Children in adoptive families: overview and update.

(RESEARCH
UPDATE REVIEW)
Journal of the American Academy of Child and Adolescent Psychiatry; 10/1/2005; Sveda, Sally A.
Objective: To summarize the past 10 years of published research concerning the 2% of American children younger
than 18 years old who are adoptees.
Method: Review recent literature on developmental influences, placement outcome, psychopathology, and
treatment.
Results: Adoption carries developmental opportunities and risks. Many adoptees have remarkably good outcomes,
but some subgroups have difficulties. Traditional infant, international, and transracial adoptions may complicate
adoptees' identity formation. Those placed after infancy may have developmental delays, attachment
disturbances, and posttraumatic stress disorder. Useful interventions include preventive counseling to foster
attachment, postadoption supports, focused groups for parents and adoptees, and psychotherapy.
Conclusions: Variables specific to adoption affect an adopted child's developmental trajectory. Externalizing,
internalizing, attachment, and posttraumatic stress disorder symptoms may arise. Child and adolescent
psychiatrists can assist both adoptive parents and children.
J. Am. Acad. Child Adolesc. Psychiatry, 2005;44(10):987-995. Key Words: adoption, placement, foster care,
attachment, parenting.
Adoption has changed in the United States. In the early 1900s, it became closely associated with child welfare.
Often, too many children were available for adoption; adoptive parents could be selective. Adoptive families were
expected to mirror biological kinship. Children were placed according to race, religion, and predicted physical and
intellectual characteristics. Children's lives were made to appear as if they had begun the day that they joined their
adoptive families. Records were sealed, cutting the adopted child off from his or her past. Older, nonwhite, and
disabled children and sibling groups were often considered unadoptable.
Beginning in the 1970s and continuing until today, many more middle-class parents were seeking to adopt than
there were "matched" children available, especially infants. Private agency and attorney-arranged adoptions
became more prevalent and often expensive. The nature of international adoptions also changed. After the World
War II, many families adopted orphans from war-torn European countries. Today, most adoptive parents are
childless couples (Bimmel et al., 2003). With the number of adoptable children diminishing, the foster care system
became the source of more adoptions. Because some children were not legally free and others with special needs
required unavailable subsidies (Rosenfeld et al., 1997), more children entered the foster care system than moved
into permanent homes. Assisted in part by federal legislation, permanency planning and child-centered policies
with a goal of timely adoption of foster children gradually evolved (Howe, 1999).
About 120,000 young people are adopted annually in the United States. Adoptees younger than age 18 years total
about 1.5 million, just over 2% of American children. Of these, two thirds were placed with biologically unrelated
parents. The remainder of these children were adopted by relatives or stepparents (Evan B. Donaldson Adoption
Institute, 2003a; Fields, 2001). In most states, adoption of a healthy infant may be arranged by attorneys with no
agency involvement. In 1992, private agencies completed 47% of adoptions, public agencies 16%, and
independent arrangers 37% (National Adoption Information Clearinghouse, 2004; Stolley, 1993). In the past
decade, international adoptions have doubled to 20,000 annually. Adoptees do not have uniform life experiences.
Some adopted children have experiences that are virtually identical to those of children raised by their biological
parents; others have suffered severe deprivation and multiple disruptions of their caretaking environment before
adoption.
Other important aspects of adoption have also changed. Nontraditional arrangements such as transracial, singleparent, kinship, and gay adoptions have become more frequent; open communication with birth families is now
more likely (Grotevant and McRoy, 1997). Reunions between late-adolescent or adult adoptees and their birth
parents are common (Moran, 1994). Because fewer children are available from the racial and ethnic backgrounds

that some adopters prefer, birth parents have become empowered, particularly in private adoptions in which a
birth parent may now choose among several prospective adoptive couples (DellaVecchio, 2000).
