Arch Dis Child: first published as 10.1136/adc.49.3.165 on 1 March 1974. Downloaded from

Review article

Archives of Disease in Childhood, 1974, 49, 165.

The fate of the adopted child SULA WOLFF From the Department of Psychological Medicine, Royal Hospital for Sick Children,

Problems of adoption research far from shying away from such ventures, in fact Until quite recently adoption was considered to be revealed themselves as willing and interested such a delicate social transaction that outcome research subjects. studies were attempted only on self-selected Other difficulties in the interpretation and subjects. McWhinnie (1967), for example, studied usefulness of the results of adoption research then adults whom she recruited by asking general became apparent. These are twofold. First, as practitioners to canvas patients known by them to with all long-term longitudinal studies, the factors have been adopted. Clearly, not all adults on these found to determine outcome of adoption in people doctors' lists had revealed their adoptive status and who are now adults relate only to the circumstances certainly only a proportion of these in fact agreed to which existed when these particular people were take part in McWhinnie's study. The finding that children. Public attitudes to illegitimacy, family only 21 of the 58 people studied were well or fairly size, one-parent families, and to adoption are well adjusted at the time of follow-up may reflect the changing. The choice of whether or not to place a adverse effects of growing up adopted. It is more baby for adoption may be determined by quite likely, however, to be a measure of the personality different considerations now than 30 years ago. difficulties of that special group of adopted people The selection of adoptive children and of adoptive who were well known to their doctors because of parents, the quality of infant care before adoption, frequent surgery attendances, who chose to reveal and the procedures used in the adoption process may their adoptive status to their physician, and who, have changed radically in three decades. Studies of http://adc.bmj.com/ finally, were so involved still with this aspect of their the outcome of adoptions that took place in the lives as to volunteer to participate in adoption 1940s are unlikely to be really helpful in our decision research. Studies of selected samples of adopted making now. In contrast, outcome studies in people, e.g. comparisons between adopted and childhood have a great deal more to offer in terms of nonadopted attenders at child psychiatric clinics practical relevance, despite the fact that the ultinite (Borgatta and Fanshel, 1965), or in psychiatric future of the children studied remains uncharted. inpatient units for children and adults (Simon and A second difficulty in the interpretation of the Senturia, 1966), or studies of adopted people who findings of adoption research is that comparisons of on October 6, 2021 by guest. Protected copyright. chose to look up their birth certificates in order to adopted children with other children cannot control trace their true parents (Triseliotis, 1973), provide for the initial processes of selection, that is, the information only about selected aspects of adoption, self-selection of mothers who offer their babies for failing to give an overall picture of outcome. adoption and the selection of babies by adoption In Norway, where much personal information is societies. This is the chief difficulty in interpreting available for statistical purposes on a national basis, the results of the British Child Development study it was found that people adopted in the late 1930s which is a source of much information about the had had no more mental hospital admissions or future of illegitimate children (Crellin, Kellmer- criminal convictions 25 years later than the general Pringle, and West, 1971; Seglow, Kellmer-Pringle, population (Bratfos, Eitinger, and Tau, 1968). and Wedge, 1972). Perhaps as a result of changing public attitudes and The questions we would really like answered are also of the impetus to adoption research by research the following. First, when a mother has an workers who are themselves adoptive parents a illegitimate baby is it better for the baby to be number of personal follow-up studies of unselected adopted than for the mother to assume its care? adoptions have now been done. Adoptive parents, That is, is adoption better or worse than other forms 165 Arch Dis Child: first published as 10.1136/adc.49.3.165 on 1 March 1974. Downloaded from

