Adoption

One of the earliest adoptions in the Western tradition was that of Moses, rescued by the daughter of Pharaoh, a rich and possibly single parent. He grew up in a transracial and transreligious placement, which ran into difficulties when he discovered the true family and religion of his birth. Over 3000 years later the public on two continents were transfixed by the story of twins bought on the internet.¹ Adoption, a way of providing a child with a substitute family, generates strong feelings and has always been influenced by social change.

Adoption became legal in the United Kingdom in 1926 in response to the first world war and the 1918 influenza epidemic, and it became practicable with the development of safe artificial infant feeding. For the next 50 years adoption practice was primarily about finding babies for childless couples. The “perfect” baby was newborn, white, and developmentally normal. Since there were always more applicants than babies the definition of “the perfect adopter” could be restricted by age, marital and professional status, and wealth. Adoption practice was designed to prevent birth and adoptive parents from meeting and sharing identifying information. Even today a child is given a new NHS number at the time of legal adoption.

By 1970 effective contraception, the legalisation of abortion, acceptance of single parents, and better welfare benefits produced a dramatic drop in the number of babies available for adoption. Adoption then began to be seen as a solution to the care problems of children whose parents were unwilling, unable, or unfit to care for them. Children needing adoption now are likely to have complex physical, emotional, developmental, and educational needs and have often been damaged by inadequate parenting, abuse, and neglect.² Few are babies, and many require placement with siblings. Many will have had multiple placements already, and many children remain in contact with their birth families.

Adoptive families are now recruited for their ability to parent children with lifelong complex needs. Legislation in England does not exclude any family structure as inappropriate for a child's upbringing. Experience has shown that single people, older couples with their own children, gay men and women, people who have remarried, childless couples, and people with disabilities can all have much to offer specific children.

Today's dilemmas in adoption practice include identifying circumstances that justify permanently removing children from their birth parents, finding permanent families for very traumatised children, resolving policy dilemmas around transracial placements, and ensuring that intercountry adoption is carried out in the best interests of the child. Modern adoption practice emphasises openness and exchange of information between birth and adoptive families.

Relatively few children are adopted in the UK, and recent government policy is to increase the number of children adopted from care by 40-50% by 2005. Falling from a peak of 27 000 in 1968, only 2220 children were adopted from care in 1999, a rate of 4%.³,⁴ Despite the publicity given to intercountry adoption, in 1999 only 272 children were adopted from outside the UK.⁵ At any one time, however, local authorities in England look after 58 000 children. Most will eventually return home, although a worrying number spend their childhoods in the care of the state: about 40% of looked after children on 31 March 1999 had been in care for three years or more.³

For most babies the emotional, social, and educational outcomes of adoption are good. Older children, however, bring to their adoptive families their own unique personal histories, family memories, and developing behavioural traits. These adoptions are more vulnerable, and rates of adoption breakdown increase from 10% for children placed under the age of 10 to 20%-40% for those placed when over 10.⁶ Nevertheless, even late placed children enjoy a full recovery of physical health and growth; most make academic progress; and as adults their level of social adjustment is better than that of those who remained in care or returned to their birth family.⁶ Most adopters express a high degree of satisfaction with their decision to adopt.

The government's recent white paper on adoption includes proposals for England and Wales to back up its plan to increase the number of adoptions.⁷ These include additional financial support for adoption, new national adoption standards, increased funding for social work training, additional family court judges to reduce delays in the court system, paid adoption leave, and increased post-adoption support. A new national adoption register for England and Wales will match children with adoptive parents, and an adoption taskforce will tackle poor performance. Tight timescales will be introduced for both child care planning and assessment of adoptive parents

Adoption is an important but neglected issue in the medical profession.⁸ A doctor can write “adopted” on a patient's record without realising the meaning of this for the patient. Separation from a birth family can underlie a range of chronic psychosomatic illnesses. Doctors who counsel infertile couples need to appreciate that few will succeed in adopting the baby they desperately want and the magnitude of the task involved for couples adopting older children. Medical examinations on potential adopters are done outside the NHS and paid for by adopters themselves. This practice needs to be reviewed. Society urgently needs substitute parents from all classes and cultures.

If adoption is to become a real option for a group of very damaged children the health service must match increased social resources with knowledgeable and sensitive general practitioners, paediatricians, and child psychiatrists to provide post-adoption support to children and their families. Adopters require not only personal reserves of tolerance and understanding but the unflagging interest and support of post-adoption services. Health and educational provision for these disadvantaged children may make or break an adoption placement.

Thousands of children have benefited from the generosity and commitment of their adoptive parents.⁶ The ability to give a child a second chance is rare within medicine. It is vital to assure the quality and continued resourcing of this small but important service within the NHS.