Abandoned Chinese Children:
International and Domestic Adoption, Institutional Care
and Rehabilitation of Disabled Children

International Adoption
For thousands of Americans, the distant and sometimes abstruse debate on human rights in China has taken literal human form in an abandoned Chinese infant placed for adoption in their family. Since the promulgation of the 1991 adoption law, which first permitted international adoption, over 28,000 Chinese children, overwhelmingly girls, have been placed in American families. Only Russia has placed more children in the United States during the same time period. The desire to adopt Chinese children, 80% of who are placed within U.S. families, continues to grow and waiting periods of one to two years for a referral are not uncommon.

This surge in Chinese adoptions can be accounted for, in part, by the increasing availability of Chinese children during an era when principal referring countries such as Korea have limited the number of children available for placement. However, a variety of factors has fueled this growth including the historic preference of Americans for adopting girls, availability of children at an earlier age than many other countries and acceptability of single parents. For most of this time period, China had the requirement that adoptive parents be above 35 years of age, a limit that included most potential adoptive parents in the U.S. Many families also have an intense interest in Chinese culture and a desire not only to adopt a child from China but also to make Chinese traditions an integral part of their family’s life.

Over the past decade, adoption paperwork, fees and in-country processing have been standardized, with few surprises awaiting families when they arrive in China. Another fact that stands in stark contrast to adoptions in other countries is that there is little evidence of corruption in the adoption process. While many families have viewed the actual adoption trip to other nations as an ordeal to be survived, virtually every family adopting from China with whom I have spoken treasured their trip and found the populace welcoming and officials courteous and efficient.

Officials at the China Center for Adoption Affairs take their work very seriously and diligently attempt to match the characteristics of the adoptive family with those of a potential child. They have been anxious to improve the process of child placement, welcomed input from adoption professionals and have taken suggestions to heart. Medical information has improved as the program has matured. For example, regarding hepatitis B, a serious infection often acquired at birth, children once were tested at two months of age, a point in time where false-negative tests are probable due to the biology of that disease. Consequently, some children who tested negative at this early age were found to be positive when they reached their adoptive homes. Eager to improve the process, most testing has been moved to 6 months of age, a time when the results are quite valid.

Since 1998 my staff and I have spent significant time in eight Social Welfare Institutions in China and have spoken to adoptive parents who have visited dozens more. Most were large facilities in major cities, so I cannot comment on the conditions in smaller, rural orphanages. There was no difficulty gaining access to these orphanages and the staffs were open and friendly. My overall impression is that directors and caregivers are extremely committed to the children in their care, facilities are continuing to improve and there is a clear desire to do as much as possible to provide an optimal outcome. While some institutions still had few caregivers per child, many were staffed at a ratio of three to five children per caregiver. One Social Welfare Institute, which was also a rehabilitation facility for severely disabled children, had a one-to-one caregiver ratio during daytime hours. Turnover of healthy children into adoptive families appears to be rapid. One of the problems we have faced trying to evaluate our early intervention projects is that most of the children we tested were placed for adoption so rapidly that we could not reevaluate them following program initiation.

Most children are in good health when placed with their adoptive parents. Illnesses are primarily limited to respiratory infections and gastrointestinal problems, the most common illnesses in this infant-toddler age group. In rare circumstances where children are very ill, parents accessed the better quality pediatric programs and received good care. In the handful of cases I am aware of where the child died while the family was in China, officials were very willing to place another child with the family.

In one study of adopted Chinese children, unsuspected diagnoses were present in 18% of children and included hearing loss, disturbances in vision, orthopedic problems and congenital anomalies (1). This percentage is similar to that seen in international adoptees from other parts of the world. I am not aware of attempts to knowingly portray a child who had a serious illness as being healthy and suspect that most of these situations arise because of limited diagnostic capabilities. For children in the special needs program, most conditions are accurately diagnosed and generally correctable once the child arrives in the United States.

The medical conditions afflicting Chinese adoptees are those seen in international adoptees worldwide (2-5). Latent or active tuberculosis infection (3.5-10%), hepatitis B (3.5-6%) and intestinal (7.1-9%) and cutaneous parasites are the most common infectious diseases. Hepatitis C and syphilis are quite uncommon (< 1%) and HIV infection has yet to be reported in an American Chinese adoptee. As in most countries, the most common medical problems are deficiencies in micronutrients (3) such as iron (14-35%), iodine (10%), and calcium/phosphorous/vitamin D (14%). Chinese adoptees also share with many international adoptees a significant risk of being under-immunized against common childhood infectious diseases (6-8), as well as a propensity for chronic cough and respiratory infections due to exposure to significant air pollution. The one problem that does occur more commonly in Chinese adoptees is a higher risk (up to 14%) of having elevated blood lead levels (=10 micrograms/deciliter) (9).

