A Letter From Dr. Dana Johnson

Dear Adoptive Parent:

After reviewing the medical records of nearly 15,000 institutionalized children, I can conclusively state that the most difficult area in adoption medicine is predicting the needs of children adopted from orphanages.  Unfortunately, there is no shortage of dogmatic opinion, both positive and negative, on the outcome of these children.  Recently I have been quoted as saying that 85% of institutionalized children are normal.  If so, why are so many families seeking help for their adopted children through organizations like the Parent Network for Post-Institutionalized Children (PNPIC)?  Confused by what you have heard?  I am.

The major problem is that we are only beginning to understand how these kids are doing.  Studies utilizing appropriately selected and tested institutionalized children have been too few to say with any certainty what percentage are normal (even if we could define what we mean by "normal").  It is also quite clear that the situation changes with time.  Some children resolve problems, whereas others begin to exhibit them as the years pass.  All contemporary studies of institutionalized adoptees from abroad deal with a rather narrow span of time within two to five years of placement.  Without valid data, we are left with our own opinions which, of course, are shaped by our personal experience with adoption, by conversations with families we have come in contact with in our practice, and by our own world view.

What do we really know, and what can we say about institutionalized children as a group?  More importantly, what can we say about the child you have adopted or are considering adopting?  Certainly, no one is in a position to provide statistics on what percentage are abnormal or normal.  Even if we did have the data, they would address the status of institutionalized children at an early age.  Twenty years from now, worries that your child had language delays at four years of age will be replaced by concerns of whether your child has acquired the tools to be successful as an adult; e.g., a positive self-image, a high school diploma and independent living skills.  No one is in the position to even speculate on these long-term issues.

Since I am offering advice in the absence of irrefutable facts, you are entitled to know my personal view on this subject.  Nothing would please me more than to have all institutionalized children find permanent homes.  However, nothing would make me feel worse than having a family adopt a child they were unprepared to parent.

What are the chances that my child will be normal on arrival?
Let me be blunt.  The chance of an institutionalized child being completely normal on arrival in your home is essentially zero!  Here's why:

Kids aren't in orphanages because they come from loving, intact families with a good standard of living and ready access to good health care and nutrition.  Abandonment by a destitute single parent with poor prenatal care and inadequate diet is the most common reason why a child is available for adoption.  The second most common reason is termination of parental rights because of neglect and/or physical/sexual abuse (often alcohol-related).  Over 50% of institutionalized children in Eastern Europe are low-birthweight infants, many were born prematurely, and some have been exposed to alcohol while still in the womb.  Finally, children with major medical problems or physical handicaps may be placed in orphanages by their parents due to limited access to corrective treatment and rehabilitation services.  These kids are a high-risk group by any standard.

An orphanage is a terrible place to raise an infant or young child.  Lack of stimulation and consistent caregivers, suboptimal nutrition and physical/sexual abuse all conspire to delay and sometimes preclude normal development, speech acquisition and attainment of necessary social skills.  Many never find a specific individual with whom to complete a cycle of attachment.  Physical growth is impaired.  Children lose one month of linear growth for every three months in an orphanage.  Weight gain and head growth are also depressed.  Finally, congregate living conditions foster the spread of multiple infectious agents.  Intestinal parasites, tuberculosis, hepatitis B, measles, chickenpox, middle ear infections, etc., are all found more commonly in institutional care settings.

Despite these considerations, adoption, whether formal or informal, has always been a superior method of assuring survival for children whose parents are unwilling or unable to care for them.  However, adoption can also affect child development in profound ways.  Data collected over the past three decades support adoption as a superior means of promoting normal development in children permanently separated from birth parents.  Out of calamity and loss, children recover and progress to become functionally and emotionally competent adults.  For children suffering severe neglect or abuse in early life, an adoptive family is a remarkable environment for healing emotional and physical trauma, and reversing developmental deficits.*

Good luck to you, and best wishes,

Dana E. Johnson, M.D., Ph.D.

*from Elsevier Science Ireland, Ltd.