption Work Sheet. This exercise gives you an opportunity to describe the experiences you have had that impacted your view of adoption, to assess how this experience affected your opinion about adoption, and to probe how this experience might impact your ability to discuss adoption in your professional role.
Option 2 of 2: Values Exercise – Imagine Team Activity This exercise will increase your awareness of your own preferences as they relate to adoption by using a guided imagery technique.
Preparing to Train – TurningPoint □ Test this and all equipment at the office before leaving for the training site. □ TurningPoint set-up: o Step one: Set up the laptop and LCD as you would with a regular training. Ensure that the TurningPoint software is saved on the laptop desktop. o Step two: Insert the “receiver” into the USB port. o Step three: Open the TurningPoint software by double clicking on the “TurningPoint” icon on the desk top. o Step four: Then open up the TTT PowerPoint presentation. There will be a TurningPoint icon in the toolbar on the upper left-hand side.
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o Step five: To run the Hardware Wizard, select Tools and choose “setting.” Click the “Polling Test” tab at the upper left side of the screen. You can now test your hardware by clicking on “start test” in the lower right hand corner. Test the key pads by pushing any button on each of the Response Cards in turn. When finished, click “end test.” Then click “done” to end the Hardware Wizard. o Step six: If you have run a test prior to the training you will need to remember to “Reset” the session before starting the slide show. To do this, click on the “Reset” button on the toolbar and then click on reset session. o Step seven: Start the slide show.
Required Materials/Equipment and Room Set-up for this Module • Pre-test • Flip chart easel and flip chart • Parking Lot Poster • Markers • F’s test sentences • The Option of Adoption Video • TV-VCR or DVD Player • Laptop and Projector • Screen to show PowerPoint presentation and DVD’s • TurningPoint hardware (receivers and remote devices) • TurningPoint software uploaded to computer
Pre-test • Administer pre-test as directed in Module 1, page 11.
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Module 1: Introduction
Objectives:
Differentiate personal and professional attitudes, experiences, and possible biases related to adoption so that counseling, including the adoption option, is provided in an objective, non-biased way.
Content • Welcome and Introductions • Pre-test • Personal and Professional Values
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Trainer’s Comments (8 minutes) • Welcome participants Introduce yourself. Identify your employer and role in adoption or options counseling. Also inform group that today you are representing Spaulding for Children, the agency that received this federal grant and developed this curriculum. • Provide location of restrooms • Discuss cell phone use • Discuss breaks and lunch • Share requirements to receive nursing contact hours. All participants receive contact hours if they sign in, are present for the entire program, complete the pre-test and the post test, complete the “Training Reflection Feedback Form,” and submit the documents to the trainer. The Certificate of Completion, which provides documentation of contact hours, is given to participants when the final documents are turned in. • Post “Parking Lot” poster in rear of room or off to the side so participants have easy access to it. Do not hang it near the trainer or at the front of the room. Make sure that participants have post-it notes to write their questions on. Explain that the post-it notes are for participants to ask questions they choose not to ask out loud, for questions that come up but will be covered in a later module, or for questions the trainer needs to get answers to before the end of the day. All questions on the parking lot will be addressed by the trainer before the end of the day. • See Trainers Preparation (Module 1, page 1) for explanation of the parking lot. • Explain use of Participant Handbook (PH) • Explain use of Turningpoint Hardware. TurningPoint is an educational tool using response devices within a PowerPoint presentation. The TurningPoint slides are either ‘Multiple Choice’ or ‘True or False’ questions that you as the audience respond to using your response devices. The computer automatically tallies the answers and provides a graph with the answers. It is completely anonymous and allows the trainer to check the audiences’ understanding of the training material. It helps
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us, as the trainer, to check to make sure we have explained the material well and in a way that is clear to you as participants.
As the trainer, you will proceed through the PowerPoint presentation as you normally would. When you come to a TurningPoint slide, there will be a toolbar at the top of the slide indicating that the polling is open. Once the audience has answered the question, click to proceed and a graph will display the audiences’ responses. Click again and you will continue to navigate through your presentation.
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
I feel comfortable and confident discussing adoption as one of the options in family planning. (Test Question)
The goal of the training is to enhance the ability of health care and helping professionals provide adoption information and referrals to pregnant women, teens, and men, who are experiencing an unplanned/unintended pregnancy on an equal basis with all other courses of action in a nondirective, noncoercive manner.
In July of 2001, a notice and request for proposal was issued by DHHS to develop and implement “Infant Adoption Awareness Training Program” (IAATP) curricula. Spaulding for Children was awarded the grant for the 2001 to 2004 period. This grant was funded and awarded to Spaulding for Children for two years in 2004, for another five years in 2006, and recently awarded this grant again for 17 months..
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The purpose of these programs is to prepare “representative staff” from section 1001 clinics; school-based health clinics; section 330 health centers; and private, non-profit health centers who serve pregnant women; and to offer and provide information to their patient/clients about the option of adoption on an equal basis with other options.
The purpose of the grant is to help health care professionals learn appropriate ways to assist a pregnant woman or teen who MIGHT want to consider adoption for her unborn or newborn child.
We will not include information about international adoption, foster care adoption, or older child adoption. See Participant Handbook, Module 1, page 11 for a copy of the Children’s Health Act.
As we go through the day please remember that Infant Adoption Awareness is about EDUCATING, NOT ADVOCATING for adoption.
• The UIA (Understanding Infant Adoption) training series consists of six modules. Each training module will provide information that will build on the previous module. See Participant Handbook, Module 1, page 2.
Module 1, Introduction - provides an overview of the curriculum content, general requirements for options counseling, and a beginning exercise on adoption awareness.
Module 2, Adoption Practice - focuses on adoption history, various types of adoption, adoption perspectives from members of the triad, and adoption values.
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Module 3, Laws and Procedures - focuses on State and Federal laws regulating adoption and rights of birth parents, adoptive parents and birth grandparents; laws related to consent for medical treatment by teens; and mandated reporting laws for health care professionals.
Module 4, Social, Cultural and Personal Influences - focuses on working with adults and teens around emotional, cultural, religious/spiritual, family, and lifestyle issues influencing the decisions about the pregnancy.
Module 5, Nondirective Techniques and Informed Choice - focuses on knowledge development and skills training in nondirective techniques.
Module 6, Resources and Community Referrals - focuses on identifying needs and connecting the patient/client to appropriate resources.
• The content of this training raises some sensitive issues. If you are uncomfortable with any of the activities, feel free to limit your participation.
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Participant Introductions
Note to Trainer: You have 7 minutes for introductions. • Please have the participants introduce themselves giving the name of their employer, their position, and how long they have worked in this area. Use one of the following two ice breakers in your introductions.
• If your group size permits, ask each participant to share their expectation or a question about adoption that they want to be sure is covered during the training. These comments should be written on a flip chart. Option 1 – “Something about you” This ice breaker typically flows with participants sharing their expectations for the day (which you will write on the flip chart). Inform the participants to give some thought as to what they want to learn or accomplish during the day. Then instruct participants to think of something about themselves that no one would know just by looking at them and be prepared to share it with the rest of the group. For the actual activity invite them to share their name, the name of their employer, their position, how long they have worked in this area, the expectations for the day, and something about them that no one would know just by looking at them. Share that sometimes we make assumptions or jump to conclusions based on what someone looks like or how they are dressed. Option 2 – The “f” Test Distribute the “f” slip for the exercise and have participants leave it face down until everyone has received a copy. The “f” slip can be found in Module 1, Page 29. When all have a copy, have them turn it face-up and give them about 6 seconds to count the number of “f’s” in the sentence. Have them turn it face-down. Ask them how many “f’s” there were. They will answer anything from 3 to 6. The correct number is 6. They probably missed the “f” in of.
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Ask how many “s’s” were in the sentence. They probably will have no idea because that wasn’t what they were focused on knowing. There are 7. Now ask what the sentence was about. They will probably know something about “scientific files.” Again, it wasn’t what they were focused on knowing. Share that the point is if they are focused on knowing some particular information from or about their patient/client they may be missing something else that could be important. Watch biases and preconceived expectations as well as being routine. Pre-test (20 minutes)
Trainer’s Comments • This training program is federally funded and requires ongoing evaluation. We are administering a pre-test and post test as part of the ongoing evaluation. You must complete both the pre-test and the post test to receive your Certificate of Completion at the end of the training.
• We will be using scanable answer sheets for the pre and post tests. Say to participants; “At the end of the day you will receive the correct answers from the trainer. We would like to encourage you to please provide your name and address for use by our evaluator for future contact and evaluations.”
• You have a manila envelope with the materials provided to you today. Please separate the yellow pre-test from the envelope as this is the test you need to take now. Please put your name on the outside of the manila envelope and put the envelope aside for use at the end of the day. The pre and post tests are both numbered so this helps the evaluators match up the two tests and they are then able to monitor how well we have done as trainers.
• Your individual test results are confidential and known only to an independent evaluator.
• Please complete the pre-test now. Please do not fold the scannable answer sheet or write on the test question sheets. You will have 20 minutes. I will pick them up at your table.
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Personal and Professional Values (8 minutes)
Trainer’s Comments • Everyone is touched by adoption in one way or another. • Approximately 135,000 adoptions are completed in the United States each year. 1.7 million homes contain an adopted child, which comprises 4% of all homes that have children. Of these about 13,000 to 14,000 involved infants who are voluntary relinquished domestically. Of non-stepparent adoptions each year, approximately 59% are from the child welfare system, 26% are from abroad (intercountry) and 15% are domestic infants. (Source: Safeguarding the Rights and Well-Being of Birthparents in the Adoption Process, November 2006, Prepared by: the Evan B. Donaldson Adoption Institute). • Refer participants to Participant Handbook, Module 1, page 4. • The health care provider’s professional responsibilities in options counseling includes knowing the choices available, having basic knowledge of the implications of the different choices, providing information on each choice, and making referrals so that patient/clients can get the additional information they need before making their informed decisions about their pregnancies. • The health care provider has the professional responsibility of presenting all options to the client without providing their own opinion of what they would have done in the same situation or what they think the patient/client should do. • It is not the health care provider’s responsibility to agree with the patient/clients’ decision and in fact they should not let their opinion be known. • It must also be remembered that the patient/client’s choice includes the right to refuse information. • Value systems, individual and professional, are an organized set of beliefs that are important in guiding individual behavior.
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• Consistent with nationally recognized medical standards, family planning projects must offer pregnant women the opportunity to be provided information and counseling regarding prenatal care and delivery, infant care, foster care or adoption, and pregnancy termination. • If requested to provide such information, family planning providers are to provide neutral, factual information on each of the options, and referrals upon request, except with respect to any option(s) about which the pregnant woman indicates she does not wish to receive such information and counseling. • These organizations include: The Bureau of Family Health Care American College of Obstetricians and Gynecologists Child Welfare League of America Council on Accreditation for Children and Families American College of Nurse – Midwives National Association of Social Workers • A chart with the standards of various organizations entitled “Clinical Guidelines for Nondirective Counseling of Pregnant Women” is in the Participant Handbook, Module 1, pages 16 and 17.
• It is recognized that the scope of “options counseling” varies by organization, both Title X funded as well as other public and private nonprofit health centers. • This training directs the content to health care staff in any of these settings who respond to questions from patient/clients providing basic information, and then referring patient/clients to pregnancy counseling and/or adoption agencies to provide more in-depth “counseling.” • “The Family Planning Services and Population Act of 1970 added Title X, Population Research and Voluntary Family Planning Programs” to the Public Health Services Act. Section 1001 of the act authorized grants to assist in the establishment and operation of family planning projects. (Source: USDHHS, OPHS, OPA Jan. 2001) A copy of this act can be found in your Participant Handbook, Module 1, page 11.
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• Title X family planning guidelines create a context for information that will be presented in this module. The Title X guidelines meets or exceeds those of most professional organizations. • Title X programs, funded under section 1001 of the Public Health Service Act, 42, U.S.C. 300, have always been required to offer options counseling to women with unplanned pregnancies. • NOTE TO TRAINER: There are two options for this exercise. Describe the activity you have chosen to use in this training.
Option 1 of 2 – Lecture (5 minutes) USE THIS OPTION IF PARTICIPANTS ARE PREDOMINATELY TITLE X EMPLOYEES • Refer participants to Participant Handbook, Module 1, page 5.
• Title X family planning programs are required to: Offer pregnant adults/teens the opportunity to be provided information and counseling regarding each of the following options: prenatal care and delivery, infant care, foster care or adoption, and pregnancy termination. Provide neutral, factual information and nondirective counseling on each of the options and referral on any option the woman chooses. Provide services without subjecting individuals to any coercion to accept any specific method. Provide services in a manner that protects individual dignity. Provide for social services related to family planning, including counseling, referral to and from other social and medical services. Provide for coordination and use of referral arrangements with other providers of health care services, local health and welfare departments, and health services projects. • Central to the provision of services to pregnant women is the concept of informed consent. Informed consent requires that the pregnant woman: is provided information about all the options available to her and the consequences of each choice,
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is competent, for example has the intellectual/mental and legal capacity to make a choice/decision and is not forced by any external persons or situations to make a particular decision. • Even though you may not work in a Title X funded organization, these standards are consistent with those of most professional organizations. • This training will include more detailed discussions of nondirective, noncoercive counseling and informed consent as these concepts are important to health care and adoption professionals. • Individuals, as well as professions, are guided by multiple or changing clusters of values, rather than single or isolated values. • Personal values must be recognized and controlled so that they do not interfere with professional responsibilities. (Test Question) • Values clarification is a process that helps to identify the personal and professional values that guide an individual’s actions. It is an ongoing developmental process. • You have an article in your Participant Handbook, Module 1, page 18, “Legal and Ethical Considerations for Health Care Professionals in Pregnancy Counseling and Adoption,” which provides additional information on values and ethics.
Transition We will now do a values exercise which allows us to see how any experiences with adoption might affect your opinion about adoption as well as your ability to discuss adoption in your professional role. TRAINER NOTE: Continue in Trainer Guide, Module 1, page 17 with one of the Values Exercises provided.
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Option 2 of 2: The Option of Adoption Video
USE THIS OPTION IF THE ATTENDEES ARE NOT PREDOMINATELY TITLE X EMPLOYEES
The Option of Adoption Video (17 minutes)
Video Description
The Option of Adoption is a 17-minute video that provides a foundation to nurses and other health care providers about the importance of their interactions with women faced with unintended pregnancies. Included are first person testimonials from young women explaining how their interactions with health care providers have affected them, as well as insights from nurses and other health care professionals regarding the importance of their interactions with young women facing an unintended pregnancy.
Directions
• Tell participants to watch for and be aware of the importance of their interactions with women faced with unintended pregnancies. • Play video
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Trainer’s Comments • This video clearly shows the importance of health care providers and the work you do with women facing an unintended pregnancy. What you say and do is important. • What are some of the comments made in the video that you see as important to remember in your work as health care providers? . How painful this decision could be . How alone the young women felt . How important a kind word was to them during this time
Trainer’s Comment • Individuals, as well as professions, are guided by multiple or changing clusters of values, rather than single or isolated values. • Personal values must be recognized and controlled so that they do not interfere with professional responsibilities. (Test Question) • Values clarification is a process that helps to identify the personal and professional values that guide an individual’s actions. It is an ongoing developmental process. • You have an article in the pink pages in your Participant Handbook, Module 1, page 18, “Legal and Ethical Considerations for Health Care Professionals in Pregnancy Counseling and Adoption,” which provides additional information on values and ethics. • So in order to proceed through the rest of the training recognizing our personal biases, we are going to engage in an individual values clarification activity.
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Transition We will now do a values exercise which allows us to see how any experiences with adoption might affect your opinion about adoption as well as your ability to discuss adoption in your professional role. • TRAINER NOTE: There are two options for this exercise. Describe the activity you have chosen to use in this training.
Option 1 of 2: Values Exercise (7 minutes) Personalized Adoption Work Sheet
Overview • This exercise gives the participants an opportunity to describe the experiences that may have impacted their view of adoption, to assess how this experience may have affected their opinion about adoption, and to probe how this experience might impact their ability to discuss adoption in their professional role.
Directions • Ask participants to turn to Personalizing Adoption Work Sheet, Participant Handbook, Module 1, page 8. • Instruct the participants to read and answer the questions. They will have 5 minutes to complete the question and answers. Upon completion, debrief with the participants as a large group.
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• As the trainer it is helpful to briefly share your own personal adoption experience to have an example of what it meant and how it has impacted or does impact you in your professional role, before asking the participants to complete the exercise.
Trainer’s Comments • Please read and answer the questions in the Participant Handbook, Module 1, page 8. You will have 5 minutes to write down your adoption experiences and answer the questions. • You can volunteer to share this experience in the large group. No one will be required to tell their story.
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Option 1 of 2 Personalizing Adoption Work Sheet (5 minutes)
Please take 5 minutes to think about your personal adoption experience in answering the following questions. If you choose, you may share this experience.
My experience . . .
How might this experience affect the way I view adoption?
How might my experiences and views affect my ability to discuss the adoption option with my patient/clients?
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Large Group Discussion Ask for two to three volunteers to share their adoption experience with the large group. Have each volunteer talk about how their experience has affected their values regarding adoption.
Trainer’s Comments • Personal life experience can create the basis for individual values around adoption. • It is important to be aware of how our values can impact our work with patient/clients. • It is a constant challenge to keep our personal biases from influencing our professional responsibilities. However, the first step in managing the influence of personal biases is to recognize that they exist and to actively monitor our conversations and actions with patient/clients to ensure that they give accurate information and do not reflect our personal biases.
TRAINER NOTE: Continue in Trainer Guide, Module 1, page 23 with the Trainer’s Comments.
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Option 2 of 2: Values Exercise – Imagine (5 minutes) Individual Activity
Overview • This exercise is to increase your awareness of your own values as they relate to adoption and how this can influence your work with patient/clients by using a guided imagery technique.
Directions Ask participants to turn to Values Exercise - Imagine, Participant Handbook, Module 1, page 9.
TRAINER NOTE: If male trainee is present, include male perspective. • It is important to be aware of how our values can impact our work with patient/clients. • This is a personal exercise. If it makes you uncomfortable due to your personal background, you may choose to think about something else during this exercise. • Have participants close their eyes during the exercise and ask them to “Imagine when you were 18 years old, who were your friends? Put yourself back into that time. You just found out that you are pregnant. The father of the baby left town to attend college, and you have no relationship with him.” • “Think about what you are feeling. Don’t speak, just think about it.”
PAUSE
• “Who do you want to tell?” • “Were you planning on having a baby?”
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• “What choice about the pregnancy are you thinking of making? (Parenting? Abortion? Adoption?)”
PAUSE.
• “We will not be asking you to share this information with the group. With your eyes closed, raise your hand when you have decided what you will do.”
PAUSE.
• “Now let’s assume that option is no longer available to you. What is your second choice? With your eyes closed, raise your hand when you have decided what you will do.”
PAUSE.
• “Now imagine that your 18-year-old daughter is pregnant. What do you hope/want her to decide? With your eyes closed, raise your hand when you have decided.”
PAUSE.
• “It is okay to open your eyes now.”
Trainer’s Comments • The purpose of this exercise is to increase your awareness of your own values as they relate to adoption. • We all have our biases and values and the more aware of them that we are, the more we can separate our own opinions from the process of helping a patient/client determine what is the best decision for them. • Interestingly, sometimes what we think is best for us or for one person is not what we think is best for another person. • Did that happen to anyone here? • Does anyone want to share after this exercise?
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• Allow a minute to talk. If no one chooses to speak, recognize this is a sensitive issue that people may not be comfortable talking about. • It is a constant challenge to keep our personal biases from influencing our professional responsibilities. However, the first step in managing the influence of personal biases is to recognize that they exist and to actively monitor our conversations and actions with patient/clients to ensure that you give accurate information that does not reflect your personal biases. • Are there any questions or comments related to the interplay between personal and professional values and adoption?
Trainer’s Comments
• Module 1 is the beginning of the six module UIA training series. It provided an overview of the content of the curriculum, reviewed the professional standards, and offered you an opportunity to begin to look at your own values about adoption. • Do you have any questions or comments about any of the material covered in this module? • The health care provider’s professional responsibilities in options counseling includes knowing the choices available, having basic knowledge of the implications of the different choices, providing information on each choice, and making referrals so that patient/clients can get the additional information they need before making their informed decisions about their pregnancies. • Personal values must be recognized and controlled so that they do not interfere with professional responsibilities. (Test Question) • It is important to separate personal values from professional values in providing options counseling. (Training Reflection Feedback Form) • It is important to be aware that personal attitudes, experiences and possible biases may impact the work with patient/clients. (Training Reflection Feedback Form)
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TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Personal values must be recognized and controlled so that they do not interfere with professional responsibilities. (Test Question)
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
The healthcare professional should make their opinion known to their patient/client and tell their patient/client what they would do in the situation. (Test Question)
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Transition • Remind participants to review; “Public Law 106-310, Children’s Health Act,” “Clinical Guidelines for Nondirective Counseling of Pregnant Women,” and “Legal and Ethical Considerations for Health Care Professionals in Pregnancy Counseling and Adoption,” in the reference materials (pink pages) of their Participant Handbook, Module 1, pages 11-22. • Now that we have introduced the format for the day, the modules we will be covering, talked a little about Title X requirements, and started to explore our personal feelings about adoption, we will move into adoption practices and how they have changed over time. • We will now proceed to Module 2, Adoption Practices.
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To Find Out More About It
Child Welfare League of America. (2000). CWLA Standards of Excellence for Adoption Services. Washington, D.C.: Child Welfare League of America, Inc.
Council on Accreditation. (2001). COA Standards for Adoption Services. New York: Council on Accreditation for Children and Family Services, Inc.
Council on Accreditation. (2001). COA Standards for Pregnancy Counseling and Supportive Services. New York: Council on Accreditation for Children and Family Services, Inc.
Freundlich, Madelyn. (2000). Adoption and Ethics: The Market Forces in Adoption. Washington, D.C.: Child Welfare League of America, Evan B. Donaldson Adoption Institute.
Freundlich, Madelyn. (2001). Adoption and Ethics: The Impact of Adoption on Members of the Triad. Washington D.C.: Child Welfare League of America, Evan B. Donaldson Adoption Institute.
Freundlich, Madelyn. (2001). Adoption and Ethics: Adoption and Assisted Reproduction. Washington D.C.: Children Welfare League of America, Evan B. Donaldson Adoption Institute.
National Adoption Information Clearinghouse. (2001). How Many Children Were Adopted in 2000 and 2001? Washington, D.C.: The National Adoption Information Clearinghouse.
Public Health Services Act, Title X/Section 1001 and Community Health Centers Act Section 330.
The George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy (2001). Clinical Guidelines for Nondirective Counseling of Pregnant Women. Washington, D.C.: The George Washington University.
United States Department for Health and Human Services, (2001) Program Guidelines for Project Grants for Family Planning Services.
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FINISHED FILES FINISHED FILES FINISHED FILES ARE THE RESULT ARE THE RESULT ARE THE RESULT OF YEARS OF OF YEARS OF OF YEARS OF SCIENTIFIC STUDY SCIENTIFIC STUDY SCIENTIFIC STUDY COMBINED WITH COMBINED WITH COMBINED WITH THE EXPERIENCE THE EXPERIENCE THE EXPERIENCE OF YEARS OF YEARS OF YEARS FINISHED FILES FINISHED FILES FINISHED FILES ARE THE RESULT ARE THE RESULT ARE THE RESULT OF YEARS OF OF YEARS OF OF YEARS OF SCIENTIFIC STUDY SCIENTIFIC STUDY SCIENTIFIC STUDY COMBINED WITH COMBINED WITH COMBINED WITH THE EXPERIENCE THE EXPERIENCE THE EXPERIENCE OF YEARS OF YEARS OF YEARS FINISHED FILES FINISHED FILES FINISHED FILES ARE THE RESULT ARE THE RESULT ARE THE RESULT OF YEARS OF OF YEARS OF OF YEARS OF SCIENTIFIC STUDY SCIENTIFIC STUDY SCIENTIFIC STUDY COMBINED WITH COMBINED WITH COMBINED WITH THE EXPERIENCE THE EXPERIENCE THE EXPERIENCE OF YEARS OF YEARS OF YEARS FINISHED FILES FINISHED FILES FINISHED FILES ARE THE RESULT ARE THE RESULT ARE THE RESULT OF YEARS OF OF YEARS OF OF YEARS OF SCIENTIFIC STUDY SCIENTIFIC STUDY SCIENTIFIC STUDY COMBINED WITH COMBINED WITH COMBINED WITH THE EXPERIENCE THE EXPERIENCE THE EXPERIENCE OF YEARS OF YEARS OF YEARS FINISHED FILES FINISHED FILES FINISHED FILES ARE THE RESULT ARE THE RESULT ARE THE RESULT OF YEARS OF OF YEARS OF OF YEARS OF SCIENTIFIC STUDY SCIENTIFIC STUDY SCIENTIFIC STUDY COMBINED WITH COMBINED WITH COMBINED WITH THE EXPERIENCE THE EXPERIENCE THE EXPERIENCE OF YEARS OF YEARS OF YEARS FINISHED FILES FINISHED FILES FINISHED FILES ARE THE RESULT ARE THE RESULT ARE THE RESULT OF YEARS OF OF YEARS OF OF YEARS OF SCIENTIFIC STUDY SCIENTIFIC STUDY SCIENTIFIC STUDY COMBINED WITH COMBINED WITH COMBINED WITH THE EXPERIENCE THE EXPERIENCE THE EXPERIENCE OF YEARS OF YEARS OF YEARS
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114 STAT. 1101 PUBLIC LAW 106–310—OCT. 17, 2000 Public Law 106–310 106th Congress An Act to amend the Public Health Service Act with respect to children’s health.
Be it enacted by the Senate and House of Representatives of the United States of America in Congress assembled,
SECTION 1. SHORT TITLE. This Act may be cited as the ‘‘Children’s Health Act of 2000’’.
TITLE XII—ADOPTION AWARENESS Subtitle A—Infant Adoption Awareness SEC. 1201. GRANTS REGARDING INFANT ADOPTION AWARENESS. Subpart I of part D of title III of the Public Health Service Act, as amended by section 801 of this Act, is amended by adding at the end the following section:
SEC. 330F. CERTAIN SERVICES FOR PREGNANT WOMEN. (a) INFANT ADOPTION AWARENESS.— (1) IN GENERAL.—The Secretary shall make grants to national, regional, or local adoption organizations for the purpose of developing and implementing programs to train the designated staff of eligible health centers in providing adoption information and referrals to pregnant women on an equal basis with all other courses of action included in nondirective counseling to pregnant women. (2) BEST-PRACTICES GUIDELINES.— (A) IN GENERAL.—A condition for the receipt of a grant under paragraph (1) is that the adoption organization involved agree that, in providing training under such paragraph, the organization will follow the guidelines developed under subparagraph (B). (B) PROCESS FOR DEVELOPMENT OF GUIDELINES.— (i) IN GENERAL.—The Secretary shall establish and supervise a process described in clause (ii) in which the participants are— (I) an appropriate number and variety of adoption organizations that, as a group, have expertise in all models of adoption practice and that represent all members of the adoption triad (birth mother, infant, and adoptive parent); and 42 USC 254c–6. (II) affected public health entities. (ii) DESCRIPTION OF PROCESS.—The process referred to in clause (i) is a process in which the participants described in such clause collaborate to develop best-practices guidelines on the provision of adoption information and referrals to pregnant women on an equal basis with all other courses of action included in nondirective counseling to pregnant women. (iii) DATE CERTAIN FOR DEVELOPMENT.—The Secretary shall ensure that the guidelines described in clause (ii) are developed not later than 180 days after the date of the enactment of the Children’s Health Act of 2000. (C) RELATION TO AUTHORITY FOR GRANTS.—The Secretary may not make any grant under paragraph (1) before the date on which the guidelines under subparagraph (B) are developed.
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(3) USE OF GRANT.— (A) IN GENERAL.—With respect to a grant under paragraph (1)— (i) an adoption organization may expend the grant to carry out the programs directly or through grants to or contracts with other adoption organizations; (ii) the purposes for which the adoption organization expends the grant may include the development of a training curriculum, consistent with the guidelines developed under paragraph (2)(B); and (iii) a condition for the receipt of the grant is that the adoption organization agree that, in providing training for the designated staff of eligible health centers, such organization will make reasonable efforts to ensure that the individuals who provide the training are individuals who are knowledgeable in all elements of the adoption process and are experienced in providing adoption information and referrals in the geographic areas in which the eligible health centers are located, and that the designated staff receive the training in such areas. (B) RULE OF CONSTRUCTION REGARDING TRAINING OF TRAINERS.—With respect to individuals who under a grant under paragraph (1) provide training for the designated staff of eligible health centers (referred to in this subparagraph as ‘trainers’), subparagraph (A)(iii) may not be construed as establishing any limitation regarding the geographic area in which the trainers receive instruction in being such trainers. A trainer may receive such instruction in a different geographic area than the area in which the trainer trains (or will train) the designated staff of eligible health centers. (4) ADOPTION ORGANIZATIONS; ELIGIBLE HEALTH CENTERS; OTHER DEFINITIONS.—For purposes of this section: (A) The term ‘adoption organization’ means a national, regional, or local organization— (i) among whose primary purposes are adoption; (ii) that is knowledgeable in all elements of the adoption process and on providing adoption information and referrals to pregnant women; and (iii) that is a nonprofit private entity. (B) The term ‘designated staff’, with respect to an eligible health center, means staff of the center who provide pregnancy or adoption information and referrals (or will provide such information and referrals after receiving training under a grant under paragraph (1)). (C) The term ‘eligible health centers’ means public and nonprofit private entities that provide health services to pregnant women. (5) TRAINING FOR CERTAIN ELIGIBLE HEALTH CENTERS.— A condition for the receipt of a grant under paragraph (1) is that the adoption organization involved agree to make reasonable efforts to ensure that the eligible health centers with respect to which training under the grant is provided include— (A) eligible health centers that receive grants under section 1001 (relating to voluntary family planning projects); (B) eligible health centers that receive grants under section 330 (relating to community health centers, migrant health centers, and centers regarding homeless individuals and residents of public housing); and (C) eligible health centers that receive grants under this Act for the provision of services in schools. (6) PARTICIPATION OF CERTAIN ELIGIBLE HEALTH CLINICS.—
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In the case of eligible health centers that receive grants under section 330 or 1001: (A) Within a reasonable period after the Secretary begins making grants under paragraph (1), the Secretary shall provide eligible health centers with complete information about the training available from organizations receiving grants under such paragraph. The Secretary shall make reasonable efforts to encourage eligible health centers to arrange for designated staff to participate in such training. Such efforts shall affirm Federal requirements, if any, that the eligible health center provide nondirective counseling to pregnant women. (B) All costs of such centers in obtaining the training shall be reimbursed by the organization that provides the training, using grants under paragraph (1). (C) Not later than 1 year after the date of the enactment of the Children’s Health Act of 2000, the Secretary shall submit to the appropriate committees of the Congress a report evaluating the extent to which adoption information and referral, upon request, are provided by eligible health centers. Within a reasonable time after training under this section is initiated, the Secretary shall submit to the appropriate committees of the Congress a report evaluating the extent to which adoption information and referral, upon request, are provided by eligible health centers in order to determine the effectiveness of such training and the extent to which such training complies with subsection (a)(1). In preparing the reports required by this subparagraph, the Secretary shall in no respect interpret the provisions of this section to allow any interference in the provider- patient relationship, any breach of patient confidentiality, or any monitoring or auditing of the counseling process or patient records which breaches patient confidentiality or reveals patient identity. The reports required by this subparagraph shall be conducted by the Secretary acting through the Administrator of the Health Resources and Services Administration and in collaboration with the Director of the Agency for Healthcare Research and Quality. (b) APPLICATION FOR GRANT.—The Secretary may make a grant under subsection (a) only if an application for the grant is submitted to the Secretary and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this section. (c) AUTHORIZATION OF APPROPRIATIONS.—For the purpose of carrying out this section, there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 2001 through 2005.’’.
Subtitle B—Special Needs Adoption Awareness SEC. 1211. SPECIAL NEEDS ADOPTION PROGRAMS; PUBLIC AWARENESS CAMPAIGN AND OTHER ACTIVITIES. Subpart I of part D of title III of the Public Health Service Act, as amended by section 1201 of this Act, is amended by adding at the end the following section: SEC. 330G. SPECIAL NEEDS ADOPTION PROGRAMS; PUBLIC AWARENESS CAMPAIGN AND OTHER ACTIVITIES. (a) SPECIAL NEEDS ADOPTION AWARENESS CAMPAIGN.— (1) IN GENERAL.—The Secretary shall, through making grants to nonprofit private entities, provide for the planning, development, and carrying out of a national campaign
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to provide information to the public regarding the adoption of children with special needs.
(2) INPUT ON PLANNING AND DEVELOPMENT.—In providing for the planning and development of the national campaign under paragraph (1), the Secretary shall provide for input from a number and variety of adoption organizations throughout the States in order that the full national diversity of interests among adoption organizations is represented in the planning and development of the campaign. (3) CERTAIN FEATURES.—With respect to the national campaign under paragraph (1): (A) The campaign shall be directed at various populations, taking into account as appropriate differences among geographic regions, and shall be carried out in the language and cultural context that is most appropriate to the population involved. (B) The means through which the campaign may be carried out include— (i) placing public service announcements on television, radio, and billboards; and (ii) providing information through means that the Secretary determines will reach individuals who are most likely to adopt children with special needs. (C) The campaign shall provide information on the subsidies and supports that are available to individuals regarding the adoption of children with special needs. (D) The Secretary may provide that the placement of public service announcements, and the dissemination of brochures and other materials, is subject to review by the Secretary. (4) MATCHING REQUIREMENT.— (A) IN GENERAL.—With respect to the costs of the activities to be carried out by an entity pursuant to paragraph (1), a condition for the receipt of a grant under such paragraph is that the entity agree to make available (directly or through donations from public or private entities) non-Federal contributions toward such costs in an amount that is not less than 25 percent of such costs. (B) DETERMINATION OF AMOUNT CONTRIBUTED.—Non-Federal contributions under subparagraph (A) may be in cash or in kind, fairly evaluated, including plant, equipment, or services. Amounts provided by the Federal Government, or services assisted or subsidized to any significant extent by the Federal Government, may not be included in determining the amount of such contributions. (b) NATIONAL RESOURCES PROGRAM.—The Secretary shall (directly or through grant or contract) carry out a program that, through toll-free telecommunications, makes available to the public information regarding the adoption of children with special needs. Such information shall include the following: (1) A list of national, State, and regional organizations that provide services regarding such adoptions, including exchanges and other information on communicating with the organizations. The list shall represent the full national diversity of adoption organizations. (2) Information beneficial to individuals who adopt such children, including lists of support groups for adoptive parents and other postadoptive services. (c) OTHER PROGRAMS.—With respect to the adoption of children with special needs, the Secretary shall make grants—
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(1) to provide assistance to support groups for adoptive parents, adopted children, and siblings of adopted children; and (2) to carry out studies to identify— (A) the barriers to completion of the adoption process; and (B) those components that lead to favorable long-term outcomes for families that adopt children with special needs. (d) APPLICATION FOR GRANT.—The Secretary may make an award of a grant or contract under this section only if an application for the award is submitted to the Secretary and the application is in such form, is made in such manner, and contains such agreements, assurances, and information as the Secretary determines to be necessary to carry out this section. (e) FUNDING.—For the purpose of carrying out this section, there are authorized to be appropriated such sums as may be necessary for each of the fiscal years 2001 through 2005.’’
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Clinical Guidelines for Nondirective Counseling of Pregnant Women
Organization Guideline Type Non Language Cite Mention directive Adoption Bureau of Policy “…Health center clinic protocols Primary Health Information should reflect the current Care Notice: 98-23 guidelines established by health agencies or professional organizations such as the N/A Part II.7.a N/A Agency for Health Care Policy and Research, the American College of Obstetrics and Gynecology…”
American Guideline for “In the event of an unwanted College of Women’s pregnancy, the patient should be Obstetricians Health Care counseled about her options: 1) Routine and continuing the pregnancy to term Assessment Gynecologists and keeping the infant, 2) Y s: Under 18 Y continuing the pregnancy to term Years of and offering the infant for legal Age adoption, or 3) terminating the pregnancy.”
Child Welfare Standard of “The pregnant adolescent should League of Excellence: be provided with individual and America Services for group counseling about her Adolescent options: 1) continuing the Pregnancy pregnancy to term and keeping Standard Y Y Prevention, the infant, 2) continuing the 4.10 Pregnant pregnancy to term and offering Adolescents, the infant for legal adoption, or and Young 3) terminating the pregnancy.” Parents
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Organization Guideline Type Non Language Mention Cite directive Adoption Council on Standard: “The organization offers Accreditation Pregnancy counseling to help expectant for Children Counseling and parents decide if they want to and Families Supportive parent the child, plan for Standard Y Y Services adoption, transfer custody of the S13.2.01 child, or terminate the pregnancy.”
American Code of Ethics “Nurse-midwives share College of for Certified professional information with Nurse- Nurse- their clients that leads to Y Code Four N Midwives Midwives informed participation and consent. This sharing is done without coercion, or deception.” National Policy “The nature of the reproductive Association of Statement: health services that a client “Social Social Family Planning receives should be a matter of Work Workers and Y client self-determination in Speaks”: N Reproductive consultation with the qualified Page 113, Choice health care provider furnishing Policy Four them.” American House of “It is the policy of the AMA to Medical Delegates: (1) support the provision of Association Adoption Policy adoption information as an option to unintended Y pregnancies; and (2) support and H-420.973 Y encourage the counseling of women with unintended pregnancies as to the option of adoption.”
Produced by: The George Washington University School of Public Health and Health Services, Center for Health Services Research and Policy (CHSRP), November 2001 for the Department of Health and Human Services, Health Resources and Services Administration, Bureau of Primary Health Care.
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Legal and Ethical Considerations for Health Care Professionals in Pregnancy Counseling and Adoption
This article applies the law and accepted values and ethics of the health care profession to the practice of providing pregnancy options counseling. It describes conditions under which coercion can occur and defines noncoercive counseling. In addition, the article explores the concept of informed consent, as it applies to adoption. This information is intended to provide a legal and ethical framework in which to provide information and make effective referrals for pregnancy counseling and adoption services.
Background and the Law
In July of 2000, the Secretary of Health and Human Services issued regulations establishing requirements for recipients of family planning grants under section 1001 of the Public Health Service Act, 42 U.S.C. 300. The rules revoked the “gag rule” that restricted family planning grantees from providing abortion-related information in their grant-funded projects and reinforced a requirement that 1001 clinics provide information on all pregnancy options on an equal basis. Specifically, the law, as interpreted in the administrative rules, requires that the grantee:
Provide services in a manner that protects the dignity of the individual. Provide services without regard to religion, race, color, national origin, handicap disabilities condition, age, sex, number of pregnancies or marital status. Provide neutral, factual information and nondirective counseling on any option the pregnant woman requests including:
o prenatal care and delivery o infant care, foster care or adoption o pregnancy termination Provide for social services related to family planning, including counseling, referral to and from other social and medical services agencies and any ancillary services which may be necessary to facilitate clinic attendance. Provide for coordination and use of referral arrangements with other providers of health care services, local health and welfare departments, hospitals, voluntary agencies and health services projects supported by other Federal programs.
The Infant Adoption Awareness Training Program was funded by the Federal government to develop curricula that would help health care professionals provide information and support for the adoption option and make informed referrals for
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pregnancy counseling and adoption services for patient/clients who choose one or both of these options for further exploration.
Ethics and Values Underpinning the Provision of Public Health Services
Ethics defined: Ethics is a set, theory or system of moral principles or values. Making an ethical decision means making a choice that is consistent with a moral or professional code.
Because the health professional’s own values will be challenged in this work, it is especially important to be grounded in a set of accepted professional standards of conduct or ethics that support him/her to be unbiased and objective. Some of the ethical values in public or community health care that relate to options counseling include:
The Value of Self-Determination: This value respects a person’s autonomy and capacity to shape his/her own life. This is based on the belief that better outcomes will result when a person’s self-determination is respected, as well as the different views of self-determination among ethnic, cultural and religious groups. The Value of Equity: The value of equity means being treated equally or fairly. The principle of equity also implies that it is unjust to treat people the same who are different. Do all persons in different socio-economic and cultural groups have equal access to needed adoption information and services? Are all persons offered information on an equal basis with other options in unplanned pregnancy situations? The Value of Well-Being: This value assumes that any clinical intervention is to improve client’s health and well-being. However, to determine what constitutes health or well-being for a client one must consider the client’s subjective preferences. It is the health care practitioner’s role to understand the patient/client’s needs and present reasonable alternatives to the patient/client and/or surrogate decision-makers in a way that enables patient/clients and/or their surrogate decision-makers to choose those they prefer.
A decision-making framework that may help clarify ethical dilemmas includes:
Assessment: Decide whose problem it is. Who should make this decision? Who should be included in this decision? Diagnosis: Gather additional data. Have as much information about the situation as possible. Be up to date on any related laws or organizational policies.
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Outcome Identification: Identify with the patient/client as many alternatives as possible. The more options identified, the more likely it is that an acceptable solution will be found. Planning: Help the patient/client choose, from the options identified, the one that best satisfies his/her needs and preferences. Implementation: Help the patient/client carry out the decision, including collaboration with referral sources to implement the decision. Evaluation: Evaluate the results of the referral. From the patient/client’s perspective, what is working and not working?
What is Coercion? Coercion occurs when someone with more perceived power or authority forces a decision upon a patient/client; talks them into a decision; provides information that is incomplete or misleading; and/or offers gifts, bribes or other incentives for making a particular choice. Coercion could occur as a result of a parent of a minor child, or a husband or birth father, exerting excessive pressure on the patient/client. And it is especially detrimental when it occurs in collaboration with a “professional” lending credence to the forceful position.
For purposes of referring persons for pregnancy counseling and adoption, it is important to understand that coercion could possibly occur in many different ways. Coercion can simply be the result of overly directive, controlling, and/or subjective counseling from someone that the patient/client trusts. In adoption, coercion may consist of offering financial or other non-financial benefits to a person who is in desperate need or particularly vulnerable because of their situation. It could also occur through threat of violence or retribution.
What is Nondirective, Noncoercive Counseling? Noncoercive interventions include interviewing, counseling, and/or providing information and making referrals. Noncoercive methods present information and options through the use of open-ended questions designed to help the patient/client identify his/her options and preferences and make an informed decision that satisfies his/her needs and preferences. A nondirective, noncoercive intervention requires that the helping professional support the decisions made by the patient/client, including the decision to refuse information, even if he/she does not agree with these decisions.
What is Informed Consent? Informed consent is consent given after the patient/client or patient/client’s legal representative has been provided with complete information as to the conditions or situation requiring intervention, the choices/options in services or treatment, the consequences or probable consequences of each option with the patient/client freely choosing one course in lieu of another.
Informed consent in adoption is not very different from informed consent in health care. Although the health professional will not be involved directly in the consent process in an
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adoption matter, he/she will want to have reasonable assurances that the patient/client will not be exploited or “harmed” by the resource they refer the client to for services. In adoption and in health care, informed consent requires knowledge, voluntariness, and competency. These elements are defined as follows:
Knowledge: requires an explanation of the condition/situation requiring intervention; a description of the nature and purpose of all alternatives; description of any expected risks or consequences of the intervention, disclosure of the possibility that the proposed intervention will be unsuccessful, explanation of consequences of intervention or, if no intervention is given, an explanation of consequences of not receiving an intervention. Voluntariness: requires that the patient/client must be free to accept or reject the proposed treatment without any physical or psychological coercion. Competency: requires that the patient must be of sound mind and legally and mentally capable of making an informed decision.
How Can a Health Care Professional be Most Effective in Providing Information and Making Referrals? Providing pregnancy options information will be difficult because of realistic time constraints, but it can be particularly challenging in circumstances where there are significant conflicts within a family or other conflicting factors, such as differences in the helper’s and patient/client’s values, cultural/religious beliefs, and/or socio-economic background. Nonetheless, most health care professionals will take the time and care to provide necessary information and referral because they know how important their actions may be to their patient/client’s future. Health care professionals can maximize their effectiveness in providing information on pregnancy options and resources when they:
understand and demonstrate compassion for a patient/client’s unique situation. operate within the ethics and values of their profession, consistent with the policies and mission of their health care settings. provide information and support for patient/clients to be effective advocates for themselves and their unborn child in seeking help. develop a resource bank of quality, responsive and ethical referral sources. make referrals that are responsive to a patient/client’s needs and preferences, including culture, race, religion, ethnicity, and/or language.
Adoption will not be the chosen alternative for the majority of patient/clients seen by health care professionals but, for some individuals and their children, it may be a preferred course of action.
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Due to the finality of an adoption decision, it is important for health care professionals to offer their patient/clients information and help in finding a resource that meets their service needs and preferences, guarantees protections from coercion and/or exploitation, and provides necessary information for a fully informed consent to adoption.
Judith McKenzie, MSW Executive Consultant McKenzie Consulting, Inc. February 2002
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Module 2: Adoption Practices (60 minutes without optional activity)
Trainer’s Preparation
Module Contents and Training Process • Introduction • Historic and Current Practice • Change Over Time • Culture, Attitudes, and Beliefs/How Different Cultures View Adoption • Accurate and Neutral Adoption Language • The Adoption Triad and the Relationship Continuum
Preparing to Train • Preview the Adoption Then and Now video, which shows historical footage about adoption practice. This video also features the members of the adoption triad, adoption providers, pregnancy counselors and health care providers discussing the complexities, emotions and values related to adoption. • Preparations for discussion on the adoption triad.
• Prepare to have participants engage in a team activity reviewing accurate and neutral adoption language.
Optional Activity: Types of Adoption - Team Activity
The purpose of this activity is for participants to explore their own values and preferences regarding the types of adoption, to experience these options from the perspective of each member of the triad, and be able to understand differing opinions, values and perspectives.
If you choose to use this optional exercise you will need to prepare four flip chart pages. These need to be titled Closed/Confidential Adoption, Semi-Open Adoption, Open Adoption/Fully Disclosed Adoption and Kinship Adoption. The flip chart pages then need to be placed around the room, providing enough space between them for small groups to gather and write their remarks.
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Required Materials/Equipment and Room Set-up for this Module • Adoption Then and Now Video • TV-VCR or DVD Player • Laptop and Projector • Screen to show PowerPoint Presentation and DVDs • Flip chart easel • Flip chart
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Module 2: Introduction
Objectives: Discuss how adoption is viewed historically and currently and how it has changed over time. Describe the various types of adoption as well as current adoption practices. Select neutral adoption language to facilitate open communication about adoption. Describe the adoption triad. Describe the options birth parents have when considering adoption. Describe the psychological and emotional reactions, including grief and loss that the birth parents are likely to experience as they consider their options.
Content • Introduction • Historic and current practices • Accurate and neutral adoption language • The adoption triad and the relationship continuum
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Trainer’s Comments
Participant Handbook, Module 2, page 2.
Historical Perspective of Adoption: (5 minutes)
• Adoption has been practiced by many cultures and religions throughout human history. • Adoption in colonial America was treated as a transfer of property and was mostly informal rather than legal. • For instance, in the late 1800s and early 1900s approximately 150,000 orphans from the urban northeastern United States were taken by train throughout the Midwest and West. Children on these “orphan trains” were “put up for adoption” by being placed on railroad platforms for prospective parents to view and choose which child or children they would like “to adopt.” (Test Question) • In addition, during the late 1800s and until the mid 1900s American Indian children were systematically removed from their families generally without cause and adopted into non-Indian families. • Many other children were also removed from their families based only on poverty or other non-neglect or abuse criteria and adopted. • Adoption as a legal process began in the mid 19th century. • In 1851, the state of Massachusetts enacted the first state statute concerning adoption. • Modern practices, however, were slow to develop with many children impacted by practices that would be considered inhumane today.
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• Definition of Adoption: Adoption is a legal process. A permanent parent and child relationship is formed by the transfer of parental rights from one set of parents to another individual or couple who is willing to assume those rights and responsibilities over the child. • Adoption practice has changed dramatically over the last 60 years and continues to be an evolving process.
• Individuals central to the adoption process are the birth parents, the child or adoptee, and the adoptive parents. As a group, they are called “the triad.” You will see various members of the triad in the next video. Later we will also discuss the various types of adoptions.
“Adoption Then and Now” Video and Large Group Discussion (30 minutes)
Video Description
Adoption Then and Now is a 24-minute documentary-style videotape featuring a historical perspective of issues in adoption, including an introduction to a variety of issues that are unique to the adoption experience. Additionally, adoptive families, birth parents, adult adoptees and professionals share their perspectives.
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Directions • Tell participants to watch for key themes and issues in adoption that are portrayed in the video. • Tell participants to turn to Participant Handbook, Module 2, page 4 and be prepared to respond to the two questions after viewing the videotape. . In what areas has adoption changed the most over the past 60 years? . What are your thoughts on the lifelong impact of adoption on all members of the triad? • Play the video.
Large Group Discussion • In what areas has adoption changed the most over the last 60 years? (Responses from previous trainings are in italics). Confidentiality Openness; not as much secrecy Use of the internet to find families – search for birth families Children other than infants are being adopted Single parents are adopting Orphanages Birthparents more involved in decision making Supply and demand Rating of baby; matching Order: love, marriage, baby Right baby for family Legalization of adoption Involvement of birth father
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• Tell participants to go to Participant Handbook, Module 2, page 16-21, Issues and Perspectives in Adoption: Then and Now. • Search and Reunion (Test Question) Then: Birth parents who released their children and adoptees were discouraged from any future contact. Now: Many birth parents and adoptees look for and are reunited with each other. Most states have laws/legal procedures for facilitating this process. • Adoptable Children (Test Question) Then: Unhealthy or potentially unhealthy infants or children of color were not offered for adoption. Now: Infants of all races, ethnic origins and disabilities are adopted. • Coercion (Test Question) Then: Birth parents were often coerced into placing a child due to financial and social factors. Now: Most states have laws regarding what expenses can be paid. There are also laws prohibiting a person from placing his/her child if there was force, duress, or coercion. • We must point out that this historical perspective was that of the dominant culture. Other cultures experienced adoption differently.
• What are your thoughts on the lifelong impact of adoption on all members of the triad? Loss and grief need to be resolved at different life stages. Adoptees seem to have “a missing piece” until they either accept this or have a reunion experience. Remember Yoline from the video. Adoption decision is always a part of each member of the triad’s life.
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• We will discuss grief and loss as it relates to the adoption triad after we discuss accurate and neutral adoption language and the relationship continuum.
Accurate and Neutral Adoption Language Overview (10 minutes)
This activity helps participants to understand how language surrounding the issue of adoption has changed over time.
Trainer’s Comments • The language of adoption has changed as practices have changed. • This will also continue to evolve over time. • Adoption is a process, not a label. • When speaking about adoption, it is important to use accurate and neutral adoption language. Certain terms have the effect of closing doors and serving as barriers to having an open discussion about adoption.
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Directions • Refer participants to the Adoption Language Worksheet in the Participant Handbook, Module 2, page 6. Tell them that these are some common words or phrases associated with adoption. Tell them they will now complete the worksheet answering why the “Please Use…” language is preferred.
Team Activity • When speaking about adoption, it is important to use accurate and neutral adoption language. Let’s take a few moments to look at some terms. • Using the Adoption Language Worksheet found on the next page, discuss with your tablemates why the “Please Use…” language is preferred.
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ADOPTION LANGUAGE WORKSHEET
Instead of: Please use: Why? (possible responses) 1. Adopt out, give Make an adoption “Make an adoption plan” conveys that away, put up plan, choose adoption is a decision that has been for adoption adoption thought through. “Adopt out, give (Test Question) away, put up for adoption” conveys that the event is done casually or without thought. It also conveys the belief that the child is an object. 2. Keep the baby Chose to parent her Keeping the baby denotes a passive child, made a decision-making process. Parenting parenting plan. indicates that raising a child is an active process. Keep and give away things not people. Denotes that child will always be a baby; not a lifelong decision. 3. Real parent, Birth parent, “Real parent” conveys that adoptive natural parent biological parent parents are not real, natural or entitled (Test Question) to parent. “Birthparent” is an accurate description of the relationship between a child and the person who gave birth to them. 4. Not their own Adopted person, By differentiating own versus adopted, child adoptee, came to their the speaker invalidates the adoptive family through relationship. adoption 5. Illegitimate Born to unmarried or Illegitimate has a lot of negative single parents. connotations. Is the person illegal, fake, or not real?
