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Adopted Children in Their Adoptive Families
Symposium on Behavioral Pediatrics
Adopted Children in Their Adoptive Families Marshall D. Schechter, M.D.,* and F. Robert Holter, M.D.** The pediatrician as a practitioner and consultant has the unique opportunity to observe adoptive children and their adoptive parents, and hopefully, to influence the course of the child's development. In this context the pediatrician is called upon to function in many ways. He may be consulted concerning the original or subsequent adoptions; the timing of adoptions; the relationship of adoptive and biologic children; the timing and methods of informing the adopted child about his adoption, the reaction of the adoptive child and others - children and adultsto adoption. It is most likely that he also will be consulted concerning the adoptive child's interest in or quest for his biologic parents. Adoptive children and their adoptive parents are subjected to kinds of stresses not borne by nonadoptive children and parents. It has been reported that this stress produces a marked increase in the incidence of emotional disturbance in adopted children. n . 13. 15.20.21 In view of this finding it is likely that the pediatrician will be called upon to evaluate and render judgments concerning emotional disturbances, their causation, and their management. In fulfilling this responsibility, his clinical skill, emotional objectivity, and psychological understanding will be put to test. Many pediatricians will wish to enlist the help of the child psychiatrist for consultation concerning, and treatment of, these children and their families. Accordingly, it will be our purpose in this article to discuss those aspects of psychological and psychosocial functioning which bear upon the adoptive child in his adoptive family. Consideration will be given both to factors which are important in normal growth and development and to the kinds of information which have been obtained concerning emotional disturbances in adoptive children.
GENERAL CONSIDERATIONS Considerable attention has been devoted in child development studies to the importance of many aspects of the parent-infant relationship 'Professor and Director of Child and Adolescent Psychiatry, State University of New York, Upstate Medical Center, Syracuse •• Assistant Professor of Child and Adolescent Psychiatry, State University of New York, Upstate Medical Center, Syracuse
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in the development of both the infant and the parents. Important elements contributed by the mother begin with choice of her partner and proceed through the course of her pregnancy and delivery, influencing markedly the child's infancy and later development. ':' The most salient factor influencing the mother's effect on the child originates in her relationship with her own parents. Fathers bring to the family their own experiences, capabilities, and concepts of family and children. Each infant child brings his own unique potentials and capacities which contribute to the mother-infant dyad23 ,24 and the circular interaction in that dyad,14 Although the newborn infant has potential for physical and psychological growth, it will be some time before he develops sufficient mental structure to be considered as a separate psychological entity outside of the mother-infant relationship. In t~e meantime, not only the mother's care and attention, but especially her emotional investment in her infant provides the nurturing climate and catalytic influence for optimal development. Her ability to do this is augmented by the feelings of the father (and the extended families of both parents). Studies have shown that important impetus to the mother-infant relatedness takes place in the first few minutes, hours, and days of the infant's life, and interference with the development or disruption of this natural mother-infant bond in the postpartum period can alter the quality and degree of attachment of mother and infant. t This tie antecedes birth, being established early with the multitude of feelings, fantasies, and the life circumstances with which the biologic mother is involved throughout the term of the pregnancy. Pregnant women will often remark on what an active or inactive baby they are carrying and predictions as to the sex of the child will be suggested based on the distribution of body fat and the position of the fetus throughout the pregnancy. Since adoptive parents do not have this usual nine month period to experience the child's rhythms and the support from important people in their lives, this early "fit" between mother and child is potentially at "risk." Recognition of this should alert the pediatrician to the need for special attention to the working through of any emotional distance between the adopted infant and adoptive mother. The situation confronting parents making the decision to adopt is most often one in which there has been the necessity to adjust to some condition which has been adverse to their biologically becoming parents. This means additional stress of some sort and places the parents also, at least potentially, at risk. We are not suggesting that adoption is not a valuable social institution, or that it is to be viewed with paralyzing apprehension. Rather we would like. to emphasize the reality that there are special factors involved in the adoptive parents, as "Changes in adoptive practices present the pediatrician with new challenges. This was reflected in a discussion of a presentation at the International Congress for Child Psychiatry in Philadelphia in July 1974, when Dr. Schechter received several communications that adoption agencies recently have had to become much more concerned with the adoption of older children due to the unavailability of infants for adoption. tFries and Wolff" feel the interaction of the first three to four weeks is so important that they include the experience along with genetic endowment, prenatal, and perinatal experience in what they call the constitutional complex or core.
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well as in the child, which need attention in order to most effectively facilitate the adoptive-integrative process. Beyond this we would like to emphasize that the special circumstances which have led to adoption will not only play an important role in the development of personality structure in the adopted child but also, in the event of emotional disturbance in the adopted child, parental problems will potentially contribute to the presenting symptom picture. Therefore, initial knowledge of the circumstances of the adoption can provide base-line information which can be useful in counseling the parents about the development of their child. In the event of emotional disturbance, this base-line information also can be useful in the evaluation and treatment of:' the child. Like any child, the adoptee responds to illnesses and stresses commensurate with his psychological stage of development. Thus the adoptee being told of having been born from a woman other than the adoptive mother, will react in accordance with his understanding, intellectually and psychologically, at any given age. Decisions as to when or what to tell about his birth history should depend therefore on the adoptee's age and the psychosexual conflicts which might be present at this time.
