October 2012, VOLUME130 /ISSUE 4

The Pediatrician’s Role in Supporting Adoptive Families

  1. Veronnie F. Jones, MD, PhD,
  2. Elaine E. Schulte, MD, MPH, and
  3. the Committee on Early Childhood and Council on Foster Care, Adoption, and Kinship Care


    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 aware of the adoptive parents’ need to be supported in their communication with their adopted children.

    • adoption
    • kinship care
    • adoption by same sex parents
    • transracial adoption
    • communication

    Changing Picture of Adoption

    According to the 2007 National Survey of Adopted Children, approximately 2% of the child population in the United States was adopted, accounting for 1.8 million children.1,2 Approximately 38% of these children were adopted from foster care, another 38% joined families through private domestic adoption, and 25% were adopted internationally. Furthermore, approximately 24% of adopted children were adopted by relatives, including 17% from foster care, and 37% of children were adopted privately in the United States.1,2 Overall, 49% of adopted children were male; 39% of children adopted internationally and 57% adopted through the foster care system were male. Adopted children tended to be older than the general population, with only 14% younger than 5 years, compared with 27% in the general population. Adopted children were less likely to be white or Hispanic, but this varied by the type of adoption. Children adopted through the foster care system tended to have the highest percentage of black children, at 35%, whereas children adopted internationally had the least number of black children, at 3%. Children adopted privately in the United States were more likely to be white, at 50%, whereas children adopted internationally were least likely to be white, at 19%. The majority of children adopted internationally were of Asian descent (59%), with 33% originating from China. Adopted children were less likely to live in households with incomes below the poverty level than the general population (12% vs 18%, respectively). Conversely, 46% of adopted children live in households with incomes no higher than 2 times the poverty level. Similar to the general population, 69% of adopted children lived with 2 married parents. Eighty-five percent of adopted children were reported by parents to be in excellent or very good health, and 78% reportedly had adequate health insurance.1 Knowing the current picture of adopted children, pediatricians can play a significant role in the adoption process by providing counseling to parents during the preadoption phase and subsequently providing support for the adoptive family.3 Additionally, by understanding the unique medical, developmental, mental health, and behavioral needs of the adopted child, pediatricians can provide optimal health care for these patients.

    Adoption can be domestic or international. Domestic adoption involves adopting a child from within the United States. International adoption involves adopting a child who was born outside the country, with the intention of bringing the child to live in the United States. Regardless of the type of adoption, the biological family may have continued contact of varying degrees with the child for whom an adoption plan has been chosen, ranging from complete confidentiality to unlimited direct contact.1,4,5 In fact, more than one-third of children in nonrelative adoptions have had some contact with their birth parents. Private domestic adoptions account for the majority of contact, with 68% of adoptive families reporting communication with birth parents, whereas 39% of families of children adopted from foster care and 6% of families of children adopted internationally acknowledge some degree of contact with birth parents.

    Adoptive families are changing.615 It is estimated that every year, approximately 120 000 children, representing 2% of the US population, are adopted.1,7,8 The source of adoptees has undergone a transition. The number of adoptions from domestic sources, including foster care, has been increasing, and international adoptions have declined.1,7 Blended families, families with gay or lesbian parents, and families with older parents are providing more homes to children through adoption, although exact numbers are difficult to obtain.6 Single-parent adoptions have become increasingly more common.911 Research from the 1970s found that an estimated 0.5% to 4% of people completing adoptions were single, compared with 8% to 34% of adopters in the 1980s. This percentage remained relatively stable in the 2000s.9 Additionally, more children are being placed long-term with relatives, who may or may not formalize the relationship through adoption.4,1215 Twenty-three percent of children adopted from the foster care system were adopted by relatives, and an additional 22% were adopted by nonrelatives who knew the child before the adoptive process. In other domestic adoptions through the private sector, 41% were adopted by relatives, and an additional 7% were adopted by previously known nonrelatives.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.1,2 Others may be adopted by the only foster parent they have encountered. There were fewer newborn infants and more older children being placed for adoption. Sibling groups were often placed together. A child may be adopted into a family of the same ethnicity and/or race or into a family with members of different groups.1,4,6,14 Four of 10 adopted children were in transracial adoptions.1 Kinship care showed an increase.1,12

