the role of mental health professionals in adoption

The Role of Mental Health Professionals in Adoption

• Kunti: Son, I did not come simply in the happy hope of clutching you to my breast, but to take you back where you by right belong. You are not a charioteer’s son, but of royal birth – so cast aside the insults that have been your lot and come where they all are – your five brothers

• Karna: But Mother, I am a charioteer’s son, and Radha’s my mother – glory greater than that I have none. Let the Pandavs be Pandavs, the Kauravs Kauravs – I envy nobody.

• Kunti: With the puissance of your arms recover the kingdom that’s your own, my son. You, vanquisher of foes, will live with your kinsmen, sole ruler in your kingdom, sitting on your jewelled throne, sharing power with none.

• Karna: Throne, indeed! To one who’s just refused the maternal bond are you offering, Mother, assurances of a kingdom? The riches from which you once disinherited me cannot be returned – it’s beyond your powers. When I was born, Mother, from me you tore mother, brothers, royal family – all at one go.

• If today I cheat my foster-mother, her of charioteer caste, and boldly address as my own mother a royal materfamilias, if I snap the ties that bind me to the lord of the Kuru clan, and lust after a royal throne, then fie on me!

The Role of MHPs in Adoption

• Psychopathology in Adoptees: Fact or Artifact?

• Nature of Psychiatric Problems in Adoptees

• Etiological Factors

• Adoption Competent Clinical Practice

• Developmental Challenges in Adoption

• Telling the Adopted Child

– Laws on Adoption in India

Is there a Problem?

• Although it is estimated that only about 1-2 percent of all children under 18 years of age are nonrelated adoptees, studies have shown that the incidence of referral of this group for psychological/ psychiatric services significantly exceeds this figureDavid M. Brodzinsky Adjustment to Adoption: A Psychosocial Perspective Clin Psychol Review Vol 7 pp 22-47 (1987)

• Adopted children comprise about 8-10% of all patients seen in outpatient settingsJerome, L. (1993). A comparison of the demography, clinical profile and treatment of adopted and non-adopted children at a children’s mental health centre. Canadian Journal of Psychiatry, 38: 290-294.

INCREASED PSYCHOPATHOLOGY IN ADOPTEES: FACT OR ARTIFACT?

Are these elevated referral figures

1. An accurate reflection of the incidence of psychiatric problemsamong adoptees?

2. Are figures so high that an ascertainment bias should besuspected?

3. Do adoptive parents have a “lower threshold” for referral suchthat they seek assistance for minor problems?

4. Since adoptive parents are better educated/ more affluent,perhaps they are in a better position to recognize psychologicalproblems and obtain intervention?

David M. Brodzinsky Adjustment to Adoption: A Psychosocial Perspective Clin Psychol Review Vol 7 pp 22-47 (1987)

Epidemiological data supports both hypotheses that

• The rate of psychiatric problems among the population of adopted children and adolescents is lower than data from clinic samples, lending support to the notion that adoptive parents do have a relatively low threshold for psychiatric referral (Deutsch, 1990; Warren,1992)

AND• Ascertainment bias notwithstanding, the bulk of the

evidences indicates that the rate of psychiatric problemsamong adopted children and adolescents is still greaterthan in the non-adopted population(Brodzinsky, Schechter, Braff, & Singer, 1984; Brodzinsky, Radice, Huffman, & Merkler, 1987; Deutsch,

1990; Lindholm & Touliatos, 1980; Lipman, Offord, Racine, & Boyle, 1992 Verhulst, Versluisden Bieman, & Althaus, 1990; Warren, 1992)

Referral Bias for Psychiatric Disorders in Adopted Children

• Higher Socio-economic Status

– More affluent / better educated than general population

– “Even when SES was controlled for, adoptees still are more likelyto be referred for Psychiatric treatment than non-adoptedchildren”

Warren, S.B. (1992). Lower threshold for referral for psychiatric treatment for adopted adolescents. Journal of the American Academy of

Child and Adolescent Psychiatry, 31: 512-527.

• Adoptive parents are simply more anxious about the healthand welfare of their children

– Expect to find adopted children disproportionately represented inall medical settings

– “Adoptees were not significantly more likely to receive medicalservices than non-adoptees”

Dalby, J.T., Fox, S.L., and Haslam, R.H.A. (1982). Adoption and foster care rates in pediatric disorders. Developmental and Behavioral Pediatrics, 3, 61-64.

Referral Bias for Psychiatric Disorders in Adopted Children

• Familiarity with Social-Service Agencies during adoptionprocess

– “Many adoptive parents do not use agencies, and among thosewho do, contact is generally not extended”

Deutsch, C.K., Swanson, J.M., Bruell, J.H., Cantwell, D.P., Weinberg, F., and Baren, M. (1982). Overrepresentation of adoptees in children with the

Attention Deficit Disorder. Behavioral Genetics, 12: 231-238.

“In summary, we cannot satisfactorily account for the lowerthreshold for psychiatric referral among adoptive families byfocusing on parent characteristics.

Perhaps, then, there is something about the nature and/or theseverity of psychiatric problems of adoptees that causes theiradoptive parents to be more likely to seek professionalintervention.”

