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## Complete Summary

#### GUIDELINE TITLE

Families and adoption: the pediatrician\'s role in supporting
communication.

#### BIBLIOGRAPHIC SOURCE(S)

Borchers D. Families and adoption: the pediatrician\'s role in
supporting communication. Pediatrics 2003 Dec;112(6 Pt 1):1437-41. \[16
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14654626)

#### GUIDELINE STATUS

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years
by the authoring body, at which time a recommendation is made that the
policy be retired, revised, or reaffirmed without change. Until the
Board of Directors approves a revision or reaffirmation, or retires a
statement, the current policy remains in effect.

### COMPLETE SUMMARY CONTENT

 SCOPE\
 METHODOLOGY - including Rating Scheme and Cost Analysis\
 RECOMMENDATIONS\
 EVIDENCE SUPPORTING THE RECOMMENDATIONS\
 BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS\
 QUALIFYING STATEMENTS\
 IMPLEMENTATION OF THE GUIDELINE\
 INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT
CATEGORIES\
 IDENTIFYING INFORMATION AND AVAILABILITY\
 DISCLAIMER

### SCOPE

#### DISEASE/CONDITION(S)

-   Adoption

-   Medical, developmental, and mental health illnesses

#### GUIDELINE CATEGORY

Evaluation\
Management\
Prevention

#### CLINICAL SPECIALTY

Family Practice\
Pediatrics

#### INTENDED USERS

Physicians

#### GUIDELINE OBJECTIVE(S)

To provide information for pediatricians about adoption so this
knowledge may be shared with adoptive families

#### TARGET POPULATION

Adopted children and their families

#### INTERVENTIONS AND PRACTICES CONSIDERED

1.  Comprehensive medical and psychological evaluation and history

2.  Evaluation of behavioral and emotional concerns and initiation of
    therapy

3.  Age-appropriate handling of developmental issues of adoption with
    the child

4.  Understanding the issues of loss for the adoption triad- the child,
    the adoptive family, and the biological family

5.  Addressing issues of race, ethnicity, and culture differences

6.  Supporting special issues of kinship adoption

7.  Providing information regarding community resources, support groups,
    locating biological families, and mental health professionals

8.  Modeling positive adoptive language for the families

#### MAJOR OUTCOMES CONSIDERED

Not stated

### METHODOLOGY

#### METHODS USED TO COLLECT/SELECT EVIDENCE

Hand-searches of Published Literature (Primary Sources)\
Hand-searches of Published Literature (Secondary Sources)\
Searches of Electronic Databases

#### DESCRIPTION OF METHODS USED TO COLLECT/SELECT THE EVIDENCE

Not stated

#### NUMBER OF SOURCE DOCUMENTS

Not stated

#### METHODS USED TO ASSESS THE QUALITY AND STRENGTH OF THE EVIDENCE

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE EVIDENCE

Not applicable

#### METHODS USED TO ANALYZE THE EVIDENCE

Review

#### DESCRIPTION OF THE METHODS USED TO ANALYZE THE EVIDENCE

Not stated

#### METHODS USED TO FORMULATE THE RECOMMENDATIONS

Expert Consensus

#### DESCRIPTION OF METHODS USED TO FORMULATE THE RECOMMENDATIONS

Not stated

#### RATING SCHEME FOR THE STRENGTH OF THE RECOMMENDATIONS

Not applicable

#### COST ANALYSIS

A formal cost analysis was not performed and published cost analyses
were not reviewed.

#### METHOD OF GUIDELINE VALIDATION

Peer Review

#### DESCRIPTION OF METHOD OF GUIDELINE VALIDATION

Not stated

### RECOMMENDATIONS

#### MAJOR RECOMMENDATIONS

**Changing Picture of Adoption**

There are various types of adoption. In domestic adoptions and some
intercountry adoptions, biological families may have continued contact
of varying degrees with the child for whom they have chosen an adoption
plan, ranging from complete confidentiality to unlimited direct contact.
A child may be adopted into a family of the same ethnicity and/or race
or into a family with members of different groups. Many children are
adopted after having spent time with a family through the foster care
system, often after lengthy stays in multiple homes. Kinship permanency
may be established by grandparents, aunts or uncles, siblings, or other
relatives through legalized guardianships or adoptions or through
informal nonlegalized agreements within a family. Intercountry
adoptions, which also may involve adoptions across ethnic and racial
lines, also are increasing in number. See the original guideline
document for more details.

