(Received May 15; revision accepted for publication September 26, 1967.)
ADDRESS: School of Public Health, University of Michigan, 1 1 11 E. Catherine Street, Ann Arbor,
Michigan 48104. . .
..
. .. Pimwrmcs, Vol. 41; No. 2, ‘February 1968
519
PEDIATRIC
CONSULTATION
IN ADOPTION
PRACTICE
Donald C. Smith, M.D.
School of Public Health, Universttj of Michigan, Ann Arbor, Michigan
ABSTRACT. Certain recent trends and develop-ments in the field of adoption have emphasized the role of the pediatric consultant in adoption
prac-tices. These changes include a steady increase in
the number of adoption placements each year, a
signfficant decrease in the ratio of adoptive parents to adoptable children, a broadening of the concept of adoptability, and an acceptance by both the
agency and adoptive parents of the child with spe-cial problems and needs.
By providing consultant services to an adoption agency, a pediatrician assumes important and
satis-fying responsibilities that not only test his diagnos
tic skills and knowledge of the natural history of childhood disease, but also demand an understand-ing of current trends and developments in adop-tion practice, the role of community agencies in
adoption, and insight into the consultation process
itself. The role of consultant gives the pediatrician an exceptional opportunity to contribute to the ef-fectiveness of the adoption agency and thus to the
welfare of children in his community. Pediatrics,
41 :519, 1968, ADOPTION, PEDIATRIC PRACTICE,
CON-SULTATION.
I
NBEASINGLY the pediatrician is asked toserve as a specialized medical consul-tant to a variety of community agencies
and organizations, both public and private. Of particular significance are adoption agencies, which afford him an opportunity to use his specialized knowledge of children
and their needs and to participate in a gen-eral community responsibility.
Most adoption agencies retain the ser-vices of a pediatric consultant on some kind of part-time basis. The responsibilities as-sumed by these physicians vary from
agen-cy to agency. In smaller agencies the pedia-trician may serve in a purely clinical capac-ity in assessing the medical problems of
in-dividual children awaiting adoption. In agencies with larger case loads he is likely to be in a position to utilize not only clini-cal skills but also to be actively involved in
shaping the agency’s short- and long-term
policies and practices. Both of these
situa-tioris, however, give the pediatrician an op-portunity to contribute in a number of
ways to the adoption process. To discharge this responsibility capably, the pediatrician
needs both knowledge of current trends in
the field of adoption and understanding of
the particular areas in which he can most
effectively give assistance, provide
supervi-sion, and aid the work of the adoption
agency.1
TRENDS IN ADOPTION
Within the past 5 years, the number of
adoptions has increased by approximately
6% yearly. Today there are nearly 2 million
adopted children in the United States. In 1965, an estimated 142,000 children were
placed for adoption-more than three times the number adopted in 1941-and, of these, 54% were adopted by nonrelatives. The percentage of adoptions arranged by social agencies has also increased. The number of agency and independent adoptions were nearly equal in 1951; by 1965, however,
so-cial agencies handled 69% of adoptions by nonrelatives.2
Although the number of children being adopted and the number of applicants
con-tinues to rise, the ratio of adoptive parents to adoptable children is declining. The ratio
is now much less than the formerly report-ed 10 to 1, and in some communities is even less than 1 to 1. This decline is attrib-uted to high illegitimacy rates and to
ad-dition, early marriage and the recent gains in the treatment of infertility afford married
couples a greater chance of producing their
own children.
Both social agencies and adoptive
appli-cants have significantly changed their con-cepts of adoptability and their acceptance of the hard-to-place child. In an effort to
adapt to these changes, adoption agencies have modified their philosophies on the placement of children with special
prob-lems and needs: the handicapped, the ra-cially mixed, and children from minority groups. At the same time, criteria used in considering adoptive applications, includ-ing the required length of time mar-ried, proof of natural or adopted children in the applicant’s family, and the lime
be-tween application and home study, have been adjusted. Adoptive applicants have also broadened their attitudes. Their expec-tations are now more like those of natural parents.#{176}
RESPONSIBILITIES OF THE CONSULTANT
In serving as consultant to an adoption
agency, the pediatrician must distinguish those responsibilities to the agency from his more traditional role with children and
families in private practice. Consultation may be defined as a process in which the
consultant shares his knowledge, skill, and experience to the end that planning can be done and action taken. The responsibility for decision and action remains with the
in-dividual or agency seeking consultation. A
pediatric consultant to an adoption agency is primarily responsible to and for the child, and secondarily to the agency who shares
its responsibilities for the health and wel-fare of the child. Pediatric consultation forms an integral, indispensable part of the adoption process. As a consultant, the
pedi-atrician’s responsibilities include : medical clearance prior to placement, assistance in the selection of adoptive parents, consulta-lion with adoptive parents, guidance in the
0 For further elaboration of adoption trends and
practices see references 1 and 2.
use of community facilities, participation in staff development programs, liaison with the community physician, development of medical and hospital policies, and evalua-lion of current adoption procedures.
