Supporting Parents So That They Can Support Their Internationally Adopted Children: The Larger Challenge Lurking Behind the Fatality Statistics:

We are pleased to be asked to comment on the letter by Miller and colleagues. Adoptive parents in the United States are embracing the option of international adoption on an unprecedented scale. Numbers have increased sharply in the past decade as families increasingly adopt children who have experienced high numbers of pre- and postnatal threats to normal brain and behavioral development (Gunnar, Bruce, & Grotevant, 2000; Johnson, 2000). We share Miller and colleagues’ shock and horror that there have been any fatalities of children at the hands of their adoptive parents, let alone 18 fatalities in the past 10 years. However, though they call for professionals to “be alert to the warning signs” that adoptive parents may be at risk of abusing their children, we believe that this emphasis diverts attention from the larger concern that many parents are struggling to manage their children’s significant developmental and behavioral problems in the face of meager access to professional support. As Miller and colleagues note, the problems for these families begin with the adoption process. We agree that “it is incumbent on all practitioners to educate prospective parents for the challenges they might face.” However, who will inform the prospective parents of these risks? Adoption agencies should, certainly. However, even the best agencies struggle with the conflict between adequately informing prospective parents of potential risks and the desire to obtain adoptive placements for needy children. Pediatricians are typically a source of sound, independent advice; however, relatively few in the United States are trained in international adoption concerns. And then we come to the most challenging concern raised but not addressed by Miller and colleagues: Who do these parents turn to when they receive a child whose issues threaten to overwhelm them? One would hope they could turn to their adoption agency. However, postadoption services in most agencies are either absent or modest at best. And, though the number of international adoption clinics and pediatricians is growing, they are not available in all states and exist primarily in major metropolitan areas. Although some parents do travel to have their children evaluated at these clinics, the time and expense of such trips make this option prohibitive for many families. Thus, parents go to their local pediatrician, and it is unfortunately true that many are still told by these pediatricians not to worry, that love will make all the problems they are describing go away with time. One would hope that the school system would be a helpful resource for these struggling parents; however, parents are often told the child should not be evaluated for special services until the child is proficient in English. Parents report these conversations with school officials even when their child was adopted several years before beginning school. Psychological services for children and families are equally problematic. Compounding the crisis we face in the United States because of a shortage of clinical child psychologists and psychiatrists is the fact that few of these mental health professionals have received training in issues particular to international adoption in general and postinstitutionalized children specifically. Furthermore, insurance rarely pays for more than a few visits with a behavioral or mental health professional, even when a child’s emotional or behavioral problems are serious. As is the case for some birth families, social services professionals in Minnesota and Wisconsin have told us that some parents who adopt internationally have felt compelled to terminate their parental rights to access services their child’s needs. Finally, irrespective of the difficulty in finding qualified guidance, there is as yet no consensus on how to describe the complex developmental landscape of international adoption. As described by Miller and colleagues, children arriving in their families after prolonged periods of institutional neglect and privation often present with significant developmental delays and behavior problems (Albers, Johnson, Hostetter, Iverson, & Miller, 1997; Johnson et al., 1992; Miller, Kiernan, Mathers, & Klein-Gitelman, 1995);, however, most show “remarkable catch-up growth and development within months of arriving home.” The resilience side of the international adoption story is often emphasized by researchers (e.g., van Ijzendoorn & Juffer, 2005) and adoption professionals. As long as this is the story they are told, it is easy to see how families seeking to adopt internationally might believe that despite some risk their adoption story will have a happy ending. Amidst the good news of international adoption, we somehow have to be able to clearly inform parents of the very real potential they face of adopting a child who will have persistent difficulties regulating attention and behavior, forming secure emotional relationships with parents, and performing academically without special education and tutorial support (Gunnar & van Dulmen, 2007; O’Connor & Rutter, 2000; O’Connor & Zeanah, 2003; Roy, Rutter, & Pickles, 2004; Rutter, Kreppner, & O’Connor, 2001; van Ijzendoorn & Juffer, 2005, 2006). Thus we argue that underlying the horrific tales of child fatalities is a much larger issue involving the failure of multiple systems to provide the support and help needed by families who adopt internationally. Although no one can argue with the need for professionals to be sensitive to signs that a parent is likely to abuse his or her child, emphasizing the need to search out the parents who cannot cope with the sometimes-excruciating load of managing a child with serious cognitive and emotional issues obscures the larger point. More Americans than ever before are adopting children who have experienced significant deprivation and neglect, leading to the likelihood that increasing numbers of parents are struggling with child developmental issues that confound them, exhaust them, tax them financially, and for which they need help that is not as readily available as Miller and colleagues, perhaps inadvertently, seem to imply.