Season 1, Episode 9: Dr. Maria Kroupina, a pediatric psychologist at the Adoption Medicine Clinic at the University of Minnesota and the director of the Birth to Three Program and the Early Child Mental Health Program, discusses her role in promoting positive mental health outcomes for adoptees. She describes the history of the Adoption Medicine Clinic and the research and clinical work conducted by their team. She outlines her own role in supporting parents to provide a buffering relationship for their children as they encounter and cope with stressors. In discussing the interdisciplinary work at the clinic, she highlights the role of attachment and specific intervention approaches used by their team to support children following early experiences of abuse and neglect.

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Dr. Emily Helder: Hi, welcome. I’m Dr. Emily Helder and I’m here with Dr. Maria Kroupina. She’s a pediatric psychologist with the Adoption Medicine Clinic at the University of Minnesota, and she’s also the director of the Birth to Three Clinic and the Early Child Mental Health program.

Her academic work focuses on the development of children who have experienced early adversity or toxic stress, identifying those children early, getting them intervention to try to prevent negative long-term outcomes. And she’s also the co-author of a chapter in the Handbook of Adoption entitled “Adoptees with disabilities and medical concerns.”

So welcome. Thanks so much for being here. So I’d like to start by asking you a bit about your role at the Adoption Medicine Clinic. Can you tell me how you came to be in that role and what kinds of things you enjoy about your work?

Dr. Maria Kroupina: I do have a very long relationship with the clinic and, myself, as you hear from my accent, when I joke that I’m from Minnesota, people don’t trust me because you can hear right away that, you know, my accent is, can let you know that I am from Eastern Europe. I’m from Moscow, myself. I did clinical degree in clinical psychology, which is equals about the master’s and child clinical psychology in Moscow. And then I came to do my PhD at the Institute of Child Development, which is, one of the best, I think is still considered the best program, graduate programs in child psychology in United States. I came to do my PhD and I think it was my second year when I started Child development that Dr. Dana Johnson, and it would be like ’96, ’97 something, you know, he, when he came to talk about, you know, children that they start to see in the clinic, before when  they were seeing the little infants from Korea and India, they did know how to help them as a medical team. But when they started to see Eastern European children, they had so many questions and so many questions about development and the children are old and they didn’t know how to help them. It started to research that Institute became an engaged in the research and I, I as a graduate student, probably we did run the first research participant, uh, from one of the Eastern European countries at that time. Then that became a wave of research funded by NIH,  in Minnesota, in the United States and Romania that I think that changed the conceptually, how we see early mental health and how we see early adversity, risk factors, how we are developing not only our next research questions, but also how we’re developing clinical programs. Ah, that’s why I was able and was lucky to be with the program starting really at the beginning when, you know, like people asking, what about mental health? We’ll have medical doctors. We have OT, we have PT.

What, what mental health, correct. Okay. That was, that’s where we were. Uh, and now, now we see how much we need each of these areas and how we need to work together to emphasize the complexity of the issues these children have. As far the history, I did go from graduate student to do research to do clinical work, to right now.

I’m, I’m very proud of all the work our clinic is doing with foster care children, and we also develop based on what we learn about early development, we develop our own program, Birth to Three that  is also designed for other high risk groups of young children.

Dr. Emily Helder: Yeah. And I wanted to ask you a little bit about that Birth to Three clinic.

Could you say a bit more about what kinds of services are offered there? What, what that looks like.

Dr. Maria Kroupina: We do have, this clinic is designed for the children birth to three who experience multiple risk factors and it’s again, the first group is, we started with children, adopted from institutional care, now we are seeing foster care children, but it’s also a big group of children who were exposed to stress due to medical conditions.

Due to, like NICU babies, children with heart transplants, other complex medical conditions who go for hospitalization. Possible stress related to pain, maybe the isolation from parents, to different risk factors. That’s kind of the groups that experience really high level of stress. But we do work, of course, with primary pediatrics clinics and sleep problems, the problems related to parental stress that we also engage, but the idea of this program to help, to integrate understanding of mental, early mental health, early brain development into pediatric practice from a specialty clinic like Adoption Clinic to primary care. And also we do have an outpatient clinic that we see the children, we’ll provide intervention, and now we’re starting to do more and more inpatient, uh, work when we can see babies in, when they are in the hospital with their parents, it’s kind of the scope of the work we are doing.