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Large Group Discussion • Have participants share their “Why” answers for Item 1. This can be done by having one table share their answers and then ask if others have anything to add. After all the answers have been exhausted, the trainer makes sure that the participant’s answers cover all the significant points. • Repeat this process for the remaining items. • Can you think of other terms or phrases that you have heard of that are insensitive or inaccurate?
Transition Another aspect of adoption that continues to evolve is the types of adoption. Next we will explore the Relationship Continuum.
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The Relationship Continuum (10 minutes)
Trainer’s Comments • Today, adoption has a variety of options available to the birth and adoptive families. • With the child at the center of the decision-making, birth and adoptive families are asked to negotiate the amount of contact they wish to have with one another. When speaking of an adoption being open, semi-open, or closed we are speaking of the relationship between the birth and adoptive families. • In general, adoption agencies attempt to bring families together who have similar wishes regarding contact. For example, a birth mother who wants a fully disclosed or open adoption would not be shown the profile of an adoptive family who desires a confidential adoption. • In making adoption agreements, it is important for the parties to state their expectations clearly. • Having an “open adoption” does not imply anyone is legally obligated to continue to have contact. • It is also important to note that adoption agreements in many states are good faith agreements and not legally binding contracts. In these informal agreements either birth or adoptive families may choose to change or stop previously agreed upon visits and contacts. • It is always the adoptive family’s responsibility to ensure their child’s safety and well-being and certain issues might make continued contact unwise. • All decisions should be made with the child’s best interest at the heart of the discussion. • Some states, however, do have legally binding agreements that are enforceable. This will be discussed in further detail in Module 3, Adoption Law and Procedure.
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• Non identifying information (medical and social history on each of the birth parents and their families) must be shared with adopting parents. (Test Question) This is true for all adoptions. • Because of the varied requests and connections people make with one another in planning an adoption, there exists a continuum of approaches to the type of adoption. For simplicity, we are labeling the continuum, using terms which are most commonly recognized: confidential/closed, semi-open, and fully disclosed/open. See Participant Handbook, Module 2, pages 8-10.
CONFIDENTIAL or CLOSED ADOPTION • Characteristics include: The adoptive family receives a non-identifying medical and social history on each birth parent and their family. No identifying information is shared between the adopting and birth families. No communication or contact between the parties is expected. The potential birth parents may participate in selecting the adoptive family through non-identifying adoptive family profiles. In some states, an adoptee can access the adoption file upon adulthood. This means that they will be able to learn their birth parents identity. These states typically have a provision to address the issue of future contact. This will be discussed further in Module 3. Remember the video we just viewed – who had a confidential or closed adoption? Jerri, Michelle and Kyrras.
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SEMI-OPEN ADOPTION • Characteristics include: The adoptive family receives non-identifying information (medical and social history on each birth parent and their family). Birth parents and adoptive parents maintain contact with each other after the adoption finalizes, through a third party, such as an agency or attorney. (Test Question) This typically includes pictures and/or letters to each other sent on a previously agreed upon time schedule. For example, some people agree to send pictures of the child more frequently during the first year and then once or twice a year thereafter until the child reaches age 18. The birth parents agree to maintain a current address with the agency and update the agency/adoptive family with any pertinent information, such as medical information. Some adoptive parents agree to accept birthday and/or holiday presents from the birth parents. Direct contact may occasionally occur, usually at the agency or pre-arranged meeting place. Anonymity is typically maintained. Remember the video – who had a semi-open adoption? The birth couple was Andria and Ross. The adoptive couple was Doug and Debbie.
FULLY DISCLOSED or OPEN ADOPTION
• Characteristics include: Full disclosure of identifying information between parties occurs. For instance, addresses and names are shared between the birth and adoptive parents. (Test Question)
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Contact between the birth and adoptive family is direct, without the agency as the intermediary. Open adoptions most typically imply that there is a trusting relationship between the parties. Some are flexible relationships where the birth parent(s) are considered part of the adoptive family’s extended family, and vice versa.
Having an “open adoption” does not imply anyone is legally obligated to continue to have contact. Open adoption does not imply any legal obligation and either the birth or the adoptive family can change their plans regarding contact at any time; unless the adopting family lives in a state where there are legally binding open adoption agreements. This will be discussed in more detail in Module 3. Get-togethers are based on the lifestyle of the families; much like one would determine the extent of contact with in-laws. Remember the video – who had the fully disclosed or open adoption? Katie was the birth mother. The adoptive mom was Angela. • No two open adoptions are the same. Contact between the members of the triad may be spontaneous and initiated by either party at any time. Some may be determined by a previously developed agreement of scheduled contact/visits and/or phone calls, and/or letters/pictures. Parties may renegotiate contact over time. Most states do not have binding agreements. Adoptive parents maintain control over contact once the adoption is final. (Test Question) This will be discussed further in Module 3.
KINSHIP ADOPTION In many states, a close relative (grandparents, aunts, uncles, brothers and sisters) can adopt utilizing a less intense procedure for the adoption. Culturally, many more relatives, and even non-biological relatives, may be considered kin by the parents; however, every state defines a relative adoption differently. This will be discussed further in Module 3.
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Kinship or relative adoptions are a permanent and legal arrangement that is intended to last forever, like all other adoptions. (Test Question) This is notably different from the more informal family care, where, for example, the grandmother does most of the parenting for a temporary time until the parent(s) is able to take over parenting responsibility. Remember the video – who had the kinship adoption? . Caprice was the birth mother. The adoptive mom was her mother. In their case the adoption was fully open.
Trainers Comments
• As we have discussed, adoption today has a variety of forms and the relationships between the members of the triad can and do vary depending on the individual situation. • In all adoptions, social and medical information is shared between the birth and adoptive family. • Refer participants to Participant Handbook, Module 2, page 7. The grid demonstrates information shared in various types of adoption.
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CLOSED SEMI-OPEN OPEN KINSHIP ADOPTION ADOPTION ADOPTION ADOPTION
Adoptive family receives non-identifying information from the birth family Birth parents may participate in selection of the adoptive family unless it would violate MEPA/IEP Federal Law There are grief and loss issues for all parties Adoptive parents are responsible for all of the adoption fees Birth parents can update/send personal or medical information for the adoptive parents & child Communication between the birth and adoptive family is through a third * party or intermediary Communication between the birth and adoptive family is direct, no * intermediary Identifying information is shared between both parties *
* Based on individual circumstances
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• Because of the varied requests and connections people make with one another in planning an adoption, there exists a continuum of approaches to the type of adoption. • Kinship adoptions, for example, can fall anywhere along the relationship continuum. • It is recognized that a “one size” adoption does not fit all. People and relationships change over time. The adoption may start with specific agreements and arrangements, and later variations may occur as life stages change. It should be noted that it is normal for contact to ebb and flow throughout the lifespan of the adoption.
• All members of the adoption triad experience loss. Adoption can only happen as a result of loss; a person who was adopted may experience the loss of birth parents, extended relatives, community, culture and sometimes language. For birth parents, pre and post adoption counseling and supports are typically available to address their immediate issues. For some adoptive parents there may be the loss of the experience of pregnancy and having their biological child. • It is important to note that grief and loss accompany every adoption, no matter which type is selected. Adoption can only happen as a result of loss. Open adoption is not a cure for grief and loss. (Test Question) • Refer participants to Participant Handbook, Module 2, page 36 to review ‘Stages of Grief Following Delivery for Parents Planning Adoption.” This chart, developed by Gayle Ward, MA Education Institute, Kinship Center, summarizes the stages of grief both birth and adoptive families may experience after the child is born and while all remain in the hospital. • Many cultures traditionally did not engage in legal adoptions; but did informal adoptions, i.e. placed children with related or non-related caregivers without legal paperwork.
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• Some cultures where informal adoption has long been the practice may not be aware of financial and other benefits that may be available through legal adoption. • Adoptive parents are encouraged to be honest with their children about their adoption and celebrate rather than hide the fact. • In recent years birth and adoptive families started speaking out and said they wanted more involvement in the adoption planning process, and all three member groups of the triad wanted more information to be shared. In general participation and control by all parties has increased tremendously in the last 20 years. • It is not unusual for fathers to want to be involved in this process. It continues to be a challenge, however, for many providers to help them be full participants. • The birth father’s role has changed tremendously. Whereas once it was not necessary to even ask his name, it is now expected that he will participate in the process. We also know how important his genetic and family history is for the child. • Ongoing contact may reduce some anxieties, such as birth parents and the child not knowing whether or not the other is alive. However, some birth families will say the idea of having an ongoing relationship makes it MORE difficult for them to handle the grief of not raising the child. • Grief and loss is a process, it changes over time, and is triggered by new losses. Different people handle the grief and loss process in various ways. It is not something that should be minimized. • Birth parents may accept the loss and work through the grief, but feelings of loss may re-emerge over time and at perceived significant occasions i.e. birthdays, placement date, and/or holidays. • Birth parents never forget their child. The goal is for birth parents to integrate the loss into their ongoing lives and gain feelings of control so that they can move forward. Those who have a history of prior losses may find it more difficult to consider another loss of this nature.
TRAINER NOTE: If you choose not to do the following Optional Exercise turn to Trainer Guide, Module 2, page 22, Trainer’s Comments.
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Optional Exercise Types of Adoption – Team Activity Exercise (20 minutes)
Overview
• The purpose of this activity is for participants to explore their own values or preferences regarding the types of adoption, to experience these options from the perspective of each member of the triad, and be able to understand differing opinions, values and perspectives. There is no ‘right’ way and there is a lot of variation in types of adoption.
Directions • If the four flip chart pages titled Closed/Confidential Adoption, Semi-Open Adoption, Open Adoption/Fully Disclosed Adoption and Kinship Adoption were not placed on the wall in the morning, please put them up now. • Participants have the opportunity to select the type of adoption they prefer by walking over to the flip chart page of their choice. They will have the opportunity to pick different options if they want to, when asked to be in the shoes of different members of the triad. After they have had the opportunity to make a choice from all 3 perspectives, they stay in their 4 groups and get 5 minutes to write the pros and cons of the type of adoption on the flip charge page they came to with their final decision. The exercise ends with participants presenting the information they discussed in their small groups for 5 minutes (each of 4 groups has a scribe and a presenter). Reinforce their use of appropriate language during the exercise. • If a particular type of adoption has not been chosen, you the trainer should present the pros and cons of that type of adoption from the different perspectives of the triad, or ask the group to think of some. • If there is only one person at a flip chart page, the trainer joins to discuss the pros and cons.
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Trainer’s Comments • Now we are going to take a few minutes to do an activity about the types of adoption. • You’ll notice there are 4 flip chart pages on the wall with the options we have discussed. This activity is designed to have you think about how you would prefer to have an adoption handled in your family. Select the type of adoption that you would be most comfortable with if you were involved in an adoption and go stand by the flip chart page representing that type of adoption. You can go to the flip chart page, or you can stand between two flip chart pages if that best represents your preference. • Now, imagine you are the birth parent, if that is not what you were already thinking when you selected a type of adoption. If you would select a different type of adoption, go there now. PAUSE • Now, you are the child. If you would prefer a different arrangement between triad members, go to the flip chart page representing the type of adoption you now prefer. PAUSE • Now, you are the adoptive parent. Would you select a different type of adoption? Go ahead and move to the flip chart page representing that type of adoption, if it is different from where you are now. PAUSE • Now, remain where you are or if you are between two flip chart pages please go to the closest flip chart page and join that group.
Large Group Discussion • The trainer will lead the discussion by standing next to a poster with the group that is there. Ask the members of the small group to list the pros and cons of that
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type of adoption for each member of the triad. Once discussion is completed go to the next poster and repeat discussion. Note: As participants report the pros and cons make sure their comments are accurate. Clarify and correct adoption misconceptions – if it is a legal issue note it will be discussed in the next module.
• Different people make different choices based on their own perspectives. • Because their choices differ, are others wrong? Sometimes the birth mother and birth father make different agreements (one stays in touch and one doesn’t). Sometimes the birth grandparents are the ones who have an ongoing relationship with the child and neither birth parent does. Sometimes families pick one type of adoption and it changes over time (usually becoming more open, but sometimes more closed). • For those of you who switched types of adoption, can you explain why you switched? • Did peer pressure affect anyone when selecting a type of adoption? • Open and semi-open adoptions are on a continuum. • How do the family roles change with a kinship adoption? (i.e., if grandmother becomes mother does mother become sister?)
Trainer’s Comments (5 minutes) • Adoption has been practiced by many cultures and religions throughout human history. Adoption practice has changed over the last 60 years and continues to do so. • Adoption is a legal process. • Individuals central to the adoption process are the birth family, adoptive family and the adoptee. • Remember that in every adoption, the records are sealed. Every state stores adoption records differently and has different laws regarding access to a sealed adoption file. The issue of accessing the adoption files at adulthood, search and reunion and the birth father and mother’s rights regarding the confidentiality of the adoption file is discussed in Module 3.
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• It is important to note that grief and loss accompany every adoption, no matter which type is selected. Adoption can only happen as a result of loss. Open adoption is not a cure for grief and loss. (Test Question)
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Grief and loss are not “cured” in an open adoption. (Test Question)
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
In open adoption the birth or adoptive family can change their plans regarding the openness, unless they live in a state where there are legally binding open adoption agreements. (Test Question)
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TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
In a semi-open adoption families may maintain contact via a third party. (Test Question)
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
In the past birth parents were often coerced into placing a child for adoption due to financial and social factors. (Test Question)
Remember to draw participant’s attention to the key points contained in this module: Non-identifying information, social and medical history for each birth parent and their families must be shared with the adoptive family. (Test Question) Kinship or relative adoptions are lifelong and legal arrangements. (Test Question) Coercion (Test Question)
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o Then: Parents were often coerced into placing a child with someone else due to financial situations or social factors.
o Now: Most states have laws regarding what expenses can be paid. There are also laws prohibiting a person from placing her/his child if there was force, duress, or coercion. • It is important to understand how the history of adoption may impact your thinking and the thinking of others. (Training Reflection Feedback Form) • It is important to remember the need to use neutral adoption language. (Training Reflection Feedback Form) • It is important to be able to identify and describe current adoption practice, the different types of adoption, and the relationship continuum. (Training Reflection Feedback Form) Refer participants to Participant Handbook, Module 2, pages 16-36 to review; “Issues and Perspectives in Adoption: Then and Now,” “Ethical Considerations in Adoption,” “A Brief Description of Open Adoption,” “Remove Barriers and Latino Families will Adopt,”“ Looking Back Over the Landscape of Adoption,” “Grief and Loss and the Open-Adoption Process,” and “Stages of Grief Following Delivery for Parents Planning Adoption.”
Transition • Are there any questions or comments related to adoption practices? • We will take a 15 minute break. • When we reconvene, we will discuss adoption laws specific to your state.
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To Find Out More About It
Babb, Anne L. (1999). Ethics in American Adoption. Westport, CT: Bergin & Garvey. Child Welfare League of America. (2000). CWLA standards of excellence for kinship care services (KC). Washington, D.C: Author.
Chippindale-Bakker, Foster Linda. (1996). Adoption in the 1990’s: Sociodemographic Determinants of Biological Parents Choosing Adoption. Child Welfare, LXXV, 4, 337- 355.
Committee for Hispanic Children and Families, Inc. (1996). Cultural competence and Latino adoption. New York: Author.
Crumbley, Joseph. (1999). Transracial Adoption and Foster Care. Washington, D.C. Child Welfare League of America, Inc.
Diller, Jerry (1999). Cultural Diversity: A Primer for the Human Services. Belmont, CA: Wadsworth Publishing.
Everett, J.E., Chipungu, S.S.,Leashore, B.R. (Eds.). (1991). Child Welfare: An Afrocentric perspective. New Brunswick, NJ: Rutgers University.
Freundlich, Madelyn. (2000). Adoption and Ethics: The Role of Race, Culture and National Origin in Adoption. Washington D.C.: Child Welfare League of America, Evan B. Donaldson Adoption Institute.
Hartman, A., Laird, J. (1990). Family treatment after adoption: Common themes. In D. Brodzinsky and M.D. Schechter (Eds.) The psychology of adoption (pp. 221-239). New York: Oxford University Press.
Hartman, Ann. (1977). Finding Families: An Ecological Approach to Family Assessment in Adoption. Beverly Hills, CA: Sage Publications, Inc.
Hill, R.B. (1977). The strengths of black families. New York: Emerson Hall.
Hill, R. (1997). The strengths of African American families: Twenty-five years later. Washington, D.C: R & B Publishers.
Haugard, Jeffrey, Schustack, Amy, Dorman, Karen. (1998) Birth Mothers Who Voluntarily Relinquish Infants for Adoption.. Adoption Quarterly, 2, 1, 89-97.
Hulsey, Tara McComb. (2001). Association Between Early Prenatal Care and Mother’s Intention of and Desire for the Pregnancy. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 276-282.
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Jordan, J. (1998). Report from the Bahamas. In M.L. Anderson & P.H. Collins (Eds.) Race, Class and Gender: An Anthology. (pp. 34-43). Belmont, CA: Wadsworth Publishing Co.
Lakin, Drenda. (1992). Empowering Adoptive Families: Issues in post adoption services. Baltimore, MD: Baltimore City Department of Social Services.
Lindsay, J.W. (1996). Pregnant? Adoption is an option: Making an adoption plan for a child. Buena Park, Ca: Morning Glory Press.
Lecca, Pedro J., Quervalu, Ivan, Nuses, Joao, Gonzales, Hector (1998). Cultural Competency in Health, Social and Human Services. New York: Garland Publishing, Inc.
McAdoo, H. P. (1997). (3rd Ed.). Black Families. Thousand Oaks, CA: Sage Publications.
McRoy, R.G., Oglesby, Z, Grape, H. (1997). Achieving same-race adoptive placements for African American children: Culturally sensitive practice approaches. Child Welfare, 76, pp. 85-104.
Mills, C.S., Usher, D. (1996). A kinship case management approach. Child Welfare, 75, pp. 600-617.
Muller, Ulrich, Perry, Barbara. (2001). Adopted Persons’ Search for and Contact with Their Birth Parents: Who Searches and Why - I ? Adoption Quarterly, 4, 3, pp. 1-39. Muller, Ulrich, Perry, Barbara. (2001). Adopted Persons’ Search for and Contact with Their Birth Parents II: Adoptee-Birth Parent Contact. Adoption Quarterly, 4, 3, pp. 39- 62.
National Indian Child Welfare Association. (1996). Cross-cultural skills in Indian child welfare: A guide for the non-Indian. Portland, OR: Author.
Oros, Marla T., Perry, Lesley A.; Heller, Barbara R. (2000). School Based Health Services: An Essential Component of Neighborhood Transformation. Family Community Health, 23, 2, pp. 31-35.
Ortega, R. M., Guillean, C. , Najera, L.G. (1996). Latinos and child welfare/Latino y el bienestar del nino- Voces de la communidad. Ann Arbor, MI: University of Michigan.
Russell, Marlou. (1996) Adoption Wisdom: A Guide to the Issues and Feelings of Adoption. Santa Monica, CA.: Broken Branch Productions.
Spaulding for Children. (1996). Adoption Support and Preservation Curriculum. Southfield, Michigan.
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Spaulding for Children. (1995). Cultural Competence Curriculum in Adoption. Southfield, Michigan.
Sudarkasa, N. (1997). African American families and family values. In H.P. McAdoo (3rd Ed.) Black Families (pp. 9-40). Thousand Oaks, CA: Sage Publications.
Taylor-Brown, Susan, Teeter, Judith Ann, Blackburn, Evelyn, Oinen, Linda Weddeerburn, Lennard. (1998)Parental Loss Due to HIV: Caring for Children as a Community Issue – The Rochester, New York Experience. Child Welfare, LXXVII, 2, pp.137-159.
Williams-Gray, Brenda (2001). A Framework for Culturally Responsive Practice.” Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and other Practitioners. (pp 55-83). New York: Columbia University Press Publishers.
Wilson, M. (1991). The context of the African American family. In J.E. Everett, S.S. Chipungi, B.R. Leashore (Eds). Child Welfare: An Africentric perspective (pp. 85-118). New Brunswick, NJ: Rutgers University.
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Issues and Perspectives in Adoption: Then and Now
CULTURE, ATTITUDES AND BELIEFS: HOW DIFFERENT CULTURES VIEW ADOPTION
Different cultures experience adoption differently. Culture overlaps into all facets of one’s values, decision-making, and lifestyle. Native American culture experiences adoptions differently than other cultures:
• A knowledge of the historical perspective of the Native American populations is helpful in being culturally sensitive to issues faced by a Native American person facing an unintended pregnancy. This may include: Culture overlaps into all facets of one’s values, decision-making, and lifestyle. The historical perspective of the Native American population is helpful in being sensitive to the cultural issues faced by a person experiencing an unintended pregnancy. 1800s – Movement of Native Americans to RESERVATIONS. 1870s - 1930s – ASSIMILATION of Native Americans to white/European culture. Indian children are sent to Boarding Schools to unlearn their native culture, and become “civilized.” 1950s – U.S. Government seeks to TERMINATE their working relationships with the Native Americans. BIA (Bureau of Indian Affairs) contract with the Child Welfare League of America, sparking the adoption movement of Indian children with non-Indian parents. 1960s – The RELOCATION of Native Americans to big cities to obtain vocational training. 1970s – SELF-DETERMINATION becomes paramount as the Indian Child Welfare Act (ICWA) becomes law; stopping the adoption of Indian children by non-Indian parents; preventing the unwarranted removal of children from their families; preserving tribal sovereignty. • Throughout history these traumas have continually broken the interlocking generational education passed on from grandparents to grandchildren. • The ongoing historical trauma is that of experiencing the inter-generational grief from the past and passing on to future generations the sense of loss. • Within the Native American culture, the prevailing societal standards for children have been: Are they (1) safe, (2) cared for, (3) loved? • Many tribal nations do not believe in separating children from their family.
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• Family is often defined as not just the nuclear family, but extended family, clan, neighborhood, and tribe. ICWA defines a placement preference order designed to serve the best interests of the child, emotionally, physically, and culturally. • Sensitivity to cultural norms within the Native American population can assist us in providing high-quality services. • Persons of culture traditionally did not engage in legal adoptions but did informal adoptions, i.e., placed children with related or non-related caregivers without legal paperwork.
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Issues and Perspectives in Adoption: Then and Now
Adoption Issue Then Now Adoption Viewed Adoption was seen as a Adoption is seen as a lifelong as an Event single event that occurred process. Adoption is viewed as at a point in time. impacting the lives of birth parents, adoptive parents, the adoptee and future generations of all of the above. Adoption as a Prior to the 1850s adoption Adoption is viewed as a legal process Legal Process was usually an informal regulated by state and federal laws. process. Children were Statutes vary from state to state. viewed as property and formal or legal adoptions were not considered necessary. Informed Consent Birth mothers were often More help is available to prepare and coerced into placing a child support birth mothers throughout the with someone else due to process. financial situations and/or Birth fathers are required to consent other social factors. to adoption or have rights terminated. Birth fathers were not Court oversight is required to ensure required to consent to an that birth parent decisions are adoption. informed and voluntary. Full Disclosure Agencies kept vital Most states now specify what non- information about the identifying information (medical child’s history from psycho-social) must be shared with adopting parents. adopting parents. Many wrongful adoption Most agencies provide full disclosure suits were filed against of required information. Agencies agencies. require adopting parents to sign an acknowledgement of receipt of the required information and, in some cases, a waiver absolving the agency of liability for information received after the adoption. Coercion Birth parents were often Most states have laws regarding what coerced into placing a expenses can be paid. There are also child with someone else laws prohibiting a person from due to financial situations placing her/his child if there was or social factors. (TEST force, duress, or coercion. QUESTION)
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Adoption Issue Then Now Physical Matching Primary concern was given Families adopt children from a and Adopting to matching physical variety of racial and ethnic Family Preferences attributes of the child with backgrounds. those of the adoptive Emphasis is on meeting the needs and parents. best interests of the child. Adoptions of unmatched children were delayed. Types of Adoption Adoptions were primarily Adoptions can be open and closed. for healthy white infants. Adoptions can be agency facilitated All formal adoptions were or facilitated by an attorney. legally sealed “closed.” Usually done by licensed adoption agencies and/or courts. Secrecy and Secrecy, anonymity and At minimum, adopters and adoptees Confidentiality sealing adoption records receive non-identifying information were the rule. including medical histories of the Infertile couples often birth parents. feigned a pregnancy when In direct consent placements, birth adopting a baby. parents must select the adoptive Individuals were often not parents. told they were adopted. It is possible to have an open adoption, where a birth parent(s) maintains an ongoing relationship with the adoptive family and child. Adoption practice supports adopters to tell the adopted child that he/she is adopted.
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Adption Issue Then Now Search and Reunion Adoption records were Many birth parents and adoptees closed “forever.” look for and are reunited with each Birth parents who released other. Most states have laws/legal their children and adoptees procedures for facilitating this were discouraged from any process. (TEST QUESTION) future contact. (TEST In most states birth parents have no QUESTION) legal rights to contact with the child Birth parents and adoptive after placement. In open adoption parents were promised that contact is continued due to the trusting they did not have to “worry” relationship all parties have developed. about any future contact. In some states, however, an open adoption agreement is developed.
Adoptable Children For the most part, formal Children adopted now include: adoptions dealt with Infants of all races, ethnic origins and healthy white infants. disabilities. (TEST QUESTION) Unhealthy or potentially Older children who have experienced unhealthy infants or life in the child welfare system and/or children of color were not have other special needs. offered for adoption. Children from other countries in need (TEST QUESTION) of adoption.
Who Can Adopt Middle class, two parent, Families of all races, ethnicities, and childless white couples. religions adopt. (TEST QUESTION) People of all ages who are married or single may adopt, including those with children. (TEST QUESTION) Most children in the child welfare system are adopted by foster parents or relatives. Stepparents who adopt their stepchildren make up another significant number of adoptions.
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Supply and Demand Prior to the 1960s supply of With the change in social mores healthy white infants was occurring in the 1960s and early 1970s, high enough to meet the more unmarried birth mothers decided demand of infertile couples to retain custody of their babies. wanting to adopt. More women entering the work force delayed having children. This contributed to a rise in infertility rates and in couples seeking adoption as a way to build a family. As the demand for children increased, the supply of healthy white infants decreased. More couples seek inter-country adoption as an alternative to domestic infant adoption. Fees Paid by Little or no regulation of this In most states, there are laws which Adoptive Parents practice. regulate the fees paid to birth parents, adoption agencies and or adoption attorney. This will be discussed further in Module 3.
Trans-racial Adoptions • Began in the 1950s with inter-country adoption of Asian children and with a federal initiative to place Native American children into the cities. • By the 1960s and 70s, more children of color were being placed in white families. • Significant federal legislation was passed recognizing the sovereign rights of Indian tribes to plan for Native American children. • In 1996, federal legislation was enacted that prohibits denying or delaying individuals the right to foster and/or adopt a child on the basis of race. • Federal legislation prohibits delaying a child’s adoption on the basis of race of the child or the foster/adoptive parent. • Increased focus on recruitment of families of color for children waiting for adoption. • Despite the increase of minority families fostering and adopting, there are a disproportionate number of children of color growing up in foster care.
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Ethical Considerations in Adoption
Ethical Considerations in Adoption
In adoption, every state has certain laws that determine how adoptions proceed. We are now going to look at some broader standards of practice that govern adoption practice. Some of these are addressed in specific state statutes. Others are general standards recognized by most adoption practitioners.
Rights of the Birth Family Right to: • Choose adoptive family. The birth parent also has the right not to choose the adoptive family. • State their desires regarding the level of contact and information sharing from confidential to fully disclosed. • Financial support for legal fees, counseling expenses, reasonable living expenses and actual medical expenses related to the pregnancy or birth of the child. Birth parents are not responsible for paying back expenses if they change their mind and decide to parent the child. • Social and legal counsel- Birth parents are entitled to have their own attorney. Adoptive parents are responsible for paying for the attorney. Most states actually require that birth parents have social counseling available to them. • Be free from pressure and coercion to place a child for adoption. • Develop an adoption plan and birthing plan. An adoption plan can include things like the type of adoption the birth parent chooses, the type of family the birth parent wants to choose, and the family the birth parent chooses. The birthing plan lays out what should happen in the hospital. For example, adoptive parents may come to the hospital, they may be in the delivery room, the child can be taken immediately to the nursery or stay in the room with the birth mother, the adoptive parents may take the baby directly home from the hospital or the baby may go into a temporary foster placement. All of these are options for the birth parents to decide. • Terminate the adoption until the revocation period has passed.
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Rights of the Adoptive Family Right to: • State their desires regarding the level of contact and information sharing. They also have the right to choose an adoption that falls on the continuum from confidential to fully disclosed. • Back out of an adoption agreement. Adoptive parents can decline a potential adoptive situation. They can also change the relationship with the birth parents after placement without legal recourse in most states. • Have education, social and legal counsel. • Have access to the medical and social history
Rights of the Adoptee Right to: • Safe and nurturing placement that is in their best interest. • Have access to their medical and social history. • Have access to their adoption file at adulthood in some states.
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A Brief Description of Open Adoption
It’s hard to imagine a term more misunderstood than “open adoption.” Between the imprecision of the word open and the many variations in the ways that “open adoption” is practiced, the words are at risk to lose their capacity to carry much if any useful information. The confusion surrounding open adoption is not an insignificant matter because confusion easily leads to unmet expectations and disappointment. Our first task, as we begin our consideration of this subject, is to clarify some of the language commonly used in the practice of adoption. Here are some words people use:
• “Openness in adoption” is a phrase that suggests a range of options is available. The expression correctly indicates that adoption arrangements are not all alike; some are more open than others. This phrase does not, however, indicate how extensive the options are, so it is important for potential adoption participants to gain clarity about the exact nature of the available options. • “Open placement” means the birth family and adoptive family have some time- limited interaction. Most of the interaction is pre and perinatal, and it usually ends within a year of placement. • “Semi-open adoption” suggests that some information will be exchanged and that some limited ongoing communication may be possible. Coming from another angle, some people refer to this approach as “modified closed adoption.” • “Open adoption” is a form of adoption in which the child enjoys a continuing relationship with his/her birth family. The communication and interaction between the families is direct, ongoing and centered on meeting the needs of the child.
There are several ways to get a handle on open adoption. One approach is to describe the behaviors it involves. In most open adoption plans, the birth family selects the prospective adoptive family before the baby is born. The two families meet face to face and exchange full identifying information. Together they negotiate a mutually satisfactory plan for the many years of interaction that lies ahead.
Although open adoption involves a set of observable behaviors, it is better understood as a set of attitudes. Open adoption only comes fully alive when it is founded on sincere care and mutual respect. Psychologist Randolf Severson states it well when he puts open adoption in the context of “courage, compassion and common sense.” It takes courage to face uncertainty, compassion to consider the experience from the perspective of others, and common sense to give the situation the practicality necessary so it truly serves the interests of everyone involved. When attitudes are positive and birth families and adoptive families work cooperatively and sacrificially on behalf of children, the results can be extraordinary. On the other hand, an arrangement that meets the technical definition of open adoption but lacks heart does not satisfy its attitudinal necessities. The best way to understand open adoption is to think of it as a relationship.
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Relationships are at the heart of open adoption. This is a helpful way to think of open adoption because, although the idea of open adoption may strike some as novel, everyone knows something about how relationships work. Some relationships, of course, are easier to maintain than others, but most are very cordial. It is not unusual for birth parents and adoptive parents to see each other as friends, although it does not always work out that way. If not friends, we at least hope for friendly.
In The Children of Open Adoption, Kathleen Silber and Patricia Martinez Domer observe that there is a distinctive quality to this relationship. They suggest that the relationship is familial, that it has the feel of “kinship.” They write, “In open adoption, the birth family is extended family, like other relatives within the adoptive family.” This insight sheds additional light on open adoption and de-mystifies open adoption even more. Most of us have a range of feelings about our extended family – some members are more enjoyable than others – but few would argue that they are unimportant.
The most common problems associated with open adoption are essentially relationship issues. Does a plan to get together at 3:00 on Saturday mean 3:00, or does it mean some time that afternoon? As most any half hour sitcom television show amply illustrates, the opportunity for misunderstandings to pop up in any relationship is unlimited. On the other hand, all of the joys we know through relationships are also available through open adoption.
The great advantage of open adoption is that it liberates birth parents, adoptive parents, and adopted persons from the burdens of secrecy that were built into the closed system of adoption. Secrecy stirs powerful psychology. Virtually everyone knows something from personal experience of the tension and anxiety that goes with keeping secrets. Similarly, everyone knows the frustration of “being in the dark.” It is an obvious truth that most of us are far more comfortable when “all the cards are on the table” and we know the facts of the situation we are in.
In several states in the western region of the United States, open adoption contracts do fall under provisions of the civil courts. Since the dynamic that sustains these relationships over time is trust, it is crucial that they are entered into with utmost care. If a participant turns out to be unreliable, there is nowhere to turn for recourse. Although open adoption is literally as old as Moses, it has only taken hold in the United States in the last couple of decades. For that reason, research findings about open adoption are still limited. With some exceptions, most of the research to date suggests that participants are very satisfied with the way their arrangements are working.
Jim Gritter, MSW, ACSW
February 2002
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Remove Barriers and Latino Families will Adopt By Maria L. Quintanilla, LCSW, Executive Director, Latino Family Institute
The Latino Family Institute (LFI), a federally and state funded adoption and foster care agency in Southern California, understands that certain factors keep Latino families from pursuing formal adoption. Director Maria Quintanilla has identified procedures that neutralize barriers for Latino families, foster trust in agencies, and empower families. Her findings, summarized below, address issues unique to the Latino adoption experience.
Like many other communities of color, Latinos have an established history of informal adoption—children have long been raised by grandparents, aunts and uncles, and god- parents. The Latino Family Institute (LFI) was founded to help Latino families navigate the adoption process and help Latino children. Then, before implementing a program to help families, LFI developed a clear understanding of the organizational and cultural barriers that keep Latino families from adopting.
Organizational Barriers Mistrust of government agencies: For Latinos, experiences both in their countries of origin and in the U.S. keep them from seeking contact with government agencies or organizations they view as government agents. Corruption and political persecution are common in many Latin American countries and inspire fear in both immigrant families and acculturated Latinos. Social service agencies, often perceived as extensions of the government, are automatically mistrusted. In California, recent anti-immigrant initiatives have led to even more government mistrust. Prospective adopters’ concerns about their immigration status, as well as that of other family members, may prevent Latinos from submitting to fingerprinting and background checks. Families may also be reluctant to openly talk about themselves during the home study process.
Traditional agencies not viewed as community friendly: Many traditional adoption agencies are located in areas inaccessible to the Latino community. Staff members fail to reflect Latinos’ community or speak their language, forms are not available in Spanish, and agency hours do not accommodate working people. Other discouraging practices include a lack of timely response to initial inquiries; delays in processing; limited agency contact between the time when the home study is completed and a child is placed; and the length and complexity of application forms, financial reports, and legal documents. Few traditional agencies are open to walk-in clients or those who prefer to drop off paperwork, common practices for Latinos and consistent with the cultural custom of personalismo—the preference for personal rather than impersonal or institutional contacts.
Lack of culturally and linguistically responsive recruitment strategies: Efforts to approach the Latino community with culturally appropriate recruitment and retention strategies—available in both English and Spanish—have been limited. Culturally responsive services may be lacking because traditional agencies harbor the
Module 2 - Page 39 Trainer’s Guide - 1Day DRAFT UIA 4 – 1 Day - Module 2 12/12/11 institutionalized belief that Latinos, particularly immigrants, do not adopt or will not meet qualifications. The Latino community in general is viewed as system dependent, rather than as a resource for children in the system. Because of these beliefs, traditional adoption recruitment approaches are not well suited for Latino families.
Cultural Barriers Lack of knowledge about eligibility requirements: Many Latinos are not aware that they are eligible to adopt, since only the wealthy are able to adopt in their countries of origin. Believing that the income standards must be even higher in the United States, some Latinos are reluctant to pursue the adoption process.
Stigma attached to infertility: The stigma of infertility is painful for any couple and Latinos—raised in a culture that highly values fertility, virility, and children—are especially vulnerable. For many Latinos, giving birth to children may be their life goal and how they define family. Infertility affects the entire family and as a couple deals with their loss, the extended family grieves their lost roles as grandparents, aunts, and uncles. Some infertile couples feel that inquiring about adoption is an admission of their infertility.
Religious beliefs may further intensify the stigma. Some Latinos believe that infertility is a punishment from God. Because they cannot oppose God’s will, these couples believe infertility is their cross to bear and they must simply accept childlessness. High number of male children available for adoption: Approximately 900 (or 15 percent) of the children available for adoption in California are Latino males. Historically, Latino families have been proud of raising sons, yet when it comes to adoption, Latinos prefer daughters. Our experience indicates that when married couples adopt, wives who initiate the adoption process feel more able to relate to girls. As with other ethnic groups, Latino parents believe that females are easier to handle, less aggressive, and more openly affectionate than males.
In addition, cultural beliefs suggest that a girl is more likely to remain close to her family throughout her life, while a boy will be less involved with his family of origin as he gets older. Latino families may also be influenced to adopt a girl because of negative media portrayals of Latino males as criminals and gang members. To respect his wife’s wishes, a Latino husband may put his desire to raise a son on hold, and take full responsibility for the couple’s infertility. In this way he can compensate for his feelings of helplessness and regain his role as the family provider.
Misconceptions about children with special needs: Latino families may become discouraged about adopting a child who has an alarming diagnosis or label, such as prenatal drug exposure, attention deficit hyperactivity disorder, or post-traumatic stress disorder. Since children of color are more likely to be labeled, many Latino children available for adoption will have one or more of these designations.
Medical etiology versus folk etiology: Some Latino families have misconceptions about the cause of their adopted child’s behavioral, health, or developmental delays. For
Module 2 - Page 40 Trainer’s Guide - 1Day DRAFT UIA 4 – 1 Day - Module 2 12/12/11 example, a family might believe that a child’s medical conditions are due to the birth mother’s choice of adoption for the child. Depending upon how strongly entrenched they are in these beliefs, parents may be less willing to be matched with children who have special needs and less willing to comply with treatment plans.
Overcoming Barriers To retain Latino families, agency staff must anticipate prospective parents’ needs. Address the topics listed below (in recruitment materials, orientation sessions, pre-service trainings, and throughout the approval process) and your agency can help to address Latino families’ concerns and make the path to adoption welcoming:
• Reinforce that services are free: In Latin American countries, only the wealthy can afford to pay the cost of agency adoptions (though informal and kinship adoptions without agency involvement are quite common). Explain early on that the government pays the agency to find families and even provides subsidies to help families raise adopted children. Let the families know that the government wants to help children find permanent homes, because families are good for children and because adoptive parents save the government money. • Clarify your agency’s relationship with the government: Latino families, especially immigrant families, are often more willing to work with private nonprofits than public agencies. If your agency is nonprofit, tell families that it is not operated by the government. Whether your agency is public or private, reinforce that information collected about families is confidential. Prospective parents worry (for themselves or for other family members living in their home) that getting involved with adoption agencies may bring scrutiny from immigration bureaus or police. Be upfront about what information will be collected and why, and with whom it will be shared. • Establish personal relationships between staff members and prospective families: Introduce all staff members at orientation. Give families an organizational chart with all of the staff members’ names and contact information. Clarify staff members’ roles and responsibilities, and emphasize that staff are trained professionals, available as resources to the families. Latino families typically appreciate knowing the title and training that professionals who are serving them have earned. • Acknowledge stereotypes and help families examine their own biases: Latino families frequently express a preference for girls. Ask them about this preference. They will likely say that girls stay closer to the family, cause less trouble with the law, and won’t have substance abuse problems. Discuss societal stereotypes about Latino males and help families to see that they too are buying into the belief that Latino boys are criminals and gang members (and help them to recognize that girls get into trouble too). Highlight that without permanent, loving families, children are far more likely to live up to these stereotypes. • Address spirituality: Allow families to talk about spiritual beliefs, especially any related to their infertility. Overcome their initial hesitation to talk by
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depersonalizing the discussion. Say, “Other families have told us that they believe infertility is a punishment from God or a cross to bear. Have you heard those sorts of ideas?” Always mention that many families see infertility not as punishment from God, but instead as a calling to adopt. Involving other Latino families who have already adopted as speakers can also help. • Explain who the children are and where they’ve come from: Explain in detail the process by which children become available for adoption, letting prospective parents know that children have not been kidnapped or stolen (as may be a concern in their country of origin). Be honest about abuse and neglect the children may have suffered. Clarify the difference between corporal punishment and abuse. Latino families may fear that the way they were raised or the way they raised other children was abusive and withdraw from the process. Tell them that because of the children’s histories, spanking is not an acceptable form of discipline. Then share other techniques that are effective. Discuss common treatment plans used to help children with different special needs (medication, physical therapy, counseling, etc.), mentioning that using folk treatments is acceptable but only in conjunction with the traditional interventions.
The Latino Family Institute has worked hard to make adoption a feasible option for Latino families in California. To learn more about ways in which your agency can more effectively reach out to and retain Latino families, contact Maria Quintanilla at LFI, 1501 West Cameron Avenue, Suite 240, West Covina, California 91790; 800-294-9161 (Español) or 626-472-0123 or log onto www.lfiservices.org.
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Looking Back Over the Landscape of Adoption by a Reunited First Father
Part 1: The Landscape
People use 'Life is a Journey' as a common and powerful metaphor that helps them understand their lives, and explain what to expect to others. In the same spirit one can talk about the landscapes that journey passes through, in an attempt to provide some signposts for those who are not as far 'down the road'. Of course, everyone's journey is her/his own and (with any luck) will never pass through some of the rougher terrain that others may have found.
I, and many others, have found ourselves shuttled off to the land of closed adoption with little preparation, no roadmaps, no advice on the dangerous bits. Indeed, many of us are actively misled by others or by our own needs. Also, many starting out on this particular journey, don't consider that they are taking others along with them and that the journey will ultimately end with the emergence of the adult adoptee.
The following is offered in the spirit of capturing, for your use (or not), what I and many others have found, looking back, to be a good path to take. One commonly traveled with success and with a minimum of risk.
Sometimes individuals feel either in control or powerless in this landscape. There are also certainly areas where one side or the other of the triad can be ambushed or get lost if they tread off the beaten path. Consider that power shifts over time, ultimately residing with the adult adoptee. If, at that time, the adoptee has been led well in the journey, all will prosper. Time is a great leveler and all parents (whether involved in adoption or not) lose their children to adulthood.
Part 2: Where Others Have Trod
The beaten path through the landscape of closed adoption: • The adoptee becomes the child of the adoptive parents through a decision often made voluntarily by their first parents. • The adoptive parents will be the adoptee's parents forever. • They will be that adoptee's guardian throughout childhood. • The adoptee will experience no other parenting and will always see the adoptive parents as, simply, their parents. • The adoptee has another mother and father, in addition to their parents. • All of these adults are part of the adoptee and involved in who she/he is and who she/he will become. Adoption does not change this.
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• In many instances, the adoptee's first mother/father consciously gave the parents those things listed above. • The adoptee's second mother and father actively sought those things listed above. • The adoptee's first mother/father did not agree to more than that. • The second mother/father can not claim more - this is not an issue of power, it is an observation of fact. • All these adults agreed to a closed adoption, because they believed or were convinced that was the best way to parent the adoptee for all concerned. • The adoptee did not have a voice, but will form an opinion. • Some of the adults may have other reasons for closed adoption. In this case, the adoptee needs you to set these reasons aside. If you don't she/he will either push them aside or become personally diminished, hurt, and fail to be whole. • The adoptee, as all people do, will form their own opinion of their life and the roles people played and continue to play in it. • The adoptive parents are not the adoptee's ancestors and never will be. Adoption does not change this. • The adoptee will (and should) seek to know those ancestors. She/he will probably strive towards (and succeed at forming) a loving relationship with them. • All involved can be included and all can be friends, proud of the adoptee and proud of collaborating on her/his success and the success of your individual adult relationships. • The adoptee does have two families. Childhood will be spent with one. Her/his life will be spent as she/he chooses. The other half of their family will probably be broad enough to include many people that will value the adoptee and will be valued in return. • These relationships across a broad, extended family are no more (or less) threatening to the adoptive parents than those the adoptee might have within their second family. • The adoptee will be happier and healthier if these truths are known and seen to be comfortable. • The adoptive parents are responsible, as all parents are, to expose their child to the truth. • The adoptee, as all children do, will assess their experience of parenting based, in part, on how well the truths above are dealt with.
Let me suggest that the statements above do not assert intent, rather they observe fact. Adoption is very poorly understood and, worse, often poorly presented, even by those accountable (or at least, who should be accountable) to explain it in a manner sufficient
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Part 3: How It Could Be
It is not the agencies' or social workers' role to make decisions or to guide a decision to a predetermined outcome. It is their responsibility to explain the truths of adoption. They should be required to explain what will be lost and what will be gained. They should also be required to explain what will not be lost or gained. They should be liable to prove that they have ensured informed consent without bias. They should be liable to deliver basic services (such as non-identifying information exchange) as well as any other service committed to as part of the adoption.
Here are some closing thoughts: • Future success and happiness is not tied immutably to the factors most often reviewed in making an adoption decision (wealth, stability, two parents, advantage, etc). Families with those things do fail, and those without them do succeed. • First parents will remain the child's ancestor - they can't change that, and they should not deny or hide from that. • First parents will lose the experience of their offspring's childhood and the ability to influence their parenting. If they agree to a closed adoption, they may lose all knowledge of these events as well. If that is undesirable, they should not make that choice, period. This should be agreed to and documented in advance. • Second parents will gain a parenting experience. They will raise a person. They will have a parent-child relationship with that person forever, whatever they make of it. • Second parents will not gain a sole descendant as if they were fertile. They will become part of an extended family to which the adoptee is the tie and a permanent member - even if they choose not to exercise this fact. If this is undesirable, they should not adopt. This should be agreed to and documented in advance. • Adoptees will not remain children forever, and adoption has no claim on adults. The agency should be contracted, in writing, to act as an information trust on their behalf, and be sued out of existence should they fail in this role. • The responsible adults do not need to accept the views or practices of the agencies. If a particular agency will not agree in writing to what the parties would like, then no agreement should be made.
Adoption can be rewarding, wonderful, satisfying, productive, loving, and many other things... but these things must accrue to all the involved parties in an inclusive and unbiased fashion. Stereotypes about first or second families or the children they share should be as offensive as those about race. While there are many of good will involved in
Module 2 - Page 45 Trainer’s Guide - 1Day DRAFT UIA 4 – 1 Day - Module 2 12/12/11 assisting adoption, there are also bigots who should be eliminated. While there is much light in the population at large, there is also ignorance. Reprinted with permission
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Grief and the Open Adoption Process By Candace Kunz- Published in PACT
I once worked with a birth mother who assured me that she wouldn't experience sadness or loss like the "old-time" birth mothers, because she was participating in an open adoption. This way she could see her child and know that he was okay and happy. Being able to be a part of his life would spare her the feelings that had haunted so many women who had placed their children for adoption in closed situations.
Although some of what this birth mother related to me reflected a common philosophy about open adoption, it also reflected a myth about the grief process - a process that occurs regardless of the kind of adoption a woman chooses.
When I first learned about open adoption I, too, felt that women would be spared the difficult feelings of loss and grief. It was impressed upon me that through respect and the power of choice, birth mothers of open adoption would be able to readily move forward with their lives and not be burdened by an intense grief process. However, I have learned in my experience counseling birth mothers that grief, loss and sadness accompany even open adoption to some degree.
Often, prospective adoptive parents will assure themselves that their child's birth mother feels so good about her adoption she is unlikely to feel badly for any significant period of time. Attaching themselves to this belief can prove to be disheartening and threatening when they experience the birth mother's grief firsthand. Often this exposure first occurs at the hospital and catches them off-guard. Many birth mothers have told me that they felt abandoned at the hospital when they were experiencing sadness and grief. The adoptive parents left the room, to allow the birth mother her privacy, perhaps because they did not know what else to do.
It is important to know that there is nothing adoptive parents can do to alleviate the pain. Feeling sadness and loss when separated from one's child is to be expected. It is extremely difficult to gauge the grief responses a birth mother will experience, but she should not be discouraged from freely expressing them. Whether a birth mother shares her pain or not, it is there. This is in complete contrast to the elation experienced by the adoptive parents.
Often, adoptive parents need reassurance that their child's birth mother feels okay about her decision in spite of her sadness. Even if she feels certain that she made the right decision it does not mean she won't grieve. Open adoption offers the possibility for birth mothers to know and experience some of their children's lives. The lifetime of wondering what happened and if their child is okay is minimized during this process. What used to take women who participated in closed adoptions years, if ever, to resolve, may not take as long for women in open adoption. Nevertheless, issues of loss and grief accompany
Module 2 - Page 47 Trainer’s Guide - 1Day DRAFT UIA 4 – 1 Day - Module 2 12/12/11 every adoption. It is important, for everyone involved in open adoption, not to perpetuate the myth that the adoption grief of birth mothers has been eliminated by the openness. Approaching the process realistically entitles birth mothers to their feelings and at the same time allows them the opportunity to openly share these feelings.
Module 2 - Page 48 Trainer’s Guide - 1Day DRAFT UIA 4 – 1 Day - Module 2 12/12/11 Stages of grief following delivery for parents planning adoption
Birth Parents Adoptive Parents Early Labor: Nervous, fearful, sometimes Nervous, fearful, fearful of being anxious for privacy, bonds to nurses “unchosen.” Worried about medical view Mid Labor: If epidural, often wants Thrilled to be included, some deep adoptive parent included. feelings of unexpressed envy, anticipatory, fluctuating between empathic and needed, unspoken. Post partum - First few hours: Elated Elated to see the child in the flesh, flooded birth is over, eager to share the beauty of with feelings of gratitude, also on a bit of the child, on somewhat of a “high.” a “high.” First night alone in the hospital: Often Beginning some anxiousness about “If wants rooming in, has quiet, private time she’s with the baby all this time … she with child. might change her mind.” Wanting to spend time with baby, not wanting to interfere, feeling envy and displaced. Second day: Often flooded with intense Aware and observing of increasing mother child feelings that have perhaps connection of mother and child. Terrified not been expected. Feeling singularly” mother will claim the child. Ashamed of capable of a bond that “no one else” can some of their “ownership” have like “I do.” competitiveness. Discharge discussions: Signatures given Anxious for discharge to get underway. that allow baby to leave with someone Wanting to hurry along paperwork. other than parent, reality beginning to Discussions about naming. skin in. Resentment can bubble up. An internal struggle around the decision. Sometimes a fear to tell the adoptive Sometimes resentment regarding the parents there are doubts. Fear of letting mother’s second guessing. “I thought she them down OR a re-decision to choose was so sure of this.” adoption and awareness that baby is leaving soon. Hovering OR Withdrawal out of self protection. Wanting to spend time with baby, sometimes mixed feelings about adoptive Spending time in nursery to know new parents in nursery with baby, ashamed of parenting skills, resentful if baby goes to not wanting to share. mom’s room. 2nd or 3rd day: Grief swelling over Unsure how to handle leaving with baby. separation. Dawdling around actual discharge. Tearful and sometimes getting Anxious at how long a discharge can take. last ditch “suggestions from friends and family OR a rushed departure, cut and Wanting to dress baby in their own way, run, needing alone time, needing to go also feeling sad for mother sometimes home. guilty. Developed by Gayle Ward, MA Education Institute, Kinship Center
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Module 3: Adoption Law and Procedure (60 minutes)
Trainer’s Preparation
Module Contents and Training Process
• Federal Adoption Laws
• State Adoption Process
• State Adoption Laws
• Rights of Birth Parents
• Children’s Protective Service
The module focuses on presentation of Federal and State adoption laws and provides information on the adoption process for the state in which the training is conducted. Special attention is given to the rights of birth parents and implications for infant adoptions.
Preparing to Train
At the start of this module place three flip chart pages on the front wall. One flip chart page will say Multiethnic Placement Act (MEPA), one will say Indian Child Welfare Act (ICWA), and one will say Servicemembers Civil Relief Act (SCRA). You may refer to these when you are discussing the various Federal laws.