For children in the child welfare system, federal legislation allows earlier termination of parental rights. The
Adoption Assistance and Child Welfare Act of 1980 provided federal funds to cover state-subsidized adoption
payments. The Adoption and Safe Families Act of 1999 and the Promoting Safe and Stable Families Amendments
of 2001 increased the number of nontraditional adoptions as well as those in later childhood. The InterEthnic
Placement Act (Section 1808 of the Small Business Job Protection, Personal Responsibility and Work Opportunity
Reconciliation Act of 1996) now prohibits considering the race, color, or national origin of potential adoptive or
foster parents when placing children. Failing to comply was made a violation of the Civil Rights Act of 1964.
Despite legal efforts to make adoption more "fair," legislatively driven placement choices may not best serve the
interests of minority and older children (Howe, 1999).
Until recently, few well-designed research studies studied various aspects of adoption; many reports were
anecdotal. Fortunately, in the past decade, some well-designed studies of traditional and nontraditional adoption
have been published.
PLACEMENT OUTCOME
The cognitive and emotional adjustment of many adoptees is favorable, but that outcome may depend on both the
child's preplacement experiences and the age at which he or she is placed. "Adoption may even be considered a
protective factor" (Bimmel et al., 2003) because when adopted children are compared with illegitimate children
who were institutionalized, remained with their mothers, or who were later returned to their mothers, adopted
children fared far better, especially those in two-parent families (Miller et al., 2000b). Follow-up studies of children
placed as infants show almost uniformly positive outcomes. Fergusson et al. (1995) reported a 16-year
longitudinal study of a cohort of 1,265 New Zealand children born in 1977, 3.5% of whom were adopted at birth.
The remainder of the sample remained with their birth families, 88.8% with both parents, and 7.7% with a single
parent. Adolescents living with one biological parent were most likely to exhibit externalizing behaviors, but these
behaviors were also more prevalent in the adolescent adoptees than among adolescents living in two-parent birth
families. The groups did not differ in the prevalence of internalizing problems. Because most adoptees had grown
up in advantaged homes and as a group did not manifest a higher prevalence of internalizing problems, the
authors speculated that their higher externalizing scores may reflect some genetic risk, whereas the lower level of
externalizing problems compared with children from single-parent homes may be a result of the good homes in
which they grew up.
Despite the common belief that better outcomes are associated with earlier placement, Moore and Fombonne
(1999) studied a clinical population of British adoptees and found that although both boys and girls were at
increased risk of disruptive behavior disorders, including conduct disorders and attention-deficit/hyperactivity
disorder, it made no difference whether the child was adopted before age 2 years or much later; however, lack of
an adopted, nonclinical comparison group makes it difficult to assess how representative these children were of
the adopted population at large.
Benson et al. (1994) used a variety of self-report scales to study 715 adoptive families in the United States,
including 881 adolescents adopted domestically or internationally before 15 months of age, 78 nonadopted
siblings, and 1,262 parents. On the whole, these adoptees felt well-adjusted and had good self-esteem. The vast
majority of parents felt that they were deeply committed to their child; 95% endorsed the statement, "I feel
deeply attached to my child," 87% "My child and I couldn't be closer," and 79% "I deeply understand my child."
The authors attributed their positive results to the children's early adoption, which gave them the opportunity to
form solid early attachments.
Children adopted at older ages and boys are more likely to have their placements disrupted (Rushton et al., 1995).
Although only about 3% of infant-placed adoptions are disrupted, 7%-21% of children placed from foster care in
the United Kingdom have their adoptions disrupted (Rushton et al., 1995). This difference is usually attributed to
the later-adopted children having been more traumatized. They are likely to have suffered prenatal malnutrition
and drug and alcohol exposure, postnatal trauma (Barth, 1994), losses of biological or foster parents, social
instability, and stigmatization (Rosenfeld et al., 1997, 1998).
Older studies identified several variables associated with successful later-child adoption: relatively young age at
placement, female, placement with biological siblings, and adoption by one's own long-term foster parent or by

parents with strong parenting skills. Children with cognitive limitations or physical handicaps generally are not at
high risk of adoption disruption.
ATTACHMENT AND LOSS
Successful adoption requires that the child attach to a new family, even though the very concept of "adoption"
contains an element of its opposite: rejection and relinquishment. For that reason, the idea of loss is important to
adoptees and their adoptive and birth parents. Children adopted from overseas may feel rejected not only by birth
parents but by the entire country of origin.
