What Challenges Might We Experience Once a Child Joins
Our Home through Adoption or Fostering?
By Staci England MSW, Hollie Wan B.Sc., and Erica Liu Wollin PsyD
The initial period after placement may not be as smooth as many adoptive or foster parents may hope. Issues for both parents and children can surface quickly or gradually and some parents may feel they do not have all the necessary tools to cope with the unfolding situation. Below are some questions that may arise for your family and information to help you decide how best to navigate these challenges.
“Why do I feel negative feelings or no feelings at all toward this child?”
There is a tendency on the part of parents who have chosen adoption or foster care to expect the bond between themselves and the child to develop naturally and quickly. However, it is important to be patient with both yourself and the child during the early periods of adjustment.
Not all adoptive or foster parents fall in love with a child the minute they enter the family. If this is your experience, you are not alone and it is okay to acknowledge these feelings. You have only recently met this child and it will take time to become familiar with your adopted or foster child. Similarly, these children have experienced great loss, and need time to adjust to their new home, feel safe, and learn to interact warmly with new people. You may not feel reciprocity at first, which could affect your initial feelings (Davenport, 2016).
“I’ve been eager for this child to join my home, so why am I feeling so low?”
Postnatal Depression has become a recognized struggle which is now frequently met with compassion and understanding. Unfortunately, Post-Adoption Depression is rarely discussed, although it is not a rare occurrence with 18-26% of mothers reporting some struggle. Circumstances that contribute to Post-Adoption Depression include unmet expectations, fatigue, lack of social support, discovering unknown special needs, and previous struggles with infertility (Neubert, 2012 & Nazarov, 2013).
Amy Rogers Nazarov (2013) described her Post-Adoption Depression: “Around week four, my appetite waned. I started bursting into tears for no reason at all… I became preoccupied… I began missing work deadlines, ignoring calls from friends, wearing the same ratty black pants day after day. Sleep was strangely elusive.”
Adoptive parents find it difficult to discuss these feelings because they wanted the adoption so much and have worked so hard to bring the child home. The adjustments necessary to welcome a child home through adoption require just as much time off work and support from friends and family as bringing a child into the family by birth. Yet parents may feel shame or guilt for struggling, and feel there is nowhere to talk about the way they are feeling. If you are struggling with Post-Adoption Depression, counseling or a support group with other newly adoptive parents can be helpful to address your feelings.
“I feel alone, burnt out. I have no space to care for myself.”
It is important to be mindful of your own mental and emotional condition, especially during difficult transitions. Bringing an adopted child home requires many shifts in routine, lifestyle, and identity. All of this can become overwhelming (Neubert, 2012). Well-prepared adoptive parents work hard to ensure the child’s primary attachment is established with them, and avoid lots of other people caring for or holding their children; however this can lead to exhaustion and disruption of parental self-care.
If you have not already created a community of support for your family, now is the time to enlist family and friends to be intentional in creating a nurturing and supportive environment for your family. You may need to be more willing to ask for help from your partner, your family, your community, or bring in some outside assistance. However, help that doesn’t understand the unique issues of adoption can be quite frustrating or even add stress rather than decrease it; so you may also need to help others understand your child in order to be of more help to you. A short article on talking to your family and friends can be found here (Singer, 2016).
“How can I tell if my adopted or foster child is struggling with attachment?”
Every child has a unique personality and set of experiences, so it is to be expected that some children will take a longer time to adapt to their new environment. For those who have experienced trauma, allowing themselves to feel safe and accepted by their new family can be especially difficult.
Most children learn to attach from the way their early caregivers cultivate attachment and are likely to develop the same style (Qualls, Corkum, & Buckwalter, 2019). This means attachment can be complicated for children who have been looked after by multiple caregivers due to institutional care or multiple foster placements, or for those who have experienced abuse and/or neglect.
According to Attachment Theory, children develop one of four attachment styles:
1. Secure attachment, 2. Ambivalent / Preoccupied attachment 3. Avoidant / Dismissing attachment, 4. Disorganised attachment
● Can separate from parents to explore
● Greets parents’ return positively
● Prefers parents to strangers
● Will seek out parent when frightened or upset
● May be wary of strangers
● Very distressed when parents leave
● Not easily comforted when parents return
● May avoid parents
● Does not seek contact of comfort from parents
● Little or no preference for parents over strangers
● Mixture of avoidant and resistant behaviour
● May seem dazed, confused, or apprehensive
● Around age 6, may take on a parental role toward other children or parent
From Cherry (2020)
For children that have had strong bonds with birth or foster families, those early experiences of learning to attach will help them with attaching to you and others throughout life. But this also means they will likely need time and help grieving the loss of those close relationships.