Barbara D. Ingersoll (1997) Psychiatric Disorders Among Adopted Children, Adoption Quarterly, 1:1, 57-73

Nature of Psychiatric Problems Among Adoptees• Studies done before DSM-III (1980) did not identify specific

diagnoses most characteristic of adoptees– Consensus that adoptees were prone to acting-out behaviour

• parental defiance • running away• sexual acting out• aggressive and antisocial behavior

• (Austad and Simmons, 1978; Bohman and Sigvardsson, 1980; Borgatta and Fanshel, 1965; Goodman, Silberstein, & Mandell, 1963; Menlove, 1965;

Schechter et al., 1964)

• Some investigators also specifically noted– increased motor activity (Goodman et al., 1963; Menlove, 1965; Nichols and Chen, 1981)

– impulsivity (Nichols and Chen, 1981)

• “These descriptors suggest diagnoses of attention deficit hyperactivity disorder (ADHD), oppositional defiant disorder (ODD), and conduct disorder (CD)”

• Deutsch, C.K. (1990). Adoption and attention deficit disorder. In L.M. Bloomingdal and J.W. Swanson (Eds.), Attention deficit disorder IV: Current concepts and emerging trends in attentional and behavioral disorders of childhood. New York: Pergamon Press, p. 67-79.

Nature of Psychiatric Problems Among Adoptees• “Rate of adoption among ADHD children was approximately eight

times the prevalence of adopted children in the general population, indicating that adopted children are, in fact, disproportionately represented among children with ADHD”Deutsch, C.K., Swanson, J.M., Bruell, J.H., Cantwell, D.P., Weinberg, F., and Baren, M. (1982). Overrepresentation of adoptees in children with the Attention Deficit Disorder. Behavioral Genetics, 12: 231-238.

• “In the Colorado Adoption Project adopted boys were more likely to be classified as at-risk for CD than non-adopted boys”Coon, H., Carey, G., Corley, R., and Fulker, D.W. (1992). Identifying children in the Colorado Adoption Project at risk for conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 503-511.

• A large-scale study of 2,148 international adoptees found that adopted adolescent boys – obtained particularly high scores on the Delinquent and Hyperactive scales of

the Child Behavior Checklist

– were more likely to have clinically severe externalizing disorders

Verhulst, F.C., and Versluis-den Bieman, H.J.M. (1995). Developmental course of problem behaviors in adolescent

adoptees. Journal of the American Academy of Child and Adolescent Psychiatry, 34: 151-159.

Nature of Psychiatric Problems Among Adoptees

• “Elementary school-age adopted children were rated higher by teachers in conduct disorders, personality problems, and socialized delinquency, but not in inadequacy-immaturity or psychotic signs”Lindholm. B. W., & Touliatos. J. (1980). Psychological adjustment of adopted and nonadopted children. Psychological Reports, 46, 307-3 10

• “Adopted children were rated by both mothers and teachers as higher than non-adopted children in psychological and school-related problems and lower in social competence and school achievement”Brodzinsky et al (1984) Psychological and academic adjustment in adopted children. Journal of

Consulting and Clinical Psychology 52, 582-590

Nature of Psychiatric Problems Among Adoptees

• Most empirical work on adoption has been atheoretical in nature– making it difficult to interpret the patterns emerging from the

research. • Failure to differentiate between related and nonrelated

adoptees• Failure to control for mediating variables like

– age of placement – pre-placement history– Socioeconomic status – family composition

• Frequent use of measures and procedures that are of questionable reliability and validity


Nature of Psychiatric Problems Among Adoptees“On the average, adopted children are more likely to manifest psychological problems than nonadopted children.

On the other hand, it is also clear that only a minority of adopted children manifest clinically significant symptomatology.”

“An examination of the relationship between children’s age and patterns of adjustment suggests that the higher incidence of psychological problems associated with adoption is restricted to children in the middle childhood years and adolescence.”David M. Brodzinsky Adjustment to Adoption: A Psychosocial Perspective Clin Psychol Review Vol 7 pp 22-47 (1987)

“Adopted children come to professional attention at higher-than-expected rates in part because:

(a) they manifest a higher incidence of psychiatric problems than

do non-adopted children; and,

(b) their problems are mainly of the externalizing kind, which adults find annoying and aversive.

Barbara D. Ingersoll (1997) Psychiatric Disorders Among Adopted Children, Adoption Quarterly, 1:1, 57-73

Etiology of Psychiatric Illnesses in Adoptees

• Environmental Factors

–Pre-Adoption Events

–Post-Adoption Events

• Genetic Factors

Environmental Factors: Pre-adoption• Pre & Peri-natal events may adversely affect adoptees as

– most adopted children (at least those on whom most studies to date are based) are born to young, unmarried mothers, a group who often do not receive adequate prenatal care

Adams, H.M., and Gallagher, U.M. (1993). Some facts and observations about illegitimacy. Children, 10, 43-47.

– “Teenage pregnancies are associated with low birth-weight which in turn is associated with behavioral and emotional problems in childhood”

Breslau, N., Klein, N., and Allen, L. (1988). Very low birthweight: Behavioral sequelae at nine years of age. Journal of the American Academy of Child and Adolescent Psychiatry, 27: 605-612.

– substance abuse during pregnancy places children at clear risk for emotional and behavioral problems

– “birth parents of adoptees tend to be impulsive risk-takers so we expect at least some to be substance abusers“

Smith, P.B., Nenney, S.W., Weinman, M.L., and Mumford, D.M. (1982). Factors affecting perception of pregnancy risk in the adolescent. Journal of Youth and Adolescence, 11: 207- 217.

Environmental Factors: Pre-adoption• “early environmental adversities were associated with

higher levels of later problems

Verhulst, F.C., Althaus, M., and Versluis-den Bieman, H.J.M. (1992). Damaging backgrounds: Later adjustment of international adoptees.

Journal of the American Academy of Child and Adolescent Psychiatry, 31: 518-524.

