Adopted Child Syndrome David Kirschner
- The "adopted child syndrome" refers to an extreme form of adoption-related psychopathology, including provocative, antisocial behaviors as well as associated personality disturbances that-at least on the surface-are similar to those included in the DSM-IV diagnosis of conduct disorder.
- The adopted child syndrome can be differentiated from the diagnosis of conduct disorder by underlying adoption-specific psychodynamics, greater emotional vulnerability, and better prognosis.
- Adoption does not necessarily give rise to psychopathology; however, it must be considered a risk factor-perhaps a precipitating one-in some families who are dysfunctional in terms of key adoption issues and parent-child interactions.
- Accessible vulnerability distinguishes the adopted child syndrome from conduct disorder and is crucial in the differential diagnosis. Typically, the child reveals an elaborate preoccupation with his or her origins and the circumstances of the adoption as well as a hypersensitivity to rejection of any kind.
- The atmosphere within an adoptive family often discourages curiosity about adoption, thereby leading the child to conclude that something painful and bad-something pertaining to his or her own character-is being kept secret.
- Feeling abandoned and rejected by his or her birth parents may lead to powerful feelings of ambivalence; as a consequence, the adopted child may act out against the adoptive parents as well as therapists, teachers, and other authority figures.
- The current emphasis on anonymity in adoption proceedings encourages the denial of feelings and distorts understanding of the true complexities involved in this process. However, even full disclosure of the identity of the birth parents and the reasons for adoption may not entirely alleviate any pathogenic conditions.
|INTRODUCTION For some time, mental health professionals have noted a large proportion of conduct disorders and extreme antisocial behavior among clinically referred adopted children and adolescents as compared with their nonadopted counterparts (Menlove, 1965; Offord, Aponte, & Cross,1969; Sabalis & Burch,1980; Schechter, Carlson, Simmons, & Work, 1964; Weiss, 1985). Although the influence of genetics may partially account for this pattern (Graham & Stevenson, 1985; Herrnstein & Wilson, 1985; Mednick, Gabrielli, & Hutchings,1984), a growing body of clinical literature (Brinich, 1980; Easson,1973; Kirschner, 1990, 1992; Kirschner & Nagel, 1988; Nickman,1985; Toussieng,1962) as well as firstperson accounts by adult adoptees (Lifton, 1988, 1994) have identified unique psychological problems encountered by adoptees during childhood and adolescence. Complications in identity formation and adoption-related psychopathology, fantasies, and behavior are the most commonly cited examples. Especially in cases involving a genetic predisposition for behavioral disorders, such psychological complications are seen as critical factors in the etiology of antisocial psychopathology in adoptees.|
The renewed focus on psychopathology among adoptees has fostered controversy. Some parties have argued against the delineation of adoption-specific psychiatric or psychological disturbances, warning that adoptees and adoptive parents might be stigmatized and that prospective adoptive parents might be discouraged from adopting (Bartholet, 1993; Feigelman, 1986; Klagsbrun,1986). Nonetheless,the adoption community increasingly acknowledges emotional problems that may be engendered by traditional, "closed" adoptions (in which the identities of the birth parents are kept from the adoptive parents and child, and vice versa). As a result of this new awareness, proponents of "open" adoptions (arrangements in which all parties are known to
|each other [Chapman, Dorner, Silber, & Winterberg, 1987a, 1987b; Lifton, 1988, 1994]) and advocates of disclosing closed adoption records are challenging the adoption establishment. Indeed, most observed cases of the "adopted child syndrome" have occurred in children who were adopted during infancy through closed adoptions. The adopted child syndrome refers to an extreme form of adoption-related psychopathology, including provocative, antisocial behaviors as well as associated personality disturbances that are superficially similar to those found under the DSM-IV diagnosis of conduct disorder (American Psychiatric Association, 1994). The adopted child syndrome can be differentiated from the latter diagnosis by underlying adoption-specific psychodynamics, greater emotional vulnerability, accessibility to and motivation for therapy, and better prognosis (Table 1).|
Although the prevalence of acting-out disorders among clinically referred adoptees is widely reported in the literature, the term adopted child syndrome remains controversial. Furthermore, although many unique issues and related clinical problems are not uncommon among adopted children, it has not been established whether serious emotional and behavioral problems occur more frequently among adoptees than nonadoptees in the general population. Adoption per se does not necessarily give rise to psychopathology; however, it must be considered a risk factor-perhaps a precipitating one--in some families deemed dysfunctional in terms of key adoption issues and parent-child interactions.