166 Sula Wolff of child care for the illegitimate ? Secondly, there Three major studies have clarified this issue. is a group of questions relating to the adoption Helen Witmer and her associates in Florida (1963) process itself. Is there an optimal time for compared 484 adopted children with an equal adoption ? Do the circumstances of pre-adoption number of nonadopted. Only a very slight care matter ? What features in the baby and in the difference in emotional adjustment was found prospective adopters make for success? What between the two groups, and this was entirely due to procedures in the adoption process itself promote or an excess of psychiatric disorder among children hinder a good outcome? placed in their adoptive homes after the age of 1 month, especially if adoption had been preceeded by a period of institutional care or by multiple place- Emotional and educational adjustment of ments. Overall, 80% of adoptions were entirely adopted children satisfactory. The suggestion that adopted children as a group Michael Bohman (1970) studied 168 10- and may be more disturbed psychiatrically than other 11-year-old children in Stockholm placed through children came from the findings in Britain and the main public adoption agency with nonrelatives. America that among clinic attenders He compared these children and their families with a many more children are adopted (between 5 and representative sample of Stockholm schoolchildren 13%) than in the population at large (generally of the same age studied a few years earlier by using between 1 and 2%) (Borgatta and Fanshel, 1965; the same methods and questionnaires. Bohman's Triseliotis, 1970; Bohman, 1970). It was not main findings were that as a group adopted children, surprising to find an excess of emotional disorder in especially boys, displayed more nervous disorders a group of children of families who have had to face such as restlessness, poor concentration, and conflict a number of exceptional stresses. The parents have with peers, but had no excess of antisocial behaviour. had to come to terms with their infertility; they have While adoptive parents reported few behaviour had to endure an often arduous evaluation problems, teachers assessed more adopted children, procedure; and they have had to cope with the especially boys, as maladjusted than controls (22 O/ difficult task of disclosing to their child his adoptive of adopted compared with 12% of control boys). status. Adopted children have had to accommodate Difficulties with reading and writing were commoner to the idea of two sets of parents, one of whom gave among the adopted of both sexes than among the them up, and to uncertainties about their origins and controls, and were related to pre- and perinatal identities which may never be resolved. Both complications. Though problem children were over-represented in the adopted group, only 2 cases parents and children have had to adapt to their http://adc.bmj.com/ minority status in society. of markedly severe behaviour disorder were found. Possible genetic or other constitutional dis- These results need to be viewed in relation to the advantages of children placed for adoption were at environment provided for the children by their one time not thought to prejudice outcome, since it adoptive parents. Socially and materially these has been found repeatedly (e.g. by Skeels and families were superior to those in the control group, Harms, 1948) that the socially and culturally and in addition adoptive parents expressed more advantageous environment provided by adoptive positive attitudes than other parents to a variety of parents engenders intellectual capacities in adopted aspects of their lives. On the other hand, just as in on October 6, 2021 by guest. Protected copyright. children resembling more those of their adoptive the control group, 1 child in 6 had already lost one of than of their true parents. That the intellectual his parents through death or divorce during the first ability of adopted children does not quite match that 10 years of his life. Clearly, the screening of nonadopted children reared under similarly procedures of potential adopters had not succeeded favourable conditions, and that intellectual or, more in ensuring a particularly secure family life for the accurately, educational acceleration can occur at adopted child. some cost will be discussed below. The National Child Development Study of a Despite the known stresses of adopted children representative sample of British children born in one and their parents, one could not be sure whether the week of 1958 allowed comparative studies of a high proportion of adopted children among number of special groups of children, among them psychiatric clinic attenders reflected a true excess of the illegitimate and the adopted. The findings pathology or indicated rather the greater uncertainty published so far relate to outcome of these children of adoptive parents or their more ready recourse to at the age of 7 years (Crellin et al., 1971; Seglow et helping agencies, since all these parents had already al., 1972). Comparisons between adopted children experienced a social work contact. and controls from the rest of the national sample Arch Dis Child: first published as 10.1136/adc.49.3.165 on 1 March 1974. Downloaded from