• “Such events have a deleterious effect not only on a child’s psyche, but on the developing nervous system itself, thus paving the way for later learning, behavior, and emotional problems”Barbara D. Ingersoll (1997) Psychiatric Disorders Among Adopted Children, Adoption Quarterly, 1:1, 57-73

•Abuse Neglect•Malnutrition Poor medical care•Lack of adequate stimulation•Weak or ruptured relations with caretakers

Pre-Adoption Biological Ramification-1 • “ It is common to observe elevated levels of cortisol (which indicate

increased activation of the HPA axis) in individuals experiencing many types of chronic stress.

• Looked-after children more commonly display a pattern of blunted cortisol production”Kertes, D.A., Gunnar, M.R., Madsen, N.J., & Long, J.D. (2008). Early deprivation and home basal cortisol levels: A study of internationally adopted children. Development and Psychopathology, 20, 473–491.

• Typically, cortisol levels diurnally peak shortly after awakening in the morning. These levels then decrease rapidly throughout the morning and are extremely low by bedtime.

• In contrast, the pattern of HPA dysregulation for looked-after children involves low morning cortisol levels that remain low throughout the dayBruce, J., Fisher, P.A., Pears, K.C., & Levine, S. (2009). Morning cortisol levels in preschool-aged foster children: Differential effects of maltreatment type. Developmental Psychobiology, 51, 14–23.

• May be a ‘down regulation’ of the system as a protective response to the absence of responsive carevan der Vegt, E.J.M., van der Ende, J., Kirschbaum, C., Verhulst, F.C., & Tiemeier, H. (2009). Early neglect and abuse predict diurnal cortisol patterns in adults: A study of international adoptees. Psychoneuroendocrinology, 34, 660–669.

Pre-Adoption Biological Ramification-2 • “On neuropsychological tests that tap domains of executive

functioning, such as working memory and inhibitory control, foster children perform poorly”Lewis, E.E., Dozier, M., Ackerman, J., & Sepulveda-Kozakowski, S. (2007). The effect of placement instability on adopted children's inhibitory control abilities. Developmental Psychology, 43, 1415–1427.Pears, K.C., Kim, H.K., & Fisher, P.A. (2008). Psychosocial and cognitive functioning of children with specific profiles of maltreatment.Child Abuse and Neglect, 32, 958–971.

• “We found differential patterns of brain activation for foster and for non-maltreated children on a computer task that requires children to exhibit inhibitory control”Bruce, J., Fisher, P.A., Graham, A.M., Moore, W.E., III, Peake, S.J., & Mannering, A.M. (2013). Patterns of brain activation in foster children and nonmaltreated children during an inhibitory control task. Development and Psychopathology, 25, 931–941.

• “Lower levels of activation (ERP) in the prefrontal cortex in response to feedback were found among foster children during an error-monitoring task”Bruce, J., McDermott, J.M., Fisher, P.A., & Fox, N.A. (2009). Using behavioural and electrophysiological measures to assess the effects of a preventive intervention: A preliminary study with preschool-aged foster children. Prevention Science, 10, 129–140.

Environmental Factors: Post-Adoption• “A poor fit between an adoptee’s innate abilities and parental

expectations might lead to emotional problems among some adopted children”Jerome, L. (1994). Adoption and psychiatric referral: Letter to the editor. Journal of the American Academy of Child and Adolescent Psychiatry, 33: 906.

– Adoptees perceive parent expectations to be higher than biological children doScarr, S., and McAvay, G. (1990). Predicting the occupational status of young adults: a longitudinal study of brothers and sisters in adoptive andbiologically related families. Cited in Deutsch, C.K. (1990)

– Adoptive parents of children with conduct problems are more achievement oriented than adoptive parents of children without conduct problemsCoon, H., Carey, G., Corley, R., and Fulker, D.W. (1992). Identifying children in the Colorado Adoption Project at risk for conduct disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 31, 503-511.

WHY THE EXTERNALISING DISORDERS?• “One could argue that children who are unable to live up to parental

expectations would be more likely to become anxious, demoralized, and depressed, which is not the way in which adoptees with psychiatric disorders present”Barbara D. Ingersoll (1997) Psychiatric Disorders Among Adopted Children, Adoption Quarterly, 1:1, 57-73

Genetic Factors

GENETIC FACTORS • Strong heritability factor for externalizing behavior disorders

– “First-degree relatives of probands with ADHD are up to five times more likely to have ADHD than relatives of control subjects”Biederman, J., Faraone, S.V., Knee, D., Tsuang, M.T. (1990). Family-genetic and psychosocial risk factors in DSM-III attention deficit disorder. Journal of the American Academy of Child and Adolescent Psychiatry, 29, 526-533.

– “A high familial aggregation is seen for CD and aggressive, antisocial behavior.”Lahey, B.B., Piacentini, J.C., McBurnett, K., Stone, P., Hartdagen, S. and Hynd G. (1988). Psychopathology in the parents of children with conduct disorder and hyperactivity. Journal of the American Academy of Child and Adolescent Psychiatry, 27: 163-170

– “These findings on adopted-away children of antisocial biological parents provide evidence for a genetic factor in the etiology of CD and aggressive, antisocial behavior”

Cadoret, R.J., Yates, W.R., Troughton, E., Woodworth, G., and Stewart, M.A. (1995). Genetic environmental interaction in the genesis of aggressivity and conduct disorders. Archives of General Psychiatry, 52, 916-924

– 526 identical twin pairs and 389 fraternal twin pairs – “Much greater concordance for ADHD in identical (monozygotic)

twins than in fraternal (dizygotic) twins.”– Gjone, H., Stevenson, J., and Sundet, J.M. (1996). Genetic influence on parent-reported attention-related problems in a Norwegian general population twin sample. Journal of

the American Academy of Child and Adolescent Psychiatry, 35: 588-596.

