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 ADOPTED CHILDREN
Medical Research in the Ancient and the
Biblical Times from the Viewpoint of
Contemporary Perspective

This Research is constructed purely

from an examination of passages from
the Bible, exactly as written.

Liubov Ben-Nun
 As children grow they gradually develop a self-concept - how they
see themselves, and self-esteem – how much they like what they see.
With adoption, these normal concepts are damaged and childhood
issues of self-image, attachment and loss are difficult. The discovery
by children that they are adopted is very painful, since these children
may feel that their biological parents abandoned them.
Studying the available literature on adoption, whether ancient or
contemporary, could shed light on this issue and provide tools for
better management of adopted children in modern times. This study
deals with adoption in antiquity, and evaluates adoption as described
in the Bible. All biblical texts were examined and three children –
Moses, Esther, the adopted daughter of Mordekhay, and Mefivoshet
who were adopted at different stages of their life were studied. This
research deals with modern trends in adoption. The process, reasons
for adoption, and consequences, adoptive parents' perceptions, and
adoption policy were evaluated from the contemporary perspective.

69th Book
About the Author
Dr. Liubov Ben-Nun, the Author of dozens Books and Articles that have
been published in scientific journals worldwide.

Professor Emeritus at Ben Gurion University of the Negev, Faculty of

Health Sciences, Beer-Sheva, Israel. She has established the "LAHAV"
International Forum for research into medicine in the Bible from the
viewpoint of contemporary medicine.

NOT FOR SALE

 ADOPTED CHILDREN

Liubov Ben-Nun
Professor Emeritus

Ben-Gurion University of the Negev

Faculty of Health Sciences
Beer-Sheva, Israel

Finding Moses. Nicolas Poussin. 1651

B.N. Publication House. Israel. 2016.

E-Mail: L-bennun@smile.net.il

Technical Assistance: Ilana Siskal

All rights reserved

Distributed Worldwide

NOT FOR SALE

 CONTENTS
FOREWORD 5
INTRODUCTION 9
DEFINITION 11
ANCIENT CIVILIZATIONS 12
BIBLICAL TIMES 14
MOSES 14
REASONS FOR ADOPTION
AGE AT ADOPTION
ATTACHMENT
PHYSICAL PROBLEMS
PSYCHOSOCIAL PROBLEMS
DEVELOPMENTAL DELAYS
LANGUAGE AND SPEECH DISORDER – MOSES "SLOW OF SPEECH
AND SLOW OF TONGUE"
ESTHER 85
PARENTAL DEATH
A NEW FAMILY
ATTACHMENT
MEFIVOSHET 95
LIVING WITH CHRONIC DISEASE
SPECIAL HEALTH NEEDS
ADOPTION FROM MIDDLE AGES TO MODERN TIMES 101
TYPES 109
OPEN VERSUS CLOSED
RELATIVES/UNRELATED INDIVIDUALS
PRIVATE DOMESTIC ADOPTIONS
FOSTER CARE ADOPTIONS
INTER-COUNTRY ADOPTIONS
INTERNATIONAL ADOPTION
MILITARY FAMILIES
LESBIAN, GAY COUPLES
ADOPTIVE PARENTS' PERCEPTIONS 127
ADOPTION POLICY 129
SUMMARY 132
ABBREVIATIONS 144
 5

L. Ben-Nun Adoption

FOREWORD
Adoption always represents for the child a loss of emotional ties
with birthparents and a development of new attachments with
adoptive parents. Adoption can be considered as a life-time process
of the members involved in the adoption triangle that is birth
parents, adoptive parents and the child. The loss of emotional bonds
from primary caretakers is a psychological trauma and mournings
difficulties in adoptees should be addressed. There are problems
with the development of new attachments with adoptive parents
such as loyalty conflicts, the revelation of the adoption and family
romance phantasy in adoption; the search for their origin by young
adoptees; aspects of family dynamics in the adoptive process and the
specific difficulties adoptive parents encounter (1).
Children adopted from care are at increased risk for mental health
difficulties. The mental health and psychological development of
children placed for adoption by one UK Local Authority were
assessed. The pattern and prevalence of difficulties to existing data
including that on Looked-After Children were compared. Totally, 106
families were initially approached and parent interviews and at least
partial questionnaire data were gathered on 47 children, 72.3% of
whom were known to have been maltreated prior to adoption. Of
the 34 children with a complete data set including Development and
Well-Being Assessment, 76.4% met full criteria for at least one
neurodevelopmental or mental health diagnosis, a markedly higher
rate than comparison data on Looked-After Children or community
samples. Less than half of those identified with a mental health
diagnosis had received any prior diagnosis, and only a minority had
received appropriate services. Despite the children's difficulties, the
great majority of parents reported high enjoyment of bringing up
their child (2).
The past 10 years of published research concerns the 2% of
American children younger than 18 years old who are adoptees.
Review recent literature on developmental influences, placement
outcome, psychopathology, and treatment was summarized.
Adoption carries developmental opportunities and risks. Many
adoptees have remarkably good outcomes, but some subgroups have
difficulties. Traditional infant, international, and transracial
 6

L. Ben-Nun Adoption

adoptions may complicate adoptees' identity formation. Those

placed after infancy may have developmental delays, attachment
disturbances, and posttraumatic stress disorder. Useful interventions
include preventive counseling to foster attachment, postadoption
supports, focused groups for parents and adoptees, and
psychotherapy. The data indicate that variables specific to adoption
affect an adopted child's developmental trajectory. Externalizing,
internalizing, attachment, and PTSD symptoms may arise. Child and
adolescent psychiatrists can assist both adoptive parents and
children (3).
Parents of 165 children adopted from Romania and 52 children
adopted from within the United Kingdom rated the success of the
adoptions when the children were 11 years old. As was the case at
two earlier study waves, satisfaction was found to be extremely high.
Both positive and negative assessments were generally stable
between ages 6 and 11, although for the children who had more
problems there was an increase in negative evaluation, albeit within
an overall positive picture. Parents' evaluations were somewhat
more negative for this group of children; however, parents reported
that having the child as part of their family was very rewarding.
Negative evaluation was not directly related to age at placement, but
appeared to be a reflection of the later-placed children's higher rates
of problem behavior. As found at earlier assessment waves, child
factors, in particular conduct problems and inattention or
overactivity, were key in predicting parental evaluations at age 11, as
were four domains closely associated with institutional deprivation,
namely cognitive impairment, quasi-autistic patterns, inattention or
overactivity, and disinhibited attachment. The findings emphasize
the need for early intervention for children in severely deprived
conditions, and for access to postadoption services that target the
particular problem behaviors the children may exhibit (4).
Families of internationally adopted children may face specific
problems with which GPs may not be familiar. Problems faced by
families before, during and after the arrival of their internationally
adopted child were explored and the usefulness of a specific medical
structure for internationally adopted children, which could be a
resource for the GP were assessed. A qualitative study was
conducted using individual semistructured guided conversations and
21 families that had adopted a total of 26 children internationally in
 7

L. Ben-Nun Adoption

the Puy de Dome department, France, in 2003 were interviewed.

The history of these families, from the start of the adoption project
to its achievement, is complex and warrants careful analysis. Health-
care providers should not only consider the medical aspects of
adoption, but should also be interested in the histories of these
families, which may play a role in the forming of attachments
between the adoptee and their adoptive parents and prevent further
trouble during the development of the child. Adoptive parents have
similar fears or transient difficulties that may be resolved quickly by
listening and reassurance. Most such families would support the
existence of a specific medical structure for internationally adopted
children, which could be a resource for the general practitioner.
However, the health-care providers were divided on the subject and
expressed their fear that a special consultation could be stigmatizing
to children and families. A specific consultation with well-trained and
experienced practitioners acting in close collaboration with GPs and
pediatricians possibly is of help in better understanding and
supporting adopted children and their families (5).
Since the decade of 1980, the model of stress and coping
proposed for the assessment of vulnerability of adoptive families
emphasizes that the emotional adjustment of those adopted is
moderated by variables such as institutionalization, the manner and
age at which the adoption was revealed, the change of first name,
and the contact with the biological family. The relationship of these
variables to the perceived parenting style, mood, and self-esteem of
the adopted adolescents was investigated. Participants in the study
were 68 adolescents, between the ages of 14 and 15, adopted during
infancy through judicial channels. The adolescents responded to a
questionnaire about the history of adoption and to scales of
Parenting Styles, Depression and Self-esteem. The results indicated
that the late revelation of adoption and the change of the first name
were connected with higher levels of depression and low self-esteem
and to more frequent perceptions of negligent or authoritarian
parenting style. The contact with the biological family was frequently
mentioned among those who perceived their parents as authoritative
and presented the best indicator of mood and self-esteem. There is
the necessity for multidisciplinary actions which can improve the
psychological adaptation of the adopting families (6).
 8

L. Ben-Nun Adoption

There is great controversy regarding the impact of openness in

adoption, especially the impact of such an arrangement on adopted
children. Three indicators of the level of child participation in the
openness arrangement were examined: 1] level of openness reported
by adoptive parents, 2] level of information adopted children
reported having about their birthparents, and 3] whether adoptive
parents have withheld any pertinent information gained through
communication with the birthmother from the adopted child.
Totally, 171 children (90 males, 81 females; mean age = 7.99) were
studied to assess how that participation influenced their conceptual
understanding of what adoption means, general self-worth,
satisfaction with level of openness, and curiosity about birthparents.
Overall, providing information about a child's birthparents will
confuse the child about the meaning of adoption or lower the child's
self-esteem, but neither will it move them to levels of understanding
that are beyond their cognitive capabilities to reach (7).

References
1. Steck B. Parent child relations problems in adoption. Prax Kinderpsychol
Kinderpsychiatr. 1998;47(4):240-62.
2. DeJong M, Hodges J, Malik O. Children after adoption: exploring their
psychological needs. Clin Child Psychol Psychiatry. 2015 Dec 16. pii:
1359104515617519. [Epub ahead of print]
3. Nickman SL, Rosenfeld AA, Fine P, et al. Children in adoptive families:
overview and update. J Am Acad Child Adolesc Psychiatry. 2005;44(10):987-95.
4. Castle J, Groothues C, Beckett C, et al. Parents' evaluation of adoption
success: a follow-up study of intercountry and domestic adoptions. Am J
Orthopsychiatry. 2009;79(4):522-31.
5. Lesens O, Schmidt A, De Rancourt F, et al. Health care support issues for
internationally adopted children: a qualitative approach to the needs and
expectations of families. PLoS One. 2012;7(2):e31313.
6. Reppold CT, Hutz C. Effects of the history of adoption in the emotional
adjustment of adopted adolescents. Span J Psychol. 2009;12(2):454-61.
7. Wrobel GM, Ayers-Lopez S, Grotevant HD, et al. Openness in adoption and
the level of child participation. Child Dev. 1996;67(5):2358-74.
 9

L. Ben-Nun Adoption

INTRODUCTION
Adoption norms and practices are different from society to
society. In Western society, modern adoption is generally private,
infrequent, and formal involving a complete transfer of parental
rights. There still can be a stigmatism about adoption. There is red
tape in this country to adopt a child making it very complicated and
keeping the process moving slowly. However, this is not so in such
cultures as with the Hawaiians. In fact, there are different types of
adoption and they took place quite frequently. The transfer of the
children were not complete the child could still have ties with the
biological parents. As seen in Africa and Asia, adoption is a means to
strengthen family bonds (Carp, p4) (1).
Children join adoptive families through domestic adoption from
the public child welfare system, infant adoption through private
agencies, and international adoption. Each pathway presents
distinctive developmental opportunities and challenges. Adopted
children are at higher risk than the general population for problems
with adaptation, especially externalizing, internalizing, and attention
problems. The field's emphasis on adoptee-nonadoptee differences
highlights biological and social processes that affect adaptation of
adoptees across time. The experience of stress, whether prenatal,
postnatal/preadoption, or during the adoption transition, can have
significant impacts on the developing neuroendocrine system. These
effects can contribute to problems with physical growth, brain
development, and sleep, activating cascading effects on social,
emotional, and cognitive development. Family processes involving
contact between adoptive and birth family members, co-parenting in
gay and lesbian adoptive families, and racial socialization in
transracially adoptive families affect social development of adopted
children into adulthood (2).
The consequences of variations in levels of openness in adoption
were examined, especially focusing on the dynamics of the adoptive
family system from the perspective of the adoptive parents.
Participants included the father, mother, and at least one adopted
child in 190 adoptive families, and 169 birthmothers, drawn from
adoption agencies across the U.S. Families included 62 confidential,
17 time-limited mediated, 52 ongoing mediated, and 59 fully
 10

L. Ben-Nun Adoption

disclosed adoptions. When compared to parents in confidential

adoptions, those in open adoptions generally demonstrated higher
levels of acknowledgment of the adoption, empathy toward the
birthparents and their child, a stronger sense of permanence in the
relationship with their child as projected into the future, and less fear
that the birthmother might try to reclaim her child. Despite these
mean differences, variations within all levels of openness were
present, and the ongoing process was involved in building a family
through adoption (3).
One of the major questions of human development is how early
experience impacts the course of development years later. Children
adopted from institutional care experience varying levels of
deprivation in their early life followed by qualitatively better care in
an adoptive home, providing a unique opportunity to study the
lasting effects of early deprivation and its timing. The effects of age
at adoption from institutional care are discussed for multiple
domains of social and behavioral development within the context of
several prominent developmental hypotheses about the effects of
early deprivation (cumulative effects, experience-expectant
developmental programming, and experience-adaptive
developmental programming). Age at adoption effects are detected
in a majority of studies, particularly when children experienced global
deprivation and were assessed in adolescence. For most outcomes,
institutionalization beyond a certain age is associated with a step-like
increase in risk for lasting social and behavioral problems, with the
step occurring at an earlier age for children who experienced more
severe levels of deprivation. Findings are discussed in terms of their
concordance and discordance with our current hypotheses, and
speculative explanations for the findings are offered (4).
The available literature on adoption, whether ancient or
contemporary, could shed light on this issue and provide tools for
better management of adopted children in modern times. This study
deals with adoption in antiquity, and evaluates adoption as described
in the Bible. All biblical texts were examined and three children –
Moses, Esther, the adopted daughter of Mordekhay, and Mefivoshet
- who were adopted at different stages of their life were studied.
Finally, this research deals with modern trends in adoption. The
process, reasons for adoption, consequences, adoptive parents'
 11

L. Ben-Nun Adoption

perceptions, and adoption policy were evaluated from a

contemporary perspective.

References
1. TED Case Studies. Available 14 January 2016 at
http://www1.american.edu/TED/adopt.htm
2. Grotevant HD, McDermott JM. Adoption: biological and social processes
linked to adaptation. Annu Rev Psychol. 2014;65:235-65.
3. Grotevant HD, McRoy RG, Elde CL, Fravel DL. Adoptive family system
dynamics: variations by level of openness in the adoption. Fam Process. 1994;
33(2):125-46.
4. Megan M. Julian. Age at adoption from institutional care as a window into the
lasting effects of early experiences. Clin Child Fam Psychol Rev. 2013; 16(2):101–45.

DEFINITION
Adoption comes from the Old French word adoptare, meaning "to
choose for oneself” (1). Adopt refers to bring up (a child of other
parents) as one's own child after undergoing certain legal formalities
(2). Adoption is a process whereby a person assumes the parenting
of another, usually a child, from that person's biological or legal
parent or parents, and, in so doing, permanently transfers all rights
and responsibilities, along with filiations, from the biological parent
or parents. Unlike guardianship or other systems designed for the
care of the young, adoption is intended to effect a permanent change
in status and as such requires societal recognition, either through
legal or religious sanction. Historically, some societies have enacted
specific laws governing adoption; where others have tried to achieve
adoption through less formal means, notably via contracts that
specified inheritance rights and parental responsibilities without an
accompanying transfer of filiations. Modern systems of adoption,
arising in the 20th century, tend to be governed by comprehensive
statutes and regulations (3).

References
1. Adoption. Available 20 January 2016 at https://www.vocabulary.com/
dictionary/adoption
2. The Penguin English Dictionary. Robert Allen (Consultant ed.). Penguin Books.
London. 2003.
 12

L. Ben-Nun Adoption

3. Adoption. Available 20 January 2016 at

https://en.wikipedia.org/wiki/Adoption.

ANCIENT CIVILIZATIONS
The practice of adoption in ancient Rome is well documented in
the Codex Justinianus (1,2). Markedly different from the modern
period, ancient adoption practices put emphasis on the political and
economic interests of the adopter (3), providing a legal tool that
strengthened political ties between wealthy families and created
male heirs to manage estates (4,5). The use of adoption by the
aristocracy is well documented; many of Rome's emperors adopted
sons (4).

Trajan became emperor of Rome through adoption, a customary

practice of the Empire that enabled peaceful transitions of power.

Infant adoption during Antiquity appears rare. (3,6). Abandoned

children were often picked up for slavery (5) and composed a
significant percentage of the Empire's slave supply (7,6). Roman legal
records indicate that foundlings were occasionally taken in by
families and raised as a son or a daughter. Although not normally
adopted under Roman Law, the children, called alumni, were reared
in an arrangement similar to guardianship, being considered the
property of the father who abandoned them (6).
Other ancient civilizations, notably India and China, used some
form of adoption as well. The goal of this practice was to ensure the
continuity of cultural and religious practices; in contrast to the
Western idea of extending family lines. In ancient India, secondary
sonship, clearly denounced by the Rigveda (8) continued, in a limited
 13

L. Ben-Nun Adoption

and highly ritualistic form, so that an adopter might have the

necessary funerary rites performed by a son (9). China had a similar
idea of adoption with males adopted solely to perform the duties of
ancestor worship (10).
Polynesia is a vast string of islands in the Pacific Ocean, including
Hawaii, New Zealand, Easter Island, Tonga, and French Polynesia.
The practice of adopting the children of family members and close
friends was common among the cultures of Polynesia including
Hawaii where the custom was referred to as hānai (11).
Before the beginning of seventeenth century the institution of
adoption hardly existed in the way that we see it now, there was no
legal documentation. This establishing by law the social relationship
of parent and child who are not biological first appears in the Code of
Hammurabi, drafted by the Babylonians around 2285 B.C. which
provided that "if a man has taken a young child 'from his waters' to
sonship and has reared him up no one has any claim against the
nursling." Adoption was also practiced in Ancient Egypt, Greece, the
Middle East, Asia and societies in Africa and Oceania. (Carp, p 1-3).
The majority of these were done for the needs of the adults for
purposes of kinship, religion, or community (12).

ASSESSMENT: adoption was practiced in ancient civilizations

including Rome, Egypt, Greece, the Middle East, Asia, Africa, India
and China, and Polynesia.

References
1. Code of Hammurabi. Adoption. Available 20 January 2016 at
https://en.wikipedia.org/wiki/Adoption.
2. Codex Justinianus. Adoption. Available 20 January 2016 at
https://en.wikipedia.org/wiki/Adoption.
3. Brodzinsky A. Surrendering an infant for adoption: the birth mother
experience. In: The Psychology of Adoption. Brodzinsky DM, Schechter MD (eds.).
New York, NY: Oxford University Press. 1990.
4. Kirk HD. Adoptive Kinship: A Modern Institution in Need of Reform. 1985.
5. Mary Kathleen Benet. The Politics of Adoption. 1976.
6. John Boswell. The Kindness of Strangers: The Abandonment of Children in
Western Europe from Late Antiquity to the Renaissance. University of Chicago Press.
1988. Available 12 February 2016 at https://books.google.co.il/books?id=MR1D29F0
yyQC&redir_esc=y191998.
7. Scheidel W. The Roman Slave. Available 20 January 2016 at
http://www.princeton.edu/~pswpc/papers/authorMZ/scheidel/scheidel.html.
 14

L. Ben-Nun Adoption

8. Tiwari A. The Hindu Law of Adoption. Central Indian Law Quarterly. 2005;
Vol. 18.
9. Bhargava V. Adoption in India: Policies and Experiences. 2005.
10. Menski W. Comparative Law in a Global Context: The Legal Systems of Asia
and Africa. 2000. Available 20 January 2016 at
https://books.google.co.il/books?id=s7ohU5v8Lu8C&redir_esc=y.
11. Adoption. Available 15 January 2016 at
https://en.wikipedia.org/wiki/Adoption.
12. TED Case Studies. Available 12 January 2016 at
http://www1.american.edu/TED/adopt.htm

BIBLICAL TIMES
MOSES
As children grow they gradually develop a self-concept - how they
see themselves, and self-esteem – how much they like what they see
(1). With adoption, these normal concepts are damaged and
childhood issues of self-image, attachment and loss are difficult (2).
The discovery by children that they are adopted is painful, since
these children feel that their biological parents abandoned them (3).
This present research evaluates adoption as described in the
Bible. The research deals with the great leader Moses, thus the
reasons of his adoption, the consequences of his adoption, and
whether adoption was associated with any psychological problem in
Moses were evaluated.

Moses rescued from the Nile.

Veronese Paolo (Eigent Paolo Caliari).
 15

L. Ben-Nun Adoption

At the time of Moses' birth, the Hebrew slaves in Egypt suffered

from various cruel decrees of Pharaoh. One such decree was that
every newborn Jewish male should be killed. So when Moses was
three months old, in an attempt to save him, his Jewish mother put
him in a crib among the reeds on the bank of the Nile. Pharaoh's
daughter found the crib, took the baby and raised him as her own
son. She gave him the name of Moses, meaning “son” in Egyptian,
although the text explains the name with the words “because I drew
him out of the water” (Exodus 2:10). So “And Pharaoh’s daughter said unto
her, take this child away, and nurse it for me, and I will give thee thy wages.
And the woman took the child and nursed it” (2:9). The wet nurse hired
by Pharaoh’s daughter to breast-feed Moses was actually his
biological mother.

Pharaoh's Daughter finds Moses. Lawrence Alma-Tadema.

Moses was adopted, grew up and was educated in the house of

Pharaoh. As a grown man, Moses killed an Egyptian, who was
beating a Hebrew slave and fled into the Sinai desert.
Later Moses was commanded to return to Egypt and free his
people from slavery, with a direct appeal to the King of Egypt. In
reply Moses argued: "I am not eloquent, neither yesterday, nor the day
before, nor since thou hast spoken unto thy servant: but I am slow of speech,
and of a slow tongue (a heavy mouth and a heavy tongue" (4:10) and "..I am
stammerer.." (6:12). Nevertheless, Moses returned to Egypt, and led
the Jewish people out of Egypt, from slavery to freedom.
 16

L. Ben-Nun Adoption

Moses and the Burning Bush. Dieric Bouts.

We see that the great leader, Moses, was an adopted child. Did
Moses suffer from any physical or emotional problem that can be
linked to his adoption? What were consequences of this adoption?

The Well of Moses by Claus Sluter, 1395–1403.

Carthusian monastery of Chartreuse de Champmol built as a burial site
by the Burgundian Duke Philip the Bold, Dijon, now France.

References
1. Okun BF, Andersen CM. Understanding diverse families. What practitioners
need to know. New York: Guilford Press. 1996, p. 376.
2. Community Paediatrics Committee, Canadian Paediatric Society. Position
Statements. Understanding adoption: a developmental approach. Pediatrics &
Health. 2001;6:282-3.
3. Kim SP. Adoption. In: Kaplan HI and Sadock BJ (eds.). Comprehensive
Textbook of Psychiatry, Vol. 2. Fourth ed. Williams & Wilkins, Baltimore/London.
1985, pp. 1829-31.
 17

L. Ben-Nun Adoption

REASONS FOR ADOPTION. There are many reasons for placing

children in a foster family or in an institution that will care for their
physical, emotional and educational needs in the short, medium or
long-term (1). Reasons for fostering include family dysfunction,
and/or violence, marital disruption or separation, and maternal death
(2), infant or child neglect, physical and sexual abuse of children,
alcohol and drug abuse, serious physical or mental illness in either
parent, or prolonged absences of parents from their children for
various reasons such as employment at distant locations or irregular
hours of work, severe floods, landslides in mountainous regions,
cyclones, massive tidal waves, volcanic eruptions, wars, and mass
movements of human refugees (1). Childhood psychological or
psychiatric disorders may necessitate placement, at least in the
short-term (3).

ASSESSMENT: among the numerous reasons listed above, there is

no one that can be related to Moses. His adoption was associated
with Pharaoh’s brutal decree that every Jewish newborn male should
be thrown into the river. Is spite of this decree, Moses survived since
an Egyptian family adopted him.

References
1. Gracey M. The challenges of fostering infants and children. Acta Paediatr.
2003;92:787-9.
2. Sarkar NR, Biswas KB, Khatun UHF, Datta AK. Characteristics of young foster
children in the urban slums of Bangladesh. Acta Paediatr. 2003;92:839-42.
3. Almgren G, Marcenko MO. Emergency care use among a foster care sample:
the influence of placement history, chronic illness, psychiatric diagnosis, and care
factors. Brief Treatment Crisis Intervention. 2001;1:55-64.
4. Ben-Nun L. The First adopted child in the Bible. In Ben-Nun L. (ed.) Moses.
The medical Record and the Family Life cycle of the Great Leader of the Jewish
People. B.N. Publication House. Israel. 2010, pp. 55-65.

AGE AT ADOPTION. Parents of 211 adopted children, now young

adults, were interviewed about their children's behavior and
development during childhood and adolescence. The children were
placed for adoption at different ages. The quality of children's pre-
placement care also varied, older-placed children generally
experiencing adverse backgrounds prior to joining their adoptive
parents. Depending on their quality of pre-placement care, the
 18

L. Ben-Nun Adoption

children were placed in one of three groups for the purposes of

analysis: 1] baby adoption, 2] older-children adoptions in which
children had enjoyed satisfactory care as babies, and 3] older children
adoption in which children had experienced adverse care as babies.
The rate of adolescent problem behaviors varied between these
three groups, with the older-children adoptions/adverse baby care
group showing the highest rates. A quarter of the baby-adopted
children had problem behaviors during adolescence. By contrast, no
problem behaviors were reported in 28% of the older-
adopted/adverse baby care children (1).
Timing of adoption is a significant factor for establishing the
relationship with fostering family. When infants are placed in foster
homes before the age of one year, they rapidly achieve a stable a
relationship with their foster caregiver, and the quality of the
relationship matches the internal model (secure and insecure) of the
foster caregiver. If, however, they are placed after the age of one
year, the relationship itself takes longer to develop and is more apt to
be insecure, even if the foster parent’s perception of the relationship
is secure (2).
One of the major questions of human development is how early
experience impacts the course of development years later. Children
adopted from institutional care experience varying levels of
deprivation in their early life followed by qualitatively better care in
an adoptive home, providing a unique opportunity to study the
lasting effects of early deprivation and its timing. The effects of age
at adoption from institutional care are discussed for multiple
domains of social and behavioral development within the context of
several prominent developmental hypotheses about the effects of
early deprivation (cumulative effects, experience-expectant
developmental programming, and experience-adaptive
developmental programming). Age at adoption effects are detected
in a majority of studies, particularly when children experienced global
deprivation and were assessed in adolescence. For most outcomes,
institutionalization beyond a certain age is associated with a step-like
increase in risk for lasting social and behavioral problems, with the
step occurring at an earlier age for children who experienced more
severe levels of deprivation (3).
 19

L. Ben-Nun Adoption

ASSESSMENT: children are placed for adoption at different ages.

Timing of adoption is a significant factor for establishing the
relationship with fostering family. When infants are placed in foster
homes before the age of one year, they rapidly achieve a stable a
relationship with their foster caregiver. If they are placed after the
age of one year, the relationship is insecure.
Moses was adopted at three months. Thus, it is most likely that a
stable secure relationship developed between Moses and his
Egyptian family.

References
1. Howe D. Parent-reported problems in 211 adopted children: some risk and
protective factors. J Child Psychol Psychiatr. 1997;38:401-11.
2. Stoval KC, Dozier M. The development of attachment in new relationships:
Single subject analyses for 10 foster infants. Dev Psychopathol. 2000;12:133-56.
3. Julian MM. Age at adoption from institutional care as a window into the
lasting effects of early experiences. Clin Child Fam Psychol Rev. 2013; 16(2):101-45.

ATTACHMENT. Adoption holds particular interest for attachment

researchers. Although children adopted as babies experience almost
continuous care by their adoptive parents, older placed children
experience at least one major change of caregiver when they join
their adoptive family. In the majority of cases, older placed children
have generally suffered a pre-adoption history of abuse, neglect
and/or rejection. Older placed children's attachment histories and
internal working models established in relationship with their initial
careers remain active in relationship with their new careers.
Transactional models have helped both researchers and practitioners
to understand the dynamics of parent-child relationships in cases
where insecure children with histories of neglect, abuse and rejection
find themselves in new care giving environments. The childhood
experiences of adult adopted people and their current levels of
contact with their adoptive mothers, and in cases where people had
searched for and found birth relative, current levels of contact with
their birth mother were examined. Although no information was
collected on the adopted adult's pre-placement history, age at
placement was used as a proxy measure to examine whether older
placed children reported different adoption experiences and what
their current levels of contact were with their adoptive and birth
 20

L. Ben-Nun Adoption

mothers. The findings show that age at placement was associated

with adopted people's reported experiences of being adopted and
current rates of contact with their adoptive and birth mothers, with
those placed at older ages most likely to report that they 1] did not
feel they belonged to their adoptive families while growing up, 2] did
not feel loved by their adoptive mother, 3] were least likely to remain
in high-frequency contact with their adoptive mother, and 4] were
least likely to remain in high-frequency contact with their birth
mother. An attachment perspective is used to interpret the findings.
Children adopted at older ages appear more likely to have
experienced an insecure attachment relationship with their adoptive
mother (1).
The development of attachment between adopted children and
their adoptive parents with a focus on the particular issues in
international adoptions is described. There are the questions of
settling in, trauma in the country of origin, the motivations of the
adoptive parents, diagnosis and various psychopathological
manifestations, outpatient and inpatient modes of therapy, are the
treatment of children of various ages with the necessity for intensive
counseling and psychotherapy for the adoptive parents. This will
enable the parents to work through early trauma, which will give
them and their adopted child the basis for developing healthy
attachment patterns. This in turn will enable the child to mature and
integrate into society. Many of the approaches regarding attachment
and adoption may be applied to foster children and their foster
parents (2).
Infant attachment and developmental functioning shortly after
international adoption were examined. At 14 months, infant-mother
attachment and mental (MDI) and psychomotor (PDI) development
were assessed in 70 internationally adopted children. Mean age at
arrival was 5.5 months, mean stay in the adoptive family 8.7 months.
Adopted children's MDI and PDI did not deviate from normative
scores. Their secure-insecure attachment distribution was
comparable with that of normative groups. However, more adoptees
were disorganized attached (36 vs. 15% in normative groups).
Temporary residence in a foster home in the country of origin before
adoption was related to higher MDI and PDI, whereas disorganized
attachment in the adoptive family was related to lower MDI and PDI
scores. The data indicate that the majority of internationally adopted
 21

L. Ben-Nun Adoption

children form secure attachment relationships and function at

normative developmental levels shortly after adoption. Residence in
a foster family before adoption may partly prevent developmental
delays (3).
Due to early-childhood adversity, adopted children often display
delays in their cognitive and motor development and have problems
developing secure attachment relationships with their adoptive
parents. The results of all available studies on the attachment and
the cognitive and motor development of internationally adopted
children from China were presented in the first years after arriving in
the adoptive family. Seven pertinent studies were found, based on
five samples examined in the U.S., Canada, and the Netherlands.
Regarding cognitive and motor development (five studies) the
adoptees showed a delayed development at arrival in the adoptive
family. As soon as six months after arrival the adoptees were, on
average, functioning within normal ranges, although their catch-up to
non-adopted children was not yet complete. Two years after arrival
the catch-up to non-adopted peers appeared to be complete.
Regarding attachment (two studies) observations of attachment six
and twelve months after adoption showed less secure and more
disorganized attachment for the adopted children compared to the
normative distribution of non-adopted children. Two years after
adoption, observations of attachment confirmed a catch-up in secure
attachment, but the adoptees still displayed more insecure
disorganized attachment than children in the norm group (4).
The attachment patterns of late-adopted children (aged 4-7) and
their adoptive mothers during the first 7- to 8-month period after
adoption were examined and the effect of adoptive mothers'
attachment security on the revision of the attachment patterns of
their late-adopted children were evaluated. Attachment patterns
were assessed in 20 adoptive dyads and 12 genetically related dyads
at two different times: T1 (time 1) within 2 months of adoption and
T2 (time 2) 6 months after T1. The children's behavioral attachment
patterns were assessed using the Separation-Reunion Procedure and
the children's representational (verbal) attachment patterns using
the Manchester Child Attachment Story Task. The attachment
models of the adoptive mothers were classified using the Adult
Attachment Interview. There was a significant enhancement of the
late-adopted children's attachment security across the time period
 22

L. Ben-Nun Adoption

considered (p=0.008). All the late-adopted children who showed a

change from insecurity to security had adoptive mothers with secure
attachment models (p=0.044). However, the matching between
maternal attachment models and late-adopted children's attachment
patterns (behaviors and representations) was not significant. The
data suggest that revision of the attachment patterns in the late-
adopted children is possible but gradual, and that the adoptive
mothers' attachment security makes it more likely to occur (5).

ASSESSMENT: due to early-childhood adversity, adopted children

often display delays in their cognitive and motor development and
have problems developing secure attachment relationships with their
adoptive parents.
The majority of internationally adopted children form secure
attachment relationships and function at normative developmental
levels shortly after adoption.
Attachment six and twelve months after adoption is less secure
and more disorganized for the adopted children compared to the
normative distribution of non-adopted children. Two years after
adoption, the adoptees still display more insecure disorganized
attachment than children in the norm group.
Moses was adopted, grew up, educated in Pharaoh's family. It is
most likely that secure attachment relationships developed between
Moses and his Egyptian family.

