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Adults Who Are Adopted: Implications for Nurse Practitioners
BRIEF REPORT
Adults Who Are Adopted: Implications for Nurse Practitioners Anna Forster, MS, Karen J. Foli, PhD, RN, Kathleen Abrahamson, PhD, RN, and Elizabeth Richards, PhD, MSN ABSTRACT
In this article we briefly explore the literature on psychological issues in adults who were adopted as infants or children. Monitoring for signs of psychological risks and staying up to date on appropriate resources are 2 ways nurse practitioners in family and adult primary care can assist their patients who are adopted. These patients are a unique population, and health care providers need to be competent in understanding the dynamics of adoption to enhance the quality of care they provide. Keywords: adoption, adult, psychological disorders Ó 2016 Elsevier Inc. All rights reserved.
INTRODUCTION
I
1
n 2012, 119,514 children were adopted. Approximately, 5 million Americans living today are adoptees.2 This population is heterogeneous, and the exposure to difficult environments before being adopted varies.3 The literature describing outcomes for children and adolescents who are adopted is extensive, yet far less is known about these individuals as they progress into adulthood. Historically, disclosure of the adopted person’s medical history and birth family information has been through closed/confidential or open adoption arrangements. In a closed adoption, no identifying information is exchanged between the adoptive family and birth parents.4 Once the adoption is finalized, the state seals the records. Although there is variation between states, records are usually not available to the individual who has been adopted.4 The second type of adoption, emerging in the mid- to late-1980s5 and increasingly common, is open adoption. Open adoption allows information, such as medical history, to be shared among the adoption triad.4 Research findings support positive outcomes with open adoption: Siegel6 reported that young adults who were part of an open adoption described opportunities to develop identity, expand family, and process feelings. Adults who were adopted have increasingly sought and demanded unsealed birth records to better understand their health histories and reconnect with birth families. www.npjournal.org
Although there is support for resiliency in individuals who have been adopted, psychological issues that may be related to being adopted as an infant or child can appear in adolescence and adulthood. We describe implications for general practice nurse practitioners (NPs), with a focus on risk for suicide, depression, and substance abuse. PSYCHOLOGICAL ISSUES
An increased incidence of suicide among adopted individuals has been found as they progress into adolescence and adulthood. These individuals have 4-fold greater odds of suicide attempts and are 3-4 times more likely to commit or attempt suicide than nonadopted individuals.7,8 Individuals adopted between the years 1946 and 1968 showed a higher rate of suicide during a 14-year time span after adoption, from 1987 to 2001.9 Depression also appears to be a risk factor in adopted persons. Researchers have found that adopted individuals were 1.6 times more likely to develop a mood disorder (including major depressive disorder) throughout their lifetimes.10 Adoptees were found to have significantly higher depression scores when compared with their nonadopted friends.3 Finally, Cubito and Obremski Brandon11 described higher rates of depression in their study of 716 adoptees ranging in age from 21 to 61 years, when compared with nonadopted individuals. The Journal for Nurse Practitioners - JNP
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Alcohol and substance abuse/dependence have also been found in higher numbers of adopted persons, who were 2.1 times more likely to meet criteria for substance abuse/dependence than their nonadopted counterparts.12 Hjern et al.7 reported that adoptees were 5 times more likely to be addicted to drugs and 2-3 times more likely to abuse alcohol than nonadopted individuals. A study of adopted southwestern American Indian tribe members found an association with adoption and development of alcohol and drug abuse.13 von Borczyskowski et al.14 found that adoptees had an elevated risk of drug abuse when compared with the general population. Adoptees with parents who had abused substances had a higher rate of substance use disorders in adulthood, and more admissions and treatment for substance use than other individuals.15 Anxiety disorders were also found to be correlated with being adopted. Robin et al.13 found a higher association of anxiety in adopted individuals over nonadopted individuals, especially in women. Adopted adults overall were found to have a 1.5 times greater chance of developing an anxiety disorder during their lifetime.10 Panic disorder without agoraphobia, specific phobia, and generalized anxiety disorder were the most common anxiety disorders among this group.10 Additional, less common, psychological disorders were also present. When compared with nonadopted individuals, there was an increase in antisocial personality disorder in adopted individuals.13 Robin and colleagues13 discovered this problem set did not decrease from childhood to adulthood, as the disorder remained stable over a 20-year period. More research is needed to make conclusions regarding these relationships. IMPLICATIONS FOR ADVANCED PRACTICE NURSES
