Adoption is an ancient practice, although not a universal one, since some Islamic interpretations of the Koran ban adoption, while supporting other means of looking after orphaned or abandoned children. It was codified more than 4,000 years ago by the Babylonians, and is described in the Bible, for example, in the adoption of Moses by the daughter of Pharaoh. The ancient Romans practiced both the adoption of children and that of adults, in order to provide a suitable heir for the family. Similar practices, with similar motivation, are described in China, in ancient Egypt, Greece, and, until fairly recently, in the Polynesian societies of Tahiti, and Hawaii. Originally, adoption was designed to benefit the adopter, by providing them with a successor, someone to carry out rituals after their death, someone to work on their behalf and support them, or someone to cement a critical power alliance.

Informal adoption has been part of American society since before the institutionalization of the world’s first adoption statute by the Commonwealth of Massachusetts in 1851. The formalization of adoption developed in the context of the “boarding out” in foster care of babies from almshouses, the system of apprenticing and indenturing impoverished children, and the practice of sending homeless children from the Northeast by orphan trains to work in farming communities in the Midwest. In the first part of the twentieth century, most adoptions in the United States were still informal, without confidentiality for any of the parties, sometimes driven by financial motives on the part of the mother, and frequently accompanied by the stigma of illegitimacy and fear of the inheritance of defective genes. Throughout the twentieth century, the states, and later the federal government, have steadily formalized the practice of adoption even where it continues to be independently organized by physicians, lawyers, and the families involved. Significant social change has also affected the numbers and context in which adoption takes place. The adoption of infants was a particularly common practice in the 20 years prior to 1970. Many unmarried mothers chose (or were pressured to choose) adoption over single parenthood, and many healthy infants (mostly white) were placed, often in great secrecy because of the stigma associated with illegitimacy, with unrelated, childless, adoptive parents. The number of nonrelative adoptions increased from about 33,800 in 1951 to 89,200 in 1970.

In the 1970s, a number of social forces impacted on the numbers of children available for adoption, and their age and status. The widespread use of birth control, the availability of abortion, and the acceptance of single parenthood had a significant impact on the availability of infants, especially white infants, for adoption by unrelated couples. The number of unrelated adoptions declined from 89,200 in 1970 to 47,700 in 1977. The adoption of a healthy infant is now an often-expensive undertaking, out of the reach of many middle class couples.

In parallel with these social changes affecting the availability of babies for adoption, two other groups of children became increasingly recognized as suitable for adoptive placements. First, in the mid-1970s, there was a new recognition of the numbers of children living, often in significant instability and for many years, in temporary foster care family placements because of neglect and abuse in their families of origin. In the 1980s, there was a move toward planning for permanency,
and an acceptance that children, even older children previously seen as “unadoptable,” might benefit from adoptive placement. The Adoption Assistance and Child Welfare Act of 1980 was designed to prevent children in foster care from languishing in temporary situations, and to facilitate adoptions for children who could not be reunified with biological families. After conclusions from policy and social science that adoption was more stable than long-term foster care, Congress passed the Adoption and Safe Families Act (ASFA) in 1997. This legislation requires planning for permanence for children in foster care within a year of removal, and termination of parental rights for children who have been in foster care 15 out of the last 22 months. The Adoption Promotion Act (2003) gave enhanced incentives for adoption of older children. As a result of these shifts in policy and legislation, over the last 15 years increasing numbers of children from the foster care system have been placed for adoption. The numbers rose nationwide from approximately 25,000 in 1995 to around 50,000 in each of the last 5 years. The focus for these children has shifted from adoption for the psychological or financial benefit of adults to adoption for the psychological benefit of the child. More recently, increasing numbers of children have been adopted from foster care by relatives into so-called “kinship” placements.

The second largest group of children affected by changes in adoption practices has been children adopted from overseas. These so-called “international” adoptees arrived in the United States and in European homes initially in the aftermath of World War II, and then after the wars in Korea and Vietnam. Korean adoptees began arriving in the United States and Europe in 1955; originally, many of these children were the offspring of non-Korean military fathers and Korean mothers, but international adoption from Korea has continued, though in lesser numbers, ever since. More than 150,000 Korean children have been adopted by U.S. parents. As time has passed, American parents have continued to adopt children from other countries, including China, Russia, India, Romania, Guatemala, and Colombia. Since 1989, for example, more than 20,000 Chinese children, mostly baby girls, have been adopted by American parents (2) and more than 17,000 have arrived from Guatemala (3). In the United States and other countries— Sweden, Denmark and the UK— similar practices have resulted in a phenomenon known as “visible” adoption: that is, because of the child’s and parents’ physical appearance, it is obvious that the child is adopted.

As a result of these developments in social policy and legislation, clinicians are likely to encounter the adoption triad of adopted child, biological parent(s), and adoptive families, affected by adoption in notably different ways. First, there are children relinquished by their biological parents, and adopted through private, often church-affiliated, agencies, or independently through attorneys, clergy, or physicians. Statistics on such adoptions are not routinely collected (4); however, the most recent figures from the mid-’90s suggest numbers approaching 50,000 a year, a significant decline from the peak of the 1950s and ’60s. Most children adopted by this route are adopted as babies and young infants, either directly from hospital or after short periods in relatively good quality foster homes. Many biological parents, especially mothers, retain some contact with these children, either directly with the adoptive families, or indirectly through the placing agency, through “open” adoption. The adoptive families of many privately adopted U.S.-born and international adoptees are, because of the expense of private adoption, relatively socioeconomically advantaged. Second, the practice of international adoption means that many young children, most between the ages of 3 months and 3 years, arrive in the United States from overseas, often after spending time in orphanages or foster homes, where their care may have been less than optimal and about which reliable information may be missing. Most of these children have scant access to information or contact with their biological parents, and some have little experience with the culture and language of their country of origin. Third, about 50,000 children a year are adopted, either by unrelated families who may also have been their foster parents, or by relatives, from the publicly funded child welfare system. More than half of these children are adopted after the age of 6, many of them in adolescence, and they are likely to be from racial or ethnic minorities. Most have been in temporary custody for more than 4 years, and have suffered significant trauma and neglect. Their adoptive families may be more likely to be older, single parents, and financially less well off.

