PEDIATRICS Vol. 112 No. 6 December 2003, pp. 1437-1441
Families and Adoption: The Pediatrician’s Role in Supporting Communication
Deborah Borchers, MD and
Committee on Early Childhood, Adoption, and Dependent Care
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ABSTRACT
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Each year, more children join families through adoption. Pediatricians have an important role in assisting adoptive families in the various challenges they may face with respect to adoption. The acceptance of the differences between families formed through birth and those formed through adoption is essential in promoting positive emotional growth within the family. It is important for pediatricians to be informed about adoption and to share this knowledge with adoptive families. Parents need ongoing advice with respect to adoption issues and need to be supported in their communication with their adopted children.
Abbreviations: AAP, American Academy of Pediatrics
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CHANGING PICTURE OF ADOPTION
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There are various types of adoption. In domestic adoptions and some intercountry adoptions, biological families may have continued contact of varying degrees with the child for whom they have chosen an adoption plan, ranging from complete confidentiality to unlimited direct contact.1 A child may be adopted into a family of the same ethnicity and/or race or into a family with members of different groups.1 Many children are adopted after having spent time with a family through the foster care system, often after lengthy stays in multiple homes.1,2 Kinship permanency may be established by grandparents, aunts or uncles, siblings, or other relatives through legalized guardianships or adoptions or through informal nonlegalized agreements within a family.1 Intercountry adoptions, which also may involve adoptions across ethnic and racial lines, also are increasing in number.1
Adoptive families are changing. Increasing numbers of single-parent families, blended families, families with gay or lesbian parents, and families with older parents are providing homes to children through adoption. More children are being placed long-term with relatives, who may or may not formalize the relationship through adoption.1 Children may have had multiple sets of foster parents before their adoption, some of whom may maintain contact with the child after the adoption. Marked increases in the number of adoptions of children with special needs have been seen in the last 2 decades.3 There are fewer newborns and more older children being placed for adoption. Sibling groups are often placed together. Many of the children who are in need of adoptive families have complex medical, developmental, behavioral, educational, and psychological challenges. These may be the result of biological or environmental stressors experienced while the child was living with the biological family or may have been initiated or exacerbated while the child was in temporary care.4
Modern technology has changed the face of adoption. Although not commonly viewed as such, surrogate parenthood and embryo adoptions are adoptive relationships.1 The Internet has led to wider dissemination of information about children waiting for permanent families and has established a new system of support among adoptive families. Information about adoption on the Internet may not always be reliable, however, and the broad and instant reach of the World Wide Web also allows great potential for unethical practices in adoption.5
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MEDICAL ISSUES
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Children who join their families through adoption must have a comprehensive medical evaluation to identify medical needs. Standards for the medical care of children in foster care have been published by the American Academy of Pediatrics (AAP)6 and District II of the AAP.7 For children adopted internationally, this evaluation includes but is not limited to screening tests and assessment of immunization status as recommended by the AAP Committee on Infectious Diseases in the Red Book.8 Acute and chronic medical problems, vision and hearing loss, and developmental delays should be identified and addressed. Behavioral and emotional concerns need to be evaluated aggressively with appropriate therapy initiated. Pediatricians should help families in accessing mental health and developmental services when needed.
Pediatricians may be asked to review preadoption medical and mental health records to help families understand the current and potential future medical, developmental, and mental health needs of children they plan to adopt. This may include conditions related to complications of pregnancy, poor nutrition, prematurity, lack of prenatal care, and genetic diseases. In counseling families, all attempts should be made to obtain a complete medical and psychological history of the child, particularly in assessing potential special needs of a child. Through comprehensive preplacement assessment, parents should assess their resources and abilities to meet a particular child’s needs. With the help of pediatricians, families then may be better able to negotiate adequate adoption subsidies including but not limited to educational needs and mental health insurance coverage.9
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DEVELOPMENTAL UNDERSTANDING OF ADOPTION
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Although parents and children gain so much in becoming a part of an adoptive family, children who join their families through adoption often experience issues of loss relevant to adoption.10 Although these feelings of loss may be more rooted in societal expectations of genetically based attachments rather than in any inherent biological loss, they nonetheless are experienced by many adopted people.11
Just as a child’s thinking and self-concept change at various stages of development, so does a child’s understanding of the meaning of adoption. Until 3 years of age, most children do not realize there is a difference between their adoptive family and families in which children are reared by their biological parents.12 From the time a child is adopted, it is appropriate for families to use language on a routine basis that relates to adoption, laying the groundwork for children to later understand these abstract concepts. There are many books on adoption for even young children. Through the use of available resources as well as pictures about a child’s own adoption story, parents should relate to children the story of how their family came to be. These foundations are important in the later development of positive attitudes about adoption, a child’s birth parents, and himself or herself.13
By about 3 years of age, however, children become self-absorbed and may believe that they magically cause all things that happen to them.13 Children love to hear their adoption stories. At this age, most children begin to ask questions about what adoption means, yet children adopted at a very young age do not understand that they have another family besides the family with whom they live. Separation issues may be more pronounced than they are in peers, especially with children who remember the loss of biological or foster parents, siblings, or other relatives.13 Children at this age may feel responsible for the loss of their first family as well as for the repeated losses through moves in and out of foster care. They may fear that their adoptive parents will abandon them in the same way once their hidden flaws are discovered.13 Some children may express yearnings to have been "in the belly" of their adoptive mother.12
By the time children enter kindergarten, they realize that most of their peers are not adopted. They also learn that some children may be living with biological parents in circumstances that are similar to those experienced by their own biological parents (eg, single-parent families or conditions of poverty). This, once again, may lead children to feel responsible for their biological parents’ decision not to raise them.
