Changing Picture of Adoption
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. A child may be adopted into a family of the same ethnicity and/or race or into a family with members of different groups. Many children are adopted after having spent time with a family through the foster care system, often after lengthy stays in multiple homes. 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. Intercountry adoptions, which also may involve adoptions across ethnic and racial lines, also are increasing in number. See the original guideline document for more details.
Medical Issues
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) and District II of the AAP. 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. 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.
Developmental Understanding of 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. 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.
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. See the original guideline document for additional information on toddler, preschool, elementary school, and adolescent attitudes and behavior.
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. 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. 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. 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.
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. 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. 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. As children age, they should have control over telling their adoption history outside the family. See the original guideline document for more details.
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. 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. 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. 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. Parents who have not experienced racism personally may need to pay extra attention to teaching their children effective ways to respond to racism. See the original guideline document for more details.
Special Issues in Kinship Adoption
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.
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.
Searching for Biological Family and Cultural Ties
As children age into adolescence and adulthood, adoptive children may wish to seek out more information about their biological families. 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. 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. 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.
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.