Adoptive parents have the difficult task of disclosing and discussing the adoption with their child (Nickman, 1996).
It is not surprising that children often respond to this information with painful emotions that may persist in one
form or another for many years; parents need to support this long-term process. Nickman found that children
expressed three types of loss: "overt loss" of relationships and familiar environments, "covert loss" of self-esteem
because they had been relinquished or removed, and "status loss" arising from feelings of stigmatization within
the family or society at large. Today, almost all adopted children manifest at least one of these types of loss.
Pilowsky and Kates (1996) describe how previous abuse and neglect can distort a foster child's internal working
model of what an average caregiver is like and create the expectation that substitute parents will be like the
abusive and negligent parents (i.e., bad and unreliable). That inner conviction impedes their ability to quickly
make an adequate, nurturing attachment.
Parental attachment to their adopted infant has also been studied (Juffer et al., 1997; Lee and Twaite, 1997;
Stams et al., 2002). Disappointment about infertility can strain a marriage. Although infertile parents may need
time to mourn the biological child they cannot have, they may on short notice receive an adoptive child they are
not yet entirely prepared for emotionally. Adopted children may sense parents' ambivalent feelings (Brinich, 1995)
and respond with anger and diminished self-esteem. Dynamics in the extended family also matter: adoptive
parents whose own parents support adoption are helped in their new roles. Long delays between the adopted
child's placement and the adoption's being legally finalized can also jeopardize parental attachment because
adoptive parents may feel "on trial" and less legitimately and permanently connected to their child (Cohen et al.,
1996). When children are placed later and in open adoptions, they do far better if their biological parents sanction
attachment to the adoptive family and when their adoptive parents respect the biological family (Pavao, 1998;
Shapiro et al., 2001).
The practical and emotional factors can be complicated. An inherent tension exists in trying to balance an adopted
individual's need for information and continuity with the past, the birth parents' privacy rights, and the adoptive
parents' right to raise their child as they see fit (Appell and Boyer, 1995; Davis and Chiacone, 1996). Some legal
scholars (Holmes, 1995; Woodhouse, 1995) assert that the United States needs to change its laws and policies to
make them more child centered. This would make stable, nurturing relationships a higher priority than rights to
biological connection. Holmes (1995) also illustrates how complex the issues are by proposing that present policy
be changed to acknowledge that adopted children have a connection to their birth families and legitimate rights to
knowledge about them.
"Open adoption," which allows various degrees of contact between birth parents, adoptive parents, and the child,
is one contemporary approach to resolving this dilemma (Demick and Wapner, 1998; Grotevant et al., 1994;
Grotevant and McRoy, 1997.) In some localities, open adoption has become the most prevalent type. For instance,
Lee and Twaite (1997) studied 238 adoptive mothers who had had contact with biological mothers before birth
and during the child's first two years. They found that adoptive mothers who had met the birth mother beforehand
tended to feel favorably toward her; that attitude was maintained when contact continued. Grotevant et al. (1994)
reported similar findings. Grotevant and McRoy (1997) found that for 4- to 11-year-old children in Minnesota,
openness neither helped nor interfered with self-esteem and socioemotional adjustment.
Special problems arise when adoption follows months or years of institutional care. A study of children adopted
from eastern European orphanages found that those placed in adoptive homes at 8 months or older showed
predominantly disorganized attachment at age 4 (Chisholm, 1998; Marcovitch et al., 1997). Furthermore,
endocrine changes have been found in maltreated, institutionalized children (Carlson and Earls, 1997; Carlson et
al., 1995). Rutter (1998) documented cognitive delays and recovery. Later, O'Connor and Rutter, with English and
Romanian Adoptees (ERA) Study Team and the ERA Study Team (2000) and their study team compared three
groups of Romanian children reared in "profoundly depriving" institutions and placed in British homes before age 6
months (n = 58), between 6 and 24 months (n = 59), and between 24 and 42 months (n = 48) to a group of
children born in the United Kingdom and placed in adoptive homes before age 6 months (n = 52). All of the

children were evaluated at ages 4 and 6 years, except the latest-placed Romanian children, who were evaluated at
age 6 years. The frequency of serious attachment problems increased with institutional duration. Reactive
attachment disorder symptoms did not diminish in the 2-year period after placement in adoptive families.