    The number of adoptions of children with special needs has increased markedly in the past 2 decades.11,16 Many adopted children have complex medical, developmental, behavioral, educational, and psychological challenges.1,2,7,16,17 In fact, 39% of adopted children were classified as having special health care needs, compared with 19% in the general population.1 Furthermore, more than half of children adopted from foster care (54%) were considered to have special health care needs.1,7,17 Adopted children were more likely than nonadopted children to have asthma and to have moderate or severe health problems. Also, adoptive parents were more likely than nonadoptive parents to be told that their child had a learning disability, developmental delay, and/or physical impairment. Mental health issues, such as attention-deficit/hyperactivity disorder, autism, mental retardation, and emotional problems were more commonly reported in adopted children with special health care needs. These conditions may be the result of biological and/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.14 Despite the reported issues, most adoptive parents rated their children’s health as “excellent” or “very good.”1

    Modern technology has contributed to the changing face of adoption. 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.18

    Pediatric Issues

    Pediatricians may be asked to review preadoption health records to help families understand the current and potential future medical, developmental, and mental health needs of children they plan to adopt.3,19 Pediatricians may be able to use health records to help parents determine additional questions that could clarify a particular health issue or diagnosis and help parents elucidate what special needs they are prepared to accept. When reviewing medical records, the Privacy and Security Rules of the Health Insurance Portability and Accountability Act must be considered.20 The Privacy and Security Rules define how covered entities use individually identifiable health information, or personal health information. If a covered entity is not involved, then adherence to Health Insurance Portability and Accountability Act rules may not be required, but other regulations may come into play.

    Specific issues to address in the health records may include conditions related to complications of pregnancy, poor nutrition, preterm birth, lack of prenatal care, genetic diseases, alcohol use, substance abuse, early brain cognitive development, and growth trends of the child. 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. Pediatricians without expertise in this area may seek out and refer hopeful adoptive parents to pediatricians listed on the Council on Foster Care, Adoption, and Kinship Care Web page who have experience in preadoptive evaluations.21

    Children who join their families through adoption must have a comprehensive medical evaluation to identify medical needs.2224 This should be completed soon after placement in an adoptive home to confirm and clarify existing medical diagnoses, assess for any previously unrecognized medical issues, discuss developmental and behavioral concerns, and make appropriate referrals. It is recommended that pediatricians review the standards for medical care of adopted children that have been published by the American Academy of Pediatrics (AAP).22,25 For children adopted internationally, this evaluation includes but is not limited to screening tests and assessment of immunization status, as recommended in the Red Book.22 Acute and chronic medical problems, vision and hearing loss, and developmental delays should be identified and addressed. Behavioral, emotional, learning, and developmental concerns need to be evaluated, with appropriate therapy initiated as needed.

    The pediatrician can provide information to parents concerning issues of transition and adjustment of the child into the adoptive family.25 For many, this may be an easy transition, but others may experience varying degrees of difficulty during this phase in their lives. The child may experience symptoms of anxiety, display signs of depression, or withdraw from his or her environment. The child may demonstrate misbehaviors that are atypical and may also experience school difficulties. Sleep and feeding problems may be prominent during this period. The following AAP resources are available to guide the pediatrician in management: Addressing Mental Health Concerns in Primary Care: A Clinician’s Toolkit,26AAP Developmental and Behavioral Pediatrics,27 and Guide to Learning Disabilities for Primary Care: How to Screen, Identify, Manage, and Advocate for Children with Learning Disabilities.28

