The following excerpt is drawn from a peer review that Viola Bernard wrote for Hospital and Community Psychiatry, a professional journal. Even though she was a trained psychoanalyst and the Freudian tradition was an important source for psychopathology studies revealing adoption as a factor in emotional and developmental problems in children, Viola Bernard sharply criticized clinicians and researchers, such as Marshall Schechter, who claimed to show that adoption led directly to increased psychiatric risks. One of the things that is notable about this excerpt is that it was written in 1986, when a virtual consensus in professional and public opinion supported the belief that adoption was a “risk factor” of one kind or another. Psychopathology studies had been vigorously contested during the 1960s. For example, H. David Kirk, author of Shared Fate, protested the methodological flaws of psychopathology research. One of Bernard’s most astute observations here is that modern adoption was a moving target rather than a static institution whose psychiatric implications remained constant. Practices with a direct bearing on children’s mental health had changed dramatically during the postwar era and, in Bernard’s view at least, had generally improved. These included the expansion of adoptability that special needs adoptions represented, changing thinking about “telling,” and the growth of reform movements that criticized confidentiality and sealed records and promoted search and reunion.

Comments for the attention of the authors:

The paper is described as a literature review of “the incidence” and elsewhere of the “reported incidence” of psychiatric problems among adoptees. But instead of overall incidence, it actually reports on the extent of adoptee over-representation in clinical settings, and their rate of service utilization, as compared with non-adoptees in the same caseload. Rate of inpatient and outpatient over-representation and service utilization cannot be equated with overall incidence of disorder among the total adoptee population. By now, there is general professional agreement that various diagnostic categories of adoptees are over-represented in such settings, as reported in most, though not all, of the articles you discuss. You note such variations, but mainly in terms of their numerical differences. Actually, many other variables seem relevant to these differences, such as the quality and methodologies of the research, and the range of time periods when the studies were done with respect to the changes in adoption practices and in the adoptee population.

In a single sentence in the Abstract, you combine the finding from the literature of “increased risk of psychiatric problems in adoptees” with the generalization that this is “because of genetic transmission of disease.” Thus, the first part of the sentence refers to incidence, the stated purpose of the review, while the second part makes the conceptual leap that the incidence revealed by the literature reviewed is caused by genetics. The references cited do not in toto support this causation. . . .

Your basic method of assessing “incidence” of adoptee psychiatric disorder is by comparing the numbers of adoptees and non-adoptees with similar symptoms in a given clinical setting, as well as with the rate of such symptoms in the general population. In fairness to you, this is a widely used approach in the literature about the rate of adoptee psychopathology. Nevertheless, not only do some of us not regard the over-representation at clinics as a reliable indicator of the true incidence, but we also challenge the appropriateness of the comparison groups. Non-adopted children comprise the bulk of the child population, so the “non-adopted” as a category is too undifferentiated. Among the non-adopted are groups who lack permanent or adequate parenting for diverse reasons, as do adoptees, and who require substitute care, including institutions, foster care, or catch-as-catch-can informal arrangements. As a more appropriate method, I think, some follow-up studies compare adjustment after adoption, foster care, and post-placement return to biological parents. . . . Thus, the apparent error in comparing rates of maladjusted adoptees in clinical settings with maladjusted non-adoptees in those settings, and psychiatric illness in the general population is that the first category seems too narrow, the second too broad, and the third statistically questionable. . . .

The reliability of conclusions from this paper seems diminished by the time span covered by the bibliography, in view of the rapid pace of changes in adoption practices over the past few decades, and still in process—changes that are significant to the extent and nature of adoptee problems. Thus, a major shift in social philosophy has expanded the range of adoptability to what used to be termed “hard-to-place” children. These include children who are older than formerly, of a wider range of ethnicity, and with mental, emotional, and physical handicaps. . . . These [also] include, for example, various adoptive practices: the impact on adjustment of telling and not telling adoptees about their adoption and how to tell them and when; problems of individuation and identity related to needs for direct contact with natural parents (i.e., searching and reunions); recognition of some degree of cerebral damage among some adopted children referable to inadequacies of prenatal and perinatal care; screening and helping adoptive-parent applicants in terms of their own adoption-related psychological problems; inclusion of a broader range of adoptive parents in terms of SES [socio-economic status] through such means as subsidized adoptions, and converting prior foster parents into adoptive parents.

So in sum, I reluctantly conclude that this painstaking and interesting review not only does not advance knowledge beyond what is already accepted—the genetic risks of schizophrenia and affective illness, for example, or adoptee over-representation in clinical settings—but also, for the reasons mentioned, can provide a misleading picture of adoption.