Romanian adoptees placed before they were 6 months old differed little from the British-born sample in
Ainsworth's Strange Situation Test and demonstrated little if any attachment disturbance. The authors speculated
that some recovery may occur over time in the later-placed children. Later (Rutter, O'Connor, and ERA Study
Team, 2004), the segment of the Romanian population who remained in the institutions between 24 and 42
months was compared at 6 years of age with U.K.--born children who had not been deprived and had been placed
before age 6 months. The majority of Romanian-born children showed substantially normal cognitive and social
functioning after family rearing. A substantial minority had persistent deficits, suggesting that institutional
deprivation could lead to some form of early damage but that these effects were not inevitable.
RISK AND PSYCHOPATHOLOGY
Numerous studies have found that adopted children are overrepresented in mental health settings (e.g., Brand
and Brinich, 1999). Recently, many contributing factors have been identified.
Ingersoll (1997) emphasized that adopted adolescents are in treatment more frequently because they have more
problems, particularly acting-out behaviors that "tend to be more distressing to parents compared with
internalizing problems such as depression" (Miller et al., 2000b). Sharma et al. (1998) noted that adoptees
constitute "between 10% and 15% of [children] in residential care facilities and inpatient psychiatric settings," far
higher than their percentage in the general population. Previous work had found that, even controlling for the
level of behavioral disturbance, adopted children were more likely than nonadopted children to receive psychiatric
treatment. Following that line of reasoning, Ingersoll (1997) concluded, as have several others, that the
overrepresentation of adopted children in clinical populations is the result of complex factors, including more
frequent problems as well as a referral bias because adoptive parents, who today are often both more educated
and of higher socioeconomic status, are more likely to seek help for their adopted children (Miller, 2000a).
For any child, chronic malnutrition, low birth weight, physical and emotional neglect, and stimulus deprivation
before adoption affect physical growth and cognitive-emotional development (Cermak, 2001; Johnson, 2002).
Howe (1997) investigated the effects of early care on later problems. He compared interviews with the adoptive
parents of 122 children placed as infants who had a history of satisfactory preadoptive care, the parents of 20
children adopted later in childhood after their birth parents' initially adequate caretaking became substantially
worse, and the parents of 69 children adopted later in childhood whose early care was deficient. The later-adopted
children who had received deficient early care experienced the most problems. However, one fourth of the earlyadopted, satisfactory early-care group showed significant problems during adolescence, and 28% of the lateradopted, adverse early-care group did not show serious adolescent problems. Clearly, statistically, good early care
was protective against behavioral and psychiatric problems, even when things worsened in the biological family
later on. However, these children were more likely to be compliant and anxious. Interestingly, in the one fourth of
the early-adopted, satisfactory early-care group who became difficult adolescents, the only risk factor that
emerged was the presence in the home of nonadopted siblings, raising the possibility that in comparison with
these siblings, the adoptees felt stigmatized within their families or were treated differently.
Does adoption improve the lot of children who are placed after foster care? Not surprising, data indicate that later
placement and poor early care increase risk, whereas good early care is protective (Fergusson et al., 1995; Howe,
1997). Clinically, the situation for foster children improves after adoption, yet many remain troubled because their
extensive deprivation and traumatic life experiences leave lasting effects (Rosenfeld et al., 1997; Rushton et al.,
1995). Problems may also arise from stigmatization associated with being adopted or having been fostered. Welldesigned studies by Cadoret et al. (1995) concluded that adverse adoptive home environments interact with
biological background factors to increase rates of aggressivity and conduct disorders among adopted adolescents.
Some work suggests that in addition to vulnerabilities, adopted children have certain strengths. For instance,
Sharma et al. (1996) found that although adopted children had a small but consistently lower level of adjustment
on factors such as drug use, negative emotionality, antisocial behavior, optimism, and school adjustment, they
also had a significantly higher score in prosocial behavior (Sharma et al., 1998). The latter study also notes that
adopted children showed fewer social problems and withdrawn behavior as compared with norms.