Adoption has a long history and has affected many millions of children and adults. Most estimates range from 2.5% to 3.5% of the population, and the most recent U.S. data (for 2001) suggest that between 120,000 and 130,000 children are adopted each year (4). It is a practice that is likely to continue, driven by the needs of orphaned, abandoned, and neglected children worldwide, and by the profound desire of adults to parent and nurture children of their own. Even though the majority of adoptions result in well adjusted, well loved children and contented families, child and adolescent psychiatrists will continue to see all three members of the adoption triad— birth parents, adoptive parents, and especially adopted children— in their clinical practices. Attempts to answer some of the questions that arise from the natural experiments of adoption will continue to give rise to fascinating and productive research.

Most adopted children and families appear to fare well, and, in the context of a relatively unusual family composition, follow a normal developmental track, albeit with some characteristic differences and challenges not faced by children raised by their biological parents. Some authors have suggested that adoption in itself is always a loss or an injury to a child’s self-esteem— it is unlikely that we have the evidence to prove that this is indeed always the case, and we run the risk, in taking this view, of assuming that the merely different is in fact pathological. Most clinicians, and most adoptive professionals and families, today support the practice of telling children early about their origins and the circumstances of adoption. Perhaps the increasing numbers of domestic and international transracial adoptions has had the effect of lessening the secrecy and stigma that used to surround it. Giving children information early, even before they are ready to wholly comprehend the information (5), leads to a process of understanding governed by the external facts, the child’s internal cognitive and emotional development, and the family’s ability to talk comfortably about the issues.

At some point, however, adopted children become more curious about their origins and relationship with the parents, real or fantasy, who gave birth to them, and cared for them prior to their adoption. As their toddlers and preschool children become aware of the realities of pregnancy and child birth, adoptive parents will face questions about the adopted child’s origins and early life, and will need to find ways to answer them honestly and openly. Just as young children whose parents divorce are likely to see themselves as responsible for the divorce, because of their behavior or attitude, so adoptive preadolescent children may assume that they were given for adoption because they were in some way damaged or defective, or unwanted because they were a boy, not a girl, or vice versa. As in other families referred for clinical intervention, it is not uncommon to find that the children have not shared such feelings or thoughts, sometimes because of a wish to protect their parents’ perceived vulnerabilities. Although systematic
research has not demonstrated it, it is also not uncommon, or surprising, to find adoptive children anxious about being removed from their adoptive families.

Adolescence appears to be a particularly sensitive time for many adoptive families, and possibly a significant stressor for adopted children, for a number of reasons, some inherent to the normal developmental process of adolescence, and some unique to the adoptive situation. The process of developing and focusing self–identity is clearly impacted by the reality of adoption; adopted adolescents may have little actual information about their biological roots and families, and may find their adopted parents are uncomfortable and guarded about their child’s curiosity. The wish of the adopted adolescent or young adult to search for their biological family, and meet their first parents, almost universally welcomed by those biological parents, is, sadly, for some adoptive parents exquisitely painful and may be experienced as rejection, even when the adolescent does not have that intent. In some families, this issue becomes focused on the idealization of the biological parent, and used as a weapon in a war of control around the adolescent’s emerging independence.

The challenges of normal parenting are focused in somewhat different ways for adoptive parents, even when the adoption takes place in infancy. Adoptive parents face relating to children who may not resemble them physically or psychologically, may be placed with them abruptly, and with little preparation, or with whom the legal course of adoption may delay the development of confidence in a future with the child. Moreover, many adoptive couples have already faced the considerable and often prolonged trauma and grief of infertility and its treatment. Research and clinical experience supports the view that unresolved grief over the loss of the potential for a natural child may interfere with the emotional availability of new adoptive parents. As their children grow, adoptive parents face questions and doubts, from themselves, the child and from others, about their role and abilities in comparison to “real” parents. Some extended families may perceive, and at times voice, rejection of the adopted child in comparison to “real” children. Even where such overtly pathological attitudes are not apparent, there are some clinical situations in which parents clearly experience difficulties in attaching to, owning, and accepting their adopted child, especially (6) that child’s expression of instinctuality— soiling, sexual curiosity, aggression, and eating. It has been suggested (7) that such difficulties result in strong prohibitions and negative expectations, and may even contribute to the referral of adopted children to clinical settings.

Even before the recent upsurge in the adoption of children from the welfare system, it was fairly clear that adopted children were overrepresented in clinical populations. Some of the literature supporting this finding dates from a time when most adopted children were placed in their adoptive families as infants. Studies from the 1960s, cited by Durdeyn (7) in a previous edition of this text (8,9,10,11,12,13), establish that adopted children were overrepresented in outpatient settings, and tended to be referred for externalizing behaviors.

More recent studies of inpatient settings (14,15,16) support the conclusion that adopted children are more commonly referred and admitted, with rates as high as 21% of inpatient adolescents in one study (15), though generally falling around 10% of admissions. Warren’s (16) study showed that the referrals among adopted children were for generally lesser problems. Some evidence (17) suggests that differences seen between adopted, foster, and nonadopted children in behavioral problems and rates of referral were the result of a small group of influential cases, rather than a reflection of the group as a whole.