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Assisting Adoptive Families: Children Adopted at Older Ages

Family Matters
Elizabeth Ahmann, ScD, RN Deborah Dokken, MPA

Ellen Singer Madeleine Krebs

Understanding the adoption experience can help health care providers develop sensitivity to the special tasks of adopted children and their families. Children who are adopted at older ages may face particular challenges. Age at adoptive placement, the burden of loss, pre-adoptive experiences, and the challenge of attachment are all significant issues in older-child adoption. Pediatric nurses demonstrate sensitivity and support to adopted children and their families by using appropriate language about adoption; understanding the significance of missing health information; providing appropriate referrals as needed; and displaying an open, caring attitude.

hildren who have joined their families through adoption each have their own personal stories while sharing many commonalities. All adoptees face the developmental task of incorporating their unique history and individual thoughts and feelings about the adoptive experience into the identities they form as they grow to adulthood. Most children and adults who were adopted find that what they hear and see about adoption in the world around them can have a powerful influence on their beliefs about themselves. For this reason, the attitudes held about adoption by professionals, including health care providers, can have a significant impact on the lives of adopted people. Understanding the adoption experience can help health care providers develop the necessary sensitivity to the special tasks faced by adopted children and their families. Important issues to understand include the impact of age and pre-adoptive experiences at adoptive placement; the burden of loss and grief; and the challenge of attachment. Sensitivity, understanding, and support from pediatric nurses interacting with adopted children and their families involves use of appropriate language about adoption (referred to as positive adoption language); reassurance with regard to the issue of missing health information; provision of appropriate referrals as needed; and as always, demonstration of an open, caring attitude.

Impact of Age at Placement

In order to comprehend the challenges involved in a childs adjustment to adoption, it is important to have knowledge about the impact of a childs age at placement. Although infant adoption is common in private agency or independent domestic adoptions, it is less common in public domestic adoptions. Among children adopted from the foster care system, at most 2% are under 1 year of age (Evan B. Donaldson Institute, n.d.). Most children needing homes whether born in the United States or overseas are not infants. In fact, in the adoption community, the term older child adoption generally refers to children over the age of 3. According to the 2000 U.S. Census, 1.6 million adopted children lived in U.S. households; of these, 199,136 were adopted internationally (half from Asian countries). Many of these international placements were children adopted at older ages (exact statistics are not available). Additionally, in 2005, the latest year for which totals have been finalized by the U.S. government, 513,000 children were in foster care (see Table 1 for a definition) in the United States and 22% of these children (some 114,000 children) were avail-

Table 1 What is Foster Care?

Foster care occurs when social service departments assume custody for children removed from their families because of abuse or neglect. When possible, children are placed with extended family members. This is called kinship care. If family members are not able or willing to provide care, non-kin foster families care for the children, sometimes in sibling groups. During placement, social workers determine if return to the birth family is possible and what services would be needed for this to occur. The majority of children in foster care do return to their birth families (U.S. Department of Health and Human Services, 2006). However, children whose parental rights are terminated become available for adoption either by extended family members (kinship adoption), by their current foster families, or by other prospective adoptive parents.

Ellen Singer, LCSW-C, is Therapist and Adoption Educator, The Center for Adoption Support and Education, Inc., Burtonsville, MD. Madeleine Krebs, LCSW-C, is Clinical Coordinator, The Center for Adoption Support and Education, Inc., Burtonsville, MD.

The Family Matters section focuses on issues, information, and strategies relevant to working with families of pediatric patients. To suggest topics, obtain author guidelines, or to submit queries or manuscripts, contact Elizabeth Ahmann, ScD, RN; Section Editor; Pediatric Nursing; East Holly Avenue Box 56; Pitman, NJ 080710056; (856) 2562300 or FAX (856) 2562345. 170

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able for adoption (U.S. Department of Health and Human Services, 2005). The preponderance of children in the foster care system needing adoptive homes are over 6 years of age (U.S. Department of Health and Human Services, 2003). Many of these children will have gone back and forth from birth family to foster homes or will have experienced more than one foster placement prior to adoption. Children who have spent time with birth family or kin, foster families, or in institutions prior to joining their adoptive families bring a history of (and loss of) these relationships. They also bring a range of experiences some remembered, others not that shape their personalities and behavior. The complex prior histories of most children adopted today pose enormous challenges for the children and their adoptive families. The child is challenged that they must integrate their experiences into their developing identity (Who am I?), while the parents strive to make sense of the childs complex needs and at the same time integrate the child into the family.

