Experts Speak

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There are a number of important resources for adoption information covering issues from a variety of perspectives. Holt has gathered some of this information to feature in "Experts Speak"... These experts are leaders in the field of child welfare and adoption and Holt values their insights and expertise.

Telling the Adoption Story
By Holly van Gulden

Additional topics and presenters will be added to this site. If you have a specific topic you would like addressed, email susanc@holtintl.org

Adopting the Institutionalized Child
by Dr. Dana E. Johnson, MD, PHD

Telling the Adoption Story
by Holly van Gulden

Adopting an Institutionalized Child:
What are the Risks??

BY: Dana E. Johnson, M.D., PH.D.

After reviewing the medical records of nearly 1,000 institutionalized children, I can conclusively state that the most difficult area in adoption medicine is predicting the needs of children adopted from orphanages. Unfortunately, there is no shortage of dogmatic opinion, both positive and negative, on the outcome of these children. Recently I have been quoted as saying that 85% of institutionalized children are normal. If so, why are so many families seeking help for their adopted children through organizations like PNPIC (The Parent Network For The Post-Institutionalized Child)? Confused by what you have heard? I am.

The major problem is that we are only beginning to understand how these kids are doing. Studies utilizing appropriately selected and tested institutionalized children have been too few to say with any certainty what percentage are normal (even if we could define what we mean by “normal”). It is also quite clear that the situation changes with time. Some children resolve problems, whereas others begin to exhibit them as the years pass. All contemporary studies of institutionalized adoptees from abroad deal with a rather narrow span of time, within two to five years of placement. Without valid data, we are left with our own opinions-which, of course, are shaded by our personal experiences with adoption, by conversations with families we have come into contact with in our practice and by our own world view.

What do we really know, and what can we say about institutionalized children as a group? More importantly, what can we say about the child you have adopted or are considering adopting? Certainly, no one is in a position to provide statistics on what percentage are abnormal or normal. Even if we did have those data, they would address the status of institutionalized children at an early age. Twenty years from now, worries that your child had language delays at four years of age will be replaced by concerns of whether your child has acquired the tools to be successful as an adult; e.g., a positive self-image, a high school diploma and independent living skills. No one is in the position to even speculate on these long-term issues.

Following are questions which address issues that I feel should be considered when adopting an institutionalized child. Since I am offering advice in the absence of irrefutable facts, you are entitled to know my personal view on this subject. Nothing would please me more than to have all institutionalized children find permanent homes. However, nothing would make me feel worse than having a family adopt a child they were unprepared to parent.

What are the chances that my child will be normal on arrival?

Let me be blunt. The chance of an institutionalized child being completely normal on arrival in your home is essentially zero! Here’s why:

Kids aren’t in orphanages because they come from loving, intact families with a good standard of living and ready access to good health care and nutrition. Abandonment by a destitute, single parent with poor parental care and inadequate diet is the most common reason why a child is available for adoption. The second most common reason is termination of parental rights because of neglect and/or abuse (often alcohol related). Over 50% are low birth weight infants, many were born prematurely, and some have been exposed to alcohol in utero. These kids are a high-risk group by any standard.
An orphanage is a terrible place to raise any infant or young child. Lack of stimulation and consistent caregivers, suboptimal nutrition and physical/sexual abuse all conspire to delay and sometimes preclude normal development. All institutionalized children fall behind in large and fine motor development, speech acquisition and attainment of necessary social skills. Many never find a specific individual with whom to complete a cycle of attachment. Physical growth is impaired. Children lose one month of linear growth for every three months in the orphanage. Weight gain and head growth are also depressed. Finally, congregate living conditions foster the spread of multiple infectious agents. Intestinal parasites, tuberculosis, hepatitis B, measles, chicken pox, middle ear infections, etc., are all found more commonly in institutional care settings.

Will I be able to determine the nature and severity of my child’s immediate health needs prior to arrival?

I have seen very few children for whom sufficient information on prenatal factors, birth weight, and postnatal growth and development were available to say that the child was normal. A more common situation is identifying children who clearly are very abnormal. These children who have the typical facial and growth characteristics of fetal alcohol syndrome, children with clear neurologic abnormalities and children with autistic-like behavior. It is impossible to predict the exact needs of most children which is why you should have your child evaluated by knowledgeable professionals after arrival. Most institutionalized children, especially those older than two years of age need rehabilitation services to correct deficits imposed by orphanage life.

Even if a child initially appears normal, remember that many problems are not apparent even at the time of arrival in your home. For example, children with significant attachment issues often do not exhibit these behaviors until they feel secure in their new environment. The challenges of school, particularly the transition between kindergarten and first grade, may unmask subtle intellectual impairments and learning disabilities.