Dr. Emily Helder: Wow.

That sounds like a really unique, uh, opportunity, interdisciplinary and really targeting a wide range of ages for kids. That’s really exciting.

Dr. Maria Kroupina: And I want to stress. I think we would never be there if not for the work with adoption medicine program. Historically I think it’s important to recognize it’s a, this program is pioneering so many ideas from research to clinic that then they become a part of our work, but then we also can translate to other populations. It’s been historically the program that very on top on doing research, learning from research and moving forward with the most innovative ideas.

Dr. Emily Helder: Yeah. And that’s actually why we were so excited to have your team participate in the Handbook, because I think there’s lots of people around the world that recognize your clinic and the innovative approach.

Yeah, I wanted to ask you a bit about the chapter. So the beginning of the chapters starts with a history, a background of adoption with a special focus on adoption of children with disabilities or with, with medical concerns. You alluded to this a little bit, in what you said earlier about when Dr. Johnson approached you, how things were changing in terms of what kinds of kids were coming. Um, but I’d love for you to say a little bit more about how you’ve seen the trends in adoption changing in your clinical work, in the kinds of kids that you’re seeing, in the kinds of things that you need to address.

Dr. Maria Kroupina: As I said initially it was more like babies coming, but then we have a big, big trend of children from institutional care in Europe, in China. That would be the major countries when we saw children coming in. Initially that we all thought that that’s quite a new group will not be able to learn from this group.

And that’s where kind of, we became struck by how much similarities between, what we see in this group to children that we are seeing, traveling from one foster care family to another, seeing abuse, neglect that we conceptually can really learn from children from institution. And you ask about the trends, definitely, um, unfortunate, sad trend, uh, that we don’t see this adoption for multiple reasons.

And we all hope that it would be a reason that this family, more families adopt children domestically, it’s unfortunately not completely the case and many, it’s very related to political issue and like Russia, we, I was myself participating in raising the voice of the children. We all understand that it’s more to that than, uh, the will of the parents to open their hearts and as professionals to help them, uh, right now, would we definitely see, uh, less of children coming from institutional care internationally, but we see more children adopted from foster care domestically, which is wonderful, wonderful and how many children need help? And, um, I do feel like we’re better prepared. We have more resources it’s far from enough, or not enough from what we need to give to these families and to the children. And I always, you know, tell parents when we talk to them that, uh, you know, parents feel guilty when they can’t help a complex child, particularly if it’s a mental health needs.

And I do feel like as a society, we need to raise our voice. And I hope for this chapter and the more we talk about this will help our society to understand. If you raise a child with medical condition, like for example, a child with cardiac problem we always train parents. We help them to understand them.

We’ll give them specialists. We’re not as good about mental health in early development, in understanding of neglect, abuse, prenatal exposures. We need to be outspoken about this, and we need to be proactive in helping parents. The parents would not feel overwhelmed and they will feel prepared and ready. We all strongly believe that, um, that will change the world and, uh, what we, um, and over the years we saw in terms of the best intervention for any child is the family, the best intervention for the family is preparation and preventative care, not catching up when we see this family already coming to us with enormous need when the child like years in the family. No we need to prepare and we need to understand these children need a longitudinal, um, clinical follow up that allow us to assess and give help at different point of development. It’s not about one time.

It’s about being available for parents to know where the resource is and I would say I find it the most rewarding when we hear from parents say, when something happens, they say, Oh good. We know who we can email and ask the question, find resources. We’re not yet there with all we want to be. But I would say in the years that I’m again, the first I’m trying to remember what it was, whether ’96 or ’97 when it was my first time in the clinic as a graduate student. We are far from this place, we’re far, but we still are learning. And I do think we need to be outspoken as much as possible. And I do hope that we will be able to continue to do as much as possible training. We need to train professionals out there who can do this work and who can create the centers like our center to prepare families and provide support for them, through the years as they’re helping their child, because brain is a mystery, a mystery we all learn every day and by supporting child and supporting the parents, we can reach the points that we never believe at the beginning. And we do have so many wonderful stories to share.

