1. Assessment of
Suitability for 17
Adoption
Adoption as an accepted method of building a family is gaining ground both
in the domestic and international contexts.
I feel strongly that children should be assessed for adoption only by someone
who is especially interested and has the expertise in the matter. This may be
a child health clinic doctor who has specialised in the subject, a paediatrician
or child psychiatrist who is especially interested in it. It is a tragedy for both
child and adopting parents if a mistake is made. No child should be rejected as
being unsuitable for adoption without an expert seeing the child and agreeing
with the diagnosis. It is a disaster for a child to be rejected for adoption on the
basis of an incorrect diagnosis that the child is intellectually disabled or spastic.
When assessing a child’s suitability for adoption, it must be constantly
remembered that the interests of the child are the primary consideration.
Nevertheless, the interests of the adopting parents have to be considered,
for they have a considerable bearing on those of the child. One has to try to
prevent an intellectually disabled child being unwittingly adopted, in order
to protect the adopting parents from a tragic disappointment, and to protect
the adopted child from possible rejection. An important aim of the doctor is
therefore the detection of a severe intellectual or physical disability. It may be
argued that one should attempt to match the child’s developmental potential
with that of the intelligence and social status of the adopting parents, as was
done in Arnold Gesell’s clinic in New Haven. This is a debatable aim, but it
is difficult to deny that a child who is thought to be of slightly below average
developmental potential would fit in better in the home of a manual labourer
than in the home of professional parents. More research is needed in this area
of adoption.
A child a little below the average at 6 months might well prove to be above
average if placed in a good loving stimulating home; if placed in a less good home,
he may become further disabled. In the same way, a intellectually superior baby
might not be expected to achieve his best if placed in a poor home. Admittedly,
it is not the function of the paediatrician to choose the home for a baby; but
in deciding whether a baby is suitable for adoption, he may be influenced in
his decision by observing the sort of foster parent who wants to adopt. Gould1
in his book on Stress in Children wrote that ideally it would be most desirable
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2. 370 Illingworth’s The Development of the Infant and Young Child
to match the abilities and temperament of the child to those of the adoptive
parents. I am not sure that it would. I am not sure that it would be better for
an anxious mother to adopt an anxious child as the poor fit between the dyad
worsens the anxiety of both.2
Knowing the importance of environmental factors in schizophrenia, it
might well be better to try to place a child of a parent with schizophrenia in
a particularly calm and stable home with low, expressed emotion of, critical
comments, hostility and over involvement.3
The assessment is made, as always, on the basis of the history, the examination
and the interpretation.
The History
The importance of a full history, prior to developmental examination, has
already been described. It would be wrong to agree to any child being adopted
without a proper history concerning the real parents, the pregnancy, birth-
weight, duration of gestation, the delivery and the condition of the child in the
newborn period. One must know whether there is a family history of hereditary
or communicable diseases, such as AIDS and other blood-borne infections and
particularly of degenerative diseases of the nervous system or of psychoses. One
must know whether there is a history of illnesses during pregnancy, such as pre-
eclampsia or antepartum haemorrhage, which increase the risk of abnormality in
the child. One must know about any factor making the child ‘at risk’, or more
likely than others, to be abnormal. The greatest ‘risk’ factor of all is probably
extreme prematurity or a marked discrepancy between the birth weight and
gestational age (small-for-dates), but it is essential that none of these factors
should be given an exaggerated importance. For instance, a history of intellectual
disability in a parent should certainly not be regarded as contraindicating the
adoption of the child. A history of epilepsy in a mother should not prevent a
child being adopted, for the genetic risk is only a small one. That risk would
have to be fully understood by the adopting parents. I find a constant tendency
to exaggerate the importance of these factors. The doctor who assesses the baby
should note the factors carefully and keep them in proper perspective. He should
17
then concentrate on assessing the child, and except in the case of degenerative
CHAPTER
diseases of the nervous system and recurrent major illness like bipolar mood
disorder or psychoses he should be careful not to give the ‘risk’ factors more
importance than they merit (Chapter 13), but if there is doubt, he will ask to
see the child again say at 10 months, prior to clinching the adoption, in order
that he can assess the rate of development. Immunisation history should be
collected wherever available; however, it should be kept in mind that children
being adopted are likely to have had fragmented care and limited continuity
of medical records.
The paediatrician may be asked for advice as to whether a normal child can
be adopted into a home containing an intellectually or physically disabled child.
There is no easy answer to this. If he is adopted it is likely that he will suffer
in various ways. He may grow up to be embarrassed by his disabled ‘sibling’:
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3. Assessment of Suitability for Adoption 371
the mother may suffer physical, emotional and financial stress as a result of
having a severely disabled child, and so the adopted child may suffer: and there
is likely to be favouritism for the disabled child. The normal child may be held
responsible for the disabled child after the death of the parents. The decision
must depend on the severity of the disability and other family circumstances.