    After completion of the comprehensive evaluation, pediatricians can help families that have not finalized the adoption to be more prepared to negotiate adequate adoption subsidies. Adoption assistance may involve access to medical care, counseling or therapy, special equipment, tutoring programs, and other support services that may help children who have special needs. The type and amount of assistance vary by state.29 Finally, providing information about available community services, such as early child intervention programs and support groups, may ease the transition for the expected family. The Child Welfare League of America also may be a valuable resource for pediatricians and adoptive families.30

    Developmental Understanding of Adoption

    Just as a child’s thinking and self-concept changes at various stages of development, so does a child’s understanding of the meaning of adoption.3133 It is generally agreed that the child should be told of the adoption, but there is disagreement on when the information should be given. Until 3 years of age, most adopted children do not realize there is a difference between their family and families in which children are reared by their biological parents.32 From the time a child is adopted, it is appropriate for families to use adoption language, as described later in this statement, on a routine basis. Using adoption language early helps to lay the groundwork for children to later understand these abstract concepts. It also provides the time that may be needed for the parents to become comfortable sharing their child’s adoption with family and friends.34 The pediatrician can facilitate the parents’ comfort level by introducing the adoptive parents to available resources, such as support groups. The pediatrician can also suggest books on adoption for the parent and even young children.29,35 Through the use of available resources, as well as any pictures that may help describe 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.34,36 It is also important for the pediatrician to remind parents that adoption issues come in and out of focus for children over time and may be dormant for periods. During nodal points in development, specific issues may become more relevant for the child. The pediatrician can counsel adoptive parents about the need to understand the child’s questions surrounding the adoption in the context of the child’s current development and answer questions in a way that promotes self-esteem.

    By approximately 3 years of age, however, children become self-absorbed and may believe that they magically cause all things that have happened to them.3335 Three-year-old children often 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. 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. Some children may express yearnings to have been “in the belly” of their adoptive mother.32 By the time children enter kindergarten, they realize that most of their peers are not adopted. They also may 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 are most likely thinking about them.33,36 When children are 6 to 12 years of age, they realize that, in gaining an adoptive family, they have also lost a biological family.33,37 Realization of this loss may be one of the underlying issues in the emotional adjustment of adopted individuals giving rise to the appearance of increased adjustment difficulties during this period.33 At the same time, school-aged children may identify with their imagined 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 other family members. They may experience denial of these differences as well as of the adoption itself.36 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—particularly 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. Although internationally adopted children are more likely to have attention-deficit/hyperactivity disorder and learning concerns,38 these do not exist in isolation and may be a result of posttraumatic stress disorder or reactive attachment disorder. When children well adapted to a high-threat environment, such as an institution, attempt to integrate into a new world, as at school or on the playground, they may find themselves ill prepared.39 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, or 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.4,36 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 adolescence approaches, physical and mental changes are rapidly occurring.40 Teenagers are developing the ability to do abstract thinking. Concepts like adoption may be internalized and could have gray areas instead of black or white. Adolescents might go through an intense period of self-reflection in an attempt to define their identities, but as adolescents develop and begin the task of separation and individuation, adoption issues commonly become very important. This may widen the gap between the adoptee and the adoptive family. It is important for pediatricians to recognize that the consolidation of identity is not the same as an identity crisis, and pediatricians should neither over- nor underpathologize children and adolescents. Also, it is important to remember that identity development is not unique to adopted children, but it can add to its complexity. 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 and may look to identify with their perceived biological families even more. The teenager may try identities similar to those of their biological families, whether known or imagined, which may include changes in physical appearance, religion, and customs.36 The adolescent may question parental views and authority of the adoptive parents and may partake in behaviors that may be out of character, such as engaging in risk-taking activities similar to those that may have led to their conception, including participating in unprotected sex. The adolescent may also take on other activities that played a part in the biological parent’s (or parents’) decision to make an adoption plan, such as substance abuse. These actions may be the teen’s way of connecting to his perceived birth family; however, the adolescent may wish to avoid making similar mistakes as the biological parents. Although the adolescent may be fully committed to the adoptive family, he or she may have a heightened curiosity about the past and his or her biological family, creating a feeling of ambivalence. The teenager may feel a sense of betrayal to his or her adoptive family if this avenue is explored, but he or she needs to develop his or her own sense of belonging as well as a sense of autonomy. The adoptive family may fear the loss of the teen to the biological family, ultimately resulting in increased conflict. The conflicting emotions may be exacerbated as adolescents head toward emancipation from their family and as separation comes to the forefront. Both the child and the family may experience increased emotional uncertainty at the thought of moving away from the adoptive family and home.36 The pediatrician can play a role in helping the adolescent and family by stressing the need to keep the lines of communication open. The pediatrician should be aware of available community resources, such as support groups and counselors, to help the family explore their feelings in a safe environment.

