Dr. McGuinness is Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, and Dr. Robinson is Clinical Associate Professor, College of Nursing, University of South Alabama, Mobile, Alabama.
The authors disclose that they have no significant financial interests in any product or class of products discussed directly or indirectly in this activity, including research support.
Address correspondence to Teena M. McGuinness, PhD, CRNP, FAAN, Professor, School of Nursing, University of Alabama at Birmingham, NB 320, 1530 3rd Avenue South, Birmingham, AL 35294-1210; e-mail: email@example.com.
Ordinarily, adoptions do not cause international incidents, but in 2010 an adoptive American mother sent her elementary school-age child, unaccompanied, on an airplane back to Moscow, Russia. The mother cited his severe behavioral difficulties as the reason (Levy, 2010a). Because of the incident, Russian authorities suspended adoptions from Russia for several weeks but later allowed them to resume. Early in December 2010, representatives from the United States and Russia met for a fifth time to reemphasize their mutual commitment to a comprehensive agreement covering intercountry adoptions (Intercounty Adoption, U.S. Department of State, 2010b). The unaccompanied child incident came on the heels of several news reports about children adopted from Russia and later killed at the hands of their American parents (Barry, 2009; Hurdle, 2010). The image of international adoption seemed to change from that of warm, loving families to shocking reports of abuse, neglect, and deaths. How did this occur? What role does the behavior of the child play in these incidents, and what is known about the behavior of children adopted from Russia?
Adoption Practice Today
Adoption has been practiced for thousands of years and in all historical eras (Palacios & Brodzinsky, 2010). World War II brought a huge increase in adoptions, as nearly 1 million children were adopted into Western countries from the end of the War until present times (Selman, 2009). The wave of international adoptions continued relatively unnoticed by the American public until more than 100,000 children had entered the United States—the majority of which were from Korea (Kim, 1995). Unlike many other countries, children from Korea often had the advantage of spending time in family foster care before adoption into U.S. families; this critical family time bolstered these children’s development prior to adoptive placement. As the number of children adopted for Korea decreased, and children who had spent time in orphanages and institutions increased, a difference was noted in the adjustment of the children.
A significant shift occurred by the early 1990s: The Iron Curtain fell, and Romania and the countries that comprised the former Soviet Union became leading source countries for adoptive U.S. families (Intercounty Adoption, U.S. Department of State, 2010a). All children adopted from the former Soviet Union share the common experience of having spent at least some portion of their sensitive developmental years from birth to age 3 in orphanages (McGuinness & Dyer, 2006). In contrast, children adopted from Chinese orphanages have typically spent less time in institutional settings because of early adoptive placement and thus have fewer developmental challenges (Selman, 2009).
Institutionalization: A Multidimensional Risk Factor
Almost a century of scientific literature has demonstrated that placement of children into any institutional setting, such as an orphanage, is a risk factor for poor child health and development, due to myriad factors. Orphanage living has long been associated with delays in psychosocial development and cognitive deficits, as well as nutritional and growth deficiencies (Chapin, 1915; Frank, Klass, Earls, & Eisenberg, 1996). Chapin (1915) called the nation’s attention to the appalling death rates of infants in orphanages in the United States: nearly 100% in some foundling homes! Over the course of the next 25 years, “less lethal” foster homes replaced U.S. orphanages for infants (Bakwin, 1942, p. 30). It took another 40 years for a family foster care system to become the American model for care for children; foster families or kinship care with grandparents, aunts, and uncles became the norm.
Unfortunately, these desirable settings for children are rarely found in other nations. For example, in Russia (currently the third leading source country for international adoptions for the United States, with China and Ethiopia first and second) an estimated 700,000 children live in orphanages (Levy, 2010b), a number that exceeds the number of orphans at the end of World War II. Thus, it would seem there is no lack of children needing adoptive homes, and there are many American families who would like to adopt. Despite this obvious potential to place these children in homes in the United States, adoption from Russia has slowed significantly due to adverse events and their attendant publicity such as deaths of children at the hands of their American families.
Since 1996, 20 fatalities of internationally adopted children have occurred due to abuse and neglect by their adoptive parents (Barry, 2009; Hurdle, 2010; Miller, Chan, Reece, Tirella, & Pertman, 2007). Of these 20 deaths, 16 were adopted from Russia, two from China, and two from Guatemala. Each child’s death is a tragedy; however, a frequent theme in all of these deaths has been behavioral problems of the children. With 80% of the fatalities occurring in children from Russia, an obvious question must be asked: Is there something in the behavior of children adopted from Russia that predisposes them to adverse events in adoptive families?