NPs are in a position to provide informed care to individuals who have been influenced by adoption. A provider who is adoption competent understands the individuality of the experience of adoption while also appreciating the unique dynamics that adoption presents, such as loss and grief, and issues surrounding attachment and identify.16 Educational preparation is key to the NP successfully assessing and treating adult patients who are adopted. Specific e352
The Journal for Nurse Practitioners - JNP
lecture content of adopted persons with psychological and medical needs, which may be overlooked without the context of adoption, should be incorporated into NP curricula for pediatric, family, and adult tracts. This content should begin at the baccalaureate level.17 NP-PATIENT RELATIONSHIP
One of the most important aspects of primary care is the NP-patient relationship. Patients may be unsure of whether the health care provider is comfortable addressing adoption-related emotions or issues. NPs should ensure they communicate that they are available as a resource and support contact to form a crucial NP-patient bond. This bond supports delivery of individualized and holistic care. NPs function as therapeutic listeners, as some adopted persons need to share their experiences to process issues. Although the NP may begin that process, referral to a therapist, who will be available on an ongoing basis, is appropriate. LACK OF MEDICAL HISTORY
Unless the patient has been able to access his or her birth records and family medical history, there will be significant gaps in the medical record. Unknown medical histories may leave individuals feeling vulnerable. They will not know if they are at risk for substance abuse or depression, which can be familial in nature. In addition to a thorough physical exam, the NP should be extra vigilant to remind the patient to obtain recommended screenings and preventive health maintenance. This preventive step could result in early detection of disease states, and potentially decrease morbidity and mortality of the individual. MONITORING FOR DEPRESSIVE SYMPTOMS AND SUICIDE
Patient safety is the highest concern, and the most salient implication for practice is to monitor for signs of suicide risk. Practitioners can screen for suicidal ideation and intent in the primary care setting and effectively triage those patients with positive screens. The Center for Epidemiological Studies Depression Scale18 and Patient Healthcare Questionnaire-219 are valid depression screening tools available to NPs. Volume 12, Issue 8, September 2016
SIGNS OF SUBSTANCE ABUSE AND DEPENDENCE
NPs should also monitor for the signs and symptoms of substance abuse as patients may be in denial or hiding dependence. In the same manner as vigilance regarding depressed mood and suicidal ideation, NPs need to be aware that these patients are susceptible to alcohol and substance abuse, and monitor for signs and symptoms. The CAGE questionnaire is a screening tool that can be used to screen for alcohol abuse, and CAGE-AID can be used for alcohol and drug abuse screening.20,21 If a patient’s screen is positive, referral to a specialist is warranted. CONCLUSION
The NP should provide patient-centered care to individuals who have been adopted as there are many variables that contribute to the risks of suicide, substance abuse, and depressive symptoms. In addition, individuals process the experience of adoption in different ways. NPs need to be aware of the challenges an adult can face as an adopted individual, which may affect aspects of their psychological functioning. Being aware of the risk factors and gaps in medical histories will allow NPs to provide focused, preventive, and quality care. References 1. Children’s Bureau. Trends in U.S. adoptions: 2008-2012. 2016. https://www .childwelfare.gov/pubs/adopted0812/. Accessed February 14, 2016. 2. Herman E. Kinship by Design: A History of Adoption in the Modern United States. Chicago: University of Chicago Press; 2008. 3. Borders LD, Penny JM, Portnoy F. Adult adoptees and their friends: current functioning and psychosocial well-being. Family Rel. 2000;49(4):407-418. 4. National Adoption Center. Types of adoptions. http://www.adopt.org/types -adoptions/. Accessed February 18, 2016. 5. Wolfgram SM. Openness in adoption: what we know so far—a critical review of the literature. Social Work. 2008;53(2):133-142. 6. Siegel DH. Growing up in open adoption: young adults perspectives. Fam Soc J Contemp Soc Serv. 2012;93(2):133-140. http://dx.doi.org/10.1606/1044-3894 .4198. 7. Hjern A, Lindbald F, Vinnerljung B. Suicide, psychiatric illness, and social maladjustment in intercountry adoptees in Sweden: a cohort study. Lancet. 2002;360(9331):443-448.