Review and be totally comfortable with the content and delivery methods required for the module. While all questions need to be discussed the highlighted questions listed at the start of each of the sections (birth mother, birth father, adoptive family, court procedure, and miscellaneous) are particularly important and must be clearly covered and understood by the participants.
Make sure to select the methodology you will use to train the Frequently Asked Questions (FAQs) and make sure you have the materials necessary for the chosen method.
Training methodologies are:
Option 1 of 2: FAQs (Lecture) Lecture from the FAQ. Cover all questions in each category, making sure that you cover the highlighted questions carefully and completely. This activity explores State adoption laws by simply lecturing off of the FAQ pages along with brief lecture section.
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Option 2 of 2: FAQs (Pre Printed Cards) This exercise uses the FAQs which are pre-printed on 3 ½ x 4 inch cards of varying colors. All questions related to birth mother are on green cards, those for birth fathers are on yellow cards, those for adoptive families are on blue cards, those related to court and the court process are on pink cards, and miscellaneous questions are on white cards. Separate the question cards placing the highlighted questions found in the FAQ’s together and the remaining question cards together. Give all question cards in the highlighted question group to the participants as this insures that you will cover these questions carefully and completely. Place the remaining question cards to the side until the other questions have been answered and then these can be passed out. You may either hand out the question cards to the participants or place them in a box, bag or basket and let the participants choose cards for themselves. Let each person read their question out loud, and then you as the trainer will answer it. You should then ask the participants; “who else has a question related to that group” (for example birth mothers) and answer all those questions at that time. Once the question has been asked retrieve the card and do not put it back in the container with the unanswered cards. Continue to give participants the opportunity to choose another question and ask it as time permits.
Required Materials/Equipment • Frequently Asked Questions with State Specific Answers • Rights of Birth Parents • Box, bag, or basket and completed Q&A cards • Flip chart, posters or index cards • Three flip chart pages with Multiethnic Placement Act (MEPA) on one, Indian Child Welfare Act (ICWA) on one, and Servicemembers Civil Relief Act (SCRA) printed on the final one. These will be used for the Federal law discussion. • TV-VCR or DVD player • Laptop and Projector • Screen to show PowerPoint presentation and DVD’s
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Module 3: Introduction
Objectives: Describe Federal laws, (MEPA and ICWA) that regulate adoption. Describe state-specific laws that regulate adoption and adoption procedures. Describe the rights of birth mothers and birth fathers.
Content • Federal Adoption Laws • State Adoption Process • State Adoption Laws • Rights of Birth Parents • Children’s Protective Service
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Trainer’s Comments • Many health care professionals feel that bringing up adoption is difficult as they feel the patient/client might have questions and emotions that you do not feel prepared to answer or handle. • This module will provide information on Federal and State laws and answer questions about the adoption process in Michigan. • Both Federal and State laws govern adoption in the United States.
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Federal Adoption Laws (5 minutes)
• Federal law essentially regulates inter-state adoption matters, adoption of Native American children, and issues of discrimination in the placement of children by agencies receiving federal funding.
• State law regulates all other processes affecting adoptions.
• Understanding the major provisions of Federal and State laws will provide useful background information when talking to patient/clients about the adoption option.
• It is not expected that you will become experts on adoption laws. Rather, you will have sufficient information to dispel some of your patient/client’s misunderstandings about adoption and to feel comfortable talking about adoption as an option.
• You should always feel comfortable saying, “I am not an expert in adoption law; but I can offer some general information and refer you to someone who can provide more complete information.”
• Let’s begin with a discussion of the pertinent Federal laws. Refer participants to Participant Handbook, Module 3, page 2.
The Howard M. Metzenbaum/Multiethnic Placement Act (MEPA) of 1994 - PL 103-382, Sections 551-555
• MEPA/IEP, as amended, states “…Neither the State nor any other entity in the State that receives funds from the Federal Government and is involved in adoption or foster care placements may delay or deny the placement of a child for adoption or into foster care, on the basis of the race, color, or national origin of the adoptive or foster parent, or the child, involved.”
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• An adoption agency receiving Federal funds may not, nor may it steer a birth parent to adoptive parents by race, color, or national origin. MEPA insures that federally funded agency adoptions are not delayed based on race, color, or national origin of either the child or adoptive parent. (Test Question) Not all adoption agencies receive federal funding.
• Birth parents do not have the right to specify the race, color or national origin of the adoptive parents in the case of federally funded adoption agencies.
• A more complete version of MEPA/IEP is found in the Participant Handbook, Module 3, page 25.
• Refer participants to Participant Handbook, Module 3, page 2.
Indian Child Welfare Act (ICWA) – PL 95-608 of 1978 (Pertaining to children involved in the child welfare system)
In 1978, the Federal Indian Child Welfare Act (ICWA) was passed. Under the Act, Indian Tribes were granted extensive jurisdiction in child welfare cases involving Indian children, recognizing “that there is no resource that is more vital to the continued existence and integrity of Indian Tribes than their children.”
The Act “established minimum standards for the removal of Indian children from their families and placement of such children in foster or adoptive homes which will reflect the unique values of Indian culture.”
• Placement and adoption of Native American children is governed by their tribe, whose authority is legislated by the U.S. Government. (Test Question)
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• There are over 560 federally recognized Indian tribes in America. Federally recognized Indian tribes are considered by the American government to be sovereign nations.
• Tribes have the authority to care for Native American children, as well as to intervene in court cases regarding adoption.
• Membership is not the same as enrollment. Each Indian tribe sets its own membership criteria. Some Indian tribes base membership on a specific blood quantum while other tribes only require proof of lineage from a tribal member. The only way to know for sure is to ask.
• If the child is eligible for tribal membership and the tribe chooses to intervene, the tribe will approve the placement.
• If either parent has Native American heritage, a contact must be made to the appropriate tribe to determine if the child qualifies for tribal membership.
• If the child qualifies and the tribe chooses to intervene, the tribe will contact relatives for placement. If extended family members cannot adopt, the tribe has the authority to place the child for adoption with other tribal members. The third placement choice is a different tribe. The final placement choice is with a family outside the Native American community.
Implications for Voluntary Infant Adoption:
Although federal law does not require notice to the tribe in voluntary infant relinquishments, it is considered best practice to make notice when there are indications the child is of Native American heritage.
• A more complete version of ICWA is found in the Participant Handbook, Module 3, page 26.
• Refer participants to Participant Handbook, Module 3, page 2.
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Servicemembers Civil Relief Act of 2003 (SCRA), formerly known as Soldiers’ and Sailors’ Civil Relief Act of 1940 (SSCRA)
• In addition to the specific adoption related Federal laws we have just reviewed another important Federal law to understand is the Servicemembers Civil Relief Act (SCRA) of 2003.
• A service member who is either the plaintiff or the defendant in a civil lawsuit may request a stay, a postponement of a court proceeding in which he/she is a party. A service member may request a stay at any point in the proceedings. In order to apply for these protections the service member must actually be a party to the suit. This provision only applies to civil lawsuits, suits for paternity, child custody suits and bankruptcy debtor/creditor meetings. The service member should have his/her commander write a letter to the court and the opposing party’s attorney stating that the service member is unable to attend the proceedings.
Implications for Voluntary Infant Adoption:
• If the child’s father is a service member, the adoption process may be affected by this act.
• If the father wants to plan for his child but cannot be available for hearings, his rights to the child may not be terminated just because he is not present. Fathers need to be located and heard before an adoption plan can be made.
• Before we discuss the Frequently Asked Questions, we will briefly discuss an overview of the basic Adoption Legal Process. Refer participants to Participant Handbook, Module 3, page 5.
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Adoption Legal Process for Michigan (5 minutes – This is a brief overview)
1. Age of Birth Parents
• If you are working with a patient/client under the age of 18, it is important to share with him or her that parental consent, or a court petition and appointment of guardian to consent to the release, will be required to release his or her child for adoption.
2. Adoption Attorney or Adoption Agency
• Birth parents choose to use one of the following:
a) Adoption Attorney i. The birth parents would select the adoptive family. ii. The adoptive parents have to get a family home study from a licensed child welfare agency, if not already completed.
b) Adoption Agency i. The adoptive parents will have a home study completed and approved by the adoption agency. ii. The birth parents can choose to select the adoptive parents and consent to the placement of the child with these adoptive parents. iii. The birth parents can choose to release their parental rights to the adoption agency. The adoption agency or the birth parents would be able to select the adoptive parents. This is the birth parents’ decision. The rights of both birth parents must be terminated before an adoption petition can be filed in court.
3. Relative Adoption or Kinship Adoption through Court
a) The birth parents choose the adoptive family. b) The court conducts a relative home study. c) Both birth parents consent to the adoption.
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4. Filing of Legal Documents in Court
• Supervision of the adoptive placement, which is required by the court for at least six months, is typically conducted by the placing adoption agency.
a) If the adoption is filed by an Adoption Attorney, supervision of the placement is conducted by the adoption agency that completed the adoptive family’s home study. b) If the adoption is filed by the court, supervision will be arranged with a licensed child welfare agency. c) Upon completion of the required supervision period of the adoptive placement, the only circumstances that would prevent the finalization of the adoption would be if:
i. The adoption agency or the court did not feel that the continued placement would be in the child’s best interest. ii. The adoptive family decides they no longer wish to proceed with the placement of the child in their home.
5. Finalization of Adoption
• The adoption is finalized after:
a) The supervisory period is completed b) The supervising agency recommends finalization, and c) The court enters the final Order of Adoption
6. Expenses
• Agency fees as well as birth parent expenses, as allowed by the laws of the State, are paid by the adoptive family. These fees may include:
a) Legal fees charged for consultation, assessment, the preparation of legal documents, legal representation and necessary court costs. b) Home Study fee, agency fees and post placement supervision fees. c) Birth parent expenses including legal fees of the birth mother, medical care, the living expenses of the birth mother during her pregnancy and up to six weeks after delivery, traveling expenses necessitated by the adoption and counseling. d) Fees are not charged by agencies to expectant parents for pregnancy counseling or adoption services. These expenses are paid by the adoptive parent fees or donations made to the agency. e) Fees are not something that needs to be a part of the expectant parents’ decision making process.
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• All expenses paid by the adoptive parents must be disclosed to and approved by the court. • All expenses paid by the adoptive parents are seen as a gift and not a contracted obligation. If either birth parent decides not to proceed with the adoption plan, they are not obligated to reimburse these expenses.
7. Michigan Safe Delivery of Newborns Law
a) The anonymous surrender of a newborn within 72 hours of birth to an emergency services provider implies consent and release of the infant to a child placement agency for the purpose of adoption. b) The surrendering parent may or may not provide non-identifying information. c) Either the surrendering or non-surrendering parent has 28 days to petition the court to regain custody and must submit to DNA testing to verify the relationship.
8. Legal Father or Putative Father
• The Legal Father:
a) Is married to the birth mother or b) Has established paternity through the court
• The Putative Father:
a) Is a man not married to the birth mother, who has not acknowledged paternity, but whom the birth mother says is the child’s father. b) May file paternity at the birth of the child or express intent to file paternity before the child’s birth by signing a statement under oath and filing it with any court in the state. c) When the putative father who has filed a Notice of Intent to Acknowledge Paternity does not come forward to voluntarily release or consent to an adoption, the court notifies the putative father of the existence of the child and grants him the right to come before the court and establish why his parental rights should not be terminated. d) Notice of a Hearing to Determine the Identity of the Birth Father is also served on any other men suspected by the birth mother to be the father of the child. e) The birth parents have equal rights in terms of their child; one parent can not make an adoption decision if the other parent is opposed and able to parent. When the parents are not in agreement the birth mother can make an adoption plan, the birth father can present his case in court, and the judge would make the final decision on whether to allow the adoption or to allow one parent to parent..
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9. Legal Concerns
• Revoking Consent:
a) Following the hearing, birth parents have 21 days to petition for a rehearing. If no petitions are submitted the child is considered free for adoption. b) A rehearing will generally only be granted if there is fraud, duress or other compelling circumstances – not just that the birth parent has changed his or her mind. c) Following the Order Terminating the Parental Rights (after the initial hearing or rehearing), a parent has 21 days to appeal the order entered by the court. An appeal is not a rehearing, but an allegation of significant error in the proceedings.
• Overturning an Adoption:
a) Once an adoption is filed, only fraud and/or intentional legal flaws can cause it to be overturned. The adoption is finalized once the post placement supervision period has expired and the court enters the Final Order of Adoption.
Trainer Comments (5 minutes – This is a brief overview)
• We have described the adoption process in Michigan. In doing so, we talked about the services available from adoption agencies and adoption attorneys. We will now talk about the specific services agencies, adoption attorneys and pregnancy counseling centers provide to patient/clients. • These are some general guidelines and, of course, no two agencies or attorneys will be identical in the types of service they provide or the way they deliver these services. • Please turn to Participant Handbook, Module 3, pages 9 and 10.
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Adoption Agencies
• Typically, adoption agencies are licensed by the state to provide pregnancy counseling and adoption services. The role of the agency is to assure that not only the legal issues are handled correctly, but that the social and emotional issues are addressed through counseling as well. Some adoption agencies are prohibited from providing information about and/or referral for pregnancy termination services due to agency policy. You need to be aware of what services each agency provides in order to make an effective referral. • Adoption agencies provide counseling support and/or referrals to address other needs. Most will have temporary (foster) care available if a parent is in need of additional time, post partum, to decide about adoption and prefers the baby not be with the prospective adoptive parents while making this final decision. • Most adoption agencies will provide follow-up services regardless of whether the mother ultimately decides to parent the child or make an adoption plan. • Adoption agencies provide a one-stop service for adopting families, which includes a home study before placement and reporting to the court after placement. Adoption agencies have court-approved waiting families whom they have prepared for adoption. Prospective birth parents may select a family from this pool. Birth parents may release their parental rights to the agency, in which case the agency is the legal guardian of the child until the adoption is completed in court. Birth parents may also execute “direct consent” to the adoption, in which case the birth parents remain the legal parent until the adoption is formalized in court. • Generally, adoption agencies have no fees for pregnancy counseling or adoption services for birth parents.
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Adoption Attorneys
• In most states, attorneys can provide the legal services required for an adoption. Some attorneys have resources they refer to for services such as counseling. Some attorneys are members of the American Academy of Adoption Attorneys and subscribe to the standards set forth by that professional organization. The State of Michigan permits attorneys to act as adoption facilitators. • The attorney often has profiles of approved adoptive families to consider if the birth parents do not already have someone in mind. • Adopting families need to contact an adoption agency who will conduct the home study, provide post placement supervision and the final report to the court. These services cannot be provided by attorneys in Michigan. • Attorneys do not typically get involved in post adoption services. • The attorney fees for both the birth and adopting family are usually paid for by the adopting family.
Pregnancy Counseling Services
• Some adoption agencies provide pregnancy counseling to expectant parents. • Some organizations provide pregnancy and options counseling, though they do not provide adoption services. They have partnerships with particular adoption agencies that they refer to. Some may provide related services such as pregnancy testing, maternity clothes and assistance, or referrals to meet other needs during pregnancy and postpartum if the decision is to parent. • Some pregnancy counseling centers are prohibited from providing information about and/or referral for pregnancy termination services due to agency policy. If
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Title X standards are being applied in the agency, the service will include information on all options, as well as foster care. • Other resources may include a pregnancy counseling specialist within a larger mental health center or within a clinic where fees may be applied. • These organizations may be government and/or donation funded and may or may not charge fees.
Trainer’s Comments
• At this point, we are going to review some legal questions and answers related to adoption. See Participant Handbook, Module 3, pages 11-21.
• Describe the training option chosen from below:
Option 1 of 2 – Frequently Asked Questions (Lecture - 40 minutes)
Overview
• This activity explores state adoption laws by lecturing off of the FAQ pages. Participant Handbook, Module 3, pages 11-21.
Directions • The trainer will lecture all the state laws being sure to carefully and completely cover the highlighted questions listed first in each section (birth mother, birth father, adoptive family, court, and miscellaneous)
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• Refer to Trainer Guide, Module 3, pages 18 to 28 for the Frequently Asked Questions and their state specific answers.
• Use stories from practice where appropriate to illustrate a particular law.
Option 2 of 2 – Frequently Asked Questions (Preprinted Cards - 40 minutes)
Overview • This exercise uses the FAQs which are pre-printed on 3 ½ x 4 inch cards of varying colors. All questions related to birth mother are on green cards, those for birth fathers are on yellow cards, those for adoptive families are on blue cards, those related to court and the court process are on pink cards, and miscellaneous questions are on white cards.
Directions • Option 2 of 2: Frequently Asked Questions – Preprinted Questions - A box, bag or basket will be needed. All the questions have been printed from the FAQ’s for each of the categories: birth mother related, birth father related, adoptive parent related, the court process, and miscellaneous. • Separate the question cards placing the highlighted questions found in the FAQ’s together and the remaining question cards together. • Give all question cards in the group of highlighted questions to the participants as this insures that you will cover these questions carefully and completely. Place the remaining question cards to the side until the other questions have been answered and then these can be passed out. • You may either hand out the question cards to the participants or place them in a box, bag or basket and let the participants choose cards for themselves. Let each person read their question out loud, and then you as the trainer will answer it. You should then ask the participants; “who else has a question related to that group” (for example birth mothers) and answer all those questions at that time. Once the question has been asked retrieve the card and do not put it back in the
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container with the unanswered cards. Continue to give participants the opportunity to choose another question and ask it as time permits. • Refer to Trainer Guide, Module 3, pages 18 to 28 for the Frequently Asked Questions and their state specific answers
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Frequently Asked Questions About Adoption in Michigan
WARNING: Adoption is a serious legal proceeding that involves the termination of the legal parental rights of birth parents and the assumption of legal parental responsibilities by the adoptive parents. Individuals who are contemplating an adoption should consult legal and child welfare professionals before proceeding. The information contained in this document is only a general summary of Michigan adoption policies and procedures. It is not intended to substitute for legal advice about any particular individual or situation.
TRAINER NOTE: All highlighted questions must be addressed and answered first before proceeding to the remainder of the questions.
BIRTH MOTHER RELATED
1. When can the mother of the baby start the adoption process?
At anytime after she becomes pregnant. Mother cannot sign any legal paperwork to release or consent to her child’s adoption until after the child is born.
MCL 710.55
2. What expenses can the adoptive parents pay to or on behalf of the birth mother and child?
Expenses that can be paid for, by law, include: o Medical, hospital, nursing or pharmaceutical expenses o Living expenses of a mother before the birth of the child and no more than 6 weeks after the birth o Counseling expenses related to the adoption, if not provided at no fee by the adoption agency o Traveling expenses necessitated by the adoption o Legal fees related to the adoption
Fees are not charged by agencies to expectant parents for pregnancy counseling or adoption services.
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Fees are not something that needs to be a part of the expectant parents’ decision making process.
All expenses paid by the adoptive parents must be disclosed to and approved by the court.
If either birth parent decides not to proceed with the adoption plan they are not obligated to reimburse these expenses.
MCL 710.54
3. Can a minor mother independently sign legal documents placing the child for adoption (consent to the adoption)?
No, a minor mother’s consent is not valid unless a parent, guardian or GAL (Guardian ad litem) also executes consent.
MCL 710.43 (7)
4. When does the birth mother actually sign the legal documents required for the adoption?
The legal documents are signed by the birth parents, after the birth of the child, at a court hearing. Typically, this takes at least one month.
5. Can the birth mother change her mind before signing the legal documents to the adoption?
Yes, nothing is legal until the consent or voluntary releases are signed by the birth mother and the Order Terminating the Rights of the birth parents is signed by the judge.
6. Can the birth mother change her mind after signing the legal documents to the adoption?
Following the hearing, birth parents have 21 days to petition for a rehearing. A rehearing will generally only be granted by the court if there is fraud, duress or other compelling circumstances – not just that the birth parent has changed his or her mind. Following the Order Terminating the Parental Rights (after the initial hearing or rehearing), a parent has 21 days to appeal the order entered by the court. An appeal is not a rehearing, but an allegation of significant error in the proceedings.
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MCL 710.64-65
7. Can the birth mother communicate with the adoptive parents and child after the adoption?
Yes, but only if the adoptive parents are willing, and either party can change their minds at anytime. There are no legally binding “open” adoption contracts in the State of Michigan.
8. Can the birth mother choose the adoptive parents?
Yes. However, the statute requires that the prospective adoptive parents have an approved home study completed by a licensed child-placing agency. If it is a relative direct adoption, the courts can complete the home study.
MCL 710.23
9. Can the birth mother see and hold the baby after the birth?
Yes, the birth mother retains all legal rights to her child until releasing her parental rights or providing consent to an adoption in Court.
10. Can a birth mother anonymously surrender a newborn child?
Yes. Under the Michigan Safe Delivery of Newborns Law, a birth parent can anonymously surrender a newborn within 72 hours of birth to an emergency services provider. This implies consent and release of the infant to a child placement agency for the purpose of adoption. The parent may or may not provide non-identifying information. Either the surrendering or non-surrendering parent has 28 days to petition the court to regain custody and must submit to DNA testing to verify the relationship. The court will hold a best interest hearing to determine custody of the child.
MCL 712.10-.20
11. What happens if the birth parents do not agree that adoption should be the plan?
Consent, voluntary release or termination of parental rights must occur for both birth parents before an adoption petition can be filed. If the birth mother was married at the time of conception or birth, her husband is considered the legal and only father, unless a court determines otherwise. He must consent or release before the child can be placed for adoption. If a putative father establishes paternity, he must also consent or release before the child can be placed for adoption.
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MCL 710.43
BIRTH FATHER RELATED
1. Does the father of the baby have to be notified of the birth and the mother’s adoption plan?
Yes, the courts must provide legal notice to legal fathers and putative fathers prior to termination of parental rights. If the birth father is unknown or cannot be located, the court will require showing of reasonable efforts to find him and give him notice. If he cannot be found, the court will take testimony regarding this.
MCL 710.34
2. Can the father of the baby choose the adoptive parents?
Yes, with the agreement of the birth mother. However, the statute requires that the prospective adoptive parents have an approved home study completed by a licensed child-placing agency. If it is a relative direct adoption, the courts can complete the home study.
MCL 710.23
3. What happens if the biological father of the baby is not the baby’s legal father?
If there is a legal father, many courts do not recognize the rights of putative fathers. A married man is the legal father of a child conceived or born during the marriage, although he can challenge that determination.
MCL 710.34 & 710.36
4. Can the biological father of the baby give notice that he intends to plan to parent the baby before the baby is born?
Yes, a person claiming under oath to be the father of the child can file a verified Notice of Intent to Claim Paternity with the court in any county before the birth of a child born out of wedlock. Notice will be filed with the Department of Community Health, Vital Records Division. The person will be presumed to be the father unless the mother states otherwise.
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MCL 710.33
5. Can a minor father independently sign legal documents placing the child for adoption (consent to the adoption)?
No, a minor father’s consent is not valid unless a parent, guardian or GAL (Guardian ad litem) also executes consent.
MCL 710.43 (7)
6. When does the birth father actually sign the legal documents required for the adoption?
A legal birth father, just like the birth mother, must sign legal documents at a court hearing, after the birth of the child. Typically, this is at least a month’s time. A putative father is not required to appear at a court hearing, although he can choose to appear in court and sign the legal documents for the adoption if he would like to do so. The putative father can sign a legal document, before the birth of the child, voluntarily stating that he is/may be the father of the child and deny any interest in custody of the child.
7. Can the birth father change his mind before signing the legal consents to the adoption?
Yes, nothing is legal until the consent or voluntary releases are signed and the Order Terminating the Rights of the birth parents is signed by the judge.
8. Can the birth father change his mind after signing the legal consents to the adoption?
Following the hearing, birth parents have 21 days to petition for a rehearing. A rehearing will generally only be granted if there is fraud, duress or other compelling circumstances – not just that the birth parent has changed his or her mind. Following the Order Terminating the Parental Rights (after the initial hearing or rehearing), a parent has 21 days to appeal the order entered by the court. An appeal is not a rehearing, but an allegation of significant error in the proceedings.
MCL 710.64-.65
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9. Can the birth father communicate with the adoptive parents and child after the adoption?
Yes, but only if the adoptive parents are willing, and either party can change their minds at anytime. There are no legally binding “open” adoption contracts in the State of Michigan.
10. How is the father of the baby notified of the mother’s adoption plan?
The father, either legal or putative, is notified via personal service. MCL 710.36
11. What happens if the husband (legal father) is not the biological father?
Same as #4 above.
12. What happens if the mother does not know who the biological father is?
The court would hold a hearing to determine who the father is. Reasonable efforts must be made to locate the putative father and proceed with termination of parental rights.
MCL 710.36 (1)
13. What happens if the mother refuses to give the name of the biological father?
The mother is required by the court to provide as much information as she has about the identity of the father. Notice must be given to any and all putative fathers.
MCL 710.36
14. Can a birth father anonymously surrender a newborn child?
Yes. Under the Michigan Safe Delivery of Newborns Law, a birth parent can anonymously surrender a newborn within 72 hours of birth to an emergency services provider. This implies consent and release of the infant to a child placement agency for the purpose of adoption. The parent may or may not provide non-identifying information. Either the surrendering or non-surrendering parent has 28 days to petition the court to regain custody and must submit to DNA testing to verify the relationship. The court will hold a best interest hearing to determine the custody of the child. MCL 712.10-.20
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15. What happens if the birth parents do not agree that adoption should be the plan?
Consent, voluntary release, or termination of parental rights must occur for both parents before an adoption petition can be filed. If the birth mother was married at the time of conception or birth, her husband is considered the legal and only father, unless a court determines otherwise. He must consent or release before the child can be placed for adoption. If a putative father establishes paternity, he must also consent or release before the child can be placed for adoption.
MCL 710.43
ADOPTIVE PARENT RELATED
1. Can the adoptive parents prevent the birth parents from communicating with the child after the adoption?
Yes. Once the adoption is finalized, the adoptive parents have full rights in decision making for that child, regardless of what may have been discussed or agreed upon prior to the adoptive placement. However, adoptive parents are strongly encouraged not to make any promises to a birth parent they do not intend to keep.
2. Under what circumstances can an adopted child communicate with the birth parents?
If the adoptee is a minor, the decision would be made by the adoptive parents. After the age of 18, when the adoptee is an adult, he or she may seek out their birth parents via the Central Adoption Registry. If the birth parents have not prohibited the release of information, the adoptee may be given the latest information filed on the location of the birth parents.
MCL 710.27b
3. When is the adoption final?
When the court grants the adoption petition and enters a final Order of Adoption, generally after 6 months of post placement supervision
MCL 710.56
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4. Who can be an adoptive parent?
A married couple or a single person, who have had an approved home study completed by a licensed child welfare agency, may petition the court for adoption.
MCL 710.23
5. What information about the birth parents and the child must be provided to the adoptive parents?
Before placing a child for adoption, the adoption agency or court must provide the prospective adoptive parents with a written document containing all non- identifying and reasonably obtainable information that is not confidential under state or federal law. This information includes, but is not limited to: o Date and time of birth o Hospital and city in which the child was born o Health and genetic history of the child, including prenatal care, medical conditions at birth and subsequent health history o An account of the health and genetic history of the biological parents and other members of the child’s family, including such things as known hereditary diseases o Racial, ethnic and religious background o Educational, artistic, athletic, etc. achievement of the child’s family o Hobbies, special interests, and school activities of the child’s family
MCL 710.27 (1)
6. What procedures are followed to ensure that adoptive parents are fit to adopt a child?
A home study is completed by a licensed child welfare agency. The statute details the requirements for prospective adoptive parents.
MCL 710.23f (1)-(6)
7. Can the potential adoptive parents have the child placed with them prior to the actual court procedures?
Yes, the child can be placed temporarily with the adoptive family prior to the consents or the releases by the birth parents. The statute outlines the legal requirements for this temporary placement.
MCL 710.23d
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8. Who supervises the adoptive placement and for how long?
A licensed child welfare agency typically supervises the placement for 6 months; however, supervision may be extended up to 18 months, based on the best interest of the child. Upon recommendation from the child welfare agency, the court enters a final Order of Adoption.
MCL 710.26 (2)
COURT SPECIFIC PROCEDURES
1. When do the birth parents actually sign the legal documents for adoption?
The legal documents are signed by the birth mother and the legal birth father (if a legal birth father has been named), after the birth of the child, at a court hearing. Typically, this is at least a month’s time. The putative father can sign a legal document, before the birth of the child, voluntarily stating that he is/may be the father of the child and deny any interest in custody of the child. A putative father is not required to appear at a court hearing, although he can choose to appear in court and sign the legal documents for the adoption if he would like to do so.
2. Who initiates the adoption process?
Either the birth parents or the adoptive parents can initiate adoption proceedings through a licensed child welfare agency or an attorney.
3. When are the legal adoption papers filed with the court?
The petition for adoption is filed in the court after the parental rights of the birth parents have been terminated at a court hearing.
4. What happens if the birth parents do not agree with the adoption plan?
Consent, voluntary release or termination of parental rights must occur for both parents before an adoption petition can be filed. If the birth mother was married at the time of conception or birth, her husband is considered the legal and only father, unless a court determines otherwise. He must consent or release before the child can be placed for adoption. If a putative father establishes paternity, he must also consent or release before the child can be placed for adoption.
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MCL 710.43
5. Can the baby be placed for adoption without the consent of the birth mother and/or birth father?
No, consent by the birth parents and an Order Terminating the Rights of the birth parents issued by the court must be provided prior to adoptive placement.
MISCELLANEOUS QUESTIONS
1. Are contracts or binding agreements between birth parents and adoptive families regarding openness allowed?
In Michigan, any ancillary agreements, such as an openness plan or an openness agreement, are NOT legally binding. Most child welfare agencies will prepare a written agreement and the parties will sign this agreement; however, this agreement is to be used as a guide should there be any disagreements in later years about the level of openness. Birth parents are advised by the agencies, and also are told by the court, that any agreements are not legally binding. In fact, many judges tell the birth parents very clearly during the hearing that any agreements they may have signed with the adoptive family are not legally enforceable. Upon release of parental rights or upon consent to adoption by the birth parents, the parental rights of the birth parents are terminated. This ends any legal rights of the birth parents to the child, including the right to visitation. The legal rights are then vested with the adoptive parents, including the right to determine who has access to their child. Adoptive parents are also told by the agencies that the agreements are not legally binding, but are instead “good faith” agreements.
2. What is the process for accessing adoption files, including identifying information?
If the adoptee is a minor, the decision would be made by the adoptive parents. After the age of 18, when the adoptee is an adult, he or she may seek out their birth parents via the Central Adoption Registry. If the birth parents have not prohibited the release of information, the adoptee may be given the latest information filed on the location of the birth parents.
MCL 710.27b
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3. What is considered a kinship adoption? How is kinship adoption handled? Are home studies necessary? Who can conduct them? Is there a fee?
In Michigan, relative means an individual related to the child within the fifth degree by marriage, blood or adoption. Kinship, or relative, adoptions are a permanent and legal arrangement that is intended to last forever, like all other adoptions. Relative Adoption or Kinship Adoption through Court:
o The birth parents choose the adoptive family. o The court conducts a relative home study. o Both birth parents consent to the adoption. o A home study fee may be assessed, dependent upon who completes the home study and in what county the family resides.
Trainer’s Comments
• Point out the “Rights of Birth Parents in Adoption” in the Participant Handbook, Module 3, page 22. • It is important to remember that birth parents have the right to develop their own adoption and birthing plans. (Test Question) • Ask participants if they have other questions related to birth parent rights and answer the questions.
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State Specific Rights of Birth Parents (5 minutes)
• The Michigan Adoption Code - MCL 710.21-710.70, includes several rights for birth parents: Birth parents decide what type of adoption to choose – direct consent placement or agency placement. Birth parents authorize the temporary transfer of custody to adoptive parents. Birth parents can revoke temporary transfer of custody and have child returned within 24 hours, unless the Court makes a finding that the child comes under the jurisdiction of a child protective proceeding. • In addition: The birth mother and father, if known, must sign a release or consent for adoption. If the birth parent is an un-emancipated minor, the release must also be signed by the parent or a guardian who has been given specific authority to consent, or a guardian named by the court for that purpose. If the minor is legally emancipated, then no other signature is required. If either parent is unknown, the court must make a finding that the identity cannot be determined after reasonable efforts to identify the parent or parents have been made. Putative Father:
o A putative father is a man not married to the mother and who has not acknowledged paternity, whom the mother says is the child’s father.
o A putative father may file paternity at the birth of the child or express intent to file paternity before the child’s birth by signing a statement under oath and filing it with any court in the state.
o When the putative father who has filed a Notice of Intent to Acknowledge Paternity does not come forward to voluntarily release or consent to an adoption, the court notifies the putative father of the existence of the child and grants him the right to come before the court and establish why his parental rights should not be terminated.
o In situations where a birth mother has decided to relinquish her rights, a birth father may legalize his paternal relationship to the child and claim custody of the child, when the court determines this is
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appropriate. The court assesses whether the father was supportive or non-supportive. A supportive father is one who, within the last 90 days, established a custodial relationship or demonstrated substantial and regular support or care, according to their ability, for the mother during the pregnancy or the child after birth. A non-supportive father is one who has provided neither financial and/or emotional support.
o Courts must provide legal notice to putative fathers prior to terminating rights.
The Evan B. Donaldson Adoption Institute lists the following as rights that all birth parents should have:
. To make the placement decision in a fully informed manner devoid of pressure or concern. . To reconsider an adoption plan at any point prior to the legal finalizing of the relinquishment. . To be informed from the start of any monetary expectations – such as repayment of financial assistance – if she changes her mind about placement. . To exercise all parental rights he/she wishes prior to placing a child for adoption. . To be treated with dignity, respect, and honesty. . To have independent legal counsel to protect her/his best interests in the process. . To receive nondirective counseling to help her/him understand all of the options and resources available and the implications of the decision. . To be legally assured that promises and agreements regarding ongoing information or contact made as a part of the process will be adhered to.
For more information regarding the rights of birth parents you may want to read “Safeguarding the Rights and Well-Being of Birthparents in the Adoption Process”, prepared by the Evan B. Donaldson Adoption Institute Revised with Foreword January 2007.
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Trainer Comments
• In addition to specific adoption related questions, including those related to the rights of birth parents, health care professionals generally have questions about other laws specific to child protection referrals, minor consent, competency and notification or reporting laws regarding adults and minors.
• Let’s review the Child Protection Law together.
• Please turn to the Participant Handbook, Module 3, page 24.
Child Protection Law (5 minutes)
• Child Protective Services Referrals Another issue that health care professionals may face when working with pregnant adolescents is the need to report incidents of abuse, neglect or exploitation to the proper state child protection agency. A referral to CPS is required in the following situations:
o When the parent or other person responsible for the pregnant teen’s care: - refuses to have her in the home - threatens to harm the teen and/or the child - refuses to consent to medical care required to prevent death or a serious long-term disabling condition for the teen and/or child
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o When the pregnancy resulted from incest. o When the pregnancy resulted from rape by a person having regular and substantial contact with the teen and who has a close personal relationship with the teen’s mother.
o A child is born to a mother who has had previous children removed from her care due to abuse or neglect.
o A child is born to a mother and has symptoms of drug withdrawal. o A child is born to a mother who states that she does not want to take the child home, has no one to care for the child, and does not want to release the child for adoption at this time.
o A child is born to a mother who exhibits abusive/neglectful behaviors to the child while in the hospital or who abandons the child in the hospital.
o A child is 12 years of age or less and is pregnant.
Trainer’s Comments • It is important to have an understanding of the Federal and State laws which govern adoption as well as the rights of the birth parents and child. The three federal laws we discussed were MEPA, ICWA, and the Servicemembers Civil Relief Act. (Training Reflection Feedback Form) • It is important to have an understanding of the Child Protection Law in your state. Some of the important points to remember are that you, as health care professionals, are mandated reporters and as such must report suspected incidents of abuse, neglect or exploitation to the proper state child protection agency. (Training Reflection Feedback Form) • It is important to have knowledge and understanding of the rights of birth mothers and birth fathers. (Training Reflection Feedback Form) • An adoption agency receiving Federal funds may not, nor may it steer a birth parent to adoptive parents by race, color, or national origin. MEPA insures that federally funded agency adoptions are not delayed based on race, color, or national origin of either the child or adoptive parent. (Test Question)
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TurningPoint Question 6. Ask participants to answer the question on the slide using the remote devices.
7. When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses.
8. Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Adoption laws are specific to each state and may change over time. (Test Question)
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Placement and adoption of Native American children is governed by their tribe, whose authority is legislated by the U.S. Government. (Test Question)
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TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly. It is important to remember that birth parents have the right to develop their own adoption and birthing plans. (Test Question)
Transition • Hopefully, this module has provided you sufficient information so that you feel comfortable enough to talk about these issues with your patient/clients. • Do you have any questions or comments about any of the material covered in this module? • Remember, you are not expected to be legal experts. However, you do have references for the laws discussed should you desire further information. • You can check the State legislative website for updates.
• We will now take a break for lunch.
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To Find Out More About It
State of Michigan Laws
Statutory reference for the Adoption Law and Child Protection/Child Abuse & Neglect Law: Michigan Adoption Code (MCL 710.21 – 710.70). Michigan Safe Delivery of Newborns (MCL 712-10 – 712.20). Michigan Child Protection Law (MCL 722.) www.legislature.mi.gov
Federal Laws
The Howard M. Metzenbaum Multiethnic Placement Act (MEPA) of 1994 – PL 103-382, Sections 551-555 as amended by the Small Business Job Protection Act- Provision for Removal of Barriers to Interethnic Adoption (IEP) of 1996, PL 104-188, Section 1808. http://www.acf.hhs.gov/programs/cb/laws_policies/cblaws/safe2003.pdf
Indian Child Welfare Act, PL 95-608 of 1978. http://www.nicwa.org/policy/law/icwa/ICWA.pdf
Servicemembers Civil Relief Act of 2003 (SCRA), formerly known as Soldiers’ and Sailors’ Civil Relief Act of 1940 (SSCRA). http://www.access.gpo.gov/uscode/title50a/50a_10_1_.html
Smith, S. (November 2006, revised January 2007). Safeguarding the rights and well- being of birthparents in the adoption process. (White Paper). Evan B. Donaldson Adoption Institute. Retrieved from: http://www.adoptioninstitute.org/research/2006_11_birthparent_wellbeing.php
Evan B. Donaldson Adoption Institute, (Revised with Foreword January, 2007), “Safeguarding the Rights and Well-Being of Birthparents in the Adoption Process” Evan B. Donaldson Adoption Institute, (November 2007),“For the Records: Restoring a Legal Right for Adult Adoptees.”
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MEPA/IEP
The Multiethnic Placement Act of 1994, as amended by the Interethnic Adoption Provisions of 1996 (hereafter, “MEPA/IEP”), prohibits public agencies from delaying or denying a foster or adoptive child’s placement based on the race, color or national origin of the child or the prospective parent. The “delay or deny” provision also is a Title IV-E State Plan requirement at 471 (a)(18) of the Social Security Act. Additionally, MEPA/IEP prohibits such agencies from denying prospective parents the opportunity to become foster or adoptive parents based on the child or the parent’s race, color or national origin. Denying an individual the opportunity to become a foster or adoptive parent based upon the child or parent’s race also is a violation of Title VI of the Civil Rights Act of 1964. Finally, MEPA/IEP requires that agencies subject to MEPA/IEP diligently recruit foster and adoptive families who reflect the ethnic and racial diversity of the children in the State who need foster and adoptive placements. The “diligent recruitment” provision of MEPA/IEP also is a Title IV-B State Plan requirement at 422 (b)(9) of the Social Security Act.
Consequently, agencies may not routinely consider race, color or national origin within making foster care or adoptive placements. They similarly may not create a two-tiered system of foster care or adoptive placements whereby prospective parents are treated differently based upon their race, color or national origin relative to that of the child they wish to foster or adopt. Agencies may not act in a manner that discourages or dissuades prospective parents from pursuing foster parenting or adoption across race, color or national origin lines.
MEPA/IEP does not affect or interfere with the placement preferences that are established by the Indian Child Welfare Act.
MEPA/IEP applies to public agencies that receive Title IV-E funds. It also applies to entities (including private or non-profit agencies) that contract with public agencies to perform child welfare services. Title VI applies to entities that receive Federal financial assistance.
Source: Department of Health and Human Services, February 2002
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Indian Child Welfare Act (ICWA)
In 1978, the Federal Indian Child Welfare Act (ICWA) was passed. Under the Act, Indian Tribes were granted extensive jurisdiction in child welfare cases involving Indian children, recognizing “that there is no resource that is more vital to the continued existence and integrity of Indian Tribes than their children.”
The Act “established minimum standards for the removal of Indian children from their families and placement of such children in foster or adoptive homes which will reflect the unique values of Indian culture.”
In any involuntary proceedings in State court, where the court knows or has reason to know that an Indian child is involved, the party seeking the foster care placement of, or termination of parental rights to, an Indian child must notify the parent, or custodian and the Indian child’s Tribe, or if the Tribe is unknown, the Secretary of Interior.
Extensive jurisdiction in child welfare cases involving Indian children is given to Indian Tribes including: • Identification of Indian children by the State child welfare agency • Indian parents and Tribes have the right to notice of, and to intervene, in State proceedings involving Indian children • Special preference for placement of Indian children with (1) a member of the child’s extended family, (2) other members of the Indian child’s Tribe, or (3) other Indian families and as specified in the law, or (4) a different order of preference if ordered by Tribal resolution. • Active efforts to prevent the breakup of the Indian family, including use of Tribal community services and culturally appropriate programs. • Use of Tribal courts in child welfare matters. Tribes have the right to intervene in State proceedings, or have the proceedings transferred to the jurisdiction of the Tribe or to decline such transfer.
States are required to comply with this law in their child welfare practices.
In October 1994, the Social Security Act was amended to require States, in consultation with Tribes and Tribal organizations, to include a description of the State’s compliance with ICWA in the Title IV-B, subpart 1 State plan (now combined with other programs into the State Child and Family Services Plan).
In addressing ICWA, states are required to describe in their plan, (1) the Indian population of the State, (2) the consultation process used with all of the Tribes, (3) procedures for addressing cases involving children from out-of-State Tribes, and (4) the areas of concern that are raised by the Tribes through the consultation process.
Source: Department of Health and Human Services, February 2002
Module 3 - Page 38 Trainers Guide – MI DRAFT UIA 4 – 1 Day - Module 4 12/12/11 Module 4: Social, Cultural & Personal Influences (60 minutes)
Trainer’s Preparation
Module Contents and Training Process • Various influences of family, community, and culture that may impact a pregnant woman • Explore birth father issues and how to engage birth fathers in the process • Special issues in working with teens
Preparing to Train • Review content and become familiar with information regarding culture, birth fathers and teen development. • Review and select the option you will use during the training. The options are as follows: Option 1 of 2: Team Activity (Trainers Guide, Module 4, page 4 directions and Pages 4 -20 activity and discussion) This activity is designed to have the participants explore the specific influences birth fathers and culture, as well as being a teenager, may have on a woman’s decision-making process as she faces an unintended pregnancy. The first section involves a brainstorming activity of influences in general, highlighting the three areas to be discussed in more detail. Prepare six flip chart pages with one of the following headings on each page: 1. Culture - Characteristics 2. Culture - Influences 3. Birth Father - Influences 4. Birth Father - How to engage 5. Teens - Characteristics 6. Teens - Influences Place the culture charts together on one side of the room, the birth father charts on another wall and the teen charts together on a different wall. This should be done before participants return from lunch.
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Option 2 of 2: Lecture with Kesha Video (short version) (Pages 21-26) Lecture material regarding adolescent development, birth father influences, and cultural influences and how this may impact a person’s decision-making process regarding an unintended pregnancy. Preview video and accompanying lecture material regarding the influences that being a teenager may have on a woman and her decision regarding an unintended pregnancy.
Team Activity: Influences Activity
• The exercise is designed to have participants experience the many influences pregnant women may face in making a decision. Participants break up into small groups and each team is given a scenario. Each member of the group assumes a role from the scenario. Based on their role what they say may influence the pregnant woman in her decision-making process.
Required Materials/Equipment and Room Set-Up for this Module • Flip chart and markers • Kesha video (short version) • TV-VCR or DVD Player • Laptop and Projector • Screen to show PowerPoint presentation and DVD’s
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Module 4: Introduction
Objectives: Recognize how family, peers, community, religious beliefs and cultural values can influence the patient/client’s decisions about adoption. Demonstrate sensitivity to family, community, and cultural values while providing support to patient/clients. Recognize how birth father can affect decisions considered or made by pregnant women. Develop strategies to better engage the birth father. Identify developmental factors that affect teens experiencing an unintended pregnancy. Describe characteristics of culturally responsive services.
Content • Influence of Family, Community, Culture in Pregnancy • Birth Father Issues and Considerations • Special Issues in Working with Teens • Impact of Pregnancy on the Adolescent’s Development
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Influences of Family, Community & Culture on Pregnancy (20 minutes) Option 1 of 2: Team Activity (Pages 4-17). Option 2 of 2: Lecture with Kesha video (Pages 21-39).
Option 1 of 2: Team Activity
Trainer’s Comments In this module we will be discussing the many influences that may impact a woman when experiencing an unintended pregnancy.
• How do we make decisions? Our decisions are influenced by many different things, which may tell us the “right” thing to do. We don’t live in a vacuum…we have all kinds of people, opinions and messages coming at us. Everyone we know has an opinion. We listen to some opinions more than others; it depends on our relationship to that person. It also depends on our age, our needs, the expertise of the person giving the advice, and our own values and personalities. • Let’s explore further the various influences that may affect a woman faced with an unintended pregnancy.
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Large Group Discussion • What are some of the influences that may affect a woman’s decision-making process when faced with an unintended pregnancy?
Using a flip chart, record the participant’s responses: • Some of the possible responses may be: Family Age/Teen Friends Future goals or plans Society and Media Education and knowledge of options Birth Father Religion Beliefs and Values Economic Situation • We will be highlighting three areas and discuss them in more detail. These are the influences that culture, the birth father and being a teenager may have on the decision-making process. If time allows, we will discuss the other factors noted by the group.
• Have the participants count off 1-2-3. Tell the participants in the first group to list, on the first flip chart page, characteristics of culture and on the second flip page how these characteristics might influence a pregnant woman’s decision- making process. Tell the participants in the second group to write down on the first flip chart page how the father influences the decision-making process and on the second flip chart page, how can we engage him in the process. Tell the participants in the third group to write down on the first flip chart page typical characteristics of being an adolescent and on the second how being an adolescent may influence their decision-making process when faced with an unintended pregnancy.
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• Tell the participants that group 1 should go the flip chart page titled culture, group 2 should go to the flip chart page titled birth father, and group 3 should go to the flip chart page titled teens. Instruct the groups that we will be exploring ways in which each of these factors may influence a pregnant woman.
• After 10-15 minutes, have the participants return to their seats before beginning a large group discussion.
Large Group Discussion (10 minutes) • Begin with the group that discussed culture. Have a spokesperson report the group’s answers to what are some of the characteristics of culture. TRAINER NOTE: Use the following comments to complete the discussion. Be sure to cover the material below if it has not already been discussed by the group.
• What do we mean by culture? Some possible responses may include: . Language . Patterns of Dress . Foods . Mores . Habits . World View . Common Language . Common History . Common recreational/leisure activities
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. Role of women in culture . Socio-economic status . Role of men . Methods of child rearing. . Common beliefs and the messages we live by. • The list could go on. • Now have the spokesperson for the group review what the group determined regarding the influences culture may have on the decision-making process. Some possible responses may include: . Culture may dictate expectations, i.e. children must remain with family. . Culture may dictate that men make the decisions in the family. . The role of women may be seen as being a parent only, with any other role not seen as an option. • There are no right answers, no right or wrong values.
• What might be important to remember when working with someone of a culture different than your own? • Possible Responses: That they may have a different perspective on the situation. That they may have a different priority in the situation. That their perspective is more important than mine. That they have a right to make their own decision about their lives. That they may relate to my authority as a healthcare professional in extreme terms, trying to please me rather than making the best decision for themselves and their child.
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Trainer’s Comments
• Refer participants to Participant Handbook, Module 4, page 3, “Providing Culturally Responsive Services.”
• Cultural responsiveness requires that the health care provider be aware and respectful of the cultural norms held by the patient/client that may influence his/her decision-making or his/her perception of the available options. (Test Question) • Culturally responsive services treat the individual first, while simultaneously considering his/her cultural norms and values as expressed by the patient/client. • To be culturally sensitive, a healthcare and/or helping professional should be aware that they probably lack complete knowledge about a patient/client’s family and culture, even if they share race/ethnicity. (Test Question) • Refer to pink pages in the Participant Handbook, Module 4, page 55 for additional information entitled “Self Assessment Worksheet.” • We need to avoid assumptions about someone’s culture based on their color or ethnicity. To learn about someone’s culture we need to ask open-ended questions. • When working with someone from a different culture remember building rapport may take longer to establish. Take time for mutual introductions, observe the patient/client and follow their lead in the amount of formality preferred or information they want to share. • If the health care provider does not know much about the patient/client’s culture, being sincerely open about his/her lack of knowledge and desire to learn is a sign of respect. For example, you may tell a patient, “My experience in working with Latinos/Hispanics is limited. Help me understand your unique experiences.”
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• Health care providers need to be aware of the perceived power differential that can exist between them and their patient/clients. For example, some Latino/Hispanic patients who are less acculturated may defer decisions to you as a sign of respect for your position. Therefore, it is important that you maintain a neutral position.
• Family members, close friends, and/or the perceptions of the patient/client’s community may play a role in the decision-making process. Therefore, you need to be open to including extended family members in your discussions if the patient/client requests this. • It is important to remember that diversity within cultures exists and that the best approach is to work with every patient/client as an individual. • A patient/client’s level of acculturation plays a major factor in the decision- making process. Levels of acculturation depend on how long an immigrant has lived in the United States and how they make sense of their values from their country of origin and integrate those values from their country of origin and integrate those values into their new host country. It may vary within families as well. • When an interpreter is required, remember to speak to the patient/client not the interpreter. • Lack of eye contact may not mean that a person is passive or disinterested. Eye contact in many cultures may be considered disrespectful. • Are there any questions that you have regarding culture, cultural influences, and the role they can play in a woman’s decision-making process when faced with an unintended pregnancy? • For comprehensive training on cultural competence, see the Introduction to Cultural Competence training by Spaulding for Children.
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Transition
• We have discussed culture and how a pregnant person’s culture, which includes values and beliefs, can influence their decision making. Now it is time to check our own values and beliefs and how they might influence our thinking in an individual activity. This activity will help us identify influences we are impacted by.
• Please read the scenarios listed in you Participant Handbook, Module 4, page 4. • These are all situations of women facing an unintended pregnancy. Please read and then mark in your book whether you think each of these women chose parenting or adoption. Do not share this with your neighbor just yet.
Large Group Discussion (10 minutes)
• After each profile ask the participants the following questions:
• Raise your hand if you think this patient/client chose adoption? Parenting? • Could someone share with the group why they feel this patient/client made the decision they did? What information made you vote the way you did?
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Profiles:
1. I am Caucasian and twenty-two years old. I grew up in an upper middle class family. The father is a longtime boyfriend. Church has always been important to my family. I plan to go back to college after the baby is born.
2. I am a nineteen year old woman. I am from Guatemala. I have a three year old daughter at home with my mother. I work at a restaurant and send money back home. I am living with my sister and her husband. I do not know where the father is living now.
3. I am twenty-one years old. I am African-American. I have two young children. I am not married, but have been with the same man for a longtime. He is the father of all three children. I work at a fast food restaurant.
4. I am twenty-nine years old. I am Caucasian. This is my 6th pregnancy. The kids, their father, and I live in a trailer park. Things are really tight right now. My husband is looking for work, but can’t seem to find a job.
5. I’m 41 years old and married. I’m Hispanic and my husband is Caucasian. I have two grown daughters from a previous relationship and an 11 year old son at home. My husband and I did not intend to get pregnant.
6. I’m 30 years old, and I have a 3 year old son. I am Native American and work part time as a waitress. I have no relationship with my son’s father nor the man I was dating when I got pregnant. I am not a member of the tribe, but I want to enroll. I myself am adopted, and I need to get more information from my adoptive parents before I can enroll.
Trainers Note: Focus all participants’ comments towards understanding that every situation is unique.