– “Much greater concordance for delinquency and aggressive behavior, in MZ than in DZ twins”

Edelbrock, C., Rende, R., Plomin, R., and Thompson, L.A. (1995). A twin study of competence and problem behavior in childhood and early adolescence. Journal of Child Psychology and Psychiatry, 36, 775-785.

GENETIC FACTORS • Evidence for Externalising Disorders in Parents

– Biological mothers of adoptees have elevations on five of nine clinical scales of the MMPI, most notably the psychopathic deviate subscale Horn, J.M., Green, M., Carney, R., and Erickson, M.T. (1975). Bias against genetic hypotheses in adoption studies. Archives of General Psychiatry, 32, 1365-1367.

– “In our experience with four adoption agencies over several years, the most common psychiatric diagnosis among biological parents relinquishing children for adoption was antisocial behavior or antisocial personality”Cadoret, R.J. (1990). Biologic perspectives of adoptee adjustment. In D.M. Brodzinsky & M.D. Schechter (Eds.), The psychology of adoption. New York: Oxford University Press, 25-41.

GENE-ENVIRONMENT INTERACTION“…..this vulnerability is compounded in some adoptees who have experienced pre-, peri-, and post-natal adversity”Barbara D. Ingersoll (1997) Psychiatric Disorders Among Adopted Children, Adoption Quarterly, 1:1, 57-73

Gene-Environment Interaction

• “Concluding that adopted children from a compromised genetic background are inevitably destined to a poor outcome is patently false and amounts to therapeutic nihilism”Faraone, S.V., Biederman, J., Keenan, K., and Tsuang, M.T. (1991). A family genetic study of girls with DSM-III attention deficit disorder. American Journal of Psychiatry, 148: 112-117.

– “the very fact that concordance between monozygotic twins is less than 1.00 for all psychiatric disorders indicates that environmental factors play a significant role in the expression of genetic potential

– Adverse home environments (those in which SES is low and there is much family turmoil, dysfunction, and psychopathology) have been shown to produce a much higher incidence of adolescent CD than would be predicted by either genetic or environmental factors acting independentlyCadoret, R.J., Yates, W.R., Troughton, E., Woodworth, G., and Stewart, M.A. (1995). Genetic-environmental interaction in the genesis of aggressivity and conduct disorders. Archives of General

Psychiatry, 52, 916-924.

Clinical Implications

• Eschew the assumption that psychological problems in adopted children and adolescents are primarily attributable to the fact of adoption, per se

• If behavioral and emotional problems appear, early intervention would seem preferable to a ‘‘watch-and-wait’’ strategy– Problems to which adoptees are prone tend to worsen over time

– CD in its full-blown form is notoriously refractory to treatment

• Risk factors which should alert adoptive parents to the need for early intervention include – a difficult temperament in infancy

– early poor school performance

Clinical Implications• Hyperactivity and attention problems by themselves do not

predict the development of CD, although they are certainly troublesome in their own right and clearly merit professional intervention

• Patterns of aggression and oppositional defiant behavior, however, especially in combination with restlessness and overactivity, tend to be stable over time and are important predictors of later CD and antisocial behavior

• Avoid assuming that the source of all problems resides within the child’s genes and/or early history of adversity

• Parents and professionals must be willing to explore all factors which might bear on the child’s adjustment, including past and current patterns of dysfunction within the parents and other family members

Adoption Competent Clinical Practice• “Adoptive parents consistently report that their greatest post-adoption support

need is mental health services provided by someone who understands adoption”Smith, S. L. (2010). Keeping the promise: The critical need for post-adoption services to enable children and families to succeed. New York, NY: Evan B. Donaldson

Adoption Institute.

• A review of literature failed to produce any formal definitions of adoption competence or lists of specific practices defined as reflecting adoption competency.

• “Since 2008, the Center for Adoption Support and Education (C.A.S.E.) has provided leadership for a multiyear initiative, Training and National Certification for Adoption Competent Mental Health Practitioners, funded by multiple private foundations.

• C.A.S.E. convened a group of nationally recognized experts, including parents, who specified the knowledge, skills, and values competencies in 18 domains that mental health practitioners need to be adoption-competent.

• The expert panel also developed the following definition of an adoption-competent mental health professional:

Anne J. Atkinson , Patricia A. Gonet , Madelyn Freundlich & Debbie B. Riley (2013) Adoption Competent Clinical Practice: Defining Its Meaning and Development, Adoption Quarterly, 16:3-4, 156-174,

• An adoption-competent mental health professional has

– The requisite professional education and professional licensure

– A family-based, strengths-based, and evidence-based approach to working with adoptive families and birth families

– A developmental and systemic approach to understanding and working with adoptive and birth families

– Knowledge, clinical skills, and experience in treating individuals with a history of abuse, neglect, and/or trauma

– Knowledge, skills and experience in working with adoptive families and birth families.

• An adoption-competent mental health professional understands:

– The nature of adoption as a form of family formation

– The clinical issues that are associated with separation and loss and attachment

– The common developmental challenges in the experience of adoption

– The characteristics and skills that make adoptive families successful.

• An adoption-competent mental health professional is :

– Culturally competent with respect to the racial and cultural heritage of children and families

– Skilled in using a range of therapies to effectively engage birth, kinship, and adoptive families toward the mutual goal of

• helping individuals to heal

• empowering parents to assume parental entitlement and authority

• assisting adoptive families to strengthen or develop and practice parenting skills that support healthy family relationships

– Skilled in advocating with other service systems on behalf of birth and adoptive families.(Center for Adoption Support and Education, 2009)

• A total 485 persons responded to the survey

– 87% were adoptive parents

– 9.1% were adopted persons

– 8.1% were members of an adoptive family

– 7% were birth parents

– 17.2% reported themselves as “other” (typically a professional role related to adoption)

#1 Understands the impact of separation and loss on individuals and families and the importance of attachment in creating healthy relationships.