**Medical Issues**

Children who join their families through adoption must have a
comprehensive medical evaluation to identify medical needs. Standards
for the medical care of children in foster care have been published by
the American Academy of Pediatrics (AAP) and District II of the AAP. For
children adopted internationally, this evaluation includes but is not
limited to screening tests and assessment of immunization status as
recommended by the AAP Committee on Infectious Diseases in the *Red
Book*. Acute and chronic medical problems, vision and hearing loss, and
developmental delays should be identified and addressed. Behavioral and
emotional concerns need to be evaluated aggressively with appropriate
therapy initiated. Pediatricians should help families in accessing
mental health and developmental services when needed.

Pediatricians may be asked to review preadoption medical and mental
health records to help families understand the current and potential
future medical, developmental, and mental health needs of children they
plan to adopt. This may include conditions related to complications of
pregnancy, poor nutrition, prematurity, lack of prenatal care, and
genetic diseases. In counseling families, all attempts should be made to
obtain a complete medical and psychological history of the child,
particularly in assessing potential special needs of a child. Through
comprehensive preplacement assessment, parents should assess their
resources and abilities to meet a particular child´s needs. With the
help of pediatricians, families then may be better able to negotiate
adequate adoption subsidies including but not limited to educational
needs and mental health insurance coverage.

**Developmental Understanding of Adoption**

Although parents and children gain so much in becoming a part of an
adoptive family, children who join their families through adoption often
experience issues of loss relevant to adoption. Although these feelings
of loss may be more rooted in societal expectations of genetically based
attachments rather than in any inherent biological loss, they
nonetheless are experienced by many adopted people.

Just as a child´s thinking and self-concept change at various stages of
development, so does a child´s understanding of the meaning of adoption.
See the original guideline document for additional information on
toddler, preschool, elementary school, and adolescent attitudes and
behavior.

**Communicating About Adoption with Children**

Even before a child understands the words \"adoption,\" \"adopted,\" and
\"biological family\" or \"birth family,\" it is important that these
words be a part of a family´s natural conversation, whether the adoption
is open or confidential, kinship, or foster-adoptive placement. Families
should be discouraged from \"waiting until just the right minute\" to
tell children that they were adopted, because this may leave children
feeling betrayed and wondering what else their parents may have hidden
from them. Children may also learn information from peers or neighbors,
which may impair the trust between parent(s) and child. It is important
to share with even very young children their adoption story, starting
with their birth, not the adoptive family´s initiation of the adoption
process. An honest approach in the discussion of a child´s biological
family and the adoption process will give a child permission to ask
questions or to make statements about adoption and at the same time will
take away the veil of secrecy that often implies that being adopted is a
negative condition.

Some information in a child´s past may be private or difficult for the
parent to share with the child. Open discussion with a child is
important in building bridges of trust and security within a family.
Even the most difficult information, such as previous sexual or physical
abuse or having been conceived in the context of rape or incest,
eventually should be shared with a child at a developmentally
appropriate age. The child and parents should be counseled regarding the
child´s privacy about facts pertinent to the adoption. The parents and
the child need to be cautioned that once information is shared, it
cannot be taken back. Parents should guide children in what they will
share with strangers, friends, and extended family. Facts shared with
children about their adoption should always be accurate, and adoptive
parents should admit when information is not available. As children age,
they should have control over telling their adoption history outside the
family. See the original guideline document for more details.

**Racial, Ethnic, and Cultural Differences**

Children adopted by parents of a different race, ethnicity, or cultural
background may have other concerns specific to their identities.
Families need to acknowledge openly the racial differences that exist
between their child and themselves. Relationships with others of the
same race or ethnic group, including adults and children, may be very
helpful to a child. Whenever possible, an adopted child should be given
the opportunity to learn more about the heritage of the country of his
birth or of his ethnic group. Role-playing with children with respect to
stereotypes and racist statements may help them to feel in control when
they encounter inevitable comments from strangers, friends, or extended
family members. Parents who have not experienced racism personally may
need to pay extra attention to teaching their children effective ways to
respond to racism. See the original guideline document for more details.