It is a common misconception that if a child is affectionate, it means they have no attachment issues. In actuality, a child may be affectionate but solely on their terms, or overly affectionate with anyone (indiscriminate/disinhibited), or affectionate yet terrified of abandonment and thus constantly seeking affection in order to be reassured. These are all signs of potential attachment issues if the behaviour is prolonged (Qualls, Corkum, & Buckwalter, 2019).
Attachment is not an either/or concept. It is more like a continuum in which some children develop a secure attachment easily and others struggle to varying degrees. If your child is struggling to attach, it does not mean you have done anything wrong, but there may be things you can do to help. You can find out more about attachment styles through the resources below or by speaking with a therapist who is familiar with attachment issues.
“Why is my child behaving like this?”
Many parents are perplexed by behaviours they see in their adopted or foster children. If your adopted child is exhibiting difficult behaviours, here are factors to consider:
Biological Factors: Hunger, fatigue, or under-hydration can profoundly impact behaviour. Keep a regular routine with plenty of healthy snacks and water. It is a good idea to provide these before a child is overly hungry or thirsty, as some adopted or foster children have difficulty sensing their bodily cues. Additionally, vitamin deficiency or other hormonal imbalances can affect sleep, energy levels, and brain chemistry needed to manage emotions and behaviours (Purvis & Cross, 2018). You can talk with your pediatrician about supplements or medications that may help balance your child’s body chemistry.
Expression of Needs: It is important to remember that all behaviour is a form of communication. Many children in adoption or foster situations did not have responsive, attuned caregivers to show them healthy ways to express feelings. This leaves them struggling to communicate through behaviours that you may find confusing, scary, or hurtful. This table offers some possible ways to interpret behaviours that your child is exhibiting 
Stress Responses and Trauma: Behaviours can also be rooted in the state of your child’s nervous system. Though wired for connection, the nervous system also scans the environment for threats. Each person’s nervous system will perceive different things as threats, based on both chemical makeup and past experiences (Dana, 2018). A healthy nervous system has a wide “Window of Tolerance”, while one exposed to early adversity may have a narrower window. This can lead to stress responses that are markedly intense, or shut down (Gill, 2017, Johnson 2019).
Children can also experience trauma triggers in their environment which they cannot express. From their environments and interactions with caregivers, they also developed survival skills to help them cope. For instance, a child may learn to imitate violence or to lie to avoid abuse from a caregiver, or to steal or hoard things to make sure their needs are met. While distressing, these behaviours may have developed as a survival strategy for your child (Purvis & Cross, 2018).
Read on to learn more about trauma and how it affects our parenting.
“Has my child experienced trauma?”
It can be easy to ignore your adopted or foster child’s past experiences and focus on building a healthy new relationship. Unlike a biological child who has had mostly a shared history with their parents since conception, an adopted or foster child has also been shaped by previous experiences of which adoptive or foster parents may be unaware. This trauma can include aspects such as a birth mother using substances while pregnant or living in chronic stress, the child feeling rejected by their birth parents, being left to cry for long periods of time, and/or physical or psychological abuse or neglect while staying in birth or foster homes or institutions.
Young children also don’t remember their story in a way they can verbally express with others, but their bodies remember what they have lived through and respond accordingly (Purvis & Cross, 2018). This can be evidenced in their insecurities, behaviours, and reactions.
It is important to acknowledge what your child has or may have been through and look for patterns in their responses. We discuss trauma-informed parenting approaches next. You may also need to work with a therapist experienced in attachment and preverbal trauma specifically; a team approach to address the experiences your child has faced will make a strong foundation.
“Am I using parenting strategies that are not a good fit for my foster or adopted child?”
At the root of all adoption or fostering situations is an experience of loss for a child. The impact of this loss can vary based on the experiences that follow and all these experiences and memories your child brings into the home should be considered in parenting.
The experience of loss or trauma can leave children extra sensitive to feelings of rejection or prone to behaviours that they learned for survival that seem manipulative (Purvis & Cross, 2018). Parenting approaches that are mindful, offer connection, explain transitions, and share some control can reduce anxieties that lead to aggressive lashing out or silent withdrawal and shut down. In contrast, parenting that is very rigid, withdrawn, or punitive can add to the child’s fears and feelings of abandonment.