#2 Understands that adoptive families and adopted persons experience developmental challenges and is able to work effectively with families and individuals on these issues.

#3 Works with adoptive families and adopted persons with a clear understanding of individual and family development and the multiple service systems with which families and individuals are involved.

Psychosocial Understanding of Adoption• “The experience of adoption exposes parents and children to a

unique set of psychosocial tasks that interact with and complicate the more universal developmental tasks of family life (described by Erikson)”

• “For family members to move forward to more advanced, mature levels of adoption adjustment there must be an adequate (although not necessarily complete) resolution of the crises associated with adoption-related tasks.”

• “The degree to which adoptive parents and their children acknowledge the unique challenges in their life, and the way in which they attempt to cope with them, largely determines their pattern of adjustment”


Age Period Psychosocial Crises

Infancy Trust vs Mistrust

Toddler Preschool years

Autonomy vs Shame&DoubtInitative vs Guilt

Middle Childhood Industry vs Inferiority

Adolescence Ego Identity vs Identity Confusion

Infancy • Parents are more likely to meet the baby’s needs in ways that

promote a basic sense of security if – The general caretaking atmosphere is characterized by warmth and low

anxiety

– Parents are secure in their parental roles

– Parents have realistic expectations concerning their child’s behavior and development

• Inadequate caretaking, where the baby’s needs are met inconsistently and in an unsatisfying way (promoting a sense of mistrust or insecurity in the infant) is likely if – Heightened parental anxiety

– A mismatch between parental expectations and infant characteristics and behavior

• Several factors can complicate the development of basic trust– All of which relate to the transition to adoptive parenthood

1. Infertility • Relates to self-image and one’s basic sense of masculinity and

femininity (Kraft, Palombo, Mitchell, Dean, Meyers, & Schmidt, 1980; Shapiro, 1982)

– Inadequate resolution

– unconscious use of adoption as a way of avoiding the issue

• individual and/or marital adjustment problems - general anxiety, depression, a devalued self-image, resentment of one partner for another, disruptions in marital communication,etc,

• This threatens the development of a caretaking atmosphere conducive to the emergence of trust and security in the infant

2. Uncertainty of Placement timing • Uncertain length of wait

• In-depth evaluation process is an “intrusive”, anxiety provoking experience

3. Absence of appropriate role models • Realistic perspective of adoption process unavailable

• Likely to develop unrealistic expectations about transition to adoptive parenthood

4. Social Stigma surrounding Adoption • adoption still is seen as a “second best route to parenthood”

• adoptive parents frequently must justify to others why they have made their particular decision – likely to facilitate parental anxiety and resentment.

5. Developing attachments in late placements • Children placed for adoption early in their lives (within first 06

months or so) develop identical secure attachment relationships with mothers as do non-adopted infants (Singer et al, 1985)

• Maladjustment likelier in later placements – acute distress accompanying the severing of a previously established

attachment relationship

– child has never developed a secure attachment due to multiple foster placements.

Toddlerhood and the Preschool Period

Toddlerhood and the Preschool Period• Child is primarily concerned with developing a sense of autonomy

and initiative; being able to – separate from parents physically, (and psychologically)– do things for oneself in ways that bring about

• Self-satisfaction• Approval from others

• Parents are more likely to facilitate positive socio-emotional adjustment if they meet child’s strivings for independence with – Patience, understanding & Self-confidence

• Parents are more likely to facilitate negative socio-emotional adjustment if they meet child’s strivings for independence with – Anxiety, Insensitivity & Insecurity

• “The hallmark of secure attachment to caregivers is the infant’s and young child’s ability to use these individuals – To reduce their stress level– Regain their security– Provide them with sufficient confidence to resume constructive activity,

including renewed separation from the caregivers

• “Parents experience ambivalence when they recognize that their children have begun the process of becoming psychologically independent human beings; individuals with their own needs, desires, thoughts, & fantasies. “David M. Brodzinsky Adjustment to Adoption: A Psychosocial Perspective Clin Psychol Review Vol 7 pp 22-47 (1987)

• In most adoptive families the telling process begins during the preschool years, usually between two and four years of age Mech. EV. (1993). Adoption: A policy perspective. In B. Caldwell 8 H. Ricciuti (Eds.). Review of Child Development Research. Vol 3. Chicago: University of Chicago Press.

• Telling creates a psychological gap or separation between parents and child where none existed before. – Acknowledges openly to all family members that the basic biological link

between parents and children, is absent in their particular family

– This process accentuates the growing gulf between parents and children and creates anxiety in many adoptive parents in an area that already is fraught with ambivalent feelings

School Age Years

School Age Years• “As children enter the school age years, a new psychosocial theme emerges

: the need to be industrious, to master things, to understand.” (Erikson, 1963)

• A positive sense of self emerges when parents/teachers

– Pose tasks for children that they that they recognize as interesting and worthy , and can accomplish

– When children’s efforts are reinforced

• A sense of inadequacy or inferiority emerges when

– children are made to feel that their efforts and achievements are insignificant

– when their thoughts, desires, fantasies, and actions are not taken seriously, or are actually discouraged

• “This is the time when adopted children actively attempt to master / understand their adoptive status- and all of its implications.