References
1. Howe D. Age at placement, adoption experience and adult adopted people's
contact with their adoptive and birth mothers: an attachment perspective. Attach
Hum Dev. 2001;3(2):222-37.
2. Brisch KH. Attachment and adoption: diagnostics, pychopathology, and
therapy. Prax Kinderpsychol Kinderpsychiatr. 2015;64(10):793-815.
3. van Londen WM, Juffer F, van Ijzendoorn MH. Attachment, cognitive, and
motor development in adopted children: short-term outcomes after international
adoption. J Pediatr Psychol. 2007;32(10):1249-58.
4. Juffer F, Finet C, Vermeer H, van den Dries L. Attachment and cognitive and
motor development in the first years after adoption: a review of studies on
internationally adopted children from China. Prax Kinderpsychol Kinderpsychiatr.
2015;64(10):774-92.
5. Pace CS, Zavattini GC. 'Adoption and attachment theory' the attachment
models of adoptive mothers and the revision of attachment patterns of their late-
adopted children. Child Care Health Dev. 2011;37(1):82-8.
 23

L. Ben-Nun Adoption

PHYSICAL PROBLEMS. The arrival of a newly adopted child into

the family is usually a joyous time. Behavioral concerns arise in many
internationally adopted children, most of whom are infants or
toddlers at the time of placement with their adoptive families.
Problems with feeding, sleeping, and other daily activities are often
prominent in the first few weeks after the adoption (1).
At adoption, 15% of children are physically healthy and
developmentally normal (2), but the majority exhibit a variety of
problems such as short stature, low birth weight, impairment of head
growth, and non-organic failure to thrive (3,4), polyphagia and
polydipsia, (5,6), poor nutritional status and inappropriate feeding
practices (7), cleft lip, hypospadias, single limb defect and ventricular
septal defect (6), HIV infection (8,9), dental carries, chronic otitis
media, strabismus, fetal alcohol syndrome (10,11), congenital adrenal
hyperplasia, cardiomyopathy, seizures, septo-optic dysplasia,
hepatitis, tuberculosis, parasites, syphilis (6,9), scabies and lice (6),
iron deficiency anemia and thalasemia (12,13).
Visual function, ocular dimensions and neuropaediatric findings in
adoptees from Eastern Europe were evaluated. Children, 72 of 99,
born during 1990-5 and adopted from Eastern Europe to western
Sweden during 1993-97 were studied. Bivariate and regression
analyses indicate a significant positive correlation between visual
acuity and perceptual organization, as well as between strabismus
and verbal comprehension. Fetal alcohol syndrome was correlated
with low visual acuity, subnormal stereovision and small optic discs.
Small head circumference was related to low visual acuity and small
optic disc. Small optic discs were related to low birth weight and
preterm birth. Large optic cups were correlated with poorer
perceptual organization. In this group of adoptees from Eastern
Europe, ophthalmological findings were correlated with
neuropaediatric findings, especially those arising from prenatal
adverse events resulting in growth deficiency and central nervous
system damage (14).
The ophthalmological conditions in children adopted
internationally by Spanish families were described, and the influence
of the world region of origin and the preadoption period of
institutional care on these conditions was assessed. A descriptive,
observational, cross-sectional study was conducted on 232 children
divided into four groups according to world region of origin: Group 1,
 24

L. Ben-Nun Adoption

Eastern Europe (n=95); Group 2, Asia (n=95); Group 3, Central and

South America (n=26); and Group 4, Africa (n=16). A complete
ophthalmological study was carried out and the groups were
compared for the prevalence of ophthalmological conditions. Of
children, 57.8% (134) presented ophthalmological abnormalities. The
prevalence of ametropia was correlated with the world region of
origin, and was significantly higher in Group 3 (65.4%) compared to
the remaining groups. Strabismus and optic nerve hypoplasia (15.8%
and 3.2%, respectively) were more prevalent in Group 1. The
preadoption institutional care period was longer in children in Groups
1 and 3 (24.5 and 27.7 months, respectively). The data indicate that
children adopted from Central and South America had the highest
prevalence of ametropia. Adopted children from Eastern Europe
showed a weak tendency to present strabismus and optic nerve
hypoplasia. Adoptive parents, pediatricians and ophthalmologists
should be aware of the high prevalence of ophthalmologic conditions
in internationally adopted children and provide the means for a
prompt diagnosis and appropriate treatment (15).
The occurrence of vision and hearing deficits in international
adoptees and their associations with emotional, behavioral and
cognitive problems were evaluated. The MnIAP was a 556-item
survey that was mailed to 2,969 parents who finalized an
international adoption in Minnesota between January 1990 and
December 1998 and whose children were between 4 and 18 years-
old at the time of the survey. Families returned surveys for 1,906
children (64%); 1,005 had complete data for analyses. The survey
included questions about the child's pre-adoption experiences and
post-placement medical diagnoses, and the CBCL. Information on
hearing and vision screening and specific vision and hearing problems
was also collected via a telephone survey from 96/184 children (52%)
seen between June 1999 and December 2000 at the University of
Minnesota International Adoption Clinic. In both cohorts, 61% of
children had been screened for vision problems and 59% for hearing
problems. Among those children screened, vision (MnIAP = 25%,
telephone survey = 31%) and hearing (MnIAP = 12%, telephone
survey = 13%) problems were common. For MnIAP children, such
problems were significant independent predictors for T scores > 67
for the CBCL social problems and attention subscales and parent-
reported, practitioner-diagnosed developmental delay, learning and
 25

L. Ben-Nun Adoption

speech/language problems, and cognitive impairment. Hearing and

vision problems are common in international adoptees and screening
and correction are available in the immediate post-arrival period.
The importance of identifying vision and hearing problems cannot be
overstated as they are risk factors for development and behavior
problems (16).
China has become a leading country for international adoption
because of the relatively young age of the children and reported
positive conditions of the orphanages. Seventy infant girls adopted
from China at 8 to 21 months of age (mean age = 13 month) were
examined on arrival in Canada and 6, 12, and 24 months later.
Comparisons were made with non-adopted Canadian girls of similar
age and from a similar background with adoptive parents on indices
of growth and standardized measures of mental, psychomotor, and
language development. At arrival, children who arrived from China
were smaller physically and exhibited developmental delays
compared to current peers. Children were functioning in the average
range on physical and developmental measures within the first six
months following adoption. However, they were not performing as
well as current peers until the end of their second year after
adoption. Even then, there was developmental variation in relation
to comparison children and continuation of relatively smaller size
with respect to height, weight, and head circumference. Physical
measurement was related to outcomes at various points on all
developmental measures. Deprivation experience in the first year of
life has more long-lasting effects on physical growth than on mental
development. The variable most consistently related to development
was height-to-age ratio. As a measure of nutritional status, these
findings reinforce the critical importance of early nutrition (17).
Since 1986, American parents adopted > 17.300 children from
Guatemala. Retrospective chart review was conducted of 103
children who were evaluated after arrival in the U.S. at an
international adoption specialty clinic, and a case-matched study was
conducted of a subgroup of 50 children who resided in either an
orphanage or foster care before adoption. Mean age at arrival was
16+/-19 months. Mild growth delays were frequent among children.
Mean z scores for weight, height, and head circumference were,
respectively, -1.00, -1.04, and -1.08. Children from foster care have
significantly better z score for height, weight, and head
 26

L. Ben-Nun Adoption

circumference than those orphanages of mixed care. Among children

who were younger than two years at arrival growth measurements
correlated inversely with age. Infectious diseases included intestinal
parasites (8%), and latent tuberculosis (7%). Other medical
conditions were anemia (30%), elevated lead levels (3%), and
phenotypic features suggestive of prenatal alcohol exposure (28%).
Cognition, expressive and receptive language, and activities of daily
living skills correlated inversely with age at arrival for children who
were younger than two years at adoption (18).
The characteristics of puberty and response to GnRH* agonist
treatment in adopted children compared with children with IPP were
evaluated. Seventeen girls with central IPP (group A) and 11 girls
adopted from Asia and Central and South America (group B) with
respect to auxological data at presentation of puberty and response
to GnRH agonist treatment were evaluated. In adopted girls, age at
onset of puberty was later and duration of treatment was shorter. At
the start of treatment, H-SDS was +1.67 S.D. in group A. In group B,
H-SDS was comparably increased (+0.04 S.D.) assuming that the
mean H-SDS in their native country is lower than the mean on the
Dutch curve. During treatment, H-SDS decreased in both groups.
Group A reached a final height of 166.2 cm (-0.3 SD) and group B of
156.1 cm (-1.9 SD). Predicted adult height at the start of treatment
underestimated final height in group A and overestimated final
height in group B. At the end of treatment, predicted adult height
overestimated final height in both groups. The SDS for weight was
above the mean in both groups at the start of treatment and
increased even more during treatment. The age of occurrence of
menses after treatment was stopped was the same in both groups
(12.7 and 12.8 Years, respectively). The data show that despite the
difference in timing of puberty between girls with IPP and adopted
girls with early puberty, their response to treatment was similar in
many aspects (19).
The risk of developing precocious puberty in intercountry
adoptees, children immigrating with their family, and descendants of
immigrants living in Denmark were assessed. Patients who were
registered with the diagnosis of precocious puberty during the period
1993-2001 were identified through the national patient registry. The
(*GnRH – See All Abbreviations, Page 144).
 27

L. Ben-Nun Adoption

background population of children born from 1983 to 2001 were

identified through the unique Danish Civil Registration System and
subsequently categorized as being Danish (n=1,062,333), adopted
(n=10,997), immigrating with their family (n=72,181), or being
descendants of immigrants (n=128,152). In the study period, 655
children developed precocious puberty during 5,627,763 person-
years at risk. Adopted children were followed during 39,978 person-
years at risk, during which 45 girls and 6 boys developed precocious
puberty. The risk of developing precocious puberty was significantly
increased 10 to 20 times in adopted girls compared with girls with
Danish background. The risk of developing precocious puberty
depended on the country 7of origin. In children immigrating with
their family, the risk of developing precocious puberty was only
marginally increased. Older age at adoption significantly increased
the risk of precocious puberty in adoptees independent of region of
origin. The incidence rate ratio was significantly higher in children
adopted after the age of two. In children immigrating with their
family, effect of age at migration was not found. In this large,
nationwide, register-based study including 655 cases of precocious
puberty, intercountry boys and girls were 10 to 20 times more likely
to develop precocious puberty compared with the Danish reference
group. Older age at adoption significantly increased the risk of
precocious puberty. Uncertainty of the exact age is a well-known
problem in adopted children, and systematic underestimation of age
might bias the result. However, using the worst-case scenario that all
children who according to the Danish Civil Registration System were
adopted after two years of age were in fact one year older, and still
were observed a highly increased risk of precocious puberty
associated with adoption and especially with adoption after two
years of age. The risk of precocious puberty was not increased in the
large group of children adopted from Korea. One case of precocious
puberty was identified among Korean children, whereas > 20 cases of
precocious puberty would have been expected if the risk for a Korean
child was at the same level as observed among adopted children
from India and South America. In the study population, 99% of
Korean children were adopted before 2 years of age, which may
contribute to explaining the finding. In Korea, children appointed for
adoption are often living in foster care settings from birth to
adoption, whereas most other countries are reported to take care of
 28

L. Ben-Nun Adoption

the children in orphanages before adoption. It can be speculated

whether a relation between preadoption living conditions and later
risk of precocious puberty exists. Genetic factors play a key role in
the timing of puberty, and large variations in age at menarche are
observed worldwide. Age at menarche is reported to be in the same
age range in South Korea as in well-off populations in other parts of
the world, indicating that the different risk of precocious puberty
observed between Korean and other adoptees probably cannot be
explained by genetic factors alone. The finding that the risk of
precocious puberty was significantly increased among adoptees in
contrast to what was seen in children immigrating with their families
contradicts a direct effect of migration. An increasing number of
papers have shown long-term effects of certain prenatal and
postnatal growth patterns, including advancement in pubertal
maturation after poor intrauterine growth and catch-up growth
during childhood. Different growth patterns and dietary habits
between adoptees and children immigrating with their families might
contribute to explain the findings. Stressful psychosocial factors in
infancy and childhood may lead to earlier pubertal maturation. In
general, adoptees have experienced several traumatic life events,
and that these events may alter the susceptibility for developing
precocious puberty. Foreign-adopted children originating from
regions other than Korea had a 15- to 20-fold increased risk of
precocious puberty compared with Danish-born children, whereas
adoptees originating from Korea had no increased risk of precocious
puberty. While children immigrating with their families had no
increased risk of precocious puberty. The effect of country of origin
might be explained by genetic factors or by different environmental
exposures and living conditions in the different countries. Older age
at adoption increased the risk for premature onset of puberty, which
may suggest that environmental factors influence the risk of
precocious pubertal development in adopted children (20).
Retrospective studies have indicated that internationally adopted
girls are at high risk of developing precocious puberty.
Hypothetically, this could be due to selection bias. Age at reaching
pubertal milestones in healthy internationally adopted girls in a
prospective, clinical study was examined. A longitudinal cohort study
included 276 randomly recruited internationally adopted girls. At
baseline, age ranged from 4 to 13 years. Participants were followed
 29

L. Ben-Nun Adoption

with biannual examinations over a period of 2 years. Examinations

included height, weight, Tanner staging, blood sampling and bone
age assessment. Age distribution at entering pubertal stages B2-B5
(breast development), PH1-PH5 (pubic hair development) and
menarche was estimated by probit analysis. Data were compared to
a reference population of Danish-born girls, studied cross-sectionally.
Mean age at B2+ was 9.5 years (95% prediction interval 7.1-12.0
years) and mean age at menarche was 12.1 (10.2-14.0) years in
adopted girls, which was significantly lower compared to the
reference group (p<0.0003). Of adopted girls, 16% entered stage B2
before eight years of age. The puberty-related rise in LH, FSH and
estradiol was detected at earlier ages in adopted girls compared to
the reference group. The data indicate that internationally adopted
girls have a significantly higher risk of precocious pubertal maturation
compared to Danish-born girls (21).
Precocious puberty has been more frequently observed in the
population of children adopted from abroad. A study was therefore
carried out to assess the prevalence of this early onset of puberty.
Thirteen cases of precocious puberty have been examined in ten
adopted girls and three adopted boys, and the clinical characteristics
and other contributing factors have been described. In the group,
three of the cases were familial. A questionnaire was also completed
by 99 French families with children adopted from abroad, and
analyzed to determine the frequency of early pubertal development.
The parameters included were age, weight and height at the time of
adoption, date of onset of puberty, age at first menstruation for the
girls, and current height and weight. Thirteen children had a very
high growth recovery rate from the time that they arrived in France.
For the period from time of adoption to the onset of puberty, mean
height increased from -1.3 to +1.5 SDS and the mean weight-for-
height factor increased from +1.2 to 1.9 SDS. The weight-height
recovery rate following adoption seems to be the direct cause of
early pubertal development in certain children, notably in those with
a particularly rapid growth rate (between 6 years 6 months and 8
years 9 months for the girls, and between 8 and 10 years for the
boys). In children adopted at an early age, a 'biological memory'
seems to exist regarding the renutrition phenomenon which was
instrumental in accelerating the onset of puberty some years after
adoption. In the adoptive families, the frequency of precocious
 30

L. Ben-Nun Adoption

puberty was 44.9% in the group of 49 girls compared to 8.6% in the

group of 35 adopted boys, and it mainly concerned children from
Africa (57%), followed by those from South and Central America
(57%), Asia (45%), and Eastern Europe (29%). The data indicate that
a higher rate of precocious puberty was found in the adopted girls,
with a significantly lower rate in the adopted boys. The etiological
factors involved seemed to be mainly nutritional, and influenced by
leptin and insulin-like growth factor 1 (IGF1) levels (22).
The number of children adopted from abroad by Italian families
has increased during the last years. Since 2001 to 2004 the number
was more than 10,000, mainly from Eastern Europe. Most of the
internationally adopted children reside in orphanage before adoption
where they may experience malnutrition, exposure to infectious
diseases, environmental deprivation, and neglect. Their pre-adoptive
records were scarcely reliable and their immunization status was not
always adequate. The most common long-term problems of
internationally adopted children concerned developmental and
scholastic delay especially if they came from a long and severely
deprived institutional setting, precocious puberty and, during
adolescence, depressive disorders as well as antisocial behaviors.
The data indicate that inter-country adopted children are at
increased risk for health and social problems and have to be
recognized as a group of subjects requiring special medical
attentions. Specialized centers for internationally adopted children
where they could receive medical evaluations upon arrival and a
prolonged health follow-up should be set up (23).
Nearly 220,000 children have been adopted from other countries
by American parents since 1986. Approximately 65,000 children have
arrived from China and Russia, mostly in the past 6 years. Most of
these children reside in orphanages before adoption, where they
may experience malnutrition, environmental deprivation, neglect,
and exposure to infectious diseases. After arrival to the U.S.,
international adoptees should undergo specialized screening
evaluation for infectious diseases and other conditions. Infectious
conditions of special concern include hepatitis B and C, syphilis, HIV
infection, tuberculosis, and presence of intestinal parasites. Before
the adoption occurs, the infectious disease consultant may assist the
primary care provider and the adoptive family with advice about
travel and review of preadoptive medical records. After the
 31

L. Ben-Nun Adoption

adoption, the infectious diseases consultant assess the adequacy of

the child's vaccination record from the birth country and to assist in
screening, evaluation, and management of infectious diseases (24).
International adoptions have become increasingly common in the
U.S. Children awaiting international adoption and families traveling
to adopt these children can be exposed to a variety of infectious
diseases. Compared with the U.S., foreign countries often have
different immunization practices and methods of diagnosing,
treating, and monitoring disease. Reporting of medical conditions
can also differ from that of the U.S. The prevalence of infectious
diseases varies from country to country and may or may not be
common among adopted children. The transmission of tuberculosis,
hepatitis B, and measles from adopted children to family members
has been documented. Infectious organisms (e.g., intestinal
parasites), bacterial pathogens (e.g., Bordetella pertussis and
Treponema pallidum), and viruses (e.g., HIV and hepatitis viruses)
may cause clinically significant morbidity and mortality among
infected children. Diseases such as severe acute respiratory
syndrome or avian influenza have not been reported among
international adoptees, but transmission is possible if infection is
present. Family members may be infected by others during travel or
by their adopted child after returning home. Families preparing to
adopt a child from abroad should pay special attention to the
infectious diseases they may encounter and to the precautions they
should take on returning home (25).
An update and overview of infectious disease issues in children of
international adoption are provided. International adoption by U.S.
families has decreased since 2004. Countries from where children
are adopted have changed by 2011, with Ethiopia the second largest
contributor of international adoptees after China. Since 2003,
international adoptees are older, as fewer young children (< 1 year of
age) have been available for adoption. Although children are
declared healthy in their home countries, medical disorders are often
missed or become apparent after adoption. Comprehensive
evaluations by providers in the U.S. after adoption frequently identify
unsuspected medical disorders, infections, as well as delayed or
incomplete vaccination in these recently adopted children. Early
identification of infections allows treatment of potential
communicable diseases and updating of immunizations. All
 32

L. Ben-Nun Adoption

international adoptees on arrival in the U.S. should be evaluated by a

health practitioner knowledgeable in adoption medicine to identify
medical problems, especially infections (26).
Celiac disease is an inflammatory disease of the small intestine. A
complete management and differential diagnosis of such disease
includes food intolerances, intestinal infections, and irritable bowel
syndrome. An 8-years-old adoptive girl from Congo with negative
medical history is described. Patient followed for recurrent
abdominal pain and diarrhea associated to Giardia infection,
u7nresponsive to antiparasitic therapy. Persistence of symptoms
despite antiparasitic therapy, prompted to perform: 1] Blood
screening of Celiac disease, which was negative; 2] Genetic
evaluation of celiac disease, which revealed the presence of HLA-DQ2
heterodimer; and 3] Esophagogastroduodenoscopy, which showed
duodenal villous atrophy and crypt hyperplasia, associated with
Helicobacter Pylori infection. The child was treated in accordance
with international recommendations using a gluten-free diet and
specific antibiotics, which lead to the resolution of the symptoms.
The patient's clinical history seems peculiar, considering that,
recurrent Giardiasis may mimic the symptoms of Celiac disease and
simulate clinical and histological picture of active Celiac disease (27).
Since 2000, American families have adopted 1,700 children from
Ethiopia. Retrospective chart reviews of the arrival health status of
all 50 (26F:24M) children from Ethiopia/Eritrea seen in the
International Adoption Clinic were evaluated. Prior to adoption,
most children resided with relatives; 36% were > 18 months old prior
to entry into care. More than 50% were true orphans, often due to
HIV. Arrival age ranged from 3 months to 15 years (mean +/- SD 4
years +/- 43.8 months). At arrival, growth z scores were near-average
(weight -.59, height -.64, head circumference -.09); significantly
better than adopted children from Guatemala, China, or Russia.
However, some Ethiopian children were significantly growth delayed.
Age at adoption did not relate to growth delays. Medical issues on
arrival included intestinal parasites (53%, [14% with ≥ 3 types]), skin
infections (45%), dental caries (25%), elevated liver transaminases
(20%), latent tuberculosis (18%), and hepatitis B (2%). Age-
appropriate vaccines had been administered in 15-77% of children
(depending on specific vaccine). Behavior problems were
uncommon. Gross/fine motor and cognitive skills were
 33

L. Ben-Nun Adoption

approximately 86% of expected for age. Age correlated inversely

with developmental scores for cognition (p=0.003). The data show
that Ethiopian/Eritean adoptees differ from other groups of
internationally adopted children: they reside for relatively long
periods of time with relatives prior to institutionalization, often have
uncertain ages, exhibit few behavioral problems at arrival, have
better growth, and may have less severe developmental delays.
Whether these differences at arrival predict better outcomes for the
Ethiopian/Eritrean children is unknown (28).

ASSESSMENT: there are various diseases that can be found in

adoptees. Did some physical disease afflict Moses? Moses’ medical
file, that is the biblical text, indicates no physical diseases. It can
therefore be concluded that Moses was a healthy child who did not
suffer from any physical disease.

References
1. Miler LC. Immediate behavioral and developmental considerations for
internationally adopted children transitioning to families. Pediatr Clin North Am.
2005;52:1311-30,vi-vii.
2. Johnson DE, Miller LC, Iverson S, et al. The health of children adopted from
Romania. JAMA. 1992;268:3446-51.
3 . Albers LH, Johnson DE, Hostetter MK, et al. Health of children adopted from
the former Soviet Union and Eastern Europe. Comparison with preadoptive medical
records. JAMA. 1997; 278:922-4.
4. Blizzard RM. Psychosocial short stature. In: Lifshitz F (ed.). Pediatric
Endocrinology. New York, NY, Marcel Dekker Inc. 1990, pp. 77-91.
5. Powell GF. Failure to thrive. In: Pediatric Endocrinology. New York, NY,
Marcel Dekker Inc. 1990, pp. 133-46.
6. Jenista JA, Chapman D. Medical problems of foreign-born adopted children.
Am J Dis Child. 1987;141:298-302.
7. Gracey M. The challenges of fostering infants and children. Acta Paediatr.
2003;92:787-9.
8. Siamwica R. AIDS and orphans: legal and ethical issues. SAfAIDS News.
1998;6:15-6.
9. Hostetter MK, Iverson S, Thomas W et al. Medical evaluation of
internationally adopted children. N Engl J Med. 1991;325:479-85.
10. Sokoloff B, Carlin J, Pham H. Five-year of Vietnamese refugee children in the
United States. Clin Pediatr (Phila). 1984;23:565-70.
11. Miler BS, Kroupina MG, Iverson SL, et al. Auxological evaluation and
determinants of growth failure at the time of adoption in Eastern European
adoptees. J Pediatr Metab. 2009;22:31-9.
12. Fuglestad AJ, Lehnman AE, Kroupina J. Iron deficiency anemia in
international adoptees from Eastern Europe. J Pediatr. 2008;153:272-7.
 34

L. Ben-Nun Adoption

13. Veneman NG, Waalkens HT, Tamminga RY. Anemia in adopted children not
always iron deficiency. Ned Tijdschr Geneeskd. 2006;150:1369-72.
14. Andersson Grönlund M, Landgren M, et al. Relationships between
ophthalmological and neuropaediatic findings in children adopted from Eastern
Europe. Acta Ophtalmol. 2010;88(2):227-34.
15. Cavero-Roig L, Díaz-Conradi Á, Negre-Loscertales A, et al. Eye disease in
international adoption: Importance of the region of origin. An Pediatr (Barc). 2015;
82(5):293-301.
16. Eckerle JK, Hill LK, Iverson S, et al. Vision and hearing deficits and
associations with parent-reported behavioral and developmental problems in
international adoptees. Matern Child Health J. 2014;18(3):575-83.
17. Cohen NJ, Lojkasek M, Zadeh ZY, et al. Children adopted from China: a
prospective study of their growth and development. J Child Psychol Psychiatry.
2008;49(4):458-68.
18. Miller L, Chan W, Comfort K, Tirella L. Health of children adopted from
Guatemala: comparison of orphanage and foster care. Pediatrics. 2005;
115(6):e710-7.
19. Kempers MJ, Otten BJ. Idiopathic precocious puberty versus puberty in
adopted children; auxological response to gonadotrophin-releasing hormone agonist
treatment and final height. Eur J Endocrinol. 2002;147(5):609-16.
20. Teilmann G, Pedersen CB, Skakkebaek NE, Jensen TK. Increased risk of
precocious puberty in internationally adopted children in Denmark. Pediatrics.
2006;118(2):e391-9.
21. Teilmann G, Petersen JH, Gormsen M, et al. Early puberty in internationally
adopted girls: hormonal and clinical markers of puberty in 276 girls examined
biannually over two years. Horm Res. 2009;72(4):236-46.
22. Baron S, Battin J, David A, Limal JM. Precocious puberty in children adopted
from foreign countries. Arch Pediatr. 2000;7(8):809-16.
23. Cataldo F, Accomando S, Porcari V. Internationally adopted children: a new
challenge for pediatricians. Minerva Pediatr. 2006;58(1):55-62.
24. Miller LC. International adoption: Infectious diseases issues. Clin Infect Dis.
2005;40(2):286-93.
25. Staat DD, Klepser ME. International adoption: issues in infectious diseases.
Pharmacotherapy. 2006;26(9):1207-20.
26. Ampofo K. Infectious disease issues in adoption of young children. Curr
Opin Pediatr. 2013;25(1):78-87.
27. Tchidjou HK, De Matteis A, Di Iorio L, Finocchi A. Celiac Disease in an
Adoptive Child with Recurrent Giardia Infection. Int J Health Sci (Qassim). 2015;
9(2):193-7.
28. Miller LC, Tseng B, Tirella LG, et al. Health of children adopted from Ethiopia.
Matern Child Health J. 2008 ;12(5):599-605.
 35

L. Ben-Nun Adoption

PSYCHOSOCIAL PROBLEMS. Although the majority of adopted

children are well adjusted, adopted children evidence proportionally
more behavioral problems when compared to nonadopted children.
The existing literature is organized into five explanatory models: 1]
genetic or "biosocial" factors, 2] pathogenesis of the adoption
process, 3] long-term effects of impaired preadoption childrearing, 4]
referral bias in adoptive parents, and 5] impaired adoptive parent-
adoptee relations. A psychosocial model to explain the high rate of
behavior problems among adopted children is highly plausible and
further suggests that it comes time for a new awareness and
appreciation for the normative aspects of adoption (1).
Many interacting forces shape the unique experience of adoption.
The adoptive parents' fantasies, fears, and perceived lack of
entitlement to the child can detrimentally influence their parenting
abilities. The adopted child's powerful needs to master early
abandonment may lead to maladaptive behaviors; the adoptive
parents are confronted with fears and fantasies regarding the child's
past and future (2).
Serious emotional and behavioral problems, poor school
achievements (3-7), cognitive problems (8,9), rocking, self-injury,
unusual sensory interests, and eating problems (10) characterize
foster children. Maladaptive behaviors, including episodes of anger
and unprovoked acting out (often diagnosed as attachment disorder)
may be severe and can be detrimental to a child’s integration into a
new family (11). Reactive attachment disorder, pervasive
developmental disorder, oppositional defiant disorder, and ADHD
represent a cluster of specific and less-specific behaviors occurring
over time are associated with impairments in social and interpersonal
functions and educational achievements (12). Other disorders
include depression, anxiety, fetal alcohol syndrome, central auditory
processing disorder, learning disabilities, mental retardation, solitary
play, temper tantrums, gaze aversion or shyness, enuresis (13,14),
and speech and language delays (15).
Internationally adopted children are often delayed in their
development and demonstrate more behavior problems than
nonadopted children due to adverse preadoption circumstances.
This is especially true for children adopted from Eastern European
countries. This paper presents results from an ongoing longitudinal
study of 119 internationally adopted children from non-European
 36

L. Ben-Nun Adoption

countries during their first two years in Norway. Several scales

measuring different aspects of the children's development are
included in the study: communication and gross motor development,
temperamental characteristics, and behavior problems. The results
show that internationally adopted children are delayed in their
general development when they first arrive in their adoptive families.
After two years the children have made significant progress in
development. However, they still lag behind in communication and
motor skills compared to non-adopted children. The temperamental
characteristics seem very stable from time of adoption until two
years after adoption. The children demonstrate a low frequency of
behavior problems. However, the behavior problems have changed
during the two years. At time of adoption they show more
nonphysically challenging behavior while after two years their
physically challenging behavior has increased (16).
Adoption studies provide important insights into the impact of
changed rearing environments for children's development. A
number of studies reporting on the childhood adjustment of
adoptees have found an increased risk for disruptive behavior
problems when compared with children brought up in intact families.
Adopted women showed positive adult adjustment across all the
domains examined, while adopted men demonstrated some difficulty
in two specific domains - employment and social support (17).
This was a five-year follow-up of adopted children and
adolescents. Thirty-five adoptees and 23 control subjects were
assessed. Five years earlier, the initial sample consisted of 57 pairs of
adoptees and controls. The results showed that both adopted and
control subjects were improved at the follow-up assessment and that
there were insignificant differences in clinical diagnosis and social
adaptation between the groups. Compared with the controls, the
adoptees were scored higher on a behavior scale (Revised Behavior
Problem Checklist) by parents. Adoption at six month of age was
associated with better overall psychosocial functioning. Significantly
more adoptees were not living with their adoptive families (18).
Conduct and emotional difficulties were assessed in a group of
Romanian adoptees at age 11, and served as a follow-up to
assessments performed when the children were 6 years old. There
was a significant increase in emotional difficulties, but no conduct
problems for the Romanian sample since age 6. Emotional difficulties
 37

L. Ben-Nun Adoption

were significantly more prevalent at age 11 in the Romanian group

than in a within-UK adoptee group. These difficulties in the
Romanian adoptee group were significantly and strongly related to
previous deprivation-specific problems (disinhibited attachments,
cognitive impairment, inattention/overactivity and quasi-autism);
however, the presence of such early problems did not account fully
for the onset of later emotional problems (19).
With the increase in the number of children being adopted by
Israeli families from abroad, the medical system has to face
heretofore with unfamiliar medical and developmental challenges.
Many of the biological mothers of these children were substance
abuse and suffered from a variety of illnesses and nutritional
deficiencies during their pregnancy. Their infants and young children
were placed in orphanages at a very young age. The ensuing
emotional and environmental deprivation in many cases affected
negatively the neurological, physical and emotional development of
these children (20).

Moses. Rafael.

Findings on the role of preadoption adversity on long-term

clinical-range problems in adopted Chinese girls are reported. Four
waves (2005, 2007, 2009 and 2011) of problem behavior data on
1,223 adopted Chinese girls (M = 4.86 years, SD = 2.82 in 2005) were
collected from the adoptive mothers with the CBCL. At Wave 1
(2005), data on the following indicators of preadoption adversity was
collected: age at adoption, physical signs/symptoms (e.g., sores) of
preadoption adversity, developmental delays at arrival,
refusal/avoidance behaviors and crying/clinging behaviors toward
 38

L. Ben-Nun Adoption

adoptive parents during the first 3 weeks of adoption. The

percentage of clinical-range internalizing problems was 11.1%, 16.5%,
11.3%, and 16.1% at Wave 1, Wave 2, Wave 3, and Wave 4,
respectively; the corresponding percentage of clinical-range
externalizing problems was 8.4%, 10.5%, 8.4% and 9.9%, respectively;
and the corresponding percentage of clinical-range total CBCL
problems was 9.3%, 13.0%, 9.8% and 12.6%, respectively. Controlling
for demographic variables, indicators of preadoption adversity,
except age at adoption, increased the odds for clinical-range behavior
problems. Longitudinal path models revealed that controlling for
demographic variables and the children's adjustment status in the
previous wave, refusal/avoidance remained significant in predicting
clinical-range internalizing, externalizing and total CBCL problems at
Wave 2, delays at arrival and signs/symptoms were significant in
predicting clinical-range internalizing problems at Wave 3. Overall,
adoptees with clinical-range CBCL problems in earlier waves were 9-
28 times to show clinical-range CBCL problems in subsequent waves
(21).
The term adoption or adoptive filiations is understood as referring
to the legal act by which family ties are created between two persons
such that a relationship of fatherhood or motherhood is established
between them. The problems derived from prenatal exposure to
alcohol and other risk factors, from hypostimulation during the
'critical period' in institutionalized patients (especially those adopted
from eastern European countries) and their relation with ADHD were
outlined. Deeper look into the diagnosis, prevention and treatment
of these problems was evaluated. These children have problems in
terms of psychosocial relationships, behavioral problems, delayed
language or reading development and, above all, ADHD. In practice,
it is extremely difficult to separate the two factors during the
assessment of children adopted from eastern European countries in
neuropaediatric consultations. Exactly how all these factors are
interrelated is not well understood. The data indicate that there is a
close relationship between prenatal exposure to alcohol and the
consequences of adoption (22).
Research on adjustment of internationally adopted children
indicates that, although they have adequate development, more
emotional and behavioral problems are detected compared with
nonadopted children. Emotional and behavioral characteristics of a
 39

L. Ben-Nun Adoption

sample of 52 internationally adopted minors were examined with the

BASC, comparing the outcomes with 44 nonadopted minors, all of
them of ages between 6 and 11 years (mean age = 8.01 years).
Results indicate differences between adopted and nonadopted
children related to somatization, adopted minors are those that
obtain lower scores in the scale, and in the adaptability scale, where
nonadopted minors obtain higher scores. Significant differences
were found in the adaptive abilities scales, suggesting that
nonadopted boys show better abilities than adopted ones, while no
differences were found among girls. In general, boys present higher
scores in externalizing symptomatology and depression than girls.
Among adopted children, time spent in an institution is a variable
that has negative impact on the onset of externalizing and
internalizing problems. Minors coming from Eastern Europe display
more attention problems, poorer adaptive abilities and poorer
interpersonal relations than the rest of the minors. According to the
age at placement, attention problems appear in minors adopted after
the age of three years (24).
Behavior problems were investigated in 342 6- to 18-year-old
children adopted from psychosocially depriving Russian institutions
that provided adequate physical resources but not consistent,
responsive caregiving. Results indicated that attention and
externalizing problems were the most prevalent types of behavior
problems in the sample as a whole. Behavior problem rates
increased with age at adoption, such that children adopted at 18
months or older had higher rates than never-institutionalized
children but younger-adopted children did not. There was a stronger
association between age at adoption and behavior problems during
adolescence than at younger ages at assessment. Children adopted
from psychosocially depriving institutions had lower behavior
problem rates than children adopted from severely depriving
Romanian institutions in the 1990s. Early psychosocial deprivation is
associated with behavior problems, children exposed to prolonged
early deprivation possibly are especially vulnerable to the
developmental stresses of adolescence, and severe institutional
deprivation is associated with a higher percentage of behavior
problems after a shorter duration of exposure (25).
With the increase in international adoptions during the last
decade, many researchers have investigated the developmental
 40

L. Ben-Nun Adoption

outcomes of these adoptees, including their extreme behaviors.