Acting-out behaviors, specific personality and interpersonal relationships, ideational content, and psychodynamics characterize the adopted child syndrome.
|BEHAVIORAL PATTERNS By assessing only the behavioral patterns of an adopted child, it is all too easy to misdiagnose the adopted child syndrome as conduct disorder. Like conduct disorder, the adopted child syndrome is characterized by various forms of antisocial acting out, primarily directed against parental and authority figures. Pathologic lying, stealing, fire setting, promiscuity, substance abuse, and running away (or threats to do so) are typical; assaultiveness occurs in severe cases. The child socializes with "streetwise" delinquents, antisocial children or adults, often of a lower socioeconomic class than that of the adoptive||family. School problems frequently include truancy, academic underachievement, and specific learning problems. If unresolved, these behavioral problems usually escalate with age, leading the child into conflicts with school and legal authorities. In some cases, after several failed attempts to reason with the child, discipline him or her, and even have him or her clinically treated, the adoptive parents may finally submit a petition for court custody or seek placement of the child in a hospital or other residential treatment facility.|
| It is noteworthy that adoptees who display signs of the syndrome typically have been raised in a middle class environment, where antisocial behavior is not widely modeled by adults or sanctioned by most of their peers.PERSONALITY AND INTERPERSONAL RELATIONSHIPS:|
The personality profile of the child with the adopted child syndrome resembles that of a person with conduct disorder: More specifically, the impulsiveness and low frustration tolerance typically associated with conduct disorders are present in the adopted child syndrome. The child may display a superficial charm, shamelessly prevaricate to and manipulate others, and show little guilt or remorse for hateful acts or transgressions committed. The child may lack deeply felt, meaningful relationships. Interactions with parents and authority figures are marked by frequent provocative and disruptive limit-testing behavior. Finally, the child seems to expect or invite rejection by his or her parents and other authority figures.
As the adoptee shares his or her private adoption-related thoughts, fantasies, and dreams, the vulnerable side of his or her personality emerges. This accessible vulnerability distinguishes the adopted child syndrome from DSM-IV-type conduct disorder and is crucial to the differential diagnosis and treatment planning. Typically, the child reveals an elaborate preoccupation with his or her origins and the circumstances of the adoption as well as a hypersensitivity to rejection of any kind.
In projective test responses, play therapy, or interviews, the child will reveal privately held questions, fantasies, and beliefs about his or her origins. This ideation often is distorted, unrealistic, and obsessive - especially with regard to having two sets of parents. The child often demonstrates elaborate images of the unknown birth parents, who are believed to be either
|evil, immoral, and rejecting or idealized, loving, generous, and powerful. The child often believes that the birth mother was promiscuous, even a prostitute. These fantasies may be understood as attempts to cope with the injury of the imagined rejection. Because he or she partially identifies with his or her birth parents as they are idealized, such fantasies invariably distort the child's self-image. The child also struggles with feelings of anger toward the adoptive parents that are aroused by these fantasies. Their role in the adoption may be construed as theft in the child's mind, as well as an aggression against both the birth parents and the child. The adoptive parents' failure to recognize the child's urgent curiosity about his or her original parents may be taken as a rejection of the birth parents and, by extension, a rejection of the genetic heritage of the child. The child tends to construe their failure to discuss adoption candidly as a form of lying. Paradoxically, children may feel the need to protect their adoptive parents from their interest in their birth parents but also resent feeling obligated to them for "the rescue" (Lifton, 1988).|
THE CHILD'S QUEST FOR IDENTITY
Information about one's beginnings and ancestors is an essential building block in identity formation during childhood and adolescence. An adopted child usually learns little about his or her origins, perhaps a few details (often fictional) about his or her birth parents and an idealized version of the adoption (the "chosen-child" story). As the child matures, he or she reworks and reinterprets this story, which is poorly understood during early childhood (Brodzinsky, Schecter, & Henig, 1992). In addition to whatever is imparted by his or her adoptive parents, the child also gleans cultural clues. For instance, children become aware that, in many adoptions, the birth parents are not married.