**Special Issues in Kinship Adoption**

For children who are placed for foster care or adoption within their
biological family, separation issues are lessened. At the same time,
these relationships present particular challenges for a family. There
may be a reluctance of other family members to confirm the adoptive
parents as the child´s actual parents, and reference may be made within
the family setting to a child´s \"real\" parents. Boundaries must be set
regarding the type of contact, timing, and granting of parental
responsibility to the biological parents.

It is important that pediatricians provide support to these families,
particularly in the area of validating the adoptive parents´ rights to
make decisions for the child. Kinship adoptive parents may be reluctant
to share with the child painful information involved in the
circumstances leading to the separation from the biological parents.
Failing to share the truth with the child will only lead to damaged
trust and increase anxiety for the child. The biological parents and
kinship adoptive parents must communicate about the sharing of
information and what language will be used, keeping in mind the child´s
developmental stage. Through contact with local child welfare agencies
and other community resources, financial assistance, respite care, and
support services for families with a kinship adoptive placement, whether
formal or informal, may be available.

**Searching for Biological Family and Cultural Ties**

As children age into adolescence and adulthood, adoptive children may
wish to seek out more information about their biological families.
Individuals who joined their families through international adoption may
choose to make a trip to the country of their birth. Domestic adoptees
may pursue reunification with biological relatives through a reunion
registry, may choose to reestablish ties in a lapsed open adoption, or
may develop a stronger interest in understanding kinship ties. Although
some adoptive parents may view their child´s searching for his or her
biological family as a sign of rejection, it is actually a sign of
healthy emotional growth in the search for an identity. All members of
the adoption triad may need the help of mental health professionals to
work through these situations. Pediatricians are encouraged to become
aware of local community resources for adoptive families, including
resources for locating information about biological families, support
groups, adoption conferences and services, and mental health
professionals.

**Modeling Positive Adoption Language**

Pediatricians are encouraged to model positive adoption language for all
families. Adoptive families are \"real\" families; siblings who joined a
family through adoption are \"real siblings.\" Biological parents do not
\"give up a child for adoption,\" which might imply to the child that he
or she was of less worth and was given away. Rather, they \"make an
adoption plan for a child.\" A biological mother should not be
identified as a \"natural parent,\" as this implies that adoptive
families are \"unnatural.\" A child´s racial identity, adoption, or
birth in another country should never be the identifying characteristics
for any child. It is never appropriate to ask how much a child \"cost.\"
In modeling positive adoption language, pediatricians can use vocabulary
that reflects respect and permanency about children and their families.

As more children each year become part of permanent families through
adoption, it is becoming increasingly important for pediatricians to be
aware of and knowledgeable about adoption. Pediatricians play an
important role in helping families deal with the differences, the
losses, and the many other issues surrounding the adoption of a child.
Pediatricians are encouraged to have a greater understanding about
adoption to be able to advise and support parents as they communicate
about adoption with their children. It is also important for a
pediatrician to remind families of the importance of forthright
communication about adoption. Open acknowledgment of the adoptive
relationship helps to nurture a child´s self-esteem as he or she grows
in the understanding of what it means to join a family through adoption.
Effective communication about adoption is important for the long-term
mental and physical health and well being of each child and family.

#### CLINICAL ALGORITHM(S)

None provided

### EVIDENCE SUPPORTING THE RECOMMENDATIONS

#### TYPE OF EVIDENCE SUPPORTING THE RECOMMENDATIONS

The type of supporting evidence is not specifically stated for each
recommendation.

