Assessment of                                   Suitability for                                   17                      ...
370      Illingworth’s The Development of the Infant and Young Child            to match the abilities and temperament of ...
Assessment of Suitability for Adoption       371           the mother may suffer physical, emotional and financial stress ...
372      Illingworth’s The Development of the Infant and Young Child            to objects and finger–thumb apposition. He...
Assessment of Suitability for Adoption       373           their neighbours and relatives see the child. They may be respe...
374      Illingworth’s The Development of the Infant and Young Child            flu-like symptoms, skin rashes, tonsured h...
Assessment of Suitability for Adoption       375           the adoption for ensuring the long-term success of this family ...
376      Illingworth’s The Development of the Infant and Young Child             8. Alcohol dependence: Previously alcohol...
Assessment of Suitability for Adoption             377            10. Rowe J. Parents, Children and Adoption. London: Rout...
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Sample chapter illingworth’s the development of the infant and young child normal and abnormal by nair to order call sms at +91 8527622422

  1. 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 desirableChapter17.indd 369 09/08/12 2:46 PM
  2. 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 should17 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’:Chapter17.indd 370 09/08/12 2:46 PM
  3. 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 approachChapter17.indd 371 09/08/12 2:46 PM
  4. 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 be17 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 whenChapter17.indd 372 09/08/12 2:46 PM
  5. 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 haveChapter17.indd 373 09/08/12 2:46 PM
  6. 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 child17 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 beforeChapter17.indd 374 09/08/12 2:46 PM
  7. 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.26Chapter17.indd 375 09/08/12 2:46 PM
  8. 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. References17 1. Gould F. Stress in Children. London: Churchill; 1968. 2. Schreier SS, Heinrichs N. Parental fear of negative child evaluation in child social anxiety. CHAPTER Behav Res Ther. 2010;48(12):1186–93. 3. Polanczyk G, Moffitt TE, Arseneault L, et al. Etiological and clinical features of childhood psychotic symptoms: results from a birth cohort. Arch Gen Psychiatry. 2010;67(4):328–38. 4. Committee on adoption and dependent care. The role of the paediatrician in adoption with reference to ‘the right to know’. Pediatrics. 1977;60:378. 5. Kreider RM, Cohen PN. Disability among internationally adopted children in the United States. Pediatrics. 2009;124(5):1311–8. 6. Glidden LM, Johnson VE. Twelve years later: adjustment in families who adopted children with developmental disabilities. Ment Retard. 1999;37(1):16–24. 7. Glidden LM, Pursley JT. Longitudinal comparisons of families who have adopted children with mental retardation. Am J Ment Retard. 1989;94(3):272–7. 8. McGlone K, Santos L, Kazama L, Fong R, Mueller C. Psychological stress in adoptive parents of special-needs children. Child Welfare. 2002;81(2):151–71. 9. Kornitzer M. Adoption. London: Putnam; 1976.Chapter17.indd 376 09/08/12 2:46 PM
  9. 9. Assessment of Suitability for Adoption 377 10. Rowe J. Parents, Children and Adoption. London: Routledge and Kegan Paul; 1966. 11. Tizard B. Adoption: A Second Chance. London: Open Books; 1977 12. Wolkind S. Medical aspects of adoption and foster care. Clin Dev Med. No. 74. London: Heinemann. 13. Jenista JA. Special topics in international adoption. Pediatr Clin North Am. 2005;52(5):1479– 94, ix. 14. Chambers J. Preadoption opportunities for pediatric providers. Pediatr Clin North Am. 2005;52(5):1247–69, v-vi; 15. Jones VF. Committee on early childhood, adoption, and dependent care. comprehensive health evaluation of the newly adopted child. Pediatrics. 2012;129(1):e214–23. 16. Nicholson LA. Adoption medicine and the internationally adopted child. Am J Law Med. 2002;28:473–90. 17. Tieman W, van der Ende J, Verhulst FC. Psychiatric disorders in young adult intercountry adoptees: an epidemiological study. Am J Psychiatry. 2005;162(3):592–8. 18. Patterson CJ. Children of lesbian and gay parents: psychology, law, and policy. Am Psychol. 2009;64(8):727–36. 19. Schor EL. American Academy of Pediatrics Task Force on the Family. Family pediatrics: report of the task force on the family. Pediatrics. 2003;111(6 Pt 2):1541–71. 20. Ahmann E. Working with families having parents who are gay or lesbian. Pediatr Nurs. 1999;25(5):531–5. 21. Committee on Psychosocial Aspects of Child and Family Health, American Academy of Pediatrics. Coparent or second parent adoption by same-sex parents. Pediatrics. 2002;109:339–40. 22. Johnson DE. International adoption: what is fact, what is fiction, and what is the future? Pediatr Clin North Am. 2005;52(5):1221–46, v. 23. Bennett RL, Motulsky AG, Bittles A, et al. Genetic counselling and screening of consanguineous couples and their offspring: recommendations of the National Society of Genetic Counselors. J Genet Couns. 2002;11:97–120. 24. Tsuang MT, Owen MJ. Molecular and population genetics of schizophrenia. Neuropsychopharmacology – 5th Generation of Progress. 2008 American College of Neuropsychopharmacology, 5034-A Thoroughbred Lane, Brentwood, TN 37027. 25. McGuffin P, Rijsdijk F, Andrew M, Sham P, Katz R, Cardno A. The heritability of bipolar affective disorder and the genetic relationship to unipolar depression. Arch Gen Psychiatry. 2003;60(5):497–502. 26. Merikangas KR, Pine D. Genetic and other vulnerability factors for anxiety and stress disorders. 5th Generation of Progress. 2008 American College of Neuropsychopharmacology, 5034-A Thoroughbred Lane, Brentwood, TN 37027. CHAPTER 27. Tsuang D, Faraone SV, Tsuang MT. Psychiatric Genetic Counseling. 4th Generation of Progress. 2000 American College of Neuropsychopharmacology, 5034-A Thoroughbred Lane, Brentwood, TN 37027. 17Chapter17.indd 377 09/08/12 2:46 PM