Find out more about attachment and/or trauma informed parenting approaches here .
“I didn’t expect to need to parent this way. This wasn’t how I was raised. This child pushes my buttons.”
We previously discussed the attachment styles of children  . However, every person - including yourself - has had some experience of attachment, or the lack thereof, in their childhood history. Your relationship with your own caregivers may give invaluable insight into your reactions to your child’s behaviours. Adoption therapist Karen Buckwalter gives this example: “I often have parents that … say things like ‘well, we are not allowed to be angry at my house,’ that means that person is completely unprepared for the level of anger some of these children may be expressing” (Qualls, Corkum, & Buckwalter, 2019). If your parents even now are judging your parenting, or express values and beliefs about parenting that contradict to what you have committed to through your adoption preparation and training, this may cause additional stress or confusion.
It’s important to understand why certain behaviours from your child may cause you to feel more frustrated or anxious than others. Being attentive to your own emotional status will help you thoughtfully choose responses to behaviours that may be eliciting emotional reactions and will help you notice and repair any breaks in the relationship more quickly (Bryson, 2020). These repairs in your relationship are essential for building resilience in your child.
Spend time reflecting on the nature of your relationship with your caregivers in order to gain understanding of yourself. You may also want to take the Adverse Childhood Experience (ACE) Scale to find out your score and understand how this might have impacted you.
Knowing your own attachment style and background may help you understand and shift your reactions, and to respond differently to your child’s behaviours, thus helping your child behave differently with you. It can also improve your own mental health! The book Parenting from the Inside Out can guide you in understanding how your childhood is impacting your parenting. You can also find out more about your attachment style here and work with a therapist so you can learn and grow alongside your adopted child.
“Is my child grieving? What can I do about it?”
Adopted and foster children often grieve the losses and transitions they are experiencing, and young children may not have the verbal ability to express what they are feeling. As adults it is important for us to pause and think about the abilities of our children, not only based on their chronological age, but also their developmental stage. Grief in children can look like sadness, rage, confusion, or relief, and it may be more likely to show itself in play or art rather than words. Grief can also be seen in regressive behaviours like thumb sucking, bedwetting, separation anxiety, aggression, or risk taking (Jackson, 2015).
You can help your child by recognizing grief in these different behaviours, and creating space to communicate about the loss with words and through art or play. You could say, “You seem really sad right now. It is hard to miss people we love. What could we do to help that hurt in your heart feel better?” Many people believe that children cannot handle the truth, but they are feeling the loss regardless. Not speaking about the loss only leaves children to grieve alone (Jackson, 2015).
You can find activities to help children process grief through The Dougy Center (National Center for Grieving Children & Families) and by working with a therapist.
“It doesn’t matter that my child is a different race than me, does it?”
It is wonderful that you as adoptive and/or foster parents love your child no matter where they are from or which race they are. If you have opted for transracial adoption, and you have noticed signs that your child is struggling, being part of a transracial family would be a crucial variable to consider as you work to understand how your child is feeling and help them cope.
Your child can experience micro aggressions - incidents of indirect or subtle discrimination - as early as kindergarten (Wintner, Almeida, & Hamilton-Mason, 2017). Being on the receiving end of micro-aggression, whether intentional or not, can contribute to struggles your adoptive or foster child is facing and should not be overlooked. Older adopted and foster children will be more aware of race and may have complex feelings or internal conflicts regarding being in a transracial family. If parents are aware of this possibility from the beginning, sensitivity to these issues can go a long way in helping your child establish trust and settle into a loving relationship.
“My child’s behaviours are very extreme. What else could be going on?”
If your child is exhibiting very extreme behaviours such as aggression which makes others feel unsafe, chronic lying or stealing, ongoing self-injury, prolonged rages, inconsolable crying, inability to calm down, or other behaviours of concern, it would be important to consider what other factors might be affecting your child. These issues could be rooted in prenatal exposure to substances which was overlooked or not disclosed, reactive attachment disorder, or another special need which has not been identified. It is also important to work with a professional who is experienced in these issues.