SPECIAL PROBLEMS When to Adopt In a previous study,20 it was found that in the nonadoptive situation children were born on an average of 2.5 years after marriage. In contrast to this, children were adopted on an average of 10.5 years after marriage. The decision to adopt frequently had been made many months or years before actual placement but generally only after the adopting parents (especially the woman) had undergone multitudinous physiological and psychological tests for their lack of fecundity. Often, in the case of agency placements, the parents also had undergone intense scrutiny of all aspects of their personal habits, finances, and motives for adoption. Rarely in any other medical situation is the personal decision-making process so influenced by so many other people. During the period of time when these investigations are in process, the prospective adoptive parents are forced to acknowledge their own grief over their psychological loss of what was considered from childhood an expected bodily function. Children, when asked about anticipated vocations, will have changing thoughts conditioned by ageappropriate fantasies and conflicts. However, it is rare that pre teenagers will ever change their expectations that they will be parents in adulthood, often considering reproducing a family situation quite like that in which they were reared. The need to face the facts of infertility forces prospective adoptive parents to deal with what to them is a bodily defect quite analogous to the feelings people experience following an amputation. Societies have continually pressured for the birth of children as may be seen in tax laws around the world. It is only recently with the con-
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cern about the "population explosion" that some people of marriageable age have begun to think about other alternatives within marriage. Still the pervasive and persistent desire to fulfill a parental role is evident, especially in women. Their feelings of not belonging, not being complete, or not feeling the real proof of their femaleness come up palpably and forcibly with case studies of those applying for adoption. 12 , 19 Unfortunately, adoption of an infant is subject to the economic law of supply and demand which means that even when the prospective adoptive parents have evaluated the cause of infertility and passed all of the hurdles of the agency evaluation, babies mayor may not be readily available. The number of infants currently available for adoption has decreased markedly because of changes in abortion laws, societal mores permitting the unwed to keep their children, and better contraceptive regimens. This lack of sufficient numbers of available infants for adoption is emphasized by a number of agencies now requiring a pre-application for a regular adoption application, and increases the delay in completing an adoption, thus putting added strain on many childless couples. This has then led to the development of a "grey market" in independent adoptions-the results of which in terms of outcome do not seem that different from agency adoptions. 27 There is the realistic concern of parents, however, that signed releases from the biologic mother may not be properly executed, therefore in independent adoptions, another anxiety factor is constantly present. One other factor which plays a role in the integration of an adoptive child into the home is the age of the adoptive parents when the child is placed. Since, as was mentioned above, the adopting couple has been married longer (and therefore are older) than those having their first biologic child, the possible resiliency in coping with the normal developmental processes may thus be adversely affected. Because of this age factor, a number of years ago the Child Welfare League in this country recommended that the adopting mother should not be older than 38 and the adopting father no older than 42.
CHARACTERISTIC PROBLEMS Special Developmental Problems in the Adopted Child In the past, the highest percentage of infants available for adoption came from out of wedlock pregnancies. It is interesting to note that in the American Medical Association's Handbook for Physicians on Mental Retardation, birth out of wedlock was listed among others in a table on high-risk infants. It appears that prenatal care for unmarried women often is delayed and inadequate. Further, despite more liberalized attitudinal changes in our society, many of these women experience extra stresses of anxiety, depression, and guilt3 without getting sufficient emotional support. This suggests that the baby born out of wedlock is subjected to potentially adverse neuroendocrine influences intrauterin ely which may contribute to the increased number of adoptees seen, not only in psychiatric facilities,20 but also in learning disability l l and neurologic clinicsP The adoptive child may therefore have been sensi-
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tized toward greater reactivity to changes in handling (especially if foster care occurs before adoptive placement) making attachment somewhat more difficult. Agencies worldwide have advocated telling the child of his adoption as early as possible. In one instance, the case worker from a most reputable agency told-the adopting parents as she handed them their five day old son to incorporate the word "adopted" into their daily contact by rocking the baby to sleep and saying soothingly "go to sleep my darling adopted baby!" Sexual curiosity and questions about the birth process occur most frequently during the height of the Oedipus complex following which identifications with the moral and ethical codes of the parents result (superego formations). When the adoptive child receives information regarding two sets of parents (adoptive and biologic), this process in incorporating one "parental conscience" can be interfered with, potentially accounting for the increase in numbers of sexual and aggressive symptoms in the adoptee. 2 • 2o This "allergist" concept of telling is based on the notion that if the "allergen" (the word "adopted") is presented in small dosages frequently, when the knowledge of the adoptive status really is understood, "anaphylactic shock" will not take place. The fallacy in this rationale . is that the word "adopted" usually does not have a cognitive meaning before the age of four to five years. Suffice it to say that if the information concerning being conceived and born by a different mother and father is given at the time of the consolidation of parental values (the fantasy of the family romance),5 it can give the child the confused notion that there are in reality two sets of parents whom he needs to incorporate-one set possibly representing certain potentially good values and the other set representing certain potentially bad values. As part of a related problem confronting these children and their adoptive parents, there frequently develops during later adolescence and early adulthood, a desire to find their biologic parents so that they can discover their own place in the continuum of mankind. This search (detailed in such works as the book entitled The Search for Anna Fisher,4 a television program the summer of 1974 entitled "A Stranger Who Looks Like Me," and the work of Jean Paton 17 ) creates problems both for the adoptive parents, the biologic parents, and their respective families. Because of the sealed birth certificate for children put up for adoption in most states, the adoptee has to overcome extraordinary hardships in order to get any information even concerning familial illnesses asked for in every physical examination. 7 A recent publication from the Adoption Research Project in Los Angeles22 highlights some of these concerns. In that paper, the authors indicate that adoptees are much more vulnerable to identity problems as they enter late adolescence and young adulthood. When older children are placed for adoption, the child and the adoptive family must handle the mourning process as the child attempts to give up attachments to his previous parents or parent surrogates. This process is made more difficult in those older children (above one year of age) who also have a physical handicap or are interracially adopted, as