Understanding Loss in Adoption

All adopted children must at some time process the devastating losses related to no longer being raised by their own birth families. Loss in adoption is a complicated and profound experience, but particularly so for children adopted from the public child welfare system. Before permanent placement in adoptive homes, most children and teens in foster care have been involved in what is known as the concurrent planning process, the process of simultaneously working toward family reunification while also establishing an alternative plan for being in a (non-birth) permanent family. Although well intended, the uncertainty involved in concurrent planning is very difficult for children. Boss (1999) terms such experiences ambiguous loss and explains that . . . the greater the ambiguity surrounding ones loss, the more difficult it is to master it and the greater ones depression, anxiety, and family conflict (p. 7). Ambiguous loss has no definitive closure. For example, some children may have no contact with their birth parents/birth family and do not know if this is a permanent loss. Others may believe that they will return to live with their family, or that their family members will resume contact with them. Even when children continue to have contact with their birth family, they must still grieve for the loss of the parenting relationship. The loss of birth family remains ambiguous even for those children whose parents rights have been terminated and who are placed in adoptive homes. Loss of the parenting relationship does not mean the birth parent is not psychologically present in the mind and heart of the adopted child. Children experiencing this type of loss are haunted by many questions: Will I go back home? Can my mom get herself together to take care of me? When will I see my sisters? Should I let my foster/adoptive dad get close to me? Do other kids at school know whats happened to my family and me? Why couldnt I go and live with my Grandma? More often than not, the children cannot articulate their feelings and thus carry the burden of these emotions alone. In addition to the loss of their birth families, many children in foster care have experienced multiple foster placements. Each time they move, children lose not only their foster parents and siblings, but also possibly friends, teachers, and pets. Children may lose whatever possessions they have as well clothing, books, photos, mementos, and so forth. Children adopted internationally at older ages also have experienced multiple losses loss of birth family, loss of foster family, loss of caregivers, loss of siblings, loss of friends, and loss of country, which may include loss of heritage, culture, religion, and so forth. PEDIATRIC NURSING/March-April 2008/Vol. 34/No. 2

Children in foster care and orphanages may have experienced trauma in the forms of neglect and physical, sexual and emotional abuse, including witnessing violence, either prior to or while in care. These children may come from parental backgrounds of substance abuse and/or psychiatric disturbance. The inability to control what is going on around oneself, or what is happening to ones life, combined with the inability to effectively communicate the feelings of grief for ones losses, can seriously erode both a childs sense of trust in themselves as well as trust in others. This results in low selfesteem and feelings of incompetence, as well as a view of the world as unfair, unsafe, and unmanageable. These are powerful emotions for a child to have to bear. Research has demonstrated negative effects of chronic stress on the developing brain, including an impact on learning as well as emotional regulation (Gray, 2007). Also, if not recognized and alleviated, these feelings can have a serious negative impact on a childs behaviors and emotional ability to attach to new caregivers.

Understanding the Challenge of Attachment

Attachment to the adoptive family is an important aspect of the adoption experience and is impacted by a number of factors. As Fahlberg (1991) has documented extensively in her work, children who do not appropriately grieve for past losses will not be able to successfully attach in future relationships. Children who move from foster care to adoption need to have time to acknowledge and accept the reality of having multiple sets of parents, and grieve for the loss of not being raised by the first set (and possibly interim foster parents as well). Fahlberg notes that during the grief process, a tremendous amount of psychological and, sometimes, physical energy is diverted into coping with strong emotions energy that is then not available for attachment work with the new family. According to Brodzinskys model, a childs adjustment to placement is determined by multiple factors: primarily how the child perceives or appraises the experience, but also the type of coping mechanisms the child employs to deal with related stress (Brodzinsky, Smith, & Brodzinsky, 1998). For example, when children view placement as threatening (perhaps due to its signal of finality of loss of the birth parents or due to uncertainty about being fully accepted by the adoptive family), they are likely to express negative emotions, such as confusion, anger and anxiety. They may also demonstrate poor coping mechanisms. Individual characteristics, as well as environmental variables, will affect stress and coping. Cognitive level, self-esteem, and sense of personal control are relevant, as is developmental stage. For example, adolescents face enormous challenges in adjusting to placement because of the additional complexity of identity issues faced at this age. Familial experiences and placement attributes are also important in the attachment process. The behaviors and attitudes older children quite commonly exhibit when stressed by an adoptive placement can pose many challenges and stresses for their adoptive family. Adoptive parents who have had training to prepare them for adopting an older child may handle the adjustments more easily. Adequate familial supports are another important factor in the attachment process.