Collectively, these results have not always appeared consistent
across studies, perhaps because studies have used children reared in
institutions or not, the institutional environments vary in severity,
children spend different lengths of time in the institution and are
assessed at different ages, and studies use different outcome
measures. In an attempt to discern more order in the literature, this
review focuses on 18 studies, each of which used the CBCL, and their
outcomes are viewed with respect to these parameters. Results
suggest that the major factor contributing to extreme behaviors is
age at adoption, with those adopted after 6/18 months having more
behavior problems, especially Internalizing, Externalizing, and
Attention problems. Generally, samples of post-institutional children
have more problems than samples of mixed or non-institutional
internationally adopted children, and some problems are more likely
to be manifest in adolescence, suggesting the effects of deficient
early experiences are not simply the persistence of learned behavior
but more general dispositions that become more noticeable or
severe during adolescence. Early deficient social-emotional
caregiver-child interactions characterize most institutional
environments as a possible major cause of later difficulties in post-
institutionalized children (26).
International adoption involves more than 40,000 children a year.
The effects of international adoption on externalizing behavior
problems during adolescence are estimated. The prevalence of
externalizing problem behaviors in samples of adolescents who were
adopted from a foreign country as infants or young children was
compared to non-adopted adolescents. Medline, Inist and psycInfo
were searched from 1960 to 2005 using the terms adopt* combined
with behavior problem, behavior disorder, maladjustment or mental
health. The search was limited to English and French-language
publications. Studies that were selected involved adoptees in the
general population and compared international adoptees with non-
adopted controls. Adoptees from 12 to 22 years old were included.
Studies using the CBCL or related measures to measure externalizing
problem behavior were included. Ten studies from 1990 to 2002 and
two meta-analyses (2003, 2005) were reviewed. Six studies conclude
that internationally adopted adolescents exhibit more externalizing
behavior problems than do non-adopted adolescents, and four
 41

L. Ben-Nun Adoption

studies conclude that there is no difference between the two groups.

The two meta-analyses conclude that the prevalence of externalizing
behavior problems is increased. The difference, however, is small.
International adoptees with preadoption adversity show more
externalizing problems than international adoptees without evidence
that extreme deprivation adoption is not a risk factor in the
adjustment of adolescents. Differences between groups of adopted
and non-adopted adolescents may reflect the presence of a small
number of severely disturbed adolescents, possibly with extremely
adverse pre-placement histories (27).
Children adopted internationally and their families are a
heterogeneous group. Internationally-adopted children have a range
of developmental and behavioral difficulties. The current evidence
documenting developmental outcomes for children and common
behavioral and mental health concerns, including attachment
difficulties, may impact children and their families after international
adoption. Pediatricians must be thoughtful to individualize the care
of adoptive children and not make assumptions shortly after
adoption. It is critical to avoid using "standard" parenting advice that
may not apply to children who have experienced loss, deprivation,
separation, and instability in their early lives. By listening to families,
carefully evaluating children, and monitoring progress over time,
pediatricians can avoid the pitfall of oversimplifying and
underestimating the complexity and challenges that these families
face. Instead, pediatric primary care providers can play a key role in
maximizing the potential of an internationally adopted child and his
or her family (28).
The cross-sectional relationship between child conduct problems
and parent-child conflict at least partially originates in the shared
environment. However, as the direction of causation between
parenting and delinquency remains unclear, this relationship could
be better explained by the adolescent's propensity to elicit conflictive
parenting, a phenomenon referred to as an evocative gene-
environment correlation. Thus, the prospective relationship between
conduct problems and parent-child conflict in a sample of adoptive
families was examined. Participants included 672 adolescents in 405
adoptive families assessed at two time points roughly four years
apart. Results indicated that parent-child conflict predicts the
development of conduct problems, whereas conduct problems do
 42

L. Ben-Nun Adoption

not predict increases in parent-child conflict. Such findings suggest

that evocative gene-environment correlations are highly unlikely to
be an explanation of prior shared environmental effects during
adolescence. Because the adolescents in this study do not share
genes with their adoptive parents, the association between conduct
problems and parent-child conflict is indicative of shared
environmental mediation in particular (29)..

ASSESSMENT: various psycho social problems can be related to

adoption. Was Moses afflicted by some psychological disorder? An
answer is found in a subsequent event. When Moses was an adult,
he killed an Egyptian man because he was beating a Hebrew slave.
This episode indicates that Moses knew his identity, that is, that he
was a Jew, and opposed the repressive policies towards the Jews of
his adoptive father, Pharaoh, the powerful ruler of Egypt. Moses was
raised and educated in an Egyptian family and could have remained
an Egyptian. But, as the Jew he relinquished his luxurious life and a
bright future as an Egyptian and devoted entirely to a single mission –
to lead the Jewish people out of Egypt. So duality of feelings, on the
one side his connection with his Egyptian family and on the other the
devotion to the Jewish people, led to some emotional distress
expressed by the upheaval when Moses killed an Egyptian oppressor.
Nevertheless, there is no data to indicate any severe mental disorder
in Moses.

References
1. Peters BR, Atkins MS, McKay MM. Adopted children's behavior problems: a
review of five explanatory models. Clin Psychol Rev. 1999;19:297-328.
2. Derdeyn AP, Graves CL. Clinical vicissitudes of adoption. Child Adolesc
Psychiatr Clin N Am. 1998;7:373-88.
3. Albers LH, Johnson DE, Hostetter MK, et al. Health of children adopted from
the former Soviet Union and Eastern Europe. Comparison with preadoptive medical
records. JAMA. 1997;278:922-4.
4. Moffat ME, Peddie M, Stulginskas J, et al. Health care delivery to foster
children: a study. Health Soc Work. 1985;10:129-37.
5. Simms MD. The foster care clinic: a community program to identify treatment
needs of children in foster care. J Dev Behav Pediatr. 1989;10:121-8.
6. Dubowitz H, Feigelman S, Zuravin S, et al. The physical health of children in
kinship care. Am J Dis Child. 1992;146:603-10.
7. Simms MD, Halfon N. The health care needs of children in foster care: a
research agenda. Child Welfare. 1928;73:505-24.
 43

L. Ben-Nun Adoption

8. Morrison SJ, Ames EW, Chisholm K. The development of children adopted

from Romanian Orphanages. Merril Palmer Q . 1995;41:411-30.
9. Rutter M, the English and Romanian Adoptee Study Team. Developmental
catch-up and delay following adoption after severe global early privation. J Child
Psychol Psychiatry. 1998;39:465-76.
10. Becket C, Bredenkamp D, Castle J, et al. Behavior patterns associated with
institutional deprivation: a study of children adopted from Romania. J Dev Behav
Pediatr. 2002;23:297-303.
11. Gracey M. The challenges of fostering infants and children. Acta Paediatr.
2003;92:787-9.
12. Stein MT. Challenging case. International adoption: a four-year-old child
with unusual behaviors adopted at six months of age. J Dev Behav Pediatr. 2003;
24:69.
13. Blizzard RM. Psychosocial short stature. In: Lifshitz F (ed.). Pediatric
Endocrinology. New York, NY, Marcel Dekker Inc. 1990, pp. 77-91.
14. Powell GF. Failure to thrive. In: Pediatric Endocrinology. New York, NY,
Marcel Dekker Inc. 1990, pp. 133-46.
15. Croft C, Beckett C, Rutter M, et al. Early adolescent outcomes of
institutionally-deprived and non-deprived adoptees II: language as a protective
factor and a vulnerable outcome. J Child Psychol Psychiatry. 2007;48:31-44.
16. Dalen M, Theie S. Internationally adopted children from non-European
countries: general development during the first two years in the adoptive family.
ScientificWorldJournal. 2012;2012:375436.
17. Collishaw S, Maughan B, Pickles A. Infant adoption: psychosocial outcomes in
adulthood. Soc Psychiatry Psychiatr Epidemiol. 1998;33:57-65.
18. Kotsopoulos S, Walker S, Copping W, et al. A psychiatric follow-up study of
adoptees. Can J Psychiatry. 1993;38:391-6.
19. Colvert E, Rutter M, Beckett C, et al. Emotional difficulties in early
adolescent following severe early deprivation: findings from the English and
Romanian adoptees study. Dev Psychopathol. 2008;20:547-67.
20. Senecky Y, Diamond G, Sapir T, Inbar D. Growth and development aspects of
international adoption. Harefuah. 2003;142:694-717.
21 . Tan TX, Camras LA, Kim ES. Preadoption Adversity and Long-Term Clinical-
Range Behavior Problems in Adopted Chinese Girls. J Couns Psychol. 2016 Jan 11.
[Epub ahead of print]
22. Fernández-Mayoralas DM, Fernández-Perrone AL, López-Arribas S, Pelaz-
Antolín A, Fernández-Jaén A. Attention deficit hyperactivity disorder and adoption.
Rev Neurol. 2015;60 Suppl 1:S103-7.
23. Bimmel N, Juffer F, van IJzendoorn MH, et al. Problem behavior of
internationally adopted adolescents: a review and meta-analysis. Harv Rev
Psychiatry. 2003;11(2):64-77.
24. Barcons-Castel N, Fornieles-Deu A, Costas-Moragas C. International
adoption: assessment of adaptive and maladaptive behavior of adopted minors in
Spain. Span J Psychol. 2011;14(1):123-32.
25. Merz EC, McCall RB. Behavior problems in children adopted from
psychosocially depriving institutions. J Abnorm Child Psychol. 2010;38(4): 459-70.
 44

L. Ben-Nun Adoption

26. Hawk B, McCall RB. CBCL behavior problems of post-institutionalized

international adoptees. Clin Child Fam Psychol Rev. 2010;13(2):199-211.
27. Harf A, Taïeb O, Moro MR. Externalizing behaviour problems of
internationally adopted adolescents: a review. Encephale. 2007;33(3 Pt 1):270-6.
28. Weitzman C, Albers L. Long-term developmental, behavioral, and
attachment outcomes after international adoption. Pediatr Clin North Am. 2005;
52(5):1395-419, viii.
29. Klahr AM, McGue M, Iacono WG, Burt SA. The association between parent-
child conflict and adolescent conduct problems over time: results from a longitudinal
adoption study. J Abnorm Psychol. 2011;120(1):46-56.

DEVELOPMENTAL DELAYS. Developmental delays include gross

motor delays, fine motor, and speech and language delays (1-4).
Evaluation of children at adoption indicates 70% delays in gross
motor skills, 82% in fine motor, 53% in social and emotional skills,
and 59% in language skills (1).
Most international adoptees have rapid catch-up of the delays
common at arrival. Language, fine motor, visual reception, executive
function, attention, and sensory skills in international adoptees
preschoolers were evaluated. It was hypothesized that pre-adoptive
risk factors, development at arrival, and the post-adoptive
environment (time in day care) would predict developmental and
behavioral outcomes and school readiness. Thirty seven
international adoptees (12M:25F), aged 4-5 years previously seen in
the clinic (mean arrival age 12 months), were evaluated with
standardized tests of development, language, executive function,
attention, and sensory skills, along with demographic information,
parent interview, and review of arrival clinic records. Fine motor and
visual reception skills at arrival ranged from average to very below
average. At follow up, most international adoptees were average or
above average in fine motor, visual reception, and language skills, but
many had concerning scores for attention (42%), executive function
(11%) and sensory skills (48%). Arrival expressive language T scores
(Mullen) predicted follow-up scores for expressive language
(p=0.005). Arrival fine motor scores (Mullen) correlated with follow-
up auditory comprehension scores (p=0.002) and inversely with
inattention scores (p=0.003). Arrival visual reception scores
correlated inversely with global measures of attention (p=0.005,
ADHD scores (p=0.002, and to a lesser extent hyperactivity (p=0.03).
 45

L. Ben-Nun Adoption

Age at arrival was a strong predictor of language performance,

attention regulation, executive function, and sensory processing.
Children who spent more time in day care had significantly more
difficulty with emotional control (p=0.005). Although international
adoptees have good catch-up in specific areas of development,
difficulties with attention regulation, executive function, and sensory
processing may increase the risk of later school problems (5).
The development of a sample of 106 (67 girls) internationally
adopted children over a period of 18 months was followed. Children
were adopted from five birth regions, including China, Korea, Latin
America, Eastern Europe, and other Asian countries. Mean age at
adoption was 11 months. Mothers completed the Ages and Stages
Questionnaire at 6, 12, and 24 months post-adoption, assessing
children's gross and fine motor, communicative, personal-social, and
problem solving skills. The sample as a whole demonstrated linear
improvement over time in most developmental domains, but
children with initially low scores remained significantly lower than
other children at the 18-month follow-up. At the first time point,
communication was the domain where children most commonly
experienced delays. Children with medical problems had significantly
lower developmental scores than those without medical diagnoses.
Ages and Stages Questionnaire scores were unrelated to age at
adoption, but significant differences by birth country region were
found. Across most domains, children adopted from Eastern Europe
showed generally lower scores than children adopted from other
birth regions (7).
The extent of developmental delays in girls adopted from China,
their subsequent early intervention enrollment, and the delays and
early intervention related to their academic performance and
internalizing problems in adolescence were examined. The sample
included 180 adolescent girls (M = 13.4 years, SD = 2.0 years) who
were adopted at 3-23.5 months (M = 11.5 months, SD = 3.7 months).
Data on the adopted Chinese girls' delays at arrival and early
intervention enrollment in physical therapy and speech-language
therapy were collected from the adoptive mothers at the Baseline;
data on the adopted Chinese girls' present academic performance
and internalizing problems were collected from the adoptive mothers
and adopted girls at Wave 4 six years later. Of the adoptees, 55%
had moderate-to-severe delays when first arrived at the adoptive
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L. Ben-Nun Adoption

homes. Motor delays significantly increased the odds for physical

therapy (OR 3.98, 95% CI 2.18-7.82, p<0.001) and speech-language
therapy (OR 2.36, 95% CI 1.50-3.72, p<0.001). Social-cognitive delays
significantly increased the odds for physical therapy (OR 1.90, 95% CI
1.36-2.63, p <0.001) and speech language therapy (OR 1.63, 95% CI
1.22-2.17], p<0.001). Motor delays were negatively associated with
academic performance but positively associated with internalizing
problems. The adoptees who had developmental delays at arrival
and subsequently enrolled in early intervention scored significantly
lower on academic performance than their peers who had delays but
did not enroll in early intervention, as well their peers who had no
delays and did not enroll in early intervention (8).
Internationally adopted children often have delays at adoption
and undergo massive catch-up after adoption. Before achieving
developmental catch-up, however, delays at adoption present a risk
for internationally adopted children's adjustment, but it remains
unknown whether such delays foreshadow internationally adopted
children's outcomes after catch-up development has completed or
ceased. In the current analysis, menarche as a practical marker was
utilized to indicate the cessation of developmental catch-up. Delays
at arrival predicted long-term outcomes in 132 postmenarcheal teens
(M = 14.2 years, SD = 1.7) who were adopted from China at 16.6
months (SD = 17.1). In 2005, adoptive parents provided data of
medical evaluation results on their children's delay status in gross
motor skills, fine motor skills, social development, emotional
development, and cognitive development. Six years later in 2011,
data on parent-child relationship quality were collected from parents,
and data on the adoptees' academic competence and internalizing
problems were collected from both parents and adoptees. The data
indicated that gross motor delay at arrival predicted academic
performance (parent-report: b = -0.34, p<0.01) and internalizing
problems (self-report: b = 0.26, p<0.05; parent-report: b = .33,
p<0.01). Other delays were insignificant in predicting any of the
outcomes (9).
The behavioral development of 4- to 8-year-old South Korean
children placed in institutional care (n=230) or adopted
internationally (n=382) was compared with age of entry, parental
status, reason for institutionalization, and postinstitutionalization
parental contact as risk factors for institutionalized children. There
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L. Ben-Nun Adoption

was a placement effect of adoption and support for age of entry and
parental status as risk factors. Relinquished children institutionalized
before age two fared the poorest across groups. Children after age
two with deceased/unknown parents fared best among
institutionalized children. Institutionalization due to family
disruption was a risk for relinquished children only, whereas parental
contact did not increase the risk for behavioral problems (10).

ASSESSMENT: developmental delays include gross motor delays,

fine motor, and speech and language delays. Internationally adopted
children often have delays at adoption and undergo massive catch-up
after adoption. Gross motor delay at arrival predicted academic
performance. Children with medical problems had significantly lower
developmental scores than those without medical diagnoses.
The Biblical text states that Moses biological mother attempted to
save his life from the cruel decree of Pharaoh to kill all newborn
Jewish males, by putting him into a crib among the reeds on the
banks of the Nile. Fortunately, Moses was saved when Pharaoh’s
daughter adopted him. Baby Moses was lucky since his biological
mother suckled him even after his adoption. This factor had a
positive effect on the child’s development and provided Moses with
the self-confidence he needed in his entire life. We have insufficient
evidence to suggest that Moses suffered from some type of delay in
gross motor, fine motor, social and emotional skills.

References
1. Albers LH, Johnson DE, Hostetter MK, et al. Health of children adopted from
the former Soviet Union and Eastern Europe. Comparison with preadoptive medical
records. JAMA. 1997;278:922-4.
2. Becket C, Bredenkamp D, Castle J, et al. Behavior patterns associated with
institutional deprivation: a study of children adopted from Romania. J Dev Behav
Pediatr. 2002;23:297-303.
3. Dubrovina I. Psychological Development of Children in Orphanages. Moscow:
Prosvechenic Press. 1991.
4. Groze V, Ileana D. A follow-up study of adopted children from Romania. Child
Adoles Soc Work. 1996;13: 541-65.
5. Jacobs E, Miller LC, Tirella LG. Developmental and behavioral performance of
internationally adopted preschoolers: a pilot study. Child Psychiatry Hum Dev. 2010;
41(1):15-29.
7. Welsh JA, Viana AG. Developmental outcomes of internationally adopted
children. Adopt Q. 2012;15(4):241-264.
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L. Ben-Nun Adoption

8. Tan TX. Developmental delays at arrival, early intervention enrollment, and

adopted Chinese girls' academic performance and internalizing problems in
adolescence. J Genet Psychol. 2 014;175(3-4):318-31.
9. Tan TX, Rice JL, Mahoney EE. Developmental delays at arrival and
postmenarcheal Chinese adolescents' adjustment. Am J Orthopsychiatry. 2015;
85(1):93-100.
10. Lee RM, Seol KO, Sung M, et al. The behavioral development of Korean
children in institutional care and international adoptive families. Dev Psychol. 2010;
46(2):468-78.

LANGUAGE AND SPEECH DISORDER – MOSES "SLOW OF SPEECH AND

SLOW OF TONGUE". Moses, the greatest national leader of his time,
occupies a unique place in the history of the Jewish people because
of what he achieved: he turned a rabble of slaves into a nation, and
led them out of Egypt, from slavery to freedom. He was a religious
and spiritual leader, who led the Children of Israel for forty years in
the Sinai Desert, where he gave them the Torah, judged them, set up
the Tent of Congregation, but did not enter the Land of Israel and his
place of burial is unknown (2).
Moses son of Amram and Yocheved, who is now known as “Moses
our Teacher” suffered from language and speech impediment.
Moses’ medical record is displayed before us when Moses is ordered
to lead the Children of Israel out of Egypt, and his reply as given in
Exodus is: “I am not eloquent, neither heretofore, nor since thou hast
spoken unto thy servant: but I am slow of speech, and of a slow tongue”
(Exodus 4:10), and “…I am stammerer..” (6:12). And indeed he was
accompanied by his brother Aharon, who acted as his spokesperson,
as it is written: “…Aaron thy brother shall speak unto Pharaoh…” (7:12). It
can be concluded, therefore, on the basis of what is written in the
Bible, that Moses had a speech impediment (3,4).
The purpose of this research was to review and examine, in the
light of contemporary medical definitions, the language and speech
disorder possibly suffered by Moses: was he afflicted with
stammering, or was it just an inability to speak eloquently before the
King?
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Moses. 1610. Guido Reni. 1610.

Galleria Borghese, Roma.

Language is the expression of human communication through

which knowledge, belief, and behavior can be experienced,
explained, and shared. This sharing is based on systematic,
conventionally used signs, sounds, gestures, or marks that convey
understood meanings within a group or community. Recent research
identifies "windows of opportunity" for acquiring language, written,
spoken, or signed, that exist within the first few years of life (1).
Between six and eight million individuals in the U.S. have some
form of language impairment. Disorders of language affect children
and adults differently. For children who do not use language
normally from birth, or who acquire impairment during childhood,
language may not be fully developed or acquired. Many children
who are deaf in the U.S. use a natural sign language known as
American Sign Language. U.S. shares an underlying organization with
spoken language and has its own syntax and grammar. Many adults
acquire disorders of language because of stroke, head injury,
dementia, or brain tumors. Language disorders also are found in
adults who have failed to develop normal language skills because of
mental retardation, autism, hearing impairment, or other congenital
or acquired disorders of brain development (1).
Primary or SLI are diagnosed in children who have clinically
significant impairments in their development of spoken language in
the absence of sensory or neurodevelopmental disorders. Spoken
language in this case includes the ability to understand words,
sentences, and connected speech as well as the ability to express
messages using appropriate vocabulary, grammar, and discourse.
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Standards for the diagnosis of SLI vary and therefore prevalence

estimates across studies vary accordingly. Variation in prevalence
appears to be affected by a pattern of recovery for many children
during the early preschool years. Much greater stability over age is
seen in children during the school years (1).

References
1. Statistics on Voice, Speech, and Language. Available 10 February 2016 at
http://www.nidcd.nih.gov/health/statistics/pages/vsl.aspx.
2. Biblical Encyclopedia. Yediot Acharonot. The Jerusalem Publishing House.
1987, Vol. 3.
3. Ben-Nun L. Moses. Language and speech disorder – Moses "Slow of speech
and slow of tongue". In: Ben-Nun L. (ed.) The Medical record and the family Life
Cycle of the Great Leader of the Jewish people. 2010;43-54.
4. Ben-Noun L. Speech disorder in biblical times - Moses: a heavy mouth and a
heavy tongue. Harefuah. 1999;136:906-8.

THE BIBLICAL STORY. When Moses was three months old, in an

attempt to save him, his mother put him in a crib among the reeds on
the bank of the Nile, where he was found by Pharaoh’s daughter who
took pity on him, took him with her and thus saved his life. She gave
him the name of Moses, meaning “son” in Egyptian, although the text
explains the name with the words “because I drew him out of the water”
(Exodus 2:10). He was adopted and grew up and was educated in the
house of Pharaoh. As an adult he had to flee Egypt after he slew an
Egyptian oppressor who was beating a Hebrew slave. He fled into
the Sinai desert, and there he saved the daughters of Jethro, Priest of
Midian, from the shepherds who drove them out, and married one of
them, Zipporah. The turning point in his life came when he was
commanded to return to Egypt and free his people from slavery, with
a direct appeal to the King of Egypt: “….Let my people go…” (5:1). In
reply, Moses argued: “I am not eloquent, neither heretofore, nor since
thou hast spoken unto thy servant: but I am slow of speech, and of a slow
tongue (a heavy mouth and a heavy tongue)” (4:10) and “…I am
stammerer..” (6:12). So he was accompanied by his brother Aharon,
who acted as his spokesman, as it is written: “…Aaron thy brother shall
speak unto Pharaoh…” (7:2).
Here Moses announces that he suffers from a speech
impediment. What would be the modern definition of this type of
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L. Ben-Nun Adoption

disorder? Was Moses a stammer, and if so, what symptoms did it

represent? Or was it just that Moses did not have the eloquence
required to speak with the King of Egypt?

References
1. A New Hebrew Concentrated Dictionary. Abraham Even Shoshan (ed.). Kiryat
Shepher. 1980.
2. Even Odem J, Rotem Y. New Medical Dictionary. Rubin Mass Publishing
House, Jerusalem, 1967.

LANGUAGE AND SPEECH DEVELOPMENTAL DISORDER. The first

signs of communication occur when an infant learns that a cry will
bring food, comfort, and companionship. Newborns also begin to
recognize important sounds in their environment, such as the voice
of their mother or primary caretaker. As they grow, babies begin to
sort out the speech sounds that compose the words of their
language. By 6 months of age, most babies recognize the basic
sounds of their native language. Children vary in their development
of speech and language skills. However, they follow a natural
progression or timetable for mastering the skills of language. The
milestones for the normal development of speech and language skills
in children from birth to five years of age is help doctors and other
health professionals determine if a child is on track or if he or she
may need extra help. Sometimes a delay may be caused by hearing
loss, while other times it may be due to a speech or language
disorder. Children who have trouble understanding what others say
(receptive language) or difficulty sharing their thoughts (expressive
language) may have a language disorder. SLI is a language disorder
that delays the mastery of language skills. Some children with SLI
may not begin to talk until their third or fourth year. Children who
have trouble producing speech sounds correctly or who hesitate or
stutter when talking may have a speech disorder. Apraxia of speech
is a speech disorder that makes it difficult to put sounds and syllables
together in the correct order to form words (1).
Language disorders are identified when a person has difficulty
with expressive language, receptive language, or pragmatic language.
Speech disorders are identified when a person's voice, fluency, or
articulation call attention to the speaker because his or her speech is
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L. Ben-Nun Adoption

sufficiently different from the norm. Speech and language

development can be detected using typical milestone markers (2).
Language and literacy play a larger role in adolescence
independent functioning than nonverbal abilities in both typically
developing adolescents and adolescents with specific language
impairment (3).
Delay in acquiring language and speech is the most common form
of this developmental disorder in children, and there are two main
types - difficulties in understanding language (receptive type) and
difficulties in speaking, defective oral expression (expressive type)
(4). The reasons for the delay in acquiring language and speech
include: defective hearing at various levels up to complete deafness,
repeated inner ear infections, cognitive disturbance, mental
retardation, autism, environmental deprivation, unstimulating
environment, delayed maturity where language structure and speech
are correct but are suitable to a lower chronological age (5-7).
Specific developmental disorder of speech and language is part of
a more general category of neurodevelopmental disorders, which is
encountered in 7-10% of the childhood population. These children
exhibit a significant impairment in speech and language
development, which cannot be justified by hearing impairment,
cognitive impairment, neuromuscular or orofacial disorders, as well
as by emotional or environmental factors. Specific developmental
disorders of speech and language are often comorbid with other
neurodevelopmental disorders, such as motor coordination disorder
and ADHD. These disorders are usually detected in early childhood
and commonly treated during the preschool and school years.
Despite this fact clinical and empirical evidence suggest that often
these disorders persist beyond the school years, even though the
symptomatology may be differentiated. Whether specific
developmental language disorders are encountered only during
childhood, and, if they persist, how they are manifested in adulthood.
Possible factors which may lead to these manifestations are
analyzed. A considerable body of research has shown that even
though the symptoms of children with specific developmental
language disorders are resolved before the end of childhood, a
significant part of this population continues to have persisting
difficulties through adolescence and into adulthood. The continuity
of this disorder may sometimes be directly linked to language
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disorder, as in the case of learning impairments or, on the other

hand, symptoms may be related with those of conduct disorders,
social adjustment disorder, emotional and psychiatric disorders in
adolescence and adulthood. It therefore appears that specific
developmental language disorder is often an early symptom of other
disorders in the future. Even though the precise mechanisms which
are responsible for these disorders are not yet known, it is possible
that a fragile neurobiological substratum in these disorders may
explain why early symptoms are usually manifested as language
disorders and later develop into other disorders over time. However,
these symptom changes may be linked to other parameters, such as
the increasing social and emotional demands made on these
individuals with increasing age, which may be a contributing
environmental parameter to an already vulnerable system. Despite
all of the limitations in the long term study of these children, it is
suggested that in some way, and not in all cases, pathology may
continue into adulthood, although with a different symptomatology,
which is linked to behavioral and social adjustment, as well as with
more pervasive psychiatric disorders. It is suggested that a
continuum of services may be necessary for these cases into
adulthood (8).
An answer to the question of Moses’ speech impairment may lie
in the description of an episode in the desert. When the Children of
Israel reached the Wilderness of Zin, there was no water, and the
people began to quarrel with Moses (Numbers 20:1-3). Then Moses
and his brother were commanded “.. speak to the rock… and it shall give
forth its water…” (20:8). But Moses instead of speaking, hit the rock
“..with his rod he smote the rock twice: and the water came out
abundantly…” (20:11). Does this account indicate that Moses was
unable to speak with this particular rock? Did he indeed stammer?
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L. Ben-Nun Adoption

Moses strikes water from the stone. Francesco Bacchiacca.

Evidence suggests a heightened risk of psychiatric disorder in

children with speech-language impairments. However, not all forms
of language impairment are strongly associated with psychosocial
difficulty, and some psychiatric disorders (e.g., ADHD) are more
prevalent than others in language-impaired populations. The present
study assessed the psychosocial adjustment in adolescence of young
people with history of speech-language impairment, and investigated
specific relationships between language deficits and psychiatric
disorders. Seventy-one young people (aged 15-16 years) with a
preschool history of speech-language impairment were assessed
using a psychiatric interview (K-SADS) supplemented by
questionnaires probing social encounters and parental reports of
behavior and attention. Their psycho-social adjustment was
compared with that of a cross-sectional control group of age-
matched controls. Overall, the rate of psychiatric disorder was low in
the clinical sample and children whose language delay had resolved
by 5.5 years had a good outcome. For those whose language
difficulties persisted through the school years, there was a raised
incidence of attention and social difficulties. These difficulties were
partially independent and associated with different language profiles.
The group with attention problems showed a profile of specific
expressive language difficulties; the group with social difficulties had
receptive and expressive language difficulties; and the group with
both attention and social difficulties was of low IQ with global
language difficulties. The data demonstrate that amongst children
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with speech-language delays at 5.5 years, those with more severe

and persistent language difficulties and low nonverbal IQ are at
higher risk of psychiatric morbidity in adolescence (9).

ASSESSMENT: the first signs of communication occur when an

infant learns that a cry will bring food, comfort, and companionship.
Children who have trouble understanding what others say (receptive
language) or difficulty sharing their thoughts (expressive language)
may have a language disorder. Delay in acquiring language and
speech is the most common form of this developmental disorder in
children, and there are two main types - difficulties in understanding
language (receptive type) and difficulties in speaking, defective oral
expression (expressive type).
Language disorders are identified when a person has difficulty
with expressive language, receptive language, or pragmatic language.
Speech disorders are identified when a person's voice, fluency, or
articulation call attention to the speaker because his or her speech is
sufficiently different from the norm.
Was Moses afflicted by development language and speech
impediment? Did Moses exhibit at least one of the above symptoms,
as defined by DSM-IV? There is not enough information in the
biblical documentation to determine this.

References
1. Speech and Language Developmental Milestones. Available 20 January 2016
at http://www.nidcd.nih.gov/health/voice/pages/speechandlanguage.aspx.
2. Sharp HM, Hillenbrand K. Speech and language development and disorders in
children. Pediatr Clin North Am. 2008;55:1159-73, viii.
3. Conti-Ramsden G, Durkin K. Language and independence in adolescents wit
and without a history of specific language impairment (SLI). J Speech Lang Hear Res.
2008;51:70-83.
4. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 3 rd ed., revised. Washington DC, APA. 1987.
5. Dworkin PH. The preschool child: developmental themes and clinical issues.
Curr Prob Pediatr. Year Book Med Inc. 1988;18:73.
6. Gualtieri CT, Koriath UK, Bourgondeien MV, et al. Language disorders in
children referred for psychiatric services. J Am Acad Child Psychiatry. 1983;22:165.
7. Pour SE. Speech delay in children. Harefuah. 1990; 118:243.
8. Vlassopoulos M, Anagnostopoulos DC. Specific developmental disorder of
speech and language in adulthood. Psychiatriki. 2012;23 Suppl 1:74-81.
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9. Snowling MJ, Bishop DV, Stothard SE, et al. Psychosocial outcomes at 15

years of children with a preschool history of speech-language impairment. J Child
Psychol Psychiatry. 2006;47(8):759-65.