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these factors tend to draw energies which should be available for attachment to the adoptive parents and their families. Attitudes Within the Family The adopted child can be treated by the adoptive parents in a number of different ways which might lead to pathologic reactions. The child can be the external representative of their own defect-lack of fecundity. The child can be emotionally overprotected because of the difficulty in having a child at all. There can be both conscious and unconscious feelings about raising "someone else's child." This latter attitude is expressed by some parents when seen for consultation for a developmental deviation when they say "what do you expect from a child with bad blood in his veins," or "heredity will tell." These feelings are often influenced by feelings and attitudes (either positive or negative) of grandparents or relatives toward the adoption, and the concerns adoptive parents have about being left if the child indicates a desire to search for his biologic parents. This latter threat recreates in the adoptive parent the background for possible recrudescence of old unresolved problems related to the infertility which originally led to the adoption itself. A problem early on in placement that can affect the attachment of parent to child is the possible difference in the child's biologic rhythms from that of the adopting family-rhythms which biologic parents become palpably aware of during the nine months of the pregnancy. It may be much more difficult if the child does not physically or mentally resemble the adoptive parents (a very special positive quality inherent in most agency placements). Adopting parents having prior biologic children may note as another source of conflict differences in their feelings between the biologic and adopted children. This is not by any means always to the detriment of the adopted child. We have seen situations where the biologic child reacted as an offended child as he was not the specially "chosen" one as was the adoptee. Problems Within the Community Societal attitudes, even today, are exemplified in Hawthorne's The Scarlet Letter10 where the "sins" of the parents are visited on the child. The can be seen in the pejorative term "illegitimate child" constantly used to describe the child born out of wedlock. Perhaps this not only relates to moralistic attitudes within our culture but to the self-fulfilling expectations that adopted children do not turn out as well along a number of parameters as do the nonadopted. 15 • 16 There is a popular belief that following adoption, biologic pregnancy will occur. This, in the few studies published,!' 9. 25 does not seem to differ from the expected recovery cure of patients seen in infertility clinics. What and When to Tell As was mentioned above, not only do adoptive agencies in this country strongly recommend telling the child early about his adoptive
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status, but this is the regulation of many nations belonging to the World Health Organization who require adopting parents to sign a contract that they will tell as soon as they can. 26 Our opinion is that each child must be considered individually before making a decision on "when" and "what" to tell. Some of the factors influencing the decision are the age, intelligence,- curiosity, and conflict states in the child and/or the family. It obviously depends too on the age of the child when adopted so that a child placed for adoption at four years of age or over will be well aware of the process involved, even though there may be a later need to recall the specific events .. There are other times when the parents have no control over the timing of the telling. This occurs when neighbors, relatives, or others who know, either cannot resist talking about the adoptive status of the child or, having talked about it at home, the children of these people discuss it with the adopted child. In these instances, the parents must discuss the questions the child asks, answering them within the context of the child's psychosexual state of development and his ability to understand. If at all possible, we feel it would be best to wait to tell the child about the adoption process until he is between six and ten years of age. Even though the child may ask about conception around four or five .'years of age, he is asking for a piece of general information and not necessarily about his own origin. Just as it is advisable to postpone elective surgery if possible until the latency period to avoid misinterpretation based on normal developmental conflict states, in a similar fashion, it is our suggestion (again, if possible) to delay telling about the adoption until the same time. Parental attitudes are critical and crucial in the telling whatever the age of the child. We question use of the story of "the chosen one" usually told to soften the blow of the actual adoption process, since in a number of children and adults questions have occurred as to why they were "unchosen" originally. The suggestions of H. David Kirk in his book Shared Fate 12 are probably the most cogent in this situation. He suggests that the child without biologic parents (therefore having a defect) and the adoptive parents being infertile (therefore also having a defect) share the fate which has brought them together because they both need each other. Children can relate to adoption as they become aware of small animals who are taken from their mothers and are raised in a different family. These examples can be expanded with other children in the neigh..: borhood who are also adopted. Contacts with other adoptees can be expanded further with the parents joining local and state organizations of adoptive parents. The telling process often needs to be repeated and modified to correlate with the child's questions, and emotional and behavioral responses. The pediatrician needs to give continued support and education to the parents to help them understand the child's responses. Many children show little reaction initially and then, like a timed fuse, periodic eruptions occur related to that initial discussion and the possible elaborated
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distortions that can result. At times, specific developmental delays can occur centered around the stress this knowledge can produce, and possible referrals to a child psychiatrist for evaluation should be considered.