Dr. Emily Helder: Yeah. Yeah. It seems that your model, if it could be replicated it would really help reduce some of the adoption disruption, adoption dissolution, some of that model of giving that prevention and education at the front end and helping early before problems get, um, more intense, you know, can help keep kids more stable in families.

Dr. Maria Kroupina: Yeah, that’s what we’re hoping, that we’re working toward. That’s why we collect data. We’re trying to think and analyze always what will work, because we, that’s, that’s an idea to develop a model. And for me that what we are moving to, with servicing more children, not only domestically adopted, but in foster care and working with biological parents with foster families that’s unique  opportunity to give more services for these children to see less disruption and that outcome.

Dr. Emily Helder: Yeah. Yeah. When you, one of the things that I read in the chapter as we were working on, it was about the assessment that’s done of children and of families early on, you know, shortly after the adoption placement and in the assessments afterwards. And one of the things that was discussed in the chapter was about buffering relationships  for kids who’ve experienced early stress. And I wonder if you could say a bit more about what that looks like, like what kinds of behaviors are you looking for parents to be doing? and why is that so important?

Dr. Maria Kroupina: Uh, you know, uh, it’s important to understand that any human infant born will need to be taken care of, you know, like, and in parent’s response to the child behavior, you know, like child’s crying and responding, that’s a buffering practice. It’s not the magic, it’s things parents do intuitively every day. And that’s an optimal relationship that develops very slowly as a building over the year, first years of life, starting the first day.

And it’s by learning this, understanding your child. Hearing the child and seeing and responding to them and then slowly moving also a child to learn that sometimes child won’t get their way and it’s safe and it’s okay to be frustrated, but in those crying, um, little one who is sitting on the floor wants extra cookie, but it’s also buffering if mom or dad saying “you’re okay, you just upset because you want a cookie, but unfortunately it’s not possible.” That’s a buffering because they are parents communicating a very kind supportive relationship with child to learn frustration. And that’s all these moments that they build the healthy brain. And, you know, if we know that, uh, any experience, almost any experience, you remember, you know, I saw children from the Haiti earthquake of one child experienced this with parents and another child was, um, from institutional care home was dropped on the street and at two, both kids, why the effect is so different, correct? Because if you’re with parent, parents can protect, understand, see the need. If a child is doing this on their own that’s when we talking about toxic. When we are talking about too much and overwhelmed, of course, the most devastating for child when protective relationship becomes, um, you know, less protective by abusing or neglect. That’s what we see is very complex. And that’s unfortunately what the problem is, to get these kids who experience toxic stress or their relationship, that instead of buffering, is hurting a child emotionally, physically, ignoring the children, these children develop coping skills. They cope with it. They need to deal with that somehow and to take care and offer these children, when they come to their family, much more complex, much more complex. And now we always tell parents we all wish children should come with a book and if you read and you start to kind of know what to do, unfortunately, that doesn’t work like this trust, trauma, adversity, changes them in a unique way. Sometimes we see twins and they completely, parents need to learn. And that’s why we need professional help. Um, again, you know, they need professional help for mothers, young mother who single, depressed, and has a hard time to read a child signals. Correct. And we need help there.

Or we need help when the children who had the experience of no buffering relationship, who don’t know how to signal, how to ask for help. They need help here to walk this road. Um, the strategies are much more complex. I, first, remember it’s important for just say like how we do this, this and this. I would say, um, first of all, has been important to recognize, to be honest, and give consultation with a complex case when we talk about the children with multiple risks.

Dr. Emily Helder: Yeah. One of the things that I chatted a bit about with, um, Judith Eckerle and with Megan Bresnahan, when I chatted with them was that they really appreciated the interdisciplinary, um, nature of the clinic because you could each kind of contribute toward decisions related to behaviors that families are asking you about. And, and so, you know, what you’ve been describing are behaviors that might be driven by early attachment relationships that are disrupted, missing, um, marked by abuse. Uh, and Judith talked a bit about medical conditions speaking into that. Um, Megan talked about sensory issues, so I’m wondering in the interdisciplinary nature of things, um, how, what are you looking for when you’re assessing families to say, Hey, I think this is related to an attachment piece and this behavior that they’re asking about versus a sensory issue, you know, what are some clues for you, uh, as you’re meeting with families?