PREVALENCE OF SPEECH AND/OR LANGUAGE DISORDER. The

range of prevalence estimates was between 2% and 8% with an
overall median prevalence of 5.95%. Most studies reported a greater
prevalence of SLI in boys than girls. The male to female sex ratios
varied from .98:1 to 2.30:1. Risk factors for SLI have been found to
concentrate on family factors (1,2). Limited parental education, and
parental history of speech, language, and/or learning problems were
associated with elevated rates of SLI (3,4). By contrast, breast
feeding served as a protective factor even in the context of parental
education. Reading impairments strongly associated with SLI (5,6).
Frequency of speech and language disorder is estimated at 0.2%-
13%, and the ratio between boys and girls is three to one (7). In the
UK, a study evaluated referrals between January 1999 and April 2000
by the pediatric speech and language therapy service of
Middleborough Primary Care Trust, an area of social deprivation. Of
the 1100 referrals, 14.9% failed to attend and 9.8% had normal
functioning. The distribution of the disorder type was: 5.3%
dysfluency, 2.0% voice or nasality disruption, 20.4% receptive
language difficulties, 16.9% expressive language difficulties, and
29.1% speech difficulties. A further 0.7% had special educational
needs and 0.8% had speech and language impairment but refused
consent. The majority of referrals were between two and six years
old, more boys than girls, and socioeconomic status matched that of
the general population (8).
The prevalence of speech sound disorder in young children is 8-
9%. By the first grade, roughly 5% of children have noticeable speech
disorders; the majority of these speech disorders have no known
cause. Usually by 6 months of age an infant babbles or produces
repetitive syllables such as "ba, ba, ba" or "da, da, da." Babbling soon
turns into a type of nonsense speech called jargon that often has the
tone and cadence of human speech but does not contain real words.
By the end of their first year, most children have mastered the ability
to say a few simple words. By 18 months of age most children can
say 8 to 10 words and, by age 2, are putting words together in crude
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sentences such as "more milk." At ages 3, 4, and 5 a child's

vocabulary rapidly increases, and he or she begins to master the rules
of language. It is estimated that more than 3 million Americans
stutter. Stuttering affects individuals of all ages but occurs most
frequently in young children between the ages of 2 and 6 who are
developing language. Boys are 3 times more likely to stutter than
girls. Most children, however, outgrow their stuttering, and it is
estimated that less than 1 percent of adults stutter (9).
The prevalence of speech-language impairments in children have
been estimated for several languages, primarily in developed
countries. Teachers' estimates of incidence and overall prevalence of
speech-language impairments and its subtypes as a function of
gender, age and grade level were examined, and the screening
instrument on Nepalese children was validated. The adapted
teachers' screening instrument, namely a-TSLRC, was administered to
2,776 (690 and 2,086) primary school children aged 5-11 years (mean
8.1 years). The screening was conducted at four different points in
time, i.e. Incidences I and II, and each incidence consisted of a
testing and a retesting phase. Prior to this, teachers were trained in
forum meetings, and an information sheet containing an overview of
speech-language impairments, and guidelines/criteria for marking
the occurrence of speech-language impairments in the TSLRC were
disseminated. Overall prevalence of speech-language impairments in
children was estimated as 8.11%. Specifically, overall speech
problems were estimated as 4.68%, and language problems as 8.0%.
Additionally, the prevalence by subtypes of speech-language
impairments as categorized in the TSLRC were reported to be 2.95%
for an articulation/phonological problems, 2.09% for stuttering,
3.42% for a voice problems, 4.97% for a receptive language problems
and 7.74% for an expressive language problems. The data indicate
that the overall results of speech-language impairments in children
via the adapted in-Nepalese criterion-referenced instrument are
supported by international studies. Justifiable reliability and validity
was obtained. Based on this overall evidence, this instrument is
useful for the screening of speech-language impairments in primary
school children in Nepal (10).
The prevalence of oral language, orofacial motor skill and auditory
processing disorders in children aged 4-10 years old was investigated
and their association with age and gender were verified. Cross-
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sectional study was conducted with stratified, random sample

consisting of 539 students. The evaluation consisted of three
protocols: orofacial motor skill protocol, adapted from the
Myofunctional Evaluation Guidelines; the Child Language Test ABFW -
Phonology, and a simplified auditory processing evaluation. Of the
studied subjects, 50.1% had at least one of the assessed disorders; of
those, 33.6% had oral language disorder, 17.1%, had orofacial motor
skill impairment, and 27.3% had auditory processing disorder. There
were significant associations between auditory processing skills'
impairment, oral language impairment and age, suggesting a
decrease in the number of disorders with increasing age. The
variable "one or more speech, language and hearing disorders" was
also associated with age. The prevalence of speech, language and
hearing disorders in children was high, indicating the need for
research and public health efforts to cope with this problem (11).
Child language development and disorder in Iran has been the
focus for research by different professions, the most prominent ones
among them being psychologists and speech therapists. Signs of
language impairment in the preschool children are estimated at 8-
12% (12).
In Brazil, the prevalence of speech disorders in the children aged
between 5 and 11 years is 24.6%. Speech disorders prevalence in
children aged 5 years is 57%, and 42% between 8 and 10 years. The
frequency of speech disorders is similar for both sexes (13).
The epidemiological profile of the population attending primary
health care units in the western region of the city of São Paulo, Brazil,
was investigated highlighting referred speech-language and hearing
complaints. A cross-sectional observational study was conducted in
primary health care units. Household surveys were carried out and
information was obtained from approximately 2,602 individuals,
including (but not limited to) data related to education, family
income, health issues, access to public services and access to health
services. The speech-language and hearing complaints were
identified from specific questions. The results revealed that the
populations participating in the survey were heterogeneous in terms
of their demographic and economic characteristics. The prevalence
of referred speech-language and hearing complaints was 10%, and
half the users of the public health system who had complaints were
monitored or received specific treatment. The findings highlight the
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need to reorganize the speech-language pathology and audiology

service in the western region of São Paulo, as well as the need to
improve the Family Health Strategy in areas that do not have a
complete coverage in order to expand and improve the diagnostics
and the speech-language pathology and audiology actions related to
the prevention, identification, and rehabilitation of human
communication disorders (14).
Without instruction, most children master the complexities of
spoken language by the age of six or seven years. About 5% of
apparently healthy children, however, struggle to acquire basic
competence in one or more aspects of spoken language and are
classified as having specific language impairments (15).

ASSESSMENT: speech and language impediment is a prevalent

condition although different prevalence rates in various countries are
observed.

References
1. Tomblin JB, Smith E, Zhang X. Epidemiology of specific language impairment:
Prenatal and perinatal risk factors. J Commun Disord. 1998;30:325-344.
2. Tomblin JB. Risk factors associated with specific language disorder. In:
Wolraich M, Routh DK (eds.). Developmental and behavioral pediatrics.
Philadelphia: Jessica Kingsley Publishers. 1992.
3. Bishop DVM. Genetic and environmental risks for specific language
impairment in children. Philos Trans R Soc Lond B Biol Sci. 2001;356 (1407):369-380.
4. Stromswold K. Genetics of spoken language disorders. Hum Biol. 1998;70
(2):297-324.
5. Catts HW, Fey ME, Zhang X, Tomblin JB. Estimating the risk of future reading
difficulties in kindergarten children: A research-based model and its clinical
implementation. Language Speech and Hearing Services in Schools. Language,
Speech, and Hearing Services in Schools. 2001:32:38-50.
6. Catts HW. The relationship between speech-language impairments and
reading disabilities. J Speech Lang Hear R. 1993;36:948–58.
7. Baker L, Cantwell DP. Developmental language disorder. In: Kaplan HI &
Sadock BJ (eds.). Comprehensive Textbook of Psychiatry, Vol. 2, fourth ed. Williams
& Wilkins. 1985, pp. 1700-5.
8. Broomfeld J, Dodd B. Children with speech and language disability: caseload
and characteristics. Int J Lang Commun Disord. 2004;39:393-24.
9. Statistics on Voice, Speech, and Language. Available 10 February 2016 at
http://www.nidcd.nih.gov/health/statistics/pages/vsl.aspx.
10. Thapa KB, Okalidou A, Anastasiadou S. Teachers' screening estimations of
speech-language impairments in primary school children in Nepal. Int J Lang
Commun Disord. 2016 Jan 12.
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11. Rabelo AT, Campos FR, Friche CP, et al. Speech and language disorders in
children from public schools in Belo Horizonte. Rev Paul Pediatr. 2015;33(4):453-9.
12. Kazemi Y, Stringer H, Klee T. Study of child language development and
disorders in Iran: A systematic review of the literature. J Res Med Sci. 2015;20(1):
66-77.
13. Garcia de Goulard BN, Chiai BM. Prevalence of speech disorders in
schoolchildren and its associated factors. Rev Saude Publica. 2007;41:726-31.
14. Samelli AG, Rondon S, Oliver FC, et al. Referred speech-language and hearing
complaints in the western region of São Paulo, Brazil. Clinics (Sao Paulo). 2014;
69(6):413-9.
15. Stromswold K. The genetics of speech and language impairments. N Engl J
Med. 2008;359:2381-3.

SCREENING. No recommendation exists for or against routine use

of brief, formal screening instruments in primary care to detect
speech and language delay in children through 5 years of age. The
evidence was updated on screening and treating children for speech
and language since the 2006 US Preventive Services Task Force
systematic review. Medline, the Cochrane Library, PsycInfo,
Cumulative Index to Nursing and Allied Health Literature,
ClinicalTrials.gov, and reference lists were evaluated. Studies
reporting diagnostic accuracy of screening tools and randomized
controlled trials reporting benefits and harms of treatment of speech
and language were included. Evidence was not found for the impact
of screening on speech and language outcomes. In 23 studies
evaluating the accuracy of screening tools, sensitivity ranged
between 50% and 94%, and specificity ranged between 45% and 96%.
Twelve treatment studies improved various outcomes in language,
articulation, and stuttering; little evidence emerged for interventions
improving other outcomes or for adverse effects of treatment. Risk
factors associated with speech and language delay were male
gender, family history, and low parental education. A limitation of
the paper is the lack of well-designed, well-conducted studies
addressing whether screening for speech and language delay or
disorders improves outcomes. Several screening tools can accurately
identify children for diagnostic evaluations and interventions, but
evidence is inadequate regarding applicability in primary care
settings. Some treatments for young children identified with speech
and language delays and disorders possibly are effective (1).
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ASSESSMENT: several screening tools for speech and language

delay can accurately identify children for diagnostic evaluations and
interventions.

Reference
1. Wallace IF, Berkman ND, Watson LR, et al. Screening for speech and language
delay in children 5 years old and younger: a systematic review. Pediatrics.
2015;136(2):e448-62.

GENETIC AND ENVIRONMENTAL FACTORS. The genetic and

environmental etiology of speech and broader language skills was
examined in terms of their concurrent relationships in young
children; their longitudinal association with reading; and the role
they play in defining the 'heritable phenotype' for SLI. The work was
based on a large sample of 4 1/2-year-old twins, who were assessed
at home on a broad range of speech and language measures as part
of the Twins Early Development Study. Genetic factors strongly
influence variation in young children's speech in typical development
as well as in SLI, and that these genetic factors account for much of
the relationship between early speech and later reading. By contrast,
shared environmental factors play a more dominant role for broader
language skills, and in relating these skills to later reading; isolated
impairments in language as opposed to speech appear to have largely
environmental origins (1).
Genetic factors have an important role in many such cases (2,3).
Children with specific language impairment are four times as likely to
have a family history of the disorder as are children who do not have
such impairment (4), and the concordance rate for this disorder is
almost twice as great for monozygotic as for dizygotic twins (5).
Genetic factors strongly influence variation in young children's
speech in typical development as well as in specific language
impairment, and these genetic factors account for much of the
relationship between early speech and later reading. By contrast,
shared environmental factors play a more dominant role for broader
language skills, and when relating these skills to later reading isolated
impediments in language as opposed to speech impediment appear
to have largely environmental origins (6).
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Previous twin studies have demonstrated high heritability of SLI

when the diagnosis is based on psychometric testing. The current
study measured the effectiveness of parent and teacher ratings of
communication skills in identifying heritable language impairment.
The CCC was completed by parents and teachers of 6-year-old twins
recruited from a general population sample. One hundred and thirty
twin pairs (65 MZ) were selected because at least one twin had low
language skills at four years of age; a further 66 pairs (37 MZ) were a
low risk group with no indication of language difficulties at four years.
Internal consistency, inter-rater reliability, and validity in identifying
language impairment were assessed for all CCC scales. CCC scales,
especially those assessing structural language skills, were highly
effective in identifying cases of language impairment, but agreement
between parent and teacher ratings was modest. Genetic analysis
revealed negligible environmental influence and substantial genetic
influence on most scales. A rater-specific effects model was fit to the
data to assess how far parents and teachers assess a common genetic
factor on the CCC. Ratings of parents and teachers were influenced
to some extent by the same child characteristics, but rater-specific
effects were also evident, especially on scales measuring pragmatic
aspects of communication. The result show strong genetic influences
on both structural and pragmatic language impairments in children
and these can be detected using a simple checklist completed by
parents or teachers (7).
Developmental speech and language disorders cover a wide range
of childhood conditions with overlapping but heterogeneous
phenotypes and underlying etiologies. This characteristic
heterogeneity hinders accurate diagnosis, can complicate treatment
strategies, and causes difficulties in the identification of causal
factors. Nonetheless, over the last decade, genetic variants have
been identified that may predispose certain individuals to different
aspects of speech and language difficulties. There are advances in
the genetic investigation of stuttering, speech-sound disorder, SLI,
and developmental verbal dyspraxia. The identification and study of
specific genes and pathways, including FOXP2, CNTNAP2, ATP2C2,
CMIP, and lysosomal enzymes, advance our understanding of the
etiology of speech and language disorders and enable us to better
understand the relationships between the different forms of
impairment across the spectrum (8).
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ASSESSMENT: genetic factors have an important role in the

development of speech and language disorder. Genetic variants may
predispose certain individuals to different aspects of speech and
language difficulties.
Did genetic factors play a role in Moses' developmental speech
impediment? In Moses case, it cannot be proved that inheritance
was responsible for this disorder.

References
1. Hayiou-Thomas ME. Genetic and environmental influences on early speech,
language and literacy development. J Commun Disord. 2008;41(5):397-408.
2. SLI Consortium. A genomewide scan identifies two novel loci involved in
specific language impairments. Am J Hum Genet. 2002;70:384-98.
3. SLI Consortium (SLIC). Highly significant linkage to the SLI1 locus in an
expanded sample of individuals affected by specific language impairment. Am J Hum
Genet. 2004;74:1225-38.
4. Stromswold K. Genetics of spoken language disorders. Hum Biol. 1998;
70:297-324.
5. Idem. The heritability of language: a review and meta-analysis of twin,
adoption and linkage studies. Language. 2001;77:647-723.
6. Hayiou-Thomas ME. Genetic and environmental influences on early speech,
language and literacy development. J Commun Disord. 2008;41:397-408.
7. Bishop DV, Laws G, Adams C, Norbury CF. High heritability of speech and
language impairments in 6-year-old twins demonstrated using parent and teacher
report. Behav Genet. 2006;36(2):173-84.
8. Newbury DF, Monaco AP. Genetic advances in the study of speech and
language disorders. Neuron. 2010;68(2):309-20.

EXPRESSIVE LANGUAGE DISORDER. Children with expressive

language disorder exhibit problems in using spoken language to
communicate their needs, thoughts, and intention. In particular,
these children may produce few spoken utterances; have
vocabularies that are limited in size and variety; use sentences that
are short, incomplete, or ungrammatical; and provide stories or
descriptions that are disorganized, confusing, or unsophisticated.
Expressive language disorder is diagnosed when a child exhibits a
selective deficit in expressive language development relative to non-
verbal intelligence and receptive language skills (1).
"Late talkers" is a term used in the scientific field of atypical
language development to describe toddlers who exhibit delay in
expressive language skills, although they do have intact receptive
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skills. An overview of the literature on late talking toddlers

underscores the risk factors for late talking as well as the parenting
and individual characteristics of this group of children. There is the
association between expressive language delay and the behavioral
and socio-emotional development of late talkers, and the language
outcomes of late talking toddlers at a later point in development (2).
In cases of expressive language disorder, the child is unable to put
his or her thoughts into words. Comorbidity is present with
difficulties in repeating, imitating or naming. There are no problems
with pronunciation, as occurs in phonological disorder, it may
present before the age of three years and is crucial between four and
seven years of age. EEG studies have been carried out not only in
expressive language disorder, but also in clinical pictures where the
language disorder was the main symptom or was associated to
neurodevelopmental pathology. A review of 100 patient records,
with patients (25 girls and 75 boys) aged between two and six years
old who had been diagnosed with expressive language disorder
(according to the DSM fourth edition) (3), and were free of seizures
and not receiving treatment was conducted (4). They were
submitted to an EEG and received treatment with valproic acid if EEG
findings were positive. Six patients (males) presented localized spike-
wave paroxysmal EEG activity in the frontotemporal region. This 6%
is a percentage that is higher than the one found in the normal
children's population (2%), but lower than the value indicated in the
literature for language disorders, which ranges between 20% and
50%. The patients responded positively to the treatment and both
expressive language and EEG findings improved. The data show that
it is possible that in expressive language disorder without paroxysms
is a dysfunction in the circuit made up of the motor cortex-
neostriatum prior to grammatical learning, whereas if there are
paroxysms there is a neuronal hyperactivity, perhaps associated with
this dysfunction or not, in cortical areas. In the cases described,
valproic acid, together with speech therapy, helped the children to
recover their language abilities (4).

ASSESSMENT: did expressive language disorder afflict Moses?

The words “I am not eloquent, neither heretofore, nor since thou hast
spoken unto thy servant: but I am slow of speech, and of a slow tongue (a
heavy mouth and a heavy tongue ” (4:10) may be linked to this type of
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disorder. However, a subsequent verse indicates that Moses after

leaving Egypt judged the people: “Moses sat to judge the people: and the
people stood by Moses from the morning unto the evening” (Exodus 28:13).
How can a judge speak to the people without communicable
language or comprehensible speech? Or was Moses’ language and
speech impediment so mild that it did not prevent him from
pronouncing judgment on the people?

References
1. Johnson CJ, Beitchman JH. Expressive language disorder. In: Sadock BJ &
Sadock V A (eds.). Comprehensive Textbook of Psychiatry. Vol 2. Eight ed.
Philadelphia, Baltimore: Lippincott Williams & Wilkins. 2005, pp. 3136-42.
2. Hawa VV, Spanoudis G. Toddlers with delayed expressive language: an
overview of the characteristics, risk factors and language outcomes. Res Dev Disabil.
2014;35(2):400-7.
3. Diagnostic and Statistical Manual of mental Disorders, fourth edition.
Washington DC, American Psychiatric Association. 1994.
4. Valdizán JR, Rodríguez-Mena D, Díaz-Sardi M. Expressive language disorder
and focal paroxysmal activity. Rev Neurol. 2011;52 Suppl 1:S135-40.

RECEPTIVE LANGUAGE DISORDER. Receptive language is the

ability to listen and understand communication. Children with
receptive-language-disorder disorder have difficulty processing
language that is spoken and/or written. Receptive language
disorders may result from a medical event (such as a stroke or brain
injury) or have unknown causes. Receptive language disorders do
not indicate low intelligence: many children with language disorders
have average to above-average intelligence. Symptoms include:
difficulty following directions (requiring clarification and repeated
directions), poor listening skills or comprehension, confusion when
confronted with complex or long sentences, difficulty with abstract
language, difficulty responding to questions, needing additional time
to process information, and problems differentiating between sounds
(1). The disorder is characterized by difficulty in understanding some
aspects of speech. The children’s hearing is fine, but they can’t make
sense of certain sounds, words, or sentences and they may even
seem inattentive (2).
Individual differences in measures of receptive language ability at
age 12 are highly heritable. Some of the genes responsible for the
heritability of receptive language ability using a genome-wide
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association approach were identified. Four Internet-based measures

of receptive language (vocabulary, semantics, syntax, and
pragmatics) were administered to a sample of 2,329 twelve-year-olds
for whom DNA and genome-wide genotyping were available. Nearly
700,000 SNPs and one million imputed SNPs were included in a
genome-wide association analysis of receptive language composite
scores. No SNPs associations met the demanding criterion of
genome-wide significance that corrects for multiple testing across
the genome (p < 5 × 10 -8). The strongest SNPs association did not
replicate in an additional sample of 2,639 twelve-year-olds. The
results indicate that individual differences in receptive language
ability in the general population do not reflect common genetic
variants that account for more than 3% of the phenotypic variance.
The search for genetic variants associated with language skill will
require larger samples and additional methods to identify and
functionally characterize the full spectrum of risk variants (3).

ASSESSMENT: children with receptive-language-disorder disorder

have difficulty processing language that is spoken and/or written.
Did receptive language disorder afflict Moses? Since the
understanding of language was not affected, this type of disorder
seems unlikely.

References
1. What is receptive language disorder? Available 12 February 2016 at
http://nspt4kids.com/healthtopics-and-conditions-database/receptive-language-
disorder-2/.
2. Johnson CJ, Beitchman JH. Expressive language disorder. In: Sadock BJ &
Sadock VA (eds.). Comprehensive Textbook of Psychiatry. Vol 2. Eight ed.
Philadelphia, Baltimore: Lippincott Williams & Wilkins. 2005, pp. 3136-42.
3. Harlaar N, Meaburn EL, Hayiou-Thomas ME; Wellcome Trust Case Control
Consortium, Davis OS, Docherty S, Hanscombe KB, et al. Genome-wide association
study of receptive language ability of 12-year-olds. J Speech Lang Hear Res.
2014;57(1):96-105.
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MIXED LANGUAGE DISORDER. Mixed receptive-expressive

language disorder (DSM-IV 315.32) (1) is a communication disorder in
which both the receptive and expressive areas of communication are
affected in any degree, from mild to severe (2).
If someone is being assessed on the Wechsler Adult Intelligence
Scale, this may show up in relatively low scores for Information,
Vocabulary and Comprehension (perhaps below the 25th percentile).
If the person has difficulty with spatial concepts, such as 'over',
'under', 'here' and 'there', he or she may have arithmetic difficulties,
have difficulty understanding word problems and instructions, or
have difficulties using words. They may also have a more general
problem with words or sentences, both understanding and speaking
them. If someone is suspected to have mixed receptive-expressive
language disorder, they can go to a speech therapist or pathologist,
and receive treatment. Most treatments are short term, and rely on
accommodations made in the person's environment, so as to be
minimally interfering with work and school functioning (3).
Children with mixed receptive-expressive language disorder
exhibit impairments in the expression and reception of spoken
language (4). Language impairment that cannot be accounted for by
factors such as below-average non-verbal ability, hearing
impairment, behavior or emotional problems, or neurological
impairments affects some 6% of school-age children. Language
impairment with a receptive language component is more resistant
to intervention than specific expressive or phonological delays, and
carries a greater risk of comorbid behavioral difficulties as well as
adverse outcomes for language development and academic progress.
Underlying explanations may account for receptive-expressive
language impairment practice (5).

ASSSESSMENT: In mixed receptive-expressive language disorder,

both the receptive and expressive areas are affected. Since the
receptive type of language disorder seems unlikely in Moses’ case,
this diagnosis can be disregarded.
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References
1. Diagnostic criteria for 315.31 Mixed Receptive-Expressive Language Disorder.
Available 12 February 2016 at http://behavenet.com.
2. Mixed receptive-expressive language disorder. Available 22 January 2016 at
http://ejje.weblio.jp/content/Mixed+receptive-expressive+language+disorder.
3. Mixed receptive-expressive language disorder. Available 12 February 2016 at
https://en.wikipedia.org/wiki/Mixed_receptive-expressive_language_disorder.
4. Johnson CJ, Beitchman JH. Expressive language disorder. In: Sadock BJ &
Sadock VA (eds.). Comprehensive Textbook of Psychiatry. Vol 2. Eight ed.
Philadelphia, Baltimore: Lippincott Williams & Wilkins. 2005, pp. 3136-42.
5. Boyle J, McCartney E, O'Hare A, Law J. Intervention for mixed receptive-
expressive language impairment: a review. Dev Med Child Neurol. 2010;52(11):994-
9.

PHONOLOGICAL DISORDER. Speech is the verbal expression of

one's cognitive content and process, and emotions. Clarity of speech
is essential to social interaction, and educational and occupational
functioning, as well as one's self confidence, self image, and sense of
self efficacy. Impairment in speech can have a negative influence on
all of these areas (1). Speech Sound Disorder, formerly known as
Phonological Disorder in the DSM -IV (2), is a DSM-5 diagnosis (3)
assigned to individuals who have difficulties in productive speech
interfering with communication and producing impairment in
functioning, and distress. In Speech Sound Disorder, phonemes, or
the basic units of speech, can be added, omitted, distorted or
changed, or substituted in a manner which makes the speaker
difficult to understand (4). Addition of sounds is defined as including
unneeded sounds in the pronunciation of the word. Omission
involves deleting sounds or syllables, e.g., the word Doggie is
pronounced as “oggie”. Distortions involve altering the correct
sound of the word, which includes lisping. Substitution is using an
incorrect sound to pronounce the word, e.g., cry is pronounced as
“Cwy”. Acquisition of articulate speech is a developmental process
which unfolds over almost a decade from birth. At age two, about
50% of a child's speech should be intelligible, and by age four, speech
should be mostly understandable. At age eight, all words used by a
child should be intelligible. Difficulties with speech production
outside of these normal developmental parameters, in the absence
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of a sensory -motor deficit, neurological problem, or facial structural

abnormality can indicate Speech Sound Disorder (3).
According to the DSM-5 (3), there are four criterions for Speech
Sound Disorder:
Persistent unintelligible speech consisting of phoneme addition,
omission, distortion, or substitution, which interferes with verbal
communication.
Interference with social participation, academic performance, or
occupational performance (or any combination thereof).
The onset of symptoms is during childhood.
The symptoms cannot be accounted for by another medical or
neurological condition, including traumatic brain injury.
In children, the prevalence of speech sound disorder is 8%-9% (4).
Children who experience frequent ear infections may develop
hearing impairment and be at risk for speech sound disorder (5).
Language impairment is seen in children with speech sound
disorder. If speech sound disorder is not corrected, and a lisp or
other speech impediment persists into adulthood, it can be a
contributing factor in social anxiety disorder. Some individuals will
be self-conscious of their lisp, overestimating how noticeable it is by
others, or assigning an overly negative impression to it (6).
Speech sound disorder can affect educational, interpersonal, and
occupational functioning (3). Peers may bully or ridicule children
who lisp, or have other indicators of speech sound disorder. Children
with speech sound disorder, as well as adults with residual speech
errors may be perceived as less intelligent, or mature, as speech
production is generally considered a marker of one's intellect and
maturity. Speech sound disorder can affect learning and literacy.
Studies have shown that 18% of children with speech sound disorder
will have difficulty reading in elementary school by about third or
fourth grade (6). Adults with unresolved speech disorders may
restrict their participation in certain activities to prevent revealing
their speech difficulty (7).
There are several diagnostic rule-outs for the clinician to consider
in speech sound disorder. In the DSM -5 (3), disorders such as
hearing impairment can in turn produce speech impairment, which in
excess of what is typically expected for the degree of hearing loss,
can be diagnosed separately as Speech Sound Disorder. There are
possible structural facial abnormalities such as a cleft palette which
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can produce difficulty with speech articulation. Dysarthria is a

discrete speech disorder due to a neurological disorder, such as
cerebral palsy. Following a traumatic brain injury affecting Broca's
area (productive speech center of the cerebral cortex), there are
possible difficulties with speech production, articulation, and ability
to retrieve words appropriate for the context (aphasia). This is not
only a different etiology, but different qualitatively than speech
sound disorder. Selective mutism involves limited speech production
secondary to anxiety. There are also normal speech variations which
are not considered a speech sound disorder, such as accents (3).
Accents are regional differences in pronunciation due to the
influence and filtering of one language through another, e.g., in
northern Vermont, the “Au” sound in the word Aunt is pronounced
with an “ awh” sound, whereas in New York State the same word is
pronounced with an “eh” sound. The difference is due to English
being filtered through French, which is an ancestral language in
northern Vermont. The correct pronunciation is relative, depending
on the region (1).
Speech sound disorder can be diagnosed, evaluated, and treated
by a speech language pathologist. In some cases, supportive
psychotherapy may be beneficial to prevent speech disorders from
contributing to social anxiety, or problems with self confidence,
particularly in adults who are self-conscious about residual speech
errors (5).

ASSESSMENT: did Moses suffer from this type of disorder? There

are insufficient diagnostic criteria for this disorder. Thus, we cannot
determine this with certainty.

References
1. Porter D. Speech Sound Disorder (Phonological Disorder) DSM-5 315.39
(F80.0). Available 16 January 2016 at http://www.theravive.com/therapedia/Speech-
Sound-Disorder-(Phonological-Disorder)-DSM--5-315.39-(F80.0).
2. Diagnostic and Statistical Manual of Mental Disorders, fourth edition.
Washington DC, American Psychiatric Association. 1994.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, fifth edition. Washington, DC. 2013.
4. National Institute on Deafness and other Communication Disorders. Statistics
on Voice, Speech, and Language. National Institute on Deafness and other
Communication Disorders. 2010. Available 16 January 2016 at
https://www.nidcd.nih.gov/health/statistics/pages/vsl.aspx.
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5. American Speech Language Hearing Association. Speech Sound Disorders:

Articulation and Phonological Processes. American Speech Language Hearing
Association. 2014. Available 18 January 2016 at
http://www.asha.org/public/speech/disorders/speechsounddisorders.htm.
6. Lewis BA, Avrich AA, Freebairn LA, et al. Literacy Outcomes of Children With
Early Childhood Speech Sound Disorders: Impact of Endophenotypes. J Speech Lang
Hear Res. 2011;54(6):1628–13.
7. Board of Regents of the University Of Oklahoma. Common Development
Speech and Language Disorders. The Department of Communication Sciences and
Disorders. 2011. Available 20 January 2016 at
http://www.ah.ouhsc.edu/csd/leaps_disorders.asp.

ELECTIVE MUTISM. Elective mutism is a rare disorder of

communication, where the child speaks fluently in familiar situations,
such as home, despite lack of speech in less familiar settings, for
example school (1,2). It is a debilitating disorder for the affected
child, as well as for their families, with detrimental implications for
the development of social skills and learning if not offered
appropriate support and treatment (2). A variety of temperamental
and behavioral characteristics, co-morbid psychiatric conditions,
neurodevelopmental delay and family factors have been associated
with the disorder. The children are excessively shy, withdrawn, 'slow
to warm up', inhibited, often avoid eye contact, fear social
embarrassment and experience significant separation anxiety on
separation from their attachment figures. Their behavior is often
perceived by others as controlling and oppositional. Often elective
mutism is typical in early childhood years. A number of constitutional
and environmental factors have been considered in its onset,
progression and response to intervention (2).
Selective mutism is a relatively rare childhood disorder
characterized by a consistent failure to speak in specific settings (e.g.,
school, social situations) despite speaking normally in other settings
(e.g., at home) (3). Most commonly, this disorder initially manifests
when children fail to speak in school. Selective mutism results in
significant social and academic impairment in those affected by it.
Studies over the past 20 years have consistently demonstrated a
strong relationship between selective mutism and anxiety, most
notably social phobia. These findings have led to the recent
reclassification of selective mutism as an anxiety disorder in the DSM,
5th Edition (3). In addition to anxiety, several other factors have
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been implicated in the development of selective mutism, including

communication delays and immigration/bilingualism, adding to the
complexity of the disorder. In the past few years, several randomized
studies have supported the efficacy of psychosocial interventions
based on a graduated exposure to situations requiring verbal
communication. Less data are available regarding the use of
pharmacologic treatment, though there are some studies that
suggest a potential benefit. Selective mutism is a disorder that
typically emerges in early childhood and is currently conceptualized
as an anxiety disorder. The development of selective mutism
appears to result from the interplay of a variety of genetic,
temperamental, environmental, and developmental factors.
Although little has been published about selective mutism in the
general pediatric literature, pediatric clinicians are in a position to
play an important role in the early diagnosis and treatment of this
debilitating condition (4).
Selective mutism is a rare and multidimensional childhood
disorder that typically affects children entering school age. It is
characterized by the persistent failure to speak in selected social
settings despite possessing the ability to speak and speak
comfortably in more familiar settings. Many theories attempt to
explain the etiology of selective mutism. Selective mutism can
present a variety of comorbidities including enuresis, encopresis,
obsessive-compulsive disorder, depression, premorbid speech and
language abnormalities, developmental delay, and Asperger's
disorders. The specific manifestations and severity of these
comorbidities vary based on the individual. Given the
multidimensional manifestations of selective mutism, treatment
options are similarly diverse. They include individual behavioral
therapy, family therapy, and psychotherapy with antidepressants and
anti-anxiety medications. While studies have helped to elucidate the
phenomenology of selective mutism, limitations and gaps in
knowledge still persist. In particular, the literature on selective
mutism consists primarily of small sample populations and case
reports (5).
Many etiologies are proposed for selective mutism including
psychodynamic, behavioral and familial etc. A developmental
etiology that includes insights from all the above is gaining support.
Accordingly, mild language impairment in a child with an anxiety trait
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possibly is at the root of developing selective mutism. The behavior

will be reinforced by an avoidant pattern in the family (6).
The latest edition of DSM-5 (3) lists selective mutism among the
anxiety disorders. This makes sense as the current paper of the
literature confirms that anxiety is a prominent symptom in many
children suffering from this condition. Research on the etiology and
treatment of selective mutism corroborates the conceptualization of
selective mutism as an anxiety disorder. At the same time, critical
points can be raised regarding the classification of selective mutism
as an anxiety disorder. Recommendations for dealing with this
diagnostic conundrum are made for psychologists, psychiatrists, and
other mental health workers who face children with selective mutism
in clinical practice (7).
Selective mutism is a rare condition that has been associated with
a wide variety of childhood psychiatric conditions. Historically
viewed as more of an oddity than a distinct diagnostic entity, early
conceptualizations of the condition were based largely on case
studies that tended to link selective mutism with oppositional
behavior. More recently, controlled studies have enhanced our
understanding of selective mutism. The current conceptualization of
selective mutism, highlights evidence supporting the notion that
selective mutism is an anxiety-related condition (8).
In 1980, four different types of elective mutism were described:
symbiotic, expressive, responsive, and passive-aggressive. Out of 68
children examined, 31 suffered from a symbiotic disorder, and the
conclusion was that this disorder is the most common form. Children
(84%) who suffered from symbiotic disorder had a symbiotic
relationship with the mother. The expressive type was the least
common, affecting only seven children, and no special reason was
found for this type of disorder. On the other hand, the 14 children
who suffered from responsive mutism had links to traumatic factors
that included sexual abuse, and all of them suffered from depression.
The group with the passive-aggressive type of elective mutism, which
included 16 children, was characterized by use of silence and refusal
to talk as a weapon (9).
Social phobia, anxiety, oppositional behavior, social skills, and self-
concept were compared in three groups: 1] children with specific
mutism (who did not speak to teachers but were more likely to speak
to parents and peers at home and school), 2] 30 children with
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generalized mutism (whose speaking was restricted primarily to their

homes), and 3] 52 community controls. Children with generalized
mutism evidenced higher anxiety at school, and more separation
anxiety, obsessive compulsory disorder, and depressive symptoms at
home. Parents and teachers reported that the social phobia and
anxiety scores of children in both the specific and generalized mutism
subgroups were higher than in controls. Children in both the specific
and generalized mutism groups evidenced greater deficits in verbal
and nonverbal social skills at home and school than controls.
Teachers and parents did not report differences in nonverbal
measures of social cooperation and conflict resolution and evidence
did not indicate that selective mutism was linked to an increase in
externalizing problems such as oppositional behavior or attention
deficit hyperactivity disorder. Although children with specific mutism
speak in a wider range of situations and appear less anxious to their
teachers than children with generalized mutism, significant socially
phobic behavior and social skill deficits were present in both groups
(10).
Early treatment and follow up for children with selective mutism
is important. The treatment includes non-pharmacological therapy
(psychodynamic, behavioral and familial) and pharmacologic therapy,
mainly selective serotonin reuptake inhibitors (6).

