A common term for adoption placements is “forever family,” indicating the child has now been legally and symbolically grafted into a new home. After being relinquished (voluntarily or not) from their birth family, some children stay with the first placement that follows. To their biological connections and culture, they might say, “goodbye forever, family.”

On the more extreme end: Some children in the Kansas foster care system navigated over 100 placements, according to a recent lawsuit. It’s not uncommon for some children to say, “Goodbye, forever family” to multiple caregivers throughout their lifespan. Such was the case in a recent controversy regarding a transracially adopted child from China. Social media influencer Myka Stauffer posted an apology about “rehoming” Huxley to another family after recognizing he needed more care than her family could provide:

“I apologize for being so naive when I started the adoption process, I was not selective or fully equipped or prepared. I received one day of watching at home online video training and gained my Hague adoption certification, which was required by my accredited adoption agency,” Stauffer wrote on Instagram.

How do you measure the intent of someone’s message along with its impact? Sometimes, they’re different. Other times, the purpose was accomplished. I think adoption, as an institution and as an experience, can be like that.

I remember standing on the playground as a fourth grader. A boy walked up to me and taunted, “Chinese, Japanese, dirty knees, look at these!” Simultaneously slanting his eyes up and down with his fingers, he finished by lifting up his shirt so we could all see his chest.

I can’t claim to know what that boy was intending on the playground. However, in that moment, as a transracial adoptee, I felt incredibly uncomfortable, foreign, inferior, embarrassed, ashamed, confused, and severely out of place. I didn’t tell my parents about it because I couldn’t imagine they’d understand; they were white, along with all the teachers. So, throughout my childhood I generally kept those incidents to myself. It wasn’t healthy and I paid for it later on.

Perhaps adoption, as an institution in need of reform and redemption, doesn’t intend to hurt us in that way. And yet it shapes lives profoundly, for better and worse.

But let’s be careful not to let the Stauffers’ story distract us from the larger narrative. Internationally and domestically, same-race and transracial adoption is the original “dissolution.” There will be an impact. Therefore, we ought to expect needs related to mental health and actively prepare the way for something (and someone) better.

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In her Ted Talk, adult adoptee Sara Jones recalls how, when she was adopted from Korea at age three, the experience overwhelmed her and she stopped speaking for six months. When she started speaking again, one of her first phrases in English was, “Sara sad.”

Not only does research show how mental health needs are intrinsically woven into the adoption experience, but youth and adult adoptees have pleaded with those in power to change the way they see and serve us (I’ve posted a list at my blog for families interested in listening).

As Christians, we navigate the “already and not yet” reality of Jesus Christ who has freed us from the penalty of sin, rescues us from its power over our lives here and now, and sends us toward the complete absence of brokenness—there and beyond the grave. His work, not ours. And yet, we’re sent as his workers, his ambassadors.

What does that mean for us, individually, as we walk throughout a fallen world, institutionally? How are we called to participate in a way that represents the hands and feet of a suffering Savior? And what do we do when we see an institution (and individuals within it) hurting people, either intentionally or because of its collateral impact?

For me, as a licensed clinician and adult adoptee, part of my professional calling is to take those kinds of questions into the foster and adoption community and serve in a way that moves the folks within it toward health and restoration.

The mental health of adoptees

To begin with, adoption-related needs are often comorbid with other mental health–related needs. This is not a personal heart-check for adoptive parents as much as it’s a community assessment of the system that uses their money, and, ultimately, a call to understand and serve the children who are impacted by the experience of birth, relinquishment, nonpermanency, and adoption.

Comorbid. Co means joint, mutual, or common. Morbid indicates disease. Comorbidity as a mental health term refers to the presence of two or more “conditions” in one person. The Diagnostic and Statistical Manual of Mental Disorders (DSM-5) is used to classify symptoms into diagnoses (such as PTSD, Depression, Anxiety, Reactive Attachment Disorder). I put conditions in quotes because I recognize not all clinicians find value in ascribing DSM-5 labels to actual people, as if they were somehow problems to be fixed, reduced to a pathology of sorts. Can it help with insurance and gaining access to services? Sometimes. Can it also help put a name to a unique experience, a set of symptoms and struggles? Certainly.

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However, as well-known psychiatrist Bessel van der Kolk puts it, “Before they reach their twenties, many patients have been given four, five, six, or more of these impressive but meaningless labels. If they receive treatment at all, they get whatever is being promulgated as the method of management du jour: medications, behavioral modification, or exposure therapy. These rarely work and often cause more damage.”

I can see it from both sides. Here are some of the common DSM-5 “labels” foster children and adoptees might receive at some point in their narrative:

Anxiety Disorder

Adjustment Disorder

Attention-Deficit Hyperactivity Disorder

Childhood Obsessive Compulsive Disorders

Conduct Disorders

Oppositional Defiant Disorder

Reactive Attachment Disorder

Post Traumatic Stress Disorder

As an adoptee and clinician, my heart sinks when I imagine how many of us might be struggling to navigate any one of those sets of symptoms right now, let alone multiple layers of them.

Take just one of those diagnoses: Some research suggests ADHD is higher among adoptees than non-adopted peers. This could be due to the increased stress related to poor neonatal conditions, separation from caregivers, or neglect during the process of foster care/adoption. There’s also the added stressor of having to make sense of life events. If an infant or toddler is wrapped up in meaning-making, it’s possible there’d be a delay in other milestones related to emotional, cognitive, and physical development. Because ADHD includes a genetic component, adoptive parents must also consider the generational impact of addiction, depression, abuse, and other factors.