• “Although most children are informed of their adoptive status in the preschool period, our research suggests that these young children actually have little awareness of what adoption means” (Brodzinsky, Singer, & Braff, 1984)

• I: What I want to ask you about is adoption. Have you heard that word before?• A: Sure, I’m adopted.• I: What does that mean? What’s adoption mean?• A: Well mommy told me that when I was a baby I came out of another lady . . .she

made me. After I was born, my mommy and daddy came and got me and took me home.

• I: So first you came out of one lady and then you went home with another lady, your mommy . . and of course your daddy too.

• A: Yep. That’s how it happens.• I: So your mommy and daddy became your parents after they got you . . . I mean

after they adopted you and brought you home.• A: (nods yes)• I: Is there any other way that grown-ups can become parents besides adopting a

child?• A: What do you mean?• I: How do grown-ups become parents? How do they become a mommy or daddy?• A: They get a child . . . adopt him.• I: Is there any other way of becoming a mommy or daddy?• A: (shakes head no)• I: Do all kids come into their families after they are adopted?• A: Yep . . that’s the way they do it.• I: So, all kids are adopted then?• A: (shakes head yes)

School-Age Years • Between 8 and 11 years, however, children’s understanding of

adoption broadens remarkably– Part of the more general process of cognitive and social-cognitive development

that emerges at this time (Brodzinsky, Schechter, & Brodzinsky, 1986; Brodzinsky et al., 1984).

• “To be adopted means not only that one has been ‘chosen’ but also that one has been relinquished or “given up”.

• Children begin to fantasize about the circumstances surrounding their relinquishment

• Begins to see possible solutions to the problems that once confronted the birth parents; problems that the birth parents were unable to solve themselves– Anger and resentment toward the birth parents

– Concern that the birth parents’ circumstances have changed and that they are now considering reclaiming their child

• “As they mature intellectually and their knowledge of adoption broadens, children come to understand the many complications associated with their family status that their parents either have ignored or downplayed in family conversations.

– A sense of uncertainty / confusion may emerge

• “At times, adoptive parents interpret the child’s concerns as indicating that they (the parents) have done a poor job in handling the telling process.

• Parental anxiety may then lead them to

– deny that the child actually is confused or has genuine concerns, or

– it may lead them to believe that the child is seriously disturbed

• Children’s confusion during this period most often is a normal part of coping with adoption

– Reflects an increasing awareness of what it means to be adopted

– Represents the beginning of a normal process of adaptive grieving


• Adoption involves loss

– for the biological parent it is the loss of the relinquished child

– for the adoptive parent it is the loss of fertility and the biological child they wanted

– adopted children, it is the loss of their birthparents and origins, and sometimes siblings as wellWard. M. (1984). Sibling ties in foster care and adoption planning. Child Welfare. 63, 321-332.

• “The behavioral and emotional patterns associated with this realisation of loss are well known.

– Shock. denial, protest, despair, and eventually recovery or reintegration are commonly observed

• “Adoptive parents need to recognize that as their children become more aware of what it means to be adopted, a certain amount of confusion and uncertainty is bound to be manifested

– These behaviors and reactions are usually part of an adaptive grieving process

• Ignoring their children’s concerns or treating them as insignificant may very well foster feelings of inadequacy or inferiority

• It is important for parents to

– Acknowledge to their children that they recognize and accept their concerns

– Encourage them to explore and resolve what one 9-year-old boy called “the master question of my life - Why was I given up for adoption?”


Adolescence

Adolescence • “Adolescence is the time when all young people actively take up the

issue of identity. • “Who am I?” becomes the central question for the developing

teenager.• “Identity provides a subjective sense of invigorating sameness and

continuity” • As part of the struggle for self-definition, adolescents seek to link their

– current sense of self with – perceptions of self from earlier periods, and with – their cultural and biological heritage

• A sense of confidence emerges with respect to identity when adolescents are able to – maintain a feeling of inner sameness and continuity across time

and across the many situations in which they find themselves– when they are able to integrate their self-perceptions with

• the feedback they receive from others • a known genealogical past

Erikson, E. (1968). Identity, Youth and Crisis. New York: W.W. Norton.

• “Adoptive parents need to recognize that for the adoptee this universal psychosocial task is often complicated by – a lack of information regarding the birth parents and the reasons

underlying the original relinquishment– by feelings of disloyalty to adoptive parents because of the

curiosity and desire for such information”

• Adopted adolescents and youth need considerable emotional support, and at times, practical guidance, from their parents, relatives, and friends in their search for identity.

• They need to feel free to explore the question of who they really are, in all of its ramifications.

• Without the support from others and without this sense of freedom to explore identity issues, adoptees are much less likely to develop – a stable and positive view of themselves – a healthy balance between individuality and autonomy– continuing connectedness to the family


Age Period Psychosocial Crises Adoptive Family Tasks

Infancy Trust vsMistrust

Resolving feelings regarding infertilityCoping with uncertainty and anxiety related to the placement processFinding appropriate role models and developing realistic expectations regarding adoptive parenthoodCoping with the social stigma surrounding adoptionDeveloping secure attachment relationships in cases of delayed placement

Toddler &Preschool Yrs

Autonomy vsShame&DoubtInitative vs Guilt

Coping with the anxiety and uncertainty surrounding the initial telling processCreating an atmosphere in which questions about adoption can be freely explored

Middle Childhood

Industry vsInferiority

Helping the child master the meaning of adoptionHelping the child in the initial stages of adaptive grievingMaintaining an atmosphere in which questions about adoption can be freely explored in light of the complications brought about by the grief process

Adolescence

Ego Identity vsIdentity Confusion

Helping the adolescent cope with genealogical bewildermentHelping the adolescent grieve for the lost self (in addition to the loss of birth parents and origins)Maintaining an atmosphere in which questions about adoption can be freely explored in light of the complications associated with the grief process (including support for the adolescent’s/ young adult’s search for origins)