ASSESSMENT: elective mutism is a rare disorder of

communication, where the child speaks fluently in familiar situations,
such as home, despite lack of speech in less familiar settings, for
example school. There is a strong relationship between selective
mutism and anxiety, most notably social phobia.
The development of selective mutism results from the interplay of
a variety of genetic, temperamental, environmental, and
developmental factors. It is characterized by the persistent failure to
speak in select social settings despite possessing the ability to speak
and speak comfortably in more familiar settings. Most commonly,
selective mutism initially manifests when children fail to speak in
school. This disorder results in significant social and academic
impairment in those affected by it.
There are four different types of elective mutism such as
symbiotic, expressive, responsive, and passive-aggressive.
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Selective mutism can present a variety of comorbidities including

enuresis, encopresis, obsessive-compulsive disorder, depression,
premorbid speech and language abnormalities, developmental delay,
and Asperger's disorders.
Was Moses affected by this disorder? Can the words “I am not
eloquent, neither heretofore, nor since thou hast spoken unto thy servant:
but I am slow of speech, and of a slow tongue (a heavy mouth and a heavy
tongue)” (4:10) and “…I am stammerer..” (6:12) be related to selected
mutism. The medical record of Moses revealed no criteria for
diagnosing anxiety or social phobia. There are insufficient diagnostic
criteria to confirm this disorder. These factors make elective mutism
as unlikely cause for speech and language impediment in Moses'
case.

References
1. Sharkey L, McNicholas F. 'More than 100 years of silence', elective mutism: a
review of the literature. Eur Child Adolesc Psychiatry. 2008;17:255-63.
2. Storgaad P, Thomsen PH. Elective mutism – a disorder of social functioning or
an emotional disorder? Ugeskr Laeger. 2003;165:678-81.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders, 3 rd ed., revised. Washington DC, APA. 1987.
4. Hua A, Major N. Selective mutism. Curr Opin Pediatr. 2016;28(1):114-20.
5. Wong P. Selective mutism: a review of etiology, comorbidities, and
treatment. Psychiatry (Edgmont). 2010;7(3):23-31.
6. Ytzhak A, Doron Y, Lahat E, Livne A. Selective mutism. Harefuah.
2012;151(10):597-9, 603.
3. American Psychiatric Association. Diagnostic and Statistical Manual of Mental
Disorders. (5th Edition). Washington, DC. 2013.
7. Muris P, Ollendick TH. Children Who are Anxious in Silence: A Review on
Selective Mutism, the New Anxiety Disorder in DSM-5. Clin Child Fam Psychol Rev.
2015;18(2):151-69.
8. Sharp WG, Sherman C, Gross AM. Selective mutism and anxiety: a review of
the current conceptualization of the disorder. J Anxiety Disord. 2007;21(4):568-79.
9. Johnson CJ, Beitchman JH. Mixed receptive-expressive disorder. In: Sadock BJ
& Sadock VA (eds.). Comprehensive Textbook of Psychiatry. Vol. 2. Eight ed.
Philadelphia, Baltimore: Lippincott Williams & Wilkins. 2005, pp. 3142-8.
10. Storgaad P, Thomsen PH. Elective mutism – a disorder of social functioning
or an emotional disorder? Ugeskr Laeger. 2003;165:678-81.
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STUTTERING. The frequency of stuttering in children is about 5%,

and the disorder may persist until adulthood (1), for some beyond 55
years of age (2). Stuttering usually appears between the ages of two
and seven years (3). The start of the disorder is usually slow and lasts
a few weeks or months, with remission and deterioration affected by
the pressure to communicate (4). The ratio between boys and girls is
three to one (3). Spontaneous and complete recovery (removing all
overt and covert markers of the pathology) occurs in 60%-80% of all
children who display incipient stuttering behaviors. As such, many
claims of therapeutic success in children who stutter are confounded
by the possibility of spontaneous recovery during the testing and
intervention period (5).
The etiology of stuttering is controversial, but contributing factors
include cognitive abilities, genetics, sex of the child, and
environmental influences. More than 80% of stuttering cases are
classified as developmental problems, although stuttering can also be
classified as a neurologic or, less commonly, psychogenic problem
(6). Although stuttering often resolves before adulthood, it can cause
significant anxiety for children and their families. Stuttering speech
patterns are often easily identifiable; when a child is learning to talk,
repetition of sounds or words, prolonged pauses, or excessively long
sounds in words usually occur. Secondary behaviors (e.g., blinking,
jaw jerking, involuntary head or other movements) that accompany
stuttering can further embarrass the child, leading to a fear of
speaking (6).
According to DSM-IV (7), the indicators of stuttering include: a
disorder of the normal flow of fluent speech, and discrepancy
between speech and chronological age, characterized by repeated
occurrences of one or more of the following: 1] repetition of
syllables and sounds; 2] lengthening of sounds; 3] breaks in speech;
4] broken words – breaks in mid-word; 5] hearing blockage – breaks
in mid-word; 6] exchanging words with the aim of avoiding
problematic words; 7] words that cause excessive physical tension;
8] repetition of one syllable in a word. The disturbance in fluency of
speech affects scholastic and occupational achievements as well as
social communication. If there are also motor or sensory disorders,
speech difficulties are more obvious (7).
Anxiety is one of the most widely observed and extensively
studied psychological concomitants of stuttering. Research
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conducted prior to the turn of the century produced evidence of

heightened anxiety in people who stutter, yet findings were
inconsistent and ambiguous. Failure to detect a clear and systematic
relationship between anxiety and stuttering was attributed to
methodological flaws, including use of small sample sizes and
unidimensional measures of anxiety. More recent research,
however, has generated far less equivocal findings when using social
anxiety questionnaires and psychiatric diagnostic assessments in
larger samples of people who stutter. An alarmingly high rate of
social anxiety disorder among adults who stutter has been
demonstrated. Social anxiety disorder is a prevalent and chronic
anxiety disorder characterized by significant fear of humiliation,
embarrassment, and negative evaluation in social or performance-
based situations. In light of the debilitating nature of social anxiety
disorder, and the impact of stuttering on QOL and personal
functioning, collaboration between speech pathologists and
psychologists is required to develop and implement comprehensive
assessment and treatment programs for social anxiety among people
who stutter. This comprehensive approach has the potential to
improve QOL and engagement in everyday activities for people who
stutter (8).
The relationship between chronic stuttering and anxiety has been
a matter of some debate over the past two decades, with a major
emphasis of research focused on examining whether people who
stutter have abnormally elevated levels of trait or social anxiety. A
systematic literature review and meta-analyses were performed
evaluating: 1] trait anxiety and 2] social anxiety, in adults who
stutter. Only studies that met strict inclusion criteria were selected
for the meta-analyses. Two meta-analyses were conducted, the first
for trait anxiety, and the second for social anxiety. Meta-analytic
results confirmed that adults with chronic stuttering do have
substantially elevated trait and social anxiety. The overall effect size
for trait and social anxiety was calculated to be 0.57 and 0.82,
respectively. The data indicate that trait and social anxiety are
definite problems for many adults who stutter (9).
Anxiety and emotional reactions have a central role in many
theories of stuttering, for example that persons who stutter would
tend to have an emotionally sensitive temperament. The possible
relation between stuttering and certain traits of temperament or
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personality was reviewed and analyzed, with focus on temporal

relations (i.e., what comes first). Preschool children who stutter (as a
group) do not show any tendencies toward elevated temperamental
traits of shyness or social anxiety compared with children who do not
stutter. Significant group differences were, however, repeatedly
reported for traits associated with inattention and
hyperactivity/impulsivity, which is likely to reflect a subgroup of
children who stutter. Available data are not consistent with the
proposal that the risk for persistent stuttering is increased by an
emotionally reactive temperament in children who stutter. Speech-
related social anxiety develops in many cases of stuttering, before
adulthood. Reduction of social anxiety in adults who stutter does not
in itself appear to result in significant improvement of speech
fluency. Studies have not revealed any relation between the severity
of the motor symptoms of stuttering and temperamental traits. It is
proposed that situational variability of stuttering, related to social
complexity, is an effect of interference from social cognition and not
directly from the emotions of social anxiety. The data provide strong
evidence that persons who stutter are not characterized by
constitutional traits of anxiety or similar constructs (10).
The topic of temperament and early stuttering and the extent to
which it involves anxiety is theoretically and clinically relevant. The
topic can contribute to theory development and clinical practices
with early stuttering. A review of the empirical literature for this area
with a view to determining which of two hypotheses might be true is
presented. The first is that, for the population of those who stutter,
unusual temperament is a causal factor for the development of the
disorder and its later association with anxiety. The second
hypothesis is that for the population of those who stutter the
developmental manifestation of anxiety is an effect of stuttering.
Both hypotheses attempt to account for the well-known association
of anxiety with chronic stuttering. A firm conclusion about the
matter would be premature at present because the literature
involved is limited and contains some inconsistencies (11).
Much research has suggested that those who stutter are likely to
be anxious. In the present study, 34 stuttering and 34 control
participants completed the FNE Scale and the EMAS-T. The FNE data
showed a significant difference between the stuttering and control
participants, with a large effect size. Results suggested that, as a
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group, a clinical population of people who stutter has anxiety that is

restricted to the social domain. For the EMAS-T, significant
differences between groups were obtained for the two subtests that
refer specifically to people and social interactions in which social
evaluation might occur (Social Evaluation and New/Strange
Situations) but not for the subtests that contained no specific
reference to people and social interactions (Physical Danger and Daily
Routines). Those who stutter differ from control subjects in their
expectation of negative social evaluation, and that the effect sizes
are clinically significant. The FNE and the EMAS-T are appropriate
psychological tests of anxiety to use with stuttering clients in clinical
settings (12).
It is possible that the words “slow of speech and slow of tongue”
express a lack of eloquence, of oratory in the use of words, rather
than stammering. Did Moses lack oratorical skills and in particular
the ability to use diplomatic words that would appeal to Pharaoh’s
heart? The contemporary definition of the language and speech
developmental impediment that afflicted Moses is therefore still
open (13-15).

ASSESSMENT: the frequency of stuttering in children is estimated

at about 5%, and the disorder may persist until adulthood, for some
beyond 55 years of age. The etiology includes cognitive abilities,
genetics, sex of the child, and environmental influences. More than
80% of stuttering cases are classified as developmental problems,
although stuttering can be classified as a neurologic or, less
commonly, psychogenic problem.
Among adults who stutter social anxiety disorder is prevalent and
chronic anxiety disorder is characterized by significant fear of
humiliation, embarrassment, and negative evaluation in social or
performance-based situations. In these adults, anxiety is restricted
to the social domain. Persons who stutter would tend to have an
emotionally sensitive temperament.
In spite of his speech disorder, Moses led the people in their first
steps to freedom and independence. In spite of a severe disability,
Moses developed a stable, mature personality, and left his mark on
human history.
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References
1. Cunningham CE, McHolm AE, Boyle MH. Social phobia, anxiety, oppositional
behavior, social skills, and self-concept in children with specific selective mutism,
generalized selective mutism, and community controls. Eur Child Adolesc Psychiatry.
2006;15:245-55.
2. Kaplan HL, Sadock BJ. Stuttering. In: Kaplan HL, Sadock BJ. (eds.). Synopsis of
Psychiatry. Behavioral Sciences. Clinical Psychiatry, 5 ed. Williams & Wilkins. 1988,
pp. 620-2.
3. Baker L, Cantwell DP. Stuttering. In: Kaplan HI & Sadock BJ (eds.).
Comprehensive Textbook of Psychiatry, Vol. 2, 6 ed. Williams & Wilkins. 1995, pp.
2272-4.
4. Bricker-Katz G, Lincoln M, McCabe P. The persistence of stuttering behaviours
in older people. Disabl Rehabil. 2008;19:1-13.
5. Saltuklaroglu T, Kalinovsky J. How effective is therapy for childhood
stuttering? Dissecting and reintepreting the evidence in light of spontaneous
recovery rates. Int J Lang Commun Disord. 2005;40:359-74.
6. Prasse JE, Kikano GE. Stuttering: an overview. Am Fam Physician. 2008;
77:1271-6.
7. Diagnostic and Statistical Manual of mental Disorders, fourth edition.
Washington DC, American Psychiatric Association. 1994.
8. Iverach L, Rapee RM. Social anxiety disorder and stuttering: current status
and future directions. J Fluency Disord. 2014;40:69-82.
9. Craig A, Tran Y. Trait and social anxiety in adults with chronic stuttering:
conclusions following meta-analysis. J Fluency Disord. 2014;40:35-43.
10. Alm PA. Stuttering in relation to anxiety, temperament, and personality:
review and analysis with focus on causality. J Fluency Disord. 2014;40:5-21.
11. Kefalianos E, Onslow M, Block S, et al. Early stuttering, temperament and
anxiety: two hypotheses. J Fluency Disord. 2012;37(3):151-63.
12. Messenger M, Onslow M, Packman A, Menzies R. Social anxiety in
stuttering: measuring negative social expectancies. J Fluency Disord. 2004;29(3):
201-12.
13. Ben-Noun L. Speech disorder in biblical times - Moses: a heavy mouth and a
heavy tongue. Harefuah. 1999;136:906-8.
14. Ben-Nun L. Speech and language impediment – Moses. "Slow of speech and
slow of tongue". In: Ben-Nun L. (ed.). Pediatrics. B.N. Publication House. Israel.
2012, pp. 159-73.
15. Ben-Nun L. In: Ben-Nun L. (ed.) Moses. The Medical Record and The Family
Life Cycle of the Great Leader of the Jewish People. B.N. Publication House. Israel .
2010.

LEARNING DISABILITY. Learning disabilities are conditions that

affect how a person learns to read, write, speak, and calculate
numbers. They are caused by differences in brain structure and
affect the way a person's brain processes information (1). Learning
disabilities are usually discovered after a child begins attending
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school and has difficulties in one or more subjects that do not

improve over time. A person can have more than one learning
disability (2). Learning disabilities can last a person's entire life, but
they may be alleviated with the right educational supports (3). A
learning disability is not an indication of a person's intelligence.
Learning disabilities are not the same as learning problems due to
intellectual and developmental disabilities, or emotional, vision,
hearing, or motor skills problems (3). Some of the most common
learning disabilities include the following (4-14):
Dyslexia. This condition causes problems with language skills,
particularly reading. People with dyslexia may have difficulty
spelling, understanding sentences, and recognizing words they
already know.
Dysgraphia. People with dysgraphia have problems with their
handwriting. They may have problems forming letters, writing within
a defined space, and writing down their thoughts.
Dyscalculia. People with this math learning disability may have
difficulty understanding arithmetic concepts and doing such tasks as
addition, multiplication, and measuring.
Dyspraxia. This condition, also termed sensory integration
disorder, involves problems with motor coordination that lead to
poor balance and clumsiness. Poor hand-eye coordination also
causes difficulty with fine motor tasks such as putting puzzles
together and coloring within the lines.
Apraxia of speech. Sometimes called verbal apraxia, this disorder
involves problems with speaking. People with this disorder have
trouble saying what they want to say correctly and consistently.
Central auditory processing disorder. People with this condition
have trouble understanding and remembering language-related
tasks. They have difficulty explaining things, understanding jokes,
and following directions. They confuse words and are easily
distracted.
Nonverbal learning disorders. People with these conditions have
strong verbal skills but great difficulty understanding facial
expression and body language. They are physically clumsy and have
trouble generalizing and following multistep directions.
Visual perceptual/visual motor deficit. People with this condition
mix up letters; they might confuse "m" and "w" or "d" and "b," for
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example. They may also lose their place while reading, copy
inaccurately, write messily, and cut paper clumsily.
Aphasia. Aphasia also called dysphasia is a language disorder. A
person with this disorder has difficulty understanding spoken
language, poor reading comprehension, trouble with writing, and
great difficulty finding words to express thoughts and feelings.
Aphasia occurs when the language areas of the brain are damaged.
In adults, it often is caused by stroke, but children may get aphasia
from a brain tumor, head injury, or brain infection.
Children with the developmental speech/language impairments
are at higher risk for reading disability than typical peers with no such
history. For children with speech impairments alone, there is limited
risk for literacy difficulties. However, even when reading skills are
within the average range, children with speech impairments may
have difficulties in spelling. Children with language impairments are
likely to display reading deficits in word decoding and reading
comprehension (15).
Learning and attention issues in kids who are adopted can present
special challenges. A child’s early life before adoption can impact his
learning issues. When kids who are adopted have learning and
attention issues, parents may face some unique challenges. Kids
come to their new families with their own cultural and health
backgrounds. It can be hard for parents to know if some of the
problems they see are related to adoption, learning and attention
issues or both (16).

ASSESSMENT: did Moses suffer from some type of learning

disability?

References
1. Learning Disabilities: Condition Information. What are learning disabilities?
Available 14 January 2016 at https://www.nichd.nih.gov/health/topics/
learning/conditioninfo/Pages/default.aspx.
2. National Institute of Neurological Disorders and Stroke. 2011. NINDS learning
disabilities information page. Available 14 January 2016 at
http://www.ninds.nih.gov/disorders/learningdisabilities/learningdisabilities.htm.
3. What is a learning disability? Available 14 January 2016 at
http://www.ldonline.org/ldbasics/whatisld.
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4. International Dyslexia Association. 2008. Dyslexia basics. Available 20

January 2016 at http://www.interdys.org/ewebeditpro5/upload/
BasicsFactSheet.pdf.
5. National Institute of Neurological Disorders and Stroke. What is dysgraphia?
Available 10 January 2016 at http://www.ninds.nih.gov/disorders/
dysgraphia/dysgraphia.htm.
6. National Center for Learning Disabilities. What is dysgraphia? Available 24
January 2016 at https://www.understood.org/en/learning-attention-issues/child-
learning-disabilities/dysgraphia/understanding-dysgraphia.
7. National Center for Learning Disabilities. What is dyscalculia? Available 24
January 2016 at https://www.understood.org/en/learning-attention-issues/child-
learning-disabilities/dyscalculia/understanding-dyscalculia.
8. Learning Disabilities Association of America. Dyspraxia. Available 24 January
2016 at http://ldaamerica.org/types-of-learning-disabilities/ dyspraxia/.
9. National Institute on Deafness and Other Communication Disorders. Available
24 January 2016 at http://www.nidcd.nih.gov/health/voice/ pages/apraxia.aspx.
10. Learning Disabilities Association of America. Central auditory processing
disorder. Available 24 January 2016 at http://ldaamerica.org/types-of-learning-
disabilities/auditory-processing-disorder/.
11. Learning Disabilities Association of America. Non-verbal learning disorders.
Available 24 January 2016 at http://ldaamerica.org/types-of-learning-
disabilities/non-verbal-learning-disabilities/.
12. Learning Disabilities Association of America. Visual perceptual/visual motor
deficit. Available 24 January 2016 at http://ldaamerica.org/types-of-learning-
disabilities/visual-perceptual-visual-motor-deficit/.
13. Learning Disabilities Association of America. Language disorders: Aphasia,
dysphasia, or global aphasia. Available 24 January 2016 at http://ldaamerica.org/
types-of-learning-disabilities/language-processing-disorder/.
14. National Institute on Deafness and Other Communication Disorders.
Aphasia. Available February 15, 2016 at http://www.nidcd.nih.gov/
health/voice/pages/aphasia.aspx.
15. Schuele CM. The impact of developmental speech and language
impairments on the acquisition of literacy skills. Ment Retard Disabil Res. 2004;
10:176-83.
16. Learning and Attention Issues in Adopted Children. Available 17 January
2016 at https://www.understood.org/en/learning-attention-issues/getting-
started/what-you-need.

SOCIAL PHOBIA. Social phobia is characterized by a clear and

continuing fear of one or more social or performance situations, in
which the individual is exposed to unfamiliar people and possible
scrutiny by others. The individual is afraid of doing something
humiliating or embarrassing (1). One symptom can indicate the
existence of phobia – fear of public speaking (2).
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Social phobia in youth may manifest differently across

development as parent involvement in their social lives changes and
social and academic expectations increase. Self-reported and parent-
reported functioning was investigated in youth with social phobia
changes with age in social, academic, and home/family domains.
Baseline anxiety impairment data from 488 treatment-seeking
anxiety-disordered youth (ages 7-17 years, n=400 with a social
phobia diagnosis) and their parents were gathered using the Child
Anxiety Impact Scale and were analyzed using generalized estimating
equations. According to youth with social phobia and their parents,
overall difficulties, social difficulties, and academic difficulties
increased with age, even when controlling for social phobia severity.
These effects significantly differed for youth with anxiety disorders
other than social phobia. Adolescents may avoid social situations as
parental involvement in their social lives decreases, and their
withdrawn behavior may result in increasing difficulty in the social
domain. Their avoidance of class participation and oral presentations
may increasingly impact their academic performance as school
becomes more demanding (3).
Longitudinal associations between social phobia and educational
and interpersonal impairments among Finnish adolescents were
examined. Participants were 3,278 adolescents (9th grade, M age
15.5 years) who completed measures of social phobia and depressive
symptoms; 2070 participated in follow-up two years later. Indicators
for educational and interpersonal functioning were assessed for each
sex separately. Among boys, aged 15 years, social phobia predicted
slow academic progression, being without a close friend or not
having a romantic relationship, and poor support from friends and
significant others at age 17. However, for girls, aged 15 years, social
phobia only predicted not having been involved in a romantic
relationship by age 17. Sex differences for adolescent social phobia
as a predictor for subsequent educational and interpersonal
impairments in late adolescence were found. Social phobia may have
a more devastating effect on boys' social and academic functioning
than in girls (4).

ASSESSMENT: social phobia is characterized by a continuous fear

of one or more social or performance situations, in which the
individual is exposed to unfamiliar people and possible scrutiny by
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others. The individual is afraid of doing something humiliating or

embarrassing.
Moses was a great leader. Surely, he did not fear from any social
situation and any social performance. For these reasons it is unlikely
that he suffered from social phobia.
References
1. First MB, Spitzer RL, Gibbon M, Williams J. Structured Clinical Interview for
Axis DSM-IV Disorders. SCID-I/P (Version 2.0) Patient Version. Hebrew version:
Shalev A, Sahar T & Abramovitz M. Department of Psychiatry, Hadassah University
Hospital, PO Box 12000. Jerusalem. 1996.
2. Johnson CJ, Beitchman JH. Mixed receptive-expressive disorder. In: Sadock BJ
& Sadock VA (eds.). Comprehensive Textbook of Psychiatry. Vol 2. Eight ed.
Philadelphia, Baltimore: Lippincott Williams & Wilkins. 2005, pp. 3142-8.
3. Hoff AL, Kendall PC, Langley A, et al. Developmental Differences in
functioning in youth with social phobia. J Clin Child Adolesc Psychol. 2015 Dec 2:1-9.
[Epub ahead of print].
4. Ranta K, La Greca AM, Kaltiala-Heino R, et al. Social phobia and educational
and interpersonal impairments in adolescence: a prospective study. Child Psychiatry
Hum Dev. 2015 Oct 29. [Epub ahead of print]

ESTHER
This is the story of King Ahashverosh, who reigned in Persia and
Midia. One day the King made a great feast in his kingdom, and
invited his beautiful wife, Queen Vashti to attend the feast, but she
refused. For this unacceptable, disobedient behavior Queen Vashti
was punished by dismissal and a new queen was sought in the
kingdom. “Now in Shushan the capital there was a certain Jew, whose
name was Mordekhay...” (Esther 2:5). Mordekhay brought his beautiful
adopted daughter Esther to the King’s house “And he (Mordekhay)
brought up Hadassa, that is, Esther, his uncle’s daughter: for she had neither
father nor mother, and the girl was fair and beautiful; and when her father
and mother were dead Mordekhay took her for his own daughter” (2:7).
Mordekhay forbade Esther to identify herself as a Jew “Esther had not
made known her people of her descent: for Mordekhay had charged her that
she should not tell” (2:10.
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Esther before Ahashverosh. Nicolas Poussin. 1650.

Among all the young women brought to the King, he fell in love
with Esther “... the king loved Esther more than all the women, and she
obtained grace and favour in his sight more than all the virgins; so that he
set the royal crown upon her head, and made her queen instead of Vashti”
(2:17). Here Esther entered a new family system, this time as Queen.
Mordekhay discovered a plot of Bigthan and Teresh to assassinate
the King. He “..told it to Esther the queen; and Esther reported it to the king
in Mordekhay’s name” (2:22). This plot was confirmed and two men
were executed. In this way Mordekhay expressed his loyalty to the
King.

Esther and Mordekhay. De Gelder Aert. 1645

Later the King promoted Haman “...and set his seat above all the
princes who were with him” (3:1). Now all the King’s servants, with the
King’s consent, bowed, and showed obeisance to Haman, all except
proud Mordekhay. So Haman began to hate Mordekhay, expanding
his hatred to all the Jews living in the country. Subsequently, “..
Haman sought to destroy all the Jews who were throughout the whole
kingdom of Ahashverosh, the people of Mordekhay” (3:6). Haman
convinced the King that the Jews should be killed, and the King sent
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the decree to all over the country “And the letters were sent by couriers
to all the king’s provinces, to destroy, to kill, and to annihilate, all Jews, both
young and old, little children and women, ..” (3:13). This was a real
tragedy. “When Mordekhay perceived all that was done, Mordekhay rent
his clothes, and put on sackcloth with ashes, and went out into the midst of
the city, and cried with a loud and a bitter cry” (4:1). So, “..there was great
mourning among the Jews, and fasting, and weeping, and wailing; and many
lay in sackcloth and ashes” (4:3). Queen Esther was “.. exceedingly
distressed ..” (4:4).

Esther. Avi Katz. Queen Esther. Andrea del Castagno.

Meanwhile, Haman prepared the tree where Mordekhay should

be hanged, although he was warned that he was about to lose
because he was dealing with a Jew “If Mordekhay.....be of the seed of the
Jews, then thou shalt not prevail against him, but thou shalt surely fall
before him” (6:13).
Esther, who knew about the impending tragedy orchestrated by
Haman, invited the King and Haman to her banquet “So, the king and
Haman came to drink with Esther the queen” (7:1). Now Esther revealed
her real status, that she was a Jew “..we are sold, I and my people, to be
destroyed, to be slain, and to perish...” (7:4). She announced convincingly
“...The adversary and enemy is this wicked Haman. Then Haman was afraid
before the king and the queen” (7:6). He tried to beg forgiveness from
the Queen “..Haman was fallen upon the divan whereon Esther lay. Then
the king said, Will he even assault the queen in my own presence in the
house?” (7:8). The King believed that Haman’s behavior was a sexual
assault on the Queen and he ordered that Haman be hanged on the
same tree that he prepared for Mordekhay. “On that day the king gave
the house of Haman the Jews’ enemy to Esther the queen. And Mordekhay
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came before the king; for Esther had told him what he was to her (her
father). And the king took off his ring, which he had taken from Haman, and
gave it to Mordekhay. And Esther set Mordekhay over the house of Haman”
(8:1,2). The Jews’ enemy, Haman, was eliminated and the Jews were
saved from death (1).

Reference
1. Ben-Nun L. Esther. In: Ben-Nun L. (ed.). Pediatrics. B.N. Publication House.
Israel. 2012, pp. 146-155.

Tomb of Esther and Mordechai.

PARENTAL DEATH. Parental death is one of the most traumatic

events that can occur in childhood that places children at risk for a
number of negative outcomes (1). The death of a loved one is a
traumatic event for anyone and even more so for a child who is losing
an attachment to a parent. It can be challenging knowing how to
help a child with their grief. How to help children confront this crisis
in a healthy way? It is important to understand not only the nature
of the child’s relationship with the parent who died, but also his or
her relationship with other important attachment figures who the
child relies on for emotional support (2).
It has been estimated that 3.5% of children less than 18 years
have experienced the death of a parent which is about 2.5 million in
the U.S. (Social Security Administration, 2000) (3).
Children who do experience a parental death are at risk for
depression, anxiety, increased physical complaints, traumatic grief
such as yearning and lack of acceptance, low esteem, lowered
academic success, and a tendency to blame others. Parental loss is
not just one event: there is a cascade of stressful events, which often
include separation from familiar family members and neighborhoods,
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parental distress among the surviving family members, sudden

financial difficulties, and the likelihood of a decrease in good
parenting as the adult around struggle to cope. Overall, the major
factor that predicts how children will fare is how well the adults
around them cope and orient (4).
Various causes can be associated with parental mortality. These
include ischemic heart disease (5); stroke (6); vascular dementia due
to cerebrovascular disease (7); fatal infectious diseases (8-14); one in
five children experience parental death from cancer, while parental
death is often paternal than maternal and is most common in parents
diagnosed with leukemia, brain, colorectal, and lung tumors (15).
Was infectious disease responsible for parental death in Esther's
case? Three pathogens were identified in different ancient teeth
samples by 16S rDNA sequence amplification: Bordetella sp.,
Streptococcus pneumoniae and Shigella dysenteriae. Sequences
from Bordetella pertussis in the lungs of an ancient male Siberian
subject, whose grave dated from the end of the 17(th) century to the
early 18(th) century (16). The data indicate the molecular
identification of the M. tuberculosis complex DNA in bone tissue
samples from recent and historic populations (17).
In Esther's case, an infectious disease can be the cause of parental
death.

ASSESSMENT: parental death may be due to a variety of causes.

What caused the death of Esther's parents?
Due to lack of space it was impossible to present all possible
causes of Esther parents' death. Nevertheless, the main causes are
mentioned.

References
1. Haine RA, Ayers T, Sandler IN, Wolchik SA. Evidence-based practices for
parentally bereaved children and their families. Prof Psychol Res Pr. 2008;39(2):113-
121.
2. Lynette Robe, Angus Strachan. Emotional and Legal Issues. When a Child's
Parent Dies. Family Law News. 2010;32(2).
3. Social Security Administration. Intermediate Assumptions of the 2000
Trustees Report. Washington, DC: Office of the Chief Actuary of the Social Security
Administration. 2000.
4. Lynette Robe, Angus Strachan. Emotional and Legal Issues. When a Child's
Parent Dies. Family Law News. 2010;32(2).
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5. Phillips AN, Shaper AG, Pocock SJ, Walker M. Parental death from heart
disease and the risk of heart attack. Eur Heart J. 1988;9(3):243-51.
6. Wannamethee SG, Shaper AG, Ebrahim S. History of parental death from
stroke or heart trouble and the risk of stroke in middle-aged men. Stroke. 1996;
27(9):1492-8.
7. Starr JM, Thomas BM, Whalley LJ. Familial or sporadic clusters of presenile
dementia in Scotland: I. Parental causes of death in Alzheimer and vascular presenile
dementias. Psychiatr Genet. 1997;7(4):141-6.
8. Menna T, Ali A, Worku A. Prevalence of "HIV/AIDS related" parental death
and its association with sexual behavior of secondary school youth in Addis Ababa,
Ethiopia: a cross sectional study. BMC Public Health. 2014 Oct 30;14:1120.
9. Bai AD, Showler A, Burry L, et al. Impact of infectious disease consultation on
quality of care, mortality, and length of stay in Staphylococcus aureus bacteremia:
results from a large multicenter cohort study. Clin Infect Dis. 2015;60(10):1451-61.
10. Armstrong GL, Conn LA, Pinner RW. Trends in infectious disease mortality in
the United States during the 20th century. JAMA. 1999;281(1):61-6.
11. Proschan MA, Dodd LE, Price D. Statistical considerations for a trial of Ebola
virus disease therapeutics. Clin Trials. 2016 Jan 14. pii: 1740774515620145. [Epub
ahead of print].
12. Ritacco V, Kantor IN. Tuberculosis 110 years after the Nobel Prize awarded
to Koch. Medicina (B Aires). 2015;75(6):396-403.
13. Hifumi T, Fujishima S, Abe T, et al. Prognostic factors of Streptococcus
pneumoniae infection in adults. Am J Emerg Med. 2015 Oct 19. pii: S0735-6757
(15)00866-9.
14. Basri R, Zueter AR, Mohamed Z, et al. Burden of bacterial meningitis: a
retrospective review on laboratory parameters and factors associated with death in
meningitis, kelantan malaysia. Nagoya J Med Sci. 2015;77(1-2):59-68.
15. Syse A, Aas GB, Loge JH. Children and young adults with parents with
cancer: a population-based study. Clin Epidemiology. 2012;4(1):41-52.
16. Thèves C, Senescau A, Vanin S,et al. Molecular identification of bacteria by
total sequence screening: determining the cause of death in ancient human subjects.
PLoS One. 2011;6(7):e21733.
17. Zink AR, Grabner W, Nerlich AG. Molecular identification of human
tuberculosis in recent and historic bone tissue samples: the role of molecular
techniques for the study of historic tuberculosis. Am J Phys Anthropol. 2005;126(1):
32-47.