Some adoption societies will now allow a child to be adopted into a home
containing a disabled child.
The Examination and Its Timing
The age at which the assessment is made is of the greatest importance. Presumably
grossly atypical infants, such as those with microcephaly or Down’s syndrome,
will have been sifted out and will therefore be unlikely to reach the doctor who
is assessing babies for adoption.
There is much to be said for a doctor assessing all adoption babies at roughly
the same age, so that he becomes thoroughly conversant with the developmental
features of that age. There is not usually much difficulty in arranging this.
It is a serious mistake, which I have seen on several occasions, to attempt
to assess a baby say at 6 weeks of age when he was born 6 or more weeks
prematurely.
In my opinion, the earliest age at which one should attempt to assess a full-
term baby is 6 weeks. This is because it is relatively easy to assess the motor
development at this age, and normal full-term babies have begun to smile at
the mother’s overtures and probably to vocalise. They will watch her intently as
she speaks to them. It is the normal practice in Britain to place an infant at the
age of 1 or 2 weeks in a foster home in which the foster parents are likely to
adopt; and the age of 6 weeks would be a convenient one for assessment, giving
the foster parents a little time in which to become acquainted with the baby.
If one is doubtful about the development at this age, he should be reassessed
at 6 months, but not sooner.
I have no doubt that it is much easier and safer to assess a baby at the age of
6 months, if this can be arranged. The difficulty lies in the foster parents’ natural
desire to clinch the adoption, and the fear that the real mother may change
CHAPTER
her mind and demand the return of the baby. At the age of 6 months, one can
readily assess the gross motor development, particularly in the sitting position;
the child has begun (at 4 or 5 months) to reach out and grasp objects without
their being put into the hand, and the maturity of the grasp can be assessed
17
at 6 months. He begins to transfer objects from one hand to the other at this
age. He begins to chew. He may have begun to imitate (e.g. a cough or other
noise). His interest in his surroundings and determination can be observed. The
maturity of his response to sound can be determined. For instance, he should
immediately turn his head to sound.
If one is doubtful about the baby’s development at 6 months, the best
time to see him again is at 10 months. By this age he should be able to stand
holding on to the furniture, and perhaps to walk, holding on to it; he may be
able to creep; but much more important than this is the index finger approach
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4. 372 Illingworth’s The Development of the Infant and Young Child
to objects and finger–thumb apposition. He should be able to wave bye and
play patacake, and he should be helping his mother to dress him by holding
his arm out for a coat or his foot out for a shoe.
In the first year, the most difficult age for assessment is 2–4 months and
the next most difficult age is 8–9 months. This is because there are so few
significant new milestones at these times. It is easy to make a mistake at 2–4
months in the assessment of motor development, and there are no useful new
developments in manipulation or social behaviour. The same applies to some
extent to the age of 8–9 months.
It is normal practice to place the child at 1 or 2 weeks in a foster home in
which adoption is desired. It is wrong to place him in an institution from birth
and retain him there for some weeks because he is likely to suffer emotional
deprivation and to be compromised as a result.
In international adoptions, following these time frames to examine the
prospective child may not always be possible.
The Possibly Disabled Child
The would-be adopting parents have a right to know about the health history
of the real parents, as far as it is known.4 In the same way, if one is uncertain
whether a baby is normal or not, the adopting parents must be told. They
will then understand why one decides to see the baby again at usually a short
interval in order to assess progress.
If the final verdict is that the child is disabled, one has to try to assess the
degree of backwardness. It is important to try to predict whether he will be
educable in an ordinary school or a school for educationally subnormal children,
and still more important to predict that he will not be suitable for education at
school. Such predictions are fraught with great difficulties, and one must take
all possible factors into account, including the head circumference in relation
to his weight. The additional finding of cerebral palsy may simplify matters, if
it is severe, or make it more difficult, if it is less severe. In all cases one has to
state the position to the parents, making it clear, if one thinks it to be the case
that the child may make an unexpected improvement and even turn out to be
17
normal. This will depend in large part on the head size.