The fate of the adopted child 167 gave results very similar to Bohman's (1970). are able to make comparisons between 160 of these Using the Bristol social adjustment guides as an children who were adopted, the 344 remaining index of maladjustment identified at school, 16% of children who were not adopted, and the legitimately 7-year-old adopted children were maladjusted, born children of the total cohort. compared with 130°o of legitimate controls. This The whole group of illegitimate children slight excess of maladjustment in adopted children compared unfavourably with the legitimates in was confined to boys (23% maladjusted adopted having a greater proportion of very young mothers, compared with 170% controls) and to children raised in more often being first born, in having poorer in middle class families (190% of adopted children in obstetric care and lower birthweight. The social families of Social Class I, II, and III nonmanual background from which their mothers came was, were maladjusted compared with 7% of legitimate however, the same as for the mothers of legitimate controls raised in families of similar social class). children. (It is of interest that at the age of 7 As far as intelligence and school performance were two-fifths of the nonadopted illegitimate children concerned, tests of ability did not differentiate were in fact living with both their own parents, between adopted and nonadopted legitimate one-fifth were with their own mother and stepfather children, and adopted children were better readers (more rarely with their own father and stepmother), than the nonadopted. However, these results and only 1 in 7 lived with their mother in the absence related only to the groups as a whole when social of other relatives. class was not controlled for. Adopted children Comparisons of the children's physical develop- were much more often raised in small, middle class ment at 7 years showed that the adopted children families, and when compared with nonadopted were the tallest, but that there were no differences children from similarly favourable backgrounds, the between the three groups in the frequency of abilities of adopted children were slightly inferior, physical defects, in vision and hearing, in hospital though their reading skills were the same as those of admissions for accidents, and in age at walking and the controls. Adopted children functioned a little talking. Nonadopted illegitimate children spoke more poorly arithmetically than controls, even when less well and illegitimate children, both adopted and social class effects were not controlled. In both nonadopted, were more often clumsy and restless, adopted and control groups boys and low birth- presumably as a result of their greater obstetric weight children were inferior educationally. difficulties. A definite hazard for adopted children has been The social circumstances under which the delineated by these studies. Because adoptive children grew up, whether the measure was the parents are most often middle class people with parents' social class, the quality ofhousing, mobility, http://adc.bmj.com/ superior intellectual endowment, and the children crowding, or finance, was greatly inferior for offered for adoption have just average intellectual nonadopted illegitimate children and significantly potentials, a proportion of adopted children will, superior for the adopted compared with the despite the cultural advantages oftheir environment, legitimates. A similar gradient was found when the prove academically 'disappointing' to their parents three groups were compared (without controlling for and hence to themselves. They are likely to suffer social class) on measures of behaviour and adjust- from excessive educational pressures. One measure ment, and ability and attainment. Adopted of this is their accelerated reading skill, while their children were superior to the legitimates and these in on October 6, 2021 by guest. Protected copyright. mathematical skills remain the same. It is possible, turn to the illegitimate, nonadopted group. too, that their failure to match up to their parents' We know, as indicated above, that when social and their own educational aspirations contributes to class factors are controlled, the adopted fare not their greater maladjustment. Boys are especially at better but slightly less well than the nonadopted in risk both because they more often have con- similar middle class homes, especially the boys. On stitutional learning difficulties, but also because they the other hand, the National Child Development are likely to have focused on them greater Study shows that the fate of illegitimate adopted educational expectations. children is vastly better than that of those not These hazards, revealed when adopted children adopted. Sadly there is a major defect in the way are compared with nonadopted legitimate children, this study has been reported. No information fade away when instead the adopted are compared whatever is provided on the preplacement with nonadopted illegitimates. Crellin and her differences between those illegitimate children given co-workers (1971) looked at the fate by the age of 7 up for adoption and those kept by their mothers. years of 504 surviving illegitimate children in the We do not know how much the more favourable National Child Development Study. The authors outcome of adopted illegitimates is due to their more Arch Dis Child: first published as 10.1136/adc.49.3.165 on 1 March 1974. Downloaded from

168 Sula Wolff favourable family environment and how much to the her resolve to have the baby adopted and will make selection processes initially involved. It may well the giving-up process very painful indeed. be that the constitutionally better endowed, more intelligent mothers of illegitimate children opted for Determinants of successful adoption adoption and that adoption societies selected the healthier babies who had been exposed to fewer Within-group comparisons of adopted children obstetric hazards. To advocate adoption for all reveal the determinants of a successful outcome. illegitimates would not ensure a similarly favourable adoption outcome for all, though it is still likely to be Factors in the child. vastly better than exposure to all the social, cultural, Age at placement. All studies, except one rather and emotional privations known to be in store for poor retrospective study where inadequate adoption illegitimate children who are not adopted. One records were matched against outcome measures finding made very clear is that the social support untested for reliability or validity (Jaffee and available from the community and from pro- Fanshel, 1970), show that the later adjustment of fessionals for mothers of illegitimate children, even adopted children and the satisfactions of their in this permissive age when prejudice has decreased adoptive parents are better when placement is early and the social work profession is being strengthened, rather than late. Humphrey and Ounsted (1963) is still less than adequate. showed that fewer children were disturbed if placed The studies cited permit some quite definite at under rather than over 6 months of age, and conclusions for those concerned with the care of Witmer and her colleagues (1963) found that even mothers of illegitimate children. In our present children placed at under 1 month fared better. state of knowledge the responsible action is to This last finding may be due to the greater arousal of facilitate rather than hinder the adoption of parental attachment by the very young baby, since illegitimate children. The fate of nonadopted from the point of view of the baby's social develop- illegitimates is poor. The outcome of adopted ment a continuous attachment figure becomes children is only slightly less good than that ofnatural necessary only after 6 months of age (Schaffer, children, though it may deteriorate somewhat if 1971). Maternal responses on the part of adoptive self-selection of mothers and selection by adoption mothers may be more adequate if they get a neonate agencies of babies became less stringent. On the rather than an older baby. Babies form smooth other hand, it will be argued, there is room for attachments to their future mothers so long as improving the outcome of adoption by the even placement occurs at or before 6 months.