    Losses in Adoption

    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.41 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.42

    All members of the adoption triad—the child, the adoptive family, and the biological family—are affected by the 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 their 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. Through understanding and acknowledgment of these losses, adoptive families, children, and biological families are able to adapt better and build healthier families.43

    Communicating About Adoption With Children

    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.35,44 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.36 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 young children their adoption story, starting with their birth, not the adoptive family’s initiation of the adoption process.36 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.32

    Some information in a child’s past may be private or difficult for the parent to share with the child. The pediatrician, potentially with the collaboration of a mental health specialist, may help the family decide how and when to disclose this information. Open discussion with a child is essential in building bridges of trust and security within a family, but it is also important that the discussion be framed with developmentally appropriate language. The family can be encouraged to present the information without judgmental comments or criticism. Even the most difficult information, such as previous sexual or physical abuse or having been conceived in the context of rape or incest, eventually may be shared with a child at a developmentally appropriate age.36

    Some parents who have dealt with infertility may be uncomfortable with the reality that their child has another family—another set of parents.37 Thus, issues of loss in the adoptive family may continue after the child is adopted into the family.32 Avoidance of discussion about the biological family will deprive children of the opportunity to ask questions, openly fantasize, or understand having a family outside the one in which they live and may give children the perception that their thoughts and questions about adoption are bad.36 It is important to tell a child that he or she was not “given up” but rather that the biological parents 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.32,36 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. There may be an opportunity for the pediatrician to encourage families to develop rituals with their child to honor the birth parents, which may take the form of a celebration during holidays or the designation of a particular ornament or saying a special prayer to commensurate the birth family. Rituals like these allow adoptive children to acknowledge and remember their past but also to honor their adoption.

    Racial, Ethnic, and Cultural Differences

    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.45 When adopted 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.36 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.45 Whenever possible, an adopted child should be given the opportunity to learn more about the heritage of the country of his or her birth or of his or her ethnic group.36,45 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.43 Parents who have not experienced racism personally may need to pay extra attention to teaching their children effective ways to respond to racism.

    Adoption by Same-Sex Parents

    Although accurate statistics are unavailable, it is estimated that gay and lesbian parents are raising approximately 4% of all adopted children in the United States, accounting for approximately 65 500 adopted children.46 Demographically, same-sex couples raising adopted children are typically older, more educated, and have more economic resources compared with other adoptive parents. Adopted children in this family composition are generally younger and more likely to be born outside the United States. Research on the subject of children raised by same-sex couples continues, primarily focusing on developmental outcomes, such as psychological adjustment, peer relationships, family relationships, and progress through school.47 The AAP published a policy statement48 and technical report49 supporting coparent or second-parent adoption in 2002 and reaffirmed the policy statement in May 2009. The basis for the policy statement was to ensure the best interest of children living in this family structure, allowing legal stability for the child. The statement pointed out that children fare better in a home in which parents, regardless of sexual identity, provided a caring, supportive, and secure home environment. After review of the literature, the AAP concluded that children who grow up with gay or lesbian parents do as well in emotional, cognitive, social, and sexual functioning as children who grow up with heterosexual parents. The pediatrician should be familiar with the existing professional literature and support families in their desire to parent children.