CHAPTER
Many foster parents, on being told that the child is thought to be backward,
state unhesitatingly that they will adopt in any case. In one way this is desirable,
because it would be a tragedy for the child if he was not adopted. In that case
prolonged stay in the foster home is the best substitute for adoption. On the
other hand, it is impossible for parents who have never had an intellectually
disabled child to know all the implications of adopting such a child. They
cannot know all that it involves. They cannot know what it is like to have an
intellectually disabled child in the home, and have to watch him all the time
for his own safety. They cannot really know the physical, social, emotional and
financial stresses to which they will be exposed. At least they will not feel the
guilt, disappointment and other attitudes which real parents feel when they
find that their own child is disabled. They will have little sense of shame when
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5. Assessment of Suitability for Adoption 373
their neighbours and relatives see the child. They may be respected for their
courage for knowingly adopting such a child. They will not expect too much of
him, and yet they may always hope for some improvement. It is reasonable to
suppose that a couple would not deliberately adopt a subnormal child unless
they were the sort of people who would be likely to be able to cope with him.
If a child is of normal intelligence, and yet is found to be disabled, there is
no objection to the child being adopted, provided that the parents understand
the implications as far as possible. Again, it would be a tragedy for the child
if he was not adopted.
About 11.7% and 12.2% of children have disability in the domestic and
international adoption.5 Many early studies on adopting children with physical
or intellectual disabilities found that adoptive families were happy with their
adoption experience.6 Some writers believe that as the disruption of the family
functioning is low while adopting children with disabilities, many parents go
on to adopt additional children with disabilities.7 On the other hand, as the
poor school performance and behavioural problems can persist often in these
children, growing a child with disability can be more stressful and more difficult
than other adoption.8 Therefore, as mentioned before, the adoptive parents
should be sensitised to both these perceptions.
Current adopting practices now raise new problems—that of religion, that of
the coloured child, and that of a child with intellectual or physical disability.9–12
The Possibly Disabled Parent
A prospective adoptive parent with impairment of special senses, who requires a
personal aide for the activities of daily living, who has schizophrenia controlled
on medication, a survivor of cancer in the distant past are all considered disabled
during adoption. But as long as the prospective parent is self-supporting and
living independently, the doctor involved in the adoption process should take
into account the abilities rather than the disabilities of the prospective parent
and encourage the process. It is said that the success of some of these adoptions
is because these parents tend to adopt children with a disability similar to
their own. But in contrast, the combination of the child’s needs and those of
CHAPTER
the parent with disability could result in overwhelming circumstances to the
adoptive parent.13
International and Transracial Adoption
17
While the domestic adoptions continue, international and transracial adoptions
have become popular. In such situations, the parents will get an adoption
referral, a description of the child with a picture, and a brief medical history
that is often inadequate or inaccurate. The parents often take this referral to
a doctor for pre-adoption records examination. Unfortunately, there are no
international standards for the record examination and counselling during
such adoptions. And yet the doctor has to explain to the adoptive parent
that children coming from deprived conditions can be small for age, can have
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6. 374 Illingworth’s The Development of the Infant and Young Child
flu-like symptoms, skin rashes, tonsured heads to combat lice, spots of baldness
due lying in hard surfaces for extended periods that can appear worrisome but
may not be of serious consequence. The record evaluation should include a
thorough review of the growth chart, birth information and maternal history,
developmental history, child’s social history, medical history and pre-adoption
laboratory investigations, reviewing the picture and if possible a videotape of
the child are essential. Readers interested in knowing the details are referred to
the report by the Committee on Early Childhood, Adoption, and Dependent
Care.14,15 The parents should be counselled about the child’s background
(cultural, ethnic, religious, language and racial differences) and a gradual
acculturation process should be planned.16 Currently, some studies have
documented that such adoptees can have a higher risk of mental health
concern later in their lives,17 but more studies are required for a definitive
understanding about the long-term effects of international adoption.
Adoption by Same Sex Parents
The doctor specialising in adoption should be aware that about half of the same
sex parents want to have children.18 In places where child adoption by same sex
parents is legally practiced, the clinician should be aware that homosexuality is
not an illness, there is no evidence to support same sex parents are ineffective
parents or have different child rearing skill and hence such adoption need not
be discouraged. In fact such adoptions can be encouraged. Such parents provide
supportive and healthy growing environment for their adopted children, and
parents’ sexual orientation as such has no significant effect on children’s mental
health or social adjustment.19 Nevertheless, the clinician should be conscious that
these children may be stigmatised, teased, made to feel different and stressed
by the various challenges they face due to anti-homosexual social attitudes.20
To minimise such stigmatising social concern the doctor can suggest co-parent
or a second parent outside the same-sex parental dyad.21 As half the adopted
children by same sex parents are under five years, the examination of the child
during adoption should follow the pre-adoption examination that has already
been described. Importantly, if the developmental age of the adoptive child
17
would permit discussion with the child about the uniqueness that comes with
CHAPTER
same sex parent adoption, it should be done in a way the child understands.