Medical Clearance Prior to Placement
Routine medical supervision of the child
is usually best provided by the staff of the hospital of delivery, and, following
place-ment in a foster home, by a pediatrician
se-lected by the agency or by the foster
par-ents’ family physician. The pediatric con-sultant sees that the care provided is ade-quate both in quantity and quality and pro-vides overall supervision of the agency’s
medical care program. He reviews the med-ical records of all children prior to their placement and examines personally those children who present unusual or
compli-cated medical problems. In both situations he reviews and analyzes the data available and requests any other needed information. He may decide that further medical studies are indicated or that a longer period of
ob-servation is required; in these instances, he can help the casework staff make the neces-sary arrangements as expeditiously as possi-ble.
In an effort to limit the number of mater-nal figures to whom the child must adjust,
some agencies place many of their infants in adoptive homes directly from the
nur-sery. When this practice is followed, the
agency should ask a pediatrician to carry
out a preplacement study during the in-fant’s first few days of life, recognizing that this appraisal will be limited to assessment of major anomalies and gross neurological behavior.
Purpose and Scope of the Preplacement
Medical Examination
ARTICLES
of the health background of the natural
parents, and (2) complete health appraisal of the child.
Much of the information concerning pre-vious medical histories can be secured by
the experienced caseworker through skillful
interviewing and by recourse to hospital records. The data obtained, however, are often incomplete or even contradictory and may have to be reevaluated by the
pedia-tric consultant before they can be useful to the agency staff.
The initial health appraisal should in-elude an evaluation and interpretation of the birth and neonatal history and a thor-ough physical examination complemented
by appropriate laboratory studies. In infan-cy these include hemoglobin determination, P-A film of the chest, serologic test for
syphilis, blood test for phenylketonuria, and urinalysis. Such an appraisal provides the basis for a plan of medical care. Ap-propriate arrangements can then be made to deal with any special medical needs or, if
there are none, for routine health supervi-sion while the child is under the agency’s
care.
Under certain circumstances, a psy-chometric examination should be part of the preplacement medical study. The need for such a procedure is best judged on an
individual basis by the pediatric consultant, but it is indicated when the family history includes familial mental deficiency or when
the observations of the physician, casework-er, or foster parents suggest some distur-bances in the child’s development. Since
testing the intelligence of infants has lim-ited meaning, it would seem preferable to classify performances of children under 3
years old in such broad categories as “aver-age,” “above average,” or “below average.”
Reexamination after 3 to 6 months (with postponement of placement) should be
considered whenever the test results are “below average” or whenever the family
history strongly suggests “familial mental deficiency,” regardless of test results. The results of such reexaminations are then
in-terpreted by the pediatric consultant in
conjunction with the caseworker and the psychologist.
The pediatric consultant assists in pre-paring the preplacement health appraisal reports, which the agency shares with the
adoptive parents and their physician. At the time the adoption is made final (usually a year after placement in the adoptive home), the physician who has cared for the
child during this interim provides the agen-cy with a summary of his observations.
Special Problems in the Placement of Handicapped Children
Gradual change in the concept of the
adoptable child both among social agencies and adoptive applicants would seem to in-dicate that now only a limited number of diseases and disabilities militate against adoption placement. The growing number of handicapped children available for
placement is of import to the pediatrician for he can take the lead in influencing
posi-tive community attitudes toward their adoption and can support and counsel par-ents who choose to adopt a handicapped child. While it is not always possible to identify those factors that are most crucial in influencing community attitudes toward this kind of problem, one obvious and di-rect means of encouraging adoption of the
handicapped is through contacts with
medi-cal colleagues, especially those engaged in
pediatric practice.
The important criterion is that the child should have the physical and intellectual
background to fulfill reasonable
expecta-lions of the adoptive parents. The variety
and complexity of handicapping conditions observed in childhood add to the impor-tance of the preplacement medical study and render pediatric consultation decisive
to successful placement. When the child has special medical problems, these should
be defined and their implications for future growth and development identified.
Antici-pated needs for special medical and
educa-tional services should be outlined as
placement until he has followed the child
closely for a certain period of time. In such circumstances, the need for further study
should be emphasized so the agency staff will understand why placement may not yet be desirable.