• All of these profiles are actual profiles where adoption was chosen. This information comes from our partner Arizona Children’s Association. Remember, as health care professionals, it is important to understand how people are influenced in different ways. It may be easy to judge what we think a person should do in any given situation. However, it is our role to provide information about all options available to our patent/clients and to help them decide for themselves what decision is best for them,
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• Next we will discuss birth father issues and considerations with our group that worked on that.
Large Group Discussion (10 minutes)
Ask the spokesperson to report the group’s answers to what are some of the influences the birth father might have on a person’s decision-making process TRAINER NOTE: Use the following comments to complete the discussion. Be sure to cover the material below if it has not already been discussed by the group.
Turn to Participant Handbook, Module 4, page 5. • Someone who may bear a great deal of influence on the decision to be made is the birth father. Engagement with him must start with the pregnant woman. Refer to pink pages in the Participant Handbook, Module 4, pages 56-57, “Common Myths and Facts for Birth Fathers” for more information about birth fathers. • It is the pregnant woman’s decision to determine how she wants the birth father engaged in the process of discussing pregnancy options with the health care professional. • Once she makes the decision to include him in the discussion with the health care professional, it is that professional’s responsibility to engage him in the process.
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• It is important, however, to remember that legally many states demand that birth fathers be contacted regarding a pregnancy and offered counseling and services. • When indicated, health care professionals can be welcoming and helpful in encouraging him to support the pregnant woman and in providing appropriate information to assist in decision making. • Health care professionals can facilitate informed decision-making by identifying strengths and building on those in making referrals. • It is important for health care professionals to engage interested birth fathers using the same techniques used to engage others: treating them with dignity and respect; actively listening to their concerns and being nonjudgmental. (Test Question) • Birth fathers can be encouraged to take an interest in their partner and the pregnancy and attend prenatal and perinatal visits, if that is what the pregnant woman chooses or wants. • Birth fathers can be encouraged to become informed about the experiences and issues of pregnancy so that they can become a partner in informed decision- making regarding pregnancy options. However, the decision to involve him is totally within the control of the pregnant woman. • Without exception, birth fathers who release their parental rights experience a range of feelings, including a sense of loss. Even the most seemingly disinterested birth father – despite his relief, despite his eagerness to sign the papers, despite his apparent urge to flee – still experiences a loss. Many birth fathers find it helpful to talk about this sense of loss, either in a professional or peer support setting. Refer to pink pages regarding birth father grief and loss, Participant Handbook, Module 4, pages 58-59, “Stages of Birth Father Grief.” • Birth fathers can be encouraged to provide information about themselves, their medical history, and their interest in contact with their child when he/she is an adult. This information needs to be given to the attorney and/or agency completing the adoption. • In open adoptions, birth fathers may be able to maintain on-going contact with their child and update any personal or medical information for the adoptive family. • Birth fathers can become custodial parents. • Birth fathers have rights that are specified by state laws.
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Engaging the Birth Father
• Why engage the birth father? See Participant Handbook, Module 4, page 6. • If the birth father is at all involved with the pregnant woman, he will play a significant role in her pregnancy option decision. Therefore, he should have as much information as possible to help him support her decision-making process. • Should the decision be to parent a child, the birth fathers’ involvement may be beneficial to the life and well-being of that child. Therefore, it is helpful if the birth father is engaged in the process from the beginning. • If both the pregnant woman and the birth father can agree, it would be beneficial if the paternal relatives be involved as well. As men have become more involved, so have their families. Extended family support can be very important. • Now have the spokesperson for the group review what their group determined regarding how to engage the birth father. Ideas to engage the birth father: • If the pregnant woman chooses to involve him, the health care professional can facilitate engagement. Talk to him directly, ask him specifically what he wants to know or talk about. Don’t assume that what you have heard from the pregnant woman represents how he feels. • Point out how important he is to the decision-making process. • Attending to his questions and concerns using nondirective, noncoercive techniques. Acknowledge this is a difficult decision for him as well. • Have resource information available about the role of the birth father in pregnancy care, birth, and parenting. • Make sure he feels welcomed by all staff. • Have male-oriented items in the office including décor, magazines, information about fathering and fatherhood programs, information on grief and loss and support groups for men.
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• Discuss honestly with staff what their feelings are about the birth father and men in general.
When to engage? • It would be beneficial for all parties involved to have the birth father involved as soon as possible so that he can be a positive support to the pregnant woman as she makes her decisions. • Are there any questions that you have regarding birth fathers and the role they can play in a woman’s decision-making process when faced with an unintended pregnancy? • For comprehensive training regarding birth fathers and their experiences regarding adoption, see Understanding the Birth Father Experience by Spaulding for Children.
Transition • Next we will discuss special issues for teens as they relate to the decision-making process when experiencing an unintended pregnancy with our group that worked on that.
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Special Issues for Teens
• How does being a teenager influence decision making? Adolescents share many common characteristics. You often hear them described as risk takers, independent, moody, influenced by peers, fearless, frightened, and holding the belief that they are omnipotent. Teens can show all of these characteristics during a typical day and their moods can be very changeable. Remember that the same characteristic can be seen as both negative and positive depending on the situation. For example, risk taking may be seen as a negative when it relates to sexual activity but seen as a positive when it relates to a teens willingness to try new things.
TRAINER NOTE: Use the following comments to complete the discussion. Be sure to cover the material below if it has not already been discussed by the group.
Trainer’s Comments • Adolescence is a time of tremendous physical, cognitive, emotional and social change. We will focus on early and middle adolescence. Refer to Participant Handbook, Module 4, page 7.
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• The adolescent brain is not fully developed. Adolescence is a time of important changes in both the structure and the function of the brain. • Dramatic changes occur in the adolescent brain and if these are understood then some adolescent behavior is more easily understood. • The prefrontal cortex, the part of the brain behind the forehead is one of the last to fully develop. The prefrontal cortex can be seen as the boss of the brain as it controls planning, working memory, organization and the modulation of moods. • As this section of the brain matures adolescents can reason better, develop more control, and make judgments better. • Maturation of the prefrontal cortex is not complete until the mid 20’s. • At the same time the prefrontal cortex is maturing there are other changes going on in the brain including increased release of dopamine, the chemical substance that is responsible for the feeling of pleasure. • Because good things feel so much better during adolescence, teens they may go out of their way to seek pleasurable experiences. • The urge to seek out rewarding and pleasurable experiences is a mixed blessing. • On the plus side, it’s part of what makes it so much fun to be a teenager. • But sometimes this drive is so intense that adolescents can exhibit a sort of reward tunnel vision. • Adolescents can be so driven to seek pleasure that they may not pay attention to the associated risks. • For example, a teenager may drive too fast or have unprotected sex without thinking of the risks because it feels so good. Source: Steinberg, Lawrence (2011). You and Your Adolescent: The Essential Guide for Ages 10 to 25 Source: Steinberg, L., Vandell, D., & Bornstein, M., (2011). Development: Infancy through adolescence, Belmont, CA: Wadsworth. • Cognitively, adolescents are still formulating their own points of view. They do this by trying out different ways of doing things and adjusting what they do based on the reactions of others or their demands and expectations.
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• Socially, adolescents look primarily to the peer group for information and guidance. While this group may be one of the largest influences on a patient/client the information they provide may not always be accurate. • Emotionally, adolescents are often egocentric in nature, operating in a self- centered manner, for example: • Early (12 to 15 years old) and middle adolescents (16 to 18 years old) have difficulty anticipating the needs of others and putting them above their own, particularly the unborn child. Research has shown that younger adolescents possess less sophisticated decision making skills than do 16 to 18 year olds. Source: Lewis, C.C. (1981) How adolescents approach decisions: Changes over grades seven to twelve and policy implications. Child Development, 52, pgs.538- 544. • Adolescents may not understand the reality and impact of caring for a baby until months after the baby is born. • For pregnant teens this normal stage of development can make them appear to be undecided, unpredictable and non-compliant. • An unintended pregnancy often strips the adolescent of this time for transition and requires him/her to make decisions and follow through with tasks on an adult level. • Some pregnant teens may not follow through on medical advice or keep medical appointments, because these activities may set them aside from the peer group and/or they underestimate its importance. • Because adolescents are experiencing a time of great change that is heightened by the crisis of an unintended pregnancy, they may need information to be repeated and presented in a number of different ways. This information may be provided by any of the helping professionals that interact with the pregnant teen. • Handouts may be helpful as the teen may review this information at a later date.
• Relationships with both parents and peers have been shown to influence the adolescent’s ability to reflect upon and develop a strategy for the future. Adolescents who do best with unintended pregnancies have the help and support of all of the adults in their lives. • Treating teens with dignity and respect and listening non-judgmentally will be most helpful. Choosing matching language can be helpful, though not to the
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extreme that it is no longer genuine. Teens can usually tell when someone is trying too hard to be cool. How do adolescents make decisions? Adolescents make decisions by:
• Identifying the options • Identifying the consequences of each option • Evaluating the desirability of the consequences • Assessing the likelihood of the consequences • Combining these steps according to a coherent “decision rule”
• Research shows that many pregnant teens, especially those in middle adolescence, mature quickly throughout their pregnancy and are able to make good decisions for themselves and their child. (Test Question)
You can help an adolescent patient/client make decisions through the decision-making process by:
• brainstorming sessions to identify ongoing support and future goals, • helping the teen practice handling difficult situations through anticipatory guidance and role-play, • helping the teen develop a plan for the future, • allowing more time for processing of information and options, and because adolescents are already experiencing a time of great change, which can be heightened by the crisis of an unplanned pregnancy, they may need information to be repeated and presented in a number of different ways.
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• Denial may be a reaction for teens, though this may be true for any age. Teens in particular may want to pretend they are not pregnant for as long as they can. Sometimes later in the pregnancy when they can feel the baby moving is when it becomes more “real” to them. Sometimes it is not until the baby is born that it becomes “real.” • Intellectually, adolescents may be very concrete, using here and now thinking. When they do consider the future they often have idealistic or unrealistic expectations due to lack of experience. Teens often under estimate the task of parenting until they face the day to day challenges of raising a child. (Test Question) • Adolescents may be less skillful than adults in identifying options because they lack sufficient knowledge alternatives and relevant life experiences to draw from; therefore, adolescents tend to need more time than adults to make an informed decision. Source: Trad, P. (1993) The ability of adolescents to predict future outcome. Part I: Assessing predictive abilities. Adolescence, (28) pgs. 111, 533 • Teen communication styles may include not being very verbal, not being very engaging, and avoiding eye contact. Despite the fact that teens tend to not be verbal and tend to give superficial answers when initially dealing with authority figures, they still need to be provided with information. (Test Question)
Trainer Note: Additional information regarding adolescents and decision making can be found in the Trainer Guide, Module 4, pages 59 - 61. They are also found in the Participant Handbook, Module 4, pages 51-53. Refer participants to these pages for future review.
Transition We have discussed how culture, birth fathers, and being a teen may influence how a woman makes a decision regarding an unintended pregnancy. Now we will discuss additional influences that may impact a woman or teen’s decision-making process when faced with an unintended pregnancy.
TRAINER NOTE: Continue in Trainer Guide, Module 4, page 364, Influences heel.
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Influences of Family, Community & Culture on Pregnancy (5 minutes)
Option 2 of 2: Lecture
• How do people make decisions? Our decisions are influenced by many different things including our culture, our age, our family and friends, our religion, our society and media which may tell us the “right” thing to do. We don’t live in a vacuum. We have all kinds of people, opinions and messages coming at us. Everyone we know has an opinion. We listen to some opinions more than others. It depends on our relationship to that person. It also depends on our age, our needs, the expertise of the person giving the advice, and our own values and personalities. • Let’s talk about the cultural influences.
• What do we mean by culture? It is language, patterns of dress, foods, mores, habits, world view, vocation/career, common language, common history, common recreational/leisure activities, family roles, and methods of child rearing. The list could go on. • A component of culture is our values and beliefs, i.e. the messages we live by. • There are no right answers, no right or wrong values.
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• What might be important to remember when working with someone of a culture different than your own? • Possible Responses: That they may have a different perspective on the situation. That they may have a different priority in the situation. That their perspective is more important than mine. That they have a right to make their own decision about their lives. That they may relate to my authority as a healthcare professional in extreme terms, trying to please me rather than making the best decision for themselves and their child.
Trainer’s Comments
• Refer participants to Participant Handbook, Module 4, page 3, “Providing Culturally Responsive Services.” • What does a culturally responsive service look like?
• Cultural responsiveness requires that the health care provider be aware and respectful of the cultural norms held by the patient/client that may influence his/her decision-making or his/her perception of the available options. (Test Question) • Culturally responsive services treat the individual first, while simultaneously considering his/her cultural norms and values as expressed by the patient/client. • To be culturally sensitive, a healthcare and/or helping professional should be aware that they probably lack complete knowledge about a patient/client’s family and culture, even if they share race/ethnicity. (Test Question)
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• Refer participants to Participant Handbook, Module 4, page 55, “Self Assessment Worksheet” for additional information. • We need to avoid assumptions about someone’s culture based on their color or ethnicity. To learn about someone’s culture we need to ask open-ended questions. • When working with someone from a different culture remember building rapport may take longer to establish. Take time for mutual introductions and observe the patient/client and follow their lead in the amount of formality preferred or information they want to share. • If the health care provider does not know much about the patient/client’s culture, being sincerely open about his/her lack of knowledge and desire to learn is a sign of respect. For example, you may tell a patient, “My experience in working with Latinos/Hispanics is limited. Help me understand your unique experiences.” • Health care providers need to be aware of the perceived power differential that can exist between them and their patient/clients. For example, some Latino/Hispanic patients who are less acculturated may defer decisions to you as a sign of respect for your position. Therefore, it is important that you maintain a neutral position.
• Family members, close friends, and/or the perceptions of the patient/client’s community may play a role in the decision-making process. Therefore, you need to be open to including extended family members in your discussions if the patient/client requests this. • It is important to remember that diversity within cultures exists and that the best approach is to work with every patient/client as an individual. • A patient/client’s level of acculturation plays a major factor in the decision- making process. Levels of acculturation depend on how long an immigrant has lived in the United States and how they make sense of their values from their country of origin and integrate those values from their country of origin and integrate those values into their new host country. It may vary within families as well. • When an interpreter is required, remember to speak to the patient/client not the interpreter. • Lack of eye contact may not mean that a person is passive or disinterested. Eye contact in many cultures may be considered disrespectful.
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Are there any questions that you have regarding culture, cultural influences, and the role they can play in a woman’s decision-making process when faced with an unintended pregnancy?
For comprehensive training on cultural competence, see the Introduction to Cultural Competence training by Spaulding for Children.
Transition
• We have discussed culture and how a pregnant person’s culture, which includes values and beliefs, can influence their decision making. Now it is time to check our own values and beliefs and how they might influence our thinking in an individual activity. This activity will help us identify influences we are impacted by.
• Please read the scenarios listed in you Participant Handbook, Module 4, pages • These are all situations of women facing an unintended pregnancy. Please read and then mark in your book whether you think each of these women chose parenting or adoption. Do not share this with your neighbor just yet.
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Large Group Discussion (10 minutes)
• After each profile ask the participants the following questions:
• Raise your hand if you think this patient/client chose adoption? Parenting? • Could someone share with the group why they feel this patient/client made the decision they did? What information made you vote the way you did?
Profiles:
1. I am Caucasian and twenty-two years old. I grew up in an upper middle class family. The father is a longtime boyfriend. Church has always been important to my family. I plan to go back to college after the baby is born.
2. I am a nineteen year old woman. I am from Guatemala. I have a three year old daughter at home with my mother. I work at a restaurant and send money back home. I am living with my sister and her husband. I do not know where the father is living now.
3. I am twenty-one years old. I am African-American. I have two young children. I am not married, but have been with the same man for a longtime. He is the father of all three children. I work at a fast food restaurant.
4. I am twenty-nine years old. I am Caucasian. This is my 6th pregnancy. The kids, their father, and I live in a trailer park. Things are really tight right now. My husband is looking for work, but can’t seem to find a job.
5. I’m 41 years old and married. I’m Hispanic and my husband is Caucasian. I have two grown daughters from a previous relationship and an 11 year old son at home. My husband and I did not intend to get pregnant.
6. I’m 30 years old, and I have a 3 year old son. I am Native American and work part time as a waitress. I have no relationship with my son’s father nor the man I was dating when I got pregnant. I am not a member of the tribe, but I want to enroll. I myself am adopted, and I need to get more information from my adoptive parents before I can enroll.
Trainers Note: Focus all participants’ comments towards understanding that every situation is unique.
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• All of these profiles are actual profiles where adoption was chosen. This information comes from our partner Arizona Children’s Association. Remember, as health care professionals, it is important to understand how people are influenced in different ways. It may be easy to judge what we think a person should do in any given situation. However, it is our role to provide information about all options available to our patent/clients and to help them decide for themselves what decision is best for them,
• Next we will discuss birth father issues and considerations with our group that worked on that.
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Birth Father Issues and Considerations (5 minutes)
• Turn to Participant Handbook, Module 4, page 4. • Someone who may bear a great deal of influence on the decision to be made is the birth father. Engagement with him must start with the pregnant woman. Refer to pink pages in the Participant Handbook, Module 4, pages 56-57 “Common Myths and Facts for Birth Fathers” for more information about birth fathers. • It is the pregnant woman’s decision to determine how she wants the birth father engaged in the process of discussing pregnancy options with the health care professional. • Once she makes the decision to include him in the discussion with the health care professional, it is that professional’s responsibility to engage him in the process. • It is important, however, to remember that legally many states demand that birth fathers be contacted regarding a pregnancy and offered counseling and services. • When indicated, health care professionals can be welcoming and helpful in encouraging him to support the pregnant woman and in providing appropriate information to assist in decision making. • Health care professionals can facilitate informed decision-making by identifying strengths and building on those in making referrals. • It is important for health care professionals to engage interested birth fathers using the same techniques used to engage others: treating them with dignity and respect; actively listening to their concerns and being nonjudgmental. (Test Question) • Birth fathers can be encouraged to take an interest in their partner and the pregnancy and attend prenatal and perinatal visits, if that is what the pregnant woman chooses or wants. • Birth fathers can be encouraged to become informed about the experiences and issues of pregnancy so that they can become a partner in informed decision-making regarding pregnancy options. However, the decision to involve him is totally within the control of the pregnant woman. • Without exception, birth fathers who release their parental rights experience a range of feelings, including a sense of loss. Even the most
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seemingly disinterested birth father – despite his relief, despite his eagerness to sign the papers, despite his apparent urge to flee – still experiences a loss. Many birth fathers find it helpful to talk about this sense of loss, either in a professional or peer support setting. Refer to pink pages regarding birth father grief and loss, Participant Handbook, Module 4, pages 58-59, “Stages of Birth Father Grief.” • Birth fathers who release their parental rights will experience loss and may find it helpful to talk about this with others, either in a professional or peer support setting. • Birth fathers can be encouraged to provide information about themselves, their medical history, and their interest in contact with their child when he/she is an adult. This information needs to be given to the attorney and/or agency completing the adoption. • In open adoptions, birth fathers may be able to maintain on-going contact with their child and update any personal or medical information for the adoptive family. • Birth fathers can become custodial parents. • Birth fathers have rights that are specified by state laws.
Engaging the Birth Father
• Why engage the birth father? See Participant Handbook, Module 4, page 6. • If the birth father is at all involved with the pregnant woman, he will play a significant role in her pregnancy option decision. Therefore, he should have as much information as possible to help him support her decision-making process. • Should the decision be to parent a child, the birth fathers’ involvement may be beneficial to the life and well-being of that child. Therefore, the birth father is engaged in the process from the beginning. • If both the pregnant woman and the birth father agree, it would be beneficial if the paternal relatives are also encouraged to be part of the process. For so long birth fathers have not been encouraged to participate, much less the paternal relatives. Extended family support can be very important during these times.
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Ideas to engage the birth father: • If the pregnant woman chooses to involve him, the health care professional can facilitate engagement. Talk to him directly, ask him specifically what he wants to know or talk about. Don’t assume that what you have heard from the pregnant woman represents how he feels. • Point out how important he is to the decision-making process. • Attending to his questions and concerns using nondirective, noncoercive techniques. Acknowledge this is a difficult decision for him as well. • Have resource information available about the role of the birth father in pregnancy care, birth, and parenting. • Make sure he feels welcomed by all staff. • Have male-oriented items in the office including décor, magazines, information about fathering and fatherhood programs, information in grief and loss and support groups for men. • Discuss honestly with staff what their feelings are about the birth father and men in general.
When to engage? • It would be beneficial for all parties involved to have the birth father involved as soon as possible so that he can be a positive support to the pregnant woman as she makes her decisions. • Are there any questions that you have regarding birth fathers and the role they can play in a woman’s decision-making process when faced with an unintended pregnancy?
Transition • Next we will discuss special issues for teens as they relate to the decision-making process when experiencing an unintended pregnancy with our group that worked on that.
For comprehensive training regarding birth fathers and their experiences regarding adoption, see Understanding the Birth Father Experience by Spaulding for Children.
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Special Issues for Teens (5 minutes)
Turn to Participant Handbook, Module 4, page 6. Large Group Discussion • How does being a teenager influence decision making? Adolescents share many common characteristics. You often hear them described as risk takers, independent, moody, influenced by peers, fearless, frightened, and holding the belief that they are omnipotent. Teens can show all of these characteristics during a typical day and their moods can be very changeable. Remember that the same characteristic can be seen as both negative and positive depending on the situation. For example, risk taking may be seen as a negative when it relates to sexual activity but seen as a positive when it relates to a teens willingness to try new things.
“Kesha” Video (short version) 10 minutes
Video Description
Kesha is a 4-minute video featuring a 14 year old girl visiting her school health center staffed by Mrs. Kaye, a registered nurse. Kesha discovers she is pregnant during this visit. Later we see Mrs. Kaye, Kesha, and Kesha’s mother talking about Kesha’s pregnancy and plans.
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Directions
• Tell participants to watch for key themes and issues in the video. • Tell participants to turn to Participant Handbook, Module 4, page 9 and be prepared to respond to the two questions after viewing the videotape. . What things and people are influencing Kesha as she makes her decision? . What are some normal adolescent characteristics that we see affecting Kesha’s reactions and decision-making process? • Play the video.
Large Group Discussion
• Let’s talk about what we saw in this video. • What things and people are influencing Kesha as she makes her decision? Her age – she is an adolescent and only 14 years old Her mother and what she wants Kesha to do Her boyfriend
• What are some normal adolescent characteristics that we see affecting Kesha’s reactions and decision-making process? Strive for independence –“ I want to go to Joelle’s Doctor” Idealistic – “James will help me” Fearless – “It’s only a baby, it’s not rocket science” Short sighted - does not understand all she will need to parent a child
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• The adolescent brain is not fully developed. Adolescence is a time of important changes in both the structure and the function of the brain. • Dramatic changes occur in the adolescent brain and if these are understood then some adolescent behavior is more easily understood. • The prefrontal cortex, the part of the brain behind the forehead is one of the last to fully develop. The prefrontal cortex can be seen as the boss of the brain as it controls planning, working memory, organization and the modulation of moods. • As this section of the brain matures adolescents can reason better, develop more control, and make judgments better. • Maturation of the prefrontal cortex is not complete until the mid 20’s. • At the same time the prefrontal cortex is maturing there are other changes going on in the brain including increased release of dopamine, the chemical substance that is responsible for the feeling of pleasure. • Because good things feel so much better during adolescence they may go out of their way to seek pleasurable experiences. • The urge to seek out rewarding and pleasurable experiences is a mixed blessing. • On the plus side, it’s part of what makes it so much fun to be a teenager. • But sometimes this drive is so intense that adolescents can exhibit a sort of reward tunnel vision. • Adolescents can be so driven to seek pleasure that they may not pay attention to the associated risks. • For example, a teenager may drive too fast or have unprotected sex without thinking of the risks because it feels so good. Reference: Steinberg, Lawrence (2011). You and Your Adolescent: The Essential Guide for Ages 10 to 25 Reference: Steinberg, L., Vandell,D., & Bornstein, M., (2011). Development: Infancy through adolescence, Belmont, CA: Wadsworth. • Cognitively, adolescents are still formulating their own points of view. They do this by trying out different ways of doing things and adjusting what they do based on the reactions of others or their demands and expectations.
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• Socially, adolescents look primarily to the peer group for information and guidance. While this group may be one of the largest influences on a patient/client the information they provide may not always be accurate. • Emotionally, adolescents are often egocentric in nature, operating in a self- centered manner. They can be moody and have coping skills that are not fully developed. • Early (12 to 15 years old) and middle adolescents (16 to 18 years old) have difficulty anticipating the needs of others and putting them above their own, particularly the unborn child. Research has shown that younger adolescents possess less sophisticated decision making skills than do 16 to 18 year olds. Source: Lewis, C.C. (1981) How adolescents approach decisions: Changes over grades seven to twelve and policy implications. Child Development, 52, pgs.538- 544. • Adolescents this age may not understand the reality and impact of caring for a baby until months after the baby is born. • For pregnant teens this normal stage of development can make them appear to be undecided, unpredictable and non-compliant. • An unintended pregnancy often strips the adolescent of this time for transition and requires him/her to make decisions and follow through with tasks on an adult level. • Some pregnant teens may not follow through on medical advice or keep medical appointments, because these activities may set them aside from the peer group and/or they underestimate its importance. • Because adolescents are experiencing a time of great change that is heightened by the crisis of an unintended pregnancy, they may need information to be repeated and presented in a number of different ways. This information may be provided by any of the helping professionals that the pregnant teen may come into contact with. • Handouts may be helpful as the teen may review this information at a later date.
• Relationships with both parents and peers have been shown to influence the adolescent’s ability to reflect upon and develop a strategy for the future.
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Adolescents who do best with unintended pregnancies have the help and support of all of the adults in their lives. • Treating teens with dignity and respect and listening non-judgmentally will be most helpful. Choosing matching language can be helpful, though not to the extreme that it is no longer genuine. Teens can usually tell when someone is trying too hard to be cool.
How do adolescents make decisions? Adolescents make decisions by:
• Identifying the options • Identifying the consequences of each option • Evaluating the desirability of the consequences • Assessing the likelihood of the consequences • Combining these steps according to a coherent “decision rule”
• Research shows that many pregnant teens, especially those in middle adolescence, mature quickly throughout their pregnancy and are able to make good decisions for themselves and their child. (Test Question)
You can help an adolescent patient/client make decisions through the decision-making process by:
• brainstorming sessions to identify ongoing support and future goals, • helping the teen practice handling difficult situations through anticipatory guidance and role-play, • helping the teen develop a plan for the future, • allowing more time for processing of information and options, and because adolescents are already experiencing a time of great change, which can be heightened by the crisis of an unplanned pregnancy, they may need information to be repeated and presented in a number of different ways.
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• Denial may be a reaction for teens, though this may be true for any age. Teens in particular may want to pretend they are not pregnant for as long as they can. Sometimes later in the pregnancy when they can feel the baby moving is when it becomes more “real” to them. Sometimes it is not until the baby is born that it becomes “real.” • Intellectually, adolescents may be very concrete, using here and now thinking. When they do consider the future they often have idealistic or unrealistic expectations due to lack of experience. Teens often under estimate the task of parenting until they face the day to day challenges of raising a child. (Test Question) • Adolescents may be less skillful than adults in identifying options because they lack sufficient knowledge alternatives and relevant life experiences to draw from; therefore, adolescents tend to need more time than adults to make an informed decision. Source: Trad, P. (1993) The ability of adolescents to predict future outcome. Part I: Assessing predictive abilities. Adolescence, (28) pgs. 111,533 • Teen communication styles may include not being very verbal, not being very engaging, and avoiding eye contact. Despite the fact that teens tend to not be verbal and tend to give superficial answers when initially dealing with authority figures, they still need to be provided with information. (Test Question) • Trainer Note: Additional information regarding adolescents and decision making can be found in the Trainer Guide, Module 4, pages 59 - 61. They are also found in the Participant Handbook, Module 4, pages 51 – 53. Refer participants to these pages for future review.
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Transition We have discussed how culture, birth fathers, and being a teen may influence how a woman makes a decision regarding an unintended pregnancy. Now we will discuss additional influences that may impact a woman or teen’s decision-making process when faced with an unintended pregnancy.
• We have talked about the influences of culture, the birth father and being a teen and how these influences impact on a woman experiencing an unintended pregnancy. Now, let’s look at the Influences Wheel and talk about some of the other influences in a person’s life and how they may impact decision-making.
Trainer’s Comments (15 minutes) • What about friends, how will they likely react? They might pressure a woman experiencing an unintended pregnancy to parent, while others might pressure her not to. • What other cultural issues may be influential in an unintended pregnancy? Possible responses:
o Religious beliefs. o Beliefs about family. We take care of our own.
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o Beliefs about who should be involved in making these decisions; individualism vs. family, male vs. female roles, authority figures (perceived status differential such as professionals know best).
o Beliefs/expectations about the role of the father of the child. o Cultural history: ICWA is a result of the grief and loss of an entire culture. • MOVING ALONG THE WHEEL, what are some other influences? • Cultural issues overlap everything. Grief and loss overlaps everything. • Sometimes influences are turned off...for example, the pregnant woman may not tell her parents or she may tell her mother and they both decide they will not tell the father, they may decide to keep it a secret from the younger siblings. • There are many reactions that may be experienced: shame, blame, anger, shock, denial, hurt, disappointment. It is very difficult to predict how someone will react. • Birth father – so much depends on how she feels about him, as well as what he wants her to do. • Media influences – TV, radio, movies, media horror stories – why would anyone choose adoption? Most adoption news is either horror stories or stories about movie stars adopting children. It is not often that we see a positive story about a woman who made an adoption plan for her child. • How does a person’s age influence decision making? • The pregnant woman’s own values, dreams and goals for her future, loss and grief, abandonment issues, prior information and/or experience related to adoption as well as other choices will influence her decision. • How far along a person is in the pregnancy can have an impact on the decision-making process. Some, young women in particular, may not have a sense of reality until they can feel the baby moving. This can affect a change of heart in either direction. • After all the influences have weighed in and she has thought of her choices, the heart may rule in spite of any contrary intellectual decision a person may have made. Influences and situations may change over time as well as the pregnant woman’s decision. When a woman changes her mind it is usually right after the baby is born. Reality sinks in. This decision has to be re-made after the baby is born. And all women need this time/opportunity to rethink their options. • We have parents and family, and it’s not just teens that are influenced or pressured by parents and family members. • School and employment can certainly impact a person’s decision regarding an unintended pregnancy.
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• An important “previous experience” to be aware of is other loss issues. The idea of birth and the idea of adoption and loss will trigger memories and feelings of prior loss, and sometimes it is just too much for someone to bear. • There are community influences that impact a pregnant woman as well including the community’s values around single parenting and teen age mothers.
• The birth father is not just an influence on the pregnant woman. He has a spot in the middle of his own influences wheel as well. If he is involved with the pregnant woman, he will likely play a significant role in her pregnancy option decision. Sometimes, just the fact that he is not involved is why the pregnant woman is not happy about the pregnancy. • We need to think about the influences and pressures on the birth father as well as on the pregnant woman. Think about the messages males are given about how they should react and handle different situations, how they should or shouldn’t express their emotions, what their role as a man or father ought to be, and whether it is ok to ask for help. Birth fathers may need someone to reach out and encourage their participation. • It is the pregnant woman’s decision to determine how she wants the birth father engaged in the process of discussing pregnancy options with the professional. The provider should be open to the males’ participation as appropriate. • The reasons we hope to engage the birth father are those we just mentioned: he has the right to the same decision-making information as the woman teen and he is likely an influence on her decision. Additionally, if an adoption is completed, he will experience loss and may find it helpful to talk about this with others, either in a professional or peer support setting. And if the woman ultimately decides to parent the child, the birth father’s involvement may be beneficial. • If both the pregnant woman and the birth father can agree, it would be beneficial for the paternal relatives to be involved as well. As men have become more involved, so have their families. Extended family support can be very important. • Without exception, birth fathers who release their parental rights experience a range of feelings, including a sense of loss. Even the most seemingly disinterested birth father – despite his relief, despite his eagerness to sign the papers, despite his apparent urge to flee – still experiences a loss. Many birth fathers find it helpful to talk about this sense of loss, either in a professional or peer support setting. Refer to pink
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pages regarding birth father grief and loss, Participant Handbook, Module 4, pages 58-59, “Stages of Birth Father Grief.”
Transition We have been discussing the many influences that impact a woman facing an unintended pregnancy. A person’s culture may influence the decision in that it may tell her ways that she should respond. A teenager will be influenced by her age in that during this developmental state teens are egocentric and still formulating their own views. The father of the baby can influence the decision through his involvement with the pregnant person. Additional factors such as peers, the media and others can also influence the woman when making a decision about an unintended pregnancy.
Now, we will further explore the influences by completing an activity.
Option 1 of 2: Team Activity
(Option 2 of 2 is found in Trainer’s Guide, Module 4, page 49).
Influences Activity: Small Groups (15 minutes)
Overview
• The following exercise is designed to have participants experience the many influences pregnant women may face in making a decision. Participants break up into small groups and each team is given a scenario. Each member of the group assumes a role from the scenario. Based on their role what they say may influence the pregnant woman in her decision-making process.
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Directions
• First determine how many scenarios you plan to use, based on the number of participants. Trainer should select the scenarios that best meet the participant’s patient/client experiences or use Trainer Guide, Module 4, page 46 to develop a scenario that would be more relevant. • Have participants count off. Group size should be no more than three to five people. For example, team one would do scenario one, Anne. Participant Handbook, Module 4 pages 12-17. • The scenarios have roles listed in order of assignment (i.e., if you only have 3 people at a table, use the first three roles). • Trainer introduces the session with the following: How do people make decisions like this? The following exercise is designed to have you experience the many influences pregnant women face in making a choice. Again, if playing a role or the activity is uncomfortable, you may watch or say little. • Trainer tells group to read scenarios to themselves, and that the information provided is background information only. Participants can choose how to use the information. • Group members should each choose a role. For example, if there are only three participants per group, group members would choose the role of the pregnant person, health care provider, and father of the baby. • The person in the role of the pregnant person will be thinking of the following: What decision might you make in this situation? What does it feel like to have so many people telling you what to do? How is this input affecting your decision-making? • Participants may write down what they would tell the pregnant person. • Individuals in each group take turns telling the pregnant woman what to do. • Each group has the option of talking amongst themselves as they are giving their views to the pregnant person; and, she can ask questions or discuss if she wants to. • You will have 5 minutes for this activity.
TRAINER NOTE: Continue in Trainer Guide, Module 4, page 47 with Large Group Discussion.
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Scenario I – Anne
• Pregnant person (1): 35-year-old woman. Very career oriented. She works long hours and is often away from home. She is 20 weeks pregnant. She never wanted children. She is an only child.
• Health care provider – OB/GYN Nurse (2): Her sister has been trying to have a baby unsuccessfully for 10 years. She has been considering adoption.
• Father of the baby (3): Also career oriented. Has always wanted to raise a family. Has had a two-year relationship with the pregnant person. Has gone to prenatal appointments and is supportive.
• Mother of pregnant person (4): Had difficulty getting pregnant and carrying a child to term. She and her husband always wanted more children.
• Friend of pregnant person (5): Best friend is married with two children. She regrets the time her children take away from her career.
• Work associate (6): She works in the fast paced banking business. Work projects are completed as a team.
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Scenario II- Wilma
• Pregnant person (1): A seventeen-year-old Native American girl who just delivered baby in the hospital. She is graduating from high school in one month and plans on joining the Navy. She is the oldest of six children.
• Her parents (mother or father...pick one) (2): Are very upset, as they didn’t know about the pregnancy. They struggle to make ends meet for six children. Parents were excited for daughter to enter the Navy as they feel it is the first “career” in their family.
• Health care provider – OB/GYN Nurse (3): Raising a grandbaby.
• Father of the baby (4): Is fifteen years old and a sophomore in high school.
• Navy recruiter (5): Can’t join the Navy with dependents.
• Friend (6): Attends alternative school and has 6-month-old baby at home. She often complains about how she has no time to hang out with her friends and that no one helps her with her baby.
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Scenario III – Mary
• Pregnant person (1): Twenty-two years old. She has two children ages four and two years. She currently lives with her mother who helps her raise the children. She is 10 weeks pregnant and an ultrasound reveals the baby has possible birth defects, as the head size is larger than normal. Mary works part time at a pharmacy and is attending junior college at night for a degree as a pharmacy technician.
• Father of the baby (2): Not recently in touch. They had a casual relationship. He lives in a neighboring town. He is married with two children. She just told him that she is pregnant.
• Health care provider – OB/GYN Nurse (3): Single parent raising two children. One of the children has spina bifida.
• Mother of pregnant person (4): Very religious and involved in the community church. She expresses her wish to have more free time to herself as she is overwhelmed with caring for her grandchildren while Mary works and goes to school.
• Friend (5): Married, has four children. Full-time, stay-at-home mother enjoys being a mother but wishes she had completed college and had a career. She envies Mary somewhat in that she is pursuing her degree.
• Boss at work (6): Wants to give her more hours and promises her a job as a pharmacy technician upon completion of degree.
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Scenario IV – Regina
• Regina (1): Regina a 16-year-old Latina, just received news that her pregnancy test is positive. She is in shock and unable to process the information. Her boyfriend is with her and he is in the same state of shock. Her first response is “How am I going to tell my parents? They struggle to keep me in private school. I was going to be the first one in my family to attend college.” The boyfriend also agrees with her statement. The boyfriend is trying to be supportive but both are holding back their full emotions.
• Birth father David (2): David, a 16-year-old Latino. He is an honor roll student and actively involved in school activities. He plans on attending a major university and intends to further his education and receive his master’s degree. He is very supportive of his girlfriend but is unsure of their futures.
• Health care provider-medical assistant (3): She was also a teen mother who was unable to continue her education. Being a single mother with responsibilities had a financial impact on her ability to further her education.
• Parents of girl (4): Parents had been on the strict side. Since Regina had been doing well in school and had never given her parents any problems they agreed it would be okay for her to have a boyfriend. The daughter is the eldest of four children. Both parents work and are very involved in church activities.
• Parents of boy (5): Parents have a very open relationship with their son; he is the eldest child of three brothers. Both parents are employed and have placed a high value on education. They have struggled to keep him in Catholic/private school. They have been forthcoming regarding his education by explaining the importance of attending college in order to better himself. His parents have constantly spoken to him regarding sexual activity.
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Scenario V – Robert
• Robert (1): Robert is a 35-year-old man. He and his wife of 10 years separated approximately a year ago. He met Berta at her aunt and uncle’s home not long after his separation from his wife. He has been seeing her since. He has no children and had not planned on having any as he feels he does not have the income and time required for the care of children. He is employed at the local Wal-Mart as a department manager.
• Health Clinic Social Worker (2): The social worker works in the community health clinic. She is available to patients and their partners to discuss concerns and needs. She and her husband have been trying to conceive a child for the past two years.
• Pregnant person (3): The pregnant person is a single woman in her mid-twenties. She is six months pregnant. She states she and the baby will not be able to stay with her aunt and uncle because finances and space are tight. She has no other relatives or friends that can help her. Financially, she will not be able to afford pre-natal care. She works part time in housekeeping at a nearby hotel.
• Mother of the father of the baby (4): Robert’s mother remains very close to numerous family members who live out of state, visiting them frequently. She has three daughters and two sons, besides Robert, all of whom have families and she feels are responsible.
• Friend of father of the baby (5): Robert’s friend is the pregnant person’s uncle. He works many hours, and his wife works two jobs to support their family which includes 3 school aged children. They struggle to make ends meet. They are very active in their church and attend several times a week.
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Scenario VI: Trainee’s Develop “Typical” Scenario Common to their Settings
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Large Group Discussion • This discussion format is to be used for debriefing the experience for all the scenarios. • Ask the pregnant woman: What was the experience like for you? • Ask the entire group: What did you notice or experience during the exercise? Were there cases where no one mentioned adoption as an option? Were there cases when only the provider mentioned adoption? Did participants feel they would have had different thoughts in different roles? How were things affected when grief or loss issues were presented? Have them give examples per their scenario. Was domestic violence mentioned as an issue during your role play? Did the health care provider do a domestic violence assessment? Was there a non-biased voice in any group? • End by asking the pregnant woman: What did you wish the provider had done/said? Did everyone tell you what to do? Did anyone ask you how you felt or what you wanted?
• As a provider, you are also in a position to provide a domestic violence assessment for your patient/client. You can ask if there have been any incidents of abuse during the pregnancy and assess whether violence is influencing a patient/client’s decision
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making. Studies show that between 4 and 9 % of women are physically abused while they are pregnant (from the PRAM database). • Additional information that is important to know and understand is included in Participant Handbook, Module 4, pages 23-54. The topics included are: “Cultural Responsiveness in Providing Options Counseling,” “Social, Cultural and Personal Influences,” “Common Myths and Facts for Birth Fathers,” “Techniques for Engaging Birth Father,” “Adolescence and the Adoption Option,” “Families in Crisis,” “Helping Teens with Future Planning,” “Special Concerns for Adult and Teens,” “Domestic Violence Wheel,” “Substance Abuse,” “Clinical Depression,” “Pregnant Teens: Discussing Family Involvement,” “Stages of Birth Father Grief.” “Cross Cultural Skills Checklist” and “Self Assessment Worksheet.”
TRAINER NOTE: Continue in Trainer’s Guide, Module 4, page 50 with Trainers Comments and TurningPoint questions,
Video and Group Discussion – Option 2 of 2
Influences Activity:
“Influences” Video
Video Description
Influences is a 3 minute video featuring, Stephanie, a young pregnant woman who repeats in her head all the advice and comments she has received from everyone she knows, including friends, family, and the birth father.
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Directions
• Tell participants to watch for key themes and issues in the video. • Tell participants to turn to Participant Handbook, Module 4, page 18 and be prepared to respond to the following questions after viewing the videotape.
1. What decision might you make in this situation?
2. What would it feel like to have so many people telling you what to do?
3. How would this input affect your decision-making?
4. Please list the helpful things you heard during the video.
5. How would this input affect your decision-making?
• Play the video.
Large Group Discussion
• Let’s talk about what we saw in this video.
What decision might you make in this situation?
What would it feel like to have so many people telling you what to do?
How would this input affect your decision-making?
Please list the helpful things you heard during the video.
How would this input affect your decision-making?
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Trainer’s Comments • Now we hopefully have a greater appreciation for the amount of information someone might have to filter through when making a pregnancy decision. • It is important that as a provider working with pregnant women you remain a neutral, listening presence because you might be the only person she comes in contact with who will be neutral. • As a provider, you are in a position of authority and expertise. Patient/clients come to you in a vulnerable position, they may already have made a decision and want your confirmation or they may be undecided and want new information. Your responses, reactions and questions should be neutral rather than a factor that sways them one way or another. • Additional information that is important to know and understand is included in Participant Handbook, Module 4, pages 23-54. The topics included are: “Cultural Responsiveness in Providing Options Counseling,” “Social, Cultural and Personal Influences,” “Common Myths and Facts for Birth Fathers,” “Techniques for Engaging Birth Father,” “Adolescence and the Adoption Option,” “Families in Crisis,” “Helping Teens with Future Planning,” “Special Concerns for Adult and Teens,” “Domestic Violence Wheel,” “Substance Abuse,” “Clinical Depression,” “Pregnant Teens: Discussing Family Involvement,” “Stages of Birth Father Grief.” “Cross Cultural Skills Checklist” and “Self Assessment Worksheet.”
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses.
Module 4 - Page 50 Trainer’s Guide – 1 Day DRAFT UIA 4 – 1 Day - Module 4 12/12/11 o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Cultural responsiveness requires that the health care provider be aware and respectful of the cultural norms held by the patient/client that may influence his/her decision-making or his/her perception of the available options. (Test Question)
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Research shows that many pregnant teens, especially those in middle adolescence, mature quickly throughout their pregnancy and are able to make good decisions for themselves and their child. (Test Question) Intellectually, adolescents may be very concrete, using here and now thinking. When they do consider the future they often have idealistic or unrealistic expectations due to lack of experience. Teens often under estimate the task of parenting until they face the day to day challenges of raising a child. (Test Question) Despite the fact that teens tend to not be verbal and tend to give superficial answers when initially dealing with authority figures, they still need to be provided with information. (Test Question)
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TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
In working with adolescents the health care professional should offer material multiple times and in multiple formats, help with anticipatory guidance, and offer neutral factual information on all options.
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
It is important for health care professionals to engage interested birth fathers using the same techniques used to engage others: treating them with dignity and respect; actively listening to their concerns and being nonjudgmental. (Test Question)
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TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
It is important for health care professionals to consider the issue of domestic violence when working with pregnant patient/clients. It is important to identify and understand the special considerations when working with teens who are experiencing an unintended pregnancy. (Training Reflection Feedback Form) It is important to demonstrate skills in engaging teens and adults in discussing their personal situations and exploring pregnancy options and future planning. (Training Reflection Feedback Form) It is important to identify characteristics of culturally responsive services. (Training Reflection Feedback Form) It is important to identify the influences that impact decision making (family, community, culture, values ad beliefs) and to have a sound understanding of how to discuss these issues with patient/clients. (Trainer Reflection Feedback Form) It is important to understand birth father issues and considerations as well as identify skills for engaging birthfathers in offering information and referral for pregnancy and adoption counseling. (Training Reflection Feedback Form)
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Transition In this segment we discussed some influences that may impact a woman’s decision, regarding her unintended pregnancy. In the next module we will cover nondirective techniques for informed decision- making.
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To Find Out More About It
Applegate, Jeffrey. (1988). Adolescent Fatherhood: Developmental Perils and Potentials. Child and Adolescent Social Work, 5, 3 205-217.
Berry, Helen, Shillington, Audrey, Peak, Terry, Hohman, Melinda. (2000). Multi-Ethnic Comparison of Risk and Protective Factors for Adolescent Pregnancy. Child and Adolescent Social Work Journal, 17, 2, 79-96.
Blake, Susan, Simkin, Linda, Ledsky, Rebecca, Perkins, Cheryl, Calabrese, Joseph. (2001). Effects of a Parent-Child Communications Intervention on Young Adolescents’ Risk for Early Onset of Sexual Intercourse. Family Planning Perspectives, 33, 2, 52-61.
Brindis, Claire, Boggess, Jan, Katsuranis, Frances, Mantell, Maxine, McCarter, Virginia, Wolfe, Amy. (1998). Family Planning Perspectives, 30, 2, 63-123.
Christmon, Kenneth. (1990). The Unwed Adolescent Father’s Perceptions of his Family and of Himself as a Father. Child and Adolescent Social Work Journal, 7, 4. 275-283.
Clapton, G. (1997). Birth fathers, the adoption process and fatherhood. Adoption & Fostering, 21 (1), 29-36.
Corcoran, Jacqueline. (2001). Multi-Systemic Influences on the Family Functioning of Teens Attending Pregnancy Prevention Programs. Child and Adolescent Social Work Journal, 18, 1, 37-49.
Cushman, Linda, Kalmuss, Debra Namerow, Pearila. Placing an Infant for Adoption: The Experiences of Young Birth mothers. ( 1993) Social Work, 38, 3, 264-279.
Dunst, C., Trifetter, C., Deal, A. (1988). Enabling and Empowering Families: Principles and Guidelines for Practice. Cambridge: Brookline Books.
Dworkin, R.J., Harding, J.T., Schreiber, N.B. (1993). Parenting or placing: Decision- making by pregnant teens. Youth and Society, 25, 75-92.
Gold, Rachel, Sonfield, Adam. (2001). Family Planning Perspectives, 33, 2, 81-87.
Harner, Holly M., Burgess, Ann W., Asher, Janice B. (2001). Caring for Pregnant Teenagers: Mediolegal Issues for Nurses. Journal of Obstetrics, Gynecologic and Neonatal Nursing, 30, 2, 139-147.
Kalmuss, D. (1992). Adoption and Black teenagers: The viability of a pregnancy resolution strategy. Journal of Marriage and the Family, 54, 75-92
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Kingon, Yvonne S., O’Sullivan, Ann L. (2001). The Family as a Protective Asset in Adolescent Development. Journal of Holistic Nursing, 19, 2, 102-121.
Koniak-Griffin, Deborah, Turner-Pluta, Carmen. (2000). Health Risks and Psychosocial Outcomes of Early Childbearing: A Review of the Literature. Journal of Perinatal & Neonatal Nursing, 15, 2, 1-17.
Kring, Thomas C. (1998) The Adolescent Family Life Program and Adoption Research. Adoption Quarterly, 2, 47-54.
Lane, Terry S., Clay, Cassandra. (2000). Meeting the Service Needs of Young Fathers. Child and Adolescent Social Work Journal, 17, 1, 35-53.
Mason, M.M. (1995). Out of the shadows: Birth fathers’ stories. Edina, MN: O.J. Howard Publishing.
Propst, Maureen G., Phillips, Billie Rhea, Andrew, Michael. (2001) Addressing Sexuality-Related Needs in Practice: Perspectives of Maternal/Child and Women’s Health Nurses. Journal of Continuing Education in Nursing, 32, 4, 177-182.
Risley-Curtiss, Christina. (1997). Sexual Activity and Contraceptive Use Among Children Entering Out-of-Home care. Child Welfare, LSSVI, 4, 475-497.
Sachdev, P. (1991). The birth father: A neglected element in the adoption equation. Families in Society, 72, 131-138.
Santelli, John, Robin, Leah, Brener, Nancy, Lowry, Richard. (2001). Timing of Alcohol and Other Drug Use and Sexual Risk Behaviors Among Unmarried Adolescents and Young Adults. Family Planning Perspectives, 33, 5, 200-205.
Santelli, John, Lindberg, Laura, Adma, Joyce, McNeely Clea, Resnick, Michael. (2000) Adolescent Sexual Behavior: Estimates and Trends From Four Nationally Representative Surveys. Family Planning Perspectives, 32, 4, 156-165.
Somers, Cheryl, Fahlman, Mariane. (2001). Effectiveness of the “Baby Think It Over” Teen Pregnancy Program. Journal of School Health, 71, 5, 188-195.
Stevenson, Wendy, Maton, Kenneth, Teti, Douglas. (1999). Social support, relationship quality, and well-being among pregnant adolescents. Journal of Adolescence. 22, 109- 121.
VanOrnum, W., Mordock, J.B. (1991). Crisis Counseling with Children and Adolescents: A guide for Nonprofessional Counselors. New York: Continuum Publishing Co.
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Vincent, Murray L., Paine-Andrews, Adrienne, Fisher, Jacquie, Deveraux, Randolph, Dolan, Holly, Harris, Kari, Reinger, Belinda. (2000). Replication of a Community- Based Multicomponent Teen Pregnancy Prevention Model: Realities and Challenges. Family Community Health, 23, 28-45.
Whitaker, Daniel, Miller, Kis, Clark, Leslie. (2000). Reconceptualizing Adolescent Sexual Behavior: Beyond Did They or Didn’t They? Family Planning Perspectives, 32, 3, 111-117.
Williams, Elizabeth, Sadler Lois. (2001). Effects of an Urban High School-Based Child Care Center on Self-Selected Adolescent Parents and Their Children. Journal of School Health, 71, 2, 47-51.
Williams-Gray, Brenda (2001). A Framework for Culturally Responsive Practice.” Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and other Practitioners. (pp 55-83). New York: Columbia University Press Publishers.
Zavodny, Madeline. (2001). The Effect of Partners’ Characteristics on Teenage Pregnancy and Its Resolution. Family Planning Perspectives, 33,5, 192-199.
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Supplemental Resources for Working with Adolescents:
1. Additional Research:
• Steinberg, L. (April 2011). Demystifying the Adolescent Brain, Educational Leadership, pages 42-45.
• http://cals- cf.calsnet.arizona.edu/fcs/bpy/content.cfm?content=decision_making Adolescents face a number of challenges in making healthy decisions because they: o may see only either-or choices rather than a variety of options (Fischhoff et al., 1999); o may lack the experience, knowledge or feeling of control over their lives to come up with alternative choices (Fischhoff et al., 1999); o may misperceive certain behaviors as less risky, and may be overly optimistic about their ability to recognize and avoid threatening situations (Cohn, Macfarlane, Yanez, & Imai, 1995); o may favor their own experience over probabilistic evidence when determining the likelihood of the consequences of their actions (see Jacobs & Potenza, 1991, as cited in Fischhoff et al., 1999); o may focus more on the social reactions of their peers when deciding to engage in or avoid risky behaviors (Beyth-Marom, Austin, Fischhoff, Palmgren, & Jacobs-Quadrel, 1993); o may not be able to accurately estimate the probability of negative consequences (Fischhoff et al., 1999; Ganzel, 1999); o may have a hard time interpreting the meaning or credibility of information when making decisions (Fischhoff et al., 1999); and o may be influenced by their emotions and fail to use decision- making processes (Fischhoff, 1992).