www.npjournal.org
8. Keyes AM, Malone SM, Sharma A, Iacono WG, McGue M. Risk of suicide attempt in adopted and nonadopted offspring. Pediatrics. 2013;132(4): 639-646. 9. von Borczyskowski A, Lindblad F, Vinnerljung B, Reintjes R, Hjern A. Familial factors and suicide: an adoption study in a Swedish national cohort. Psychol Med. 2011;41(4):749-758. 10. Westermeyer J, Yoon G, Tomaska J, Kuskowski MA. Internalizing disorder in adopted versus non-adopted adults: a NESARC based study. Comprehensive Psychiatry. 2014;55(7):1595-1600. 11. Cubito DS, Obremski Brandon K. Psychological adjustment in adult adoptees: assessment of distress, depression, and anger. Am J Orthopsychiatry. 2000;70:408-413. 12. Tieman W, van der Ende J, Verhulst FC. Psychiatric disorders in young adult intercountry adoptees: an epidemiological study. Am J Psychiatry. 2005;162(3):592-598. 13. Robin RW, Rasmussen JK, Gonzalez-Santin E. Impact of childhood out-of-home placement on a southwestern American Indian tribe. J Hum Behav Soc Environ. 1999;2(1-2):69-89. 14. von Borczyskowski A, Vinnerljung B, Hjern A. Alcohol and drug abuse among young adults who grew up in substitute care: findings from a Swedish national cohort study. Child Youth Serv Rev. 2013;35(12):1954-1961. 15. Westermeyer J, Bennett L, Turas P, Yoon G. Substance use disorders among adoptees: a clinical comparative study. Am J Drug Alcohol Abuse. 2009;33:455-466. http://dx.doi.org/10.1080/00952990701315541. 16. Foli KJ, Gibson GC. Training ’adoption smart’ professionals. J Psychiatry Ment Health Nurs. 2011;18(5):463-467. http://dx.doi.org/10.1111/j.1365-2850.2011.01715.x. 17. Foli K, Forster A, Lim E. Nursing students’ perceptions of adoption: an educational preparation needed. J Christian Nurs. 2014;31(4):246-251. http://dx.doi.org/10.1097/CNJ.0000000000000100. 18. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Measure. 1977;1(3):385-401. 19. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two item depression screener. Med Care. 2003;41:1284-1294. 20. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisc Med J. 1995;94:135-140. 21. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252(14):1905-1907. http://dx.doi.org/10.1001/jama.1984.03350140051025.
All authors are affiliated with the College of Health and Human Sciences at the Purdue University School of Nursing in West Lafayette, IN. Anna Forster, MS, is a master’s graduate. Karen J. Foli, PhD, RN, is associate professor. She can be reached at [email protected]. Kathleen Abrahamson, PhD, RN, is an associate professor. Elizabeth Richards, PhD, MSN, RN, CHES, is an assistant professor. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.04.024
The Journal for Nurse Practitioners - JNP
e353
Adults Who Are Adopted: Implications for Nurse Practitioners Anna Forster, MS, Karen J. Foli, PhD, RN, Kathleen Abrahamson, PhD, RN, and Elizabeth Richards, PhD, MSN ABSTRACT
In this article we briefly explore the literature on psychological issues in adults who were adopted as infants or children. Monitoring for signs of psychological risks and staying up to date on appropriate resources are 2 ways nurse practitioners in family and adult primary care can assist their patients who are adopted. These patients are a unique population, and health care providers need to be competent in understanding the dynamics of adoption to enhance the quality of care they provide. Keywords: adoption, adult, psychological disorders Ó 2016 Elsevier Inc. All rights reserved.