Telling the Adopted Child • “There is broad consensus in the academic and practice literature that

communicative openness is desirable, if not essential”• Chris Jones & Simon Hackett (2008) Communicative Openness Within Adoptive Families: Adoptive Parents' Narrative Accounts of the Challenges of Adoption Talk and

the Approaches Used to Manage These Challenges, Adoption Quarterly, 10:3-4, 157-178

• Associations between communicative openness and the

– Well-being of the child (Brodzinsky, 2006),

– Development of a positive identity as an adopted person (Howe&Feast, 2003),

– Higher levels of satisfaction with the adoption expressed by the adoptee in adulthood (Howe & Feast, 2003; Raynor, 1980)

• “It is generally agreed that the child should be told of the adoption, but there is disagreement on when the information should be given”

• The Pediatrician's Role in Supporting Adoptive Families Veronnie F. Jones, Elaine E. Schulte and the Committee on Early Childhood and Council on Foster Care, Adoption, and Kinship Care Pediatrics; originally published online September 24, 2012;

• “Late-placed children finding communicative openness more difficult.”Howe, D., & Feast, J. (2003). Adoption, search and reunion: The long-term experience of adopted adults. London: BAAF.

• “The majority of adoptive families in our sample discussed adoption only once or on a very few occasions”Palacios, J., & Sanchez-Sandoval, Y. (2005). Beyond adopted/nonadopted comparisons. In D. M. Brodzinsky & J. Palacios (Eds.), Psychological issues in adoption: Research and practice (pp. 117–144). Westport, CT: Praeger.

• Successful adoption revelation cannot be measured by what, how much, or even when information is revealed

• Only by what the child is capable of understanding and accepting at a given point in time

• We believe that knowing and accepting these facts will contribute to a reduction in anxiety in adoptive parents as they begin this decidedly difficult task-– which should facilitate psychological adjustment among all family

members.Children's Understanding of Adoption Author(s): David M. Brodzinsky, Leslie M. Singer and Anne M. Braff Source: Child Development,Vol. 55, No. 3 (Jun., 1984), pp. 869-878

• “We caution against extreme positions on openness such as denial or insistence of difference in adoptive family life. Instead, a middle road in acknowledging difference is recommended

• The most important factor to consider in relation to communicative openness is the satisfaction of the adoptee(s) and adopter(s) with adoption communicationBrodzinsky, D. M. (1987). Adjustment to adoption: A psychosocial perspective. Clinical Psychology Review, 7, 25–47.

• Adoptive parents face the dilemma of being

– proactive in adoption talk and risking the revelation of certain details of the adoption story before the adopted child is cognitively and emotionally able to deal with them

– reactive to children’s questioning and risking the perception that they are withholding important information

• They face the challenge of communicating complex and sensitive adoption stories in ways that

– Maintain the adopted person’s self-worth

– Give an honest accountChris Jones & Simon Hackett (2008) Communicative Openness Within Adoptive Families: Adoptive Parents' Narrative Accounts of the Challenges of

Adoption Talk and the Approaches Used to Manage These Challenges, Adoption Quarterly, 10:3-4, 157-178

• 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

• Families should be discouraged from “waiting until just the right minute” to tell children that they were adopted– This may leave children feeling betrayed and wondering what else their parents

may have hidden from them.

– Children may 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.

• An honest approach in the discussion of a child’s biological family and the adoption process is recommended – Gives a child permission to ask questions or to make statements about

adoption

– Takes away the veil of secrecy which implies that being adopted is a negative condition


• Encouraged modeling of positive adoption language

– 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” • might imply to the child that he or she was of less worth and was given

away.

– Rather the biological parents made an adoption plan • in the best interest of the child’s future

• to the best of their abilities at the time

– Biological mother should not be identified as a “natural parent”• 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.”


• Create Openings for Adoption Talk– Families used life story

books as a reference point for conversations about adoption

– These were often kept in an accessible location agreed by both adoptive parents and their adopted children• Giving adopted children easy

access to them

– Children could choose • when to look at them

• when to ask questions• Chris Jones & Simon Hackett (2008) Communicative Openness Within

Adoptive Families: Adoptive Parents' Narrative Accounts of the Challenges of Adoption Talk and the Approaches Used to Manage These Challenges, Adoption Quarterly, 10:3-4, 157-178

Adoption Laws in India

• Adoption is not permitted in the personal laws of Muslims, Christians, Parsis and Jews in India.

– They usually opt for guardianship of a child through the Guardians and Wards Act, 1890.

• Indian citizens who are Hindus, Jains, Sikhs, or Buddhists are allowed to formally adopt a child.

– The adoption is under the Hindu Adoption and Maintenance Act,1956

HINDU ADOPTION AND MAINTENANCE ACT, 1956Capacity to Adopt

• Any adult Hindu male who is of sound mind can adopt a child. If the said man is married, the consent of the wife is necessary.

• A female adult Hindu of sound mind could adopt a child if she is

• Unmarried• Divorced• Widowed or• Her husband suffers from certain disabilities

– Ceased to be a Hindu– Has renounced the World– Has been declared to be of unsound mind by the court

HINDU ADOPTION AND MAINTENANCE ACT, 1956• The following conditions must be complied with: • (i) if any adoption is of a son, the adoptive father or mother

by whom the adoption is made must not have a Hindu son, son's son or son's son's son (whether by legitimate blood relationship or by adoption) living at the time of adoption

• (ii) if the adoption is of a daughter the adoptive father or mother by whom the adoption is made must not have a Hindu daughter or son's daughter (whether by legitimate blood relationship or by adoption) living at the time of adoption

• (iii) if the adoption is by a male and the person to be adopted is a female, the adoptive father is at least twenty-one years older than the person to be adopted

• (iv) if the adoption is by a female and the person to be adopted is a male, the adoptive mother is at least twenty-one years older than the person to be adopted

HINDU ADOPTION AND MAINTENANCE ACT, 1956Capacity to Give in Adoption

• Only the father can make the decision of giving a child in adoption.