What Pediatric Nurses Can Do

Pediatric nurses can support adopted children and adoptive families in many ways. The first is to use appropriate language to reflect acceptance of the adoptive family. Children and families should be referred to as just that children and families. There is no need to tag a youngster as your adopt171

ed child. In turn, children who were born to their parents should not be referred to as real or natural children. If there is discussion about the biological parent(s), it is appropriate to use the term birth parent(s). However, adoptive parents should be referred to simply as parents. This language helps parents feel secure and entitled to parent their children, and in turn conveys the understanding that adopted children belong to their parents. Secondly, nurses need to understand the issue of missing information in adopted childrens health histories. Especially when children are placed at older ages, accurate records are often not available about birth parent medical history, prenatal care, birth records, or early medical treatment. Parents often feel anxious or worried about the lack of important medical information. The attitude of medical staff should be one of reassurance that the child can be effectively treated and cared for without full information. Additionally, sensitivity to parental concern about missing information can be reflected by a statement at the beginning of any health history forms, such as: If your child joined your family through adoption, indicate the childs age at which that occurred. Please provide information regarding medical care prior to adoption, if known, and any concerns or questions you would like to raise with health care providers. In addition, for the purpose of ensuring appropriate language and sensitivity, medical records should clearly indicate that a child was adopted. Parents are usually willing to share information regarding the pre-adoptive experiences of their children, as well as their own frustrations over lack of information, if they believe that professionals respect and value their family. It is also important to note that children and teens can become quite resentful of doctors or nurses especially those who they have known for years who forget the important fact that indeed they were adopted! Third, nurses should be aware that, while all parents strive to recognize when their child is experiencing emotional, behavioral, and/or learning difficulties, adoptive parents face an additional challenge in figuring out if the difficulty indicates that their child is struggling with normal developmental concerns, early life experiences, or an issue that is related to adoption itself (see Table 2 for a list of the most common issues adoptive children face). In Barbell and Freundlichs (2001) review of the state of foster care, they noted that [T]he foster care system itself may sometimes further exacerbate [childrens] problems. As children move from one setting to another, their already compromised physical and mental health and development may deteriorate further (2001, p. 12). According to Howard and Smith, The level of damage experienced by children adopted through the child welfare system has been underestimated (1997, p. 106). In the same vein, a review of adoption research and literature by Groza and Rosenberg (2001, p. 2) led them to conclude that [A]lthough adoption is decidedly positive, there is some indication that a significant proportion of adoptees may require mental health or other therapeutic intervention. It is true that children adopted at an older age, whether from foster care or internationally, often display a variety of emotional, physical, and learning issues resulting from their early life experiences. These include depression and anxiety, attention deficit hyperactivity disorder, attachment disorder, learning disabilities, and sexual acting out. Some children have special medical needs, including AIDS or HIV. As health professionals who listen to parental concerns, pediatric nurses can assist parents by empathy as well as in determining the need for clinical intervention for behavioral and mental health concerns.

Table 2 Six Spots Where Kids Get Stuck

The Center for Adoption Support and Education (C.A.S.E.) has defined the six most common adoption-related struggles for children and teens. (See Beneath the Mask: Understanding Adopted Teens [Riley & Meeks, 2005] by Debbie Riley, Executive Director of C.A.S.E.) The following statements/questions reflect the troubling feelings that may be experienced by children adopted internationally, domestically at birth, or from foster care. 1. Difference

I am not like most kidsmy family is different. I dont look like my family (skin color, hair, eyes, etc.) I dont fit in do I belong here? I dont share my familys cultural or racial heritage.
2. Reason for Adoption

Why was I given away? Was something wrong with mewas I a bad baby? My birth mother used drugs/alcohol, neglected/abused me, etc. What does this mean about me? Whatever the reason, couldnt my birthmother (parents) solve their problems so that they could have kept me?
3. Missing Information

I dont even have a picture, I dont know what she (he, they - birth family) looks like. Im told I was left outside the orphanage , so I know nothing at all about where Ive come from. I dont even know my real birthday. My birth mother wasnt sure who my birth father was.
4. Identity

Who am I? Am I like my adoptive parents or my birth parents? I know little or nothing about my birth parents, so how can I figure out who I am? Im not white like my family, but kids and adults of my race wont accept me.
5. Loyalty

I have so many questions about my birth parents, but if I ask my adoptive parents, they will be upset and hurt. I know things were bad at home, but I love my mom and grandmother. Maybe I will live again with them someday, so how can I love my adoptive parents? I feel bad for my siblings who are still in foster care and not adopted.
6. Permanence

If my birth parents gave me away, it could happen again. My adoptive parents could do the same. Ive lived in so many foster homes, Im sure Ill be moved again. Ill be 18 soon. Will my [adoptive] parents still be there for me after I leave home?