INTRODUCTION
I
1
n 2012, 119,514 children were adopted. Approximately, 5 million Americans living today are adoptees.2 This population is heterogeneous, and the exposure to difficult environments before being adopted varies.3 The literature describing outcomes for children and adolescents who are adopted is extensive, yet far less is known about these individuals as they progress into adulthood. Historically, disclosure of the adopted person’s medical history and birth family information has been through closed/confidential or open adoption arrangements. In a closed adoption, no identifying information is exchanged between the adoptive family and birth parents.4 Once the adoption is finalized, the state seals the records. Although there is variation between states, records are usually not available to the individual who has been adopted.4 The second type of adoption, emerging in the mid- to late-1980s5 and increasingly common, is open adoption. Open adoption allows information, such as medical history, to be shared among the adoption triad.4 Research findings support positive outcomes with open adoption: Siegel6 reported that young adults who were part of an open adoption described opportunities to develop identity, expand family, and process feelings. Adults who were adopted have increasingly sought and demanded unsealed birth records to better understand their health histories and reconnect with birth families. www.npjournal.org
Although there is support for resiliency in individuals who have been adopted, psychological issues that may be related to being adopted as an infant or child can appear in adolescence and adulthood. We describe implications for general practice nurse practitioners (NPs), with a focus on risk for suicide, depression, and substance abuse. PSYCHOLOGICAL ISSUES
An increased incidence of suicide among adopted individuals has been found as they progress into adolescence and adulthood. These individuals have 4-fold greater odds of suicide attempts and are 3-4 times more likely to commit or attempt suicide than nonadopted individuals.7,8 Individuals adopted between the years 1946 and 1968 showed a higher rate of suicide during a 14-year time span after adoption, from 1987 to 2001.9 Depression also appears to be a risk factor in adopted persons. Researchers have found that adopted individuals were 1.6 times more likely to develop a mood disorder (including major depressive disorder) throughout their lifetimes.10 Adoptees were found to have significantly higher depression scores when compared with their nonadopted friends.3 Finally, Cubito and Obremski Brandon11 described higher rates of depression in their study of 716 adoptees ranging in age from 21 to 61 years, when compared with nonadopted individuals. The Journal for Nurse Practitioners - JNP
e351
Alcohol and substance abuse/dependence have also been found in higher numbers of adopted persons, who were 2.1 times more likely to meet criteria for substance abuse/dependence than their nonadopted counterparts.12 Hjern et al.7 reported that adoptees were 5 times more likely to be addicted to drugs and 2-3 times more likely to abuse alcohol than nonadopted individuals. A study of adopted southwestern American Indian tribe members found an association with adoption and development of alcohol and drug abuse.13 von Borczyskowski et al.14 found that adoptees had an elevated risk of drug abuse when compared with the general population. Adoptees with parents who had abused substances had a higher rate of substance use disorders in adulthood, and more admissions and treatment for substance use than other individuals.15 Anxiety disorders were also found to be correlated with being adopted. Robin et al.13 found a higher association of anxiety in adopted individuals over nonadopted individuals, especially in women. Adopted adults overall were found to have a 1.5 times greater chance of developing an anxiety disorder during their lifetime.10 Panic disorder without agoraphobia, specific phobia, and generalized anxiety disorder were the most common anxiety disorders among this group.10 Additional, less common, psychological disorders were also present. When compared with nonadopted individuals, there was an increase in antisocial personality disorder in adopted individuals.13 Robin and colleagues13 discovered this problem set did not decrease from childhood to adulthood, as the disorder remained stable over a 20-year period. More research is needed to make conclusions regarding these relationships. IMPLICATIONS FOR ADVANCED PRACTICE NURSES