SINGLE-PARENT, INTERNATIONAL, TRANSRACIAL, AND GAY ADOPTIONS

Concern has arisen about possible problems when the adopted child is culturally or racially different from the
adopting family or when the family itself is "nontraditional."
Studies of international adoption when abuse, neglect, or late placement is not involved indicate that children
placed with single parents and with couples had equally good social adjustment (Benson et al., 1994; Kim, 1995).
Kim (1995) reviewed 15 follow-up studies of Korean children adopted at various ages. Although some studies bore
out the familiar observation that later placement leads to more frequent problems, generally the results were
favorable; one study found Korean-born adopted children faring better initially than did an American-born adoptive
sample even though the Korean-born children were placed somewhat later (5.3 years versus 3.2 years). Kim
hypothesized that the results were so positive because internationally adopting parents tended to be family
centered, racially tolerant, college educated, middle income, and biculturally oriented, and before placement, the
children had lived in well-supervised foster homes rather than in impersonally run orphanages. Even within an
early-adopted sample, there is variability. A longitudinal study of 146 children adopted internationally before age 6
months and studied to age 7 years found that higher mother-infant attachment security predicted better social and
cognitive development in middle childhood (Stams et al., 2002). Furthermore, a recent meta-analysis (Bimmel et
al., 2003) comparing 2,317 internationally adopted youngsters with 14,345 nonadopted adolescents found that
although the majority of the adopted adolescents were well adjusted, as a group they showed more externalizing
(but not internalizing) behavior disorders.
Recently, pediatric clinics have been developed that specialize in pre- and postadoption evaluation of children from
outside the United States (Barnett and Miller, 1996; Miller, 2005; Miller et al., 1995). Preplacement pediatric
review of available information is useful, and a thorough physical examination soon after arrival is essential,
particularly when the personal and medical care in the native country was suboptimal. Early clinical findings
suggest that good-quality preadoptive care predicts better development, as does a child's age-appropriate
competence in speaking his or her native language (Miller et al., 1995).
Domestic transracial adoption has also been studied. In a 16-year longitudinal study, Vroegh (1997) examined
racial identification, general adjustment, and self-esteem in 52 adopted adolescents of African-American descent.
The 34 adolescents adopted into white families and the 18 adopted into black families were predominantly well
adjusted; however, problems of serious clinical concern were found in 3 of the 34 transracial adoptees, whereas
none were found among those raised in black families. Of the transracial adoptees, 33% identified themselves as
black, whereas 83% of the intraracial adoptees did so. Other factors may have been involved; those identifying as
black were more likely to have two black birth parents and to have darker skin color. In a review of the literature
on interethnic adoption, Fensbo (2004) concluded that late age at adoption, neglect, and institutionalization are
risk factors for psychological and behavioral problems in adoptees.
Gay and lesbian adopters often face stigma and rejection. Some states have enacted legislation denying
homosexuals, whether individuals or couples, the right to adopt. American adoption agencies and many in foreign
countries that place children in the United States may share this prejudice. However, in the past decade, many
infants from abroad have been placed with gay parents. When adopting domestically, gay parents are more likely
to be successful in having older or special-needs children placed with them than they would be in obtaining infants
(Evan B. Donaldson Adoption Institute, 2003b). Research does not indicate that children raised by homosexual
parents are at risk in any way, nor are they more likely to develop same-sex orientations than are children raised
by heterosexual couples (James, 2004).
CLINICAL MANAGEMENT AND PSYCHOTHERAPY
Increasingly, child and adolescent psychiatrists serve adopted children not only in their families but also in schools,
social services agencies, clinics, inpatient units, juvenile courts, and residential programs.
Well-designed research protocols studying psychotherapy with adoptees are lacking, but numerous case reports
(e.g., Bonovitz, 2004) suggest that simultaneous empathy with adopted children and their parents is essential.