better selection of adoptive parents, and this may http://adc.bmj.com/ redress the balance. Matching the baby to his adoptive home. Rutter (1970) has argued conclusively that predictions of future intellect and temperament cannot be made on Decision to place a child for adoption the basis of infant examinations within the first 6 It is known that at the time of labour about months of life. Even if we knew how to match two-thirds of mothers of illegitimate children have child and parents optimally for nonintellectual decided on whether or not to offer the baby for qualities of personality, we could not do so. Vital adoption (Triseliotis and Hall, 1971; Yelloly, 1965). aspects of intelligence, language for example, on October 6, 2021 by guest. Protected copyright. Doubt occurs mainly after a decision to offer the develop only during the second year of life and early child for adoption, very rarely indeed after a decision motor skills are not predictive of later abilities in to keep the baby. If babies whose mothers opted other spheres. Predictions of later intelligence are for adoption are not immediately placed in adoptive better if based on the intelligence of the natural homes but are placed instead in short-term foster parents, and good intellectual development is homes, a proportion of mothers begin to waver in safeguarded by early placement and the avoidance their decision. Direct placements from maternity of preplacement institutional care. All that can be units lead to fewer recalls (Home Office and Scottish done in infancy is to ensure the absence of disease Education Department, 1972). Triseliotis and likely to impair future functioning. Absence of Hall's study, 'Giving consent to adoption' (1971), physical disease and early placement are the best showed that the finality of a permanent placement is safeguards for the satisfactory development of the reassuring to the mother that her decision was right. adopted child. Moreover, maternity units compelling all mothers to Moreover, many adoptive parents are prepared see and feed their babies, foster attachment to the these days to care for a handicapped, illegitimate child on the mother's part which is likely to shake child and the outlook for such a child, adopted, is Arch Dis Child: first published as 10.1136/adc.49.3.165 on 1 March 1974. Downloaded from

Thefate of the adopted child 169 likely to be a great deal better than the alternatives ill physically or psychiatrically, and who are likely to that are open. Handicaps in children placed for maintain a harmonious married life. adoption include physical disease and evidence of a A recent study by Triseliotis (1970) of adoption hereditary predisposition to develop a physical or policy and practice shows that, while the proclaimed psychiatric illness. It need hardly be stressed that policies of adoption agencies would be to select only a minority of psychiatric illnesses have a genetic adopters for such characteristics, adoption practice basis (alcoholism and psychopathy do not) and that falls far short of these goals. Wide variations there is specific knowledge as to the risk to the between agencies exist in their assessment offspring of having, for example, a schizophrenic or procedures for prospective parents. Even the a manic-depressive parent. Other handicapping medical examinations of such parents are often conditions include being offered for adoption perfunctory and the methods for assessing beyond the stage of infancy or after a period of psychiatric status, personality, and the quality of the institutional care and, in the western world, having marital relationship are as a rule entirely unspecified. an ethnic background different from that of the Instead, far less important aspects are universally adoptive parents. None of these 'handicaps' when recorded in the assessment of adopters: their fully explained to prospective adopters are now religion, occupation, income, and housing. Better considered a bar to adoption (Home Office and selection of parents for adoption with special regard Scottish Education Department, 1972). The task to the diagnosis of personality disorder, psychiatric is no longer to pass a baby as fit for adoption by illness, the nature ofthe marital relationship, and the anyone, but to detect handicaps that might call for exclusion of serious physical illness can improve very specially selected adoptive parents. further the outlook for the adopted child and can to some extent compensate handicapped children by Factors in the adoptive parents. Most providing for them an exceptionally good family studies have found no connexion between the later environment. This assessment cannot be based on emotional adjustment of adoptive children and such intuitive judgements but must be founded on a external attributes of their adoptive parents as their systematic psychiatric history and a medical socioeconomic background or education (Witmer et examination. al., 1963), though for intellectual and educational progress these factors are important. Adoption process. Early placement is now There is no reason to believe that the qualities generally regarded as an important contribution to necessary to become a successful adoptive parent are successful adoption, and the Houghton Committee any different from those needed by ordinary parents. has exerted itself to examine how legal arrangements http://adc.bmj.com/ Studies of children reared by their own parents have can be modified to facilitate such early placements shown repeatedly what qualities of parents and of (Home Office and Scottish Education Department, family life give rise to psychiatric disorder in the 1972). offspring both during childhood and in later life. Many adoption agencies stress that adoptive parents need to be assessed in relation to the quality Family disruption, especially by divorce or of family life they are able to establish and to their Childless separation, but also through death, is highly child-rearing attitudes. couples cannot, on October 6, 2021 by guest. Protected copyright. associated with psychiatric morbidity in the of course, be assessed in this latter area. It is clear, offspring. however, that a straightforward psychiatric and personality assessment, based on an adequate Chronic parental ill health, physical, or especially childhood history of both parents and on a detailed psychiatric, contributes in a major way to psychiatric history of the marriage, would help to exclude disorder in the children, parentalpersonality disorder, parents with psychiatric illness and personality especially sociopathy, being the most pathogenic. problems likely to hinder their future functioning as parents. Marital strife, alcoholism, and domestic violence The Houghton Committee has also examined how have highly detrimental effects on children (Rutter, greater security can be provided, both for adoptive 1966; Wolff and Acton, 1968). parents and for long-term foster parents who wish to For the optimal development of adopted children, adopt their foster child, from the threat that until the adoption agencies need to select adoptive parents adoption is legalized they may lose the child. who are likely to survive until the child is An important question exercising adoption case independent, who do not have serious personality workers greatly is when and how the child should be disorders, who are not likely to become chronically told of his adoptive status. Triseliotis (1973) Arch Dis Child: first published as 10.1136/adc.49.3.165 on 1 March 1974. Downloaded from