Starting with this sketchy and ambiguous informa-
|tion, the child will develop many questions and seize upon many answers in his or her quest for identity.Did my birth parents love me as a baby? If so, why did they relinquish me? Maybe they disliked me. Was there something wrong with me? How would they feel about me today? Was I given up willingly or taken away by force? Were my parents cruel, immoral, criminal, or defective and so unfit to be parents? If so, does that make me the same way? Was my birth mother a prostitute? How would my adoptive parents feel about my birth parents? Would they disapprove of them? Who are my real parents? What makes my adoptive parents my parents? Would they really love me if they knew I cared about my birth parents? If I really am like my birth parents, will my adoptive parents still love me? Might they change their minds and "unadopt" me if they decided they didn't love me?|
These questions emerge in gradual fashion as the child's conceptual abilities develop.
It is hoped that the child will openly discuss these questions and the emotions attached to them (which may include grief, anger, mistrust, identity confusion, and separation anxiety). Unfortunately, a number of cultural and parental factors make the topic of adoption taboo in many adoptive families. The atmosphere within an adoptive family often discourages curiosity about adoption, enticing the child to conclude that something painful and bad (pertaining to his or her own character) is being kept a secret. Meanwhile, the child's questions remain relegated to the private domain of the imagination, where they inspire unhealthy, immature, and distorted fantasies unmoderated by reality testing or feedback from others.
In an atmosphere of denial and secrecy, even normal emotions in a growing child take on a toxic quality. For instance, all feelings of rejection may reverberate with the fantasized primal rejection by the birth parents. The child
|is also likely to feel powerless, frustrated, humiliated, and angry at the idea of having been passed along without any control over his or her own fate. If the child is inhibited from venting these thoughts and feelings as well as from obtaining any clarification or reassurance, he or she suffers an intense ambivalence toward his or her birth parents; a sense of longing, grief, anger, and mistrust often accompany such ambivalence (Lifton, 1988). In many adoptive families, parental love is implicitly conditional:|
The child is being asked to collude in the fiction that these are his only parents and to accept that his birth heritage is disposable.... Only if adopted children commit themselves fully to the identity of the adoptive clan can they have the adoptive parents' love. Already abandoned by the birth mother, the adoptive child feels no choice but to abandon her and, by so doing, to abandon his real self. This early, potential self that is still attached to the birth mother is unacceptable to the adoptive parents and, therefore, must become unacceptable to the child (Lifton, 1994, pp. 50-51).
Severely disturbed adoptees, as well as apparently well-functioning adoptees, may suffer from the implied pressure to pretend that their adoption is unimportant in defining who they are.
With normal development, the adopted child's positive and negative images of self and others, especially parents, are gradually integrated into more realistic images. This crucial development is linked to the capacity for empathy and conscience. In less ideal circumstances, adoptees may lack the opportunity to interact with or even talk about their birth parents; their view of their birth parents cultivated in the context of their adoptive family would be constricted, secretive, and two-
|dimensional. For these adoptees, good and bad images remain split, often with one set of parents identified as "all good" and the other as "all bad" (Brinich, 1980; Eiduson & Livermore, 1953; Schechter, 1960; Simon & Senturia, 1966) or with each mother split into discontinuous good and bad images (Lifton, 1994). The superego is impaired, resulting in poor impulse control, acting out, and conduct-disordered behavior. Although provocative and antisocial behavior is evident to the casual observer, the disturbed ideation and psychodynamics of the adopted child syndrome usually are hidden from view and manifest only through careful, informed clinical evaluation.|
CULTURAL AND FAMILY COMPONENTS
THE INSTITUTIONAL CONTEXT OF SECRECY:
Closed adoption remains the standard practice in our society. When a child is adopted through an agency, the adoptive parents are advised by the agency to tell the child he or she is "special" and was "chosen." At the same time, the adoptive parents may have been advised to minimize the importance of the adoption and to communicate that the adoptee is no different from a genetic child.