2. Promoting Decision Making:
• Using a general heuristic framework to help teenagers learn how to think critically about decision problems (e.g., "GOFER"-goals, options, facts, effects, and review; "going through the GOOP"-goals, options, outcomes, and probabilities) (Baron & Brown, 1991; Mann, Harmoni, & Power, 1991);
• Adolescent decision-making: the development of competence Leon Mann, Ros Harmoni, Colin Power. Available online 5 March 2004.
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Abstract
This article reviews evidence relating to the development of competence in decision-making during adolescence. The review focuses on cognitive aspects of decision-making and discusses nine indicators of competence: choice; comprehension; creativity; compromise; consequentiality; correctness; credibility; consistency; and commitment. The evidence suggests that by the age of 15 years many adolescents show a reliable level of competence in metacognitive understanding of decision-making, creative problem-solving, correctness of choice, and commitment to a course of action. Young adolescents (12–14 years) are less able to create options, identify a wide range of risks and benefits, foresee the consequences of alternatives, and gauge the credibility of information from sources with vested interests. No evidence is available relating to age differences in willingness to make choices, devise compromises, and show consistency of choices. Barriers to achieving competence in decision-making during adolescence include attitudinal constraints (e.g. beliefs about the proper age for making decisions), peer group pressures to conformity, breakdowns in family structure and functioning, and restricted legal rights to make important personal decisions (e.g. to donate blood or body tissue).
Reprint requests to Leon Mann, School of Social Sciences, The Flinders University of South Australia, Bedford Park, South Australia 5042.
• Develop your Teens Decision Making Skills:
http://pleasestoptherollercoaster.com/blog/2009/10/13/develop-your- teens-decision-making-skills/
• Decision Making
http://ag.arizona.edu/sfcs/cyfernet/nowg/sc_decision.html
• The Adolescent Brain and Decision Making Skills
http://kelly-pfeiffer.suite101.com/the-adolescent-brain-and-decision- making-skills-a163750
• Adolescent Decision Making: Implications for Prevention Programs
http://www.nap.edu/openbook.php?record_id=9468&page=1
• Decision Making and Problem Solving With Teens:
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Gives 6 steps to decision making and relates it to working with teens
http://ohioline.osu.edu/hyg-fact/5000/pdf/5301.pdf
• Decision Making Skills
http://missourifamilies.org/features/adolescentsarticles/adolesfeature23.ht m
• The Adolescent Brain: A Work in Progress
http://www.thenationalcampaign.org/resources/pdf/BRAIN.pdf
3. Counseling Skills:
• Options Counseling for Pregnant Teenagers
http://www.etr.org/recapp/index.cfm?fuseaction=pages.EducatorSkillsDeta il&PageID=89
• Decision Making for Pregnant Adolescents: Applying Reasoned Action Theory to Research and Treatment
http://www.etr.org/recapp/index.cfm?fuseaction=pages.currentresearchdet ail&PageID=188&PageTypeID=5
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Cultural Responsiveness in Providing Options Counseling
This article will provide foundational information on offering options counseling that is culturally responsive and engagement oriented. Its intent is to provide insight on how the health care professional may better operate in providing options counseling in an ever increasing multi-cultural society and not to give a “one step” formula for culturally competent practice.
The concept of cultural competence continues to evolve, as various professions tackle this challenging subject matter. Along with its underlying issues of racism and discrimination, conversations regarding cultural competence can leave persons vulnerable to criticism and guilt. As the health care profession strives to provide equal treatment to all patient/clients, health care professionals, adoption counselors and social workers must consider their own cultural association and how it impacts their practice. Health care professionals must also take a critical look at how a patient/client’s culture may influence his/her decision-making skills and how he/she is likely to respond to the options that are offered.
Definition of Culture, Cultural Responsiveness, and Cultural Competence According to the Office of Women and Minority Health in the Bureau of Primary Health Care (HRSA), culture refers to “...integrated patterns of human behavior that include the language, thoughts, communications, actions, customs, beliefs, values, and institutions of racial, ethnic, religious, or social groups.” This definition can be broadened by Diller’s idea that traditional ideas and related values are “...transferred from generation to generation,” thus providing people with ways to live and cope with life’s problems. (Diller, 1999)
Some believe that culture is learned, as it is partially made up of behaviors, values, and beliefs, which are passed on from generation to generation. Culture is threaded both consciously and subconsciously throughout the workings of everyday life, and can impact day-to-day decisions. It can illustrate an individual’s personal identification such as race, ethnicity, religion, gender, class, nationality and has influence on thoughts, actions and interactions with others. (Williams-Gray, 2001)
Cultural responsiveness is an active term that requires the health care professional to treat every patient/client as an individual first and understand that he/she will not automatically respond in a manner that is consistent with his/her culture’s norms and values. Furthermore, the actions or responses of a patient/client from a represented cultural group will not provide the template of responses for all other members of the same culture.
Cultural competence requires continuous self-assessment; expansion of one’s knowledge base of other cultures; respect for cultural differences, and the ability to adapt to meet the needs of diverse populations. (Cross, 1988) As it relates to health care, the American Association of Colleges of Nursing recommends that nursing graduates have the
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capabilities to “...provide holistic care that addresses the needs of diverse populations.” (American Association of Colleges of Nursing, 1998)
Cultural Self Awareness One step in becoming more culturally responsive is to “become grounded in learning about one’s own cultural background and heritage, and then proceed to learn about other groups’ cultural values and beliefs.”(Lecca et.al, 1998). Another step would be to consciously recognize the effect of one’s culture in viewing the world. Cross-cultural misunderstanding may be evident when it is consciously or subconsciously assumed that one’s own cultural norms are the standards everyone else follows. (Diller, 1999) According to Williams-Gray (2001), “...cultural differences may produce perceptions, coping styles, or beliefs that appear strange or even irrational to practitioners.” Health professionals need to check and recheck their perceptions and interpretations of behaviors. This is particularly true when working cross-culturally. It can also be helpful for health practitioners to learn as much about other cultures as possible. Asking patient/clients to be “cultural guides” is one strengths-based technique for doing this. However, the practitioner should continue to keep in mind that one person’s views are not necessarily a representative of an entire cultural group, nor should one be placed in that representative role. Furthermore, the patient/client may possess feelings of ambivalence or resistance in being asked to “teach” the uninformed health professional.
Engagement Health care provider’s perceptions about different cultures may impact engagement with patient/clients and the types of options that are offered. When working with people of varying cultures, it is important to make sure that the language used is universally understood. The culturally responsive health care provider needs to ensure that the patient/client understands all of the options available. This may be as simple as speaking in clear, easily understandable terms; having a translator present or referring the patient/client to an agency that can communicate in his/her native tongue.
The health care practitioner can use the same techniques to engage a multi-cultural patient/client as he/she uses with clients of similar backgrounds, being respectful, warm, and sincere. The goal is to gain the patient/client’s trust. This can be done by explaining what will happen during the interaction and such important concepts as confidentiality.
During the assessment process, open-ended questions can be useful in the avoidance of cultural stereotyping, and providing individualized treatment. The patient/client needs to be allowed to “tell his/her story in his/her own words” while the health practitioner is respectful and supportive of the emotional feelings the situation might illicit. Open- ended questions also provide answers to “...a woman’s beliefs and values, health related behaviors, and cultural rituals and practices.” (Callister, 2000) Patient/clients need to be encouraged to ask questions, while the health professional continuously checks to insure the information that is being disseminated is understood. The health care practitioner needs to be open to including a patient/client’s family members, close friends, and/or members of their “community” in the decision-making process as per the patient/client’s wishes.
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Due to the history and current existence of racism and discrimination, health care providers must be aware that there could be perceived power differentials that exist between them and their patient/clients. Patient/clients from non-dominant, cultural groups may be mistrusting, and not fully engaged in options counseling. Culturally responsive health care providers, however, can engage a mistrusting patient/client by shifting perceived power through what is called the “ultimate connection.” (Jordan, 1998) Jordan (1998) further states “…the ultimate connection must be the need we find between us…it is not only who you are, but what we can do for each other.”
Becoming a culturally competent health care professional is a lifelong process. All humans struggle with the pitfalls of stereotyping, cross-cultural misunderstanding, and language barriers. However, when a commitment is made to provide culturally responsive services, patient/clients can receive high quality health care services that are nonjudgmental and facilitate informed decision-making.
References: Abrums, M. and Leppa, C. (2001). “Beyond Cultural Competence: Teaching about Race, Gender, Class, and Sexual Orientation”. Journal of Nursing Education, 40(6) 270-275.
American Association of Colleges of Nursing. (1998). The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, DC.
Boyd-Webb, Nancy (2001). “Strains and Challenges of Culturally Diverse Practice: A Review with Suggestions to Avoid Culturally Based Impasses.” (pp. 337-350) Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and other Practitioners. New York, Columbia University Press Publishers.
Boyd-Webb, Nancy (2001). “Educating Students and Practitioners for Culturally Responsive Practice.”(pp. 351-360) Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and other Practitioners. New York, Columbia University Press Publishers.
Callister, Lynn Clark. (2001). “Culturally Competent Care of Women and Newborns: Knowledge, Attitude, and Skills”. JOGNN Clinical Issues, 30( 2) 209-215.
Cross, T.L. (1988). “Services to Minority Populations: What Does It Mean to be a Culturally Competent Professional?” Focal Point. Portland, OR” Research and Training Center, Portland State University.
Diller, Jerry (1999). Cultural Diversity: A Primer for the Human Services. Belmont, CA. Wadsworth Publishing. Jordan, J. (1998). “Report from the Bahamas”. In M.L. Anderson, & P.H. Collins (Eds.), Race, Class, and Gender: An Anthology. (pp. 34-43). Belmont, CA. Wadsworth Publishing Co.
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Lecca, Pedro J., Quervalu, Ivan, Nunes, Joao, Gonzales, Hector F. (1998). Cultural Competency In Health, Social, & Human Services. New York, Garland Publishing, Inc.
William-Gray, Brenda (2001). “A Framework for Culturally Responsive Practice” Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and other Practitioners. (pp. 55-83). New York, Columbia University Press Publishers.
Natalie Lyons, MSW Spaulding For Children February 2002
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Social, Cultural and Personal Influences
Latino/Hispanic families have always had a longstanding history of adoption. The adoption practice most commonly found in the Latino/Hispanic culture is that of informal kinship care. Latino/Hispanic families have traditionally believed that there was no need to formalize this process for a child who was blood related, a godchild and/or a close family friend. Most families feel that as long as the need of the child is being met, that the child is cared for and safe, there was no need to formalize the situation. Adoption in most Latin American cultures has been viewed as a luxury that only wealthy people could afford. Even today, in the United States you will find that a good majority of Latino/Hispanic families continue with the tradition of informal adoption.
Concerns for informal adoption care providers surface when they attempt to meet the medical needs of the children in their care. Medical issues for most Latino/Hispanic children are handled through medical clinics where information is not as cumbersome as to parental information or guardianship unless there is a major medical problem with the child. It is not until the child is ready to enroll in pre-school or school, do they begin to encounter problems with guardianship of the child. At this point a family may consider seeking legal advice regarding their options.
Statistics on the number of children in an informal kinship care setting are unknown. We can only estimate the number of children who are being taken care of by grandparents, aunts, uncles and godparents. Most of these children that are in an informal setting are not receiving any type of monetary or medical assistance. The statistics that we can refer to are through the actual Department of Children and Family Services, (DCFS) system that truly do not reflect accurate numbers.
The reasons why most Latino/Hispanic families do not formalize kinship adoptions range from mistrust of government agencies, cultural and linguistic barriers along with agencies unable to make the personal connections with families. A major issue facing some Latino/Hispanic families that may prevent them from formalizing adoption is their immigration status or the immigration status of the child.
In order for Latino/Hispanic families to formalize the adoption process, agencies must be willing to meet the needs of families and children both culturally and linguistically. Ideally we need to focus on a recruitment plan that targets not only kinship care but also one that recruits adoptive parents in open, semi-open or closed adoptions. In doing this, we must address the cultural myths through the years about adoption.
Emphasis must be put on why a birth mother chooses adoption for her infant. It is not that the birth mother is abandoning the infant. She is making a lifelong decision to give her infant a better life. We must clarify that making this type of decision is not abandonment or letting go of her responsibility but in fact the birth mother is making a decision that is in the best interest of the infant and herself. That adoption will provide a loving and stable environment for the infant.
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In cases of kinship care, it is just as important for families to formalize the adoption process. Even though Latino/Hispanic families have traditionally been supportive of family members or close friends, that is no longer sufficient because of the changes in today’s society. Today’s families must prove they have authorization to act in the best interest of a child when accessing medical attention, financial and when enrolling the child into school. We need to stress that kinship care adoption is not taking the place of the birth mother; instead it is providing the infant with lifelong connection to their birth family and security in a stable home environment.
Latino/Hispanic culture has traditionally viewed adoption as a luxury that only wealthy families who were unable to have birth children could obtain. But along with this myth is the underlying sentiment that there must be a reason why “God” has not blessed a couple with birth children. The question then arises regarding fertility, whether he is not man enough to give his wife a child or vice versa she is not a whole woman because she is unable to bear a child for her husband. Why would a couple want to adopt a child that is no relation to them; why would a couple want to care for children who most likely will have problems? We must address these old myths, that there are medical reasons why a couple cannot bear birth children of their own. We need to stress that regardless if a child is a birth child or an adoptive child, they deserve to have a loving, stable home.
Religious pressures within the Roman Catholic and other Christian faiths impact cultural myths. The Roman Catholic faith is the dominant religion of most Latin American countries followed by other Christian faiths. Religion has always played a major role within Latin/Hispanic families especially with recent immigrants and first/second generations. Levels of acculturations depend on how long an immigrant has lived in the United States and how they make sense of their values from their county of origin and integrate those values in their new host country. A person’s acculturation level may also impact their preferences in types of music, food and language. Religious examples pertaining to differences in acculturation can be observed by religious artifacts worn by the patient, going to religious services on a weekly basis, having altars in their home. More acculturated Latinos (third and fourth generation) may attend religious services on major religious holidays and may not display religious items in their homes or display them in private areas of their home.
In some instances a birth mother may seek counsel from the pastor of her church before going to any family members or friends. This is additional pressure the birth mother faces while making her decision. The overtone that most pastors will advise is: “Accept what God has given you” or “Children are a gift from God and should be accepted regardless the situation.”
A longtime myth is that Latina/Hispanic mothers do not make adoption plans. In the past this may have been true, but we are now seeing increasing numbers of birth mothers moving in this direction especially when given their full options. Latina/Hispanic birth mothers are just like any other women who are trying to make fully informed decisions.
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Historically, Latino families have had strong religious, cultural, linguistic and family ties. Any issues arising within the family, ranging from personal, medical, social to financial, have always been taken care of within the family. A common statement or sentiment that most Latino/Hispanic reference to is in the context or format that “God” will take care of us or he will guide us to making the right decision or all we can do is leave it in the hands of the Lord. This frame of thought, ranges from relationships, marriage, finances, child bearing and death. Regardless of the living situation or financial impact, Latino/Hispanic families are very proud and share whatever resources they have to help someone in need, especially a family member or close family friend.
In dealing with Latino families today, especially in California and across the United States, there are different levels of acculturation that range from recent immigrants, first generation to fourth and fifth generations. These differences can also be found inter- racially among Latinos/Hispanics. There are slight differences among Latinos/Hispanics, ranging from their food to their pronunciation of the Spanish language. The underlying commonality is that they are all family and religiously focused. Culturally and linguistically there will be differences in the type of approach used when counseling a family or providing them with information and resources. Responses may also vary pending on their acculturation level.
Health care providers must be aware of these dynamics and how levels of acculturation in their patient may impact service delivery. This awareness will help with the delivery of culturally sensitive services in working with these families. A recent immigrant and/or first generation Latino will have values or cultural pressures that are tied closer to their home of origin. Wherein a third or fourth generation Latino would be considered to be more Americanized and less apt to have direct cultural or religious pressures. Family relationships may be distant instead of the close-knit structure of an immigrant or first generation Latino.
Maria L Quintanilla, MSW, LCSW, Executive Director Latino Family Institute, Inc. West Coulno, California
Francis Marron-Zamerripa, LCSW, IAATP Program Director Latino Family Institute Gloria Cortez, Liaison Latino Family Institute January 2005
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COMMON MYTHS AND FACTS for BIRTH FATHERS
1. Myth: Birth fathers don’t care. Fact: Many birth fathers feel that their role in the process is nonexistent. Many birth fathers have reported caring and wanting to be more involved but were unsure how to. 2. Myth: The child will hate me for abandoning him/her. Fact: Making an adoption plan is not abandonment. It is making a thoughtful decision about he believes to be in the best interest of the child. 3. Myth: I am not a “man” unless I get married and parent the child. Fact: Again, making an adoption plan is a responsible decision if chosen. 4. Myth: The adoption process doesn’t consider me in the process. Fact: Most adoptions cannot be completed without he input of the birth father if he is willing and able. 5. Myth: Real men keep their babies. Deadbeat dads give them away. Fact: “Real” men make adoption plans based on informed decision making. 6. Myth: Fathers don’t experience loss because they never bond with the child. Fact: Many birth fathers feel a sense of grief and loss throughout the process and throughout their lives. 7. Myth: Birth fathers don’t try to do the “right thing”. Fact: What is right for one person may be not “right” for another. 8. Myth: Birth fathers have no rights. Fact: Birth fathers do have right specified by their state laws. 9. Myth: Birth fathers have no say in the process. Fact: Birth fathers have a great deal of input in the adoption process. They have the right to be part of the decision making. 10. Myth: Biological fathers have no rights if the mother is married. Fact: In most states there is a process for birth fathers to exert their right as the biological parent and typically they have the opportunity to establish paternity. 11. Myth: Birth fathers can’t choose the adoptive family. Fact: This is not true. Often times, the birth father is involved with the birth mother in choosing the adoptive family. 12. Myth: Birth fathers can’t plan separately from the birth mother. Fact: This is not always the case. In most states, both birth parents must agree to the adoption if present and able to do so. If they do not agree on the adoption plan, then generally, the adoption would not proceed. 13. Myth: There are no services for birthfathers.
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Fact: It is true that services for the birth fathers is limited, more and more services are being offered as efforts are being made to engage the birth father in the adoption process. 14. Myth: Counseling is for the mother only. Fact: Again, this is not true. Counseling is available to the birth father depending on the agency resources. 15. Myth: Birth fathers have no control in the situation. Fact: Although it may feel that way to many fathers, they do have rights and opportunities to plan for the child. 16. Myth: They don’t need me to do an adoption plan. Fact: In most states, the father is needed to complete an adoption plan if he is known and available.
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Techniques for Engaging Birth Father
Someone who may bear a great deal of influence on the decision to be made is the father of the baby. It is the mother of the baby’s decision to determine how she wants the father of the baby engaged in the process of discussing pregnancy options with the health care professional. Once she makes the decision to include him in the discussion, it is the health care professional’s responsibility to engage him in the process. It would be beneficial for all parties involved to have the father of the baby involved as soon as possible so that he can be a positive support to the mother as she makes her decisions.
Skills to engage the fathers: Health care professionals should be welcoming and helpful in encouraging him to support the birth mother and setting the couple on the right path for getting the help they need to make options decisions together.
Health care professionals can facilitate informed decision-making by identifying birth father strengths and building on those in making referrals.
It is important for health care professionals to engage interested birth fathers using the same techniques used to engage others: treating them with dignity and respect; actively listening to their concerns and being nonjudgmental.
If the father is at all involved with the mother, he will play a significant role in her pregnancy option decision. Therefore, he should have as much information as possible to help him support her decision-making process and issues of pregnancy so that he can become a partner in informed decision-making regarding pregnancy options. However, the decision to involve him is totally within the control of the pregnant woman.
Birth fathers can be encouraged to become informed about the experiences and issues of pregnancy.
Birth fathers who release their parental rights may experience loss and may find it helpful to talk about this with others, either in a professional or peer support setting. Therefore it is beneficial to provide referrals to local resources and support groups for fathers.
Once the choice has been made to make an adoption plan, birth fathers can be encouraged to provide information about themselves, their medical history and their interest in contact with their child when he/she is an adult.
In open adoption, birth fathers may be able to maintain ongoing contact with their child and update any personal or medical information for the adoptive family Attending to his questions and concerns using the same nondirective, noncoercive techniques discussed previously.
Having resource information available about the role of the father in pregnancy care, birth, and parenting.
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Have male-oriented items in the office including décor, magazines, coffee, and information about fathering and fatherhood programs.
Checklist: • Are there visual cues to tell men that they are welcome? • Are staff comfortable talking to men, of all backgrounds? • Is staff utilizing engagement skills to welcome and involve the fathers? • Are there strategies in place to engage fathers when they arrive at the center or clinic? • Are there male-friendly books, magazines, activities? • Are there father friendly posters or displays in the lobby and rooms of the clinic? • Are there written materials specific to the needs of the fathers? • Are there specific referrals and resources available for males? • Are there any other supportive activities geared toward men?
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Adolescence and the Adoption Option
Research indicates that 1%-5% of teens faced with an unplanned pregnancy are likely to choose adoption as an option for their child. The last 50 years has seen tremendous change in society’s perception of unmarried women who elect to keep their babies and raise them as single parents. Gone are the days when family and friends routinely coerced unwed mothers to conceal their pregnancies and subsequently release their child for adoption. The pendulum has swung to the other extreme where the expectation is often that young women will raise their child. Even adolescents who are ill equipped to parent a child feel a tremendous amount of societal pressure to do so. Often teens feel that considering placing their babies for adoption signifies that they do not care about their infants and that even considering the adoption option will be seen negatively by peers and family. Research confirms this trend as very young teens are becoming pregnant and the number of teens raising their children as single parents is increasing. Adolescents who are likely to consider adoption are those who have aspirations for college or other life goals and whose family and friends support the idea of adoption.
The Impact of Adolescent Development on the Adoption Option: Anyone raising or working with adolescents recognizes that the psychological developmental tasks of this age group bear a striking resemblance to those of preschool children. The primary task for both age groups is to separate from the family. The goal of preschoolers is to find their place as individuals within the family, while the goal of adolescents is to find their place as independent individuals within society. This developmental imperative requires that the adolescent revisit many earlier stages of development including egocentrism, magical thinking and differentiation from caregivers. Any developmental issues that were poorly handled in the preschool years may reemerge in the adolescent years.
Adolescence also serves as the staging area for teens to learn how to make decisions, often through trial and error and without the benefit of good coping skills when problems arise. Resolution of these developmental issues can result in frustration and the reemergence of control battles between teens and authority figures. Normal developmental tasks can be complicated by pregnancy and impact how the adolescent views the option of adoption.
Choosing adoption is often referred to as an unselfish act that a mother can perform for her child. This level of selflessness requires that the individual put their own needs aside to meet the needs of another. Pregnant teens, especially those in early and middle adolescence (11 – 17 years of age) or those who have experienced trauma that has impacted their development, are at a stage where they see the world as revolving around them. This level of egocentrism does not allow them to think beyond their own needs to those of their unborn child.
Egocentric thinking has adolescents viewing the child in terms of what he/she can provide for the teen including: unconditional love; a way to get out of a bad life situation; a boyfriend staying with them and/or supporting them; a disorganized or dysfunctional
Module 4 - Page 72 Trainer’s Guide – 1 Day DRAFT UIA 4 – 1 Day - Module 4 12/12/11 family staying together; a higher social status and/or increased independence. Egocentric and magical thinking also hinders a teen’s ability to learn from others or take the experiences of other teens and apply them to their situation. These are the teens that have difficulty considering future planning and who refuse to believe that they will have difficulty after the child is born. Their feeling is, “it won’t happen to me.”
Developmentally, teens are more likely to discount or reject advice and direction from parents and other adults as part of the task of establishing themselves as independent beings. Pregnant teens are being asked to follow doctor’s orders, get plenty of rest, eat nutritious foods, stop smoking, etc., all of which contradicts the adolescent’s need to test the rules and push the boundaries. Teens who perceive that adults have a ‘hidden agenda’ around adoption or are exerting pressure on them to release the child for adoption are likely to engage in control battles as a way to exert their independence. Suspicion of adoption as an adult-controlled process designed to exploit them may also be an issue for teens who are striving for independence.
Implications for Health Care Providers: Respecting the pregnant teen and understanding her world-view is the first step in offering effective services. This perspective keeps in mind that the pregnant adolescent’s need to strive for independence during a time of crisis will bring all of her dependency issues to the surface. Often this process includes angry outbursts that may be directed toward the health care professional. Not taking this behavior personally is vital in effectively working with teens. Allowing the teen as much control over the process as possible, despite outbursts of anger and immaturity, is the key. Offering choices whenever possible will also help the teen to feel a sense of control.
Despite the fact that teens tend not to be verbal and to give superficial answers when initially dealing with authority figures, they still need information. Pregnant teens need concrete information that will help them explore options. Even if the teen is likely to initially dismiss adoption as an option she needs information about adoption to demystify the process. Teens need to be given the message that they can ask questions about the adoption process and to know that no question they ask is going to be perceived as unimportant. Pregnant teens are being asked to consider information and make decisions that require mature decision-making skills. They need to hear all of the information and they may need to hear it more than once and in different ways to be able to utilize it. They also may need help to evaluate the information and weigh alternatives, such as looking at the pros and cons of placing their child for adoption.
Because adolescents have difficulty with future thinking and anticipatory problem- solving, they often underestimate the task of parenting until they are faced with the challenges of raising a child. Often it is not until the child is three to six months of age that the reality sets in for the teen mother. Even though the societal expectation is that teens will raise their children, the extent of the support they can expect from family and friends is changing. The mothers of very young teens who become pregnant may still be in the work force and unable or unwilling to offer the level of care that both the teen mother and her child will require. As families have become more mobile and more
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Peers who were supportive during the pregnancy often leave the new mother behind as they go on with their lives as adolescents, a lifestyle the teen mother no longer has the luxury of enjoying. For the first time she may understand that she is giving up her adolescence to become a parent. Health care and other helping professionals may want to consider keeping the adoption option open for discussion after the birth of the child when the teen is faced with the reality of parenting an infant. Raising the subject of what is best for the child and the teen at this stage may be an issue the teen mother is now willing to explore. The timing of an intervention is often what makes it successful.
Adolescents who have placed their infants for adoption require long-term support. Health care providers who will be having an ongoing relationship with a teen who has placed her child for adoption will need to provide opportunities for the adolescent to process the adoption experience. Being open to the adolescent’s feelings of grief and loss will help her integrate the experience and develop coping skills that serve to meet her emotional needs. Often referrals to support groups for teens that have placed their babies for adoption can be helpful.
Managing Conflict Between Parents and Teens Facing an Unplanned Pregnancy: The very nature of adolescence is to work through the task of differentiating from adult authority figures. Pregnancy in the life of the teen may refocus this struggle and can precipitate crisis in the family. Many parents will attempt to assert control over the pregnant teen by trying to make all of the decisions. For many teens this is their cue to become defiant, rejecting the parent’s attempt to control. Many regress to more infantile behavior that engages the parent and teen in a counterproductive control battle. Often the health care provider finds himself/herself in the midst of this conflict. Assessing the nature of the conflict and acting as a mediator to defuse the anger and/or negative emotions is a role that can fall to the health care provider.
The first step in this process is to allow the parent and the teen to have an opportunity to vent their feelings. This requires that the health care professional be able to take a step back and listen in a nonjudgmental way. Letting the parties know that they have been heard will make it easier to move the interaction from venting to working on the issues at hand.
A parent’s anger is never the primary emotional reaction when a teen is pregnant. Anger almost always occurs after a fear reaction and is used to hide the fear. This anger can be misdirected to the helping professional, but it is important to remember not to take on the anger. This is vital for the health care provider to be able to listen for what the parents are fearful of and to be able to address that fear. The fear can be addressed directly if the parent will not feel ashamed of being afraid. A direct response to a parent’s anger might include the following: “I know you are anxious about how this pregnancy will affect your daughter’s future, and I want you to know that I am willing to help you look at all of the options.” If the parent is likely to feel ashamed of being afraid, more anger will occur in
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an attempt to hide the shame if the fear is addressed directly. In this instance an indirect response might include the following: “It takes a lot of courage to ask for help in supporting your daughter. I can help you find the assistance you will need to work through the issues.” Letting the parent know that help and support are available may help to lessen the fear and defuse the anger.
Listening for the underlying message in what the parent is saying may give clues to his/her self-esteem or self-evaluation, which may be the reason for his/her anger. Sometimes an angry person’s words are the opposite of his/her true feelings and sometimes the words reflect a past experience in a similar situation. Shifting the parent’s perspective to work on helping and supporting the teen may help to defuse the anger. Developmentally, teens face a host of difficulties coping with an unplanned pregnancy. Health care providers will need to understand the developmental issues impacting the teen’s ability to make future planning and to assist parents in helping to support the teen to make sound decisions for herself and her child. Parents may need help to avoid control battles that encourage the teen to act out around the pregnancy and interfere with the parent providing the support that the teen will need. Teens need ongoing help and support to look at all of the options available to them during their pregnancy and beyond.
References: Harner, Holly M., Burgess, Ann W., Asher, Janice B. (2001). Caring for Pregnant Teenagers: Mediolegal Issues for Nurses. Journal of Obstetrics, Gynecologic and Neonatal Nursing, 30, 2, 139-147. Bilodeau, Lorrainne, (2001) Responding to Anger, A Workbook. Center City, MN: Hazelden.
Rosemary Jackson, MSW, ACSW Karal Wasserman, MSW, CSW New View Consultants, Inc. February 2002
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Families in Crisis
Family crisis is a stressful and disruptive event or series of events that comes with or without warning and disturbs the equilibrium of the family. A family crisis can also occur when the usual problem-solving methods of the family no longer work. All families will experience crisis at some point.
Families respond to crisis in different ways. Some see them as challenges to be overcome. Others become overwhelmed, feel helpless, hopeless and give up. Some seek help, others do it on their own. Some emerge stronger and with a greater repertoire of resources and supports and still others suffer severe psychological damage that can be demonstrated in the form of rage, frustration or techniques to intimidate others in their lives.
Regardless of how they respond, families in crisis need help. It is also important to keep in mind that families in crisis have resources and they can build on their strengths. Helping professionals have a unique opportunity and responsibility to be of assistance to families facing crisis in a broad variety of situations.
Crisis Theory: The nature of crises has been well documented in the literature, which applies to both behavioral health and physical health practitioners. Experts agree that a crisis occurs when some internal or external force disrupts a family’s balance, altering its functioning and causing a loss of equilibrium.
Coping strategies are those actions and ways of thinking that help families deal with and survive difficult situations. In crisis, previously used coping strategies may no longer work. A crisis is not simply the event that has occurred, but rather the way in which the family perceives that event. Their perceptions are based on their previous “track record” of coping with adversity and change, and the strength of their social support system. Crisis is usually resolved in a short period of time, and can have either a strengthening or weakening effect on the family unit. Although the crisis itself can be resolved, sometimes its effects will influence the family for years to come. The new balance of the family can result in changed relationships among its members, within its community and within each individual member.
Types of Crisis: Developmental crises are periods of disruption that occur at identifiable, somewhat predictable transition points during normal growth and development. One such crisis can be unplanned pregnancy or parenthood, particularly for adolescents. There are many worries that accompany this new role, including the fear of the unknown, the health of the child, the ability of the teen to provide good care for the baby and the ambivalence about being responsible for the welfare of another human being and giving up personal freedom.
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Situational crises arise from external events that occur suddenly, without warning. The terrorist attack upon the World Trade Center in New York on September 11, 2001 is an example of such a crisis. Not only was it traumatic for the individuals directly touched by the tragedy, but it impacted the entire nation and world. Situational crises cannot be planned or predicted and bring up feelings of helplessness in many individuals. These feelings can be overcome by participating in helping activities, such as donating blood, supporting the Red Cross or the families of those killed in the bombing.
Other, more health related situational crises can include debilitating disease, domestic violence, divorce, or unwanted pregnancy. These are all situations where families or one of their members may seek out health care professionals to provide support and/or to intervene.
Multiple crises are those that overlap, or come in such quick succession that families are no longer successful using their previous coping strategies. Research has shown that multiple crises compound the stress, and can lead to ill health. It also points out that families who are able to work through one crisis may find that multiple crises overwhelm them and cause more stress than they can handle.
Crisis Intervention Techniques: Nursing literature describes two methods of intervening in crisis situations, generic and individual. The generic approach addresses the nature and course of the crisis rather than the psychosocial functioning of the individual. This type of intervention does not require advanced professional counseling skills and allows health care practitioners to work with any group of people who have a crisis in common. An example would be a support group for early adolescents who are pregnant.
There are five important elements in providing generic interventions: (1) encouraging individuals and/or families to use the adaptive behaviors and coping strategies that have proven helpful in the past; (2) social support and the opportunity to be listened to without judgment; (3) the opportunity to identify strategies to cope with the practical and emotional future; (4) anticipatory guidance or the opportunity to practice the strategies identified in element three; (5) providing the family with feelings of control and hope. The individual approach works best with people who do not respond to generic intervention. It is often wise to refer these families and/or individuals to counseling professionals who can facilitate action toward gaining insight into the crisis, developing specific coping strategies and regaining a sense of equilibrium and hope.
The Role of the Health Care Provider: The most important tool of the health care provider is a thorough, comprehensive assessment. Asking the right questions and being a careful observer are key. In cases of domestic violence, or child abuse, following the correct reporting and recording procedures are critical. In an unplanned pregnancy, it is critical to discover the potential impact on the family system of bringing another child into the family. A thorough assessment can be rapid if it focuses on specific issues.
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Some critical questions to assist in crisis assessment can include: • How does the family define or perceive the crisis? • Why has the family asked for help now? • How severe is the crisis? • What risks does the family face as a result of their feeling out of control? • Are others also at risk? • How does the family think the crisis will affect their future? • What precipitated the crisis? • When did the crisis occur? • Was the crisis situational or developmental? • Were there multiple crises? • What coping strategies have been successful for this family in the past? • What coping strategies has the family tried in this situation? • What new coping strategies is the family willing to try now? • What gives the family hope that things will improve?
The health care provider can use a problem-solving model to form the basis for the family crisis resolution plan. This model includes the development of realistic future goals and perhaps some preventive planning. It also includes techniques for helping the family find ways to resolve the crisis. Assessment of the family’s needs are critical to good problem-solving and are based on the type of crisis the family is experiencing; the effect the crisis is having on the family’s life; the ways other important people in their lives are effected and their strengths and available resources.
While the plan is being carried out, it is important to have ongoing communication between the health care provider and the family. The plan needs to be reviewed and updated as often as possible so that it continues to be viable. Whenever possible, tasks need to be assigned with timeframes attached so the family regains a feeling of control over their life.
To stabilize the changes the family makes to successfully master the crisis, the health care provider can identify and reinforce all of the positive coping mechanisms and behaviors that were used. He/she can go on to discuss how these strategies worked and how they can be used to handle future stressors. It is important to summarize the crisis experience by emphasizing the family’s success. This will reinforce their feelings of self- confidence and of their abilities to handle adversity in the future. It will also help them grow closer and feel stronger as a result of their success. Most importantly, it will provide them with hope.
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References:
Aguilera, D. (1990). Crisis Intervention: Theory and Methodology. St. Louis MO: The D.V. Mosby Co.
Allender, Judith Ann RN,C, MSN, EdD, Spradley, Barbara Walton RN MN, (2001). Community Health Nursing: Concepts and Practice. Fifth Edition. Lippincott Press, Philadelphia, New York, Baltimore.
VanOrnum, W., Mordock, J.B. (1991) Crisis Counseling with Children and Adolescents: A Guide for Nonprofessional Counselors. New York: Continuum Publishing Co.
Karal Wasseman, MSW, CSW Rosemary Jackson, MSW, ACSW New View Consultants, Inc. February 2002
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Helping Teens with Future Planning
Health care providers can adapt some of the person-centered planning techniques used by mental health professionals to help teens take responsibility for themselves and their pregnancy. These techniques are similar to brief, nondirective, noncoercive interventions in that they involve a core set of beliefs which include treating the patient/client with dignity and respect; providing them with information so that they can make an informed decision and a lifeplan. They also include ways to ask questions to really understand how a patient/client perceives his/her situation; listening and hearing the patient/client’s story; and putting the patient/client in charge of solving his/her problems.
Strategies for working with teens will differ depending on whether they are in early adolescence (11-14 years of age); middle adolescence (15-17 years of age) or older adolescence (18 - 21 years of age). Chronological age cannot stand alone. Rather, a teen’s life experiences and developmental age need to be factored in as well. While many teens appear much younger than their years, there are those who are much older and wiser. Knowing the individual pregnant teen that has come to you for guidance is vital.
Identify and increase social support: The first step in helping a pregnant teen make a good future plan is to help her identify her resources and support. This can begin as a brainstorming exercise, and can be reviewed throughout the relationship with the health care provider. It can be expected that as the pregnancy progresses, the teen’s social support network will change. This change can be a focus of discussion that will help the teen look toward the future. This can also be a time for teens to meet other teens who have experienced pregnancy. It will be helpful to refer her to resources that will introduce her to women who chose to keep their babies, those who chose to terminate their pregnancies and those who chose adoption. If at all possible, the teen needs to have repeated contact with all of these “role models” so that as she thinks and rethinks her situation, she can ask more questions and obtain more information.
While peer support is helpful, it is also crucial for teens to talk with a caring adult about these interactions. During this process, inaccurate information can be corrected; myths can be demystified; and the teen can have the guidance of a nonjudgmental, noncoercive adult who cares. Oftentimes, the health care provider is the only such adult in a teen’s life, and will be the one to play this pivotal role.
Role play and/or anticipatory guidance: Helping pregnant teens practice how to handle difficult decisions, discussions and/or relationships can be a key factor in building trust with a health care provider. This can be done through role play, in which the teen rehearses what they will say to a parent or birth father, and the health care provider responds in the character of the parent or birth father. The process involves refining the dialogue until the pregnant teen is comfortable with her words and the potential responses they will elicit.
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Anticipatory guidance is a technique in which the health care provider helps the pregnant teen identify future issues that will need to be addressed, and works with her to develop a plan that makes sense in her life. It involves asking future-oriented questions and then helping the teen see the issues that he/she will need to address. For example, asking what will change when the baby is born can help guide the teen to think about how her life may change; the increased responsibility she may take on; the ways in which relationships with friends and family may change. Each of these areas can be explored through the use of open-ended questions that are designed to help the pregnant teen make an informed decision.
Information: As is true with adults, informed health-related decisions are key for teens. Because they are experiencing a time of great change that is heightened by pregnancy, they may need to have information presented in a number of different ways, a number of different times. It is important that the health care provider be patient, and present the options and/or facts each time as though it were the first. It is also helpful to provide written materials, videotapes and to discuss each resource to see how much the teen understands and how she sees the information applying to her.
Working with family crisis: Pregnant teens often find themselves in conflict with their families, which creates a time of crisis. The health care provider can work to defuse some of the emotions within the family and to help them develop ways of coping with the pregnancy. Acknowledging that the family balance is out of equilibrium as a result of the pregnancy and giving them hope that they have options will result in a renewed sense of control. This control will enable them to make informed decisions.
With teens, it is especially important to let them know that they have time after the baby is born to rethink the option of adoption. Rather than pressure the teen to make an immediate decision that will result in feelings of unresolved grief, shame and/or coercion, it will be important to maintain long-term contact and revisit adoption. If the health care provider is unable to do this, perhaps a referral to a community-based program would be best.
Research shows that many pregnant teens mature quickly throughout their pregnancy and are able to be good parents. Health care providers need to assess this throughout their relationship with the teen, and continue to offer choices, hope and nonjudgmental support.
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References: Allender, Judith Ann RN,C, MSN, EdD, Spradley, Barbara Walton RN MN, (2001). Community Health Nursing: Concepts and Practice. Fifth Edition. Lippincott Press, Philadelphia, New York, Baltimore. Bilodeau, L.(2001). Responding to Anger, A Workbook. Center City, MN: Hazelden. Dunst, C., Trivette, C, Deal, A. (1988). Enabling and Empowering Families: Principles and Guidelines for Practice. Brookline Books, Cambridge. VanOrnum, W., Mordock, J.B. (1991) Crisis Counseling with Children and Adolescents: A Guide for Nonprofessional Counselors. New York: Continuum Publishing Co.
Karal Wasserman, MSW, CSW Rosemary Jackson, MSW, ACSW New View Consultants, Inc. February 2002
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Special Concerns for Adults and Teens
• Domestic Violence • Substance Abuse • Depression • Mental Physically Impaired • Domestic Violence • Definition • DV behaviors • Power and control • Cycle of violence • Why people can’t just leave?
The Center for Disease Control defines domestic violence during pregnancy as “Physical, sexual, or psychological/emotional violence, or threats of physical or sexual violence that are inflicted on a pregnant woman.”
Furthermore, domestic violence can be a pattern of behavior in a relationship where one person tries to gain power and control over another person. Because it is a pattern of behavior, it can continue to happen again and again in a relationship. Often, a victim will hope the abuse will never happen again; but unfortunately, evidence has shown that the violence will continue.
Another characteristic of domestic violence is that the batterer will use physical harm to gain power and control over the victim. (Please refer to Power and Control Wheel resource information in Participant Handbook, Module 4, page 42.
It is also important to keep in mind that when you are providing care for a woman or teen with an unplanned pregnancy, she is “four times more likely to suffer increased abuse as a result of the unintended or wanted pregnancy.”
It is also important to consider that your patient/client might have a difficult time leaving because the batterer has spent the entire relationship cutting that person off from other resources. The person does not have the contacts with friends or family any longer and would have no one to turn to if they did leave. Often a batterer will also threaten to further harm or kill the individual or the children if she leaves.
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Domestic Violence Wheel
Individuals usually see domestic violence as only a physical act. The purpose of this sheet is to show that batterers will use many methods to exert power and control over their partner. Domestic violence is about power and control, not about being angry or losing your temper. Other types of domestic violence are: • Using coercion and threats • Using intimidation • Using emotional abuse • Using isolation • Minimizing, denying and blaming • Using children • Using male privilege • Using economic abuse
Batterers will often use more than one of these behaviors to exert power and control over their partner.
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Substance Abuse
You know the physical effects of drugs, alcohol and tobacco on the mother and the baby. Additionally it is important to consider the safety of the home environment in which the substance abuse occurs.
The pregnant woman may be at risk of physical harm from persons in or entering the home under the influence of substances.
Is home a safe environment for the pregnant woman? Consider having referral resources available which may include drug treatment centers, housing resources, substance abuse counselors, and domestic violence shelters.
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Clinical Depression
What is clinical depression?
Clinical depression is a serious and common disorder of mood that is pervasive, intense and attacks the mind and body at the same time. Current theories indicate that clinical depression may be associated with an imbalance of chemicals in the brain that carry communications between nerve cells that control mood and other bodily systems. Other factors may also come into play, such as negative life experiences such as stress or loss, medication, other medical illnesses, and certain personality traits and genetic factors. What are the signs and symptoms of depression? The symptoms of depression include feeling sad and blue, not enjoying activities once found pleasurable, having difficulty doing things that used to be easy to do, restlessness, fatigue, changes in sleep, appetite or weight, inability to make decisions, feelings of worthlessness, and thoughts of death or suicide. Symptoms of depression: persistent, sad, anxious or empty mood feelings of hopelessness or pessimism feelings of guilt, worthlessness or helplessness loss of interest or pleasure in ordinary activities decreased energy, a feeling of fatigue difficulty concentrating or making decisions restlessness or irritability inability to sleep or oversleeping changes in appetite or weight unexplained aches and pains thoughts of death or suicide
There are several types of depression -- major depression, dysthymia, bipolar depression, and Seasonal Affective Disorder.
Major depression is the most common type of depression and is characterized by at least five of the major symptoms of depression.
Dysthymia is a milder form of depression that lasts two years or more. It is the second most common type of depression but because people with dysthymia may only have two or three symptoms, may be overlooked and go undiagnosed and untreated.
Bipolar depression is the depressive phase of manic-depressive illness, in which there are both extreme highs and extreme lows. Bipolar depression symptoms are similar to those
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Seasonal Affective Disorder is a type of depression that follows seasonal rhythms, with symptoms occurring in the winter months and diminishing in spring and summer. Current research indicates that the absence of sunlight triggers a biochemical reaction that may cause symptoms such as loss of energy, decreased activity, sadness, excessive eating and sleeping.
Recently, research produced as a result of the last several National Depression Screening Days has revealed that some people may experience depression without necessarily suffering from significant or very troublesome changes in sleep and appetite. This is an intriguing finding because changes in sleep and appetite are usually considered to be hallmarks of depression.
Mental/Physical Impairments Discuss openly with the individual the impairments they may have and how they may impact their decision regarding the unintended pregnancy. Have referral resources available that will assist the individual in meeting the challenges of any impairment they may be working with.
In general in working with special issues a person must remember to be non-coercive, non-biased which will take a lot of work in you exploring your own values. Health care professionals must avoid making assumptions about the individual or situation, be willing to challenge your own beliefs. Also important is creating a support network for yourself and your staff where you can discuss potential biases. Consider the possibility that you may have to make a referral to Adult Protective Services. It would be beneficial to keep the referral number with your resource information.
Notes:
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Pregnant Teens: Discussing Family Involvement
Discuss anticipated family response to pregnancy: explore with the teen what the possible reaction of her parents will be to the pregnancy. Role play these possible reactions so teen feels prepared to have a conversation with her parents about the pregnancy.
Offer to facilitate a meeting: encourage the teen to invite her family to her next appointment with a HCP. The teen can use the health care professional or social worker as a source of support when discussing the pregnancy and options with her parents. Prepare to possibly manage conflict: If the teen’s parent is in the interview, the first step in this process is to allow the parent and the teen to have an opportunity to vent their feelings. This requires that the health care professional be able to take a step back and listen in a nonjudgmental way. Letting the parties know that they have been heard will make it easier to move the interaction from venting to working on the issues at hand. A parent’s anger is never the primary emotional reaction when a teen is pregnant. Anger almost always occurs after a fear reaction and is used to hide the fear. This anger can be misdirected to the helping professional, but it is important to remember not to take on the anger. This is vital for the health care provider to be able to listen for what the parents are fearful of and to be able to address that fear. The fear can be addressed directly if the parent will not feel ashamed of being afraid. A direct response to a parent’s anger might include the following: “I know you are anxious about how this pregnancy will affect your daughter’s future, and I want you to know that I am willing to help you look at all of the options.” If the parent is likely to feel ashamed of being afraid, more anger will occur in an attempt to hide the shame if the fear is addressed directly. In this instance an indirect response might include the following: “It takes a lot of courage to ask for help in supporting your daughter, I can help you find the assistance you will need to work through the issues” letting the parent know that help and support are available may help to lessen the fear and defuse the anger.
Listening for the underlying message in what the parent is saying may give clues to his/her self-esteem or self-evaluation, which may be the reason for his/her anger. Sometimes an angry person’s words are the opposite of his/her true feelings and sometimes the words reflect a past experience in a similar situation. Shifting the parent’s perspective to work on helping and supporting the teen may help to defuse the anger.
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STAGES OF BIRTHFATHER GRIEF
There is no “correct” way to grieve or one sudden, shining moment when you are finished grieving. But the following thoughts and feelings are experienced by many birthfathers at some point in the adoption process.
Stage Description Questions to Consider Comments from Birthfathers
This is commonly referred to as the shock or “The first thing to realize is that even if denial phase. You may question the paternity of How do I feel about this the birthfather wants to play a part in his the child and your role in the process, especially pregnancy? What are my kid’s life, he’s probably going to go into if you are no longer in a relationship with the thoughts about the role of fathers denial for a period of time. The easiest birthmother. If there is some doubt about and the needs of children? Am I way to ‘deal’ with a painful situation like Impact paternity, yo equipped to provide a child with this is just to stop looking at it. I would u may feel tremendous guilt about your doubts security, love and stability? How imagine that a lot of birthfathers enter the and unsure how to respond to your fears. You can I be supportive of the denial phase early in the pregnancy, and may also question your potential as a parent. birthmother? I would bet that a good deal of them Thoughts of your future (education, job stability never stop denying it.” and finances) may weigh heavily on your mind.
This phase refers to the first emotional reaction Do I want to be present at the following a placement. The birthfather may feel birth? How would the birthmother shocked at how much love and attachment he “It is very rewarding and healing to play a feel about me being there? What felt at the birth. He also may feel a lot of role. Witnessing the birth of my son and specific things can I do at the Chaos responsibility to comfort the birthmother and tend seeing the joy of his adoptive parents hospital and during the to her needs, rather than to his own. If he is not was the most powerful, exciting, sad, placement? If I cannot be at the involved at the birth, he may feel anger about joyful day of my life.” hospital, what can I do later to that or it may deeply pain him — or even relieve welcome my child into the world? him. Every person reacts differently.
Continued next page
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Stage Description Questions to Consider Comments from Birthfathers This phase includes the first few weeks following the placement of your child. Guilt and shame “Placing your child for adoption is a major often accompany this phase, alternating with How do I feel now? Why did I (or blow to your self confidence. Especially feelings of pride and contentment. You may feel we) make this decision in the first for us guys — though you’ll meet very confused by the rush of feelings you are having. place? What should my role be few who will admit it. You’ve got to build Intellectually, you may believe the placement now? When should I contact the that up. Being needed by the adoptive Adaptation was the right decision. But in your heart, you adoptive family or the parents is the best foundation around. In may question it — especially if the birthmother is birthmother? How should I now a way, it still allows the birthdad to still deeply grieving. Women are usually refer to my child? Who can I talk provide for the kid. We need that comfortable expressing more emotion than men. to about this decision and my because we’re guys, and we’re supposed Some men, though they may want to cry, feel feelings? to provide for our kids.” stifled during the adoption process and are unable to express their feelings. As you feel more comfortable with the adoptive What does it mean to be a parents, and as you develop your relationship “The adoptive parents were beyond birthfather? Is my life going in the with them, your role will become more clear to awesome throughout this entire process. direction I want it to? What does you. You will regain some balance in your life. I was very hesitant about meeting them, this adoption decision mean to me Adoptive families and birthfathers who have and I somewhat figured I’d be like a third Balance personally? Am I following stayed in touch have found their relationships to wheel from the beginning. But they do through on things I said I would be extremely fulfilling. Your child will benefit from great at showing me how important I am do? What do I want my child to the love, concern and involvement of both to them in general.” know about me? his/her birthparents. This phase is the point where everyone who “I still keep in contact with the adoptive grieves hopes to end up, eventually. Important What have I learned from this parents, as they do with me. It’s amazing aspects include developing your self potential; experience? What do I value that I will still be able to know my son, finding some kind of spirituality or meaning in the about this experience? How can I and no one can take that away from me adoption experience; developing awareness of continue to be a loving force in … I can watch him grow and develop how your feelings impact your relationships with the my child's life? How can I Transformation with the confidence that he is well loved your child and the adoptive family; coming to share this experience with others, and provided for. One of the best peace with yourself and your decision to place so they can learn from my story? characteristics of this adoption is that I your child for adoption; and lastly, but most Is it possible for me to help others didn’t lose a family member. I gained importantly, being mindful and appreciative of in a similar situation? many more.” your child’s presence in your life. - Based on the Phoenix Model of Grief from the book The Phoenix Phenomenon: Rising From the Ashes of Grief, by Joanne Jozefowski, R.N., Ph.D.
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Cross-cultural Skills Checklist
Use this checklist to assess how well you are applying your cultural knowledge. If you answered “Rarely/Never” or “Sometimes,” use the “Action Plan” column to start thinking about what else you need to know or do and steps you can take to improve your cross- cultural interactions.
Rarely/ Sometimes Frequently/ Action Plan Never Always I seek information from family members and other key community informants to help me respond effectively to the needs and preferences of the culturally and linguistically diverse patient/clients I serve.
Before visiting or providing services in the home setting, I seek information on acceptable behaviors, courtesies, customs, and expectations that are unique to families of specific cultural groups served in my program.
Recognizing that individuals from culturally diverse backgrounds may desire and acquire varying degrees of acculturation, I try to learn from individual patient/clients where they see themselves on the acculturation continuum.