SUMMARY The adoptive process can produce unusual stresses on the child, and biologic and adoptive parents, from prenatal to postnatal life, and through the various phases of physical and psychological development. Because of the possibility of these children and their families falling into the "at risk" category with greater potential for psychological and social problems, the pediatrician is of primary importance in diagnosis and counseling. The pediatrician can be of major help in properly diagnosing emotional, behavioral and/or learning problems occurring in adopted children. There must be a thorough evaluation of the child and his family to understand and properly treat symptomatic behavior. The pediatrician can give advice regarding developmental milestones, and especially help the adoptive parents in appreciating their conscious and unconscious attitudes so as to enhance attachment behaviors. Pediatricians are the consultants to whom parents turn for advice regarding the timing of telling about adoption. This advice needs to be individualized according to the specific child's needs. U sing a developmental conceptual framework, the pediatrician is in the best position to help the parents and their adopted children with their feelings about societal attitudes and how these can most appropriately be handled. Along this line, the pediatrician can give help and advice when and if the adoptee decides to search for his biologic parents. There is a need to clarify laws which seal the original birth certificate permitting those adoptees who wish to attain a knowledge of potentially related disease processes and an identity with his own genealogical past to do so. This would also allow the adoptee to offer his own children informati9n about their own genetic pool and an awareness of adoption as one of the most valuable and historically significant child rearing practices.
REFERENCES 1. Banks, A. L., Rutherford, R. N., and Coburn, W. A.: Fertility following adoption. Fertil, Steril., 12:438, 1961. 2. Eidison, B. B., and Livermore, L. F.: Complications in therapy with adopted children. Am. J. Orthopsychiatry, 23:795-802, 1953. 3. Everett, R. B., and Schechter, M. D.: A comparative study of prenatal anxiety in the unwed mother. Child Psych. Human Dev., 2:84-91, 1971. 4. Fisher, F.: The Search for Anna Fisher, 1st ed. New York, A. Fields Books, 1973. 5. Freud, S.: Family Romances. In Jones, E. (ed.): Collected Papers, Vol 5. New York, Basic Books, Inc., 1950, pp. 74-78. 6. Fries, M. E., and Wolff, P. J.: The influence of constitutional complex on developmental phases in separation-individuation. In McDevetto, J. B., and Settlage, C. F. (eds.): Essays in Honor of Margaret S. Mahler. New York, International Universities Press, Inc., 1971, pp. 274-296. 7. Frontiers of Psychiatry: Adoptees see sealed records as Pandora's oox of "awful truths." Roche Report, Vol. 4, No. 12, June 15, 1974.
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8. Goldstein, J., Freud, A., and Solnit, A. J.: Beyond the Best Interests of the Child. New York, Free Press, 1973, pp. 32-34. 9. Hanson, F. N., and Rock, J.: The effect of adoption on fertility and other reproductive functions. Am. J. Obstet. GynecoL, 59:311, 1950. 10. Hawthorne, N.: The Scarlet Letter. New York, Washington Square Press, 1948. 11. Kenney, T., Baldwin, R., and Meckie, J. B.: Incidence of minimal brain injury in adopted children; Child Welfare, pp. 24-29, January 1967. 12. Kirk, H. D.: Shared Fate. New York, Free Press, 1964. 13. Loshbaugh, B.: Relationships of EEG, neurological and psychological findings in adopted children (75 cases). Am. J. EEG TechnoL, 5:1-4,1965. 14. Mahler, M. S., and Furer, M. S.: On Human Symbiosis and the Vicissitudes of Individuation, VoL 1: Infantile Psychosis. New York, International Universities Press, Inc., 1968. 15. McWhinnie, A. M.: Adopted Children-How They Grow Up. London, Ruthledge and Kegan Paul, 1967. 16. McWhinnie, J. B.: Deprivation of identity. Presented at the Eighth International Congress of the International Association for Child Psychiatry and Allied Professions, Philadelphia, July 28 to August 2, 1974. 17. Paton, J. M: The Adopted Break Silence, Philadelphia, Life History Study Center, 1954. 18. Paton, J. M.: Three Trips Home. Philadelphia, Life History Study Center, 1960. 19. Schechter, M. D.: About adoptive parents. In Anthony, K J., and Benedek, T. (eds.): Parenthood: Its Psychology and Psychopathology. Boston, Little, Brown and Co., 1970. 20. Schechter, M. D., Carlson, P. V., Simmons, J. Q., et al: Emotional problems in the adoptee. Arch. Gen. Psych., 10:37-46, 1964. 21. Silver, L. B.: Frequency of adoption in children with the neurological learning disability syndrome. J. Learn. Dis., 3 :6, 11-14, 1970. 22. Sorosky, A. D., Baran, A., and Pannor, R.: Identity conflicts in adoptees. Am. J. Orthopsychiatry, 45: 18-27, 1975. 23. Spitz, R. A.: The First Year of Life. New York, International Universities Press, Inc., 1965. 24. Thomas, A., Birch, H. G., Chess, S., et al: Behavioral Individuality in Early Childhood. New York, New York University Press, 1963. 25. Tyler, K T., Bonapart, J., and Grant, J.: Occurrence of pregnancy following adoption. Fertil. SteriL, 11 :581, 1960. 26. United Nations Department of Social Affairs: A Study in the Practice and Procedures Related to the Adoption of Children. New York, Columbia University Press, 1953. 27. Witmer, H. L., Herzog, K, Weinstein, K A., et aI.: Independent Adoptions: A Follow Up Study. New York, Russell Sage Foundation, 1963.