A NEW FAMILY. According to the Census definition a family

consists of two or more people related by birth, marriage, or
adoption, and who are living together (1).
According to Hill (2), families live within a coping band in which
they use adaptive mechanisms against stressful life events. Stressors
are those life events or changes that are so serious or drastic that
they require changes in the family system, for example, the death of
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a spouse, financial crisis, or unemployment. A crisis follows when a

family is unable to adapt within its coping band. The crisis is over
when the family is able to find intra- and/or extra-familial resources
to deal with it. After that, the family continues at a higher, lower or
the same level of functioning (3).
The first stressful negative life event was the death of Esther’s
biological parents. This led to a crisis that was resolved using intra-
familial resources. Esther’s separation from her father Mordekhay
represents a stressful life event that both father and daughter coped
with. Although they separated, a family crisis did not develop. Later,
Esther was exposed to another stressful life event when she prepared
to meet the King. When the King took Esther to be his wife and she
became Queen, she experienced a positive stress. The decision of
Haman and the King to exterminate all the Jews, including
Mordechai, was a negative environmental stress, which led to a
subsequent crisis that affected all the Jews living in the country.
When Esther succeeded in eliminating the wicked Haman, the Jews
were saved. The crisis ended and the King’s family continued to
function at the higher level - Haman was hanged, his house was given
to Esther, and Mordekhay was promoted and honored as the most
respected man in the country “And Mordekhay went out from the
presence of the king in royal apparel of blue and white, and with a great
crown of gold, and with a wrap of fine linen and purple...” (8:15).
“...Mordekhay was great in the king’s house, and his fame went out
throughout all the provinces: for this man Mordekhay grew greater and
greater” (9:4).
Families play an essential role in the emotional, physical, and
social development of individual family members (4). Esther’s first
family was exposed to extremely stressful event when her parents
died and this family system disintegrated. This crisis was resolved
when Esther entered the family of Mordekhay. Mordekhay gave his
adopted daughter emotional, physical and social support. When
Esther entered her third family, as Queen, the King supported his
beloved wife. He treated her with full respect, admiration, great
honor, and affection (4).
This is the case of a young woman, Esther, who in spite of her
adoption reached great status among the people and left a mark on
history. Maternal death, poverty, childlessness and the child gender
preference of foster parents are important factors when children are
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fostered (5). The reason for Esther’s adoption was the death of her
biological parents. Fortunately, internal family resources were used
to resolve this stressful situation, with the adoption that took place
within the same family system.
Although adoptive family research has increased, most has
focused on childhood and adolescence. Despite the known
importance of parent-adolescent relationships drawn from the
general population, little is known about how adoptive family
relationships change or remain the same as adopted adolescents
enter young adulthood. Using the Sibling Interaction and Behavior
Study, the purpose of this study was to build on previous research to
explore differences in conflict, closeness, and relationship quality
between adoptive and nonadoptive families during the transition
from late adolescence into young adulthood (5). Self-report and
independent observations were collected from children, mothers,
and fathers at late adolescence (range: 14.50-18.49 years) and young
adulthood (range: 18.50-22.49 years), and analyzed using within-
subjects repeated measures. Although adoptive family dyads had
lower relationship indicators than non-adoptive family dyads, similar
trends over time occurred for both family types. Using individuation
theory, individuation occurs for both types of families, with adoptees
facing unique additional challenges during this process, including
integration of adoption status, adoption communicativeness,
adoption information seeking, and relationship with birth parents as
possible influences in this process (5).
Although children in foster care suffer various physical and mental
health problems (6-9), the biblical text indicates no signs of Esther’s
physical or mental distress. It can be concluded therefore that in
spite of being adopted Esther was not afflicted by any physical or
mental disorders.

ASSESSMENT: Esther first belonged to the family of her biological

parents. When her parents died, this family system disintegrated.
Fortunately, Esther entered a new family system, with her new
father, Mordekhay, as the head of the adoptive family.
Esther, an adoptive child, was confronted with the integration of
her adoptive status, and adoption communicativeness.
Esther’s life changed when King Ahashverosh took her to be his
wife, and by entering this new family system, she automatically
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became Queen. Esther reached great status, and began to play the
role of the Queen. She coped with her new situation, dealing with
her internal family system as well as fulfilling her duty to outside
world.

References
1. Back to notes. Family: Discussion Points from Chapter 10-Ties that Bind, the
Family under Stress. Available 15 June 2004 at http://www.people.vcu.edu/~
jmahoney/familyhtm.
2. Hill R. Generic features of families under stress. In: Parad HJ (ed.). Crisis
intervention. Family Service Association of America, New York. 1965, pp. 32-52.
3. Family Crisis. Family Crisis defined -Hill’s ABC-> theory. Available 29 June
2004 at http:www3.uakron.edu/hefe/fc fcnote7.htm.
4. Ben-Nun L. The dynamics of Queen Esther Family. In: Ben-Nun L. (ed.) Family
Medicine in Biblical Times. 2005, pp. 159-164.
5. Walkner AJ, Rueter MA. Adoption status and family relationships during the
transition to young adulthood. J Fam Psychol. 2014;28(6):877-86.
6. Sarkar NR, Biswas KB, Khatun UH, Datta AK. Characteristics of young foster
children in the urban slums of Bangladesh. Acta Paediatr. 2003;92:839-42.
7. Schor EL. The foster care system and health status of foster children.
Pediatrics. 1982;69:521-8.
8. Chernoff R, Combs-Orme T, Risley-Curtiss CR, Heisler A. Assessing the health
status of children entering foster care. Pediatrics. 1994;93:594-601.
9. Halfon N, Mendonca A, Berkowitz G. Health status of children in foster care.
The experience of then Center of the Vulnerable Child. Arch Pediatr Adolesc Med.
1995;149: 386-92.

ATTACHMENT. Adolescents' closeness to adoptive parents

attachment styles in close relationships outside their family was
examined during young adulthood. Closeness to adoptive mother
and adoptive father was assessed in 156 adolescents (M = 15.7
years). Approximately nine years later (M = 25.0 years), closeness to
parents was assessed again as well as attachment style in their close
relationships. Multilevel modeling was used to predict attachment
style in young adulthood from the average and discrepancy of
closeness to adolescents' adoptive mothers and fathers and the
change over time in closeness to adoptive parents. Less avoidant
attachment style was predicted by stronger closeness to both
adoptive parents during adolescence. Increased closeness to
adoptive parents over time was related to less anxiety in close
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relationships. Higher closeness over time to either adoptive parent

was related to less avoidance and anxiety in close relationships (1).
The good outcome of adoption would mostly depend on the
quality of adoptive parenting, which is strongly associated with the
security of parental internal working models of attachment.
Specifically, attachment states-of-mind of adoptive mothers classified
as free and autonomous and without lack of resolution of loss or
trauma could represent a good protective factor for adopted children
previously maltreated and neglected. While most research on
adoptive families focused on pre-school and school-aged children,
the concordance of parental internal working models of attachment
in adoptive dyads during adolescence was assessed. In this
investigation were involved 76 participants: 30 adoptive mothers
(mean age 51.5 ± 4.3), and their 46 late-adopted adolescents (mean
age 13.9 ± 1.6), aged 4-9 years old at time of adoption (mean age =
6.3 ± 1.5). Attachment representations of adopted adolescents were
assessed by the Friend and Family Interview, while adoptive mothers'
state-of-mind with respect to attachment was classified by the Adult
Attachment Interview. Late-adopted adolescents were classified as
follows: 67% secure, 26% dismissing, and 7% preoccupied in the
Friend and Family Interview, while their adoptive mothers' Adult
Attachment Interview classifications were 70% free-autonomous, 7%
dismissing, and 23% unresolved. A significant concordance of 70%
(32 dyads) was found between the secure-insecure Friend and Family
Interview and Adult Attachment Interview classifications.
Specifically, adoptive mothers with high coherence of transcript and
low unresolved loss tend to have late-adopted children with high
secure attachment, even if the adolescents' verbal intelligence made
a significant contribution to this prediction. The results provide an
empirical contribution concerning the concordance of attachment in
adoptive dyads, highlighting the beneficial impact of highly coherent
states-of-mind of adoptive mothers on the attachment
representations of their late-adopted adolescent children (2).

ASSESSMENT: it can be concluded that a secure attachment

relationships developed between the adopted Esther and her uncle
Mordekhay.
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References
1. Grant-Marsney HA, Grotevant HD, Sayer AG. Links between Adolescents'
Closeness to Adoptive Parents and Attachment Style in Young Adulthood. Fam Relat.
2015;64(2):221-232.
2. Pace CS, Di Folco S, Guerriero V, et al. Adoptive parenting and attachment:
association of the internal working models between adoptive mothers and their late-
adopted children during adolescence. Front Psychol. 2015 Sep 23;6:1433.

TO SUM UP: this is the story of Esther, the adopted daughter of

Mordekhay. King Ahashverosh, King of Persia and Midia, chose
Esther, among many other young women, to be his wife and Queen.
When all the servants came to bow and to show obeisance to
Haman, the adoptive father Mordekhay, proud Jew, refused to do so.
His behavior aroused Haman’s hatred, which was extended to cover
all the Jews living in the country. The wicked Haman plotted to
destroy Mordekhay, the Jew, with the all other Jews living in the
country. The King issued a decree to exterminate the Jews. This
decision led to a crisis that affected Esther, her father Mordekhay,
and all the Jews.
Thanks to Esther’s wisdom, Haman was hanged and the Jews
escaped their destruction. Esther, an adopted girl, reached great
status and left her mark on Jewish history.
Mordekhay, as a responsible father, was concerned about his
daughter’s future. He believed that Esther was suitable to be the
Queen. So he took the risk of taking her to the King’s house, while
advising her to hide that fact that she was a Jew. If the King knew
this detail, she might not be chosen to be the Queen. Mordekhay
and Esther acted as full partners in this deception.

MEFIVOSHET
After King Saul and his three sons were killed, King David began to
seek the remaining members of Saul’s family. The son of his best
friend Jonathan, Mefivoshet, who was lame, was located and brought
to the King: "And Jonathan, Saul's son had a son that was lame of his legs.
He was five years old when tidings came of Saul and Jonathan (about their
death) out of Jezreel, and his nurse took him up, and fled: and it came to
pass, as she made haste to flee, that he fell, and became lame. And his
name is Mefivoshet" (II Samuel 4:4).
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Subsequently, the King adopted Mefivoshet, and regarded him as

his own son.

LIVING WITH CHRONIC DISEASE. Electronic databases and hand

searches were made of the literature published between January
1990 - September 2007. Literature was eligible for inclusion if it
involved adolescents between 10-19 years, published in English and
used qualitative methods of data collection. Twenty studies were
identified involving young people with a wide variety of chronic
illnesses. Seven common themes were found between the identified
studies: developing and maintaining friendships; being
normal/getting on with life; the importance of family; attitude to
treatment; experiences of school; relationship with the healthcare
professionals; and the future (1).
The results of the Early Intervention Collaborative Study, a
longitudinal investigation of the cognitive and adaptive behavior
development of children with developmental disabilities and the
adaptation of their parents, extending from infancy through middle
childhood are presented. Conceptual models of child and family
development were generated and tested and contributed to the
knowledge base that informs social policy and practice. The sample
for the investigation consisted of 183 children with Down syndrome,
motor impairment, developmental delay and their families who were
recruited at the time of their enrollment in an early intervention
program in Massachusetts or New Hampshire. Data were collected
at five time points between entry to early intervention and the child's
10th birthday. Home visits were conducted at each time point and
included child assessments, maternal interview, and questionnaires
completed independently by both parents. Trajectories in children's
development and parental well-being were analyzed using
hierarchical linear modeling. Predictor variables were measured at
age 3 years when children were exiting early intervention programs.
Children's type of disability predicted trajectories of development in
cognition, social skills, and daily living skills. Children's type of
disability predicted changes in maternal (but not paternal) child-
related and parent-related stress. Beyond type of disability, child
self-regulatory processes (notably behavior problems and mastery
motivation) and one aspect of the family climate (notably mother-
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child interaction) were key predictors of change in both child

outcomes and parent well-being. Different aspects of the family
climate, family relations predicted change in child social skills. Parent
assets, measured as social support and problem-focused coping,
predicted change in maternal and paternal parent-related stress
respectively (2).
Living with a chronic disease or disability during adolescence, the
quality of parent-adolescent relationship and the adolescent's
psychosocial development interacted with each other were assessed.
Using the Swiss Multicenter Adolescent Survey on Health 2002
database, adolescents aged 16-20 years with a chronic disease or
disability (n=760) were compared with their healthy peers (n=6493)
on sociodemographics, adolescents' general and psychosocial health,
interparental relationship and parent-adolescent relationship. In
bivariate analyses, adolescents with a chronic disease or disability
had a poorer psychosocial health and a more difficult relationship
with their parents. The log-linear model indirectly linked chronic
disease or disability and poor parent-adolescent relationship through
four variables: two of the adolescents' psychosocial health variables
(suicide attempt and sensation seeking), the need for help regarding
difficulties with parents and a highly educated mother that acted as a
protective factor, allowing for a better parent-adolescent with a
chronic disease or disability relationship. The data indicate that it is
essential for health professionals taking care of adolescents with a
chronic disease or disability to distinguish between issues in relation
with the chronic disease or disability from other psychosocial
difficulties, in order to help these adolescents and their parents deal
with them appropriately and thus maintain a healthy parent-
adolescent relationship (3).

ASSESSMENT: chronic illness in childhood is characterized by

developing and maintaining friendships; being normal/getting on
with life; the importance of family; attitude to treatment;
experiences of school; relationship with the healthcare professionals;
and the future.
Suffering from a chronic disease or disability during adolescence
can be a burden for both the adolescents and their parents.
Adolescents with a chronic disease or disability have a poorer
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psychosocial health and a more difficult relationship with their

parents.

References
1. Taylor RM, Gibson F, Franck LS. The experience of living with a chronic illness
during adolescence: a critical review of the literature. J Clin Nurs. 2008;17:3083-91.
2. Hauser-Cram P, Warfield ME, Shonkoff JP, et al. Children with disabilities: a
longitudinal study of child development and parent well-being. Monogr Soc Res
Child Dev. 2001;66(3):i-viii, 1-114; discussion 115-26.
3. Christin A, Akre C, Berchtold A, Suris JC. Parent-adolescent relationship in
youths with a chronic condition. Child Care Health Dev. 2016;42(1):36-41.

SPECIAL HEALTH NEEDS. Adopted children require special

families who are willing to adopt them. They require the services of
skilled social workers to effectively place them and understanding the
physician who is involved either with their placement examination or
with their subsequent management as an adoptee. A new objective
approach to the problem is necessary (1).
An analysis was carried out of restricted-access data from the
complete long form of Census 2000, US, for internationally adopted
children aged 5 to 15 years, estimating disability rates by country of
origin, controlling for gender, age at adoption, current age, and
parental characteristics. Internationally adopted children had
disability rates similarly to those adopted domestically (11.7% vs.
12.2%, respectively) and more than twice the rate for all children in
that age range (5.8%). The adjusted odds of disability relative to
domestic adoptees ranged from one half or less (China and Korea) to
twice or more (Romania, Bulgaria, other Eastern Europe, and other
Western Europe). Health, education, and social service professionals,
as well as adoptive and prospective adoptive parents, should be
aware of the risk for disabilities among adopted children to devote
the resources necessary to addressing them (2).
The 2003 National Survey of Children's Health, funded by the
Maternal and Child Health Bureau, Health Resources and Services
Administration, was conducted as a module of the State and Local
Area Integrated Telephone Survey by the National Center for Health
Statistics, CDC. The nationally representative sample consisted of
102.353 children, including 2,903 adopted children. Estimates for 31
indicators of health and well-being for adopted and biological
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children and present adjusted estimates that control for differences

in demographic characteristics and special health care needs
prevalence were compared. Adopted children were more likely than
biological children to have special health care needs, current
moderate or severe health problems, learning disability,
developmental delay or physical impairment, and other mental
health difficulties. However, adopted children were more likely than
biological children to have had a preventive medical visit or a
combination of preventive medical and dental visits during the
previous year, to receive needed mental health care, and to receive
care in a medical home; they were more likely to have consistent
health insurance coverage, to be read to daily, or to live in
neighborhoods that were supportive, and they were less likely to live
in households in which someone smokes. These differences between
adopted and biological children remained statistically significant even
after adjustments for differences in demographic characteristics and
the prevalence of special health care needs. The results suggest that
although adopted children may have poorer health than biological
children, their parents are doing more to ensure that adopted
children have needed health care and supportive environments (4).

About 800 families who had adopted children with special needs
responded to a mailed survey. Most reported good adoption
outcomes. The presence of a handicap - vision, hearing, or physical
impairment, mental retardation, or serious medical condition was
not an important factor influencing outcome (5).
In-depth face-to-face interviews of adoptive parents of 35
children were conducted, on average, four months postplacement
(but before adoption). One-year follow-up interviews were
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conducted with 15 (43%) parents of these children. Results indicated

higher than average levels of stress, particularly on subscales related
to parent-child dysfunctional interactions and to raising a difficult
child. Increased stress levels were associated with poorer family
adjustment and with higher levels of child behavior problems. Stress
levels remained mostly unchanged over the year. Responses to
open-ended questions identified five stress categories: child
characteristics, parent-child interactions, family cohesion, parental
adjustment, and adoption service issues (6).
Requests of international adoption in China can be processed by
the ordinary way and by the so-called way "green passage". All the
children for adoption by the "green passage" have special needs
because of suffering from congenital malformations, chronic diseases
or development disabilities that need medical or surgical treatment
and a specialized monitoring in the adoptive country. The medical
literature warns that the preadoptive medical records from China do
not offer absolute guarantee of veracity. This problem has been
observed in adoptions by the ordinary way of children diagnosed like
healthy, but also it can happen in children for adoption by the "green
passage". The clinical cases of three children with special needs
recently assigned to Spanish families are presented. In all the
assignations of children with special needs from China, the Adoption
Organizations must offer to the families the complete medical
records, the certified results of the laboratory tests and the pictures
so that, of exclusive and absolutely confidential manner, they consult
with specialized doctors in order to obtain the highest information of
the health problems and to value the medical prognosis before taking
a decision on the acceptance of the adoption (7).

ASSESSMENT: adopted children have special health problems and

special health needs. In spite of their disability, they receive
preventive medical visits, dental care, and have health care insurance
coverage. Thus, it seems that Mefivoshet received all necessary
health care concerning his disability.
Psychological stress in adoptive parents of special-needs children
includes child's characteristics, parent-child interactions, family
cohesion, parental adjustment, and adoptions service issues.
What stress categories affected the King and his extensive family?
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From the contemporary viewpoint, the King's family needed

services of a skilled social worker, and/or a family physician, and/or a
pediatrician. King David by adopting Mefivoshet showed
characteristics of a humanistic character. Mefivoshet, a new family
member, received all necessary attention and all needed treatment
concerning his disability.

References
1. Davis JH, Montgomery PA. Adoption planning for handicapped children. A
medical-social work partnership. Clin Pediatr. 1981;20:292-6.
2. Kreider RM, Cohen PN. Disability among internationally adopted children in
the United States. Pediatrics. 2009;124:1311-8.
4. Bramlett MD, Radel LF, Blumberg SJ. The health and well-being of adopted
children. Pediatrics. 2007;119 Suppl 1:S54-60.
5. Rosenthal JA, Groze V, Aguilar GD. Adoption outcomes for children with
handicaps Child Welfare. 1991;70:623-36.
6. McGlone K, Santos L, Kazama L, et al. Psychological stress in adoptive parents
of special-needs children. Child Welfare. 2002;81:151-71.
7. Oliván Gonzalvo G. Adoption in China of children with special needs: the
"green passage". An Pediatr (Barc). 2007;67(4):374-7.

ADOPTION FROM MIDDLE AGES TO

MODERN TIMES
The nobility of the Germanic, Celtic, and Slavic cultures that
dominated Europe after the decline of the Roman Empire denounced
the practice of adoption (1). In medieval society, bloodlines were
paramount; a ruling dynasty lacking a natural-born heir apparent was
replaced, a stark contrast to Roman traditions. The evolution of
European law reflects this aversion to adoption. English Common
Law, for instance, did not permit adoption since it contradicted the
customary rules of inheritance. In the same vein, France's
Napoleonic Code made adoption difficult, requiring adopters to be
over the age of 50, sterile, older than the adopted person by at least
fifteen years, and to have fostered the adoptee for at least six years
(2). Some adoptions continued to occur, however, but became
informal, based on ad hoc contracts. Thus, in the year 737, in a
charter from the town of Lucca, three adoptees were made heirs to
an estate. Like other contemporary arrangements, the agreement
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stressed the responsibility of the adopted rather than adopter,

focusing on the fact that, under the contract, the adoptive father was
meant to be cared for in his old age; an idea that is similar to the
conceptions of adoption under Roman law (3).
Europe's cultural makeover marked a period of significant
innovation for adoption. Without support from the nobility, the
practice gradually shifted toward abandoned children. Abandonment
levels rose with the fall of the empire and many of the foundlings
were left on the doorstep of the Church (4). Initially, the clergy
reacted by drafting ruled to govern the exposing, selling, and rearing
of abandoned children. The Church's innovation, however, was the
practice of oblation, whereby children were dedicated to lay life
within monastic institutions and reared within a monastery. This
created the first system in European history in which abandoned
children did not have legal, social, or moral disadvantages. As a
result, many of Europe's abandoned and orphaned children became
alumni of the Church, which in turn took the role of adopter.
Oblation marks the beginning of a shift toward institutionalization,
eventually bringing about the establishment of the foundling hospital
and orphanage (4).

At the monastery gate (Am Klostertor).

Ferdinand Georg Waldmüller.

As the idea of institutional care gained acceptance, formal rules

appeared about how to place children into families: boys could
become apprenticed to an artisan and girls might be married off
under the institution's authority (5). Institutions informally adopted
out children as well, a mechanism treated as a way to obtain cheap
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L. Ben-Nun Adoption

labor, demonstrated by the fact that when the adopted died, their
bodies were returned by the family to the institution for burial (6).
The system of apprenticeship and informal adoption extended
into the 19th century, a transitional phase for adoption history.
Under the direction of social welfare activists, orphan asylums began
to promote adoptions based on sentiment rather than work; children
were placed out under agreements to provide care for them as family
members instead of under contracts for apprenticeship (7).
The growth of this model contributed to the enactment of the first
modern adoption law in 1851 by the Commonwealth of
Massachusetts, unique in that it codified the ideal of the "best
interests of the child" (7,8).
Despite its intent, though, in practice, the system operated much
the same as earlier incarnations. The experience of the Boston
Female Asylumis is a good example, which had up to 30% of its
charges adopted out by 1888 (7). Officials of the Boston Female
Asylum noted that, although the asylum promoted otherwise,
adoptive parents did not distinguish between indenture and
adoption; "We believe," the asylum officials said, "that often, when
children of a younger age are taken to be adopted, the adoption is
only another name for service" (7).
The next stage of adoption's evolution fell to the emerging nation
of the U.S. Rapid immigration and the American Civil War resulted in
unprecedented overcrowding of orphanages and foundling homes in
the mid-nineteenth century. Charles Loring Brace, a Protestant
minister became appalled by the legions of homeless waifs roaming
the streets of New York City. Brace considered the abandoned youth,
particularly Catholics, to be the most dangerous element challenging
the city's order (8,9). His solution was outlined in The Best Method
of Disposing of Our Pauper and Vagrant Children (1859) which
started the Orphan Train movement. The orphan trains eventually
shipped an estimated 200,000 children from the urban centers of the
East to the nation's rural regions (8). The children were generally
indentured, rather than adopted, to families who took them in (10).
As times past, some children were raised as members of the family
while others were used as farm laborers and household servants (11).
The sheer size of the displacement, the largest migration of
children in history, and the degree of exploitation that occurred, gave
rise to new agencies and a series of laws that promoted adoption
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L. Ben-Nun Adoption

arrangements rather than indenture. The hallmark of the period is

Minnesota's adoption law of 1917, which mandated investigation of
all placements and limited record access to those involved in the
adoption (7,8).
During the same period, the Progressive movement swept the
U.S. with a critical goal of ending the prevailing orphanage system.
The culmination of such efforts came with the First White House
Conference on the Care of Dependent Children called by President
Theodore Roosevelt in 1909 (12), where it was declared that the
nuclear family represented "the highest and finest product of
civilization" and was the best to serve as primary caretaker for the
abandoned and orphaned (7,8). Anti-institutional forces gathered
momentum. As late as 1923, only 2% of children without parental
care were in adoptive homes, with the balance in foster
arrangements and orphanages. Less than forty years later, nearly
one-third were in an adoptive home (13).
The popularity of eugenic ideas in America put up obstacles to the
growth of adoption (7,14). There were grave concerns about the
genetic quality of illegitimate and indigent children, perhaps best
exemplified by the influential writings of Henry H. Goddard who
protested against adopting children of unknown origin, saying, "Now
it happens that some people are interested in the welfare and high
development of the human race; but leaving aside those exceptional
people, all fathers and mothers are interested in the welfare of their
own families. The dearest thing to the parental heart is to have the
children marry well and rear a noble family. How short-sighted it is
then for such a family to take into its midst a child whose pedigree is
absolutely unknown; or, where, if it were partially known, the
probabilities are strong that it would show poor and diseased stock,
and if a marriage should take place between that individual and any
member of the family the offspring would be degenerates" (15).
Transracial adoption and intercountry adoption began following
the end of World War II which had left thousands of children
homeless all over the world. (Simon, Alstein, Melli, The Case for
Transracial Adoption, p1.). The incidences of such adoptions grew in
the 1950's rising and falling as conflicts produced more children such
around the Korean and Vietnam Wars. Thus unless a child was of the
same ethnicity as the adoptive parents the explanation of who they
were and why there were differences was important (16).
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The period 1945 to 1974, the baby scoop era, saw rapid growth
and acceptance of adoption as a means to build a family (7).
Illegitimate births rose three-fold after World War II, as sexual mores
changed. Simultaneously, the scientific community began to stress
the dominance of nurture over genetics, chipping away at eugenic
stigmas (1,17). In this environment, adoption became the obvious
solution for both unwed mothers and infertile couples (1).
Taken together, these trends resulted in a new American model
for adoption. Following its Roman predecessor, Americans severed
the rights of the original parents while making adopters the new
parents in the eyes of the law. Two innovations were added: 1]
adoption was meant to ensure the "best interests of the child;" the
seeds of this idea can be traced to the first American adoption law in
Massachusetts (8,18), and 2] adoption became infused with secrecy,
eventually resulting in the sealing of adoption and original birth
records by 1945. The origin of the move toward secrecy began with
Charles Loring Brace who introduced it to prevent children from the
Orphan Trains from returning to or being reclaimed by their parents.
Brace feared the impact of the parents' poverty, in general, and their
Catholic religion, in particular, on the youth. This tradition of secrecy
was carried on by the later Progressive reformers when drafting of
American laws (7).
The number of adoptions in the U.S. peaked in 1970 (19). It is
uncertain what caused the subsequent decline. Likely contributing
factors in the 1960s and 1970s included a decline in the fertility rate,
associated with the introduction of the pill, the completion of
legalization of artificial birth control methods, the introduction of
federal funding to make family planning services available to the
young and low income, and the legalization of abortion. In addition,
the years of the late 1960s and early 1970s saw a dramatic change in
society's view of illegitimacy and in the legal rights (20) of those born
outside of wedlock. In response, family preservation efforts grew
(21) so that few children born out of wedlock were adopted (8).
Since the 1970s, finding alternative permanent families for
children in foster care who could not return to their birth parents has
been a primary goal of the child welfare system. Since that time,
significant gains have been made in helping such children find
permanent homes through adoption and guardianship. Thus, a
majority of states have doubled the number of adoptions from foster
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L. Ben-Nun Adoption

care over the 1995-97 baselines established by the federal

government. Legal guardianship initiatives at the state level have
been instrumental in helping thousands of children achieve
permanence. Children who exited foster care to adoption tended to
be younger than those who exited to guardianship. Postpermanency
services and supports were important to the long-term success of
these placements. Innovative efforts to find adoptive parents and
legal guardians for children in foster care could transform the nature
of foster care if the number of children permanently living with
families who received state subsidies began to exceed the number of
children living in foster care. Looking forward, these changes would
require child welfare agencies to think creatively and thoughtfully
about how best to serve families and the children in their care (21).
The American model of adoption eventually proliferated globally.
England and Wales established their first formal adoption law in
1926. The Netherlands passed its law in 1956. Sweden made
adoptees full members of the family in 1959. West Germany enacted
its first laws in 1977 (22). The Asians opened their orphanage
systems to adoption, influenced as they were by Western ideas
following colonial rule and military occupation (7).
Although adoption is today practiced globally, the U.S. has the
largest number of children adopted per 100 live births. Adoption in
the U.S. still occurs at nearly three times those of its peers although
the number of children awaiting adoption has held steady in recent
years, hovering between 133,000 and 129,000 during the period
2002 to 2006 (23).
Foster care placement is among the most tragic events a child can
experience because it more often than not implies that a child has
experienced or is at very high risk of experiencing abuse or neglect
serious enough to warrant state intervention. Yet it is unclear how
many children will experience foster care placement at some point
between birth and age 18. Using synthetic cohort life tables and data
from the Adoption and Foster Care Analysis and Reporting System, it
has been estimated how many U.S. children were placed in foster
care between birth and age 18, finding support for three conclusions.
First, up to 5.9% of all U.S. children were ever placed in foster care
between their birth and age 18. Second, Native American (up to
15.4%) and Black (up to 11.5%) children were at far higher risk of
placement. Foster care is thus quite common in the U.S., especially
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L. Ben-Nun Adoption

for historically disadvantaged racial/ethnic groups. Differences in

foster care placement were minimal between the sexes, indicating
that the high risks of foster care placement are shared almost equally
by boys and girls (24).

ASSESSMENT: in the past, the Germanic, Celtic, and Slavic

cultures denounced the practice of adoption. Similarly, English
Common Law did not permit adoption.
Later, the idea of institutional care gained acceptance, and formal
rules appeared about how to place children into families. The
practice gradually shifted toward abandoned children.
As the idea of institutional care gained acceptance, formal rules
appeared about how to place children into families: boys could
become apprenticed to an artisan and girls might be married off
under the institution's authority. The system of apprenticeship and
informal adoption that extended into the 19th century is a
transitional phase for adoption history.
Later adoption's evolution fell to the emerging nation of the U.S.
The children were generally indentured, rather than adopted, to
families who took them in. As times pasted, some children were
raised as members of the family while others were used as farm
laborers and household servants.
Theodore Roosevelt in 1909 declared that the nuclear family
represents "the highest and finest product of civilization" and is the
best to be able to serve as primary caretaker for the abandoned and
orphaned children.
Transracial adoption and inter-country adoption began following
the end of World War II which had left thousands of children
homeless all over the world.
The period 1945 to 1974, the baby scoop era, saw rapid growth
and acceptance of adoption as a means to build a family. Americans
severed the rights of the original parents while making adopters the
new parents in the eyes of the law. In response, family preservation
efforts grew few children born out of wedlock today are adopted.
Since the 1970s, finding alternative permanent families for
children in foster care who could not return to their birth parents has
been a primary goal of the child welfare system. Significant gains
have been made in helping such children find permanent homes
through adoption and guardianship.
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L. Ben-Nun Adoption

The American model of adoption eventually proliferated globally.

England and Wales established their first formal adoption law in
1926. The Netherlands passed its law in 1956. Sweden made
adoptees full members of the family in 1959. West Germany enacted
its first.