Recognizing that “family” is defined differently by different cultures (e.g., extended family members, fictive kin, godparents), I make an effort to learn how each family defines itself.
Recognizing that male-female roles in families may vary significantly among different cultures (who makes major decisions, activities expected of male and female children, etc.), I make an effort to learn how families view male-female roles.
I understand that beliefs and concepts of emotional and physical well-being vary significantly from culture to culture.
I understand and accept that the healthcare practices and preferences of culturally diverse people may be rooted in cultural traditions.
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Self Assessment Worksheet
The following questions are intended as a guide for you to use in examining your cultural background and life experiences. Try to answer each question honestly and with an open mind. The questions are intended to help you get to know yourself a little better. Consider them in the context of your present life as well as your experience growing up as a child.
Take your time to think about how certain aspects of your cultural background may have influenced your values, beliefs, and assumptions. Think about how these values, beliefs, and assumptions could contribute to your effectiveness as a helper, and also how they could possibly interfere with your effectiveness. The process of self assessment helps you identify which aspects of your culture have given you support, helped you solve problems, and contributed to your sense of identity.
Self-awareness will ultimately help you work with your clients to draw upon their cultural heritage in the same way – as a source of strength. An honest self assessment can help you recognize your biases – the first step to overcoming them.
1. What is your cultural heritage? What was the culture of your parents and grandparents? 2.What community did you grow up in? What was the racial and ethnic composition of that community? 3.With which cultural group or groups do you identify? [In addition to thinking of culture in terms race, nationality, and ethnicity, think about other groups you belong to that can be said to have a culture of their own – for example: “baby boomers,” urban pioneers, quilters, Rotarians, runners, Civil War re-enactors, etc.] 4.Looking back on your childhood, which of your family’s values, beliefs, attitudes, customs, traditions, foods, etc., can be attributed to your ancestral/cultural heritage? 5.Growing up, what messages were given to you about people from your cultural group? (For example, were you told – implicitly or explicitly – that people from your group believe in charitable giving? Have problems with alcohol? Value education? Support liberal/conservative causes? Are discriminated against by the police?) 6.Growing up, what messages were given to you about establishing relationships with people from cultural groups different from your own? 7.What was the structure of the family you grew up in? Who was considered to be a member of your family? Were there people who were not related by blood but who were regarded as family (such as godparents, or fictive kin)? 8.In your household, were there roles and privileges that were determined by gender and/or age? What were men expected to do? What were women expected to do? What about elders? What about children? 9.What forms of communication were common in your family experience? Did people use jokes, teasing, sarcasm, story-telling? How loud did people talk? Was arguing tolerated? Could children disagree with adults? Was it okay to interrupt? 10.When did you first become aware of cultural differences between yourself and others?
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Module 5: Nondirective Techniques for Informed Decision-Making (60 minutes)
Trainer’s Preparation
Module Contents and Training Process • Understanding of core issues in options counseling • Nondirective, noncoercive techniques • Have a basic understanding of informed consent in adoption as well as the roles and responsibilities of helping professionals. • Separate professional and personal values in practice of providing adoption information.
Preparing to Train • Note that this Module includes several options that contain activities. Determine which option you will use and prepare prior to training. This will establish the flow of the training. Do not use all of the video options in this Module.
• Review materials on nondirective, noncoercive counseling and decide which option you will use.
Option 1 of 2: Lecture the nondirective, noncoercive techniques information.
Option 2 of 2: Preview the Nondirective Client Centered Approach video.
• Preview the Julie, Kesha, Isabel and Nicole video segments. Based on your expected audience, decide what video segment you will be using. Kesha may be best if the eligibles at the training work with teens/adolescents.
NOTE: If you used the Kesha (short version) in Module 4 then you should select Option 1, the Julie video.
Option 1 of 4: Preview Julie video Option 2 of 4: Preview Kesha video Option 3 of 4: Preview Isabel video Option 4 of 4: Preview Nicole video
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• Continue nondirective, noncoercive training information
Option 1 of 2: Review role play (10 min.) practice exercise and large group discussion.
Option 2 of 2: Review role play (10 min.) practice exercise and large group discussion.
Option: Preview the Discussing The Adoption Option (15 min.) Video (recommended for mainly Title X audience).
Optional Lecture (if time permits): Introducing pregnancy options in fifteen minutes or less.
Required Materials/Equipment and Room Set-Up for this Module • Nondirective Client Centered Approach Video • Julie, Kesha, Isabel and Nicole Videos • Discussing the Adoption Option Video • TV-VCR or DVD Player • Laptop and Projector • Screen to show PowerPoint presentation and DVD’s
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Module 5: Introduction
Objectives: Identify how personal culture, values, attitudes and biases may influence delivery of adoption information. Describe the techniques used, i.e. listening, rapport building, and the use of open ended questions in nondirective, noncoercive options counseling. Describe how informed consent impacts the roles and responsibilities of helping professionals.
Content • Core Issues and Nondirective Counseling • Nondirective, Noncoercive Counseling Techniques • Practice Exercise
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Trainer’s Comments
• Health care professionals have said that it can be difficult to introduce the concept of adoption with a young woman or teen experiencing an unintended pregnancy, either because they felt they might offend someone or did not want to be seen as judgmental.
• It is important to remember your professional standards when working with pregnant women. • Several national professional organizations have standards on pregnancy options counseling. We discussed these standards for a number of professional organizations in Module 1. • Although these organizations vary in the amount of detail they provide in their standards and code of ethics statements, they all share three important principles: Information is offered on all options on an equal basis. Counseling is provided in a nondirective, noncoercive manner. Patient/clients are provided the opportunity to freely choose the services or procedures they want.
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Directions • Ask participants to turn to Participant Handbook, Module 5, page 3.
• Nondirective, Noncoercive Counseling: Nondirective, noncoercive counseling methods present information and options through the use of open-ended questions. These questions are designed to help the patient/client make an informed decision that satisfies his/her needs and preferences.
• Nondirective, Noncoercive Intervention: A nondirective, noncoercive intervention requires that the helping professional support the decisions made by the patient/client, including the decisions to refuse information, even if the helping professional does not agree with these decisions.
• Do you have any questions about nondirective, noncoercive counseling or nondirective, noncoercive intervention? Does anyone have anything they would like to add to the definitions?
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Trainer’s Comments • In pregnancy options counseling, coercion could occur as a result of a parent of a pregnant minor child, or a husband or birth father, exerting excessive pressure on a patient/client, to make a particular decision. • Coercion can occur in adoption when someone with more perceived power or authority “convinces” a patient/client to make a particular decision or joins with another to talk the patient/client into a decision. • In adoption, coercion can also occur when persons or agencies promise financial or other benefits or privileges to a person in desperate need or in a particularly vulnerable situation as an inducement to have them release the child. • It is important for the health care professional to support their patient/client in making informed decisions in all such instances. • A pregnant woman or teen can be empowered by accurate information and support to make a fully informed consent in seeking adoption information and services. • Unless there are medical indications that a patient/client’s choice is counter- indicated, the health care provider supports the patient/client’s choice. This patient/client choice includes the right to refuse information.
Transition Now let’s look at nondirective, noncoercive techniques for working with pregnant women.
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Nondirective, Noncoercive Techniques (15 minutes)
Option 1 of 2: Lecture (Option 2 of 2 is found in Module 5, page 9) Directions • Ask participants to turn to Participant Handbook, Module 5, page 4, Brief Nondirective, Noncoercive Techniques. • Review the definitions of each technique and provide examples.
• Brief Nondirective, Noncoercive Techniques Physical Environment: Insure that the physical environment of your office, waiting room, or other areas of your organization reflect your clientele. Do the pictures on your wall or the magazines in the lobby match the diversity of your patient/clients? Rapport Building: Involves developing trust through verbal and non- verbal means. Verbal rapport building can include the use of compliments, expressions of caring (How would you feel most comfortable?) self-disclosure and humor. Non-verbal rapport building can include touch, eye contact, nodding, and smiling. (Test Question) Open-Ended Questions: Are questions that allow the patient/client to tell his/her story. Open-ended questions cannot be answered by a yes or no. (Test Question) Reflective Listening: Is a technique that lets the patient/client know that the health care provider is listening to what he/she is saying. This technique is often referred to as paraphrasing and/or reflective or active listening. (Test Question) Responding Nonjudgmentally: Requires the health care provider to continually assess their own values and beliefs so that they do not interfere with their work with patient/clients. (Test Question)
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Empowerment/Strength-Based Comments: Is a technique that identifies and compliments strengths in order to help an individual take control of a situation. When responding to the patient/client communication, it is helpful to notice the strengths you can identify, not just the problems and concerns. (Test Question) Empathy: Involves listening respectfully to the patient/client’s concerns and relating to the patient/client’s situation. (Test Question) Identifying Feelings: Occurs when the health care professional puts words to the emotions that are being expressed and then checks with the patient/client to make sure that his/her interpretation is correct. Defusing Anger: Defusing anger can be accomplished by several techniques including identifying and responding to the issues underlying the person’s anger, such as fear, acknowledging that fear, and shifting the person’s perspective. (Test Question) Summarizing: Is a technique in which the health care provider highlights key points of the conversation with the patient/client and checks back to make sure that his/her interpretation is correct.
Transition • Now that we have discussed all of the techniques, the key technique to use in nondirective, noncoercive intervention is the use of open-ended questions. Trainer Note: • Please turn to page 11 and continue with Examples of Open Ended Questions.
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Option 2 of 2: Nondirective Client Centered Approach Video & Discussion (15 minutes)
The Nondirective Client Centered Approach Video and Exercise (15 minutes)
Video Description
The Nondirective Client Centered Approach Video is a 10-minute videotape discussing brief nondirective, noncoercive techniques and showing examples of each.
Directions
Ask participants to turn to Participant Handbook, Module 5, page 5, Nondirective Client Centered Approach Video. • Tell participants to watch for techniques in the video that show the various techniques in the nondirective client centered approach that might help them in their work with pregnant women and teens. • Play the video.
• Ask participants what techniques they noted in video.
Rapport Building – Nurse gave a hug
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Open Ended Questions – “What did you think when you realized you were pregnant?” Physical Environment Reflective Listening – “You feel there are lots of people in your life that would not understand?” Responding Non-judgmentally – No response when young girl stated she and boyfriend used condoms “sometimes.” Empowerment/Strength Based Comments –“I am so proud of you for quitting smoking.” Empathy – “This has to be weighing very heavily on you.” Identifying Feelings – “You appear sad. Is that how you are feeling?” Defusing Anger –“I can’t blame either one for you for being angry. I can’t even imagine what you are both going through.” Summarizing
• Have they used these techniques themselves and how did that work? • Ask participants if there are other techniques they have found helpful in working with pregnant women.
Trainer’s Comments • This curriculum is designed to prepare health care professionals to better discuss the adoption option with their patient/clients. • Health care practitioners frequently handle options counseling by referring pregnant women/teens to community resources such as, pregnancy counseling and adoption agencies after having a brief discussion with the patient/client. • Module 6 will discuss resources and referrals in depth.
Transition
Transition • Now that we have discussed all of the techniques, the key technique to use in nondirective, noncoercive intervention is the use of open-ended questions. • Ask participants to turn to Participant Handbook, Module 5, page 6, Open Ended Questions.
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Trainer’s Comments • Examples of Open-Ended Questions are: How do you feel about the pregnancy? Tell me about how your life has changed with this pregnancy. How do you feel about those changes in your life? What impact do you think having this child will have on your future plans? Tell me what concerns you have about this pregnancy. Who will be helping you as you go through this pregnancy and how do you feel about their helping? There are basically three options available to you: continuing the pregnancy to birth and placing him/her for adoption by relatives or non-relatives; continuing the pregnancy to birth and parenting; or terminating the pregnancy. Which of these would you like more information on?
Large Group Discussion • Ask participants to share their experiences using open ended questions. • Ask participants to share other open ended questions that might be helpful when talking to a pregnant woman.
Directions • Ask participants to turn to Participant Handbook, Module 5, page 6, Informed Consent. • Review components of informed consent with participants.
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Informed Consent (5 minutes)
• Informed consent is given after the patient/client or patient/client’s legal representative has been provided with complete information as to: The conditions or situation requiring intervention. The choices/options in services or treatment. The consequences or probable consequences of each option. Then the patient/client freely chooses one course in lieu of another.
Trainer’s Comments • Although the roles of various helping professionals may differ, the goal of informed consent in adoption is to assure that a patient/client fully understands the present and future consequences of an adoption decision, and options other than adoption, that may be available to resolve their situation. • Informed consent by the patient/client makes them responsible for the final decision and all of its consequences. • Using this method of intervention is consistent with the health care practice of supporting the patient/client while he/she has the responsibility for the final decision-making.
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Large Group Discussion • Ask the participants the following question about the informed-consent definition: What is the connection between informed consent and using noncoercive, nondirective techniques?
o Nondirective, noncoercive methods are the foundation of informed consent.
o Both involve the patient/client having knowledge to make their own decisions.
Transition • Tell participants that in this segment we discussed noncoercive, nondirective counseling and informed consent. • Ask participants if they have any questions or comments on the issues of nondirective counseling and informed consent. • Next will be a demonstration of the techniques using a video.
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Video 1 of 4: Julie Video and Discussion (20 minutes)
Video Description
• “Julie” is a 15 minute drama that features a person who is visiting the local public health clinic. Julie has two toddlers, ages 2 1/2 and 13 months and currently lives with her grandmother. She is pregnant and meets with a nurse named Rita to discuss her options. After this meeting, Julie and Gary, the father of the baby, are seen discussing adoption. We then see Julie and Gary meeting with Rita at the health clinic a few days later.
Directions • Let participants know that they are being provided with the brief noncoercive, nondirective techniques that we discussed previously in a worksheet format. It is found in their Participant Handbook, Module 5, pages 8 and 9 and should be used in identifying when Rita, the public health nurse, uses each of these techniques. • Instruct participants to use this worksheet to record their notes. • Let participants know that they will also have an opportunity to discuss these techniques as a large group afterwards. • Play videotape.
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Techniques Examples from Video Physical Environment: Insure that the • Toys in the waiting room physical environment of your office, • Have male and teen oriented waiting room, or other areas of your magazines. organization reflect your clientele. Do the pictures on your wall or the magazines in the lobby match the diversity of your patient/clients?
Rapport Building: Involves developing • Nurse complimented Julie on trust through verbal and non-verbal means. quitting smoking. Verbal rapport building can include the use • Nurse praised Julie’s behavior with of compliments, expressions of caring children. (how would you feel most comfortable?) • Noticing family/dynamics in waiting self-disclosure and humor. Non-verbal room. rapport building can include touch, eye • Gave her a supportive hug. contact, nodding, and smiling. • Was supportive. • When Gary states he has a right to be there, Nurse states “Absolutely, come right in.”
Open-Ended Questions: Are questions • “How do you feel about the that allow the patient / client to tell his/her pregnancy?” story. Open-ended questions cannot be • “What’s the hardest thing about answered by a yes or no. being pregnant?”
Reflective Listening: Is a technique that • “Sounds like you have a lot on your lets the patient/client know that the health plate.” care provider is listening to what he/she is • When Gary says “This is your saying. This technique is often referred to fault.” Nurse responds, “I know it as paraphrasing and/or reflective or active feels that way. I’m the one telling listening. you everything you don’t want to hear.”
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Techniques Examples from Video Responding Non-judgmentally: Requires • “Couldn’t even imagine.” the health care provider to continually • Didn’t say: “You already have two assess their own values and beliefs so that kids.” they do not interfere with their work with patient/client.
Empowerment/Strength Based • Gave her the brochure. Comments: Is a technique that identifies • Provided education – eating, and compliments strengths in order to help smoking. an individual take control of a situation. When responding to the patient/client communication, it is helpful to notice the strengths you can identify, not just the problems and concerns.
Empathy: Involves listening respectfully • Stood up and hugged her. to the patient/client’s concerns and relating • “I couldn’t even imagine what you to the patient/client’s situation. are going through right now.” • “I’m saying everything you don’t want to hear.”
Identifying Feelings: Occurs when the • “You’re just exhausted and health care professional puts words to the overwhelmed.” emotions that are being expressed and then checks with the patient/client to make sure that his/her interpretation is correct.
Defusing Anger: Can be accomplished by • Gary. several techniques including listening for • Let them vent. and responding to the angry person’s fear, identifying and responding to the issues underlying the person’s anger and shifting the angry person’s perspective.
Summarizing: Is a technique in which the • Hard time; not easy choice; health care provider highlights key points options, think about them. of the conversation with the patient/client • “I’m here to support your and checks back to make sure that his/her decision.” interpretation is correct.
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Large Group Discussion
• Ask the participants the following questions about the video: . What did you think of Rita's style? . Ask the group to cite specific examples of the techniques they had seen in the video. (Use chart found on previous pages 15 and 16 with examples from Julie video during discussion; the examples are in italics). . How did Rita engage Gary, the father of the baby?
Transition • Now that we have seen examples of nondirective, noncoercive techniques we will do a role play/exercise to allow you to have a chance to practice using these techniques yourself.
TRAINER NOTE: Turn to page 30 for next exercise, Role Play/Practice Exercise.
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Video 2 of 4: Kesha Video and Discussion (20 minutes)
Video Demonstration
“Kesha” is a 14-minute drama that features a 14 year-old girl who is visiting her school health center staffed by Mrs. Kaye, a Registered Nurse. Kesha is an excellent student who discovers she is pregnant during this visit and is afraid to tell her mother.
Directions • Let participants know that they are being provided with the brief noncoercive, nondirective techniques that we discussed previously in a worksheet format. It is found in their Participant Handbook, Module 5, page 11 and 12, and should be used in identifying when Mrs. Kaye, the school nurse, uses each of these techniques.
• Instruct participants to use the worksheet to record their notes.
• Let participants know that they will also have an opportunity to discuss these techniques as a large group afterwards.
• Play videotape.
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Techniques Examples from Video Physical Environment: Insure that the • Culturally diverse posters. physical environment of your office, • Have male and teen oriented waiting room, or other areas of your magazines. organization reflect your clientele. Do the pictures on your wall or the magazines in the lobby match the diversity of your patient/clients?
Rapport Building: Involves developing • Nurse asked “How are you?” trust through verbal and non-verbal means. • Nurse makes a joke stating “That Verbal rapport building can include the use boring, huh?” when referring to of compliments, expressions of caring falling asleep in class. (how would you feel most comfortable?) self-disclosure and humor. Non-verbal rapport building can include touch, eye contact, nodding, and smiling.
Open-Ended Questions: Are questions • Nurse asks “What happens when that allow the patient/client to tell his/her you eat in the morning?” story. Open-ended questions cannot be • Nurse asks “What do you think is answered by a yes or no. making you so sleepy?” • Nurse asks “What have you been thinking?” Reflective Listening: Is a technique that • Nurse states “This is so hard, I lets the patient/client know that the health know.” care provider is listening to what he/she is • Nurse states “Yeah, you know, your saying. This technique is often referred to mom might be really angry at first, as paraphrasing and/or reflective or active she’ll probably be disappointed. listening. She might yell at you…but your mom loves you Kesha.” Responding Nonjudgmentally: Requires • Nurse asks “Do you use them every the health care provider to continually time?” when referring to birth assess their own values and beliefs so that control and Kesha replies they do not interfere with their work with “sometimes.” patient/clients. • Nurse states “You feel good about it (the pregnancy). Okay.”
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Techniques Examples from Video Empowerment/Strength Based • Nurse states “Let’s work together Comments: Is a technique that identifies and try to figure out a way that we and compliments strengths in order to help can help Kesha…” an individual take control of a situation. • Nurse states “You’re a smart girl When responding to the patient/client Kesha and I know you will make a communication, it is helpful to notice the good decision.” strengths you can identify, not just the • Nurse says “according to your problems and concerns. preference you can be seen by the doctor who visits the school…or I can refer you…” Empathy: Involves listening respectfully • Nurse states to Kesha’s mom “I am to the patient/client’s concerns and relating sure this really caught you off to the patient/client’s situation. guard.”
Identifying Feelings: Occurs when the • Nurse states to Kesha’s mother “I health care professional puts words to the can see how upset and disappointed emotions that are being expressed and then you are. And how worried.” checks with the patient/client to make sure • Nurse says to Kesha “You don’t that his/her interpretation is correct. sound real sure.”
Defusing Anger: Can be accomplished by • Nurse states to Kesha’s mother “I several techniques including listening for can see how upset and disappointed and responding to the angry person’s fear, you are. And how worried.” identifying and responding to the issues • Nurse says “Let’s talk about how underlying the person’s anger and shifting we can support Kesha.” the angry person’s perspective. Summarizing: Is a technique in which the • Nurse states “You tell me you have health care provider highlights key points nausea in the morning, your of the conversation with the patient/client teacher tells me you have been and checks back to make sure that his/her falling asleep in class, you are not interpretation is correct. sure when your last period started and you have been sexually active. All these things make me wonder if you might be pregnant.”
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Large Group Discussion
• Ask the participants the following questions about the video: . What did you think of Miss Kaye's approach? . Participants may comment that the nurse stated to Kesha that she “is pregnant” rather than “the test is positive.” Participants should follow their organizations policies and procedures as to this issue. . Ask the group to cite specific examples of the techniques they had seen in the video. (Use chart found on previous pages 19 and 20 with examples from Kesha video during discussion; the examples are in italics).
Transition • Now that we have seen examples of nondirective, noncoercive techniques we will do a role play/exercise to allow you to have a chance to practice using these techniques yourself.
TRAINER NOTE: Turn to page 30 for next exercise, Role Play/Practice Exercise.
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Video 3 of 4: Isabel Video and Discussion (25 minutes)
Video Description
• “Isabel” is a 17 minute drama that features a 42 year old married woman who is visiting her medical office for a pre-natal appointment. Isabel is 20 weeks pregnant with four other children, ages 16, 18, 20, and 22. At this meeting Rita, the nurse talks to Isabel about her options regarding her pregnancy.
Directions • Let participants know that they are being provided with the brief noncoercive, nondirective techniques that we discussed previously in a worksheet format. It is found in their Participant Handbook, Module 5, page 14 and 15 and should be used in identifying when the nurse, uses each of these techniques. • Instruct participants to use this worksheet to record their notes. • Let participants know that they will also have an opportunity to discuss these techniques as a large group afterwards. • Play videotape.
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Techniques Examples from Video Physical Environment: Insure that the • Posters in exam room physical environment of your office, waiting room, or other areas of your organization reflect your clientele. Do the pictures on your wall or the magazines in the lobby match the diversity of your patient/clients?
Rapport Building: Involves developing • Rita had eye contact with Isabel trust through verbal and non-verbal means. • Rita smiled at Isabel and nodded Verbal rapport building can include the use affirmatively as she spoke of compliments, expressions of caring • Rita complimented Isabel on her (how would you feel most comfortable?) daughters’ names, mentioning they self-disclosure and humor. Non-verbal were all named after flowers. rapport building can include touch, eye contact, nodding, and smiling.
Open-Ended Questions: Are questions • “What did you think when you that allow the patient / client to tell his/her found out you were expecting?” story. Open-ended questions cannot be • “How are you feeling about the answered by a yes or no. pregnancy?” • “How do you think a new baby will affect Joe’s ability to do that?
Reflective Listening: Is a technique that • “This must be very difficult for lets the patient/client know that the health you.” care provider is listening to what he/she is • “It seems like you have a lot going saying. This technique is often referred to on right now.” as paraphrasing and/or reflective or active • “I hear what you are saying.” listening. • “it sounds like you have a lot on your plate right now.”
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Techniques Examples from Video Responding Non-judgmentally: Requires • Didn’t say: “You already have four the health care provider to continually grown children.” assess their own values and beliefs so that • “Now that the shock has worn off they do not interfere with their work with how are you feeling about the patient/client. pregnancy?”
Empowerment/Strength Based • Gave her the brochure regarding a Comments: Is a technique that identifies support group. and compliments strengths in order to help • Provided education about older an individual take control of a situation. mothers and the additional tests When responding to the patient/client needed to rule out birth defects. communication, it is helpful to notice the strengths you can identify, not just the problems and concerns.
Empathy: Involves listening respectfully • Looked very concerned when Isabel to the patient/client’s concerns and relating began to cry and got her some to the patient/client’s situation. tissue. • “What kinds of things are you doing to alleviate the stress?” • “I know you are.” when Isabel stated she was so scared.
Identifying Feelings: Occurs when the • “You sound a little sad.” health care professional puts words to the • “You feel there are a lot of people emotions that are being expressed and then in your life who would checks with the patient/client to make sure disapprove?” that his/her interpretation is correct. • “So you feel adoption is the same as giving a child away?”
Defusing Anger: Can be accomplished by • When Isabel asked are you saying if several techniques including listening for my baby has a birth defect I should and responding to the angry person’s fear, just give him away? Her response identifying and responding to the issues was “No, no I did not mean to say underlying the person’s anger and shifting that and I especially did not mean the angry person’s perspective. to upset you. I am sorry.”
Summarizing: Is a technique in which the • “Would you like information on health care provider highlights key points anything we discussed today? of the conversation with the patient/client Prenatal testing? Support groups? and checks back to make sure that his/her Adoption? Kinship adoption?” interpretation is correct.
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Large Group Discussion
• Ask the participants the following questions about the video: . What did you think of Rita’s style? . Ask the group to cite specific examples of the techniques they had seen in the video. (Use chart found on previous pages 23 and 24 with examples from Isabel video during discussion; the examples are in italics).
Transition • Now that we have seen examples of nondirective, noncoercive techniques we will do a role play/exercise to allow you to have a chance to practice using these techniques yourself.
TRAINER NOTE: Turn to page 30 for next exercise, Role Play/Practice Exercise.
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Video 4 of 4: Nicole Video and Discussion (35 minutes)
Video Description
• “Nicole” is a 28 minute drama that features a single woman who is a senior in college and who has been accepted into a master’s program at the University. She is entering the hospital in labor, accompanied by her mother. We then see Nicole and a friend entering a clinic 8 months earlier. At that visit she learned she was pregnant, saw how her options were presented to her, and what her decision was regarding a plan for her child. She is not in a relationship with the birth father, Kevin, also a college student, but he has been somewhat involved in the process. Finally we see the birth parents, birth grandmother, baby and adopting parents (Jeff and Lori) together in the hospital.
Directions • Let participants know that they are being provided with the brief noncoercive, nondirective techniques that we discussed previously in a worksheet format. It is found in their Participant Handbook, Module 5, page 17 and 18 and should be used in identifying when the nurse, uses each of these techniques. • Instruct participants to use this worksheet to record their notes. • Let participants know that they will also have an opportunity to discuss these techniques as a large group afterwards. • Play videotape.
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Techniques Examples from Video Physical Environment: Insure that the • Posters on walls regarding physical environment of your office, pregnancy and care waiting room, or other areas of your organization reflect your clientele. Do the pictures on your wall or the magazines in the lobby match the diversity of your patient/clients?
Rapport Building: Involves developing • Was supportive. trust through verbal and non-verbal means. • Good eye contact Verbal rapport building can include the use • Provided tissue when began crying of compliments, expressions of caring • Kevin’s counselor had good eye (how would you feel most comfortable?) contact with him and sat near him, self-disclosure and humor. Non-verbal not behind a desk. rapport building can include touch, eye contact, nodding, and smiling.
Open-Ended Questions: Are questions • “How are you feeling about being that allow the patient / client to tell his/her pregnant?” story. Open-ended questions cannot be • “How do you think this pregnancy answered by a yes or no. will affect your plans?” • Counselor asked birth father; “How does a man step up?” • Hospital Nurse asked “How do you envision your time in the hospital?”
Reflective Listening: Is a technique that • “I take it that is not what you lets the patient/client know that the health wanted the result to be?” care provider is listening to what he/she is • “It sounds like parenting does not saying. This technique is often referred to fit into your short term plans.” as paraphrasing and/or reflective or active listening.
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Techniques Examples from Video Responding Non-judgmentally: Requires • When Nicole said you probably the health care provider to continually think I am a slut, the nurse assess their own values and beliefs so that responded “No, I’m guessing that they do not interfere with their work with you are an intelligent young patient/client. woman with a bright future who accidently got pregnant.” • Hospital Nurse says “I see you have made an adoption plan.”
Empowerment/Strength Based • When Nicole stated she was here to Comments: Is a technique that identifies make sure she was pregnant after and compliments strengths in order to help several at home pregnancy tests the an individual take control of a situation. nurse responded “That was smart.” When responding to the patient/client • Nurse tells Nicole “that is a very communication, it is helpful to notice the responsible decision” when she strengths you can identify, not just the states she is here for a prenatal problems and concerns. exam in case she decides to proceed with the pregnancy. • Nurse states “I can tell you’re a person who likes to have a plan.” • Hospital Nurse states “This is your baby and your delivery.” Empathy: Involves listening respectfully • “This is a bump in the road but you to the patient/client’s concerns and relating can still be responsible and it to the patient/client’s situation. doesn’t have to mess up your whole future.” • “It’s pretty overwhelming, huh?”
Identifying Feelings: Occurs when the • Hospital nurse stated “ It is going health care professional puts words to the to be difficult to say goodbye” emotions that are being expressed and then • “You are being unselfish and checks with the patient/client to make sure brave.” that his/her interpretation is correct.
Defusing Anger: Can be accomplished by • No specific examples of defusing several techniques including listening for anger were shown in this video. and responding to the angry person’s fear, identifying and responding to the issues underlying the person’s anger and shifting the angry person’s perspective.
Summarizing: Is a technique in which the • Nurse stated “It’s a lot to take in health care provider highlights key points and you do not have to make any of the conversation with the patient/client decision right now.”
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Large Group Discussion
• Ask the participants the following questions about the video: . What did you think of the clinic nurse's style? . What did you think of the hospital nurse’s style? . Ask the group to cite specific examples of the techniques they had seen in the video. (Use chart found on previous pages 27 and 28 with examples from Nicole video during discussion; the examples are in italics).
Transition • Now that we have seen examples of nondirective, noncoercive techniques we will do a role play/exercise to allow you to have a chance to practice using these techniques yourself.
TRAINER NOTE: Turn to page 30 for next exercise, Role Play/Practice Exercise.
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Role Play/Practice Exercise – Option 1 of 2 (10 minutes) This scenario involves a Labor and Delivery Nurse
Overview • This exercise allows participants to practice using nondirective, noncoercive techniques with a client by role playing in pairs.
Directions • Now you are ready to practice. Please turn to the person on your right so that we have a number of groups of two. One of the partners will be the health care provider and the other will be the pregnant patient/client. • We begin the role play with the nurse on the labor and delivery unit who is admitting a woman who arrives in labor. She has had limited prenatal care and no options counseling. The patient shares that she is no longer involved with the father of the baby and that he has stated he is not interested in further involvement. The patient further states that she does not feel she can take this baby home. The provider will start with an opening line. • You could pick an opening line from the list in your Participant Handbook, Module 5, page 19 that is consistent with the role you have at work, but if none fit your actual work environment, please pick one that is more realistic for you, so you truly have a chance to practice for a few minutes. While we are discussing the option of adoption in this training, we want to remind you how important it is to follow the established protocol at your work place regarding the other options available to a patient/client experiencing an unintended pregnancy. Let your partner know what your typical clientele will be so they can play an appropriate role for the practice.
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• Those who are playing the patient/client should use this opportunity to put themselves in the shoes of the person described, i.e., the age and the culture of the situation. • Role play will last about 5 minutes.
Admitting Labor and Delivery Nurse opening lines to select from for role play:
“I can contact our hospital social worker who can help you with this. Right now let’s determine how far along you are in labor, so we can set our priorities. We will get you help with this while you are here in the hospital.” • “You have options: parenting the child or placing him/her for adoption by relatives or non-relatives.” • “What options have you considered?” • “Tell me what you know about adoption.” • “What do you see yourself doing in the future? How will having this baby change that?”
Patient/Client opening lines to select from for role play:
• “I cannot take this baby home.” • “I don’t know what to do” • “I am just feeling overwhelmed.” • “I already have two children at home and do not know how I can care for an infant right now.”
Large Group Discussion • After 5 minutes, ask if someone tried something new and what it was like. How many times did you ask a question that you got a one word answer? Is asking open ended questions harder than it sounds?
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• Ask each person to let their partner know something they did or said that was helpful; either felt good, or helped clarify something, or encouraged you. If there was something you'd like to suggest to your partner, please do. • We don't often have the opportunity to ask/receive feedback on something we usually do only with clients. If you are comfortable, and with your partner's permission, offer feedback now.
Role Play/Practice Exercise – Option 2 of 2 (10 minutes) This scenario involves a general health care provider
Overview • This exercise allows participants to practice using nondirective, noncoercive techniques with a client by role playing in pairs.
Directions • Now you are ready to practice. Please turn to the person on your right so that we have a number of groups of two. One of the partners will be the health care provider and the other will be the pregnant patient/client. • We begin the role play with the provider already having assessed that the patient needs some information about her options and the provider is going to bring up that subject. The provider will start with an opening line. • You could pick an opening line from the list in your Participant Handbook, Module 5, page 20 that is consistent with the role you have at work, but if none fit your actual work environment, please pick one that is more realistic for you, so you truly have a chance to practice for a few minutes. While we are discussing the option of adoption in this training, we want to remind you how important it is to follow the established protocol at your work place regarding the other options available to a patient/client experiencing an unintended pregnancy. Let your
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partner know what your typical clientele will be so they can play an appropriate role for the practice. • Those who are playing the patient/client should use this opportunity to put themselves in the shoes of the person described, i.e., the age and the culture of the situation. • Role play will last about 5 minutes.
Health Care Provider opening lines to select from for role play:
• “There are basically three options to a pregnancy: continuing the pregnancy to • birth and parenting the child; continuing the pregnancy to birth and placing • him/her for adoption by relatives or non-relatives; or terminating the pregnancy. • Which of these would you like more information on?” • “What do you know about your options?” • “What options have you explored?” • “How familiar are you with pregnancy counseling?” • “Tell me what you know about adoption.” • “Tell me about a personal experience you have had with adoption.” • OR “Tell me about the adopted persons or adoptive families you know.” • “Tell me about what you have heard about adoption on television or in the • movies.” • “How do your friends and family feel about adoption.” • “What do you know about adoption?” • “What do you see yourself doing in the future? How will having this baby change • that?”
• Patient/Client opening lines to select from for role play: • “What do you mean about options?” • “I could never do that!” • “I could never give my baby away.” “My boyfriend would never let me give our baby away.”
Large Group Discussion • After 5 minutes, ask if someone tried something new and what it was like. How many times did you ask a question that you got a one word answer? Is asking open ended questions harder than it sounds?
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• Ask each person to let their partner know something they did or said that was helpful; either felt good, or helped clarify something, or encouraged you. If there was something you'd like to suggest to your partner, please do. • We don't often have the opportunity to ask/receive feedback on something we usually do only with clients. If you are comfortable, and with your partner's permission, offer feedback now.
TRAINER NOTE: If time permits, there is an optional activity, Discussing the Adoption Option video. If there is not the time needed, proceed to Trainer’s Comments, page 35.
Discussing the Adoption Option Video (If time permits – 20 minutes)
Video Description • Discussing the Adoption Option is a 15 minute video that shows a health care provider at a clinic discussing adoption as an option with Joan, who is just finding out that she has a positive pregnancy test. • Refer participants to Participant Handbook, Module 5, page 21.
Directions • Instruct participants to look for techniques that the health care provider used in approaching the option of adoption and in discussing it.
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• Let participants know they will have an opportunity to comment and discuss as a large group after the video. • Play the video tape.
Large Group Discussion • Ask participants for feedback about the video content. What do you think about the health care provider’s style? • What examples of nondirective, noncoercive techniques (i.e. building rapport and open-ended questions) did you see? Rapport Building – Eye contact and patted her hand. Open–Ended Questions – “What are you thinking and feeling?” Responding Non-judgmentally – No response when client/patient spoke of boyfriend and how they were no longer together. Empathy – “Who might be able to help you?”
Trainer’s Comments • First and foremost, we have to be assured that our patient is safe, supported, and informed in this situation. Facing an unintended pregnancy is not unusual, though it can certainly have consequences that not everyone is prepared to face. To that extent then, there are issues that we need to be mindful of in the limited time that we have with our patients. We can make a difference in 15 minutes; don't forget that. Refer participants to Participant Handbook, Module 5, pages 29-30 for additional information entitled “Introducing Pregnancy Options in Fifteen Minutes or Less.” The script is directed to the health care professional who meets with the patient/client to provide her with her positive pregnancy test results. It further assumes the health care professional has had no contact with the
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patient/client previously and will not be providing follow-up care. It assumes that the health care professional will recognize needs and secure appropriate referrals
• Health care professionals need to understand and recognize the effects culture, age, and the father of the child have on the woman or teen experiencing an unintended pregnancy and their decision making process.
• Unless there are medical indications that a patient/client’s choice is counter- indicated, the health care provider supports the patient/client’s choice. This patient/client choice includes the right to refuse information. • Refer participants to the Participant Handbook, Module 5, pages 31-43 regarding additional resource information and articles “Brief Nondirective, Noncoercive Interventions,” “Legal and Ethical Considerations for Health Care Professionals in Pregnancy Counseling and Adoption,” “Checklist for Effective Communication,” “Giving and Receiving Feedback,” and “Working with Resistant or Angry Patient/Clients.”
• Although this training is about options counseling we do recognize how significant the interval in the hospital, when labor and deliver occurs, is in the adoption process. The woman who is giving birth may reconsider, which is her right. The amount of planning for this interval is variable, and staff will have to adapt to any changing situations as they occur. This interval is likely to have a lasting impact for the birth mothers as we have seen in earlier videos. Refer participants to Participant Handbook, Module 5, pages 44-49 regarding “The Hospital Interval” and a sample “Birth and Adoption Plan for Hospital.”
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TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Nondirective, noncoercive counseling methods present information and options through the use of open-ended questions. (Test Question)
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Empathy involves listening respectfully to the patient/client’s concerns and relating to the patient/client’s situation (Test Question)
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Trainer’s Comments (5 minutes)
• Remember to draw participants attention to the key points contained in this Module: It is important to be able to identify and understand the basic techniques used in nondirective and noncoercive counseling. Some of these include rapport building, reflective listening, responding non-judgmentally, and open-ended questions.(Training Reflection Feedback Form) It is important to understand informed consent in adoption as well as the roles and responsibilities of helping professionals. Informed consent can only be given after the patient/client has received complete information about their condition or situation, the choices they have regarding treatment, and the consequences of these choices (Training Reflection Feedback Form) • Remember to draw participants attention to the test questions contained in this Module: (Test Question) • Responding Non-judgmentally requires the health care provider to continually assess their own values and beliefs so that they do not interfere with their work and patient/clients. • Open-ended questions are questions that allow the patient/client to tell his/her story. Open-ended questions cannot be answered by a yes or no. • Empowerment/Strength-Based Comments is a technique that identifies and compliments strengths in order to help an individual take control of a situation. When responding to the patient/client communications, it is helpful to notice the strengths you can identify, not just the problems and concerns. • Defusing anger can be accomplished by several techniques including identifying and responding to the issues underlying the person’s anger, such as fear, acknowledging that fear, and shifting the person’s perspective. • Empathy involves listening respectfully to the patient/client’s concerns and relating to the patient/client’s situation. • Reflective Listening is a technique that lets the patient/client know that the health care provider is listening to what he/she is saying. This technique is often referred to as paraphrasing and/or reflective or active listening.
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It is important to be able to identify and understand the techniques used in nondirective, noncoercive counseling, and to work with patient/clients in a nondirective, noncoerive manner. (Training Reflection Feedback Form) • Are there any questions about nondirective, noncoercive counseling or techniques?
Transition
• We have finished discussing nondirective and noncoercive techniques for working with our patient/clients. Now we will begin Module 6 on making appropriate referrals.
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To Find Out More About It
Aguilera, D. (1990). Crisis Intervention: Theory and Methodology. St. Louis MO: the D.V. Mosby Co.
Allender, J.A., Spradley, B.W. (2001) Community health nursing: concepts and practice. Philadelphia: Lippincott.
Abrums, Mary E., Leppa, Carol. (2001). Beyond Cultural Competence: Teaching about Race, Gender, Class and Sexual Orientation. Journal of Nursing Education, 40, 270-275.
American Association of Colleges of Nursing. (1998) The Essentials of Baccalaureate Education for Professional Nursing Practice. Washington, D.C.
Anderson, Gary R., Ryan, Angela Shen, Leashore, Bogart R. (1997). The Challenge of Permanency Planning in a Multicultural Society. Binghamton, New York: The Haworth Press, Inc.
Bausch, R.S., & Serpe, R.T. (1997). Negative outcomes of interethnic adoption of Mexican American children. Social Work, 42, 136-143.
Berg, I. K. (1994). Family based services: A solution-focused approach. New York: W.W. Norton & Company, Inc.
Besharov, Douglas J. (1994) When Drug Addicts Have Children: Reorienting Child Welfare’s Response. Washington, D.C.: Child Welfare League of America.
Billingsley, A. (1992). Climbing Jacob’s ladder: The enduring legacy of African- American families. New York: Simon and Schuster.
Boyd-Webb, Nancy (2001). Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and Practitioners. New York, NY: Columbia University Press Publishers.
Boyd-Webb, (2001). “Strains and Challenges of Culturally Diverse Practice: A Review with Suggestions to Avoid Culturally Based Impasses.” (pp 337-350) Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and Practitioners. New Your, NY: Columbia University Press.
Callister, Lynn Clark. (2001). Culturally Competent Care of Women and Newborns: Knowledge, Attitude and Skill. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 209-215.
Cesario, Sandra K. (2001). Care of the Native American Woman: Strategies for Practice, Education and Research. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 13-19.
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Child Welfare League of America. (2000). CWLA standards of excellence for kinship care services (KC). Washington, D.C:Author.
Chippindale-Bakker, Foster Linda. (1996). Adoption in the 1990’s: Sociodemographic Determinants of Biological Parents Choosing Adoption. Child Welfare, LXXV, 4, 337- 355.
Committee for Hispanic Children and Families, Inc. (1996). Cultural competence and Latino adoption. New York: Author.
Corcoran, Jacqueline. (1999). Solution-Focused Interviewing with Protective Services Clients. Child Welfare, LXXVII, 4, 461-481.
Coyer, Sharon M. (2001). Mothers Recovering From Cocaine Addiction: Factors Affecting Parenting Skills. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 71-79.
Crumbley, Joseph. (1999). Transracial Adoption and Foster Care. Washington, D.C. Child Welfare League of America, Inc.
DeJong, Peter, Miller, Scott D. (1995). How to Interview for Client’s Strengths. Social Work, 40, 6, 729-736.
Dietz, Patricia, Adams, Melissa, Spitz, Allison, Morris, Leo, Johnson, Christopher, PRAMS Working Group. (1999). Live Births Resulting From Unintended Pregnancies: Is There Variation Among States? Family Planning Perspectives, 31, 3, 132-136.
Diller, Jerry (1999). Cultural Diversity: A Primer for the Human Services. Belmont, CA: Wadsworth Publishing.
Dunst, Carl, Trivetter, Carol, Deal, Angela. (1988). Enabling and Empowering Families: Principles and Guidelines for Practice. Cambridge, MA: Brookline Books, Inc.
Edelstein, Susan B. (1995). Children with Prenatal Alcohol and/or Other Drug Exposure: Weighing the Risks of Adoption. Washington D.C.: Child Welfare League of America.
Everett, J.E., Chipungu, S.S.,Leashore, B.R. (Eds.). (1991). Child Welfare: An Afrocentric perspective. New Brunswick, N.J.: Rutgers University.
Freundlich, Madelyn. (2000). Adoption and Ethics: The Role of Race, Culture and National Origin in Adoption. Washington D.C.: Child Welfare League of America, Evan B. Donaldson Adoption Institute.
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Frost, Jennifer, Ranjit, Nalini, Manzella, Kathleen, Darroch, Jacqueline, Audam, Suzette. (2001) Family Planning Clinic Services in the United States: Patterns and Trends in the Late 1990’s. Family Planning Perspectives, 33, 3, 113-122.
Haggerty, Lois A., Kelly, Ursula, Hawkins, Joellen, Pearce, Carole, Kearney, Margaret. (2001). Pregnant Women’s Perceptions of Abuse. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 284-290.
Hartman, Ann. (1977). Finding Families: An Ecological Approach to Family Assessment in Adoption. Beverly Hills, CA: Sage Publications, Inc.
Hill, R.B. (1977). The strengths of black families. New York: Emerson Hall.
Hill, R. (1997). The strengths of African American families: Twenty-five years later. Washington, D.C: R & B Publishers.
Haugard, Jeffrey, Schustack, Amy, Dorman, Karen. Birth Mothers Who Voluntarily Relinquish Infants for Adoption. (1998). Adoption Quarterly, 2, 1, 89-97.
Henshaw, Stanley. (1998). Unintended Pregnancy in the United States. Family Planning Perspectives, 30, 1, 24-29.
Hulsey, Tara McComb. (2001). Association Between Early Prenatal Care and Mother’s Intention of and Desire for the Pregnancy. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 276-282.
Jaudes, Paula Kienberger, Ekwo, Edem E. (1997) Outcomes for Infants Exposed in Utero to Illicit Drugs. Child Welfare, LXXVI, 4, 521-533.
Jordan, J. (1998) Report from the Bahamas. In M.L. Anderson & P.H. Collins (Eds.) Race, Class and Gender: An Anthology. (pp. 34-43). Belmont, CA: Wadsworth Publishing Co.
Kost, Kathryn, Landry David, Darroch, Jacqueline. (1998). Family Planning Perspectives, 30, 5, 224-230.
Lecca, Pedro J., Quervalu, Ivan, Nuses, Joao, Gonzales, Hector (1998). Cultural Competency in Health, Social and Human Services. New York: Garland Publishing, Inc. McAdoo, H. P. (1997). (3rd Ed.). Black Families. Thousand Oaks,Cal: Sage Publications.
McRoy, R.G., Oglesby, Z, Grape, H. (1997). Achieving same-race adoptive placements for African American children: Culturally sensitive practice approaches. Child Welfare, 76, 85-104.
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Mills, C.S., Usher, D. (1996). A kinship case management approach. Child Welfare, 75, 600-617.
National Adoption Information Clearinghouse. (2002). Are You Pregnant and Thinking About Adoption? Washington, D.C.
National Indian Child Welfare Association. (1996). Cross-cultural skills in Indian child welfare: A guide for the non-Indian. Portland, OR: Author.
Northouse, Laurel L., Northouse, Peter G. (1998). Health Communication: Strategies for Health Professionals. Stamford, CN: Appleton & Lange.
Ortega, R. M., Guillean, C. , Najera, L.G. (1996). Latinos and child welfare/Latino y el bienestar del nino- Voces de la communidad. Ann Arbor, Mi.: University of Michigan.
Russell, Marlou. (1996) Adoption Wisdom: A Guide to the Issues and Feelings of Adoption. Santa Monica, CA.: Broken Branch Productions.
Saewyc, Elizabeth M. (2000), Nursing Theories of Caring: A Paradigm for Adolescent Nursing Practice. Journal of Holistic Nursing, 18, 2, 114-128.
Spaulding for Children. (1996) Adoption Support and Preservation Curriculum. Southfield, Michigan.
Spaulding for Children. (1995) Cultural Competence Curriculum in Adoption. Southfield, Michigan.
Stewart, Susan D. (1998). Economic and Personal Factors Affecting Women’s Use of Nurse-Midwives in Michigan. Family Planning Perspectives, 30, 5, 231-235.
Sudarkasa, N. (1997). African American families and family values. In H.P. McAdoo (3rd Ed.) Black Families (pp. 9-40). Thousand Oaks, Cal: Sage Publications.
Taylor-Brown, Susan, Teeter, Judith Ann, Blackburn, Evelyn, Oinen, Linda Weddeerburn, Lennard. (1998)Parental Loss Due to HIV: Caring for Children as a Community Issue – The Rochester, New York Experience. Child Welfare, LXXVII, 2, 137-159.
Veach, Patricia, LeRoy Bonnie, Bartels, Dianne. (2003). Facilitating the Genetic Counseling Process. New York: Springer-Verlay.
Williams-Gray, Brenda (2001). A Framework for Culturally Responsive Practice4”. Culturally Diverse Parent-Child and Family Relationships: A Guide for Social Workers and other Practitioners. (pp 55-83). New York: Columbia University Press Publishers.
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Williams, Gail B. (2001). Short-term Grief After an Elective Abortion. Journal of Obstetric, Gynecologic and Neonatal Nursing, 30, 174-183.
Wilson, M. (1991). The context of the African American family. In J.E. Everett, S.S. Chipungi, B.R. Leashore (Eds). Child Welfare: An Africentric perspective (pp. 85-118). New Brunswick, NJ: Rutgers University.
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Brief Nondirective, Noncoercive Interventions
The history that follows sets the stage for the development of what will be referred to in this article as brief, nondirective, noncoercive interventions. The health and mental health literature uses a variety of terms including solution-focused brief therapy; nondirective interventions; client-centered treatment; and strengths-based treatment. All these terms refer to a basic paradigm of working with patient/clients that is predicated on their ability to solve their own problems with adequate access to nonjudgmental, supportive resources and supports.
The 1960s was a tumultuous time in the United States. Many societal values were being challenged, and new ways of thinking were being developed. The health and mental health fields were no exception. One major change that occurred in these fields empowered patient/clients to begin to take a more active role in their own care. They were no longer “acted upon,” but were partners in the decision-making and events of their lives.
Around the same time, medications were identified that helped to control the hallucinations and distorted thinking that accompany many mental illnesses. Individuals with diagnoses such as schizophrenia, or manic depression (now referred to as bi-polar disorder) could live productive lives and resume control over their own destiny if they took their medicine. They could return to their communities and exercise self- determination to make decisions on their own behalf.
These factors, along with the desire to curb spiraling health care costs, gave rise to the notion of brief mental health interventions. It was no longer conventional wisdom for an individual to undergo years of psychotherapy to make changes in his/her life. Instead, it was thought that a short, focused relationship with a health care or mental health professional could facilitate growth and change.
The focus was no longer on telling someone the right thing to do, but rather helping him/her discover the answers within him/herself. This marked another change in thinking that departed from the notion that the experts know best, to the belief that individuals know what is best for them and with guidance and social support, will make decisions that serve them well.
Another major change was the blurring of the divisions between physical and mental health services. Many professional roles overlapped, and each group began to develop strategies for learning about the other and working together. What resulted was of benefit to both areas. Better-trained professionals, and higher quality patient/client care.
Who can do brief nondirective, noncoercive interventions? Health care providers, including pregnancy counselors and community nurses can utilize this type of intervention as effectively as trained mental health professionals. Good assessment skills, the ability to quickly build rapport with patient/clients while treating
Module 5 - Page 45 Trainer’s Guide – 1 Day DRAFT UIA 4 – 1 Day - Module 5 12/12/11 them with dignity and respect are key skills held by health care professionals. These skills, coupled with the ability to be good listeners and gather a lot of information in a short period of time, form the basis of brief, nondirective, noncoercive interventions.
What are the underlying beliefs of brief nondirective, noncoercive intervention? This form of intervention is interactive and is based on the idea that change is occurring all the time. It also proposes that all individuals have strengths that they can draw upon to cope with these changes. Another core belief is that positive change in one area of a patient/client’s life can lead to positive change in others. Finally, and most importantly, there is the belief that patient/clients have ideas about how to solve their problems, and in fact, many have been successful in implementing change in the past.
What are the key components of nondirective, noncoercive interventions? The two key components in providing nondirective, noncoercive interventions are asking open-ended questions that allow patient/clients to tell their stories and listening carefully to what is being said both verbally and non-verbally. An open-ended question is one that cannot be answered easily with “yes” or “no.”
Checking back with the patient/client, while they are telling their story, is important to ensure that the health care professional is getting an accurate picture of the patient/client’s perception of the issues. Sometimes this is called reflective listening, active listening or paraphrasing.
Helping patient/clients develop obtainable goals is another key component of this type of intervention. Goals need to be stated in the patient/client’s own language and need to be important to that individual. An obtainable goal is stated as the presence of something rather than the absence of something. An example of this is, “I will not eat fattening foods” versus stating it as the presence of something would be, “I will eat healthy food.” It is also helpful to look at goals as a step-by-step process and not just as a final result. Goals need to be stated in concrete, behavioral, measurable and realistic terms to increase the likelihood of success. The health care provider can help make goals more viable by asking open-ended questions that lead the patient/client to crystallize his/her thoughts and his/her plan for making change happen.