State University of New York Upstate Medical Center College of Medicine Department of Psychiatry 766 Irving Avenue Syracuse, New York 13210
Adopted Children in Their Adoptive Families Marshall D. Schechter, M.D.,* and F. Robert Holter, M.D.** The pediatrician as a practitioner and consultant has the unique opportunity to observe adoptive children and their adoptive parents, and hopefully, to influence the course of the child's development. In this context the pediatrician is called upon to function in many ways. He may be consulted concerning the original or subsequent adoptions; the timing of adoptions; the relationship of adoptive and biologic children; the timing and methods of informing the adopted child about his adoption, the reaction of the adoptive child and others - children and adultsto adoption. It is most likely that he also will be consulted concerning the adoptive child's interest in or quest for his biologic parents. Adoptive children and their adoptive parents are subjected to kinds of stresses not borne by nonadoptive children and parents. It has been reported that this stress produces a marked increase in the incidence of emotional disturbance in adopted children. n . 13. 15.20.21 In view of this finding it is likely that the pediatrician will be called upon to evaluate and render judgments concerning emotional disturbances, their causation, and their management. In fulfilling this responsibility, his clinical skill, emotional objectivity, and psychological understanding will be put to test. Many pediatricians will wish to enlist the help of the child psychiatrist for consultation concerning, and treatment of, these children and their families. Accordingly, it will be our purpose in this article to discuss those aspects of psychological and psychosocial functioning which bear upon the adoptive child in his adoptive family. Consideration will be given both to factors which are important in normal growth and development and to the kinds of information which have been obtained concerning emotional disturbances in adoptive children.
GENERAL CONSIDERATIONS Considerable attention has been devoted in child development studies to the importance of many aspects of the parent-infant relationship 'Professor and Director of Child and Adolescent Psychiatry, State University of New York, Upstate Medical Center, Syracuse •• Assistant Professor of Child and Adolescent Psychiatry, State University of New York, Upstate Medical Center, Syracuse
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in the development of both the infant and the parents. Important elements contributed by the mother begin with choice of her partner and proceed through the course of her pregnancy and delivery, influencing markedly the child's infancy and later development. ':' The most salient factor influencing the mother's effect on the child originates in her relationship with her own parents. Fathers bring to the family their own experiences, capabilities, and concepts of family and children. Each infant child brings his own unique potentials and capacities which contribute to the mother-infant dyad23 ,24 and the circular interaction in that dyad,14 Although the newborn infant has potential for physical and psychological growth, it will be some time before he develops sufficient mental structure to be considered as a separate psychological entity outside of the mother-infant relationship. In t~e meantime, not only the mother's care and attention, but especially her emotional investment in her infant provides the nurturing climate and catalytic influence for optimal development. Her ability to do this is augmented by the feelings of the father (and the extended families of both parents). Studies have shown that important impetus to the mother-infant relatedness takes place in the first few minutes, hours, and days of the infant's life, and interference with the development or disruption of this natural mother-infant bond in the postpartum period can alter the quality and degree of attachment of mother and infant. t This tie antecedes birth, being established early with the multitude of feelings, fantasies, and the life circumstances with which the biologic mother is involved throughout the term of the pregnancy. Pregnant women will often remark on what an active or inactive baby they are carrying and predictions as to the sex of the child will be suggested based on the distribution of body fat and the position of the fetus throughout the pregnancy. Since adoptive parents do not have this usual nine month period to experience the child's rhythms and the support from important people in their lives, this early "fit" between mother and child is potentially at "risk." Recognition of this should alert the pediatrician to the need for special attention to the working through of any emotional distance between the adopted infant and adoptive mother. The situation confronting parents making the decision to adopt is most often one in which there has been the necessity to adjust to some condition which has been adverse to their biologically becoming parents. This means additional stress of some sort and places the parents also, at least potentially, at risk. We are not suggesting that adoption is not a valuable social institution, or that it is to be viewed with paralyzing apprehension. Rather we would like. to emphasize the reality that there are special factors involved in the adoptive parents, as "Changes in adoptive practices present the pediatrician with new challenges. This was reflected in a discussion of a presentation at the International Congress for Child Psychiatry in Philadelphia in July 1974, when Dr. Schechter received several communications that adoption agencies recently have had to become much more concerned with the adoption of older children due to the unavailability of infants for adoption. tFries and Wolff" feel the interaction of the first three to four weeks is so important that they include the experience along with genetic endowment, prenatal, and perinatal experience in what they call the constitutional complex or core.
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well as in the child, which need attention in order to most effectively facilitate the adoptive-integrative process. Beyond this we would like to emphasize that the special circumstances which have led to adoption will not only play an important role in the development of personality structure in the adopted child but also, in the event of emotional disturbance in the adopted child, parental problems will potentially contribute to the presenting symptom picture. Therefore, initial knowledge of the circumstances of the adoption can provide base-line information which can be useful in counseling the parents about the development of their child. In the event of emotional disturbance, this base-line information also can be useful in the evaluation and treatment of:' the child. Like any child, the adoptee responds to illnesses and stresses commensurate with his psychological stage of development. Thus the adoptee being told of having been born from a woman other than the adoptive mother, will react in accordance with his understanding, intellectually and psychologically, at any given age. Decisions as to when or what to tell about his birth history should depend therefore on the adoptee's age and the psychosexual conflicts which might be present at this time.