Because most adoption records are sealed, any questions the growing child may have about his or her birth parents' character, motives, and feelings, as well as their physical appearance and other hereditary traits, cannot be definitively answered. This policy of secrecy thwarts even those adoptive parents who support and understand their child's natural curiosity.
THE FAMILY CONTEXT OF DENIAL:
Parents of most children with the adopted child syndrome exhibit tension and denial surrounding the
|issue of adoption. During the initial interview with a therapist, they may dismiss all suggestions that adoption could be an issue for the child or might in any way be related to his or her behavioral problem(s). It soon becomes apparent that serious discussion of feelings about the adoption is taboo. Although instructions from an adoption agency and the practice of closed adoption may facilitate parental denial, a pathogenic situation may arise when these external influences interact with the parents' own psychology. Some adoptive parents are prone to overreact to a child's normal sexual and aggressive behavior, especially given the specter of a genetic predisposition to such behavior. Temperamental differences between adopted parents and their child will exacerbate these tensions. Parents may warn and discipline their child excessively, and he or she may respond with defiance.|
Adoptive parents also may project their own unintegrated, unaccepted impulses onto their child, unconsciously provoking him or her to act out their wishes while consciously rejecting his or her inappropriate behavior (Eiduson & Livermore, 1953; Johnson & Szurek, 1952). An adopted child is a particularly likely target for repressed parental impulses because the parents can disown all responsibility for the behavior, often unconsciously blaming it on someone else's "bad seed." In this extreme case, the fantasized birth parents also embody the repressed impulses of the adoptive parents (Brinich, 1980; Easson, 1973).
Parents may accept and identify with their child only when he or she is well behaved, and figuratively disown him or her whenever he or she does not behave properly. By failing to accept the child's positive and negative aspects as parts of a whole, parents ultimately hamper the development of an integrated self-image and a mature superego or conscience.
Parents may avoid thinking about or discussing their
|child's feelings about adoption because they seek to avoid their own uncomfortable adoption-related feelings, such as guilt (toward the birth parents and child) and grief (for the natural child they never had). When they resist their adoption-related feelings, parents cannot empathize with the child's intense emotions and curiosity, nor can they accept or embrace those aspects of the child's emerging identity that they sense may derive from the birth parents.THE SPECTRUM OF ADOPTION-RELATED PSYCHOPATHOLOGY|
Lifton (1994) stated that adoptees undergo a cumulative adoption trauma, which "begins when they are separated from the mother at birth; builds when they learn that they were not born to the people they call mother and father; and is further compounded when they are denied knowledge of the mother and father to whom they were born" (p. 7). Lifton added that even well-functioning adoptees suffer from the unmet, often unacknowledged, need to know their birth parents as well as from the experience of growing up deprived of vital elements of their identity. In essence, virtually all adoptees "struggle with issues pertaining to self-esteem, lack of trust, and fear of abandonment" (p. 93).