Prenatal Substance Exposure: A significant percentage of children in adoptive or fostering situations have been prenatally exposed to substances. There is a set of disorders caused by prenatal alcohol exposure known as Fetal Alcohol Spectrum Disorders (FASDs). You may also have come across this disorder being referred to as Fetal Alcohol Syndrome (FAS), which is a type of FASD. Symptoms of FASD include inattentiveness, difficulty with behaviour and impulse control, poor memory, and difficulty with emotional regulation. For more information on FASD, you can visit FASD Hub.
Other substances such as methamphetamines, marijuana, heroin, and cocaine can also impact neurological development and lead to emotional and behavioural difficulties (Chasnoff, 2019).
If these symptoms are reflected in your child’s behaviour, and your child’s history is either unknown or would suggest the possibility of prenatal exposure, it is important to consider whether your adopted or foster child could have an FASD or a neurobehavioral disorder due to drug exposure. As with many disorders, early intervention offers the best chance for your child’s future by finding necessary accommodations and supports (Streissguth et al, 2004).
Reactive Attachment Disorder: Reactive Attachment Disorder (RAD) is a rare condition seen in children who experienced extreme abuse or neglect are unable to establish a bond with primary caregivers. Infants and young children with RAD will not smile or react to parents, appear withdrawn and disinterested in others, and will not seek out comfort from a caregiver, preferring to soothe and nurture themselves. These children may also have unexplained episodes of irritability, sadness, or fearfulness (Child Mind Institute, 2020). Some of these episodes can include behaviours that are violent and threatening to other family members, leaving parents struggling with their own fears and feeling desperate for help. For children with RAD, the previous home environment was a place of danger and the closeness family members desire is perceived as a threat, making home an exceptionally difficult place for these kids (Qualls, Corkum, & Buckwalter, 2019).
It is important to be selective in seeking treatment for RAD. There are several unproven and potentially harmful “treatments” that have been used, including restraint, deprivation, and some “boot camp” style approaches (Psychology Today, 2017). You can learn more about attachment-focused, trauma-sensitive therapy here and how to choose a therapist here .
Other Previously Unidentified Special Needs: A birth parent’s mental health issues may have been a significant reason they were unable to care for their child, or an underlying factor driving substance use. This may or may not be noted in your child’s paperwork, so it is important to be aware of mental health issues or developmental conditions where genetics play a part. These include, but are not limited to: Attention Deficit/Hyperactivity Disorder (ADHD), Major Depressive Disorder, Bipolar Disorder, Schizophrenia, Autistic Spectrum Disorder (Gandal et al, 2018), Anorexia Nervosa (Dockrill, 2019), and Obsessive Compulsive Disorder (Chen, 2017).
Considering these other factors can be overwhelming, because many parents did not anticipate such challenges and were not prepared for them. There is hope, however, in the wealth of information and support groups available online. And with the support of a competent mental health professional, you can work towards an accurate diagnosis, and your family can learn new ways to adapt and cope with these challenges.