School-aged children continue to face issues associated with adoption, although often they deal with them by going "underground." Although children in this stage may not ask questions or initiate discussion of issues related to adoption, they still are most likely thinking about them.13 When children are 6 to 12 years of age, they realize that, in gaining an adoptive family, they have also lost a biological family.14 At the same time, school-aged children may identify with their biological families, fantasizing about what life would have been like if an adoption plan had not been made for them. During middle childhood, children (particularly children adopted across racial and/or cultural lines) may become upset by the differences they notice in comparison with other children and may experience denial of these differences as well as of the adoption itself.13 Self-esteem issues may also complicate emotions and the thinking process during these years, because some children may wonder what flaw in them resulted in their biological parents making an adoption plan. This may be particularly true if the biological parent(s) chose to rear a sibling.
During preschool and elementary school years, peer and school problems may or may not be the manifestation for underlying adoption issues. Behaviors commonly identified as characteristic of attention-deficit/hyperactivity disorder may actually be signs of posttraumatic stress disorder, reactive attachment disorder, bipolar disorder, or sensory integration disorder. Some school assignments may be problematic for children who have joined their family through adoption. Children who have lived in foster care or in another country may not have pictures of themselves from birth or at an early age. Family tree assignments may be difficult, because children may be unsure of how to demonstrate their relationship to their biological family, adoptive family, and foster families. Information about biological ancestors also may be unavailable to the child for such a project. Tracing genetic traits through generations may be difficult even for children who have an ongoing relationship with their biological families. For children adopted by an extended family member, these simple learning assignments may create anxiety by highlighting family differences.1,13 Communication with educators about adoption issues at this age, as at other ages, may be necessary to help children deal with some of these difficult school assignments and insensitive comments about adoption, family circumstances, culture, race, and ethnicity.
As adolescents develop their identity and begin the task of separation and individuation, adoption issues commonly become very important. At 12 to 16 years of age, many adolescents become angry over the differences between their own life experiences and society’s norm of an intact family. Adolescents may continue to fantasize about their "perfect" biological family. Older adolescents may also struggle with dating issues (as do all adolescents), but in these particular relationships, they may look to identify with their biological families even more. This may include engaging in risk-taking behaviors similar to those that may have led to their conception, such as unprotected sex, or those that played a part in the biological parent’s (or parents’) decision to make an adoption plan, such as substance abuse. Adolescents may try on identities similar to those of their biological families whether known or imagined. This may include changes in physical appearance, religion, and customs.13 As adolescents head toward emancipation from their family, separation may come to the forefront. A child who was adopted at an early age may experience emotional uncertainty at the thought of moving away from the adoptive family and home.13
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LOSSES IN ADOPTION
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All members of the adoption triad—the child, the adoptive family, and the biological family—are affected by losses. Children in closed adoptions may lose the sense of their own original identity as well as ties to those with whom they share genetic links. Even children in open and kinship adoptions are aware of the way in which their families are different and will process this knowledge in different ways at different ages. Adoption may also represent loss to adoptive parents. Some adoptive parents have faced infertility, so they too may grieve the loss of genetic links to their child. In confidential adoptions, biological parents have an obvious loss of a relationship with the child they have conceived. Even in open adoption relationships, biological parents may feel the loss of not being in a parenting role with a child they conceived. Some pediatricians may also be involved in supporting a pregnant adolescent who makes an adoption plan. Through understanding and acknowledgment of these losses, adoptive families, children, and biological families are able to adapt better and build healthier families.15
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COMMUNICATING ABOUT ADOPTION WITH CHILDREN
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Even before a child understands the words "adoption," "adopted," and "biological family" or "birth family," it is important that these words be a part of a family’s natural conversation, whether the adoption is open or confidential, kinship, or foster-adoptive placement.13 Families should be discouraged from "waiting until just the right minute" to tell children that they were adopted, because this may leave children feeling betrayed and wondering what else their parents may have hidden from them.13 Children may also learn information from peers or neighbors, which may impair the trust between parent(s) and child. It is important to share with even very young children their adoption story, starting with their birth, not the adoptive family’s initiation of the adoption process.14 An honest approach in the discussion of a child’s biological family and the adoption process will give a child permission to ask questions or to make statements about adoption and at the same time will take away the veil of secrecy that often implies that being adopted is a negative condition.12