In all diagnoses, an important takeaway here is that foster and adoptive placements can contribute to that stress or serve as a factor of protection. Sometimes, they’re both.

On top of the clinical diagnoses, some adoptees struggle to make sense of the death, or perceived death, of their biological/natural parents (see author and adoption activist Valerie Andrews, the executive director of Origins Canada, for a dialogue on language).

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Biological parents, the original attachment figure, remain psychologically present yet physically absent, an idea that social worker, professor, and adoptee JaeRan Kim unpacks in her article on ambiguous loss. And when an adoptee is not given social or cultural approval to mourn that loss, it becomes more challenging to heal from it. This invalidation is called disenfranchised grief. I would never ask the couple struggling with infertility, “Why can’t you just be thankful?” We need to be just as sensitive with children navigating adoption and foster care; otherwise, we risk blocking them from such restoration.

On top of that, we must consider transracial adoption and the complexities bound within a white supremacist country, laws and policies (written or unwritten) that build or maintain inequity between racial groups, individual (internalized, interpersonal) and systemic (institutional, structural) racism, racial abuse (microaggressions), and other various forms of racialized oppression. How inconsistent is it for a country to facilitate its citizens to adopt babies into their homes but sustain walls and rules and attitudes against their peers and parents? Children notice this.

Comorbidity touches adoptees in many ways. It’s important to affirm that not all adoptees experience mental health needs at a clinically significant level. We do not want to pathologize children navigating adoption and permanency. We do want to normalize our experiences and we do want to raise awareness about our stories. If the only adoptee voices you listen to are the ones who report, “My parents were awesome and I’m so grateful,” then you miss out on rich and essential learning for your family.

Adoption disrupts many of us from the daily life experiences most take for granted, and that needs to be brought into the light. We can call it adoption, foster care, rehoming, dissolution, dissolved, disrupted … but whatever we call it, our actual lived experiences will hurt.

Where do we go from here?

I’m not the judge of anyone who has adopted or has spoken out against adoption (or “rehoming”), or even over any particular agency. A friend recently shared, “It’s not our business. We weren’t there. It’s between them and God.”

I think there’s a lot of truth to that.

My observations are not punitive; they’re meant to re-posture us as a community to consider how our current laws, policies, and beliefs around adoption don’t serve the ones being adopted. If we’re concerned about the current and next generation of adoptees, we must have the courage to ask those in power, trusted leaders, policymakers, and arbitrators to do better.

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They challenge us as Christians in two ways: our vertical relationship with God and our horizontal relationship with others.

In our relationship with God, where have we replaced God with something (or someone) else? In his book Parenting, author and theologian Paul Tripp explicitly names the tendency parents have to use their children as a means for self-serving purposes, robbing God of glory because they want it for themselves. Adoption is an occasion for those distorted desires to hijack our families and institutions for the worst of our humanity to flourish under the guise of our best humanitarian efforts.

We can’t forget the transactional nature of adoption, according to social scientists. Anthropologist Eleana Kim writes that adoptees are vulnerable to commodification, quoting sociologist Sara Dorow: “Transnationally adopted children are not bought and sold, but neither are they given and received freely and altruistically; the people and institutions around them enter into social relationships of exchange, meaning, and value that are both caring and consumptive.”

Kim adds, “This close imbrication of commodification and care can make it difficult to distinguish between the ‘caring-parent’ and the ‘consumer-parent’ or between humanitarian and egocentric motivations.”

In our relationship with others, how have we either sought to be a god or made children into gods, rather than seeking to serve as God’s ambassador? And when have adoptees seemed more like barriers between us and our desires rather than the very people we’ve been called to love?

Adoption agencies, in general, play a symbiotic role within a larger system of cultural and institutional forces, such as stigma of children born outside of marriage, lack of mental health awareness and training, barriers to education, shame-based family values, poverty, pride, nationalism, ableism, racism, religion, coercion, and sexual violence. Despite genuine progress in some post-adoption services, I believe many agencies themselves fall short of the kind of support and diligence that children and families need, and thus their practices should be reformed.

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If in adoption we were seeking to be the hands and feet of Christ, we’re also called to embrace the idea that Christ’s hands and feet were nailed to a cross by those he came to rescue. He suffered. He faced tribulation. Adopters (not just adoptees) will suffer.

This is not because humans are actual saviors, but because, like any good work, “caring for orphans and widows” (James 1:27, NLT) will demand from us strength we don’t have, pushing us to depend on the actual Savior, and will perhaps reorient our distorted motives along the way. This does not mean we can’t outsource our needs to professionals skilled in a particular domain or discipline. There are times and situations when that step makes sense. What it means is we need to count the costs of adoption and hold institutions accountable when they hide the cost from us.

Parenting in general is a place where we’re meant to serve rather than be served. And, the more we embrace that message, the more we’ll be a source of health and hope for the ones who truly need it.

Those who labor to be like Christ in this world will certainly feel the pain of his cross. Yes, for the joy set before us. Yes, toward a resurrection like his. And yes, for the keeping of many lives. And by his grace God keeps us. Even when we can’t.

Cameron Lee Small has been working to raise consciousness about faith, child welfare, and mental health since 2012, after meeting his biological mother in Korea. He provides therapy services online from Minneapolis, Minnesota, where he lives with his wife and family.

[ This article is also available in 한국어. ]