By Staci England MSW, Hollie Wan B.Sc., and Erica Liu Wollin PsyD
“為什麼我對這個孩子有負面情緒或沒有感覺？”領養父母或寄養家庭經常期望自己和孩子之間的感情會自然和迅速地增長。但是，在最初階段，對自己和孩子有耐性是很重要的。 其實並不是所有領養父母或寄養家庭會在孩子進入家庭的一刻立即愛上他。如果您也有類似經驗，您並不孤單，這些感受是可被接受的。您剛剛才遇上這個孩子，因此您需要一些時間才能認識他。同樣，這些孩子曾經經歷過重大的缺失，亦需要時間適應環境的轉變。他們需要時間去確認新環境是安全的，同時亦在學習與新認識的人交流。剛開始時您未必得到孩子熱烈的回應，這亦可能會影響您對孩子的最初感覺 (Davenport, 2016)。
Amy Rogers Nazarov（2013）是這樣描述患上領養後抑鬱症的情況： 「在迎接孩子回家後的第四週，我的食慾下降了。我開始無緣無故地哭泣… 我的專注力下降了… 我開始趕不上工作的進度，無視朋友的電話，日復日地穿著同樣的黑色褲子。我也失眠了。」
壓力反應及創傷：這些行為有可能是由孩子神經系統的狀態所致。除了與外界連接，神經系統也會探測環境中的威脅。根據化學組成的部分和以往的經歷，每個人的神經系統也會將不同的事物視為威脅（Dana，2018年）。健康的神經系統是具有寬廣的「容納之窗」，但當在年幼時遇過逆境的人，他的窗口就可能會較窄。這可能使壓力反應明顯加劇或停止運作（Gill，2017; Johnson 2019）。
孩子亦可能在身處的環境中經歷創傷，卻無法表達。孩子在他們身處的環境中透過與照料者的互動，會培養出各種生存技能 (Survival skills) 來幫助他們應對創傷。例如，兒童可能學會模仿暴力或說謊行為來逃過照料者的虐待，或以偷竊或囤積東西的行為以確保他們的需求得以被滿足。雖然這些行為令人苦惱，但卻可能是您孩子的生存策略（Purvis＆Cross，2018）。
您可以花一些時間反思您與照顧者的關係以加深對自己的認迫。您可以考慮使用Adverse Childhood Experience (ACE) Scale量表以了解自己的童年經驗所帶來的影響。
您可以協助您的孩子在不同的行為中分辨及認識悲傷的情緒，並創造空間用言語、藝術或玩樂就過去的缺失進行交流。您可以說：「你現在似乎非常難過，想念著自己愛的人卻不能與他們見面真的很痛苦。我們該怎麼辦才能使您內心的痛苦減輕？」許多人認為孩子們無法接受真相，但無論如何他們都感到悲傷。不談論缺失只會讓孩子們感到更悲傷孤獨（Jackson，2015）。 您可以通過The Dougy Center (National Centerfor Grieving Children & Families) 和咨詢治療師尋找幫助兒童處理悲傷的活動。
您的孩子在就讀幼稚園時，就 可能遭受微歧視 - 間接或不顯眼的歧視（Wintner，Almeida和Hamilton-Mason，2017）。無論微歧視是有意還是無意，您的孩子正在面對的困難不應被輕視。年紀較大的孩子會更留意自己的膚色，並因而對於自己身處異族家庭產生複雜的感受或感到矛盾。如果父母及早注意到這些可能出現的狀況，並了解孩子的感受，將更有助您與孩子建立信任和親密關係。
反應性依戀障礙：反應性依戀障礙（RAD）是罕見的疾病，通常發生在飽受虐待或忽視而無法與照料者建立關係的兒童之上。患有RAD的嬰幼兒不會對父母微笑或作出反應，顯得孤僻和對他人不感興趣，也不會向照顧者尋求安慰，反而會更喜歡自己去安慰自己。這些孩子可能還會出現無法解釋的憤怒、悲傷或恐懼（Child Mind Institute，2020），包括使用暴力和威脅其他家庭成員的行為，讓父母感到著恐懼和無助。對於患有RAD的孩子來說，以前的家庭環境是一個危險的地方，因此緊密的家人關係是一種威脅，這些孩子會覺得家庭是一個異常困難的地方（Qualls，Corkum和Buckwalter，2019）。
As adoptive or foster parents, it is in your child’s best interest to find out as much information as you can in these areas. And the more you know the better equipped you will be to help your child and find the right supports for their success. There are many resources available online to help you get started.
General Information about Adoption and online communities of support:
- Adoptive Families of Hong Kong - https://www.afhk.org.hk/
- Center for Adoption Support and Education - https://adoptionsupport.org/
- Creating a Family - https://creatingafamily.org/
- The Adoption Connection - http://www.theadoptionconnection.com/
- The Honestly Adoption Company - http://www.honestlyadoption.com/
Resources for FASD and/or substance exposure:
- FASD Forever - http://fasdforever.com/
- FASD Hub Australia - https://www.fasdhub.org.au/
- NTI Upstream - https://www.ntiupstream.com/
Resources for grief:
- The Dougy Center (National Center for Grieving Children & Families) - https://www.tdcschooltoolkit.org/kids
Resources from adult adoptees:
- The Adopted Life Blog - https://www.theadoptedlife.com/
- Adoptees On - http://www.adopteeson.com/
Resources for mental health issues and challenges:
- The Child Mind Institute - https://childmind.org/
- OCD and Anxiety Support HK - https://www.ocdanxietyhk.org/
- Mind HK - https://www.mind.org.hk/
- Focus On Children’s Understanding in School (FOCUS) - https://www.focus.org.hk/
Bryson, T. (2020). The Power of Showing Up. I Am Mom Summit. Retrieved from: https://www.youtube.com/watch?v=9Cw5JBDPbZM
Chasnoff, I. (2019, November 20). The Mystery of Risk: Drugs, alcohol, pregnancy and the vulnerable child. Insight Conference 2019. Indianapolis, Indiana. https://www.facebook.com/groups/insightlivestream2019/
Chen, A. (2017, October 17). Search Of DNA In Dogs, Mice And People Finds 4 Genes Linked To OCD. Retrieved June 13, 2020, from https://www.npr.org/sections/health-shots/2017/10/17/558300775/search-of-genes-in-dogs-mice-and-people-finds-4-linked-to-ocd