170 Sula Wolff showed that those adults who search for their own (4) Adoptive children and their parents are parents in later life tended to have experienced already burdened with a major stress: the anomaly relatively unsuccessful adoptions. They had poor of their relationship. Adoption workers need to relationships with their adoptive parents and were ensure that their lives are otherwise exceptionally often told about their adoption late or not at all. free from stress. The aim must be to select parents Those people interested in discovering their origins free from identifiable psychiatric illness and without feeling a need for reunion with their parents personality disorder, who will survive and whose tended to have had happier childhoods and to have marriage will last until the child is grown up. experienced greater and earlier frankness about their adoptive status. Yet early telling may merely be an REFERENCES index to satisfactory mothering rather than an Bohman, M. (1970). Adopted Children and their Families. essential ingredient of it. In Jaffee and Fanshel's Proprius, Stockholm. Borgatta, E. F., and Fanshel, D. (1965). Behavior Characteristics of technically not very adequate study (1970), it was Children Known to Psychiatric Out-Patient Clinics. Child found that Roman Catholic adopters, who were least Welfare League of America, . Bratfos, O., Eitinger, L., and Tau, T. (1968). Mental illness and open about the adoption both with the child and crime in adopted children and adoptive parents. Acta with outsiders, had the highest proportion of Psychiatrica Scandinavica, 44, 376. Crellin, E., Kellmer-Pringle, M. L., and West, P. (1971). Born successful outcomes in later life. Illegitimate: Social and Educational Implications. National Foundation for Educational Research in England and Wales, Conclusions Slough, Bucks. Home Office and Scottish Education Department (1972). Report of (1) Studies of adopted and nonadopted the Departmental Committee on the Adoption of Children. H.M.S.O., London. illegitimate children show that educational failure Humphrey, M., and Ounsted, C. (1963). Adoptive families referred 1 and psychiatric disorders are far commoner among for psychiatric advice. Part I. The children. British Journal ( of , 109, 599. the nonadopted and that these children continue to Jaffee, B., and Fanshel, D. (1970). Howv They Fared in Adoption: A be exposed to major social and family stress. Follow-up Study. Columbia University Press, New York and (2) In contrast, when adopted children are London. McWhinnie, A. M. (1967). Adopted Children: How They Gr'owU Up. compared with children in the general community of Routledge and Kegan Paul, London and Boston. similarly favourable social status, they are assessed Rutter, M. (1966). Children of Sick Parents. Maudsley Mono- graph, No. 16. Oxford University Press, London. by their teachers but not their parents as slightly Rutter, M. (1970). Psychological development-predictions from more disturbed, and they perform a little less well infancy. Journal of Child Psychology and Psychiatry, 11, 49. Schaffer, H. R. (1971). The Growth of Sociability. Penguin Books, intellectually. This is especially so for boys. Harmondsworth, Middlesex. (3) There is room for improvement in the Seglow, J., Kelmer-Pringle, M. L., and Wedge, P. (1972). Growing

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