Assistance in Selection of Adoptive Parents
While the major responsibility for the
Se-lection of adoptive parents is that of the agency and the internist who examines the couple, the pediatric consultant is often asked to evaluate and interpret medical findings for the agency staff. What is
im-portant to the agency is not a health history completely free of disease and disability
but rather that neither the husband nor the wife has a physical or emotional illness that
is likely to reduce life expectancy, interfere with parental duties to a significant degree,
or produce unmanageable financial prob-lems. If the agency decides that the family physician’s records indicate serious prob-lems, they may ask the pediatric consultant to review the entire record on this family. The problem of age must also be consid-ered. Although it is reasonable that the
adoptive parents be within the age range usual for new parents, the changing ratio of prospective adoptive parents to children
available for adoption makes rigid age re-quirements unrealistic and unnecessary. In
advising agency staff on the selection of adoptive parents, the pediatric consultant is often confronted with opposing desires. It is not always easy to separate what the par-ents want from what the agency must do to protect the child. An example, known to the
author, of this kind of conflict involved the application for an adoptive child from a couple, one of whom was known to have multiple sclerosis. The adoptive parents’ family physician strongly supported their
application on the basis that placement of a
child in their home would aid the wife’s feeling of well-being. The stage to which the illness had advanced was such that the
pediatric consultant felt that placement in
this home would not be in the best interests of the child. Needless to say, this decision
had to be carefully interpreted to everyone
concerned.
Consultation with Adoptive Parents
When the preplacement health appraisal of the child discloses the presence of special
medical problems, the pediatric consultant can interpret these to the adoptive parents and, upon request, to their family
physi-cian. This counseling requires both time and skill. Discussion of the child’s health problems, present and predictable, with an
opportunity for the adoptive parents to ex-press their own feelings, will do much to promote their acceptance of the child and
his limitations; it will also help them to un-derstand and respond to his needs for long-range health supervision and care.
Guidance in the Use of
Community Facilities
The pediatric consultant can guide the agency staff in the effective use of commu-nity health facilities, including public health and visiting nurse services, diag-nostic clinics, and institutional facilities. Children awaiting adoption and children in foster homes may be eligible for health ser-vices made available by new programs such
as Medicaid, Maternity and Infant Care, and Children and Youth projects, and by the Elementary and Secondary School
Edu-cation Act.4 The pediatric consultant should be familiar with these new and important
legislative acts and their implementation in
his own state. He may act as a direct liaison
between agency staff and the staff of the
community agencies responsible for the ser-vices which they make available.
Participation in Staff Development Programs
Through discussions with caseworkers on
interdiscipli-523
nary sessions involving the joint participa-lion of the casework staff, consultant pedia-trician, and consultant psychologist can be
useful in development of new policies and procedures.
Liaison with Physicians in the Community
The pediatric consultant is able to bring to the adoption agency staff new informa-tion and ideas from his field, and he is able to interpret to his medical colleagues at medical society and hospital staff meetings
what is going on in the field of adoption: current trends, effects of recent legislation,
and needs for further legislation. Thus, he is able to take the lead in formulating corn-munity attitudes to the new developments in adoption.
Development of Medical and
Hospital Policies
As a hospital staff member, the
pediatri-cian can help develop policies that insure medical and social care for the unmarried mother and her child which is adequate both in amount and in quality. He can be
instru-mental in assisting hospital administrators to formulate guidelines that not only will bring hospital policies in accord with state laws relating to the placement of children, but also will offer maximum protection to the unmarried mother and her child. With the cooperation of the obstetrical staff, a program can be established that will offer
the unmarried mother psychological coun-seling while she is still in the hospital. Pro-phylaxis and management of potential or
actual trauma could be included as a part
of this program.
Evaluation of Current Adoption Procedures
Pediatric consultants have a unique
op-portunity to take part in planning and
con-dueling research designed to measure the
success of current adoption practices from the viewpoints of the adopted child, the
adopting parents, and society at large. Re-ported studies of long-term results of
adop-lion placement are all retrospective in na-ture. We need instead well designed,
pro-spective studies that will examine the rela-live effectiveness of current adoption prac-tices and will enlarge our understanding of their long-term effects.
SUMMARY
Certain recent trends and developments in the field of adoption have emphasized
the role of the pediatric consultant in adop-lion practices. These changes include a steady increase in the number of adoption placements each year, a significant decrease in the ratio of adoptive parents to adopt-able children, a broadening of the concept of adoptability, and an acceptance by both the agency and adoptive parents of the child with special problems and needs.
By providing consultant services to an
adoption agency, a pediatrician assumes important and satisfying responsibilities
that not only test his diagnostic skills and
knowledge of the natural history of
child-hood disease, but also demand an
under-standing of current trends and
develop-ments in adoption practice, the role of corn-munity agencies in adoption, and insight into the consultation process itself. The role
of consultant gives the pediatrician an
ex-ceptional opportunity to contribute to the effectiveness of the adoption agency and thus to the welfare of children in his
com-munity.
REFERENCES
1. Adoption of Children, ed. 2. Evanston, Illinois:
The American Academy of Pediatrics, 1967.
2. Gallagher, U. M.: Adoption: Current trends. Welfare in Review, 5: 12, February, 1967.
3. Hylton, L. F. : Trends in adoption, 1958-1962. Child Welfare, XLIV:377, 1965.
4. U.S. Department of Health, Education and
Welfare: Welfare and Child Health
Provi-sions of the “Medicare” Act. Welfare in