Cherry, K. (2020, June 4). The Different Types of Attachment Styles. Retrieved August 01, 2020, from https://www.verywellmind.com/attachment-styles-2795344
Child Mind Institute. (2020, July 12). Quick Facts on Reactive Attachment Disorder. Retrieved August 01, 2020, from https://childmind.org/article/quick-facts-on-reactive-attachment-disorder/
Dana, D. (2018). “A Beginner’s Guide to Polyvagal Theory”. Retrieved from: http://www.debdanalcsw.com/resources/BG%20for%20ROR%20II.pdf
Davenport, D. (2016, August 28). "I Feel Like a Beast, but I Don't Love My Adopted Child". Retrieved from https://creatingafamily.org/adoption-category/feel-beast-love-adopted-child/
Dockrill, P. (2019, July 16). New Genetic Links Reveal Anorexia Could Be Much More Than a Psychiatric Condition. Retrieved June 13, 2020, from https://www.sciencealert.com/new-genetic-links-reveal-anorexia-could-be-much-more-than-a-psychiatric-condition
Gandal, M., Haney, J., Parikshak, N., Leppa, V., Ramaswami, G., Hartl, C., . . . PsychENCODE Consortium. (2018, February 09). Shared molecular neuropathology across major psychiatric disorders parallels polygenic overlap. Retrieved June 13, 2020, from https://science.sciencemag.org/content/359/6376/693
Gill, L. (2017, November 25). Understanding and Working with the Window of Tolerance. Retrieved June 07, 2020, from: http://www.attachment-and-trauma-centre-for-healing.com/blogs/understanding -and-working-with-the-window-of-tolerance
Jackson, K. (2015). How Children Grieve — Persistent myths may stand in the way of appropriate care and support for children. Social Work Today, 15(2), 20. Retrieved from https://www.socialworktoday.com/archive/030415p20.shtml
Johnson, C. (2019, August 16). Window-of-tolerance. Retrieved August 22, 2020 from: https://q4-consulting.com/getting-good-at-stress/window-of-tolerance/
Nazarov, A. (2013, April 03). We Adopted a Beautiful Baby. Then I Got Depressed. Retrieved August 01, 2020, from https://slate.com/human-interest/2013/04/post-adoption-depression-its-as-crippling-as-postpartum-and-much-less-recognized.html
Neubert, A. P. (2012, March 22). Expectations, exhaustion can lead mothers to post-adoption stress. Retrieved August 01, 2020, from https://www.purdue.edu/newsroom/research/2012/120322FoliResearch.html
Purvis, K. & Cross, D. (2018). TBRI 101: A Self-Guided Course in Trust-Based Relational Intervention. Fort Worth, Texas.
Qualls, L., Corkum, M., & Buckwalter, K. (2019, August 20). The Truth About RAD with Karen Buckwalter. Retrieved from http://www.theadoptionconnection.com/episode-51/
Psychology Today. (2017, June 21). Reactive Attachment Disorder. Retrieved August 02, 2020, from https://www.psychologytoday.com/intl/conditions/reactive-attachment-disorder
Singer, E. (2016) Holidays with extended family: An opportunity for connection. [PDF]. Center for Adoption Support and Education. Retrieved July 05, 2020 from: https://adoptionsupport.org/wp-content/uploads/2016/01/Holidays-with-Extended-Family-An-Opportunity-for-Connection.pdf
Streissguth, A.P., Bookstein, F.L., Barr, H.M., Sampson, P.D., O’Malley, K., and Young, J. K. (2004). Risk factors for adverse life outcomes in fetal alcohol syndrome and fetal alcohol effects. Journal of Developmental Behavioral Pediatrics, 25(4) , 228-238
Wintner, S., Almeida, J., & Hamilton-Mason, J. (2017). Perceptions of microaggression in K-8 school settings: An exploratory study. Children and Youth Services Review, 79, 594–601. doi: 10.1016/j.childyouth.2017.07.020