### BENEFITS/HARMS OF IMPLEMENTING THE GUIDELINE RECOMMENDATIONS

#### POTENTIAL BENEFITS

-   Assistance for adoptive families in the various challenges they face
    with respect to adoption

-   Promotion of positive emotional growth within the family

-   Viewing the pediatrician is a source of ongoing advice and support
    for families when communicating with their adopted children

-   Long-term mental and physical health well being of the child and the
    family

#### POTENTIAL HARMS

Not stated

### QUALIFYING STATEMENTS

#### QUALIFYING STATEMENTS

The guidance in this report does not indicate an exclusive course of
treatment or serve as a standard of medical care. Variations, taking
into account individual circumstances, may be appropriate.

### IMPLEMENTATION OF THE GUIDELINE

#### DESCRIPTION OF IMPLEMENTATION STRATEGY

An implementation strategy was not provided.

### INSTITUTE OF MEDICINE (IOM) NATIONAL HEALTHCARE QUALITY REPORT CATEGORIES

#### IOM CARE NEED

Staying Healthy

#### IOM DOMAIN

Effectiveness\
Patient-centeredness

### IDENTIFYING INFORMATION AND AVAILABILITY

#### BIBLIOGRAPHIC SOURCE(S)

Borchers D. Families and adoption: the pediatrician\'s role in
supporting communication. Pediatrics 2003 Dec;112(6 Pt 1):1437-41. \[16
references\]
[PubMed](http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?cmd=Retrieve&db=pubmed&dopt=Abstract&list_uids=14654626)

#### ADAPTATION

Not applicable: The guideline was not adapted from another source.

#### DATE RELEASED

2003 Dec

#### GUIDELINE DEVELOPER(S)

American Academy of Pediatrics - Medical Specialty Society

#### SOURCE(S) OF FUNDING

American Academy of Pediatrics

#### GUIDELINE COMMITTEE

Committee on Early Childhood, Adoption, and Dependent Care, 2003-2004

#### COMPOSITION OF GROUP THAT AUTHORED THE GUIDELINE

*Committee Members*: Chet Johnson, MD (*Chairperson*); Deborah Ann
Borchers, MD (*Lead Author*); Kerry English, MD; Danette Glassy, MD;
Pamela High, MD; Judith Romano, MD; Moira Szilagyi, MD, PhD; Dennis L.
Vickers, MD, MPH; Peter Gorski, MD, MPA (*Past Committee Member*);
Donald Palmer, MD (*Past Committee Member*)

*Liaisons*: Patricia M. Spahr, MA, National Association for the
Education of Young Children; R. Lorraine Brown, RN, BS, Maternal and
Child Health Bureau; Ada White, LCSW, ACSW, Child Welfare League of
America, Inc; Claire Lerner, LCSW, Zero to Three

*Staff*: Mary Crane, PhD, MA

#### FINANCIAL DISCLOSURES/CONFLICTS OF INTEREST

Not stated

#### GUIDELINE STATUS

This is the current release of the guideline.

American Academy of Pediatrics (AAP) Policies are reviewed every 3 years
by the authoring body, at which time a recommendation is made that the
policy be retired, revised, or reaffirmed without change. Until the
Board of Directors approves a revision or reaffirmation, or retires a
statement, the current policy remains in effect.

#### GUIDELINE AVAILABILITY

Electronic copies: Available from the [American Academy of Pediatrics
(AAP) Policy Web
site](http://aappolicy.aappublications.org/cgi/content/full/pediatrics;112/6/1437).

Print copies: Available from American Academy of Pediatrics, 141
Northwest Point Blvd., P.O. Box 927, Elk Grove Village, IL 60009-0927.

#### AVAILABILITY OF COMPANION DOCUMENTS

None available

#### PATIENT RESOURCES

None available

#### NGC STATUS

This NGC summary was completed by ECRI on May 20, 2004. The information
was verified by the guideline developer on June 23, 2004.

#### COPYRIGHT STATEMENT

This NGC summary is based on the original guideline, which is subject to
the guideline developer\'s copyright restrictions. Please contact the
Permissions Editor, American Academy of Pediatrics (AAP), 141 Northwest
Point Blvd, Elk Grove Village, IL 60007.

### DISCLAIMER

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© 1998-2008 National Guideline Clearinghouse

Date Modified: 11/3/2008