Identifying patient/client feelings is another component of nondirective, noncoercive interventions. This can be done by putting words to the emotions that are being expressed and then checking with the patient/client to make sure that this interpretation is correct. Change usually comes when individuals address their feelings and emotions around a particular issue. As long as they are able to intellectualize, they are able to stay stuck.
Responding nonjudgmentally is critical to nondirective, noncoercive interventions. Health care professionals must continually assess their own values and beliefs so they do not interfere with their work with patient/clients. When a particular patient/client elicits a strong emotional response or judgment from the health care professional, it is a good time
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to talk to a colleague or team member so that during the next meeting with the patient/client, a nonjudgmental posture can be assumed.
Are there specific types of questions that can be used in brief nondirective, noncoercive interventions? Certain types of questions support brief nondirective, noncoercive interventions. The most useful is the open-ended question, such as, “How would you describe your strengths?” Open-ended questions invite the patient/client to tell more of their story and help to identify who and what are important to them (him/her).
Another highly useful questioning technique includes the use of “what,” “who,” “when,” or “how” in the question. Some examples include, “What happened when…”, “What was different…,” “Who helped you when…”
It is less useful to ask a “why” question. “Why” questions imply blame and generate a defensive response. For example, “Why were you there?” or “Why did you do that?” are not helpful.
The least useful type of question in nondirective, noncoercive interviewing is the tag question, such as “You want to do the right thing, don’t you?” or “You don’t want to do that, do you?”
Scaling: Scaling questions are a very useful assessment tool you can use to gauge confidence, hopefulness, safety issues, willingness to make changes, take action steps towards a goal, assess progress to date and to approach many other topics that are often difficult to describe with words alone.
For example: “If I were to ask you, on a scale from 1 to 10, “10” being you have all the skills, knowledge and resources to raise a child and “1” being you don’t have any of the skills, knowledge and resources to raise a child, where would you rate yourself on this scale?” Then, follow up with:
• A compliment regarding how “high” of a skills and knowledge number they chose even if “1” is the number chosen – acknowledge their honesty and “good” judgment. • Then ask, “What would it take to move up from 5 to 6? (If “1”, then “from 1 to a 2?”). • Continue with asking open-ended, “how” and “what” type questions to elicit more details regarding the skills and knowledge. • Continue to ask, “What else would it take to move just a bit further up the scale – from a 5 to 6?”, or • Ask a relationship/scaling question like: “If your mother were here right now, what number would she say?”
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Goals: An obtainable goal is stated as the presence of something rather than the absence of something. An example of this is, “I will not eat fattening foods,” versus stated as the presence of something would be “I will eat healthy food.” It is also helpful to look at goals as a step-by-step process and not just as a final result.
Goals need to be stated in concrete, behavioral, measurable and realistic terms to increase the likelihood of success.
Even though brief, nondirective, noncoercive interventions have been given many names, the underlying themes and values are a good fit for health care providers, particularly those doing pregnancy and/or options counseling. These techniques fit with professional values and standards, with the need for brief interventions, and with the idea that patient/clients are resilient and have the capacity to make good decisions on their own behalf.
These interventions also facilitate teaming and assist helping professionals to make meaningful referrals. Speaking a common language, and holding a common set of beliefs makes networking easier and allows for more options to be given to patient/clients. Brief, nondirective, noncoercive interventions help to create an atmosphere where women can feel comfortable exploring all of their options without the fear of being judged. This climate will result in the patient/client making an informed decision that he/she can be comfortable with throughout his/her lifespan.
References: Berg, I.K. (1994). Family based services: A solution-focused approach. New York: W.W. Norton & Company, Inc. Corcoran, Jacqueline. (1999). Solution Focused Interviewing with Child Protective Services Clients. Child Welfare, 78, 4, 461-479. De Jong Peter, Miller, Scott D., (1995). How to Interview for Client Strengths. Social Work, 40, 6, 729-736.
Karal Wasserman, MSW, CSW New View Consultants, Inc. Jean Niemann, MSW, ACSW Spaulding for Children February, 2002
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Legal and Ethical Considerations for Health Care Professionals in Pregnancy Counseling and Adoption
This article applies the law and accepted values and ethics of the health care profession to the practice of providing pregnancy options counseling. It describes conditions under which coercion can occur and defines noncoercive counseling. In addition, the article explores the concept of informed consent, as it applies to adoption. This information is intended to provide a legal and ethical framework in which to provide information and make effective referrals for pregnancy counseling and adoption services.
1. Background and the Law
In July of 2000, the Secretary of Health and Human Services issued regulations establishing requirements for recipients of family planning grants under section 1001 of the Public Health Service Act, 42 U.S.C. 300. The rules revoked the “gag rule” that restricted family planning grantees from providing abortion-related information in their grant-funded projects and reinforced a requirement that 1001 clinics provide information on all pregnancy options on an equal basis. Specifically, the law, as interpreted in the administrative rules, requires that the grantee: • Provide services in a manner that protects the dignity of the individual. • Provide services without regard to religion, race, color, national origin, handicap disabilities condition, age, sex, number of pregnancies or marital status. • Provide neutral, factual information and nondirective counseling on any option the pregnant woman requests including: prenatal care and delivery infant care, foster care or adoption pregnancy termination • Provide for social services related to family planning, including counseling, referral to and from other social and medical service agencies and any ancillary services which may be necessary to facilitate clinic attendance. • Provide for coordination and use of referral arrangements with other providers of health care services, local health and welfare departments, hospitals, voluntary agencies and health service projects supported by other Federal programs.
The Infant Adoption Awareness Training Program was funded by the Federal government to develop curricula that would help health care professionals provide information and support for the adoption option and make informed referrals for pregnancy counseling and adoption services for patient/clients who choose one or both of these options for further exploration.
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Ethics and Values Underpinning the Provision of Public Health Services
Ethics defined: Ethics is a set, theory or system of moral principles or values. Making an ethical decision means making a choice that is consistent with a moral or professional code.
Because the health professional’s own values will be challenged in this work, it is especially important to be grounded in a set of accepted professional standards of conduct or ethics that support him/her to be unbiased and objective. Some of the ethical values in public or community health care that relate to options counseling include:
The Value of Self-Determination: This value respects a person’s autonomy and capacity to shape his/her own life. This is based on the belief that better outcomes will result when a person’s self-determination is respected, as well as the different views of self-determination among ethnic, cultural and religious groups.
The Value of Equity: The value of equity means being treated equally or fairly. The principle of equity also implies that it is unjust to not treat people the same who are different. Do all persons in different socio-economic and cultural groups have equal access to needed adoption information and services? Are all persons offered information on an equal basis with other options in unintended pregnancy situations?
The Value of Well-Being: This value assumes that any clinical intervention is to improve the client’s health and well-being. However, to determine what constitutes health or well-being for a client, one must consider the client’s subjective preferences. It is the health care practitioner’s role to understand the patient/client’s needs and present reasonable alternatives to the patient/client and/or surrogate decision-makers in a way that enables patient/clients and/or their surrogate decision-makers to choose those they prefer.
A decision-making framework that may help clarify ethical dilemmas includes: Assessment: Decide whose problem it is. Who should make this decision? Who should be included in this decision? Diagnosis: Gather additional data. Have as much information about the situation as possible. Be up to date on any related laws or organizational policies. Outcome Identification: Identify with the patient/client as many alternatives as possible. The more options identified, the more likely it is that an acceptable solution will be found. Planning: Help the patient/client choose, from the options identified, the one that best satisfies his/her needs and preferences. Implementation: Help the patient/client carry out the decision, including collaboration with referral sources to implement the decision.
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Evaluation: Evaluate the results of the referral. From the patient/client’s perspective, what is working and not working?
What is Coercion? Coercion occurs when someone with more perceived power or authority forces a decision upon a patient/client; talks them into a decision; provides information that is incomplete or misleading; and/or offers gifts, bribes or other incentives for making a particular choice. Coercion could occur as a result of a parent of a minor child, or a husband or birth father, exerting excessive pressure on the patient/client. And it is especially detrimental when it occurs in collaboration with a “professional” lending credence to the forceful position.
For purposes of referring persons for pregnancy counseling and adoption, it is important to understand that coercion could possibly occur in many different ways. Coercion can simply be the result of overly directive, controlling, and/or subjective counseling from someone that the patient/client trusts. In adoption, coercion may consist of offering financial or other non-financial benefits to a person who is in desperate need or particularly vulnerable because of their situation. It could also occur through threat of violence or retribution.
What is Nondirective, Noncoercive Counseling? Noncoercive interventions include interviewing, counseling, and/or providing information and making referrals. Noncoercive methods present information and options through the use of open-ended questions designed to help the patient/client identify her options and preferences and make an informed decision that satisfies his/her needs and preferences. A nondirective, noncoercive intervention requires that the helping professional support the decisions made by the patient/client, including the decision to refuse information, even if he/she does not agree with these decisions.
What is Informed Consent? Informed consent is consent given after the patient/client or patient/client’s legal representative has been provided with complete information as to the conditions or situation requiring intervention, the choices/options in services or treatment, the consequences or probable consequences of each option with the patient/client freely choosing one course in lieu of another.
Informed consent in adoption is not very different from informed consent in health care. Although the health professional will not be involved directly in the consent process in an adoption matter, he/she will want to have reasonable assurances that the patient/client will not be exploited or “harmed” by the resource they refer the client to for services. In adoption and in health care, informed consent requires knowledge, voluntariness, and competency. These elements are defined as follows: • Knowledge: requires an explanation of the condition/situation requiring intervention; a description of the nature and purpose of all alternatives; description of any expected risks or consequences of the intervention; disclosure
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of the possibility that the proposed intervention will be unsuccessful; explanation of consequences of intervention; or, if no intervention is given, an explanation of consequences of not receiving an intervention. • Voluntariness: requires that the patient/client must be free to accept or reject the proposed treatment without any physical or psychological coercion. • Competency: requires that the patient must be of sound mind and legally and mentally capable of making an informed decision.
In adoption, the birth father(s) must be afforded the same information and respect regarding informed consent, as the birth mother(s); and, in the case of unemancipated minors, a parent or guardian must also sign a release or consent to the adoption.
How Can a Health Care Professional be Most Effective in Providing Information and Making Referrals? Providing pregnancy options information will be difficult because of realistic time constraints, but it can be particularly challenging in circumstances where there are significant conflicts within a family or other conflicting factors such as, differences in the ‘helper’s and patient/client’s values, cultural/ religious beliefs, and/or socio-economic background. Nonetheless, most health care professionals will take the time and care to provide necessary information and referral because they know how important their actions may be to their patient/client’s future. Health care professionals can maximize their effectiveness in providing information on pregnancy options and resources when they: • understand and demonstrate compassion for a patient/client’s unique situation. • operate within the ethics and values of their profession, consistent with the policies and mission of their health care settings. • provide information and support for patient/clients to be effective advocates for themselves and their unborn child in seeking help. • develop a resource bank of quality, responsive and ethical referral sources. • make referrals that are responsive to a patient/client’s needs and preferences, including culture, race, religion, ethnicity, and/or language.
Adoption will not be the chosen alternative for the majority of patient/clients seen by health care professionals but, for some individuals and their children, it may be a preferred course of action.
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Due to the finality of an adoption decision, it is important for health care professionals to offer their patient/clients information and help in finding a resource that meets their service needs and preferences, guarantees protections from coercion and/or exploitation, and provides necessary information for a fully informed consent to adoption.
Judith McKenzie, MSW Executive Consultant McKenzie Consulting, Inc. February 2002
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Checklist for Effective Communication
Listening: • Are you waiting impatiently for the patient/client to stop so that you can talk? • Are you in such a hurry to offer a solution that you don’t wait to hear the problem? • Are you listening only for what you want to hear? • Do emotional blocks get in the way of your listening? • Do your biases interfere with your listening? • Do your thoughts take side excursions while the patient/client is talking? • Are you focusing on details instead of getting the main points and feelings? • Do you quit listening when the subject matter gets difficult or repetitive? • Do you have a negative attitude when listening? • Do you just pretend to listen? • Do you put yourself in the patient/client’s place to understand what makes her say the things she does? • Do you take into account that you and the patient/client may not be discussing the same issues? • Are you alert for misunderstandings that could arise because the words don’t mean the same to you as they do to the patient/client? • Do you try to find out what an argument is about? Is it a real difference of opinion or just a matter or stating the problem differently?
Speaking: • Are you careful to watch for signs of misunderstanding in your patient/clients? • Do you choose words that fit the patient/client’s knowledge base and background? • Do you think out directions before giving them? • Do you break down directives into small, easy to understand increments? • If a patient/client doesn’t ask questions about a new idea you are presenting, do you assume that he/she understands it? • Do you speak distinctly? Are distractions controlled as much as possible? • Do you group your thoughts before speaking so that you don’t ramble? • Do you put the patient/client at ease? How?
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• Do you encourage questions? How? • Do you assume that you know what the patient/client has in mind, or do you ask questions to find out? • Do you distinguish between facts and opinions? How? • Do you cause patient/clients to get defensive by contradicting their statements? • Do you influence your patient/clients to tell you what you want to hear?
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Giving and Receiving Feedback
Giving Feedback: • Focus on behavior rather than on the person. • Focus on description rather than judgment. • Focus on specifics rather than generalities. • Focus on the value it may have for the patient/client, not the release that it provides for you. • Focus on giving the amount of information that the patient/client receiving it can use, rather than the amount of information you would like to give. • Check to be sure that the feedback was clear. • Focus on the patient/client’s feelings and perceptions, not just the facts.
Receiving Feedback: • Ask for it when you want it. • Be clear about the type of feedback you are interested in receiving. • Listen nonjudgmentally when it is given. • Maintain a climate that allows feedback. • Check to be sure that you clearly understand the feedback that is given to you.
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Working With Resistant or Angry Patient/clients
Utilize Techniques for Defusing Anger: • Listen for and respond to the angry person’s fear. • Listen for and respond to the underlying issues. • Shift the angry person’s perspective. • Use humor to keep the situation in perspective. • Do the unexpected. • Use emotional honesty.
Help the Patient/Client Feel More Comfortable, Empowered and in Control: • Listen respectfully to the patient/client’s concerns. • Use the patient/client’s words whenever possible. • Empathize with the patient/client’s situation. • Reinforce the patient/client’s past success in solving problems.
Do Not Take the Patient/Client’s Behavior Personally: • Identify the root cause of the patient/client’s anger or resistance. • Keep the focus on the goal of the interview. • Avoid control battles with patient/clients.
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The Hospital Interval
When a pregnant woman in labor arrives at the hospital, it is possible that nursing staff will be unfamiliar with contemporary adoption practices, given the relative infrequency of infant adoption. Smith and Brandon (2008) point out how this essential information allows nurses to provide “appropriate, sensitive, nonjudgmental care to all persons involved in the adoption process” (p. 382). Ideally, the hospital has a perinatal social worker, who has had contact with the adoption agency social worker or attorney, and a plan is in place for the birth and hospital stay (p. 385). Ideally, nursing staff and the perinatal social worker will have read Smith and Brandon’s article and undergone this training, and have a good understanding of contemporary adoption practices as a result.
Under these ideal circumstances, the plan is exactly that, and subject to change if circumstances render it necessary, as in a labor complication that requires an emergency intervention. The plan is also subject to change if the woman who is giving birth makes different decisions about adoption during this interval, which is her right. It is also possible the circumstances will be less than ideal, that the hospital does not have a perinatal social worker or the perinatal social worker is not available when the pregnant woman in labor arrives. It is possible the adoption agency or attorney has not contacted the hospital social worker, and it is possible that no plan is in place for the birth and the hospital stay. Under all of these circumstances, labor and delivery will proceed, an infant will be born, and discharge from the hospital will occur usually within a relatively short time span. The challenge for the nursing staff is how to provide care that meets the needs of the members of the adoption triad they have contact with during this interval. The American Nurses’ Association Code of Ethics with Interpretive Statements (2001) Provision 1 states, “The nurse, in all professional relationships, practices with compassion and respect for the inherent dignity, worth, and uniqueness of every individual, unrestricted by considerations of social or economic status, personal attributes, or the nature of health problems” (p. 7).
The expectations of this provision are clear; application to these circumstances requires consideration of the woman’s right to self-determination, as well as sensitivity to the other members of the adoption triad who may be present. Personal feelings and values of the nurse must be separated from the nurse’s professional role and responsibilities. It is clearly wrong, hurtful, and unethical for a nurse to say something like, “How can you give up this beautiful baby?” The words and behaviors of the nurse that will best provide support are not known, though. It seems that affirming the woman’s role in giving birth is supportive and helpful when an adoption plan has been made or is under consideration, but whether it is better to say, “You have a beautiful, healthy daughter” or “You have given birth to a beautiful, healthy baby girl” or if the choice of words even matters is the subtle kind of thing that it would be useful to know.
DiCenso, Guyatt, and Ciliska (2005) define evidence-based nursing as “the conscious, explicit, judicious use of current best evidence in making decisions about the care of individual patients. Evidence-based clinical practice requires integration of individual clinical expertise and patient preferences with the best available external clinical
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evidence from systematic research, and consideration of available resources” (p. 565). Unfortunately, the evidence is lacking for nurses who want to know how to best support the woman who has arrived to deliver a baby when an adoption plan has been made or is under consideration.
In her dissertation, Kobovich (2002) points out the
relative absence of research-based literature describing first, the nature of the relinquishment experience for a young woman and second, nursing interventions for relinquishment in general and specifically for a time that the birth mother identifies as extremely important in the relinquishment experience—the hospital- based experience of birth and the act of relinquishment (p. 2).
In her dissertation, she used an inductive, qualitative approach to explore the experience with young women who made an adoption plan, and created focus groups with obstetrical nurses to elicit their insights about nursing actions and behaviors that are helpful and supportive. She found the birth mothers both felt “very positive about the nursing care they received” (p. 151), and one of the participants had actually anticipated a different situation, due to her circumstances. Focus groups of obstetrical nurses revealed the physical care aspects are the same, but as one nurse noted, “It’s the emotional, spiritual, and supportive care that is different” (p. 171). Instead of the joyous celebration that childbirth evokes under other circumstances, this experience is “lonely” (p. 171). The grief is different than the grief experienced by the mother of a stillborn infant, because as noted by one nurse, “that baby is always out there, that mother always wonders” (p. 172). The focus groups revealed “nurses try 1) to give the relinquishing mother as much control as possible while in the hospital, 2) to be supportive and nonjudgmental, and 3) provide mementos of the baby when asked” (p. 189). The focus groups revealed the nurses “feel that relinquishing a baby is a difficult and honorable choice and respect birth mothers for their strength and determination” (pp. 189-190). The areas identified as problematic by the nurses are how and whether to intervene related to “the relinquishing mother’s interaction with her baby”, especially if the relinquishing mother hesitates or declines close interaction and “uncertainty in the mother” (p. 193). Given the short contact the nurses have, the long-term implications of the mother’s decision, and the lack of evidence to guide them, the “tensions and sense of caution in the nurse” (abstract) regarding these problematic areas are understandable. Further research is needed.
In the absence of clear evidence, nurses can draw upon central concepts of nursing practice, the art of nursing, caring and presence. Describing the convergence of these concepts, Finfgeld-Connet (2008) states,
Nursing involves an intimate relationship-centered partnership between the nurse and patient. Situation-specific nursing actions result from multiple forms of personal and professional knowledge and are based on a value system of holistic beneficence and patient empowerment (p. 527))…
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…The art of nursing, presence and caring take place within an atmosphere of interpersonal sensitivity and intimacy, which is characterized by open and honest interactions. Personal insights are disclosed in verbal and non-verbal ways, and the nurse unobtrusively grasps the patient’s needs and responds in a kind and compassionate way. Empathy is expressed through words and actions, and a supportive nurse-patient partnership is cultivated (p. 530).
These inspiring descriptions fit well with the role of the nurse interacting with members of the adoption triad during the labor, delivery and postpartum interval prior to discharge from the hospital.
Suzanne M. Weathers, MSN, RN Lead Nurse Planner Spaulding for Children Spaulding Institute for Family and Community Development August 23, 2010
References
American Nurses Association (2001). Code of ethics for nurses with interpretive statements. Washington, DC: American Nurses Publishing.
DiCenso, A., Guyatt, G. & Ciliska, D. (2005). Evidence-based nursing: A guide to clinical practice. St. Louis, MO: Elsevier Mosby.
Finfgeld-Connet, D. (2008). Qualitative convergence of three nursing concepts: Art of nursing, presence and caring. Journal of Advanced Nursing, 63(5), 527-534.
Kobokovich, L. J. (2002). The nature of infant relinquishment as described by two voices: The relinquishing mother and the obstetrical nurse (Doctoral dissertation). Available from ProQuest Information and Learning Company. (UMI no. 3053109)
Smith, K. J. & Brandon, D. (2008). The hospital-based adoption process: A primer for perinatal nurses. MCN, 33(6), 382-388.
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(SAMPLE)
BIRTH AND ADOPTION PLAN FOR HOSPITAL NOTE: Hospital’s policies and procedures must be followed. The expectant mother may change this plan at any time.
Birth Plan For ______DOB ______Plan Created By ______Date Created ______Name of Hospital Where Delivery Is To Occur ______Address of Hospital ______Birth Mother’s Doctor and Phone Number ______
This birth mother is working with AGENCY NAME in CITY & STATE. Her pregnancy counselor is NAME. Office: PHONE # Emergency Number: PHONE #
1. When do you want your pregnancy counselor to come to the hospital? Who will call your pregnancy counselor and when? ______
2. I would like the following people to be present at the birth (check all that apply): Partner/Boyfriend/Husband/Father of Baby ______-__ Parent (s) ______ Friend(s) ______ Midwife/Doula ______ Other Relatives ______
3. My preferences during the labor and delivery (check all that apply): I would like to bring music. I would like the lights dimmed.
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I would like to videotape and/or take pictures in the delivery room. I prefer natural childbirth (no medications). I prefer to have an epidural (if possible). Other ______
4. My openness arrangement with the adoptive parents includes (check all that apply): The adoptive parents will be in the delivery room during the birth of the child The adoptive parents will be at hospital during the birth, but not in the room with me The adoptive parents will not come to the hospital until after the baby is born The adoptive parents will not come to the hospital until the baby is ready to go home I do not want to see the adoptive parents at all while I am in the hospital I want to see the adoptive parents before I leave the hospital (only once) I would like to see the adoptive parents as much as possible while I am in the hospital (without the baby) I would like to see the adoptive parents as much as possible while I am in the hospital, while my baby is also in the room (so I can see them together) Other ______
5. Is there anyone you DO NOT want to see the baby? ______
6. Contact with Baby (check all that apply): I would like to spend some time alone with my baby. I do not want to spend any time alone with my baby while I stay in the hospital. After the birth, I would like to move out of the maternity ward (if possible). I would like to give the baby his/her first feeding (if possible). I would like to change the baby’s diaper. I would like to breastfeed the baby at least once. I would like to name the baby with a name I have selected on my own.
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I have selected a name for the baby with the help of the adoptive parents. I would like to take some mementos from the hospital ______I would like a second set of mementos from the hospital for the adoptive parents
I have a gift that I would like to send home with the baby.
I would like traditions/rituals/ceremonies while at the hospital (please describe)
7. Is there any other information that you would like the hospital staff to know? ______
______Signature of Birth Mother Signature of Birth Father ______Signature of Parent (if birth mother is minor) Signature of Parent (if birth mother is minor)
______Signature of Pregnancy Counselor
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Introduction
This script is directed to the health care professional who meets with the patient/client to provide her with her positive pregnancy test results. It further assumes that the health care professional has had no contact with the patient/client previously and will not be providing follow-up care. It assumes that the health care professional will discuss the need for and make referrals for health care as necessary. The script’s purpose is to: • Provide guidance to the health care professional in raising the issue of choices with the patient/client and: • Provide guidance on appropriate referrals to other agencies with knowledge and skills to discuss the choice to the patient/client expressed interest in pursuing. This script is designed to have all the options raised in a noncoercive, nonjudgmental manner so that the patient/client knows: • She has choices. • She is free to make whatever choice she wishes without judgment. • She makes the choice of what she wishes to do about the pregnancy. • She controls the referral contract. Further, it is scripted to take fifteen minutes or less. The health care professionals’ recommended statements or questions are in quotation marks. Directions to the health care professionals are in italics.
Pregnancy Options Discussion Script:
Greet the Patient/Client
Scenario 1: Health care professional greets patient in the client waiting area.
Ms. Smith- “Hello, my name is Sally Healthcare. Please come with me.” You may want to engage in small talk on the way to the interviewing room. Once in the interviewing or examination room say, “I will be talking with you about your pregnancy test results.”
Scenario 2: Someone else brings the patient/client to the interviewing/examination room and you enter the room after the patient/client.
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“Hello Ms. Smith, I am Sally Healthcare. I will be talking with you about your pregnancy test results.” 1. Tell the Patient/Client the test result is positive.
o Most patient/clients are anxious to know the results. So tell them right away.
o “The pregnancy test is positive.” o Observe her behavior, listen and respond appropriately. 2. Discuss the Options
o If you cannot tell how the news affected her, ASK: - “What are you thinking or feeling?” - “How do you feel about the test results?”
o “What do you think the child’s father will do or say when you tell him?”
o “What impact do you think having this child will have on your future plans?”
o “There are basically three options to a pregnancy: - Continuing the pregnancy to birth and parenting the child; - Continuing the pregnancy to birth and placing the child for adoption with relatives or others; - Terminating the pregnancy.”
o What information would you like about any of these options?” o Listen and respond appropriately.
Identify Referral Options • If the patient/client states she is clear on what she wants to do and does not want any referrals, terminate the discussion: “I respect your decision. Should you change your mind, however, we welcome you to call for a referral. You can call (phone number) to get the name of an agency which can provide you with additional information and services on whatever option you choose or to help you with your choice.”
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Trainer’s Preparation
Module Contents and Training Process • This session completes the UIA training and is structured differently than the previous five Modules. • Keep in mind the adoption process which was covered in Module 3 may impact the role an attorney or agency may play in the adoption. Be prepared to clarify as needed. • Participants will discuss adoption referrals. Either a panel of community adoption providers and pregnancy counselors will join the training to discuss resources and referrals, or there will be a team activity where participants are asked to assess the needs of patient/clients and plan for the referral process.
Preparing to Train • Trainers must ensure that panel participants are identified and notified of expectations of panelists at least four weeks before the scheduled training date. There are more panel instructions on the next page if using this option. • The team activity provides an opportunity to integrate all of the materials they have received during this training by reviewing a written case scenario and identifying community resources and supports using the State Referral Resource Guide. • To close the day, trainers will summarize Module 6, as well as the entire UIA experience, administer the post test and Training Reflection Feedback Form (TRFF), and adjourn the training. The trainer will collect the post tests and TRFF near the exit. As the participants turn in their paper work the trainer will give them their Certificate of Completion.
Option 1 of 2: Panel Presentation • This activity allows participants to hear from community service providers related to adoption. These panel members give an overview of what services they provide and then participants have a chance to ask any questions. • The trainers, in consultation with local contacts, will identify representatives to participate on a panel during Module 6.
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• Panel composition may include representatives from community agencies whose services may include: Traditional adoptions Independent adoptions Special needs adoptions Open adoptions Tribal agencies Attorneys who facilitate adoptions Court personnel Pregnancy counseling services • The trainers will invite panelists verbally and in writing no less than four (4) weeks before the training. The letter should include all pertinent information regarding date, time, location, contact person, and an explanation of the format of the panel discussion. • The trainers will ask the panelists to provide a brief introduction of themselves, in writing, to the trainer at least a week before the training is to take place. This will be used by the trainer to introduce the panel member to the participants. • A sample letter to agency representatives is included in the Appendix Section. • Ask the representatives to be prepared to discuss the following topics: Types of services the agency or individual provides. Philosophy and mission of the services provided. Eligibility requirements for service. Information about initiating a referral. Information about accessing services including names and number of contacts. Time frames for receiving services. • Additionally, prepare the representatives for the possible questions the participants may ask them. These include: What services does your agency or firm provide? How long does it take to get an appointment? How much time do you spend initially with the patient/client? How many visits do you usually have with a patient/client? Who from your agency/firm is likely to work with the patient/client? Who can accompany the patient/client?
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How do you find adoptive families? What kind of information is gathered on the families who want to adopt? Do birth parents have an opportunity to meet the adoptive parents? Can the birth mother/father choose the adoptive parents? Will you work with any birth mother/father who wants to release her/his child? What kind of information do you gather on the birth mother/father? What fees are involved in adoption? How do you provide prenatal and perinatal care? Are the birth mother’s prenatal expenses covered? How long does the adoption process take? Can the birth mother/father change her/his mind at any time? What happens if the baby has some medical challenges at birth? Do you offer information in a variety of formats and languages? Do you work with birth mothers from different cultural, racial and economic backgrounds? Do you work with birth mothers who abuse substances? Do you work with relatives who want to adopt?
• Ask the representatives to confirm their attendance well before the training in case he/she cannot attend, so you will still have time to invite someone else to take his/her place. The trainer will call to re-confirm a couple of days before the training date.
Option 2 of 2: Assessing and Making Referrals for Pregnancy Counseling and Adoption Services • This activity gives participants a chance to practice making referrals. It also provides an opportunity to learn about the State Referral Resource Guide, which is available online and that can be printed out for their use. Participants use a scenario and as a team decide what referrals would be appropriate given the circumstances stated in the scenario.
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Optional Activity: Assessing and Making Referrals for Pregnancy Counseling and Adoption Services (only to be used in areas with limited local resources) • This activity gives participants a chance to network with each other regarding finding services for their patient/clients in an area with limited local resources. Required Materials/Equipment and Room Set-Up for this Module • Make sure room set-up accommodates panel if that option is chosen • Post test forms • Training Reflection Feedback Forms • Referral Resource Guide – Trainer should have a copy for display • Certificates of Completion • TV- VCR or DVD Player • Laptop and Projector • Screen to show PowerPoint presentation and DVD’s
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Module 6: Introduction
Objectives: Identify specific agencies/individuals in the local community/state that provide information and/or services. Identify resources to make informed referrals for pregnancy counseling and adoption services consistent with client/patient needs and preferences in the local community/state.
Content • Introduction • Making Successful Referrals & Pregnancy/Adoption Resources • Questions for Health Care Practitioners to ask Agencies and/or Attorneys • Questions for Patient/Clients to ask Agencies and Attorneys • Option 1 of 2 Panel Presentation: Meeting Community Service Providers of Pregnancy Counseling and Adoption Services • Option 2 of 2 Team Activity: Assessing and Making Referrals for Pregnancy Counseling and Adoption Services • Wrap-up/Adjourn • Post test/Evaluations
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Making Successful Referrals & Pregnancy/Adoption Resources
Trainer’s Comments
• Module 6 is the last module of the training and will encourage you to apply all of the information you have received in previous modules and matching resources to an identified patient/client need. This will be done by either participating in a panel discussion or using a case scenario. • Patient/clients who are pregnant require information about all of their available options. • Often there is more than one resource for a service in which case you can be helpful by identifying questions the clients might ask before deciding which resource best meets their needs. They may want referrals to additional resources including pregnancy counseling and adoption services, Department of Social Services and /or Public Heath Department programs such as Women Infants and Children (WIC). They also might need help with housing and perhaps shelter care. • Referral information works best when it is provided orally, written and /or in brochures. (Test Question) • In the Participant Handbook, Module 6, page 23 and 24 is a list of questions for health care practitioners or the patient/client to ask resources. Brainstorming questions with patient/clients is also a helpful way for them to practice the skills needed to identify suitable resources. • Referrals for further adoption information are appropriate when the patient/client desires more information about adoption. • It might also be appropriate to make a referral when the pregnant woman may be undecided and wants more information.
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Directions
• Refer participants to the Participant Handbook, Module 6, pages 17-29, to the short monographs; “Assessing Community Resources” and “Networking and Collaboration: Skills in Providing Pregnancy Options Referrals,” “Making Referrals for Pregnancy Counseling Services,” “Making Referrals for Adoption: Role of Adoption Agencies,” “Making Referrals for Adoption Services: Role of Attorneys,” “Making Referrals for Relative Adoptions and Role of Courts,” and “Supportive Resources for Pregnant Women.” Please turn to them now. • Refer participants to” Participant Handbook, Module 6, page 22, “Making Successful Referrals Checklist.” Tell participants that these are useful questions for patient/clients to ask possible service providers. • Refer participants to Participant Handbook, Module 6, page 23, “Questions for Health Care Practitioners to Ask Agencies and/or Attorneys.” These are some questions you might use when attempting to identify appropriate referrals. • Tell participants that this list of questions is to cue them to possible issues they may want to explore with a resource on behalf of a client. • Suggest that participants use these questions as they begin to assess a particular referral source. • Refer participants to Participant Handbook, Module 6, page 24, “Questions for Patient/Clients to Ask Agencies and/or Attorneys.”
Trainer’s Comments
• In addition to knowing the right questions to ask, it is important to know the right people to direct the questions to. This involves knowing about community resources. • Developing personal relationships with other service providers can be the key ingredient in making successful referrals.
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• It is important to continually update networking resources by identifying new workers, services and knowing when existing resources move or change phone numbers. • To gain additional information about an agency’s strengths and challenges, it is helpful to obtain feedback from patient/clients who have used a particular community resource. • It is helpful to develop a resource file that includes business cards of identified service providers; agency brochures; website information as well as bibliographies and relevant articles. • It is usually more effective to work with an identified patient/client to access a community resource rather than just handing out a phone number or a brochure. • Some basic questions that will help a patient/client gain access to a resource include: What services do you offer pregnant women and teens? Who should my patient/client ask for on her first contact? What are your hours of business? Do you have after hour services? What are your fees for patient/clients? • This information will be important for patient/clients who will need to contact community resources. • The State Referral Resource Guide is available online at iaatp.com. Once at the website click on Resources and then click on State Referral Resource Guide for your state. This can be printed and used at your site. It provides information for women experiencing an unintended pregnancy. Included are medical facilities, pregnancy counseling services, adoption agencies, and other service providers.
Transition
In this segment we will now have a panel comprised of representatives from a number of resources available in the community to someone experiencing an unintended pregnancy.
If using Option 2 of 2 (no panel – case scenarios) please turn to Trainer Guide, Module 6, page 13.
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Meeting Community Service Providers of Pregnancy Counseling and Adoption Services:
Option 1 of 2 (30 minutes) Panel Presentation
Overview • This activity allows participants to hear from community service providers related to adoption. These panel members give an overview of what services they provide and then participants have a chance to ask any questions. Advance Preparation • Be sure to confirm panel no less than four weeks prior to the scheduled training date. Make sure that the panel representatives understand their role in the session when you initially contact them and provide them with the topics to be discussed. • Encourage panelists from agencies, courts and/or firms to display materials, including brochures, business cards, videotapes and other public relations items to distribute to participants. • Be sure to let panelists know how many participants will be in attendance. • It is helpful for trainers to ask for additional copies of public relations materials for their own resource file and to use in future training sessions. • Make sure the room set-up is conducive to a panel presentation.
Panel composition (at least 3 different areas should be included) may include representatives from: Community adoption agencies whose services may include traditional adoptions, direct consent adoptions, special needs adoptions, and open adoptions. Tribal agencies Attorneys who facilitate adoptions Court personnel Pregnancy counseling agencies
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Topics the panel will be asked to prepare in advance • Types of services available from each community provider • Philosophy and mission of each service represented • Eligibility requirements for service • Information about initiating a referral • Information about accessing services including names and numbers of contacts • Timeframes for receiving services Anticipated questions for participants to ask panel members For service providers: • What services does your agency or firm provide? • How long does it take to get an appointment? • How much time do you spend initially with the patient/client? • How many visits do you usually have with a patient/client? • Who from your agency/firm is likely to work with the patient/client? • Who can accompany the patient/client? • How do you find adoptive families? • What kind of information is gathered on the families who want to adopt? • Do birth parents have an opportunity to meet the adoptive parents? • Can the birth mother/father pick the adoptive parents? • Will you work with any birth mother/father who wants to release her/his child? • What kind of information do you gather on the birth mother/father? • What fees are involved in adoption? • Do you provide prenatal and perinatal care? • Are the birth mother’s prenatal expenses covered? • How long does the adoption process take? • Can the birth mother/father change her/his mind at any time? • What happens if there is something wrong with the baby? • Do you offer information in a variety of formats and languages? • Do you work with birth mothers from different cultural, racial and economic backgrounds? • Do you work with birth mothers who abuse substances? • Do you work with relatives who want to adopt?
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Directions • Introduce panel members. • Exercise facilitation skills to keep presentations within time limits, and to prevent anyone from dominating discussion. Allow all panel members 3 to 5 minutes to discuss the services they provide. • Encourage participant questions but ask that they hold these questions until after all panel members have presented. Acknowledge questions and repeat question if necessary for the group to hear. • If necessary, clarify misunderstandings or confusing information given by panelists by asking clarifying questions. • Thank panelists for their contribution to the training. Give specific examples, if possible, e.g. excellent handouts, clear and concise presentations.
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Trainer’s Comments
• As previously mentioned it is important to discuss options with a patient/client to help him/her make an informed decision. • When making referrals it is important to match resources and supports with the identified needs and preferences of the patient/client. • Patient/clients have the right to refuse services and supports. • Patient/clients may want information to review before making a decision about using community resources and supports. • It may be helpful to encourage a patient/client to talk with friends, family and the baby’s father before making a decision that will have long-term effects on her life. • It is important to tell your patient/client that the child’s birth father may need to be involved if her decision is to release her child for adoption.
Transition
Tell participants that information gained from the panel discussion as well as the State Referral Resource Guide can be used by them in the future when considering what specific referrals to make for a patient/client.
In the next segment, the training will be summarized, final questions answered, the post- test will be administered and the session evaluated. Certificates of Completion will be given to participants as they turn in completed post test and Training Reflection Feedback Form.
Continue to page 28 for Trainer’s Comments and additional transitional information
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Assessing and Making Referrals for Pregnancy Counseling and Adoption Services Option 2 of 2 (20 minutes)
Overview • This activity gives participants a chance to practice making referrals. Participants use a scenario and as a team decide what referrals would be appropriate given the circumstances stated in the scenario. Participants are asked to identify needs presented for their patient/client. We hope that following the training, participants can go back to their office, print out their State Referral Resource Guide and complete the assignment with locating specific referrals depending on where their client lives.
Trainer’s Comments Share the following information with participants: • It is most often the role of the health care worker to identify other agencies and resources that can be of help to a patient/client and to pass this information on to him/her. • Making a referral involves more than providing the patient/client with an agency name and phone number. • Successful referrals include providing as much information about the referral source as possible, including the name of a contact person, agency hours, eligibility criteria, and services or resources provided. • Referral information works best when it is provided in a number of different ways; orally, written and/or in brochures. (Test Question) • Matching a patient/client with a referral source means that the health care professional must take into consideration the age, developmental level, current
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supports/resources, needs and preferences of an identified individual, and the ability of a specific referral source to meet those needs.
Directions • Assign each table a case scenario and specify 1-2 questions for them to answer. (Assigned number depends on time remaining. Also, if time is short, you may want to assign just one case scenario or complete exercise as a large group discussion.) • Ask each group to work together for 10 minutes to identify needs presented for their patient/client. • Give each group paper and markers, and ask each group to record their responses on flip chart paper. • Ask participants to determine how they would make this referral and who they would involve in the referral discussion. • Then hang the flip charts on the wall so everyone can see them. • Ask each group to identify a spokesperson to report to the large group.
Team Activity • Ask participants to turn to the four case scenarios, in the Participant Handbook, Module 6, pages 6 to 13. • Let participants know that these scenarios will introduce them to four pregnant women for whom they will be asked to help find community resources and supports that are a good match.
TRAINER NOTE: Turn to Trainer Guide, Module 6, page 27 for Large Group Discussion.
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Lillian
Lillian is a 26-year-old Hispanic, Catholic woman who has come to your clinic seeking prenatal care. She has recently moved back to the community after losing her sales job and breaking up with her boyfriend, the baby’s father. For the last year, she had been living in a major metropolitan area in another state with her boyfriend and her 5-year-old daughter from a previous relationship. Following the dissolution of her relationship with the boyfriend, Lillian moved back to her hometown to be near her mother. She is now five months pregnant. The ultrasound reveals that she is carrying a boy.
Despite the fact that she has been very successful raising her daughter, shortly after you became her health care provider, Lillian has begun to express doubts about her ability to raise another child on her own. She indicates that her father is deceased, and her mother has had to go back to work to support herself, and Lillian’s two younger siblings are still in high school. Lillian would like to continue working toward her bachelor’s degree in marketing so that she can provide a better life for her daughter, but she does not know how she can do this and take care of another child. She indicates that the baby’s father is involved in another relationship and has let her know that he is not interested in being a father at this point in his life and that he has no intention of being involved in the baby’s life.
Lillian’s aunt and her husband have approached her regarding adopting the baby. They have been married for several years, are in their forties and have not been able to have children. They recently moved to the United States from Mexico and speak very little English. Lillian seems ambivalent about the whole issue of releasing her baby. She does not know how she can go on with her life if she gives her baby to someone else to raise. She indicates that she feels pressured by her aunt but cannot think of a better alternative.
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Lillian Discussion Questions After reading the scenario, please answer the following questions in your team. Record your answers and appoint a spokesperson to report to the large group. 1. What questions would you need to ask this patient/client to make an appropriate referral for pregnancy counseling and/or adoption? “What do you know about the options you have?” “Tell me what you know about pregnancy counseling?” “Where have you in the past been referred to for pregnancy counseling? What was your experience?” 2. List those individual and community-based resources that you think could provide support for Lillian throughout her pregnancy and after the birth of the baby. Department of Social Services Public Health Maternal and Infant health advocates Maternal support Infant support WIC 3. What other issues will be important to consider when working with this patient/client? Grief and Loss of boyfriend and father Bilingual services Child care Employment Church relationships/religious issues Familial relationships (mother, aunt and uncle) 4. What questions will you need to ask or encourage this patient/client to ask when contacting pregnancy counseling and/or adoption resources?
o What are your fees and who pays for it? o Do you know about other resources that meet my needs? o Do you provide culturally sensitive services? o Can you provide services if I choose to parent the child?
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5. What barriers to effectively accessing services might this client experience? What can you do to help her articulate what she thinks her barriers might be? Barriers:
o Unresponsive agencies o Not culturally sensitive o Aunt and uncle may not be legal residents Helping her:
o Ask, “Is there anything that we have talked about that you think you might have trouble with?”
o Ask, “Do you know anyone who’s been in similar situations? What did they tell you about them?”
o Ask, “Are you worried about anything that we’ve covered so far?”
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Celia
Celia is a 40-year-old Caucasian mother of three who has brought her 10-year-old son to the clinic for treatment of his asthma. During the course of the visit, Celia shares with the health care provider that she is approximately six months pregnant and has not been having regular prenatal care.
Celia presents with fading bruises. She tells you that her husband is in jail for drug possession. Prior to his incarceration, the family had been evicted from their apartment, and she and her three children have been living with a succession of friends. She indicates that she does not have family in the area who can help her. She states that she is unwilling to seek help from her husband’s family as she is determined to make a break from him this time. Celia indicates that finding a place to live will be difficult as she was fired from her minimum wage job for excessive absenteeism after the last time her husband beat her.
On her second visit, Celia learns that her unborn child will be born with Spina Bifida. She indicates that her husband is the father of the baby, but he is physically abusive to her and she is concerned for all her children. Celia would like to make a plan to take her kids and start her life over. She is very concerned about her ability to raise another baby at this point in her life and, particularly, one born with special needs.
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Celia Discussion Questions After reading the scenario, please answer the following questions in your team. Record your answers and appoint a spokesperson to report to the large group: 1. What questions would you need to ask this patient/client to make an appropriate referral for pregnancy counseling and/or adoption?
o “What do you know about the options you have?” o “Do you know what pregnancy counseling is?” o “Where have you in the past been referred to for pregnancy counseling? What was your experience?” 2. List those individual and community-based resources that you think could provide support for Celia throughout her pregnancy and after the birth of the baby. Domestic violence counseling Domestic violence shelter Department of Social Services Public health Maternal and infant support advocacy services Maternal support Infant support WIC
3. What other issues will be important to consider when working with this patient/client? Home stability with a violent husband Housing Asthma of 10 year-old son Possible neglect of 10 year-old son Support network of friends and family Son’s schooling Safety issues Substance abuse 4. What questions will you need to ask or encourage this patient/client to ask when contacting pregnancy counseling and/or adoption resources? What are your fees and who pays for it? Do you know about other resources that meet my needs? Do you provide transportation?
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Do you provide child care? Divorce, Personal Protection Orders, custody Spina Bifida education 5. What barriers to effectively accessing services might this client experience? What can you do to help her articulate what she thinks her barriers might be? Barriers:
o Transportation o Fear of being found by husband o Transient living situation Helping her:
o Ask, “Is there anything that we have talked about that you think you might have trouble with?”
o Role play discussions and phone calls that she might have. o Ask, “Do you know anyone who’s been in similar situations? What did they tell you about them?”
o Ask, “Are you worried about anything that we’ve covered so far?”
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Skye
Skye is a 22 year old Native American woman who is raising her two young children as a single parent. Her children are a five year old daughter and a three and a half year old son. Skye dropped out of high school due to her first pregnancy. She has worked as a waitress, but she is currently unemployed yet looking for a job. Her extended family lives in a small rural community about 75 miles from the metropolitan area where Skye currently lives. Skye has one aunt who also lives nearby. Skye’s parents are divorced. Her mother lives in the small community and is raising Skye’s two teenage brothers, who are in the 8th and 10th grades. Skye is four months pregnant and came into the clinic today for her first regular pre-natal appointment.
Skye’s boyfriend, Nathan, is a 25 year old Caucasian male who had been living with her. He worked off and on as a framing carpenter in home construction. When he learned that Skye was pregnant, he said he was not ready to become a father and moved out. He has moved in with a woman he used to date before he met Skye.
During the office visit, the nurse asks Skye how things are going. Skye says she doesn’t know how she will get by without the financial support from her boyfriend, now that he has left her. She gets no child support from the fathers of her two children. Skye currently relies on government assistance and food stamps, and will get day care assistance when she finds a job. She is getting housing assistance for her apartment. She is on Title XIX medical benefits. Even with this assistance it is hard to make ends meet.
Skye tells the nurse that she is feeling overwhelmed when she thinks about the future. She is worried how she will have the energy to take care of a newborn and be able to work. She says she feels her hands are full with her two children and she does not know how she can handle raising another child, especially since the birth father is not going to help her. She has not told her family yet about the pregnancy because she is ashamed and worried what they will think of her being pregnant again. Her mother was very upset when Skye got pregnant at 16 and then again at 18, and her mother did not approve of Nathan.
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Skye Discussion Questions After reading the scenario, please answer the following questions in your team. Record your answers and appoint a spokesperson to report to the large group. 1. What questions would you need to ask this patient/client to make an appropriate referral for pregnancy counseling and/or adoption? “What do you know about the other options you have?” “Are you familiar with pregnancy counseling? I can explain it to you” “Are you a member of an Indian tribe, and if so, are you aware of services your tribe may offer?” 2. List those individual and community-based resources that you think could provide support for Skye throughout her pregnancy and after the birth of the baby. Department of Human Services Public Health Tribal Services Maternal and Infant health advocates 3. What other issues will be important to consider when working with this patient/client? Support from her extended family Employment Education / G.E.D. 4. What questions will you need to ask or encourage this patient/client to ask when contacting pregnancy counseling and/or adoption resources? Do your services comply with the laws regarding Indian children? Do you know about other resources that meet my needs? Do you provide culturally sensitive services? Can you provide services if I choose to parent the child? 5. What barriers to effectively accessing services might this client experience? What can you do to help her articulate what she thinks her barriers might be? Barriers:
o Services that are not culturally sensitive o Distance from family Helping her:
o Ask, “Would you like help talking to your mother about your pregnancy?”
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o Ask, “Do you know anyone who’s been in similar situations? What did they tell you about them?” o Ask, “Are you worried about anything that we’ve covered so far?”
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Kesha
Kesha is an African-American, 14 year old, excellent student who has come to her high school student health center because she has been vomiting for the last week during first period. A medical history reveals that she is also complaining of breast tenderness and has missed her period for the last two months. She indicates that she is sexually active and her boyfriend is a junior in the same high school. Kesha refuses to consider the possibility that she is pregnant until she undergoes a pregnancy test.
When the pregnancy is confirmed, Kesha is adamant that her mother will “kill her if she finds out.” She lives with her mother, step-father, and two younger siblings.
With help from the health center staff, Kesha tells her mother that she is pregnant. Mother is angry, after all she has told Kesha many times how difficult it is to raise a child as a teen. Mother speaks with authority because she gave birth to Kesha when she was 16-years old. She believes that Kesha has to take responsibility for the pregnancy and raise the child. According to Mother, “Kesha made her bed, now she can lay in it.” Kesha’s stepfather is quiet but seems troubled about the situation.
Kesha’s boyfriend strongly denies that he is the father of the baby. Since finding out that Kesha is pregnant, he has broken off the relationship. Kesha’s girlfriends are all very supportive of the pregnancy, and she enjoys a new sense of status among her friends. Two of her friends have had babies but since giving birth they are no longer in school. When asked what she is planning to do about the pregnancy, Kesha indicates that she is going to have the baby. She indicates that to do anything else would suggest that she does not love her baby. She indicates that once she has the baby, she will come back to school to finish her sophomore year.
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Kesha Discussion Questions After reading the scenario, please answer the following questions in your team. Record your answers and appoint a spokesperson to report to the large group.
1. What questions would you need to ask this patient/client to make an appropriate referral for pregnancy counseling and/or adoption? Beyond parenting the baby, do you know what other options are available to you? Do you know what pregnancy counseling is? 2. List those individual and community-based resources that you think could provide support for Kesha throughout her pregnancy and after the birth of the baby. Family Independence Agency – FIP (Public cash assistance) Public health Maternal and infant health advocacy services Maternal support Infant support Women, Infant and Children Teen mom support groups 3. What other issues will be important to consider when working with this patient/client? Kesha’s age Family support (mother’s support) Living arrangements Peer group influence Paternity (issues) Transportation Education alternatives and support Finances 4. What questions will you need to ask or encourage the patient/client to ask when contacting pregnancy counseling and/or adoption resources? Do my parents have to be involved? How much involvement? What are your fees and who pays for it? Do you know about other resources that meet my needs? Where do services take place? At school? At the office?
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Do you provide transportation? 5. What barriers to effectively accessing services might this client experience? What can you do to help her articulate what she thinks her barriers might be? Barriers:
o Her confidence level o Her fear level o Lack of support from Mom/family o Peer influence: “You don’t need to do all that. I didn’t.” o Unresponsive agencies Helping her:
o Ask, “Is there anything that we have talked about that you think you might have trouble with?”
o Role play discussions and phone calls that she might have o Ask, “Do you know anyone who’s been to similar places? What did they tell you about them?”
o Ask, “Are you worried about anything that we’ve covered so far?”
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Large Group Discussion • Ask for a team spokesperson to volunteer to share their work with the large group. • Direct the spokesperson to present a “thumbnail” sketch of their patient/client before discussing their assessment and referrals. • Allow each group to answer one question, rather than all questions assigned to their group. • Ask groups to report on the differences of opinion that occurred in the group during the activity, and how they resolved them. • Remind participants that clients, such as Celia, may have urgent needs for supportive services. • Remind participants that we hope they can go back to their office, print out their State Referral Resource Guide and complete the assignment with inserting specific referrals depending on where their client lives • Remind participants that the article “Supportive Resources for Pregnant Women,” in the pink pages, Participant Handbook, Module 6, page 28 will be helpful to them.
TRAINER NOTE: Turn to Trainer’s Comments, Module 6, page 28.
Optional Large Group Discussion – use only in areas where resources are limited (20 minutes) • Assessing Needs and Making Referrals • Group brainstorm on communities with limited local resources: 1. What are typical patient/client needs?
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2. What have you been doing? 3. Where are there still gaps? 4. How can these gaps be addressed? Please see Participant Handbook, Module 6, page 14.