Countertransference awareness is also needed, particularly in relation to therapists' opinions about abandonment
and rescue. Professionals may have preexisting attitudes toward adoption that interfere with objective, empathic
treatment. Some researchers have noted that therapists or healthcare workers assume that adopted adolescents
are less psychologically healthy than are other teens. If that becomes a self-fulfilling prophecy, then it may not be
surprising that Nickman and Lewis (1994) found that parents of later-adopted children often perceive mental
health professionals as lacking in understanding.

Freeark and Routbort (1996) described time-limited groups to help parents of preschool children with adoptionrelated issues. Network approaches have also helped parents of special-needs children. In one careful long-term
follow-up of network care, the most successful parents tended to be older and more pragmatic, with large families
and strong religious beliefs. Many had previous experience as foster or adoptive parents (Fine, 1993).
Clinicians agree that a child should know that he or she was adopted; they differ on when and how adoption
should be discussed. Most psychotherapists and adoption workers support disclosure as an intermittent process
that begins in the preschool years and unfolds over time. Others think that although truthfulness is desirable, the
child's maturity and cognitive capacities need to be taken into account.
Both adopted and nonadopted children of all age groups seem to understand the process somewhat better, but
according to older research, neither group really seems to understand the facts until age 8 or 9.
When adopted children need psychotherapy, the parents must be fully included in the process. Bonovitz (2004)
describes how parents' and adopted children's fantasies can interact in a destructive way and demonstrates the
value of painstaking work to help parents and children be more open with and accessible to each other. The
question of what happens when parents lack sensitivity to their child's adoption-related emotional needs or when
they bring substantial ambivalence into their relationship with their child (Brinich, 1995) is not one that lends itself
easily to research protocols, but many clinicians are familiar with such families. One example is parents' persistent
fear of their child's supposed bad heredity, leading to negative expectations and a self-fulfilling prophecy
(Rosenfeld, 2004, personal communication).
Group therapy for adopted children is a new modality that had its origins in inpatient units and now also occurs in
outpatient settings and in some schools. It has yet to be studied systematically (Pavao, 1998).
Issues that commonly arise in psychotherapy with adopted children and adolescents include feelings of
worthlessness (Brinich, 1995), fear of abandonment, special aspects of transference and countertransference
(Zuckerman and Buchsbaum, 2000), and confusion about origins, loyalty, and personal narrative (Nickman, 2004).
Adoptees may devalue themselves because they were relinquished and may devalue or idealize birth parents and
adoptive parents at different times, leading to intense and conflicted relationships with therapists. An adoptee may
also fantasize that the therapist (or, for that matter, a favorite teacher or minister) is his or her biological parent.
Not surprising, issues related to adoption follow adoptees into adult life. Close relationships, having one's own
children, and losing a loved one all may fuel emotions or increase curiosity in an adopted person. Some states
have passed laws to open the sealed adoption record for an adult adoptee. In other states, an adoptee may
petition the court to open the birth record, even if a birth parent does not consent or has died. Commonly,
agencies maintain a file of adoptees and birth parents who have written seeking information, and when both are
interested, the agency provides nonidentifying information. It can then mediate an exchange of letters that
sometimes leads to the individuals' mutually identifying themselves.
Clinical approaches to attachment problems include controversial, highly directive holding techniques aimed at
creating attachments de novo (Hughes, 1997), psychodynamic psychotherapy making use of attachment research
and established attachment measures (Blom, 2003; Rutter, 1995), and preventive programs designed to foster
attachment within the newly constituted family (Belfer and Fine, 1997; Cohen and Duvall, 1996). Juffer et al.
(1997) described an intervention to facilitate parent-child attachment in 90 families with infants adopted from Sri
Lanka and Korea, all placed before age 5 months. Families were divided into a control group and two intervention
groups. The first intervention group received a book on sensitive parenting, and the second received the book but
also viewed three video feedback sessions focused on mother-infant interaction in their home. They found that the
group that had experienced feedback demonstrated more sensitive responsiveness as well as better infant
competence and infant-mother attachment than both the control group and those who had only received the
book.