    Open Adoption

    Open adoption describes a continuum of communication between birth parents and the adoptive family. It may be restricted to the birth parents providing input into the selection of the adoptive parents, or it may describe regular communication between or face-to-face meetings with the adoptive parents, adopted child, or both.5 Pediatricians should discuss with families the extent of communication between the adoptive family and the biological family and provide needed support by identifying potential and real benefits and drawbacks to the relationship. The adoptive parents may fear birth parents will interfere in the adoptive family’s life. They may have concerns of their child’s ability to bond within the adoptive family. Anxiety may arise about the parental authority for the child. These and other issues should be part of the routine visit, allowing parents an opportunity to express their concerns. Pediatricians should be knowledgeable about resources, including support groups, available within the community.

    Special Issues in Kinship Adoption

    For children who are placed for 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 the 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, 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 may increase the 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. Support services and resources for families with a kinship adoptive placement, whether formal or informal, may be available, including local child welfare agencies, the Department on Aging’s “Grandparents Raising Grandchildren,” and other community resources, financial assistance, respite care, and services.35

    Difficult Times

    “Anniversary reactions” often occur in adopted children at certain times of the year.36 On Mother’s Day, children may think about the many mothers they have had, including their adoptive mother, biological mother, and foster mothers. 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.

    Searching for Biological Family and Cultural Ties

    As adopted children age into adolescence and adulthood, they may wish to seek out more information about their biological families.41 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.37 The experience of a reunion with the biological family may be rewarding, but there may also be some pitfalls. In preparing for contact and reunion, adopted people (and birth parents) should prepare for a whole range of realities, including rejection by the biological parent(s) and family members. Pediatricians need to be aware of the feelings the adopted child may have after meeting a sibling—either one who is older and remained with the biological parent(s) or one who was born after the adopted child was placed. 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.

    Modeling Positive Adoption Language

    Pediatricians are encouraged to model positive adoption language for all families.44 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,” because 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.36

    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 pediatricians 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.

    Lead Authors

    Veronnie F. Jones, MD, PhD, MSPH

    Elaine E. Schulte, MD, MPH

    Committee on Early Childhood, 2011–2012

    Elaine Donoghue, MD, Chairperson

    Jill J. Fussell, MD

    Mary Margaret Gleason, MD

    Veronnie F. Jones, MD, PhD, MSPH

    Alan L. Mendelsohn, MD

    Elaine E. Schulte, MD, MPH

    Patricia G. Williams, MD


    Barbara Hamilton, MA—Maternal and Child Health Bureau

    Claire Lerner, LCSW—Zero to Three

    Stephanie Olmore—National Association for the Education of Young Children


    Charlotte Zia, MPH, CHES

    Council on Foster Care, Adoption, and Kinship Care Executive Committee, 2011–2012

    Moira A. Szilagyi, MD, PhD, Chairperson

    Walter M. Fierson, MD

    David A. Harmon, MD

    Pamela C. High, MD, MS

    Paula Kienberger Jaudes, MD

    Veronnie F. Jones, MD, PhD, MSPH

    Paul J. Lee, MD

    Lisa M. Nalven, MD, MA

    Lisa Albers Prock, MD, MPH

    Linda Davidson Sagor, MD, MPH

    Elaine E. Schulte, MD, MPH

    Sarah H. Springer, MD

    Thomas F. Tonniges, MD


    Mary A. Crane, PhD, LSW


    • This document is copyrighted and is property of the American Academy of Pediatrics and its Board of Directors. All authors have filed conflict of interest statements with the American Academy of Pediatrics. Any conflicts have been resolved through a process approved by the Board of Directors. The American Academy of Pediatrics has neither solicited nor accepted any commercial involvement in the development of the content of this publication.

    • 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.

    • All clinical reports from the American Academy of Pediatrics automatically expire 5 years after publication unless reaffirmed, revised, or retired at or before that time.