Trainer’s Comments • As previously mentioned, it is important to discuss options with a patient/client to help her make an informed decision. • When making referrals, it is important to match resources and supports with the identified needs and preferences of the patient/client. • Patient/clients have the right to refuse services and supports. • Patient/clients may want information to review before making a decision about using community resources and supports. • It may be helpful to encourage a patient/client to talk with friends, family and the birth father before making a decision that will have long-term effects on her life. • It is important to tell your patient/client that the child’s birth father will need to be involved if her decision is to release her child for adoption. • Refer participants to Participant Handbook, Module 6, page 23 “Questions for Health Care Practitioners to Ask Agencies and/or Attorneys.” These are some questions you might use when attempting to identify appropriate referrals. • Tell participants that this list of questions is to cue them to possible issues they may want to explore with a resource on behalf of a client. • Suggest that participants use these questions as they begin to assess a particular referral source. • Referral information works best when it is provided orally, written and/or in brochures. (Test Question) • You have received information about the different resources available for pregnancy options information and adoption services consistent with the patient/client’s needs and preferences within their state. (Training Reflection Feedback Form)
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• You are now able to identify specific agencies/individuals in your “local area or state” which provide information or services. (Training Reflection Feedback Form) • You have learned how to explore the patient/client’s questions about pregnancy options, and strengths to match local referral sources to patient/client’s needs and preferences. • You are encouraged to use each other and trainers as resources in your future work with pregnant women. • Refer participants to Participant Handbook, Module 6, page 24, “Questions for Patient/Clients to Ask Agencies and/or Attorneys.”
In this segment, participants explored local and state resources and addressed questions relative to matching a patient/client to resources that might meet their needs and preferences. They also acknowledged unique challenges presented by lack of referral resources in their area.
TurningPoint Question o Ask participants to answer the question on the slide using the remote devices.
o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses.
o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
Referral information works best when it is presented in multiple formats. (Test Question)
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TurningPoint Question o Ask participants to answer the question on the slide using the remote devices. o When you push the “arrow” key, the computer will automatically and anonymously tally the answers and show the percentage of the responses. o Click the arrow key again and the correct answer will be highlighted. Note to the group what percentage answered the question correctly.
I feel comfortable and confident discussing adoption as one of the options in family planning. (Test Question)
(
Transition
In the next segment, the training will be summarized, final questions answered, the post test will be administered and the session evaluated.
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Trainer’s Comments • Now let’s summarize what we have learned today. In Module 1 we discussed the reasons why this training was developed as well as our values and how they may impact on our work. In Module 2 we discussed the history of adoption, the adoption triad, neutral and accurate adoption language, and the relationship continuum. In Module 3 we discussed Federal and State adoption laws. In Module 4 we looked at how culture, age, and the birth father all may have an impact on the pregnant woman’s decision making process. Module 5 spoke to nondirective, noncoercive techniques in counseling pregnant women and teens. Finally, Module 6 gave us a chance to learn about resources in the area. • Thank you all for your involvement in the training. • You will receive the answers to the tests you completed at the end of the day and this answer sheet is yours to keep. • In addition to the bibliography for this section, there is also a Reference section that contains a list of helpful websites. Also included in the Reference section is some information regarding additional materials that might be helpful to you and your patient/clients. • Review the Parking Lot and answer any questions that have not been covered during the training. • Revisit the list of expectations (if used) from the start of the training. Go over these to make sure the participants had their expectations met. • Are there any final questions? • Be sure to wrap up with goodbyes and all other remaining issues/questions prior to administering the post-test and various evaluations. Do not continue to talk once the test and evaluation begins. Tell participants they are free to go when they complete the test and evaluation.
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• Remind participants as they turn in their paper work they will be given their Certificate of Completion.
• Administer the post test and distribute the evaluation forms for this training series. • Tell participants they will get their Certificates of Completion at the door when they submit their post test and evaluation forms. • Thank the participants and adjourn the training. • Stand near the door to collect post tests and all evaluation forms. Also provide participants with test answers provided by PRES. • Give the participants their Certificates of Completion.
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To Find Out More About It
Abramson, Julie S., Mizrahi, Terry. (1996). When Social Workers and Physicians Collaborate: Positive and Negative Interdisciplinary Experiences. Social Work, 41, 3, 270-281.
Allender, J.A., Spradley, B.W. (2001) Community health nursing: concepts and practice. Philadelphia: Lippincott.
American College of Obstetricians and Gynecologists. Pregnancy Choices: Raising the Baby, Adoption and Abortion. (ACOG Patient Education Pamphlet, order on line www.acog.org) Washington, D.C.
Babb, Anne L. (1999). Ethics in American Adoption. Westport, CT: Bergin & Garvey.
Hartman, A., Laird, J. (1990). Family treatment after adoption: Common themes. In D. Brodzinsky and M.D. Schechter (Eds.) The psychology of adoption (pp. 221-239). New York: Oxford University Press.
Lakin, Drenda. (1992). Empowering adoptive families: Issues in post adoption services. Baltimore, MD: Baltimore City Department of Social Services.
Lindsay, J.W. (1996). Pregnant? Adoption is an option: Making an adoption plan for a child. Buena Park, Ca: Morning Glory Press.
Michigan Department of Community Health. (2000). Healthy Kids. Free Health Care Coverage for Pregnant Women, Babies and Children. Lansing, Mi.
Muller, Ulrich; Perry, Barbara. (2001). Adopted Persons’ Search for and Contact with Their Birth Parents: Who Searches and Why - I ? Adoption Quarterly, 4, 3, 1-39.
Muller, Ulrich; Perry, Barbara. (2001). Adopted Persons’ Search for and Contact with Their Birth Parents II: Adoptee-Birth Parent Contact. Adoption Quarterly, 4, 3, 39-62.
National Adoption Information Clearinghouse. (2000). Are You Pregnant and Thinking About Adoption? Washington, D.C.
Oros, Marla T.; Perry, Lesley A.; Heller, Barbara R. (2000) School Based Health Services: An Essential Component of Neighborhood Transformation. Family Community Health, 23, 2, 31-35.
Wyatt, Tami H., Novak, Julie C. (2000). Collaborative Partnerships: A Critical Element in School Health Programs. Family Community Health, 23, 2, 1-11.
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Sample Letter (for Panel Presentation)
(Panelist Name) (Panelist Address)
Dear (Panelist Name),
Thank you for talking with me the other day about the Infant Adoption Awareness Training Project. The goal of the panel discussion is to bring local service providers together to share information to those who serve pregnant women who may want information on pregnancy options, including adoption as an option.
The panel composition will include representatives from various community adoption resources with services such as:
• Traditional adoptions • Independent adoptions • Special needs adoptions • Open adoptions • Tribal agencies • Attorneys who facilitate adoptions • Court personnel • Pregnancy counseling services
Each representative will have an opportunity to speak to the participants.
Please be prepared to share information about the following:
• Types of services available from each community provider. • Philosophy and mission of each service represented. • Eligibility requirements for service. • Information about initiating a referral. • Information about accessing services including names and numbers of contacts. • Pregnancy counseling services.
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After each panel member has presented, the participants will have an opportunity to ask questions. Some anticipated questions may include:
• What services does your agency or firm provide? • How long does it take to get an appointment? • How much time do you spend initially with the patient/client? • How many visits do you usually have with a patient/client? • Who from your agency/firm is likely to work with the patient/client? • Who can accompany the patient/client? • How do you find adoptive families? • What kind of information is gathered on the families who want to adopt? • Do birth parents have an opportunity to meet the adoptive parents? • Can the birth mother/father pick the adoptive parents? • Will you work with any birth mother/father who wants to release her/his child? • What kind of information do you gather on the birth mother/father? • What fees are involved in adoption? • How do you provide prenatal and perinatal care? • Are the birth mother’s prenatal expenses covered? • How long does the adoption process take? • Can the birth mother/father change her/his mind at any time? • What happens if there is something wrong with the baby? • Do you offer information in a variety of formats and languages? • Do you work with birth mothers from different cultural, racial and economic backgrounds? • Do you work with birth mothers who abuse substances? • Do you work with relatives who want to adopt?
Please bring materials such as brochures, business cards, videotapes and other public relations items to give to the participants. We expect about (insert number of participants).
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The panel discussion will take place (insert Date, Time, Address). Please confirm your participation by (insert confirmation Date) by contacting (insert name) at (phone, email, fax, etc.) and providing the following information:
Name Agency / Firm
Address
Telephone Fax
E
Thank you for being an integral part of the Infant Adoption Awareness Training Project. We look forward to seeing you on (insert Date).
Sincerely, (Insert Name)
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Assessing Community Resources
At first glance, identifying a community resource that meets an individual’s specific needs may be like looking for a needle in a haystack. There are, however, some helpful techniques that can be used to assess whether a resource is a good match for a particular patient/client.
Asking clarifying questions to help patient/clients hone in on their specific needs as much as possible is the first step in the referral process. This sets the stage for focused, productive communications with community agencies or resources on their behalf.
One key factor is whether the health care provider will make the referral directly to the resource or whether it will be necessary for the patient/client to obtain the information for him/herself. Regardless of what method is used, it is recommended that the individual be “coached” to obtain information and assess its value, a skill that they can use in the future.
Most health care providers are aware of a number of community resources, either through personal networking contacts or through collecting business cards and agency brochures at conferences and meetings. These contacts can be used to narrow the search and identify a small number of resources that may work. Starting with “who you know” is always a good idea. When looking for resources and supports, it is important to trust your feelings about the interactions. Developing a trusting relationship is key to being able to honestly discuss service needs and find a good match. Assessing the following issues can help:
• Were you able to get through to the provider in a timely and easy manner? • Did you feel comfortable talking to the provider? • Did he/she treat you respectfully and confidentially? • Did he/she readily answer your questions about the range of services provided? • Did he/she respond to your specific needs or just talk generally about the services? • Would you feel comfortable sending a patient/client to this community resource?
The following questions are a good starting point for patient/clients to ask in deciding whether to make an appointment with a particular resource:
• What services do you provide in pregnancy counseling and adoption? • What are your eligibility criteria? • What are your fees? Who pays these fees? • Do you know about other resources that might meet my needs?
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• If you had a loved one needing these services, is there a resource you would recommend? • Are there any other questions that would be helpful for me to ask?
When evaluating resources and supports you will want to be able to assist your patient/clients in recognizing those aspects of the service or service provider that are important in determining a potential match for their needs and preferences. Some important questions to consider and/or coach your patient/client to consider are:
• Who does the provider consider to be the primary client? The birth parent(s), the unborn child? The adoptive parents? • Does the provider provide the full range of pregnancy counseling and adoption options that your patient/client is interested in considering? • What will this provider do to protect the rights and preferences of the patient/client(s)? • Will this provider be competent and respectful of the age, religion, ethnic and cultural background of the patient(s)/client (s)? • Will the provider provide a translator if one is needed?
Helping patient/clients find appropriate resources is an important aspect of the services offered by health care providers. Developing the knowledge and skills necessary to assess how services fit with their individual needs and preferences will enable patient/clients to become informed consumers and to advocate for themselves.
Karal Wasserman, MSW, CSW Rosemary Jackson, MSW, ACSW New View Consultants, Inc. February 2002
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Networking and Collaboration: Skills in Providing Pregnancy Options Referrals
Many women and teenagers who have unplanned pregnancies have complex service needs. It is not unusual for a health care practitioner to see multiple personal and family problems in this group. Often these patient/clients could benefit from referrals to other community resources for more intensive counseling and support services. Unfortunately, health professionals report lack of responsiveness from some referral sources. A clear understanding of the services available and a positive working relationship between agency personnel will facilitate effective provision of services to this group. Those professionals who are best at assuring that their patient/clients receive the services they need have become adept at the fine art of “networking.” (Allender, J. and Spradley, B, 2001)
Developing Networking Skills:
According to Webster, a network is “an extended group of people with similar interests or concerns who interact for mutual assistance and support.” Networking is about mutual exchange and building relationships with other providers in your community, preferably on a personal basis. It is about making every minute you are in the community count for your clients. Networking is not about making referrals to “friends.” Instead, it is about finding out who in the community will provide quality and ethical services to your patient/clients.
Some people are naturally more disposed to networking than others, but it is a skill that anyone can develop. Here are some of the techniques that can be employed to increase networking activities in your practice:
• Cultivate an attitude of continuously adding to your “resource network” for your patient/clients. • Cultivate an attitude that trusting and reciprocal relationships are the best to have in making and receiving referrals from others. • Develop relationships with persons who have different ethnic, cultural, racial and/or religious backgrounds from your own, so you can help your patient/clients access culturally relevant and competent services. • Use down time at meetings to make personal connections and learn about what other service providers do and what types of patient/clients they typically serve. • Ask for individual business cards with notes about the person’s specialty and keep the cards handy or add them to your resource bank.
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• Share your business card and information about yourself and the patient/clients you serve. • Ask for information from others about their best referral experiences and then try to make contact with the agency, preferably with those persons mentioned. • Make time to call for information and/or meet with persons who are able and willing to serve your patient/clients, consistent with best practices and standards. • Participate in cross-system/inter-agency training opportunities. • Sponsor networking and information exchange meetings at your setting, for example, “lunch and learn.” Follow up on patient/client referrals. Evaluate the services provided: • How soon after making the referral was your patient/client seen? • Was the plan of care appropriate? • Were the promised services provided? • Were the established outcomes achievable and reasonable? • Were patient/clients involved in planning? • Was discharge of the patient/client appropriate? • Was the patient/client satisfied with the services? • Use e-mail to maintain ties with others, provide information and give feedback about services.
Collaboration Opportunities and Efforts
Collaboration is usually a more formal process used by communities or groups of agencies or individuals to maximize services to patient/clients across agencies and systems. These efforts are based on the belief that there are not enough resources to go around and energy is lost in duplication of efforts, scapegoating other organizations/systems and competition between agencies.
Collaborating organizations usually have shared goals, mutual participation, greater use of resources, clearly defined responsibilities, specified outcomes, time-tables and boundaries. Collaboratives may be organized on a short-term or task basis to solve a cross-system problem or oversee a pilot project. In recent years, Federal and State governments have promoted community-level collaboratives to provide an institutionalized means to create cross-system solutions to longstanding problems and to advocate for the people of the community on an ongoing basis.
In Michigan, most counties have now formed Human Service Collaborative Bodies (HSCB’s) to bring together social services, public health, mental health, substance abuse, courts and private agencies to address county-wide resource needs. Matters of mutual concern for these collaboratives have included cross-system coordination, community-
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wide planning, pooling Federal and State funding sources to try new services, promoting relationships between agency heads and managers, removing service barriers. Some of the efforts taken on by the HSCB’s throughout the State include streamlining intake policies and procedures, cross system innovation and pilot projects, cross-system process and performance improvement and cross-system training.
Health care professionals can be included in work groups in these locally based collaboratives. Health care professionals are sometimes included with foster care professionals in work groups, but it is rare to see pregnancy counseling and infant adoption professionals included. Involving these experts in planning groups in the future will provide a fuller range of cross-system perspectives, competencies and resources to help patient/clients live successfully with their life choices.
References: Allender, J. and Spradley, B. Community Health Nursing: Concepts and Practice, 5th Edition. Lippincott, 2001.
Human Services Collaborative Body training materials and information. (Livingston and Wayne Counties)
Judith K. McKenzie, Executive Consultant McKenzie Consulting, Inc. February 2002
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Making Successful Referrals Checklist
• When talking with patient/clients, pay attention to both the expressed, implied and the perceived needs. What services have they requested or could they benefit from?
• I have identified the patient’s unique and individualized needs related to any referral i.e., language, developmental, cultural and ethnic needs.
• I have talked with the patient/client about what her/his primary concerns are and what options exist to help address them.
• I have confirmed that he or she is willing and ready to be referred.
• I have discussed with patient/client issues that might make it difficult for him or her to follow through with the referral.
• I am familiar with the agency to which I am referring the individual, including its eligibility requirements and services.
• I have provided at least two options for each service desired/needed (when possible). I have included a direct contact name and have provided these options orally as well as in writing.
• The agency I have referred has the ability to successfully respond to my patient/clients needs in a knowledgeable, culturally sensitive and respectful manner.
• I have provided sufficient information and “coaching” to help make the referral successful.
• I have made a plan to follow up with the patient/client (when appropriate) to see how things went and to determine next steps.
• I have a backup plan if this referral fails to work out for any reason.
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Questions for Health Care Practitioners to ask Agencies and/or Attorneys
1. What are the pregnancy options and services you provide to birth parents?
2. If a patient/client decides to place her child for adoption, which of the following types of adoption do you provide?
3. If you provide open adoption alternatives, what are the degrees of openness you offer?
4. What are the characteristics of clients you typically serve?
5. What kind of financial assistance do you provide access to for expectant mothers?
6. How are the health care needs of your clients met during and after pregnancy?
7. What standards do you follow in your practice?
8. What services do you provide for birth mothers and significant others after adoption?
9. Do you have a waiting list?
10. How soon can you see my patient/client?
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Questions for Patient/Clients to ask Agencies and Attorneys
1. What options will you talk with me about? 2. What services do you provide if I decide to keep my child? 3. What if I decide I want to place my child for adoption, after I take him/her home? 4. If I start the adoption process, can I change my mind? How much time will I have to change my mind? 5. I am not 18 years old. Will my parents have to be involved if I place my child for adoption? 6. Will the father of the child have to be involved if I place my child for adoption? 7. What will you need to know about me and the child’s father and why? What information will be confidential and what will be shared with the child and/or adoptive parents? 8. If my baby has special needs, is adoption still possible? 9. Can I choose the people who will adopt my child? 10. How much information is known about the people who will adopt my child? 11. Can I see my child after he/she is born? 12. Can I have contact with my child after the adoption? 13. What kind of arrangements are possible? 14. Can I be sure that the adoptive parents will let me continue to have contact with my child after they adopt him/her? 15. What do most birth mothers feel after they place their child for adoption? What services will be available to help me after I place my child for adoption? 16. Can I have contact with my child after he/she is an adult? 17. Do you have a support group for birth parents who have placed their child for adoption? 18. Is there someone who has used your services that I can talk with before making a decision? 19. Will I have to pay for services?
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Making Referrals for Adoption: Role of Adoption Agencies
All adoption agencies must be licensed by the State of Michigan. Not all agencies offer “direct consent” adoptions, but most do. Adoption agencies complete the same tasks as those listed for adoption attorneys when they facilitate “direct consent” adoptions. In this type of adoption, the birth parent must select the adoptive parents. In direct consent adoptions, the adoption agency: • interviews the birth parent and collects information required by law. • provides the birth parent with information on approved adoptive parents;. • facilitates meetings between the birth parent(s) and the potential adoptive parent(s). • assists with the selection of the adoptive parent(s) if requested. • secures release or termination of parental rights for both the mother and father. • completes the requisite legal papers for the adoption. • files the adoption petition with the court. • secures the adoption order. • transfers the child and the required medical information on the child and his/her birth family to the adoptive parents. The licensed adoption agency can also facilitate an “agency” adoption. This is a process whereby the birth parent(s) release the child’s custody to the agency by a legal procedure in court. The court terminates parental rights and orders the agency to assume the child’s custody until an adoption is completed. The birth parents are not required to personally select the adoptive parent(s) in this latter type of agency adoption, whereas, they must personally select the adoptive parent(s) in the direct consent adoption.
Indications for Referrals for Agency Adoptions
• The patient/client is seriously considering placing her child for adoption. • The patient/client prefers to work with an agency of her choice and/or religious background to place her child for adoption. • The patient/client may or may not want to select the adoptive parents. • The patient/client may want to have contact with her child after the adoption. (This cannot be guaranteed because such agreements are not legally binding, but agencies are more likely to play a role as intermediary in such circumstances.) • The unborn or newborn child is expected to have disabilities and the parent(s) has decided to place the child for adoption. • The patient/client is indicating an interest in receiving grief counseling and/or post adoption services after the adoption. Ernestine Moore, MSW, JD Spaulding for Children Judith McKenzie, MSW McKenzie Consulting, Inc. February 2002
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Making Referrals for Adoption Services: Role of Attorneys
Attorneys facilitate direct consent adoptions. In this situation, a birth parent(s) contacts an attorney, advises him/her that he/she wish to place an expected child for adoption, and would like to be involved in selecting the adoptive parent(s). The attorney:
• interviews the birth parent and collects information required by law. • provides the birth parent with information on approved adoptive parents. • facilitates meetings between the birth parent(s) and the potential adoptive parent(s). • assists with the selection of the adoptive parent(s) if requested. • secures release or termination of parental rights for both the mother and father. • completes the requisite legal papers for the adoption. • files the adoption petition with the court. • secures the adoption order. • transfers the child and the required medical information on the child and his/her birth family to the adoptive parents.
Indications for Referrals to an Adoption Attorney
• The patient/client has made a decision to place her child for adoption. • The patient/client prefers to work with an adoption attorney and select the family who will adopt their child. • Relatives wish to have an attorney involved in arranging their direct consent adoption. • The patient/client is not expecting to have contact with the adoptive parents and/or their child after the adoption is completed. (Although this may be discussed with the attorney and parents, the attorney has no legal obligation to act as intermediary in this regard.)
Ernestine Moore, MSW, JD Spaulding for Children Judith McKenzie, MSW McKenzie Consulting, Inc. February 2002
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Making Referrals for Relative Adoptions and Role of Courts
The Family Division, Juvenile Section of the Circuit Court in the county where the child is to be adopted or where the adoptive parents reside must be involved in all adoptions to provide legal safeguards. In most instances, an attorney and/or agency will bring the adoption to the attention of the court.
In a relative adoption, however, the families involved may go directly to the Court for all necessary assistance.
In all adoptions the court:
• reviews and accepts all legal documents, family study, and other information required by law. • ensures that both the birth parents’ rights have been released or terminated properly. • grants the adoption order.
Indications for a referral for a Court Adoption:
• The patient/client and relatives wish to go directly to a court to arrange a direct consent relative adoption. • The patient/client wants to arrange an adoption or guardianship with a relative and does not want to involve an attorney or cannot afford attorney involvement.
Note: Guardianship is another alternative for transferring custody to a relative. Patients/clients need to directly contact the Probate Court for a guardianship action.
Ernestine Moore, MSW, JD Spaulding for Children Judith McKenzie, MSW McKenzie Consulting, Inc. February 2002
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Supportive Resources for Pregnant Women
Most pregnant women, irrespective of economic circumstances, require additional supports during pregnancy. Pregnant women with economic challenges have additional support needs. The State of Michigan recognizes that the health and welfare of the mother before, during, and after the pregnancy impacts the well-being of the child. Michigan offers a range of government services, provided by state or local governmental agencies and by contractual private, non-profit organizations. In addition, many local organizations provide financial and other supportive services. Below is a summary of the major state- funded services available in all counties.
Financial If the woman or teen has no means of support, she should apply for public/cash assistance (Department of Human Services) at the Department of Human Services in the county where they reside. When she applies for public assistance, she will also be screened for eligibility for or referral to other programs such as: • food stamps; now called FAP – Food Assistance Program with a debit card system, called “bridge card”, instead of food coupons; • Medicaid, now called Healthy Kids; • Low Income Energy Assistance Program (LIEAP); • Maternal and Infant Health Advocacy Services (MIHAS); • Maternal Support Services (MSS), and Infant Support Services (ISS). The Department of Community Health administers the last three programs. Teens must reside with an approved adult and must be attending or have completed high school or a GED program to be eligible to receive cash assistance WIC (Women, Infants, and Children) coupons are available to purchase specific food products to ensure proper nutrition during the pregnancy. In most counties, the local public health agency certifies eligibility. The Department of Community Health and the Department of Human Services are negotiating including WIC benefits in FAP’s “Bridge Card” system at some point during this fiscal year.
Medical Services Michigan provides free Medicaid coverage, called Healthy Kids, for pregnant women. The ceiling for income eligibility varies by family situation. A toll-free number has been established to assist in determining if the woman would qualify. That number is 1– 888-988-6300. The woman does not have to have other children or receive public assistance to be eligible for coverage during and for two months after the pregnancy ends. Her other children under 19 years of age are also eligible. The MIChild-Healthy Kids application form is available at doctor’s offices, local health departments, or Family Independency Agencies. Many communities also have nonprofit agencies and churches providing applications and assistance with completing them. The pregnant woman will need to show proof of income, proof of pregnancy, proof of
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Support Services Maternal and Infant Health Advocacy Services (MIHAS) targets services to Medicaid eligible patients who are at or below 185% of poverty and who present with one or more of the following: • single parent • teen parent • abuse or neglect history • isolation or depression • low intellectual functioning or educational attainment • HIV/AIDS risk. Services are provided during the pregnancy and for two months postpartum. In some high-risk situations services continue until the child is one year of age. All necessary services are provided directly or through linkages with other organizations. Maternal Support Services (MSS) and Infant Support Services (ISS) provide supportive assistance during pregnancy and after the birth of the child. In addition to the risk factors noted for MIHAS, MSS and ISS services are provided to women who present with • dysfunctional family/domestic violence • nutritional deficits • unstable emotional status/inability to cope • negative feelings/attitudes toward the pregnancy Medicaid/Healthy Kids will pay for the services if the doctor orders them. Services include • transportation to doctor visits • childbirth and baby care classes • help with WIC enrollment and other food, nutrition services • help with personal problems
Module 6 - Page 54 Trainer’s Guide – 1 Day GLOSSARY
Abandonment: When a parent refuses to physically, emotionally, or financially support his or her child. A signed relinquishment or surrender of parental rights legally constitutes abandonment.
Abuse: Harm or threatened harm inflicted on a person through physical, verbal, emotional, or sexual means.
Active Listening: Paying attention to the patient/client and repeating in your own words what you think she/he has said and/or felt. This lets her know that you are listening to and understanding what she/he is saying and feeling. It promotes clarification and further discussion. If you are not correct in your understanding of what she/he said/felt, the patient will usually correct you
Adoptee: (preferred term, adopted individual or adopted person) - Individual who has been adopted.
Adoption: The social, emotional and legal process in which children are not raised by their birth parents, and become full and permanent legal members of another family while maintaining genetic and psychological connections to their birth family.
Adoption Agency: Legally regulated entity that provides one or more of the following: assessment of prospective adoptive parents, counseling services to birth parents, preparation and placement of children with adoptive families and post-adoption services.
Adoption Assistance Program (Title IV-E of the Adoption Social Security Act): Program created by the Adoption Assistance and Child Welfare Act of 1980. It provides federal or state payments/subsidies and other benefits designed to offset the costs of adopting eligible children who have special needs. Also known as Adoption Subsidy.
Adoption Attorney: Is an attorney who facilitates direct consent adoptions throughout the adoption process through finalization.
Adoption Benefits: Benefit such as financial assistance or monetary reimbursement for the expenses of adopting a child—available to workers through some employer-sponsored programs.
Adoption Triad Members: The three groups of individuals involved in any adoption are the birth parent(s), the adoptive parent(s), and the adopted person.
Glossary Page 1 Trainers Guide Adoptive Parent: Individual who legally adopts a child and who is legally recognized as the child’s parents.
Adoption Sensitive Services: Services which respond to the unique circumstances and needs of those touched by adoption: adopted parents and children, birth parents, extended families.
Adoption Support and Preservation Services (same as adoption sensitive services): Usually offered after the legalization of the adoption and are considered post legal adoption services.
Adult Adopted Person (Adoptee): Individual over the age of 18 years who was adopted as a child or who is adopted as an adult.
Anti-social Behavior: Behaviors that are well beyond the limits of what is acceptable behavior for most children. It may include such behaviors as skipping school, getting into fights, running away from home, persistently lying, the use drugs or alcohol, stealing, property damage, and violation of most “rules” in most settings.
Appeal: Reconsideration of an administrative or judicial decision. In context of an adoption, appeals typically involve the review of an administrative decision regarding placement or subsidy.
Attachment Bonding: An affectionate bond between two individuals that endure through space and time and serves to join them emotionally. (Klaus, 1976)
Attachment Disorder: A condition characterized by an inability to develop significant emotional connections with other people. Children, who have been abused and/or neglected, even when very young, may find it difficult to form significant ties. Signs of attachment disorder may include: difficulty maintaining eye contact, lying, and not responding to affection.
Baby Selling/Black Market Adoption: Accepting a monetary payment in exchange for providing a child to an adoptive parent or other person. Baby selling is illegal in all states.
Behavioral Disorders: Disorders influenced by factors such as heredity, brain disorders, diet, stress, and family functioning—that cause symptoms such as hyperactivity, aggression, withdrawal from social interactions, self-injurious behavior, immaturity, learning problems, excessive anxiety, or abnormal mood swings.
Birth Family: Individuals who share a child’s genetic heritage, blood relations, extended family members, and/or kinship members.
Birth Father: Biological father of an adopted child.
Glossary Page 2 Trainers Guide Birth Father’s Rights: Legal rights that a biological father may assert in relation to his child; these tend to vary from state to state and often depend on the extent of the individual’s parental involvement with the child.
Birth Mother: Biological mother of an adopted child.
Birth Parent: Man or woman who conceives or contributes to the conception of a child.
Birth Parent Counseling: Services designed to assist birth parents to explore their planning options with regard to a pregnancy of a child, and to prepare them if they choose to relinquish their child for adoption.
Birth Parent Living Expenses: Allowable expense above and beyond medical care and counseling made to or for the prospective birth mother for the purposes of assuring heath and welfare of an unborn child. Regulated by statute in some states.
Child Placement Agency: In accordance with Public Act 116, is a governmental organization or agency organized pursuant to the non-profit corporation act, for the purposes of receiving children for their placement in private family homes for foster care or adoption.
Child Placement Agency Adoption: In child placement adoptions, parent(s) releases their child for adoption to a licensed child placement agency; the court terminates the parental rights of both parents and places the child in custody of the agency. The agency selects the adoptive family and facilitates the adoption to finalization.
Claiming: The process that enables parents to raise their adoptive child in the same manner as children born to them.
Closed Adoption: Adoption in which identifying information about the birth parents and adoptive parents is considered confidential and is not made available to the other members of the adoption triad, usually as a result of state law and/or court order.
Coercion: Someone with more perceived power or authority forces a decision upon a person; talks them into a decision; provides incomplete or misleading information; and/or offers gifts, bribes or other incentives for making a particular choice.
Cognitive Delays: Delays in the customary development of a person’s ability to process information or think logically or analytically.
Confidentiality: Information or communication maintained in confidence or entrusted with confidence of another.
Glossary Page 3 Trainers Guide Consent: In the adoption process, it is a voluntary agreement by a birth parent, an individual legally recognized as a parent, or an agency that has assumed legal custody of a child, to the adoption of a child.
Cooperative Adoption: (See open adoption.)
Cultural Competence: The continuous self-assessment and expansion of a person’s knowledge of regarding other’s cultures, differences and the ability to adapt and meet the needs of diverse populations.
Cultural Responsiveness: An active term that requires professionals to treat the patients/clients as an individual and recognizing that he/she will not automatically respond in a manner that is consistent with his/her culture, norms and values. In addition, to understand that his/her judgement/response is not a reflection of all other members of the same culture.
Defusing Anger: Can be accomplished by several techniques including and/or responding to the angry person’s fear, identifying and responding to the issues underlying the person’s anger and shifting the angry person’s perspective.
Developmental Delays: A condition in which the development of the baby or child is slower than normal. Some areas that could be delayed are sitting up, walking, toilet training, talking, socializing, etc.
Developmental Disability: Childhood condition, disease, genetic disorder, growth pattern, or inability to meet developmental milestones that begins before 18 years of age, impairs the individual’s functioning and usually persists throughout the life of the individual (such as, mental retardation, autism, cerebral palsy.)
Disclosure: Act of revealing information that may be considered secret or confidential. With respect to adoption, may refer to (1) revealing background information about an adopted child and his or her birth family, including the medical and background history of the child or birth family, or (2) revealing identifying information about the child, birth family, or adoptive family.
Disruption: The act of discontinuing or annulling an adoption, in which the decision is by the adoptive parents, the child, or the legal authority, prior to finalization or legalization of the adoption.
Dissolution: Irreconcilable differences in adoptive families that occur after the adoption process is completed and result in negating the legal relationship and moving the child or children to another setting.
Glossary Page 4 Trainers Guide Dysthymia: A form of low-level depression characterized by a lack of enthusiasm for life and a sense of discouragement about the future. Other symptoms may include fatigue, insomnia, and low self-esteem.
Emotional Disturbances or Disabilities: A condition, either regular or occasional, that is often evidenced by a lack of respect for authority, problems in school, an inability to handle changes easily, and problems with other children. Other characteristics can include sleep disturbances, mood swings, and a tendency to act impulsively without considering consequences. Therapy is recommended throughout childhood and adolescence.
Empathy: Involves listening respectfully to the patient/client’s concerns and identifying with the patient’s/client’s situation, without being sympathetic.
Empowerment: Is a technique that identifies and compliments strengths in order to help an individual take control of a situation or problem.
Entitlement: The right to parent a child which includes both legal and emotional components.
Expressive Language Skills: The ability to express one’s thoughts and feelings in words. Family Integration: The process by which individuals become full-fledged members.
Fictive Kin: Individuals not related to the child or family by blood or marriage but who have a psychological/emotional attachment and are identified as “family” as a result of their role and/or bond in functioning of the nuclear family.
Finalization: The final legal step in the adoption process; may involve a court hearing where an adoptive parent or parents become a child’s legal parent(s). The process of legalizing an adoptive relationship through the probate court. Formal Communication Agreement: Established by state law, and submitted to the court. Refer to specific state law regarding communication agreements. Once approved, it is not a guarantee the contact will continue. Even in formal adoption agreements, there will be legal verbiage stating that the agreement is not legally binding.
Fost/Adopt: Placement of a child with an approved pre-adoptive foster family who intends to adopt the child if reunification is not possible and adoption becomes necessary for the child. Also called legal risk placement.
Foster Children: Children who have been placed in the state’s legal custody because their birth parents were deemed abusive, neglectful, or otherwise unable to care for them. While under state care, such children often live in foster homes or group homes.
Glossary Page 5 Trainers Guide Full Disclosure: Fully sharing information between adoptive family and birth family.
Guardianship: A court-ordered placement in which an adult assumes, with the biological parent consent/agreement, custodial care of a child (ren).
Group Home: A facility staffed by social workers and counselors that houses groups of children, typically those over the age of 5, including teens and sibling groups,—who need emergency temporary shelter or a long-term living arrangement.
Home Study: Process of assessing and preparing prospective adoptive families to determine their suitability to adopt and the type of child whose needs would best be met by them. Includes a range of evaluative activities, visits to the family’s residence, and educational activities.
Identified Adoption (designated adoption/agency-assisted adoption): is when the birth parents select and agree to place their child with specified adoptive parents and the agency provides full assessment, preparation, and counseling to the birth and adoptive families both before and after placement. The agency also ensures that relinquishment and legalization of the adoption are completed in accordance with applicable law.
Identifying Feelings: Occurs when the health care professional puts words to the emotions that are being expressed and then checks with the patient/client to make sure that his/her interpretation is correct.
Identity Formation: The process that individuals go through to clarify their values and to determine “who they are.”
Identifying Information: A term used in adoption services in reference to the collection and/or sharing of such information as the full name, address, and telephone number of a member of the adoption triad with another member of the triad.
Indian Child Welfare Act of 1978 (P.L. 95-608): Federal legislation designed to reduce the transracial placement of American Indian and Alaska Native children and to give tribal court jurisdiction over all child custody cases involving such children in an effort to prevent the decimation of American Indian and Alaska Native tribes and families.
Individualized Education Plan (IEP): A plan drawn up by a child’s special education teacher and other concerned parties that outlines specific skills the child needs to develop as well as learning activities that build on the child’s strengths.
Infant Adoption: Adoption of very young children (generally from newborn up to the age of 2 years).
Glossary Page 6 Trainers Guide Informal Adoption: Parents and children have an emotional commitment and attachment to one another; parental rights remain intact and no court has legally sanctioned this relationship.
Informed Consent: Informed consent requires that the pregnant woman is provided with information about all the options available to her and the consequences of each choice. In addition, the pregnant woman is competent to make a decision and is not coerced or forced by an external person(s) or situations to make a particular decision. In the adoption and the health care setting, informed consent requires knowledge, voluntariness, and competency.
Inter-country Adoption: When a child is from one country and is adopted by an adult from a different country. (Also referred to as international adoption.)
Intermediary: Person who acts as a facilitator between birth parents and prospective adoptive parents in arranging independent adoptions. Also, a person who facilitates post-adoption contact/reunion in adoption searches.
Interstate Adoption: Adoption of children who are residents of one state by individuals who are residents of another.
Interstate Compact on Adoption of Children: Is a federal law that ensures that all Title IV-E eligible children continue to receive services when they are adopted across state lines. It also defines universal procedures and responsibilities for sending and receiving states, and requires notification from sending states to receiving states.
Kin: Blood relatives of the child, or relative by marriage, outside of the nuclear (parent and child) family including grandparents, aunts, uncles, cousins, members of the clan, tribe or stepparents.
Kinship Adoption: Adoption of a child by that child’s relative, godparents, stepparent or other adult who has an established kinship bond with the child’s family system.
Kinship Care: The full-time nurturing and protection of children by relatives, members of their tribes or clans, godparents, stepparents, or other non-related adults who have a kinship bond with a child.
Kinship (Extended Family) Network: Includes the nuclear family, extended or blended family, and other adults viewed as family who have an active role in the functioning of the child’s family. These adults may or may not reside in the immediate area.
Learning Disabilities: A condition that makes it hard for a person to take in, sort, and store information; not a sign of below-average intelligence.
Glossary Page 7 Trainers Guide Legal Father: Man who is married to a woman at time of the conception and/or birth of a child, whether or not he is the biological father of the child. Also referred to as the presumed father.
Legal Risk Placement: (See fost/adopt.)
Loss and Grief Issues: Unresolved emotional distress that can result from being removed from one’s birth family, experiencing a parent’s death, being abandoned by a parent, being put in foster care, moving from one placement to another, or having one’s parents’ parental rights terminated. Because children often have difficulty understanding, expressing, and dealing with feelings about painful losses and separations, these issues can cause depression and acting out behaviors.
Maintenance Subsidy: Payment or stipend provided to the adoptive family for the care of a child with special needs.
Medical Subsidy (Service Subsidy): Payment for medical, mental health care, and other related health care services not covered by private health insurance or Medicaid.
Medically Fragile: Term used to describe a child with one or more severe medical problems (such as, HIV/AIDS, prenatal alcohol, or drug exposure).
Motor Skills: A person’s ability to use large and small muscle groups. Gross motor skills refer to the use of large muscles in activities such as running or jumping. Fine motor skills refer to small muscle coordination required for things like writing or buttoning a shirt.
Mutual Consent Registry: Mechanism by which a member of the adoption triad may register with a state social services department or other designated entity to indicate his or her interest in having identifying information shared with other members of the triad. Information is shared only if both parties register and there is a “match.”
Multiethnic Placement Act/Interethnic Placement Act of 1994 (MEPA): A federal law which regulates child placement agencies receiving federal funds cannot delay or deny the placement of a child for adoption solely on the basis of race, color, or national origin. Further, agencies cannot deny an applicant for adoption or fostering on the basis of race, color, or national origin. In addition, in agency adoptions, birth parent(s) cannot require agencies to specify race, color or national origin of adoptive parents. However, in direct consent adoptions, birth parent(s) may select the adoptive parent(s) of his/her choice. (See Small Business Job Protection Act/Removal of Barriers to Interethnic Adoption (IEP) of 1996.)
Network: According to the Webster Dictionary, network is an extended group of people with similar interest or concerns who interact for mutual assistance and support.
Glossary Page 8 Trainers Guide Nondirective, Noncoercive Counseling: A method in which information and options are presented through the use of open-ended questions designed to help the patient/client identify her/his options and preferences and make an informed decision that satisfies his/her needs and preferences. The nondirective, noncoercive approach is predicated on the patient’s/client’s ability to solve their own problems with adequate access to non-judgmental, supportive resources and supports.
Nonidentifying Information: Information about a child and his or her health, social, and family background that is provided to prospective adoptive parents, adopted persons, or others but does not include the identity or whereabouts of the birth parents; conversely, information about the prospective adoptive family and their background that is shared with birth parents, but does not include the identity or whereabouts of the adoptive parents.
Nonjudgmental Remarks and Responses: When reflecting back what you hear and in every response you make, we want responses based on professional, factual knowledge and free from the influences of the health care provider's own values and beliefs.
Nonrecurring Expenses: One time expenses incurred in the process of adopting a child with special needs (for example, adoptive home study cost, transportation expenses).
Open Adoption: Open adoption is not a legal type of an adoption. It is an arrangement between the birth parent(s), adoptive parent(s) and child for initial contact and continued contact after the adoption is finalized, if warranted by the adoptive parent. The contact agreement can vary in frequency, duration and type. Some types of contact can include telephone calls, correspondence, and/or personal contact, depending upon the particular situation.
Open Records: Information contained in vital statistics records such as the child’s original birth certificate, and/or in confidential and sealed adoption files, that is made available to the adopted person, adoptive parents, or others permitted access to such information under state law.
Openness: Broad range of information sharing practices among members of the adoption triad.
Oppositional Defiant Disorder (ODD): A disorder characterized by behavior such as, frequent loss of temper, a tendency to argue with adults, refusal to obey adult requests, deliberate behaviors to annoy others, spiteful and vindictive behavior, use of obscene language, and a tendency to blame others for mistakes. Symptoms sometimes indicate the early stages of Conduct Disorder (CD).
Glossary Page 9 Trainers Guide Option Counseling: Information that is shared with a pregnant woman regarding all options including prenatal care, delivery and infant care; foster care and adoption; and pregnancy termination.
Out-of-Home Care: Array of services, including family foster care, kinship care, and group residential care for children who have been placed in the custody of the state and who require living arrangements away from their birth parents.
Permanency Planning: Comprehensive assessment planning to determine long term, best interest of a child. A value and philosophy that states that all children belong in families.
Post-Adoption Service Provider: An individual who intervenes with post-adoptive families and works to keep them together as a family.
Post-Legal Adoption Services: Community-based interventions provided for adoptive families with the goal of keeping the family together.
Post-Legalization Adoption Services (Post-adoption Services): Services provided to the adopted person, and the adoptive parents and/or the birth parents by the agency providing adoption services or other community resources, after an adoption has been legalized.
Post-Placement Services: Services provided by the agency completing the adoptive placement, either directly or through referral, to the adoptive parents, adopted child or the birthparents after a child has been placed for adoption but before the adoption is legalized.
Post-Traumatic Stress Disorder (PTSD): A syndrome, sparked by traumatic past events, where a person emotionally re-lives past traumas and becomes withdrawn from current events. Symptoms may include sleeping problems, nightmares, intrusive thoughts, and difficulty concentrating.
Pre-Adoptive Counseling: Supportive and information-sharing activities providing by the adoption program to prepare children for adoption and to prepare prospective adoptive parents before a child is placed with them.
Pregnancy Counseling: Counseling that offers all the options to pregnant women related to the care of a child before and after delivery.
Private Adoption (Independent Adoption): Adoption that takes place without the involvement of legally regulated agencies, often involving physicians, lawyers or others who, for a fee, identify and/or place a child with adoptive parents.
Glossary Page 10 Trainers Guide Pro-Life Pregnancy Counseling: Offers alternative options to pregnant women related to the delivery and care of an infant/child, excluding the option of pregnancy termination.
Public Agency Adoption: Adoption arranged by a state or county social service agency with the legal authority to place children with adoptive families.
Putative Father: Man who is not married to the child’s mother and who is alleged or claims to be the biological father of a child.
Rapport Building: Involves developing trust through verbal and non-verbal means. Verbal rapport building can include the use of compliments, expressions of caring, self-disclosure and humor. Non-verbal rapport building can include touch, eye contact, nodding, and smiling.
Receptive Language Skills: The ability to process and understand others’ spoken or written words.
Reflective Listening: Is a technique that lets the patient/client know that the health care provider is listening to what he/she is saying. This technique is often referred to as paraphrasing, checking back or and/or active listening.
Relative Adoption: Adoption of a child by someone to whom the child is related (most often grandparents). (See kinship care.)
Relinquishment (See also Surrender Papers): The legal process by which birth parents voluntarily surrender rights to parent their children. After relinquishment, birth parents may or may not have a legal right to further contact with the child(ren).
Respite Care: Child care and other services designed to give parents temporary relief from their responsibilities as caregivers.
Responding Nonjudgmentally: Requires the health care provider to continually assess their own values and beliefs to avoid interfering with their work with the patient/client.
Reunion: In closed adoptions, a meeting between members of the adoption triad, often the final phase of a “search” by either an adopted adult or birth parent.
Revocation of Consent: Legal withdrawal of an agreement. In the adoption arena, withdrawal of an agreement to the adoption of a child.
Sealed Records: Documents related to an adoption such, as the original birth certificate of an adopted person and records of court proceedings that are required by law in most states to be maintained as confidential and inaccessible to all persons.
Glossary Page 11 Trainers Guide Search: Activities by a birth parent, adopted person, or adoptive parent to learn the identity and location of another member of the adoption triad, often with the intent of initiating some form of contact.
Semi-Open Adoption: Arrangement between adoptive and birth families to remain in contact with each other through an agency without releasing identifying information.
Separation Anxiety: Excessive and persistent anxiety about being separated from one’s home or parents that interferes with normal activities.
Separation: An emotional or physical break in a relationship. This curriculum focuses on the relationship between a caregiver and a child.
Sibling Adoption: Adoption of siblings by the same adoptive family. Designed to keep children together and avoid separation.
Small Business Job Protection Act/Removal of Barriers to Inter-Ethnic Placement (IEP) of 1996: A federal law that repealed exclusive language of MEPA/IEP that prohibited denying or delaying placement solely on the basis of race, color, national origin and its permissive language to allow assessments of parents of different races as to their ability and willingness to parent a child of different race. IEP clarified national intent that race plays no role in the choice of adoptive parents or the placement of children for adoption. Also, it mandates financial penalties for any state or private agency receiving federal funds that violates the provisions of MEPA or IEP. (See Multiethnic Placement Act/Interethnic Placement Act (MEPA) of 1994.)
Special Education: Specialized educational services designed to address disabilities in intelligence, language skills, perceptive skills, behavior, or social and emotional development that make it hard for a student to learn well in a regular classroom.
Special Needs: Conditions that make some children harder to place for adoption including emotional or physical disorders, age, and race, being in a sibling group, a history of abuse, or other factors. Guidelines for classifying a child as having special needs vary by state. Common special needs conditions and diagnoses include Attachment Disorder, Attention Deficit Hyperactivity Disorder (ADHD), developmental disabilities, Fetal Alcohol Syndrome (FAS), learning disabilities, and Oppositional Defiant Disorder (ODD).
Special Needs Adoption: Generally refers to the adoption of children in out-of-home care who meet certain criteria related to greater challenges in securing adoptive families for them. Most
Glossary Page 12 Trainers Guide frequently involves children who are school age; part of a sibling group; children of color; or have special physical, emotional, or developmental needs.
Special Needs Children (preferred term Children with Special Needs): Children who meet certain criteria related to greater challenges in securing adoptive families for them. Most frequently refers to children who have special physical, emotional, or developmental needs, who are school age, part of a sibling group, or sometimes to children of color. (See waiting children.)
Strengths-based Comments, Empowerment: Active listening includes the identification and feedback on the strengths, not JUST the problems/concerns you have identified. It compliments and encourages patient/client strengths in order to help her take control of the situation and the decision
Subsidized Adoption: Form of adoption in which public financial assistance is provided to a family who adopts a child determined to have special needs.
Subsidy: Grant of money by a government to an entity, enterprise, or individual to benefit the public in some way; in context of adoption, a payment made to an adoptive parent on behalf of a child with special needs.
Summarizing: Is a technique in which the health care provider highlights key points of the conversation with the patient/client and checks back to make sure that his/her interpretation is correct.
Surrender: In adoption, the voluntary act of terminating parental rights. (See voluntary relinquishment.)
Surrender Papers: Legal documents that a child’s birth parents, legal guardian, next of kin, or court-appointed friend can voluntarily sign to give up or relinquish their parental rights to the child.
Surrogacy: Practice of entering into a contract in which a woman is paid to conceive, bear, and surrender an infant to another.
System Children: Children who have entered the public child welfare system and are living in foster homes, adoptive homes, or group care.
Termination of Parental Rights: Voluntary or involuntary legal extinction of the rights of a parent to the care, custody and control of a child and to any benefits which, by law, would follow to the parent from the child, such as inheritance.
Glossary Page 13 Trainers Guide Title X: Title X of the Public Health Service Act authorizes the family planning program which makes available a broad range of family planning services and methods on a confidential and voluntary basis, as well as related preventive health care, to those desiring such services. Consistent with nationally recognized medical standards, family planning projects must offer pregnant women the opportunity to be provided information and counseling regarding prenatal care and delivery, infant care, foster care or adoption, and pregnancy termination. If requested to provide such information, family planning providers are to provide neutral, factual information on each of the options, and referral upon request, except with respect to any option(s) about which the pregnant woman indicates she does not wish to receive such information and counseling.
Transcultural Adoption: Adoption of a child of one culture by an adoptive family of another culture.
Transracial Adoption: Adoption of a child of one race by an adoptive family of another race.
Triad: A group representing three persons or things. As related to adoption process, the triad includes the birth parent(s), the adoptive parent(s), and the child.
Wrongful Adoption: Legal action against adoption agencies in which an adoptive parent seeks a monetary award based on allegations that the agency failed to disclose or misrepresented the health status or background of a child or birth family at the time the child was placed with the individual for adoption.
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Helpful Websites
www.adoption.com This clearinghouse is best for parents seeking birth mothers, profiles of adoptable kids and national listings of lawyers and agencies. www.adopt.org The National Adoption Center’s site list profiles of 2000 children with special needs who are waiting for adoptive parents. www.adoptionOnline.com A fee-based site that connects prospective parents with birth mothers. A three-month membership can cost up to $200.00. No fees paid by birth mother. There is a fee to the adoption agencies and attorneys looking for families hoping to adopt. www.TheAdoptionGuide.com The site runs by a concerned mother that tracks complaints and legal probes of agencies, a resource to avoid adoption fraud. Site provides articles and resources. http://opa.osophs.dhhs.gov/ The OPA site includes reference information about the Title X family planning program, including the statute, regulations and program guidelines. It also includes information about the OPA clearinghouse and some of the publications it makes available. http://www.naic.acf.hhs.gov/ The National Adoption Information Clearinghouse home page. Includes access to publications, bibliographies and articles related to adoption. Includes a variety of federal agencies, national resource centers and state resources on adoption. http://www.cwla.org The Child Welfare League of America includes information about all child welfare related subjects, publications, member agencies and training. http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=hstat This site includes chapter 63 Counseling to Prevent Unintended Pregnancy from the Guide to Clinical Preventive Services, a report of the U.S. Preventive Service Task Force. The Guide is regarded as the premier evidence-based reference source on the effectiveness of clinical preventive services. www.acog.org The American College of Obstetricians and Gynecologists includes informational materials and pamphlets related to pregnancy options counseling. These can be ordered on the web site.
www.spaulding.org Includes information on adoption resource materials that can be ordered via the website. Also, includes access to information related to Spaulding for Children’s Infant Adoption Awareness Training Program, the National Child Welfare Resource Center for Adoption, and includes links to federal adoption and child welfare programs and national resource centers.
Glossary Page 15 Trainers Guide www.iaatp.com The Infant Adoption Awareness Training Program website. Learn about local and computer based trainings available. www.ask.hrsa.gov/ Department of Health and Human Services, Health Resources and Services Administration Information Center. Can order publications online. www.ask.hrsa.gov/detail.cfm?id=MCHK158 Pregnancy Planning and Unintended Pregnancy. www.advocatesforyouth.org Website for teens regarding rights, respect and responsibility. www.plannedparenthood.org/library/EXTERNALLINKS/teerpreg.html List of teenage pregnancy linked websites. www.financeprojectinfo.org/WIN/childwelf.asp Information about the child welfare system, including adoption. www.aap.org American Academy of Pediatrics’ website. www.aap.org/policy/194.html Website that discusses the Pediatrician’s role in supporting adoption communication, and other various topics. www.adoption.about.com A resource web page. It discusses many aspects of adoption, the adoption process to finalization. www.adoptnet.org The National Adoption Center presenting the Learning Center, support for adoptive families. www.depts.washington.edu/pfes/cultureclues.html The University of Washington Medical Center website provides a tip sheet called “Culture Clues” for clinicians that aid in providing culturally appropriate care.
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