Behavioral Issues of Post-Institutionalized Children
Children adopted from Russia share many developmental risks. Low birth weight, orphanage living, being adopted as a toddler or later, malnutrition, and prenatal alcohol exposure are all risks to behavioral development (Miller, Chan, Tirella, & Perrin, 2009). Although some authors have noted significant gains in development (primarily in growth and social language proficiency) immediately after adoption (Juffer & van IJzendoorn, 2009), others have noted persistent developmental deficits in some adoptees who have now entered adolescence (Merz & McCall, 2010; Stevens et al., 2008).
Gunnar and van Dulmen (2007) studied internationally adopted children into Minnesota between 1990 and 1998, noting that those children with prolonged institutionalization (>24 months), in particular, had elevated scores in several problem behavior scales of the Child Behavior Checklist. Their study also noted that the rates of problem behaviors did not seem to diminish even with the positive impact of a family environment. Gunnar and van Dulmen (2007) concluded that those children adopted from Russia/Eastern Europe had a greater propensity to develop problem behaviors when compared with children adopted from other regions in the world.
Merz and McCall (2010) provided additional evidence to support the notion that adoption of Russian children after age 18 months from an institution with an inferior psychosocial milieu resulted in increased behavior problems when compared with children adopted early from more nurturing environments. Not only was the institutional environment predictive of problem behaviors, but the length of time spent in those environments prolonged effects on future behavior, especially as children reached adolescence (Merz & McCall, 2010).
Hawk and McCall (2010) noted that anxious and aggressive behaviors, as well as attention problems, were more prominent in those children who experienced prolonged exposure to institutional living and that these behaviors endured. Hawk and McCall (2010) observed “the effects of deficient early experiences are not simply the persistence of learned behavior but general dispositions that become more noticeable or severe during adolescence” (p. 199). Johnson (2009), founder of the International Adoption Clinic at the University of Minnesota and pioneer in adoption medicine, summarized the issue succinctly: “An orphanage is a terrible place to raise an infant or young child. Lack of stimulation and consistent caregivers, suboptimal nutrition and physical/sexual abuse all conspire to delay and sometimes preclude normal development” (para. 5).
Implications for Nurses
Miller et al. (2007) encouraged clinicians to offer education to those families considering international adoption. Although the majority of children thrive in their adoptive homes, some children have experienced extreme circumstances, such as abuse within birth families or at the orphanage, and in combination with prenatal alcohol exposure and low birth weight, may endure lasting behavioral problems in the areas of attention, anxiety, and social behaviors. For example, some children adopted from orphanages may be indiscriminately friendly to strangers in public places, placing the children in danger. While the concept of a “forever family” is the ultimate goal, many adjustments must be made in the early months, and making the transition from orphanage to family can be stressful for both child and family.
Not surprisingly, the problems of the children also affect the adoptive parents. Nurses should not hesitate to evaluate new adoptive parents for depression, as the phenomenon of post-adoption depression may be identified (Foli, 2009). As Miller et al. (2007) stated, “professionals caring for adopted children must be especially vigilant in identifying parents who may be showing signs of depression, stress, or extreme disappointment” (p. 379). Nurses should query new adoptive parents about their well-being and sense of satisfaction with the adoption. Children with multiple behavioral and developmental issues can present challenges even to the most experienced parents; however, all adoptive parents deserve special attention and support (Miller et al., 2009).
One suggestion for initiating discussion with new adoptive parents is to approach parents with open-ended inquiries. By discussing both the adjustment of the child within the family and the adjustment of the adoptive parents, a dialogue on this important topic is more easily begun. Nurses might say, “Tell me about the support you are receiving in your new role as mom” or “Describe any unexpected adjustments you have made with your new son.” By remaining open, honest, and nonjudgmental, it is possible for the nurse to listen to and accept strong emotions from new adoptive parents. This is an important strategy, especially for those who have adopted older children who have spent extensive time in orphanages.
Nurses should work to increase awareness of the challenges that some new adoptive families face. These strategies can improve the success of an adoption and prevent extreme difficulties such as adoption disruption or even death. Careful supportive listening is an important tool in this endeavor.
- Bakwin, H. (1942). Loneliness in infants. American Journal of Diseases of Children, 63, 30–40.
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