SPECIAL PROBLEMS When to Adopt In a previous study,20 it was found that in the nonadoptive situation children were born on an average of 2.5 years after marriage. In contrast to this, children were adopted on an average of 10.5 years after marriage. The decision to adopt frequently had been made many months or years before actual placement but generally only after the adopting parents (especially the woman) had undergone multitudinous physiological and psychological tests for their lack of fecundity. Often, in the case of agency placements, the parents also had undergone intense scrutiny of all aspects of their personal habits, finances, and motives for adoption. Rarely in any other medical situation is the personal decision-making process so influenced by so many other people. During the period of time when these investigations are in process, the prospective adoptive parents are forced to acknowledge their own grief over their psychological loss of what was considered from childhood an expected bodily function. Children, when asked about anticipated vocations, will have changing thoughts conditioned by ageappropriate fantasies and conflicts. However, it is rare that pre teenagers will ever change their expectations that they will be parents in adulthood, often considering reproducing a family situation quite like that in which they were reared. The need to face the facts of infertility forces prospective adoptive parents to deal with what to them is a bodily defect quite analogous to the feelings people experience following an amputation. Societies have continually pressured for the birth of children as may be seen in tax laws around the world. It is only recently with the con-
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cern about the "population explosion" that some people of marriageable age have begun to think about other alternatives within marriage. Still the pervasive and persistent desire to fulfill a parental role is evident, especially in women. Their feelings of not belonging, not being complete, or not feeling the real proof of their femaleness come up palpably and forcibly with case studies of those applying for adoption. 12 , 19 Unfortunately, adoption of an infant is subject to the economic law of supply and demand which means that even when the prospective adoptive parents have evaluated the cause of infertility and passed all of the hurdles of the agency evaluation, babies mayor may not be readily available. The number of infants currently available for adoption has decreased markedly because of changes in abortion laws, societal mores permitting the unwed to keep their children, and better contraceptive regimens. This lack of sufficient numbers of available infants for adoption is emphasized by a number of agencies now requiring a pre-application for a regular adoption application, and increases the delay in completing an adoption, thus putting added strain on many childless couples. This has then led to the development of a "grey market" in independent adoptions-the results of which in terms of outcome do not seem that different from agency adoptions. 27 There is the realistic concern of parents, however, that signed releases from the biologic mother may not be properly executed, therefore in independent adoptions, another anxiety factor is constantly present. One other factor which plays a role in the integration of an adoptive child into the home is the age of the adoptive parents when the child is placed. Since, as was mentioned above, the adopting couple has been married longer (and therefore are older) than those having their first biologic child, the possible resiliency in coping with the normal developmental processes may thus be adversely affected. Because of this age factor, a number of years ago the Child Welfare League in this country recommended that the adopting mother should not be older than 38 and the adopting father no older than 42.
CHARACTERISTIC PROBLEMS Special Developmental Problems in the Adopted Child In the past, the highest percentage of infants available for adoption came from out of wedlock pregnancies. It is interesting to note that in the American Medical Association's Handbook for Physicians on Mental Retardation, birth out of wedlock was listed among others in a table on high-risk infants. It appears that prenatal care for unmarried women often is delayed and inadequate. Further, despite more liberalized attitudinal changes in our society, many of these women experience extra stresses of anxiety, depression, and guilt3 without getting sufficient emotional support. This suggests that the baby born out of wedlock is subjected to potentially adverse neuroendocrine influences intrauterin ely which may contribute to the increased number of adoptees seen, not only in psychiatric facilities,20 but also in learning disability l l and neurologic clinicsP The adoptive child may therefore have been sensi-
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tized toward greater reactivity to changes in handling (especially if foster care occurs before adoptive placement) making attachment somewhat more difficult. Agencies worldwide have advocated telling the child of his adoption as early as possible. In one instance, the case worker from a most reputable agency told-the adopting parents as she handed them their five day old son to incorporate the word "adopted" into their daily contact by rocking the baby to sleep and saying soothingly "go to sleep my darling adopted baby!" Sexual curiosity and questions about the birth process occur most frequently during the height of the Oedipus complex following which identifications with the moral and ethical codes of the parents result (superego formations). When the adoptive child receives information regarding two sets of parents (adoptive and biologic), this process in incorporating one "parental conscience" can be interfered with, potentially accounting for the increase in numbers of sexual and aggressive symptoms in the adoptee. 2 • 2o This "allergist" concept of telling is based on the notion that if the "allergen" (the word "adopted") is presented in small dosages frequently, when the knowledge of the adoptive status really is understood, "anaphylactic shock" will not take place. The fallacy in this rationale . is that the word "adopted" usually does not have a cognitive meaning before the age of four to five years. Suffice it to say that if the information concerning being conceived and born by a different mother and father is given at the time of the consolidation of parental values (the fantasy of the family romance),5 it can give the child the confused notion that there are in reality two sets of parents whom he needs to incorporate-one set possibly representing certain potentially good values and the other set representing certain potentially bad values. As part of a related problem confronting these children and their adoptive parents, there frequently develops during later adolescence and early adulthood, a desire to find their biologic parents so that they can discover their own place in the continuum of mankind. This search (detailed in such works as the book entitled The Search for Anna Fisher,4 a television program the summer of 1974 entitled "A Stranger Who Looks Like Me," and the work of Jean Paton 17 ) creates problems both for the adoptive parents, the biologic parents, and their respective families. Because of the sealed birth certificate for children put up for adoption in most states, the adoptee has to overcome extraordinary hardships in order to get any information even concerning familial illnesses asked for in every physical examination. 7 A recent publication from the Adoption Research Project in Los Angeles22 highlights some of these concerns. In that paper, the authors indicate that adoptees are much more vulnerable to identity problems as they enter late adolescence and young adulthood. When older children are placed for adoption, the child and the adoptive family must handle the mourning process as the child attempts to give up attachments to his previous parents or parent surrogates. This process is made more difficult in those older children (above one year of age) who also have a physical handicap or are interracially adopted, as