• The father can give the child in adoption only with the consent of the mother– unless the mother has

• ceased to be a Hindu,

• has renounced the world

• is of unsound mind

• The mother may give the child in adoption if – the father is dead

– has completely and finally renounced the world

– has ceased to be a Hindu

– has been declared by a court of competent jurisdiction to be of unsound mind

HINDU ADOPTION AND MAINTENANCE ACT, 1956

Effect of Adoption

• When once a child has been adopted, that child severs all ties with his natural family.

– All the right and obligations of natural born children fall on him.

• The wife of a Hindu male, who adopts is deemed to be the adoptive mother.

– Where an adoption is made with the consent of more than one wife, the senior most in marriage is deemed to be the adoptive mother and the rest are given the title of step mothers.

• Clause (c) of section 8 of the Hindu Adoptions and Maintenance Act, 1956 incapacitates a married woman from taking in adoption merely on the basis of her marital status and is discriminatory in nature. Therefore, section 8 has been amended to give similar right to a female Hindu, irrespective of her marital status, as that of a male Hindu.

Similarly, sub-section (2) and (3) of section 9 curtails the right of mother to give in adoption if father is alive or is of sound mind or has not renounced the world completely and finally. The rights of father and mother under sub-sections (2) and (3) are discriminatory in nature. Therefore, section 9 of the Hindu Adoptions and Maintenance Act, 1956 has been suitably amended to give similar right to a female Hindu.

GUARDIANS AND WARDS ACT, 1890

• Applicable to all of India except the state of Jammu and Kashmir.

• Particularly outlined for Muslims, Christians, Parsis and Jews as their personal laws don’t allow for full adoption, but only guardianship.

• It applies to all children regardless of race or creed.

• Any child who had not completed 18 years of age was to be a minor.

• This child would be appointed guardians by the court or any other appointed authority.

• All these procedures took place only after an application had been placed by the person who was willing to take a child under himself and to act as his guardian.

• The applications should contain all the possible information that would have been required, including the information about the guardian and any reason as such for the guardianship.

GUARDIANS AND WARDS ACT, 1890• Once the court admits the application, a date for a hearing

would be set. The court will hear evidence before making a decision.

• Unlike in the procedures given in the Hindu Adoption and Maintenance Act, 1956, where a person once adopted has a single set of parent, here a minor and his property could have more than one guardian.

• It was required under these cases of guardianship that

– the court use its discretionary power and considered the interests of the minor.

– His/her age, sex, religion, the compatibility quotient with the guardian, the death of the parent, etc. must be taken into consideration.

– The minor’s preference may also be taken into consideration.

In conclusion…..• The important roles of adoption practitioners are

– They can alert adoptive family members at the stage of preparation and assessment to both the complexity of the task as well as the potential rewards.

– They can ensure that adopters understand the value of tools such as reports, life story books, photograph albums, and later-in-life letters.

– They can assist adoptive family members to develop a specific language, style, and set of skills that meet their family’s needs over time.

– They can provide adoptive family members with support to develop the confidence to use this language and to deal with the emotional aspects of adoption talk.

#1 Understands the impact of separation and loss on individuals and families and the importance of attachment in creating healthy relationships.

#2 Understands that adoptive families and adopted persons experience developmental challenges and is able to work effectively with families and individuals on these issues.

#3 Works with adoptive families and adopted persons with a clear understanding of individual and family development and the multiple service systems with which families and individuals are involved.

References• Anne J. Atkinson , Patricia A. Gonet , Madelyn Freundlich & Debbie B. Riley (2013) Adoption

Competent Clinical Practice: Defining Its Meaning and Development, Adoption Quarterly, 16:3-4, 156-174,


• Chris Jones & Simon Hackett (2008) Communicative Openness Within Adoptive Families: Adoptive Parents' Narrative Accounts of the Challenges of Adoption Talk and the Approaches Used to Manage These Challenges, Adoption Quarterly, 10:3-4, 157-178

• Practitioner Review: Children in foster care – vulnerabilities and evidence-based interventions that promote resilience processes Leve LD et al, J Child Psychol Psychiatry. 2012 December ; 53(12): 1197–1211.

• Nickman SL et al, Children in Adoptive Families: Overview and Update J. AM. ACAD. CHILD ADOLESC. PSYCHIATRY, 44:10, OCTOBER 2005

• David M. Brodzinsky Adjustment to Adoption: A Psychosocial Perspective Clin Psychol Review Vol 7 pp 22-47 (1987)

• Barbara D. Ingersoll (1997) Psychiatric Disorders Among Adopted Children, Adoption Quarterly, 1:1, 57-73

• Lindholm. B. W., & Touliatos. J. (1980). Psychological adjustment of adopted and nonadoptedchildren. Psychological Reports, 46, 307-3 10

• Brodzinsky et al (1984) Psychological and academic adjustment in adopted children. Journal of Consulting and Clinical Psychology 52, 582-590

• Children's Understanding of Adoption Author(s): David M. Brodzinsky, Leslie M. Singer and Anne M. Braff Source: Child Development,Vol. 55, No. 3 (Jun., 1984), pp. 869-878

Thank You

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