FUTURE DIRECTIONS
The question is no longer whether adopted children and adolescents show more global disturbance than their
nonadopted counterparts. Instead, specific variables are identified as linked to certain aspects of later adjustment.
Age at placement, psychodynamics within the family, the nature of the child's preplacement experience, and
demographic factors (e.g., whether an adoption is domestic, international, same race, or transracial) are among
the important variables.

Pertman (2000) has claimed that the newer forms of adoption, by virtue of their emphasis on diversity, have
broadened the definition of family and thus advanced America's democratic, melting-pot tradition. This optimistic
view may be justified; however, research during the past 10 years suggests that risks remain for certain adoptee
populations. Additional research needs to address the question of why some deprived children show severe
attachment disturbances and others do not (O'Connor and Rutter with English and Romanian Adoptees (ERA)
Study Team, 2000). Treatment of these disturbances is relatively new, and it remains to be seen how families who
adopt institutionalized children fare. How are clinically identified attachment disturbances and insecure and
disorganized attachment patterns related? Neuroendocrine (e.g., Carlson and Earls, 1997) or imaging studies may
eventually prove useful in predicting which institutionalized children will respond best to therapeutic interventions.
Review of the literature on high- and low-risk adoptees suggests a continuum of attachment disturbances.
Neglect, abuse, and impersonal care certainly contribute to them. Should the milder problems with self-esteem
and identity formation long recognized in some early-placed children be seen as representing the low end of this
continuum, and if so, then by what could these effects be mediated? This may be a difficult but rewarding topic
for investigation.
Findings concerning children who are adopted when they are older, especially from foster care, have important
clinical and social implications. They may require social and mental health services long after the adoption is
finalized. Because research overwhelmingly indicates that adoptions are more likely to succeed when children are
younger, children in foster care deserve to have their plight resolved as early as possible. When there is no hope
of family reunification, child welfare services and the courts ought to accelerate the termination of parental rights
for infants and preschool children.
Finally, at present, little is known about the long-term course of relationships between adoptees, their birth
parents, and their adoptive parents in open adoption and after reunion in late adolescence or adult life. Open
adoption and reunion are understood as remedying an inequitable system in which birth parents have been
stigmatized and adoptees deprived of their birth heritage. The concept of extended family has been promoted for
combined family systems, and the phrase "adoption triad" (for adoptee, adoptive parent, and birth parent) has
been suggested. Yet society has few rules or traditions to guide developing customs, and an exciting opportunity
arises for research into what form new relationships will take and how they will affect the children and families
who take part in them.
Disclosure: Dr. Derdeyn consults with Park Dietz Associates and APS Health Care. The other authors have no
financial relationships to disclose.
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STEVEN L. NICKMAN, M.D., ALVIN A. ROSENFELD, M.D., PAUL FINE, M.D., JAMES C. MACINTYRE, M.D., DANIEL
J. PILOWSKY, M.D., RUTH-ARLENE HOWE, J.D., ANDRE DERDEYN, M.D., MAYU BONOAN GONZALES, M.D., LINDA
FORSYTHE, M.D., AND SALLY A. SVEDA, M.D.
Accepted April 12, 2005.
Reprint requests to Dr. Steven L. Nickman, 114 Rawson Road, Brookline, MA, 02146; e-mail: krumpli7@aol.com.
Drs. Nickman and Forsythe are with Harvard Medical School, Boston; Dr. Rosenfeld is in private practice in New
York City and Greenwich, CT; Dr. Fine is with Creighton University, Omaha; Dr. MacIntyre is with Carolinas Medical
Center-Behavioral Health Center, Charlotte, NC; Dr. Pilowsky is with Columbia University, New York; Dr. Howe is
with Boston College School of Law; Dr. Derdeyn is in private practice in forensic and managed care in Lovingston,
VA; Dr. Gonzales is with Mental Health Services, New York Foundling Hospital, New York; Dr. Sveda is in private
practice in Newton, MA.
This article is a collaborative effort sponsored by the Academy's Committee on Adoption and Foster Care,
cochaired by Drs. Rosenfeld and Nickman.
COPYRIGHT 2005 Lippincott/Williams & Wilkins