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these factors tend to draw energies which should be available for attachment to the adoptive parents and their families. Attitudes Within the Family The adopted child can be treated by the adoptive parents in a number of different ways which might lead to pathologic reactions. The child can be the external representative of their own defect-lack of fecundity. The child can be emotionally overprotected because of the difficulty in having a child at all. There can be both conscious and unconscious feelings about raising "someone else's child." This latter attitude is expressed by some parents when seen for consultation for a developmental deviation when they say "what do you expect from a child with bad blood in his veins," or "heredity will tell." These feelings are often influenced by feelings and attitudes (either positive or negative) of grandparents or relatives toward the adoption, and the concerns adoptive parents have about being left if the child indicates a desire to search for his biologic parents. This latter threat recreates in the adoptive parent the background for possible recrudescence of old unresolved problems related to the infertility which originally led to the adoption itself. A problem early on in placement that can affect the attachment of parent to child is the possible difference in the child's biologic rhythms from that of the adopting family-rhythms which biologic parents become palpably aware of during the nine months of the pregnancy. It may be much more difficult if the child does not physically or mentally resemble the adoptive parents (a very special positive quality inherent in most agency placements). Adopting parents having prior biologic children may note as another source of conflict differences in their feelings between the biologic and adopted children. This is not by any means always to the detriment of the adopted child. We have seen situations where the biologic child reacted as an offended child as he was not the specially "chosen" one as was the adoptee. Problems Within the Community Societal attitudes, even today, are exemplified in Hawthorne's The Scarlet Letter10 where the "sins" of the parents are visited on the child. The can be seen in the pejorative term "illegitimate child" constantly used to describe the child born out of wedlock. Perhaps this not only relates to moralistic attitudes within our culture but to the self-fulfilling expectations that adopted children do not turn out as well along a number of parameters as do the nonadopted. 15 • 16 There is a popular belief that following adoption, biologic pregnancy will occur. This, in the few studies published,!' 9. 25 does not seem to differ from the expected recovery cure of patients seen in infertility clinics. What and When to Tell As was mentioned above, not only do adoptive agencies in this country strongly recommend telling the child early about his adoptive
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status, but this is the regulation of many nations belonging to the World Health Organization who require adopting parents to sign a contract that they will tell as soon as they can. 26 Our opinion is that each child must be considered individually before making a decision on "when" and "what" to tell. Some of the factors influencing the decision are the age, intelligence,- curiosity, and conflict states in the child and/or the family. It obviously depends too on the age of the child when adopted so that a child placed for adoption at four years of age or over will be well aware of the process involved, even though there may be a later need to recall the specific events .. There are other times when the parents have no control over the timing of the telling. This occurs when neighbors, relatives, or others who know, either cannot resist talking about the adoptive status of the child or, having talked about it at home, the children of these people discuss it with the adopted child. In these instances, the parents must discuss the questions the child asks, answering them within the context of the child's psychosexual state of development and his ability to understand. If at all possible, we feel it would be best to wait to tell the child about the adoption process until he is between six and ten years of age. Even though the child may ask about conception around four or five .'years of age, he is asking for a piece of general information and not necessarily about his own origin. Just as it is advisable to postpone elective surgery if possible until the latency period to avoid misinterpretation based on normal developmental conflict states, in a similar fashion, it is our suggestion (again, if possible) to delay telling about the adoption until the same time. Parental attitudes are critical and crucial in the telling whatever the age of the child. We question use of the story of "the chosen one" usually told to soften the blow of the actual adoption process, since in a number of children and adults questions have occurred as to why they were "unchosen" originally. The suggestions of H. David Kirk in his book Shared Fate 12 are probably the most cogent in this situation. He suggests that the child without biologic parents (therefore having a defect) and the adoptive parents being infertile (therefore also having a defect) share the fate which has brought them together because they both need each other. Children can relate to adoption as they become aware of small animals who are taken from their mothers and are raised in a different family. These examples can be expanded with other children in the neigh..: borhood who are also adopted. Contacts with other adoptees can be expanded further with the parents joining local and state organizations of adoptive parents. The telling process often needs to be repeated and modified to correlate with the child's questions, and emotional and behavioral responses. The pediatrician needs to give continued support and education to the parents to help them understand the child's responses. Many children show little reaction initially and then, like a timed fuse, periodic eruptions occur related to that initial discussion and the possible elaborated
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distortions that can result. At times, specific developmental delays can occur centered around the stress this knowledge can produce, and possible referrals to a child psychiatrist for evaluation should be considered.