THE `GOOD' ADOPTEE AND THE `FALSE SELF':
One form of adoption psychopathology may be the "good adoptee" or "artificial self" (Lifton, 1994)-compliant, nonrebellious, afraid to express real feelings, dedicated to preserving the relationship with his or her adoptive parents, even at the cost of thoughts and behaviors that might betray their connection to another family. Other adoptees are aware of having two selves: one is the culturally accepted "artificial" self; the other, which they may believe to be the "true" self, is linked to the imagined birth parents and feels quite
|alienated from the adoptive family. This "other" self may acquire a growing sense of urgency and frustration during adolescence or at times of family crisis. In this connection, Pine (1980) described a subgroup of children with borderline personality disorder, the characteristics of whom he first discovered in an adult adoptee "suffering from irreconcilable love-hate images toward her adoptive parents." They show an omnipresent splitting of good and bad images of self and other. Such children, often "sweet" or "good" on the surface, will reveal an absorbing inner preoccupation with hate and violence, often with homicidal or world-destruction fantasies, equally often with scant and precarious control over them. The splitting is evidenced in the lack of connection between the "good" and the "bad" self and other. Hate, unmodified by affectionate images, becomes icy or fiery, devouring of the self or the other (in mental life), and frightening-to the parent and to the therapist who discovers it (p. 179).|
At the most malignant extreme of the range of adoption psychopathology are those adoptees who murder their adoptive parents or others in a breakthrough of dissociated rage. These murders, committed under the sway of delusional notions about the adopted child's birth parents and adoptive parents, always are committed after a rejection crisis (Kirschner, 1978,1992).
IMPLICATIONS FOR CLINICAL PRACTICE
A skillful, sensitive interviewer can penetrate the tough facade of a person exhibiting features of the adopted child syndrome. This is achieved by conveying awareness of and interest in the patient's adoption-related concerns. Once the child believes it is safe to discuss these matters with a therapist-that they will be met with full respect and attention-he or she typically responds with gratitude and relief, readily confiding a great deal of
|enlightening material. In most cases, the persistent hostility aimed at the adoptive parents and other authorities should be understood as anger toward the birth parents, which has been displaced onto available parental figures. Feeling abandoned and rejected by the birth parents and transcendently connected to them at the same time, the child deals with potent feelings of ambivalence by acting out against the adoptive parents as well as therapists, teachers, and/or other authority figures.|
A fear or expectation of rejection underlies the provocative behavior of a child with the adopted child syndrome. This behavior may be understood as a counterphobic reaction (Glatzer, 1955; Kirschner, 1990), unconsciously designed to provoke rejection in order to prove that it will not occur and that the child will be accepted despite his or her unlikable qualities (Clothier, 1943).
All too often, this strategy of defensive provocation proves self-fulfilling. Adoptive parents may reach the limits of their tolerance and refer the child to the courts, a residential program, a hospital, or foster care. In this scenario, the provocative behavior still has a slightly adaptive function: The child retains some sense of control (and, hence, feels protected from utter humiliation) by virtue of sensing that he or she actively invited the rejection.
During the interviewing and testing processes of adopted children, it often helps to draw out adoption-related material by devising appropriate queries that may be used to adapt standard tests and materials. Sentence-completion, figure-drawing, and thematic perception questions and responses may be amplified; for instance, the child may be asked to specify whether parents and children in the projective responses are adopted or natural. The Gardner Adoption Story Cards and
|the `Blacky" Pictures Test have proved especially useful with adopted children and adolescents.Children may require assurance that discussions will not be repeated to their adoptive parents unless they so desire. Parents should be advised of this possible confidentiality, and their cooperation should be enlisted during the first consultation.|
Children with the adopted child syndrome are usually quite responsive to a therapist's expression of interest in the topic of adoption, responding with a rush of adoption-related concerns and fantasy material. Children who are more inhibited or inarticulate sometimes may be reached through discussions of the many popular and classic stories whose themes relate to adoption, such as "Hansel and Gretel," "Cinderella," and "Pinocchio: " Several books written for adopted children and adolescents may facilitate a clinical dialogue as well (Table 2).
Interpretation of acting-out behaviors may provide an avenue for discussion of adoption. Children may respond positively to interpretations; e.g., "Perhaps you lie because you feel you haven't been told the truth about your adoption" or, "Are you stealing because you sometimes feel you were stolen-or that your birth family was stolen from you?" Children who are especially sensitive to money issues may acknowledge a suspicion that they were sold for money by their birth parents to their adoptive parents. Running away may indicate an impulse to search for the birth parents (Lifton, 1994).