References
1. Barbara Melosh. Strangers and Kin: the American Way of Adoption. Harvard
University Press. Adoption History. 2002. Available 20 January 2016 at
http://pages.uoregon.edu/adoption/reading.html.
2. Code of Hammurabi. Available 12 January 2016 at
http://avalon.law.yale.edu/ancient/hamframe.asp.
3. Codex Justinianus. Medieval Sourcebook: The Institutes, 535 CE. Available 20
January 2016 at http://legacy.fordham.edu/halsall/basis/535institutes.asp.
4. The Psychology of Adoption. Brodzinsky and Schecter (eds.). Oxford
University Press. 1990.
5. David Kirk HD. Adoptive Kinship: A Modern Institution in Need of Reform,
1985. Available 15 January 2016 at http://www.newworldencyclopedia.org/entry
/Adoption.
6. Mary Kathleen Bene. The Politics of Adoption. 1976. Available 15 January
2016 at https://digital.lib.washington.edu/dspace-law/bitstream/handle/1773.1/
830/8PacRimLPolyJ.
7. Susan Porter . A Good Home. In: Wayne Carp (ed.). Adoption in America 2002.
Available 20 February 2016 at https://books.google.co.il/books?id=gVnx_ymDu6wC
&printsec=frontcover&redir_ esc=y#v=onepage&q&f=false.
8. Ellen Herman. Adoption History Project. University of Oregon. Timeline.
Available 22 January 2016 at http://pages.uoregon.edu/adoption/timeline.html.
9. Charles Loring Brace. The Dangerous Classes of New York and Twenty Years'
Work Among Them, 1872. Available 14 January 2016 at
https://books.google.co.il/books?id=gKg4ZsexZPIC&redir_esc.
10. Stephen O'Connor, Orphan Trains. 2004. University of Chicago Press.
Available 15 January 2016 at https://books.google.co.il/books?id=FMUlOcn61
q4C&redir_esc=y.
11. Orphan Train Heritage Society of America, Riders' Stories 2016. Available 20
January 2016 at http://www.orphantrainriders.com/riders11.html.
12. Gottlieb M. The Foundling. 2001. Available 20 January 2016 at
https://en.wikipedia.org/wiki/Adoption 76.
13. Bernadine Barr. Spare Children, 1900–1945: Inmates of Orphanages as
Subjects of Research in Medicine and in the Social Sciences in America. Stanford
University. 1992. Available 22 January 2016 at https://en.wikipedia.org/wiki/
Adoption.
14. Lawrence J, Starkey P. Child Welfare and Social Action in the Nineteenth and
Twentieth Centuries. Available 10 February 2016 at https://books.google.co.
il/books?id =him8GwThlAUC& redir_esc=y.
15. Goddard HH. Excerpt from Wanted: A Child to Adopt. Available 10 January
2016 at http://pages.uoregon.edu/adoption/archive/GoddardWCA.htm.
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16. TED Case Studies. Available 12 January 2016 at http://www1.american.edu/

TED/adopt.htm.
17. Mosher WD, Bachrach CA. Understanding U.S. Fertility: Continuity and
Change in the National Survey of Family Growth, 1988–1995. Fam Plann Perspect.
1996;28(1):4-12.
18 . The Psychology of Adoption. Brodzinsky and Schecter (eds.). 1990. Available
16 January 2016 at .ttps://books.google.co.il/books?id=7WQp2uEnogoC&
printsec=frontcover&redir_esc=y#v=onepage&q&f=false.
19. National Council for Adoption, Adoption Fact Book, 2000. Available 16
January 2016 at https://en.wikipedia.org/wiki/Adoption.
20. US Supreme Court Cases from Justia & Oyez. Available 16 January 2016 at
http://law.justia.com/constitution/us/amendment-14/90-illegitimacy.html.
21. Testa MF. When children cannot return home: adoption and guardianship.
Future Child. 2004;14(1):114-29.
22. Christine Adamec, William Pierce. The Encyclopedia of Adoption. 2nd
Edition. 2000. Available 17 January 2016 at https://en.wikipedia.org/wiki/Adoption.
23. U.S. D epartment of Health and Human Services, U.S. Trends in Foster Care
and Adoption. Available 26 January 2016 at
http://www.acf.hhs.gov/programs/cb/resource/trends-in-foster-care-and-adoption.
24. Wildeman C, Emanuel N. Cumulative risks of foster care placement by age
18 for U.S. children, 2000-2011. PLoS One. 2014;9(3):e92785.
25. Fallesen P, Emanuel N, Wildeman C. Cumulative risks of foster care
placement for Danish children. PLoS One. 2014;9(10):e109207.

TYPES

OPEN VERSUS CLOSED. Open adoption allows identifying

information to be communicated between adoptive and biological
parents and, perhaps, interaction between kin and the adopted
person (1). Rarely, it is the outgrowth of laws that maintain an
adoptee's right to unaltered birth certificates and/or adoption
records, but such access is not universal (it is possible in a few
jurisdictions, including the UK and six states in the U.S.) (2-5). Open
adoption can be an informal arrangement subject to termination by
adoptive parents who have sole authority over the child. In some
jurisdictions, the biological and adoptive parents may enter into a
legally enforceable and binding agreement concerning visitation,
exchange of information, or other interaction regarding the child. As
of February 2009, 24 U.S. states allowed legally enforceable open
adoption contract agreements to be included in the adoption
finalization (6).
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The practice of closed adoption (aka confidential or secret

adoption) (7), which has not been the norm for most of modern
history (8), seals all identifying information, maintaining it as secret
and preventing disclosure of the adoptive parents', biological kins',
and adoptees' identities. Nevertheless, closed adoption may allow
the transmittal of non-identifying information such as medical history
and religious and ethnic background (9). Today, as a result of safe
haven laws passed by some U.S. states, secret adoption is seeing
renewed influence. In so-called "safe-haven" states, infants can be
left, anonymously, at hospitals, fire departments, or police stations
within a few days of birth, a practice criticized by some adoption
advocacy organizations as being retrograde and dangerous. Closed
adoption, lack of medical history and the broken thread of family
continuity can have a detrimental impact on an adoptee's
psychological and physical health. The lack of openness, honesty and
family connections in adoption can be detrimental to the
psychological well being of adoptees and of their descendants (10).

References
1. What is Open Adoption? Available 12 January 2016 at
http://adoption.com/wiki/What_is_Open_Adoption%3F.
2. Adoption. Available 12 January 2016 at http://www.post-
gazette.com/pg/07316/833100-84.stm.
3. Adoption. Available 12 January 2016 at http://www.unsealedinitiative.
org/html/articles.html.
4. Adoption. Available 12 January 2016 at http://apostille.us/news/bill_looks_
o_open_ adoptionrecords.shtml.
5. Adoption. Available 12 January 2016 at
http://adoption.about.com/od/adoptionrights/ a/opening records.htm.
6. Postadoption Contact Agreements Between Birth and Adoptive Families:
Summary of State Law. U.S. Department of Health and Human Services,
Administration for Children and Families, Administration on Children, Youth and
Families, Children's Bureau. 2005. Available 10 January 2016 at
https://www.childwelfare.gov/pubPDFs/cooperativeall.
7. Adoptive family. Available 10 January 2016 at
http://www.allforchildren.org/pregnant/choose-adoptive-family.php.
8. Ellen Herman. Adoption History Project, University of Oregon, Topic:
Confidentiality. Available 17 January 2016 at http://pages.uoregon.edu/adoption/
topics/confidentiality.htm.
9. Bethany Christian Services. Available 17 January 2016 at
https://en.wikipedia.org/wiki/Adoption.
10. Adoption. Available 12 January 2016 at https://en.wikipedia.org/wiki/.
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RELATIVES/UNRELATED INDIVIDUALS. Adoptions can occur

either between relatives, or unrelated individuals. Historically, most
adoptions occurred within a family. The most recent data from the
U.S. indicates about half of adoptions are currently between related
individuals (1). A common example of this is a "stepparent
adoption", where the new partner of a parent may legally adopt a
child from the parent's previous relationship. Intra-family adoption
can occur through surrender, as a result of parental death, or when
the child cannot otherwise be cared for and a family member agrees
to take over (1).
Infertility is the main reason parents seek to adopt children they
are not related to. This accounts for 80% of unrelated infant
adoptions and half of adoptions through foster care (2). Of
Americans who cannot conceive or carry to term, 11-24% attempt to
build a family through adoption, and the overall rate of ever-married
American women who adopt is about 1.4% (3,4). Other reasons
include: wanting to cement a new family following divorce or death
of one parent, compassion motivated by religious or philosophical
conviction, to avoid contributing to overpopulation out of the belief
that it is more responsible to care for otherwise parent-less children
than to reproduce, to ensure that inheritable diseases (e.g., Tay-
Sachs disease) are not passed on, and health concerns relating to
pregnancy and childbirth. Although there are a range of possible
reasons, women who adopt are most likely to be 40–44 years of age,
currently married, have impaired fertility, and are childless (4).
Adoption includes parties in the adoption triad - the infant, the
biological parent(s), and the adoptive parent(s). Current adoption
laws have been influenced by a historical stigmatization of adoption
by society, states' sovereignty rights, and individual's constitutional
rights. Controversies surrounding nonrelated infant adoptions have
highlighted the inadequacies of the present system of adoption laws
and regulations. Nurses can take a proactive role in their practice by
acquiring a clear understanding of the legal issues surrounding
adoption (5).

References
1. National Council For Adoption, Adoption Factbook, 2000. Adoption Factcbook.
Available 24 January 2016 at https://www.adoptioncouncil.org/resources/adoption-
factbook.
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2. Berry M. Preparation, Support and Satisfaction of Adoptive Families in

Agency and Independent Adoptions. Child Adolesc Social Work J. 1996;13(2):157-
183.
3. Mosher WD, Bachrach CA. Understanding U.S. fertility: continuity and change
in the National Survey of Family Growth, 1988-1995. Fam Plann Perspect. 1996;
28(1):4-12.
4. Center for Disease Control. Adoption Experience of Women and Men and
Demand for Children to Adopt in the U.S. Available 16 January 2016 at
http://www.cdc.gov/nchs/data/series/sr_23/sr23_027.pdf U.S.
5. Lobar SL, Phillips S, Simunek LA. Legal issues in nonrelated infant adoption:
nursing implications. J Soc Pediatr Nurs. 1997;2(3):116-24; quiz 125-6.

PRIVATE DOMESTIC ADOPTIONS. Private domestic adoptions:

under an arrangement, charities and for-profit organizations act as
intermediaries, bringing together prospective adoptive parents and
families who want to place a child, all parties being residents of the
same country. Alternatively, prospective adoptive parents
sometimes avoid intermediaries and connect with women directly,
often with a written contract; this is not permitted in some
jurisdictions. Private domestic adoption accounts for a significant
portion of all adoptions; in the U.S., for example, nearly 45% of
adoptions are estimated to have been arranged privately (1).

Reference
1. US Child Welfare Information Gateway: How Many Children Were Adopted in
2000 and 2001? Findings: Children Adopted. Available 15 January 2016 at
Childwelfaregov.

FOSTER CARE ADOPTIONS. This is a type of domestic adoption

where a child is initially placed in public care. Its importance as an
avenue for adoption varies by country. Of the 127,500 adoptions in
the U.S. in 2000 (1) about 51,000 or 40% were through the foster
care system (2).
Over the past 25 years, kinship care placements have risen
dramatically, such that when a child enters into care, child welfare
agencies must first attempt to identify safe living arrangements with
relatives or individuals known to the child before searching for
alternatives. Quantitative research on children in out-of-home care
from 2007 to 2014 with regard to the following outcomes was
conducted to evaluate: 1] permanency (i.e., reunification, reentry,
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placement stability, and adoption/guardianship) and 2] safety (e.g.,

additional reports to child welfare). Based on these objectives, the
review identified 54 studies that examined permanency and safety
among children in two major placement types, namely foster family
and kinship care. Across studies, children in kinship care experienced
greater permanency in terms of a lower rate of reentry, greater
placement stability, and more guardianship placements in
comparison to children living with foster families. Children in kinship
care, however, had lower rates of adoption and reunification. The
findings indicate that differences in these variables diminish over
time. Findings for safety outcomes are mixed (3).
Children in foster care are the most vulnerable to experiencing
poor health compared with any other group of children in the U.S.
Children enter foster care due to experiences that have been
detrimental to their health and well-being, including child abuse and
neglect. They have significantly higher rates of all health problems
than the general population of children, including acute and chronic
illnesses, growth and developmental problems, serious mental health
problems, and difficulties accessing health services. They often
experience multiple foster care placement transitions, involvement in
multiple systems of care (e.g., mental health, juvenile justice, special
education), and aging-out of foster care at age 18 before they are
developmentally ready for independent living. While management of
the complex health and developmental needs of these children is
challenging, nurses in primary care have the expertise and obligation
to serve these vulnerable children. Priorities for clinical practice
include care coordination and interdisciplinary collaboration,
maintenance of adequate up-to-date health records, vigorous follow-
up, and health-targeted advocacy (4).
Children and adolescents who enter foster care often with
complicated and serious medical, mental health, developmental, oral
health, and psychosocial problems rooted in their history of
childhood trauma. Ideally, health care for this population is provided
in a pediatric medical home by physicians who are familiar with the
sequelae of childhood trauma and adversity. As youth with special
health care needs, children and adolescents in foster care require
more frequent monitoring of their health status and pediatricians
have a critical role in ensuring the well-being of children in out-of-
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home care through the provision of high-quality pediatric health

services, health care coordination, and advocacy (5).

References
1. US Child Welfare Information Gateway: How Many Children Were Adopted in
2000 and 2001? Available 20 January 2016 at www.childwelfare.gov.
2. Adoption. US Child Welfare Information Gateway: Trends in Foster Care and
Adoption. Available 18 January 2016 at http://www.acf.hhs.gov/programs/cb/
stats_ research/afcars/ trends.htm.
3. Bell T, Romano E. Permanency and safety among children in foster family and
kinship care: a scoping review. Trauma Violence Abuse. 2015 Oct 11. pii:
1524838015611673. [Epub ahead of print].
4. Kools S, Kennedy C. Foster child health and development: implications for
primary care. Pediatr Nurs. 2003;29(1):39-41, 44-6.
5. Health Care Issues for Children and Adolescents in Foster Care and Kinship
Care. Council on Foster Care; Adoption, and Kinship Care; Committee on
Adolescence, and Council on Early Childhood. Pediatrics. 2015;136(4):e1131-40.

INTER-COUNTRY ADOPTIONS. Inter-country adoption is an

extremely sensitive and emotional issue for the citizens of the
sending countries as well as for those in other, often more affluent,
countries who adopt these children. It must be a priority to respect
the dignity of the child's birth country as well as the dignity of the
child (1).
In the U.S., the number of inter-country adoptions has steadily
increased in the past 15 years. Healthcare providers should
understand the medical aspects of such adoptions in order to better
advise families and aid them in making an informed decision when
adopting a foreign-born child. Pretravel consultation is addressed,
including immunizations, safety issues, and how to create a
personalized prophylactic medical travel kit. Review of pictures,
videos, and the medical history of the potential adoptive child is also
discussed, as is air travel with children. Postemigration medical
examinations-include developmental and psychosocial evaluations,
general work-up with laboratory studies, and immunizations (2).
The goal of this paper is both modest and ambitious. The modest
goal is to show that inter-country adoption should be considered by
ethicists and healthcare providers. The more ambitious goal is to
introduce the many ethical issues that inter-country adoption raises.
Inter-country adoption is an alternative to medical, assisted
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reproduction option such as IVF, intracytoplasmic sperm injection,

third party egg and sperm donation and surrogacy. Health care
providers working with assisted reproduction are in a unique position
to introduce their clients to inter-country adoption; however,
providers should do so if inter-country adoption is ethically equal or
superior to the alternatives. A healthcare provider should promote
inter-country adoption unconditionally; however, in situation where
inter-country adoption is practiced conscientiously it poses no
greater ethical concern than several medical alternatives (3).
The Black Adoption Research and Placement Center is a nonprofit
organization delivering culturally specific adoption and foster care
services. The organization developed as a response to concerns in
the African-American community about the high numbers of African-
American children entering and not exiting the public foster care
system. The organization has undergone significant transformations
over its 25-year history in relation to social, political, and economic
changes that have altered the ways that the agency finances and
delivers services. Black Adoption Research and Placement Center
presents an organization that has weathered many challenges
because of its strong leadership, its commitment to governing body,
its external relationships, and its internal operations (4).
Because of major worldwide demographic changes, many Latin
American children are frequently adopted in the U.S. An overview of
the historical and contemporary circumstances, controversies
surrounding inter-country adoptions and a review of possible risk
factors for later child or adolescent maladjustment are presented.
Although a number of follow-up studies indicate a 70-80% positive
outcome, some inter-country adoptions end in painful family-child
disruptions. There is a growing need for bilingual/bicultural mental
health services to improve the initial adjustment process and to
facilitate a positive long-term outcome. These services are especially
needed when the child is older at arrival and the adopting family lives
in a mostly homogeneous community (5).
Using social justice as the conceptual foundation, the structural
barriers to socially just inter-country adoptions can exploit and
oppress vulnerable children and families participating in inter-
country adoptions. Such practices threaten the integrity of social
work practice in that arena and the survival of inter-country
adoptions as a placement option. Government structures, disparity
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of power between countries and families on both sides, perceptions

regarding poverty, cultural incompetence, misconceptions about
orphans and orphanages, lack of knowledge about the impact of
institution-based care, and the profit motive are driving forces
behind the growing shadow of unethical inter-country adoptions.
The U.S. social work community has a large role and responsibility in
addressing these concerns as the U.S. receives the most children
adopted through inter-country adoptions of all receiving countries.
In addition to the centrality of social justice as a core value of the
profession, the responsibility to carry out ethical and socially just
inter-country adoption has recently increased as a matter of law,
under the implementation legislation to the Hague Convention on
inter-country adoption (6).

References
1. Cox SS, Lieberthal J. Intercountry adoption: young adult issues and transition
to adulthood. Pediatr Clin North Am. 2005;52(5):1495-506, ix.
2. Grogg SE, Grogg BC. Intercountry adoptions: medical aspects for the whole
family. J Am Osteopath Assoc. 2007;107(11):481-9.
3. Jones S. The ethics of intercountry adoption: why it matters to healthcare
providers and bioethicists. Bioethics. 2010;24(7):358-64.
4. Schwartz SL, Austin MJ. Black Adoption Placement and Research Center at 25:
placing African-American children in permanent homes (1983-2008). J Evid Based
Soc Work. 2011;8(1-2):160-78.
5. de Verthelyi RF. Intercountry adoption of Latin American children: the
importance of early bilingual/bicultural services. Cult Divers Ment Health. 1996;
2(1): 53-63.
6. Roby JL, Rotabi K, Bunkers KM. Social justice and intercountry adoptions: the
role of the U.S. social work community. Soc Work. 2013;58(4):295-303.

INTERNATIONAL ADOPTIONS. International adoption involves

the placing of a child for adoption outside that child's country of
birth. This can occur through both public and private agencies. In
some countries, such as Sweden, these adoptions account for the
majority of cases. The U.S. example, however, indicates there is wide
variation by country since adoptions from abroad account for less
than 15% of its cases (1). More than 60,000 Russian children have
been adopted in the U.S. since 1992 (2), and a similar number of
Chinese children were adopted from 1995 to 2005 (3). The laws of
different countries vary in their willingness to allow international
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adoptions. Recognizing the difficulties and challenges associated

with international adoption, and in an effort to protect those
involved from the corruption and exploitation which sometimes
accompanies it, the Hague Conference on Private International Law
developed the Hague Adoption Convention, which came into force
on 1 May 1995 and has been ratified by 85 countries as of November
2011 (3).
Internationally adopted children come from high risk
environments that differ significantly from those of children born and
raised in the U.S. This can impact their developmental and parenting
needs. Aware adoptive parents can do many things to lessen the
effects of a highly deprived early start to life and encourage optimal
development. However, preconceived ideas and myths about
adoption often stand in the way of parental desires to provide the
best for their newly adopted child. Pediatric nurses aware of these
common myths can educate and support adoptive parents in the
early identification of potential concerns and in addressing and
ameliorating them. Preparation, planning, and use of professional
resources, as needed, can assist parents in supporting the child's
development and in achieving successful integration of the
internationally adopted child into their new family (4).
As international adoption has become more "mainstream," the
issues recently addressed in domestic adoption have become more
important in adoptions involving children originating in other
countries. Certain groups of prospective adoptive parents, such as
gay or lesbian couples, single parents, and parents with disabilities,
have begun to apply to adopt in ever increasing numbers. Children
who may have been considered unadoptable in the past are now
routinely being offered to prospective adoptive parents. The
numbers and ages of the children placed and the spacing between
adoptions have come under scrutiny. The rates of adoption
dissolutions and disruptions are being examined carefully by the
receiving and sending countries (5).
Despite the popularity of international adoption in North America
and Western Europe as a means to build a family, the knowledge of
health care professionals is often limited regarding the historical
context of this phenomenon as well as the motivations and process
experienced by adoptive parents. Although international adoption is
viewed as an acceptable if not admirable method of forming kinships
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in accepting countries, opinions in the international community are

mixed. Whether international adoptions increase or are drastically
curtailed depends on addressing the misgivings that many countries
have about placing their children abroad. Concerns center in two
broad areas: sensitivity toward preservation of family and culture and
whether the process has sufficient integrity to act in the best
interests of children and birth parents (6).
Immigrant visas issued to orphans entering the U.S. (a proxy
measure for international adoptions) totaled 13,620 in 1997, more
than double the amount in 1992. As international adoption numbers
rise, pediatric nurses encounter more adopted children and adoptive
families. Among the many adoption-related issues confronting
pediatric health care providers, the one most frequently voiced is:
"Should we do or look for anything differently in adopted children?
And, if so, what?" To address this issue, a three-fold approach is
suggested: 1] recognize the physical conditions and medical problems
prevalent in the international countries with high adoption rates; 2]
identify the unique adoption-related tasks encountered by children
according to their current developmental stage; and 3] determine
recommendations for providers, parents, and children to successfully
address or cope with these adoption-related tasks and conditions (7).

International adoption research has been called a natural

experiment by many child development researchers. How do studies
of severe early deprivation inform us about risk factors experienced
by many of these children and their impact on developmental
outcomes? Three longitudinal studies conducted by British and
American researchers in the 1990s were reviewed. Each year, over
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20,000 children were adopted from overseas, and a significant

number entered adolescence; the impact of their prenatal risk
factors, early institutionalization, and ameliorative postadoptive
environments was significant (8).
Adoptions from international countries have become an option
for many U.S. families, with over 150,000 children adopted in the
past 14 years. Typically, internationally adopted children present
with a host of medical and developmental concerns. Issues such as
growth stunting, abnormal behaviors and significant delays in motor,
speech, and language development are likely directly related to the
prenatal and early postnatal environment experienced prior to
adoption. The new family and its health-care team must quickly work
to identify and address these issues to aid the child's integration into
his or her new family. Potential issues seen in children, who are
being adopted, include the impact of early environment on
subsequent development. Possible mechanisms leading to the
developmental delays include the impact of stress on subsequent
development. By understanding the extent of expected delays and
the mechanisms likely causing the issues, the health-care team will
be in a good position to quickly identify and develop intervention
protocols that will foster the child's assimilation into his or her new
family (9).
Families who adopt internationally often need assistance in
determining which factors they need to consider when making
educational decisions for their child, and they frequently seek
guidance from their physician. Understanding how the education
system functions, how it differs from the medical system, and how
children who have been adopted internationally can succeed in
school is important for health care providers because this
information helps parents in making proactive decisions for their
children. Internationally adopted children have the best chance of
maximizing their learning potential when medical and educational
professionals work together to assist families as they plan for their
child's education (10).
The first population-based surveillance was conducted in the U.S.
of parents who adopted children from countries outside of the U.S. A
556-item survey was mailed to 2,977 parents who finalized an
international adoption in Minnesota between January 1990 and
December 1998; 1,834 (62%) parents returned a survey. Of the
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parents, 88% reported transracial adoptions (97% of the parents

were white); 57% of the adopted children were Asian; 60% were
female; and on average, the children were 18 months-old at the time
of placement. Only 15% of the parents reported household annual
incomes less than $50,000 and 71% reported they had college
educations. Sixty-one percent traveled to their child's country of
birth prior to the adoption. Almost three-quarters involved their
children in experiences related to their birth countries and 98%
would recommend international adoption. Three-quarters of the
parents believe that parental leave was an issue for them as they
adopted. This was the population-based survey of U.S. parents who
have adopted internationally. The adoptive parents were
socioeconomically different than birth parents in Minnesota and their
families were most likely to be transracial. Because international
adoption has become prevalent, it is important to understand the
strengths and needs of families that are created through this unique
form of migration (11).
A cross-national sample of 622 internationally adopted children
from India with White parents in The Netherlands (n=409), Norway
(n=146), and the U.S. (n=67) was used to contrast country-specific
bicultural socialization practices among families of transracial inter-
country adoption. The three countries vary in their degrees of
minority (U.S. > Netherlands > Norway) and Indian populations (U.S.
> Norway > Netherlands). Parental survey trends among bicultural
socialization practices, children's negative encounters about
adoption, racial and positive discrimination, and parental worry
about these issues were examined. Country-specific differences
were revealed: The U.S. and Norway (greatest Indian populations)
reported the greatest similarity in bicultural socialization practices,
classmates being a source of negative reactions/racial discrimination,
and parental worry. The American sample encountered greater
negative reactions to adoption from others; Dutch children
experienced the least negative reactions from others overall, yet as in
the U.S. (samples with the greatest minority heterogeneity) they still
noted significant experiences of racial discrimination. Country-
specific sociopolitical perceptions about adoption, ethnicity/race, and
immigration are considered as factors that may have been used to
inform parenting practices that facilitate children's biculturalism into
family life (i.e., adoptive family stigma, percentages of
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Indian/minority populations, immigration policy trends). The data

indicate that cross-national research may help inter-country adoption
policymakers and practitioners to better understand and inform
bicultural socialization practices in adoptive families (12).

References
1. US Child Welfare Information Gateway: How Many Children Were Adopted in
2000 and 2001? Available 20 January 2016 at www.childwelfare.gov.
2. Who Will Adopt the Orphans? Available 15 January 2016 at
https://en.wikipedia.org/wiki/Adoption.
3. Adopted Chinese orphans often have special needs. The Boston Globe.
Available 24 January 2016 at http://www.boston.com/news/nation/articles/
2010/04/03/adopted_chinese_orphans_often_have_special_needs./
3. Countries ratifying or acceding to the Hague Convention. Available 24 January
2016 at http://hcch.e-vision.nl/index_en.php?act=conventions.status&cid=69.
4. Narad C, Mason PW. International adoptions: myths and realities. Pediatr
Nurs. 2004;30(6):483-7.
5. Jenista JA. Special topics in international adoption. Pediatr Clin North Am.
2005;52(5):1479-94, ix.
6. Johnson DE. International adoption: what is fact, what is fiction, and what is
the future? Pediatr Clin North Am. 2005;52(5):1221-46, v.
7. Lears MK, Guth KJ, Lewandowski L. International adoption: a primer for
pediatric nurses. Pediatr Nurs . 1998;24(6):578-86.
8. McGuinness TM, Dyer JG. International adoption as a natural experiment. J
Pediatr Nurs. 2006;21(4):276-88; quiz 289.
9. Mason P, Narad C. International adoption: a health and developmental
prospective. Semin Speech Lang. 2005;26(1):1-9.
10. Dole KN. Education and internationally adopted children: working
collaboratively with schools. Pediatr Clin North Am. 2005;52(5):1445-61, viii-ix.
11. Hellerstedt WL, Madsen NJ, Gunnar MR, et al. The International Adoption
Project: population-based surveillance of Minnesota parents who adopted children
internationally. Matern Child Health J. 2008;12(2):162-71.
12. Riley-Behringer M, Groza V, Tieman W, Juffer F. Race and bicultural
socialization in the Netherlands, Norway, and the United States of America in the
adoptions of children from India. Cultur Divers Ethnic Minor Psychol. 2014;20(2):
231-43.

MILITARY FAMILIES. Military families stationed overseas and

within the U.S. are not prohibited from adopting children from the
U.S. foster care system. AdoptUSKids is working to help reduce
barriers to adoption for military families. This includes providing free
assistance to military families who are seeking to foster or adopt
children from foster care, and developing free resources for child
welfare agencies on best practices for working with military families.
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Families stationed within the U.S. can apply to foster and adopt
according to the rules of the state where he/she is stationed (1).
The adoption of foreign-born children by U.S. families is an
increasingly common occurrence, having tripled in the past 15 years.
The demographic features of international adoption have changed
dramatically over the same time period. Today's foreign-born
adoptees originate from a myriad of nations and cultures and present
challenging medical and social problems to the practitioners faced
with caring for these children and advising their adoptive families.
Military families, cosmopolitan and often stationed overseas, adopt a
large proportion of these children from foreign lands. Consequently,
military health care providers require a familiarity with the special
needs of international adoptees and the unique aspects of
international adoption, as practiced by military families (2).

References
1. Adoption Resources for Military Families. Available 18 January 2016 at
http://www.adoptuskids.org/for-families/who-can-foster-and-adopt/adoption-
resources-for-military-families.
2. Cieslak TJ, Huitink JS, Rajnik M, Ascher DP. International adoptions by military
families: a reexamination. Mil Med. 2006;171(12):1201-5.

LESBIAN, GAY COUPLES. An ecological framework was used to

examine predictors of self-perceived parenting skill among 47
lesbian, 31 gay, and 56 heterosexual couples who were adopting
their first child. Findings revealed that, on average, all new parents
perceived themselves as becoming more skilled, although gay men
increased the most and lesbians the least. Participants who were
female, reported fewer depressive symptoms, expected to do more
child care, and reported higher job autonomy viewed themselves as
more skilled pre-adoption. With regard to change, parents who
reported more relational conflict and parents who expected to do
more child care experienced lesser increases in perceived skill.
Regardless of gender, sexual orientation, and route to parenthood,
new parents experience similar, positive changes in perceived skill,
thereby broadening our understanding of parenting skill in diverse
groups. The findings also highlight the importance of examining how
gender, sexual orientation, and the family context may shape
perceived skill across the transition to parenthood (1).
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The experiences of 79 lesbian, 75 gay male, and 112 heterosexual

adoptive parents of preschool-age children were examined with
respect to their 1] level of disclosure regarding their lesbian/gay
parent and adoptive family status at their children's schools; 2]
perceived challenges in navigating the preschool environment and
advocating on behalf of their children and families; and 3]
recommendations to teachers and schools about how to create
affirming school environments with respect to family structure,
adoption, and race/ethnicity. Findings revealed that the majority of
parents were open about their lesbian/gay and adoptive family
status, and had not encountered challenges related to family
diversity. Those parents who did experience challenges tended to
describe implicit forms of marginalization, such as insensitive
language and school assignments. Recommendations for teachers
included discussing and reading books about diverse families,
tailoring assignments to meet the needs of diverse families, and
offering school community-building activities and events to help
bridge differences across families (2).
Although increasing numbers of gay and lesbian individuals and
couples are adopting children, gay men and lesbian women continue
to face increased scrutiny and legal obstacles from the child welfare
system. The adoption satisfaction, depressive symptoms, parenting
stress, and social support at 2, 12, and 24 months postplacement of
82 parents (60 heterosexual, 15 gay, 7 lesbian) adopting children
from foster care in Los Angeles County were compared. Few
differences were found between heterosexual and gay or lesbian
parents at any of the assessments or in their patterns of change over
time. On average, parents in both household types reported
significant increases in adoption satisfaction and maintained low,
nonclinical levels of depressive symptoms and parenting stress over
time. Across all family types, greater parenting stress was associated
with more depressive symptoms and lower adoption satisfaction.
Results indicate many similarities between gay or lesbian and
heterosexual adoptive parents, and highlight a need for services to
support adoptive parents throughout the transition to parenthood to
promote their well-being (3).
An overview of existing studies on gay and lesbian parenthood
and child development was conducted. Research among children
raised by homosexual parents involves methodological issues, such as
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defining homosexual families, sampling cases and controls, and

choosing structured or semi-structured evaluations. The fact that
homosexual marriage, adoption and insemination are not presently
legal in France could explain that only one study has been conducted
in France in 2000 among 58 children adopted by homosexual parents.
These children did not show an increased rate of behavior or anxiety
disorders. Concerns about lesbian parenting have focused on the
absence of a father, the homosexual orientation of the mother, and
their negative consequences on the development of the children.
Research on parenting and child rearing has repeatedly compared
lesbian and heterosexual families, and in the last 30 years a growing
body of studies on lesbian parents and the development of their
children have been published. Papers about child development,
sexual orientation, gender identity, gender role behavior,
emotional/behavioral development, social relationships and
cognitive functioning showed no difference between children of
lesbian mothers and those of heterosexual parents. Parental
functioning, the mothers' psychological health and maternal skills
were insignificantly different among lesbian mothers than
heterosexual mothers. In studies concerning gay fathers, findings
generally indicate no differences in sexual orientation, socialization,
or psychological outcomes in children of gay fathers compared to
children of heterosexual fathers. However, the first paper on the
adult attachment style dimensions of adult women who had gay or
bisexual fathers suggested that they were significantly less
comfortable with closeness and intimacy, less able to trust and
depend on others, and experienced more anxiety in relationships
than women with heterosexual fatherly. Variables related to family
processes, such as relationship quality, are currently considered more
important predictors of children's adjustment in homosexual families
than sexual orientation. The major part of the literature focused on
children aged four to 16 and the small sample size (often less than 30
children) limit the validity of these data (4).
There is a variety of families headed by a lesbian or gay male
parent or same-sex couples. Children with lesbian or gay parents are
comparable with children with heterosexual parents on key
psychosocial developmental outcomes. In many ways, children of
lesbian or gay parents have similar experiences of family life
compared with children in heterosexual families. Some special
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considerations apply to the context of lesbian and gay parenting:

variation in family forms, children's awareness of lesbian and gay
relationships, heterosexism, and homophobia. These issues have
important implications for managing clinical work with children of
lesbian mothers or gay fathers (5).
The wide variety of lesbian families who became visible during the
past 20 years gave rise to important practical and theoretical
questions. Up to now society has treated lesbian mothers differently
with regard to a number of child-issues. In the past, divorcing lesbian
mothers were often denied child custody because of their sexual
orientation and the majority of fertility centers still refuse lesbian
couples in their donor insemination programs. The present paper
reviews whether there is any theoretical and empirical evidence for
the most widespread assumptions on which such decisions have
been based. A number of psychological theories, such as
psychoanalytic theory, social and cognitive learning theory and
attachment theory are discussed with regard to the two most salient
features of lesbian families; the absence of a father and the
homosexual orientation of the mother. Meanwhile, there is a
growing body of empirical research investigating a variety of aspects
of child development, such as gender development,
emotional/behavioral adjustment and social competence. Most of
these papers involved children of divorced lesbian mothers who
spent their early years in a heterosexual household. More recently,
however, studies were sporadically carried out among children who
were raised from birth in a lesbian relationship. As early childhood
experiences have an important impact on future development, the
study of these newly created families provides a challenge for
existing psychological theories. Although many important research
questions have yet to be addressed, the results of all reviewed
studies were unanimous; none of the investigations could identify an
adverse effect of lesbian motherhood on child development (6).