SUMMARY The adoptive process can produce unusual stresses on the child, and biologic and adoptive parents, from prenatal to postnatal life, and through the various phases of physical and psychological development. Because of the possibility of these children and their families falling into the "at risk" category with greater potential for psychological and social problems, the pediatrician is of primary importance in diagnosis and counseling. The pediatrician can be of major help in properly diagnosing emotional, behavioral and/or learning problems occurring in adopted children. There must be a thorough evaluation of the child and his family to understand and properly treat symptomatic behavior. The pediatrician can give advice regarding developmental milestones, and especially help the adoptive parents in appreciating their conscious and unconscious attitudes so as to enhance attachment behaviors. Pediatricians are the consultants to whom parents turn for advice regarding the timing of telling about adoption. This advice needs to be individualized according to the specific child's needs. U sing a developmental conceptual framework, the pediatrician is in the best position to help the parents and their adopted children with their feelings about societal attitudes and how these can most appropriately be handled. Along this line, the pediatrician can give help and advice when and if the adoptee decides to search for his biologic parents. There is a need to clarify laws which seal the original birth certificate permitting those adoptees who wish to attain a knowledge of potentially related disease processes and an identity with his own genealogical past to do so. This would also allow the adoptee to offer his own children informati9n about their own genetic pool and an awareness of adoption as one of the most valuable and historically significant child rearing practices.
REFERENCES 1. Banks, A. L., Rutherford, R. N., and Coburn, W. A.: Fertility following adoption. Fertil, Steril., 12:438, 1961. 2. Eidison, B. B., and Livermore, L. F.: Complications in therapy with adopted children. Am. J. Orthopsychiatry, 23:795-802, 1953. 3. Everett, R. B., and Schechter, M. D.: A comparative study of prenatal anxiety in the unwed mother. Child Psych. Human Dev., 2:84-91, 1971. 4. Fisher, F.: The Search for Anna Fisher, 1st ed. New York, A. Fields Books, 1973. 5. Freud, S.: Family Romances. In Jones, E. (ed.): Collected Papers, Vol 5. New York, Basic Books, Inc., 1950, pp. 74-78. 6. Fries, M. E., and Wolff, P. J.: The influence of constitutional complex on developmental phases in separation-individuation. In McDevetto, J. B., and Settlage, C. F. (eds.): Essays in Honor of Margaret S. Mahler. New York, International Universities Press, Inc., 1971, pp. 274-296. 7. Frontiers of Psychiatry: Adoptees see sealed records as Pandora's oox of "awful truths." Roche Report, Vol. 4, No. 12, June 15, 1974.
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8. Goldstein, J., Freud, A., and Solnit, A. J.: Beyond the Best Interests of the Child. New York, Free Press, 1973, pp. 32-34. 9. Hanson, F. N., and Rock, J.: The effect of adoption on fertility and other reproductive functions. Am. J. Obstet. GynecoL, 59:311, 1950. 10. Hawthorne, N.: The Scarlet Letter. New York, Washington Square Press, 1948. 11. Kenney, T., Baldwin, R., and Meckie, J. B.: Incidence of minimal brain injury in adopted children; Child Welfare, pp. 24-29, January 1967. 12. Kirk, H. D.: Shared Fate. New York, Free Press, 1964. 13. Loshbaugh, B.: Relationships of EEG, neurological and psychological findings in adopted children (75 cases). Am. J. EEG TechnoL, 5:1-4,1965. 14. Mahler, M. S., and Furer, M. S.: On Human Symbiosis and the Vicissitudes of Individuation, VoL 1: Infantile Psychosis. New York, International Universities Press, Inc., 1968. 15. McWhinnie, A. M.: Adopted Children-How They Grow Up. London, Ruthledge and Kegan Paul, 1967. 16. McWhinnie, J. B.: Deprivation of identity. Presented at the Eighth International Congress of the International Association for Child Psychiatry and Allied Professions, Philadelphia, July 28 to August 2, 1974. 17. Paton, J. M: The Adopted Break Silence, Philadelphia, Life History Study Center, 1954. 18. Paton, J. M.: Three Trips Home. Philadelphia, Life History Study Center, 1960. 19. Schechter, M. D.: About adoptive parents. In Anthony, K J., and Benedek, T. (eds.): Parenthood: Its Psychology and Psychopathology. Boston, Little, Brown and Co., 1970. 20. Schechter, M. D., Carlson, P. V., Simmons, J. Q., et al: Emotional problems in the adoptee. Arch. Gen. Psych., 10:37-46, 1964. 21. Silver, L. B.: Frequency of adoption in children with the neurological learning disability syndrome. J. Learn. Dis., 3 :6, 11-14, 1970. 22. Sorosky, A. D., Baran, A., and Pannor, R.: Identity conflicts in adoptees. Am. J. Orthopsychiatry, 45: 18-27, 1975. 23. Spitz, R. A.: The First Year of Life. New York, International Universities Press, Inc., 1965. 24. Thomas, A., Birch, H. G., Chess, S., et al: Behavioral Individuality in Early Childhood. New York, New York University Press, 1963. 25. Tyler, K T., Bonapart, J., and Grant, J.: Occurrence of pregnancy following adoption. Fertil. SteriL, 11 :581, 1960. 26. United Nations Department of Social Affairs: A Study in the Practice and Procedures Related to the Adoption of Children. New York, Columbia University Press, 1953. 27. Witmer, H. L., Herzog, K, Weinstein, K A., et aI.: Independent Adoptions: A Follow Up Study. New York, Russell Sage Foundation, 1963.
State University of New York Upstate Medical Center College of Medicine Department of Psychiatry 766 Irving Avenue Syracuse, New York 13210