Dreams, daydreams, obsessions, play themes, and other mental content should be interpreted in light of adoption issues. For example, a common theme in the dreams or daydreams of adoptees is being followed or kidnapped by a stranger (symbolizing the birth parents).
If children feel guilty that curiosity about their birth parents is a betrayal of their adoptive parents, it
|is best to emphasize that the real issues are curiosity and identity, not loyalty or love.|
Therapists are also a potential resource for patients who decide to search for their birth parents. However, when minors are involved, permission from the adoptive parents should be obtained before helping patients in this manner.
Family Therapy and Collateral Sessions
Family therapy is usually contraindicated because it is essential for the child to form a bond with the therapist, usually a transference to the birth parents, so the relationship can be reworked in therapy. However, it is recommended that adoptive parents be seen periodically by the child's therapist in separate parental
|sessions or by another therapist for their own individual or couples therapy-if indicated. Parents should be sensitized to their child's continuing need for acceptance and help in assimilating the implications of adoption, in gradually understanding the motives and feelings of both sets of parents, and in integrating both sets of parents into a coherent sense of self and a complete identity. Moreover, parents should be educated to accept as normal their child's curiosity about his or her birth parents (Nickman, 1985). Reassurance that the child's interest in his or her birth parents is not a rejection of them, but rather a natural and healthy curiosity about essential aspects of his or her heritage and identity, usually mitigates adoptive parents' anxieties. Because of the danger of fueling the child's fears and anger when he or she senses dishonesty, therapists should advise parents against lying to the child. Concerns about the inheritance of antisocial behavior should be brought to light, misconceptions about age-appropriate behavior corrected, and support given for acceptable degrees and types of discipline. Adoptive parents' feelings of guilt, anger, and insecurity toward their child and his or her birth parents should be ventilated. Referrals can be made to support groups or professional treatment.|
With respect to the confidentiality of a child's sessions, the therapist should share with parents only what the child has agreed may be revealed to them. Parents should be clearly advised of the clinical importance of respecting their child's wish for confidentiality.
A significant number of support groups for adoptive families is emerging at the local level; referral to such groups is often indicated. (Up-to-date information on local groups can be obtained through the National Adoption Information Clearinghouse in Rockville, Md.) Suggested reading for adoptive parents is provided in Table 3.
|DENIAL AND THE THERAPIST:|
Therapists may be easily misled by the adoptive parents' insistence that adoption has no relevance to their child's psychopathology. It is important for therapists to look beyond the family taboo and to help parents acknowledge the importance of adoption to themselves as well as their child.
In the transference of the adoptive parents, therapists may come to represent the birth parents. Unfortunately, once the child begins to form a bond with the therapist, adoptive parents may feel threatened by their child's potential attachment and even pull their child out of therapy. It is advisable to address these feelings early, when they may still be managed.
|THE VALUE OF HONEST IN ADOPTION What is known about the adopted child syndrome suggests the advisability of opening sealed adoption records and revising current adoption practices to foster honesty and openness. The syndrome is an extreme outcome of the practice of minimizing or ignoring the adopted child's quest to understand his or her origins. The current emphasis on anonymity in adoption encourages the denial of feelings and distorts understanding of the true complexities involved in the adoption process (Chapman, Domer, Silber, & Winterberg, 1987a, 1987b). However, even full disclosure of the identity of the birth parents and the reasons for adoption may not fully correct the pathogenic conditions. In such cases, it is also necessary for parents and therapists to acknowledge-and work through-the child's intense, ambivalent attachment to both sets of parents and his or her identifications with both.|
These findings also have relevance in the screening of prospective adoptive parents. A genuine acceptance of normal, age-appropriate aggressive and sexual behavior as well as the ability to identify unacceptable behavior are particularly important qualities in prospective adoptive parents. Above all, they should possess a willingness to acknowledge and discuss openly and honestly the potentially difficult, conflict-laden issue of adoption.
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