Some information in a child’s past may be private or difficult for the parent to share with the child. Open discussion with a child is important in building bridges of trust and security within a family. Even the most difficult information, such as previous sexual or physical abuse or having been conceived in the context of rape or incest, eventually should be shared with a child at a developmentally appropriate age.13 The child and parents should be counseled regarding the child’s privacy about facts pertinent to the adoption. The parents and the child need to be cautioned that once information is shared, it cannot be taken back.14 Parents should guide children in what they will share with strangers, friends, and extended family. Facts shared with children about their adoption should always be accurate, and adoptive parents should admit when information is not available.13 As children age, they should have control over telling their adoption history outside the family.13
Some parents who have dealt with infertility may be uncomfortable with the reality that their child has another family, another set of parents.14 Thus, issues of loss in the adoptive family may continue after the child is adopted into the family.12 Avoidance of discussion about the biological family will deprive children of the opportunity to ask questions, openly fantasize, or understand having a family outside of the one in which they live and may give children the perception that their thoughts and questions about adoption are bad.13 It is important to tell a child that he or she was not "given up" but rather that the biological family made an adoption plan in the best interest of the child’s future and to the best of their abilities at the time. As children grow in their understanding of the relationship with their biological family, they may become concerned that just as they were "rejected" by their biological family, their adoptive family may also reject them.12,13 Adoptive parents may need to verbalize their commitment to their child frequently. A "life book," a compilation of all (difficult and happy) that is known about a child’s history, can be an effective tool for parents to use in helping a child to process all the thoughts and feelings about his or her adoption story.
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RACIAL, ETHNIC, AND CULTURAL DIFFERENCES
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Children adopted by parents of a different race, ethnicity, or cultural background may have other concerns specific to their identities. Even children as young as 3 or 4 years of age will be aware of the physical differences between themselves and members of other racial groups.16 When these children live in communities where they are members of an ethnic minority, the differences in racial identity will be easily apparent to classmates, other parents, and strangers. As these children enter preschool and elementary school, peers may ask questions about their biological and cultural heritage. As children reach the developmental stage of wanting to be just like their peers, these questions may provoke a variety of responses. Some of these responses might seem to the casual observer to be out of proportion for the information requested. Some remarks may be taunting or intrusive.13 Children may encounter racist remarks for the first time, particularly in situations in which they are not physically or emotionally safeguarded by their parents.
Families need to acknowledge openly the racial differences that exist between their child and themselves. Relationships with others of the same race or ethnic group, including adults and children, may be very helpful to a child.16 Whenever possible, an adopted child should be given the opportunity to learn more about the heritage of the country of his birth or of his ethnic group.13,16 Role-playing with children with respect to stereotypes and racist statements may help them to feel in control when they encounter inevitable comments from strangers, friends, or extended family members.15 Parents who have not experienced racism personally may need to pay extra attention to teaching their children effective ways to respond to racism.
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SPECIAL ISSUES IN KINSHIP ADOPTION
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For children who are placed for foster care or adoption within their biological family, separation issues are lessened. At the same time, these relationships present particular challenges for a family. There may be a reluctance of other family members to confirm the adoptive parents as the child’s actual parents, and reference may be made within the family setting to a child’s "real" parents. Boundaries must be set regarding the type of contact, timing, and granting of parental responsibility to the biological parents. All family members may need to be reminded that the adoptive parent is the responsible parent. Family gatherings may provide particular challenges, especially in cases in which the biological parents’ rights have been involuntarily terminated. Many kinship adopters have limited contact with support groups, and there may be a tendency to "keep it in the family," especially with respect to the open discussion of family secrets that led to the placement of the child with a family member. Grandparents who become adoptive parents may grieve the loss of the vision of their own children as parents while coping with the stresses of raising children again and dealing with the circumstances of the reason the child was placed with them.