NPs are in a position to provide informed care to individuals who have been influenced by adoption. A provider who is adoption competent understands the individuality of the experience of adoption while also appreciating the unique dynamics that adoption presents, such as loss and grief, and issues surrounding attachment and identify.16 Educational preparation is key to the NP successfully assessing and treating adult patients who are adopted. Specific e352
The Journal for Nurse Practitioners - JNP
lecture content of adopted persons with psychological and medical needs, which may be overlooked without the context of adoption, should be incorporated into NP curricula for pediatric, family, and adult tracts. This content should begin at the baccalaureate level.17 NP-PATIENT RELATIONSHIP
One of the most important aspects of primary care is the NP-patient relationship. Patients may be unsure of whether the health care provider is comfortable addressing adoption-related emotions or issues. NPs should ensure they communicate that they are available as a resource and support contact to form a crucial NP-patient bond. This bond supports delivery of individualized and holistic care. NPs function as therapeutic listeners, as some adopted persons need to share their experiences to process issues. Although the NP may begin that process, referral to a therapist, who will be available on an ongoing basis, is appropriate. LACK OF MEDICAL HISTORY
Unless the patient has been able to access his or her birth records and family medical history, there will be significant gaps in the medical record. Unknown medical histories may leave individuals feeling vulnerable. They will not know if they are at risk for substance abuse or depression, which can be familial in nature. In addition to a thorough physical exam, the NP should be extra vigilant to remind the patient to obtain recommended screenings and preventive health maintenance. This preventive step could result in early detection of disease states, and potentially decrease morbidity and mortality of the individual. MONITORING FOR DEPRESSIVE SYMPTOMS AND SUICIDE
Patient safety is the highest concern, and the most salient implication for practice is to monitor for signs of suicide risk. Practitioners can screen for suicidal ideation and intent in the primary care setting and effectively triage those patients with positive screens. The Center for Epidemiological Studies Depression Scale18 and Patient Healthcare Questionnaire-219 are valid depression screening tools available to NPs. Volume 12, Issue 8, September 2016
SIGNS OF SUBSTANCE ABUSE AND DEPENDENCE
NPs should also monitor for the signs and symptoms of substance abuse as patients may be in denial or hiding dependence. In the same manner as vigilance regarding depressed mood and suicidal ideation, NPs need to be aware that these patients are susceptible to alcohol and substance abuse, and monitor for signs and symptoms. The CAGE questionnaire is a screening tool that can be used to screen for alcohol abuse, and CAGE-AID can be used for alcohol and drug abuse screening.20,21 If a patient’s screen is positive, referral to a specialist is warranted. CONCLUSION
The NP should provide patient-centered care to individuals who have been adopted as there are many variables that contribute to the risks of suicide, substance abuse, and depressive symptoms. In addition, individuals process the experience of adoption in different ways. NPs need to be aware of the challenges an adult can face as an adopted individual, which may affect aspects of their psychological functioning. Being aware of the risk factors and gaps in medical histories will allow NPs to provide focused, preventive, and quality care. References 1. Children’s Bureau. Trends in U.S. adoptions: 2008-2012. 2016. https://www .childwelfare.gov/pubs/adopted0812/. Accessed February 14, 2016. 2. Herman E. Kinship by Design: A History of Adoption in the Modern United States. Chicago: University of Chicago Press; 2008. 3. Borders LD, Penny JM, Portnoy F. Adult adoptees and their friends: current functioning and psychosocial well-being. Family Rel. 2000;49(4):407-418. 4. National Adoption Center. Types of adoptions. http://www.adopt.org/types -adoptions/. Accessed February 18, 2016. 5. Wolfgram SM. Openness in adoption: what we know so far—a critical review of the literature. Social Work. 2008;53(2):133-142. 6. Siegel DH. Growing up in open adoption: young adults perspectives. Fam Soc J Contemp Soc Serv. 2012;93(2):133-140. http://dx.doi.org/10.1606/1044-3894 .4198. 7. Hjern A, Lindbald F, Vinnerljung B. Suicide, psychiatric illness, and social maladjustment in intercountry adoptees in Sweden: a cohort study. Lancet. 2002;360(9331):443-448.