Dr. Maria Kroupina: I do think first it’s a critical to have an approach I, um, you know, it’s, um, kind of, you know, like we, we need in particular for any child who hasn’t gone through this multidisciplinary assessment. We need to ensure that at least somehow they see our medical providers, that they are seen on the mental health. And this is a very, I would do see initially and always young kids it’s parents more go to a pediatrician, and a little bit older kids go, you know, older age kids go to only mental health.

None of this is a balanced approach. I think we have to have both. I do feel like, to understand mental health you need to understand genetic syndromes and need to understand prenatal exposure. Um, it’s very important, I would say and also everything related to the different health needs with the child, um, that’s critical stuff that’s being done. We totally trust Dr. Eckerle and our medical clinic on getting the really broad scope on what it can be underlying this cause that’s almost like the first thing, um, central step. To answer your question about sensory and, um, uh, relationship or based on the difficulty with developing relationship this is a complex question that you don’t always know the answer unless you walk the road. Mmm. And in multiple cases that we see over the years, it’s a combination. And also parents don’t understand both is really important. I would say that would be starting point and we learn again, health is first. We just need to be sure that the child doesn’t have health problems.

The next step, I would say, combining mental health approach with sensory, if needed. That would be the next major step to kind of help child to be more regulated and more regulated within the new relationship. Does that make sense? And that’s why that’s the most effective combination of intervention for many, many children.

Because if you are experienced this early adversity, sensory issues, and uh, emotional regulation. They all feel like combined. It’s really hard. It’s just, I would say to some degree it’s all one big part of brain, correct. We are affecting with different and very, um, targeted methods that are very complimentary. That’s how we do see it for this approach.

And that has to be the first one for you. So for children who need it, but I will tell you, uh, I’ll give you, you know, like we just did analysis. I think it was in 90 kids. So almost, you know, like. Yeah, unless it’s really a little baby. And sometimes we say okay, we need to have the consultation or we do need OT, mental health, for sure for a child sometimes. It’s just so destructive for a child not to have stable relations that, um, that I think, um, most of the kids always see in the clinic. But I do feel like, I don’t think we have enough to tease it apart, but we have become very good at working together in figuring out how to combine this approach. Hmm.

Dr. Emily Helder: Yeah, no, I would think the model of the clinic allows that integration really nicely. Yeah. To follow up on that a bit. Um, are there specific intervention approaches or intervention models that you have found really helpful in your work?

Dr. Maria Kroupina: I think the younger age we have really great models, like the two major models, one preventive, uh, relationship model. It’s ABC, Attachment and Biobehavior Catch-up intervention developed by, um, Dr. Mary Dozier, 10 sessions, preventive intervention for children just placed. that’s a wonderful start. Uh, and I think now they working more towards making it for all the children for toddlers and preschoolers, now I think they are working on this model and also they’re trying to get as early as possible. Um, There’s a wonderful preventive model for the children who have, you know, like needed more trauma related work, uh, and parents who needed additional work, Child-parent psychotherapy is another model, zero to six.

And some areas I know that people started around, it was with young school aged children. I do find that we are not as good in terms of models for them, uh, school aged children because you know, like, Oh, we have a wonderful, uh, trauma related model, TF-CBT, Trauma Focused, Cognitive Behavior Intervention. That’s a great, uh, on building relationship when you do think and be creative because this piece for some kids who just placed also need to be, there are some great programs, um, you know, like more trying to get multiple levels approach for kids. But in terms of intervention, we kind of don’t have one to address or relationship building on, um, kind of that’s kind of building trust.

We do have to develop constantly that we have more and more school aged children placed. Because we know that, unfortunately it’s not only infants and not only young children, but we need to be sure that relationships are assessed. We need to be able to oversee all spectrum of age. Um, but that, that would be, but kind of the models that we are using.

Dr. Emily Helder: Thanks so much. Those are really helpful resources. Thanks so much for your time. It was really lovely to speak with you about the chapter. Thanks again for contributing. And also for talking to me a bit about your work.

Dr. Maria Kroupina: Thank you.

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