It is important that pediatricians provide support to these families, particularly in the area of validating the adoptive parents’ rights to make decisions for the child. Kinship adoptive parents may be reluctant to share with the child painful information involved in the circumstances leading to the separation from the biological parents. Failing to share the truth with the child will only lead to damaged trust and increase anxiety for the child. The biological parents and kinship adoptive parents must communicate about the sharing of information and what language will be used, keeping in mind the child’s developmental stage. Through contact with local child welfare agencies and other community resources, financial assistance, respite care, and support services for families with a kinship adoptive placement, whether formal or informal, may be available.13
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DIFFICULT TIMES
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"Anniversary reactions" often occur in adopted children at certain times of the year.13 On Mother’s Day, children may think about the many mothers they have had, including their adoptive mother, biological mother, and foster mothers.13 On birthdays and adoption days, children may seem depressed and withdrawn instead of joyful. These anniversaries may trigger thoughts of the biological family, and children may wonder whether their biological parents still love them or even think about them. Sensitivity, particularly at these significant times, may help a child in dealing with difficult adoption issues.13
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SEARCHING FOR BIOLOGICAL FAMILY AND CULTURAL TIES
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As children age into adolescence and adulthood, adoptive children may wish to seek out more information about their biological families.10 Individuals who joined their families through international adoption may choose to make a trip to the country of their birth. Domestic adoptees may pursue reunification with biological relatives through a reunion registry, may choose to reestablish ties in a lapsed open adoption, or may develop a stronger interest in understanding kinship ties. Although some adoptive parents may view their child’s searching for his or her biological family as a sign of rejection, it is actually a sign of healthy emotional growth in the search for an identity.14 All members of the adoption triad may need the help of mental health professionals to work through these situations. Pediatricians are encouraged to become aware of local community resources for adoptive families, including resources for locating information about biological families, support groups, adoption conferences and services, and mental health professionals.
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MODELING POSITIVE ADOPTION LANGUAGE
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Pediatricians are encouraged to model positive adoption language for all families. Adoptive families are "real" families; siblings who joined a family through adoption are "real siblings." Biological parents do not "give up a child for adoption," which might imply to the child that he or she was of less worth and was given away. Rather, they "make an adoption plan for a child." A biological mother should not be identified as a "natural parent," as this implies that adoptive families are "unnatural." A child’s racial identity, adoption, or birth in another country should never be the identifying characteristics for any child. It is never appropriate to ask how much a child "cost." In modeling positive adoption language, pediatricians can use vocabulary that reflects respect and permanency about children and their families.13
As more children each year become part of permanent families through adoption, it is becoming increasingly important for pediatricians to be aware of and knowledgeable about adoption. Pediatricians play an important role in helping families deal with the differences, the losses, and the many other issues surrounding the adoption of a child. Pediatricians are encouraged to have a greater understanding about adoption to be able to advise and support parents as they communicate about adoption with their children. It is also important for a pediatrician to remind families of the importance of forthright communication about adoption. Open acknowledgment of the adoptive relationship helps to nurture a child’s self-esteem as he or she grows in the understanding of what it means to join a family through adoption. Effective communication about adoption is important for the long-term mental and physical health and well being of each child and family.
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Committee on Early Childhood, Adoption, and Dependent Care, 2003–2004
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Chet Johnson, MD, Chairperson
*Deborah Ann Borchers, MD
Kerry English, MD
Danette Glassy, MD
Pamela High, MD
Judith Romano, MD
Moira Szilagyi, MD, PhD
Dennis L. Vickers, MD, MPH
Peter Gorski, MD, MPA Past Committee Member
Donald Palmer, MD Past Committee Member
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Liaisons
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Patricia M. Spahr, MA
National Association for the Education of Young Children
R. Lorraine Brown, RN, BS
Maternal and Child Health Bureau
Ada White, LCSW, ACSW
Child Welfare League of America, Inc
Claire Lerner, LCSW
Zero to Three
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Staff
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Mary Crane, PhD, MA
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FOOTNOTES
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* Lead author 
The guidance in this report does not indicate an exclusive course of treatment or serve as a standard of medical care. Variations, taking into account individual circumstances, may be appropriate.
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PEDIATRICS (ISSN 1098-4275). ©2003 by the American Academy of Pediatrics
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The Health and Well-being of Adopted Children
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February 1, 2007;
119(Supplement_1):
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[Abstract]
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TOP
ABSTRACT
CHANGING PICTURE OF ADOPTION