www.npjournal.org
8. Keyes AM, Malone SM, Sharma A, Iacono WG, McGue M. Risk of suicide attempt in adopted and nonadopted offspring. Pediatrics. 2013;132(4): 639-646. 9. von Borczyskowski A, Lindblad F, Vinnerljung B, Reintjes R, Hjern A. Familial factors and suicide: an adoption study in a Swedish national cohort. Psychol Med. 2011;41(4):749-758. 10. Westermeyer J, Yoon G, Tomaska J, Kuskowski MA. Internalizing disorder in adopted versus non-adopted adults: a NESARC based study. Comprehensive Psychiatry. 2014;55(7):1595-1600. 11. Cubito DS, Obremski Brandon K. Psychological adjustment in adult adoptees: assessment of distress, depression, and anger. Am J Orthopsychiatry. 2000;70:408-413. 12. Tieman W, van der Ende J, Verhulst FC. Psychiatric disorders in young adult intercountry adoptees: an epidemiological study. Am J Psychiatry. 2005;162(3):592-598. 13. Robin RW, Rasmussen JK, Gonzalez-Santin E. Impact of childhood out-of-home placement on a southwestern American Indian tribe. J Hum Behav Soc Environ. 1999;2(1-2):69-89. 14. von Borczyskowski A, Vinnerljung B, Hjern A. Alcohol and drug abuse among young adults who grew up in substitute care: findings from a Swedish national cohort study. Child Youth Serv Rev. 2013;35(12):1954-1961. 15. Westermeyer J, Bennett L, Turas P, Yoon G. Substance use disorders among adoptees: a clinical comparative study. Am J Drug Alcohol Abuse. 2009;33:455-466. http://dx.doi.org/10.1080/00952990701315541. 16. Foli KJ, Gibson GC. Training ’adoption smart’ professionals. J Psychiatry Ment Health Nurs. 2011;18(5):463-467. http://dx.doi.org/10.1111/j.1365-2850.2011.01715.x. 17. Foli K, Forster A, Lim E. Nursing students’ perceptions of adoption: an educational preparation needed. J Christian Nurs. 2014;31(4):246-251. http://dx.doi.org/10.1097/CNJ.0000000000000100. 18. Radloff LS. The CES-D scale: a self-report depression scale for research in the general population. Appl Psychol Measure. 1977;1(3):385-401. 19. Kroenke K, Spitzer RL, Williams JB. The Patient Health Questionnaire-2: validity of a two item depression screener. Med Care. 2003;41:1284-1294. 20. Brown RL, Rounds LA. Conjoint screening questionnaires for alcohol and other drug abuse: criterion validity in a primary care practice. Wisc Med J. 1995;94:135-140. 21. Ewing JA. Detecting alcoholism: the CAGE questionnaire. JAMA. 1984;252(14):1905-1907. http://dx.doi.org/10.1001/jama.1984.03350140051025.
All authors are affiliated with the College of Health and Human Sciences at the Purdue University School of Nursing in West Lafayette, IN. Anna Forster, MS, is a master’s graduate. Karen J. Foli, PhD, RN, is associate professor. She can be reached at [email protected]. Kathleen Abrahamson, PhD, RN, is an associate professor. Elizabeth Richards, PhD, MSN, RN, CHES, is an assistant professor. In compliance with national ethical guidelines, the authors report no relationships with business or industry that would pose a conflict of interest. 1555-4155/16/$ see front matter © 2016 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.nurpra.2016.04.024
The Journal for Nurse Practitioners - JNP
e353