If my child isn’t normal on arrival, when will he/she catch up?

This is a question that no one can answer with certainty. We do know that your child will progress far better in your home than he/she would have in the orphanage, and that most children make tremendous gains in growth and development during the first years with their adoptive families. Unless a child is truly neurologically impaired, gross and fine motor skill as well as strength respond well to improved nutrition and stimulating environment. However, many children, especially those who spent considerable time within institutional care settings, continue to show delays in language and social skills, behavioral problems, and abnormalities in attachment behavior even after several years in their adoptive home. In most situations, therapy will improve but cannot correct the fundamental problem; e.g. fetal alcohol exposure. In these situations, the challenges will be life-long.

Since my child will likely have medical and/or developmental needs, will I be able to locate appropriate therapeutic resources within my community?

Your child’s most important resource is you and your family. Your commitment to your child’s well-being is the single most important factor in success. However, despite what you may have heard, love alone may not be enough. Expert help is frequently needed to rehabilitate a child who has suffered prolonged neglect and abuse within an orphanage.

One of the most frustrating situations a parent can face is having a child with a problem, but no access to help. Hope for the best but prepare for the worst. Before you accept a referral, seek out the resources in your community that may be necessary. These include speech and language pathologists; occupational therapists with training in sensory integration therapy; neuropsychologists who have experience evaluating institutionalized children; and therapists with experience in post-institution behavior problems and attachment disorders. Some of these services may be available for free within your school system, but many will involve significant expense. Be sure to check with your health plan to see what services are covered, at what level, and for how long. Careful investigation of these areas may help you decide if adopting an institutionalized child is an option for your family.

What are the chances that our child will have severe problems?

The likelihood that you will adopt an institutionalized child with problems so severe that they disrupt the fabric of your family is small. Educate yourself with information available through organizations such as PNPIC, then honestly evaluate your own capabilities as a parent. You may decide that the risk, though low, is too great for your situation.

If you decide to proceed, you can lower your chances of adopting such a child by obtaining appropriate information from your agency and having it reviewed by a knowledgeable physician prior to accepting a referral. An important part of this process is being prepared to say no if the needs of a certain child exceed your capabilities. Be aware, though, that you will never have all the information you need to eliminate this risk. Don’t drive yourself wild in an endless search for that one final piece of information that will guarantee a correct decision. The best decision you can hope to make is one that is well-reasoned, based on the information that is available, accompanied by the “leap of faith” that is a mandatory part of all conscious decisions to parent. If you cannot knowledgeably assume this risk, international adoption-particularly of an institutionalized child- may not be for you.

Will we be satisfied that we make the choice to adopt a child from an orphanage?

The answer to this question is the reason I remain optimistic about adopting institutionalized children. A study involving a questionnaire returned by a large number of families who adopted from Romania revealed that 90% had a positive view of their adoption. However, being satisfied with their decision to adopt did not mean that their children were problem free (whose children are?). Less than 10% of families were ambivalent about their decision, and only a small percentage were considering disruption of the adoption.

In summary:

Don’t expect your child to emerge from an orphanage unscathed.
Prepare in advance to rehabilitate your child.
Institutionalized children are a high-risk group. Make sure that you are prepared to take on the parenting challenges.
Optimism is appropriate. Most families feel positively about their adoption.

Parents whose children join their families through adoption are concerned with when, how and what to tell them about birth histories. In the words of Kizzie when explaining why she never married her lover, “Sam wasn't like us. Nobody ever told him where he came from, so he didn't have a dream of where he ought to be going.”

As a parent, you may wish you didn't have to explain where your child came from before he or she became your child, but your child needs the combination of ancestral heritage from the birth family and a sense of belonging and identity from the adoptive family to establish a whole view of self. Here are some ways to do it that best enhance the bond of understanding between you and your child.

Basic Guidelines

Children as young as six months are naturally curious about babies. By 14 to 24 months, most young children are interested in “when I was a baby.” This is a normal time to review a child's babyhood, whether adopted or not. Because this is a natural avenue of discussion about babies, the idea of adoption can be introduced through the use of a story book.

Much of the telling will be the oral passing of information. But it can be incredibly helpful to have your child's story written down. This helps you prepare and share information. It gives children something tangible when absorbing their story and establishes the normality of the information, as well as the adoption process. Preparing and sharing a personalized book also establishes the importance of every child's life journey.

Two Information Paths

In order to help your child with the issues of claiming the past and belonging to the present and future, you can create and share a baby book and create a family story book that the whole family can read together and discuss at different stages.

Baby books are very appropriate and helpful for introducing basic concepts and facts for toddlers and preschoolers. A family story book tells your child's personal history as a chapter in the overall history of the family. Family story books anchor your child in the family and can be especially helpful for children who came home after infancy or for children who experienced multiple caretakers or abuse and neglect. Anyone can benefit from the family story book, but these children do most of all.