Assessing the Capabilities of the Adoptive Family
As the family doctor often interacts with the family that is adopting the child,
it is in the interest of the child that the physician assesses the future adoptive
family members and the circumstances. It is important to determine the physical,
intellectual and emotional capabilities and willingness of the prospective
parents to parent the adoptive child. A careful assessment of the finances and
accommodation arrangements of the adopting family to support the child,
history of domestic violence, child abuse or neglect or any other criminal
behaviours, previous rejection of the family for adoption are imperative before
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7. Assessment of Suitability for Adoption 375
the adoption for ensuring the long-term success of this family building process.
This evaluation can be effectively done by interviewing all the adults in the
adopting family during a home visit by the coordinating doctor.22
Genetic Advice
The doctor who assesses the suitability of a baby for adoption frequently has
to give genetic advice. Only an expert should do this. The common problems
are as follows:
1. Consanguinity: The overall risk of congenital abnormalities in consanguineous
unions is probably somewhere between 7% and 31%.23
2. Schizophrenia: The genetic factor probably acts by predisposing to
schizophrenia under the influence of additional environmental factors.
There is probably a 13% risk of the child developing it if a parent had it.
The risk increases to 46% if both parents have schizophrenia and for an
identical twin with the disorder. In a family of five, when two siblings are
unaffected the risk for the adopted child is about 2%, but if the two other
siblings have the illness then the risk of recurrence for schizophrenia in
the adopted child increase to 18%. The risk of developing the psychosis
for half-siblings is 6% and for a first cousin is 2%.24
3. Bipolar affective disorder: The risk of the child developing it is about 12%.
The risk of developing a bipolar disorder for an identical twin is 79%, and
it is 19% for a non-identical twin. The family member may not develop it
until the age of 40 or 50, and thus identifying the prospective child at risk
becomes difficult.25
4. Epilepsy: The genetic factor is only a small one. The risk of the child being
affected is about 2.5%. The risk is much greater if both parents have epilepsy.
5. Degenerative diseases of the nervous system: If a sibling has a degenerative
disease of the nervous system, or has had infantile spasms (which can be
due to a wide variety of causes), the risk for the child who is being assessed
for adoption is greatly increased. If a parent has a degenerative disease of
the nervous system, again the risk to the child is considerable. The opinion
to be given must depend on the exact diagnosis.
CHAPTER
6. Intellectual disability: It is impossible to give sound genetic advice concerning
a child being assessed for adoption who has a defective sibling unless a
full investigation has been carried out on the defective child: one has to
do one’s best to eliminate the recessive and dominant conditions because
17
of the high risk to siblings.
7. Anxiety disorders: The risk of a child having panic disorder is 5.4 times
higher if the child has a family member with panic disorder than not.
Similarly, the risk of an identical twin developing panic disorder is 2.4
times higher than a non-identical twin. Also, studies show that the risk of
a child having obsessive compulsive disorder is 3.5 times higher if the child
has a family member with the disorder than not. Likewise, the risk of an
identical twin developing obsessive compulsive disorder is 4.9 times higher
than a non-identical twin.26
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8. 376 Illingworth’s The Development of the Infant and Young Child
8. Alcohol dependence: Previously alcohol dependence was considered mainly
environmental in origin and that there was no added risk of the child
developing it. However, studies show that there is up to 27% and 5%
vulnerability to the boys and girls, respectively, in later life, if there is a
first-degree relative who has alcohol dependence.27
It is the practice in Britain for adopting parents to be informed of the
background of the real mother and father. Discretion must be shown in this
matter. It is certain that the adopting parents must not hear for the first time
in court about diseases such as syphilis or AIDS in the real mother or father.
The legal framework that governs adoption varies from country to country.
Adoption in and from India is essentially governed by the Hindu Adoption
and Maintenance Act of 1956 and Guardians and Wards Act of 1890. India is
a signatory to the Hague Convention on Inter-country Adoption of 1993 and
thus international adoption are regularised by this convention. The ‘Guidelines
for Adoption from India – 2006’ issued by the Ministry of Social Justice &
Empowerment of Government of India streamlines and monitors international
adoptions. Successful adoption in India is seen as the harmonisation of the
triad formed by the child, the adoptive parents and the biological parents.
Organisations such as adoption agencies and children’s homes enhance the
procedures related to adoption as well as in the follow-up assessments in India.
Conclusion
Assessment of suitability for adoption is difficult, and a matter for the expert. If
there is doubt as to whether a child is in all ways normal or not, the adopting
parents must be fully informed. There will always be some risk in adoption.
Parents having their own children have no certainty that their children will be
normal, and cannot even choose the sex. But unless adopting parents are willing
to take some risk, they should not adopt at all.
References
17
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