top of page

Editorials for Clinical Practice

CHADIS Co-Director and President, Dr. Barbara Howard is a regular contributor to the Behavioral Consult column of Pediatric News and an Assistant Professor of Pediatrics at The Johns Hopkins University School of Medicine.


Dr. Howard is a developmental-behavioral pediatrician trained by Dr. T. Berry Brazelton at Harvard University. She is a national speaker on child behavior problems and is a past president of the Society for Developmental and Behavioral Pediatrics. She was a contributing author for Bright Futures™, Diagnostic and Statistical Manual for Primary Care (DSM-PC) and Bright Futures in Practice: Mental Health and has served on national committees of the American Academy of Pediatrics.

Adoption and Its Challenges

Barbara Howard, MD

When people think about adoption, they often envision a childless couple adopting an American baby unrelated to them but of the same race, with the hope of offering a better life to the child of an unwed mother. While this type of adoption does occur, it is hardly the norm in the United States today, where 1.6 million, or 2.5% of all children, are adopted.


By far, the most common scenario today is an intrafamily adoption, in which grandparents or aunts and uncles officially take over child-rearing from an absent or incapable parent.


Common, too, are adoptions by a stepparent, sealing the bond of responsibility that comes with the merging of a blended family.


Even among nonfamilial adoptions, only about half actually involve the taking in of an American baby. There was a time when many young women unprepared for parenthood put their healthy babies up for adoption. Now, many of those pregnancies end in abortion and more young single women who do decide to give birth decide to raise their children themselves.


Now, American children in the adoption pool are very different than they were, say, 25 or 30 years ago. Many are exposed to drugs in utero, and even more are born to mothers who used alcohol throughout their pregnancies, with dangerous consequences for their babies. These children typically have learning disabilities and/or strong family histories of psychiatric disorders. Not uncommonly, they have serious medical problems such as congenital heart defects, spina bifida, cerebral palsy, or severe seizure disorders.


Of course, these children very much need loving homes, and many couples yearn to provide just that. However, I have rarely seen a young childless couple seeking to adopt an American child who looks like them who had a realistic view of what to expect. They can be quite unprepared for the fact that many adopted children come carrying quite a load of genetic and intrauterine baggage.


Separate challenges lie ahead for increasing numbers of would-be parents who go overseas to adopt. In 2004, 13% of all adopted children in the United States were foreign-born; 25% of these children are from Korea and an additional 25% are from other Asian countries. These adoptions can be expensive and inconvenient and require special consideration of cultural issues. Foreign-born children may not closely resemble their adoptive parents and may benefit from thoughtful exposure during their lives to their culture of origin.


Still, my experience has been that these adoptions almost always work out very well. The children, mostly girls, tend to be healthy, and they adjust remarkably well, even after a short time in this country.


Children from certain countries, such as Russia and Romania, may have been exposed to intrauterine alcohol. They are more likely than are children adopted from Asia to suffer from medical problems and possibly neglect. Children born in some South American countries may be malnourished and may experience developmental delays.


With well-prepared parents, these problems can be accommodated, and sometimes overcome. Nonetheless, they pose powerful challenges to naïve first-time parents impulsively driven to “do good,” but not knowing the level of dedication and expense that might entail.


Regardless of the type of adoption, the institution has, at its core, legal issues. I was part of the American Academy of Pediatrics task force that recommended that homosexual couples be allowed to adopt children. Part of our mission was to ensure that legal rights would be extended to the nonbiologic parent in situations of inheritance, hospital visitation, and custody following the death of a biologic parent. These issues are important for every adoptive family.


Beyond legalities, adoption includes psychological issues as well, both for the adopting parents and the child.


It is a very serious commitment for a relative, stepparent, infertile couple, or benevolent family to adopt a child. They may have misgivings at first, or fears about the future. I think it is important to reassure adoptive families from the start that you will be a partner in the journey. But I also stress that this will be hard work, particularly if the child has special needs.


Unless they are very small, children involved in intrafamily adoptions may grieve the loss of their biologic parent(s), whether the loss was due to death, dysfunction, or other factors. Adopted children almost always wonder at some point, “What was so wrong with me that my parents abandoned me?”


All adopted children need and deserve two things. They need to be told the truth, early and often, about where they came from and why. And they need to be reassured, in words and in everyday life, that their adoptive parents love them and are here to stay.


Children adopted very young tend to do extremely well with these issues as long as honesty is constant.

Older children who may have been shuffled between homes and are scarred by abuse or neglect may really test the bounds of this commitment by acting truly awful to see if they will be thrown out. Parents need to know this may happen and be prepared for it. Denying that there are problems will only exacerbate them. Help these families access counseling and be there for them when the going gets tough.


Sometimes adoptive parents expect children to be grateful for the home they have provided. They can be startled and disappointed to realize that kids don't react that way at all. In fact, adopted children, just like all children, can be self-absorbed and demanding. The same limit-setting needs to be applied in adoptive families as it is in biologic families, along with extra love and reassurance.


Even in children adopted very young, problems may arise in adolescence, when rebellion kicks in and children may begin to display characteristics that adoptive parents fear was present in their biologic parents. They may see mild signs of dishonesty or irresponsibility that are normal; or worse, signs of social deviancy that may make them overreact to stamp it out or want to distance themselves from children “not their own.”

I remind them that parenthood is never predictable. Plenty of biologic parents see these exact characteristics in their natural children. Rare is the family tree that lacks a few weak branches. And yet, the obligations and attachments of parenthood must prevail.


Again, it's important to help such families find the support they need to carry on.


Of course, many of us are blessed to have in our practices what I call the “sainthood” parents: people who take in one special needs child after another with eyes wide open to the difficulties that may lie ahead. They are often foster parents first, forming lasting bonds with children they pull into their family sphere, lovingly and with full acceptance. They get quite adept at working the system and meeting their children's medical and emotional needs.


I salute them, as I do all adoptive parents who fully integrate children into their homes and hearts, receiving in return the joys and challenges inherent in “family,” in the broad sense that term has come to define.  


Dr. Howard’s contribution to this publication is as a paid expert to Frontline Medical Communications. E-mail her at

bottom of page