In addition, children who experience anxiety when faced with life passages of separation, such as going to preschool or kindergarten, can anchor their identity and security with a story book. “Frankie,” for example, had never been in any home longer than two years. Although he was subsequently adopted, he was about to run away after he had been with his family less than two years. The only thing he had packed in his suitcase was his baby book. His parents (after halting his flight) were advised that he needed a family story book to see where and how he was connected to his family. He was then reassured by seeing how he entered his now permanent family and how his story became part of the whole.

The Baby Book

A baby book contains basic facts about the child's birth, leaving the birth family, and joining the new family. The general rule is to keep it simple. When referring to birth parents, it is least confusing for young children to use the first names of birth parents. Also, using the terms “birthmother” or “birthfather” is confusing because at an early age, children cannot distinguish between the lady who bore them and an adoptive mom.

It is good to remember that when telling the story you are demonstrating how loss can be experienced, moved through, and handled.

When discussing your child's origins, the first elements to include are the event of birth and the key characters including the birth parents, adoptive parents, and the child. Without explaining why, children can be told that the birth parents could not take care of the baby. If you have knowledge of the birth parents, that information should be shared with your child. Emotions such as fear, confusion, and happiness should be used to describe the people in the story. Your child needs to know that people have feelings that are real because it confirms that he or she is loved and valued by birth parents.

After establishing the emotional reactions of the birth parents in your story, it is equally important for your child to understand your feelings as adoptive parents in order to present both sides of the situation. If infertility was not an issue, you can describe your interest in finding a baby who needed a home. If infertility was a factor it is all right to say to your child that you could not make a baby. It is rare for a child of any age to ask what caused infertility. Remember that your child's loss of being raised by birth parents is a mirror image of your loss through infertility of childbirth. This sharing brings you and your child closer.

It is good to remember that when telling the story you are demonstrating how loss can be experienced, moved through, and handled. Your modeling shows that when the situation has been resolved, you can still think about it and experience sadness. Just as adoptive parents can sometimes think about what life would have been like with birth children, adopted children can imagine life with their birth parents. This is perfectly normal.

Adoptive parents often do not want to discuss the separation factor that is part of an adoption story. It is painful to discuss, but it shows that birth parents felt sorrow over their decision to relinquish, even though it was the correct thing to do. Identifying, labeling, validating, and safely expressing emotions are the keys to working through the issues of a child joining the family through adoption. It is important that children know that the people who conceived and gave birth to them experienced sadness in giving up the chance to parent them. Not mentioning the birth parents’ emotions implies that the separation did not hurt because the child was not valued.

Be careful not to overemphasize this factor, however. Sensitive children may feel guilty or the need to take care of their birth parents. One way to address that issue is to occasionally mention that the birth parents have a support network, such as friends or family, which helps children realize that these adults are not alone and helpless.

The final element in the baby book concerns coming home. This allows parents to tell their story. They can relate how they discovered adoption: “Mommy and Daddy learned about adoption and decided to adopt a baby. We talked to a social worker (friend, lawyer, neighbor, etc.), and heard about you. Mommy said, ‘There’s my baby,’ and Daddy nodded and smiled.” An important aspect of this account is that it draws attention to the special connection between parents and child. The parents knew that the family was meant to include that very child. They did not want any baby; they wanted their son or daughter.

For toddlers and preschoolers, establishing the child’s basic life journey, including the emotions of birth and adoptive parents, is more important than detailed explanations as to why birth parents could not care for them. When children need more information, they will ask for it. Then parents can elaborate on the same elements used in the baby story. Even if a child does not ask for more details, it is a good idea to introduce them in middle childhood (6 to 10 years). If lack of interest continues, gently suggest the topic, such as “I would enjoy looking through your baby book with you.” But don’t force it; children will be ready when they know the information can be handled.

The Family Story Book

Family story books are created to help emphasize family membership and honoring each member of the family. It is meant to record facts, events, and feelings surrounding them. It illustrates history with photos, cutouts or drawings which can enhance its effectiveness when reviewed in later years. The book tells how the family came into being with the parents’ childhood, education, meeting, decision to parent, and decision to adopt. Each child has a chapter in order of entrance to the family. Older children can help record the story and create the book, especially their own chapters and the final chapter on family life and traditions.

Each child’s chapter includes the whole journey from birth to the present. Life story books can be created in part or whole from the baby book as a chapter in the family story book. At the beginning of each child’s chapter it is a good idea to do a visual time line with all significant events noted. The final chapter is about family traditions, vacations, pets, and whatever binds the families together. A family book helps to show how families came together and how important it is to be together.