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Table 3 Some Sources of Information and Support for Adoptive Families

The Center for Adoption Support and Education 4000 Blackburn Lane, Suite 260 Burtonsville, MD 20866 (301) 476-8525 Child Welfare Information Gateway Child Welfare League of America 440 First Street, NW, Third Floor Washington, DC 20001-2085 Phone: (202) 638-2952 Fax: (202) 638-4004 North American Council on Adoptable Children (NACAC) 970 Raymond Avenue, Suite 106 St. Paul, MN 55114 Phone: (651) 644-3036 Fax: (651) 644-9848 E-mail:

you are comfortable with adoption as a way to build families! It is very common for children to be asked invasive, personal questions about their adoption story by their peers, teachers, and even the grocery store check-out clerk. Inappropriate questions range from the very frequent, Where is your real mother? to Why didnt your (birth) family want you? As they struggle with these challenges, children need to hear adult acceptance of their family. Casual comments can have very positive results: We have quite a few children who come to our office who were adopted. or My cousin adopted a child last year. Im crazy about that kid!

Adopting an older child can bring great joy to both the child and the parents. The child becomes part of a caring forever family who will work with them through struggles and share successes and joy. While not everyone will have the willingness to work with older children and their unique challenges, for those who choose to adopt and parent an older child, the hard work can bring great happiness. Nurses attuned to the special challenges can be a support to adopted children and their families.

Barbell, K., & Freundlich, M. (2001). Foster care today. Washington, DC: Casey Family Programs. Boss, P. (1999). Ambiguous loss: Learning to live with unresolved grief. Cambridge, MA: Harvard University Press. Brodzinsky, D.M., Smith, D.W., & Brodzinsky, A.B. (1998). Childrens adjustment to adoption. Thousand Oaks, CA: Sage Publications. Evan B. Donaldson Adoption Institute. Overview of adoption in the United States. (n.d.). Retrieved June 26, 2004, from Overview.html Fahlberg, V. (1991). A childs journey through placement. Indianapolis, IN: Perspectives Press. Gray, D. (2007). Nurturing adoptions: Creating resilience after neglect and trauma. Indianapolis, IN: Perspectives Press. Groza, V., & Rosenberg, K. (1998). Clinical and practice issues in adoption. Westport, CT: Praeger Publishers. Howard, J., & Smith, S.L. (1997). Strengthening adoptive families. Normal, IL: Illinois State University. Riley, D., & Meeks, J. (2005) Beneath the mask: Understanding adopted teens. Silver Spring, MD: The Center for Adoption Support and Education. U.S. Department of Health and Human Services, Administration for Children and Families, Administration on Children, Youth and Families, Childrens Bureau. (2006, Sept.) The AFCARS Report. Retrieved September 15, 2006, from www.acf.hhs. gov/programs/cb

Adoptive parents may lack information about appropriate resources for getting children the help that they need. Nurses can be prepared to direct parents, as appropriate, to knowledgeable, adoption-sensitive mental health professionals who can provide more indepth assistance. Adoption-sensitive mental health professionals and parent support programs can readily be located through the Child Welfare Information Gateway (see Table 3). Families who have adopted through the child welfare system often find support available through the local department of social services, as well. The Child Welfare League of America and the North American Council on Adoptable Children also provide abundant educational material for parents who have adopted their children at older ages (see Table 3). Nurses may also be able to assist adoptive families whose children have special education needs. Like any family seeking to locate appropriate school services, parents may turn to the pediatricians office for advice, information about disabilities, or referrals to community specialists. It might be helpful for nurses to be aware that there is no research proving that children who were adopted have more special needs than other children. However, it is logical that the pre-adoptive experiences of some children may have long-term effects on their development. Parents may be struggling to not only understand their childs special need, but may also be feeling helpless when they wonder about the long-term impact of the difficulties. They may have been made to feel that their child is having problems because he/she was adopted, or that they should know more about his/her early life. If the pediatric nurse is understanding, supportive, and positive, adoptive parents are likely to feel that they have found a safe haven! Finally, each nurse can provide a wonderful support to children who were adopted just by letting them know that

Additional Resources
Gray, D. (2002). Attaching in adoption. Indianapolis, IN: Perspective Press. Jewett, C. (1979). Adopting the older child. Boston, MA: The Harvard Common Press. Orlans, M., & Levy, T. (2006). Healing parents: Helping wounded children learn to trust and love. Arlington, VA: Child Welfare League of America. Peck, G. (1998). Adopting the hurt child. Colorado Springs, CO: NavPress Publishing Group. Peck, G. (2002). Parenting the hurt child (2nd ed.). Colorado Springs, CO: NavPress Publishing Group. VanGulden, H., & Bartels-Rabb, L.M. (1993). Real parents, real children: Parenting the adopted child. New York: Crossroad.

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