ASSESSMENT: motives for wanting a child include happiness and

personal well-being, motherhood, and identity-development.
Pregnancies, whether planned or not, are blessed because children
are highly valued. Children secure conjugal ties, offer social security,
assist with labour, confer social status, secure rights of property and
inheritance, provide continuity, maintain the family lineage, and
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satisfy emotional needs. One of the destinies of the desire for a child
in women is the "passion for a child", the child at any cost. The
desire to have children cannot be reduced to a non-authoritative
preference whose fulfillment is optional, but has to be
conceptualized as a normative need that ought to be met.
Adoption is another way to enlarge the family. There are various
issues associated with adoption, such as anticipation of the adopted
child, international adoption, and age at placement, the adoption
experience and adopted children's relationships with their adoptive
and birth mothers, continuity and discontinuity of attachment
patterns, and the attachment and emotional understanding of an
adopted child and his adoptive parents.
There are various types of adoption including open versus closed,
by relative or unrelated individuals, private domestic adoptions,
fostering, inter-country, international, adoptions by military families,
and by lesbian or gay couples.
It is a natural desire to have a child in all available means. From
ancient times through the biblical period adoption is an acceptable
human behavior. It is understandable that an adopted child became
a new family member with all the consequent rights and obligations.

References
1. Goldberg AE, Smith JZ. Perceived parenting skill across the transition to
adoptive parenthood among lesbian, gay, and heterosexual couples. J Fam Psychol.
2009;23(6):861-70.
2 . Goldberg AE. Lesbian, Gay, and Heterosexual Adoptive Parents' Experiences
in Preschool Environments. Early Child Res Q. 2014;29(4):669-681.
3. Lavner JA, Waterman J, Peplau LA. Parent adjustment over time in gay,
lesbian, and heterosexual parent families adopting from foster care. Am J
Orthopsychiatry. 2014;84(1):46-53.
4. Fond G, Franc N, Purper-Ouakil D. Homosexual parenthood and child
development: present data. Encephale. 2012;38(1):10-5.
5. Tasker F. Lesbian mothers, gay fathers, and their children: a review. J Dev
Behav Pediatr. 2005;26(3):224-40.
6. Brewaeys A, van Hall EV0. Lesbian motherhood: the impact on child
development and family functioning. J Psychosom Obstet Gynaecol. 1997;18(1):1-16.
7. Ben-Nun L. In: Ben-N L. (ed.). Motherhood. Desire for Child. B.N. Publication
House. Israel. 2016.
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ADOPTIVE PARENTS' PERCEPTIONS

The Hague Convention on the Protection of Children suggests that
inter-country adoption be considered as a permanent care option
only after other solutions within the child's country of origin have
been exhausted. Data from the CBCL were examined for 478 Indian
children ages 4-18 adopted domestically, adopted to Norway, and
adopted to the U.S. The CBCL has a reported reliability of .9 (1,2) and
contains five subscales assessing internalizing problems plus a
summative Internalizing Scale, and three subscales assessing
externalizing problems plus a summative Externalizing Scale.
Perceptions of Norwegian, American, and Indian adoptive parents
regarding their child's functioning were compared. Children adopted
to Norway and the U.S. were perceived by their parents to be
functioning significantly better behaviorally than children adopted
within country, while controlling for age of child and gender of
adoptive parent completing the CBCL. Policymakers should examine
the evidence prioritizing within country adoption over inter-country
adoption (3).
There has been an increasing interest by couples in child adoption
due to its acceptability in recent times in our locale. The enactment
of the Child's Right Act in Nigeria has harmonized child adoption
process across the nation. With the rising demand for babies from
child care institutions by many Nigerian couples, there is need to
ascertain their perception of child adoption. The perception of child
adoption was investigated among parents/care-givers of children
attending Pediatric Clinics. The parents and care-givers of children
attending pediatrics out-patients clinics in Enugu, Enugu State, South
East, and Nigeria served as the respondents. Of them, 259 were
selected by convenience sampling method after obtaining their
informed written consent. The data were obtained using semi -
structured questionnaire administered by an interviewer. Many
caregivers (respondents) (94.2.7%) had heard of child adoption and
79.2% of them understood the actual meaning of the term child
adoption. About 1.9% of them had adopted previously. Majority of
the respondents (73.87%) preferred to adopt a child during its
neonatal age with a slight preference for adoption of male babies;
15.1% and 8.9% of the respondents gave private hospitals and middle
men, respectively, as sources of child adoption. Knowledge of the
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Government adoption laws and process was generally below average

(49.2%) among the respondents. Continued advocacy and public
enlightenment campaigns should be strengthened in order to
harmonize adoption process (4).
Inter-country adoptions from Guatemala were highly
controversial, because of the large numbers of children being
adopted to the U.S., along with evidence of corruption and child
theft. Since the implementation of The Hague Convention on Inter-
country Adoption in 2008, Guatemala's central authority for adoption
has prioritized domestic placements for children over inter-country
adoption. A possible attitudinal barrier to domestic adoption in
Guatemala, negative attitudes and prejudice against Indigenous
people were investigated through questionnaires measuring
attitudes toward adoption and attitudes toward and social distance
from the two major ethnic groups (Ladino and Indigenous).
Guatemalan university students (n=177, 61% men) were recruited
from basic required courses at a private university. Results showed
that attitudes toward adoption in general were more favorable than
toward interethnic adoption, with the most negative attitudes
toward adoption of Ladino children by Indigenous parents. Female
gender, experience with adoption and more positive attitudes about
indigenous persons were associated with more positive attitudes
toward adoption. Negative attitudes toward Indigenous persons
were associated with negative attitudes toward adoption, and served
as barriers to promoting domestic adoption in Guatemala (5).
Parental perceived discrimination was investigated as a risk factor
in a U.S. sample of 1,579 internationally adopted children ages 5 to
18 years. Drawing on stress proliferation theory, it has been
hypothesized a positive association between parental perceived
discrimination and child problem behaviors, controlling for
preadoption adversity. Differences by world region and age of the
child are expected. Adoptive parents with Asian and Latin American
children reported more discrimination than parents with Eastern
European children. Perceived discrimination was uniquely associated
with greater problem behaviors for adopted children from Asia and
Latin America, with the strongest association among Latin American
adolescents. The findings highlight the need to study postadoption
risk factors and minority status for internationally adopted
individuals and families (6).
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ASSESSMENT: in spite of some discrimination, in general, there is a

positive attitude towards adoption.

References
1. Achenbach TM. 1991. Integrative guide for the 1991 CBCL/4-18. 1991.
2. Achenbach TM, Edelbrock C S. Manual for the child behavior checklist and
revised behavior profile. Burlington: University of Vermont Department of
Psychiatry. 1983.
3. Brown S, Groza V. A comparison of adoptive parents' perceptions of their
child's behavior among Indian children adopted to Norway, the United States, and
within country: implications for adoption policy. Child Welfare. 2013;92(3):119-43.
4. Eke CB, Obu HA, Chinawa JM, et al. Perception of child adoption among
parents/care-givers of children attending pediatric outpatients' clinics in Enugu,
South East, Nigeria. Niger J Clin Pract. 2014;17(2):188-95.
5. Gibbons J, González-Oliva AG, Mylonas K. Ethnic and adoption attitudes
among Guatemalan University students. Springerplus. 2015 Dec 18;4:785.
6. Lee RM. Parental perceived discrimination as a postadoption risk factor for
internationally adopted children and adolescents. Cultur Divers Ethnic Minor
Psychol. 2010;16(4):493-500.

ADOPTION POLICY
The United Nations Convention on the Rights of the Child (1989),
The Hague Convention on the Protection of Children and Co-
operation in Respect of Inter-country Adoption (The Hague
Permanent Bureau, 1993), and the Guidelines for the Alternative
Care of Children (2009) have provided a comprehensive, rights-based
framework and guidance for developing domestic adoption and
alternative, family based care programs. Domestic adoption is a
critical component of any child-protection system and a core part of
the range of alternative care options that the United Nations and
other international organizations recommend be developed,
resourced, and made accessible to children without parental care.
Data were used from adoptive parents' postadoption and
governmental data in Romania, Ukraine, India, Guatemala, and
Ethiopia to focus on domestic adoption in each of these countries (1).
Common law adoption is an adoption which has not been
recognized beforehand by the courts, but where a parent, without
resorting to any formal legal process, leaves his or her children with a
friend or relative for an extended period of time (2,3). At the end of
a designated term of (voluntary) co-habitation, as witnessed by the
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public, the adoption is then considered binding, in some courts of

law, even though not initially sanctioned by the court. The particular
terms of a common-law adoption are defined by each legal
jurisdiction. For example, the U.S. state of California recognizes
common law relationships after co-habitation of two years. The
practice is called "private fostering" in Britain (4).
Family presence and its impact in three categories: perceptions,
complaints, and patient experience scores were evaluated. Insight is
offered for leaders into the 1st phase of PFCC adoption. Family
presence improves patient safety and satisfaction; however, 70% of
U.S. healthcare organizations maintain restrictive visitation policies.
Nursing staff six months postinnovation was surveyed to determine
staff knowledge, implementation practices, and perceived challenges
to implementation. System leaders regarding were served regarding
PFCC transformation and trended formal complaints and patient
experience scores after family presence innovation. Findings provide
insight for leaders into family presence policy adherence challenges
experienced by staff. Leaders perceived significant transformation
toward PFCC adoption postinnovation. Complaints increased
postinnovation, and patient experience scores demonstrated positive
trends. The data indicate that insight regarding challenges to policy
adherence was obtained and next steps were identified for leaders in
the transformation toward PFCC adoption (5).
Even though federal laws have had a major influence on foster
care and child welfare policy for more than 40 years, additional
reforms are needed to ensure safe and stable families for children in
care. The complex array of policies that shape federal foster care and
observes are described: a number of federal policies addressing
issues such as housing, health care, welfare, social security benefits,
taxes, and foster care reimbursement to the states form the federal
foster care policy framework. The Adoption and Safe Families Act
significantly altered federal foster care policy by instituting key
changes such as defining when it is reasonable to pursue family
reunification, expediting timelines for making permanency decisions,
recognizing kinship care as a permanency option, and providing
incentives to the state for increasing the number of adoptions.
Courts play a key and often overlooked role in achieving safety and
permanency for children in foster care. Efforts to improve court
performance have focused on increasing the responsiveness and
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capacity of courts. Policy recommendations are needed to improve

the lives of children in foster care, such as increasing investments in
children and families, redirecting funding incentives, addressing
service gaps, and enhancing accountability (6).
Building an effective child welfare system is a monumental task
facing postrevolution Romania. Following revelations on American
and Western European television about the large number of
"orphans" in Romania, many couples flocked to that country to adopt
children. A significant number of adopted Romanian children were
brought to the U.S. Some of these children evidence problems that
are bringing them to the attention of health and social service
agencies. The macroeconomic policies that led to the
institutionalization of a large number of children in Romania were
examined. Although institutional care is the current norm, a legal
basis exists for building family foster care as an alternative.
Romania's new adoption law replaces private adoptions with agency-
based work. International adoption agencies are involved in
developing community-based foster care and permanency planning
as part of their work. International adoption agencies challenge to
use clinical assessments of developmental delays and more rigorous
health examinations for children released for adoption (6).

ASSESSMENT: in general, domestic adoption is a critical

component of any child-protection system and a main part of the
alternative care options.
In Romania, although institutional care is acceptable, a legal basis
exists for building family foster care as an alternative. Romania's new
adoption law replaces private adoptions with agency-based work.
International adoption agencies are involved in developing
community-based foster care and permanency planning as part of
their work.

References
1. Groza V, Bunkers KM. Adoption policy and evidence-based domestic adoption
practice: a comparison of Romania, Ukraine, India, Guatemala, and Ethiopia. Infant
Ment Health J. 2014;35(2):160-71.
2. Geraldine Van Bueren. The International Law on the Rights of the Child. 1998.
ISBN 90-411-1091-7. Available 25 January 2016 at web:Books-Google-81MC.
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3. Joseph Goldstein. The best interests of the child: the least detrimental
alternative. 1996. Available 25 January 2016 at web:Books-Google-HkC Somebody
Else's Child.
4. Somebody Else's Child. Available 20 January 2016 at
http://www.privatefostering.org.uk/.
5. Gasparini R, Champagne M, Stephany A, et al. Policy to practice: increased
family presence and the impact on patient- and family-centered care adoption. J
Nurs Adm. 2015;45(1):28-34.
6. Allen M, Bissell M. Safety and stability for foster children: the policy context.
Future Child. 2004;14(1):48-73.
6. Johnson AK, Edwards RL, Puwak H. Foster care and adoption policy in
Romania: suggestions for international intervention. Child Welfare. 1993;72(5):489-
506.

SUMMARY
Adoption can be a painful situation for children. Studying the
available literature on adoption, either ancient or contemporary,
could shed light on this issue and provide tools for better
management of adopted children in modern times. Firstly, this study
deals with adoption in antiquity. Secondly, the research evaluates
adoption as described in the Bible. All biblical texts were examined
and three children – Moses, Esther, and Mefivoshet were studied.
Finally, the research deals with modern trends in adoption. The
process, reasons for adoption, consequences, adoptive parents'
perceptions, and adoption policy were evaluated from the
contemporary perspective.
The ancient practice of adoption was mentioned in Rome, Egypt,
Greece, the Middle East, Asia, Africa, India, China, and Polynesia.
In the Biblical times, at the time of Moses' birth, the Hebrew
slaves in Egypt suffered from various cruel decrees of Pharaoh. One
such decree was that every newborn Jewish male should be killed.
When Moses was three months old, in an attempt to save him, his
Jewish mother put him in a crib among the reeds on the bank of the
Nile. Pharaoh's daughter found the crib, took the baby and raised
him as her own son. She gave him the name of Moses, meaning
“son” in Egyptian, although the text explains the name with the
words “because I drew him out of the water” (Exodus 2:10). So “And
Pharaoh’s daughter said unto her, take this child away, and nurse it for me,
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and I will give thee thy wages. And the woman took the child and nursed it”
(2:9). The wet nurse hired by Pharaoh’s daughter to breast-feed
Moses was actually his biological mother.
There are many reasons for placing children in a foster family or in
an institution that will care for their physical, emotional and
educational needs in the short, medium or long-term. Moses
adoption was associated with Pharaoh’s brutal decree that every
Jewish newborn male should be thrown into the river. Is spite of this
decree, Moses survived since an Egyptian family adopted him.
Children are placed for adoption at different ages. Timing of
adoption is a significant factor for establishing the relationship with
fostering family. When infants are placed in foster homes before the
age of one year, they rapidly achieve a stable a relationship with their
foster caregiver. If they are placed after the age of one year, the
relationship is insecure.
Due to early-childhood adversity, adopted children often display
delays in their cognitive and motor development and have problems
developing secure attachment relationships with their adoptive
parents. Attachment six and twelve months after adoption is less
secure and more disorganized attachment for the adopted children
compared to the normative distribution of non-adopted children.
Two years after adoption, the adoptees still display more insecure
disorganized attachment than children in the non-adoptive group.
Moses was adopted, grew up, and educated in Pharaoh's family.
It is most likely that secure attachment relationships developed
between Moses and his Egyptian family.
There is a variety of diseases which can be found in adoptees. Did
some physical disease afflict Moses? Moses’ medical file, that is the
biblical text, indicates no physical diseases. It can therefore be
concluded that Moses was a healthy child who did not suffer from
any physical disease.
Was Moses afflicted by some psychological disorder? An answer
is found in a subsequent event. When Moses was an adult, he killed
an Egyptian man because he was beating a Hebrew slave. This
episode indicates that Moses knew his identity, that is, that he was a
Jew, and opposed the repressive policies towards the Jews of his
adoptive father, Pharaoh, the powerful ruler of Egypt. Moses was
raised and educated in an Egyptian family and could have remained
an Egyptian. But, as the Jew he relinquished his luxurious life and a
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bright future as an Egyptian and devoted himself entirely to a single

mission – to lead the Jewish people out of Egypt. So duality of
feelings, on the one side his connection with his Egyptian family and
on the other the devotion to the Jewish people, led to some
emotional distress expressed by the upheaval when Moses killed an
Egyptian oppressor. Nevertheless, there is no data to indicate any
severe mental disorder in Moses.
Developmental delays include gross motor delays, fine motor, and
speech and language delays. Internationally adopted children often
have delays at adoption and undergo massive catch-up after
adoption. Gross motor delay at arrival predicted academic
performance. Children with medical problems had significantly lower
developmental scores than those without medical diagnoses.
The Biblical text states that Moses biological mother attempted to
save her child’s life from the cruel decree of Pharaoh to kill all
newborn Jewish males, by putting him into a crib among the reeds on
the banks of the Nile. Fortunately, Moses was saved when Pharaoh’s
daughter adopted him. In addition, baby Moses was lucky since his
biological mother suckled him even after his adoption. This factor
had a positive effect on the child’s development and provided Moses
with the self-confidence he needed in his entire life. We have
insufficient evidence to suggest that Moses suffered from some type
of delay in gross motor, fine motor, social and emotional skills.
The first signs of communication occur when an infant learns that
a cry will bring food, comfort, and companionship. Children who
have trouble understanding what others say (receptive language) or
difficulty sharing their thoughts (expressive language) may have a
language disorder. Delay in acquiring language and speech is the
most common form of this developmental disorder in children, and
there are two main types - difficulties in understanding language
(receptive type) and difficulties in speaking, defective oral expression
(expressive type).
Language disorders are identified when a person has difficulty
with expressive language, receptive language, or pragmatic language.
Speech disorders are identified when a person's voice, fluency, or
articulation call attention to the speaker because his or her speech is
sufficiently different from the norm. Speech and language
development can be detected using typical milestone markers.
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Speech and language impediment is a prevalent condition

although in various countries different prevalence rates are
observed. Genetic factors have an important role in many speeches
and language disorders cases. Genetic variants may predispose
individuals to different aspects of speech and language difficulties.
Was Moses afflicted by development language and speech
impediment? Did genetic factors play a role in Moses'
developmental speech impediment?
Did expressive language disorder afflict Moses? The words “I am
not eloquent, neither heretofore, nor since thou hast spoken unto thy
servant: but I am slow of speech, and of a slow tongue (a heavy mouth and a
heavy tongue” (4:10) may be linked to this type of disorder. However,
a subsequent verse indicates that Moses after leaving Egypt judged
the people: “Moses sat to judge the people: and the people stood by Moses
from the morning unto the evening” (Exodus 28:13). How can a judge
speak to the people without communicable language or
comprehensible speech? Or was Moses’ language and speech
impediment so mild that it did not prevent him from pronouncing
judgment on the people? Or perhaps on this particular occasion,
Moses communicated with the people without speech or language
impediment?
Did receptive language disorder afflict Moses? Since the
understanding of language was not affected, this type of disorder
seems unlikely.
Mixed receptive-expressive language disorder is a communication
disorder in which both the receptive and expressive areas of
communication may be affected in any degree, from mild to severe.
Since the receptive type of language disorder seems unlikely in
Moses’ case, this diagnosis seems unlikely.
Speech is the verbal expression of one's cognitive content and
process, and emotions. Clarity of speech is essential to social
interaction, and educational and occupational functioning, as well as
one's self confidence, self image, and sense of self efficacy.
Impairment of speech can have a negative influence on all of these
areas. Speech sound disorder, formerly known as phonological
disorder in the DSM-IV, is a diagnosis assigned to individuals who
have difficulties in productive speech which interferes with
communication, and produces impairment in functioning, and
distress.
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Did Moses suffer from this type of disorder? There are insufficient
diagnostic criteria for this disorder.
Learning disabilities are conditions that affect how a person learns
to read, write, speak, and calculate numbers. They are caused by
differences in brain structure and affect the way a person's brain
processes information. Learning disabilities are usually discovered
after a child begins attending school and has difficulties in one or
more subjects that do not improve over time. A person can have
more than one learning disability
Did Moses suffer from some type of learning disability?
Social phobia is characterized by a clear and continuing fear of
one or more social or performance situations, in which the individual
is exposed to unfamiliar people and possible scrutiny by others. The
individual is afraid of doing something humiliating or embarrassing.
One symptom can indicate the existence of phobia – fear of public
speaking.
Social phobia is characterized by a continuing fear of one or more
social or performance situations, in which the individual is exposed to
unfamiliar people and possible scrutiny by others. The individual is
afraid of doing something humiliating or embarrassing.
Moses was the great leader. Surely, he did not fear any social
situations and social performances. For these reasons it is unlikely
that he suffered from social phobia.
Elective mutism is a rare disorder of communication, where the
child speaks fluently in familiar situations, such as home, despite lack
of speech in less familiar settings, for example school. There is a
strong relationship between selective mutism and anxiety, most
notably social phobia.
The development of selective mutism results from the interplay of
a variety of genetic, temperamental, environmental, and
developmental factors. It is characterized by the persistent failure to
speak in select social settings despite possessing the ability to speak
and speak comfortably in more familiar settings. There is a strong
relationship between selective mutism and anxiety, most notably
social phobia.
There are four different types of elective mutism, such as
symbiotic, expressive, responsive, and passive-aggressive. In
addition, selective mutism can present a variety of comorbidities
including enuresis, encopresis, obsessive-compulsive disorder,
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depression, premorbid speech and language abnormalities,

developmental delay, and Asperger's disorders.
Was Moses affected by selective mutism? Can the words “I am not
eloquent, neither heretofore, nor since thou hast spoken unto thy servant:
but I am slow of speech, and of a slow tongue (a heavy mouth and a heavy
tongue)” (4:10) and “…I am stammerer..” (6:12) be related to selected
mutism. There are insufficient diagnostic criteria to confirm anxiety,
or social phobia in Moses. Similarly, there are insufficient criteria for
diagnosing selective mutism. These factors make elective mutism as
unlikely cause for speech and language impediment in Moses' case.
The etiology of stuttering is controversial, but contributing factors
may include cognitive abilities, genetics, sex of the child, and
environmental influences. More than 80% of stuttering cases are
classified as developmental problems, although stuttering can also be
classified as a neurologic or, less commonly, psychogenic problem.
The frequency of stuttering in children is estimated at about 5%,
and the disorder may persist until adulthood, for some beyond 55
years of age. The etiology of stuttering is controversial, but
contributing factors may include cognitive abilities, genetics, sex of
the child, and environmental influences. More than 80% of
stuttering cases are classified as developmental problems, although
stuttering can be classified as a neurologic or, less commonly,
psychogenic problem.
Among adults who stutter social anxiety disorder is a prevalent
and chronic anxiety disorder is characterized by significant fear of
humiliation, embarrassment, and negative evaluation in social or
performance-based situations. In these adults, anxiety is restricted to
the social domain.
Did Moses exhibit at least one of the above symptoms, as defined
by DSM-IV?
An answer to the question of Moses’ speech impairment may lie
in the description of an episode in the desert. When the Children of
Israel reached the Wilderness of Zin, there was no water, and the
people began to quarrel with Moses (Numbers 20:1-3). Then Moses
and his brother were commanded “.. speak to the rock… and it shall give
forth its water…” (20:8). But Moses instead of speaking, hit the rock
“..with his rod he smote the rock twice: and the water came out
abundantly…” (20:11). Does this account indicate that Moses was
unable to speak with this particular rock? Did he indeed stammer?
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On the basis of what is written in the Bible, with no interpretation,

we can say that Moses suffered from a speech disorder. However,
we are not given enough information to ascertain the nature of this
disorder, and there are not enough signs to indicate that Moses
suffered from stammering.
It is possible that the words “slow of speech and slow of tongue”
express a lack of eloquence, of oratory in the use of words, rather
than stammering. Did Moses lack oratorical skills and in particular
the ability to use diplomatic words that would appeal to Pharaoh’s
heart? The contemporary definition of the language and speech
developmental impediment that afflicted Moses is therefore still
open. Moses, the first adopted child, to be described in the Bible,
was a great leader who lives in the hearts of Jewish people. In spite
of his speech disorder, Moses the Great Teacher led the people of
Israel in their first steps to freedom and independence. In spite of a
severe disability, Moses developed a stable, mature personality, and
left his mark on human history.
This is the story of King Ahashverosh, who reigned in Persia and
Midia. One day the King made a great feast in his kingdom, and
invited his beautiful wife, Queen Vashti to attend the feast, but she
refused. For this unacceptable, disobedient behavior Queen Vashti
was punished by dismissal and a new queen was sought in the
kingdom. “Now in Shushan the capital there was a certain Jew, whose
name was Mordekhay...” (Esther 2:5). Mordekhay brought his beautiful
adopted daughter Esther to the King’s house “And he (Mordekhay)
brought up Hadassa, that is, Esther, his uncle’s daughter: for she had neither
father nor mother, and the girl was fair and beautiful; and when her father
and mother were dead Mordekhay took her for his own daughter” (2:7).
Mordekhay forbade Esther to identify herself as a Jew “Esther had not
made known her people of her descent: for Mordekhay had charged her that
she should not tell” (2:10.
Among all the young women brought to the King, he fell in love
with Esther “... the king loved Esther more than all the women, and she
obtained grace and favor in his sight more than all the virgins; so that he set
the royal crown upon her head, and made her queen instead of Vashti”
(2:17). Here Esther entered a new family system, this time as Queen.
Parental death may be due to a variety of causes. What caused
the death of Esther's parents?
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Due to lack of space it was impossible to present all possible

causes of Esther parents' death. Nevertheless, the main causes are
mentioned.
Maternal death, poverty, childlessness and the child gender
preference of foster parents are important factors when children are
fostered. The reason for Esther’s adoption was the death of her
biological parents. Fortunately, internal family resources were used
to resolve this stressful situation, with the adoption that took place
within the same family system.
Families live within a coping band in which they use adaptive
mechanisms against stressful life events. Stressors are those life
events or changes that are so serious or drastic that they require
changes in the family system, for example, the death of a spouse,
financial crisis, or unemployment. A crisis follows when a family is
unable to adapt within its coping band. The crisis is over when the
family is able to find intra- and/or extra-familial resources to deal
with it. After that, the family continues at a higher, lower or the
same level of functioning.
This is the case of a young woman, Esther, who in spite of her
adoption reached great status among the people and left a mark on
history. Maternal death, poverty, childlessness and the child gender
preference of foster parents are important factors when children are
fostered. The reason for Esther’s adoption was the death of her
biological parents. Fortunately, internal family resources were used
to resolve this stressful situation, with the adoption that took place
within the same family system.
Esther’s separation from her father Mordekhay represents a
stressful life event that both father and daughter coped with.
Although they separated, a family crisis did not develop. Esther, an
adoptive child, was confronted with the integration of her adoptive
status, and adoptive communicativeness.
Later, Esther was exposed to another stressful life event when she
prepared to meet the King. Mordekhay, as a responsible father, was
concerned about his daughter’s future. He believed that Esther was
suitable to be the Queen. So he took the risk of taking her to the
King’s house, while advising her to hide that fact that she was a Jew.
If the King knew this detail, she might not be chosen to be the Queen.
Mordekhay and Esther acted as full partners in this deception.
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When the King took Esther to be his wife and she became Queen,
she experienced a positive stress. The decision of Haman and the
King to exterminate all the Jews, including Mordechai, was a negative
environmental stress, which led to a subsequent crisis that affected
all the Jews living in the country. When Esther succeeded in
eliminating the wicked Haman, the Jews were saved. The crisis
ended and the King’s family continued to function at the higher level
- Haman was hanged, his house was given to Esther, and Mordekhay
was promoted and honored as the most respected man in the
country.
Families play an essential role in the emotional, physical, and
social development of individual family members. Esther’s first
family was exposed to extremely stressful event when her parents
died and this family system disintegrated. This crisis was resolved
when Esther entered the family of Mordekhay. Mordekhay gave his
adopted daughter emotional, physical and social support. When
Esther entered her third family, as Queen, the King supported his
beloved wife. He treated her with full respect, admiration, great
honor, and affection.
Esther first belonged to the family of her biological parents.
When her parents died, this family system disintegrated.
Fortunately, Esther entered a new family system, with her new
father, Mordekhay, as the head of the adoptive family.
Esther’s life changed when King Ahashverosh took her to be his
wife, and by entering this new family system, she automatically
became Queen. Esther reached great status, and began to play the
role of the Queen. She coped with her new situation, dealing with
her internal family system as well as fulfilling her duty to outside
world.
A secure attachment relationship developed between the
adopted Esther and her uncle Mordekhay.
Thanks to Esther’s wisdom, Haman was hanged and the Jews
escaped their destruction. Esther, an adopted girl, reached great
status and left her mark on Jewish history.
Mefivoshet was the third adopted child. After King Saul and his
three sons were killed, King David began to seek the remaining
members of Saul’s family. The son of his best friend Jonathan,
Mefivoshet, who was lame, was located and brought to the King:
"And Jonathan, Saul's son had a son that was lame of his legs. He was five
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years old when tidings came of Saul and Jonathan (about their death) out of
Jezreel, and his nurse took him up, and fled: and it came to pass, as she
made haste to flee, that he fell, and became lame. And his name is
Mefivoshet" (II Samuel 4:4). Subsequently, the King adopted
Mefivoshet, and regarded him as his own son.
Chronic illness in childhood is characterized by developing and
maintaining friendships; being normal/getting on with life; the
importance of family; attitude to treatment; experiences of school;
relationship with the healthcare professionals; and the future.
Suffering from a chronic disease or disability during adolescence
can be a burden for both the adolescents and their parents.
Adolescents with a chronic disease or disability have a poorer
psychosocial health and a more difficult relationship with their
parents.
Adopted children with disabilities have special health problems
and special health needs. In spite of their disability, they receive
preventive medical visits, dental care, and have health care insurance
coverage. It follows therefore that Mefivoshet received all necessary
health care concerning his disability.
Psychological stress in adoptive parents of special-needs children
includes child's characteristics, parent-child interactions, family
cohesion, parental adjustment, and adoptions service issues. From
the contemporary viewpoint, the King's family needed services of a
skilled social worker, and/or a family physician, and/or a pediatrician.
King David by adopting Mefivoshet showed characteristics of a
humanistic character. Mefivoshet, a new family member, received all
necessary attention and all needed treatment concerning his
disability.
In the Middle ages, the Germanic, Celtic, and Slavic cultures
denounced the practice of adoption. Similarly, English Common Law
did not permit adoption. The idea of institutional care gained
acceptance, and formal rules appeared about how to place children
into families. The practice gradually shifted toward abandoned
children.
As the idea of institutional care gained acceptance, formal rules
appeared about how to place children into families: boys could
become apprenticed to an artisan and girls might be married off
under the institution's authority. The system of apprenticeship and
informal adoption that extended into the 19th century was a
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transitional phase for adoption history. Adoption's evolution fell to

the emerging nation of the U.S. The children were generally
indentured, rather than adopted, to families who took them in. As
times pasted, some children were raised as members of the family
while others were used as farm laborers and household servants.
Theodore Roosevelt in 1909 declared that the nuclear family
represented "the highest and finest product of civilization" and was
the best to be able to serve as primary caretaker for the abandoned
and orphaned children.
Transracial adoption and intercountry adoption began following
the end of World War II which had left thousands of children
homeless all over the world.
The period 1945 to 1974, the baby scoop era, saw rapid growth
and acceptance of adoption as a means to build a family. Americans
severed the rights of the original parents while making adopters the
new parents in the eyes of the law. In response, family preservation
efforts grew few children born out of wedlock today are adopted.
Since the 1970s, finding alternative permanent families for
children in foster care who could not return to their birth parents has
been a primary goal of the child welfare system. Significant gains
have been made in helping such children find permanent homes
through adoption and guardianship.
The American model of adoption eventually proliferated globally.
England and Wales established their first formal adoption law in
1926. The Netherlands passed its law in 1956. Sweden made
adoptees full members of the family in 1959. West Germany enacted
it first.
Motives for wanting a child include happiness and personal well-
being, motherhood, and identity-development. Pregnancies,
whether planned or not, are blessed because children are highly
valued. Children secure conjugal ties, offer social security, assist with
labour, confer social status, secure rights of property and inheritance,
provide continuity, maintain the family lineage, and satisfy emotional
needs. One of the destinies of the desire for a child in women is the
"passion for a child", the child at any cost. The desire to have
children cannot be reduced to a non-authoritative preference whose
fulfillment is optional, but has to be conceptualized as a normative
need that ought to be met.
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Adoption is a way to enlarge the family. There are various issues

associated with adoption, such as anticipation of the adopted child,
international adoption, and age at placement, the adoption
experience and adopted children's relationships with their adoptive
and birth mothers, continuity and discontinuity of attachment
patterns, and the attachment and emotional understanding of an
adopted child and his adoptive parents.
There are various types of adoption including open, closed, by
relatives or unrelated individuals, private domestic adoptions,
fostering, inter-country, international, by military families, and by
lesbian or gay couples.
It is a natural desire of humans to have a child in all available
means. From ancient times, including the Biblical times, to the
modern times adoption developed into an acceptable human
behavior. It is understandable that an adopted child becomes a new
family member with all the consequent rights and the obligations.
The Bible widens our knowledge on adoption, demonstrating that
even adopted children can achieve a great status in their society and
be part of the history.
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ABBREVIATIONS
ADHD Attention deficit hyperactivity disorder
a-TSLRC Adapted Teachers' Speech and Language Referral Checklist
BASC Parent Rating Scales and Self-Report of Personality
DSM The Diagnostic and Statistical Manual of Mental Disorders
CBCL Child Behavior Checklist
CCC Children's Communication Checklist
CI Confidence intervals
EEG Electroencephalogram
EMAS-T Endler Multidimensional Anxiety Scales-Trait.
FNE Fear of Negative Evaluation
GnRH Gonadotrophin-releasing hormone
GPs General practitioners
HIV Human immunodeficiency virus
H-SDS Height-standard deviation score
IPP Idiopathic precocious puberty
IQ Intelligent quotient
IVF In vitro fertilization
MnIAP Minnesota International Adoption Project
OR Odds ratio
QOL Quality of life
PTSD Posttraumatic stress disorder
PFCC Patient- and family-centered care
SD Standard deviation
SDS Standard deviation score
SLI Specific Language Impairment/s
SNPs Single-nucleotide polymorphisms

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