Preadoption risk factors that influence long-term prognosis such as prenatal malnutrition, prematurity and fetal alcohol exposure probably play a smaller role in overall outcome in Chinese adoptees than in children from other countries. Prenatal care and nutrition are generally as good and the use of alcohol by pregnant women in China is felt to be very uncommon.

The overall well being of Chinese adoptees appears to be strongly influenced by the length of institutionalization. Orphanages are well known to be the worst possible environment for normal child development. Linear growth failure is common, with children losing one month of growth for every three month in institutional care—a phenomenon termed psychosocial growth failure. Delays in one or more domains (e.g. gross and fine motor, social-emotional, language and activities of daily living) were present in 75% of children at the time of arrival.

Each year I review 2,000 adoption referrals and see 300 children for post-arrival examinations from around the world. From this perspective, I strongly feel that officials in China attempt to place children who are as healthy as possible. The adoption process is well organized, and long-term issues related to early childhood institutionalization are less common than other countries due to a younger average age at placement (12 months). Fees derived from international adoption have clearly helped improve conditions for children who remain within Social Welfare Institutions, and there is increasing use of foster care. Finally, parents are overwhelmingly satisfied with their experience. This impression is strong enough for me to have recommended adoption from China to family members and close friends.

Domestic Adoption
The glowing reports on international adoption must be muted in the case of domestic adoption in China. In researching this area, I have relied heavily on the work of Kay Johnson, Ph.D., Professor of Asian Studies and Politics at Hampshire College in Amherst Massachusetts and adoptive parent of a Chinese child (10-14). Abandoned disabled children of both sexes have been the traditional inhabitants of orphanages in China, as they have been in every country in the world where sophisticated medical care is unavailable. The situation was similar in the United States 40-50 years ago. However, in times of adversity, the Chinese preference for male children shifts the gender balance of abandonment clearly toward infant girls. Most contemporary Chinese view the ideal family as a boy and a girl. However, traditions of property transfer and the continuation of the filial line necessitate a male heir. In rural China where the majority of abandoned Chinese girls originate, old age pensions are unavailable. The practice of a daughter leaving her birth family to tend to her husband’s parents therefore makes a male child the only means of “social security” for elderly parents. These traditions essentially ensure that the rate of abandonment for healthy girls will dramatically increase during times of misfortune, as was observed during the famine years following the Great Leap Forward or during rigorous enforcement of population control measures. The number of children abandoned each year in China is unknown, but estimates range between 100,000 and 160,000.

Until the early 1990s when international adoption began directly infusing financial support, Social Welfare Institutions in China were chronically underfunded. Worldwide, there is no more politically voiceless or more vulnerable group than parentless children. The influx of abandoned girls forced orphanage directors to balance the marginal existence of the majority of children in their care with the costly medical needs of a small number of critically ill infants. Under these circumstances, they were forced to practice triage, as do orphanages around the world. Mortality at some facilities reached 50%, a figure similar to that reported in the early decades of this century in orphanages in the United States and Western Europe. That said, there is almost certainly a gender bias in how children are selected for treatment. In one particular orphanage in Wuhan, Dr. Johnson relates three instances where the desire for a boy was so strong that potential adoptive families assumed the financial burden of caring for a seriously ill, abandoned male infant despite the fact that the children were close to death.

Unfortunately, the placement of abandoned girls in adoptive families in China remains subservient to the goals of population control. In fact, the 1991 law which gave permission to adopt to childless couples above 35 years of age was designed to limit hiding an over-quota girl within a friend’s or relative’s family. Despite the limitations imposed by the law, Dr. Johnson’s work has identified a very strong desire of Chinese couples and singles to adopt healthy girls to complete their ideal family. Such adoptions are generally not through official channels and may total from 300,00-500,000 per year. These adoptions are more common in rural areas and involve girls more than boys. Transfer of children into the adoptive family is complete and the arrangements usually do not involve relatives or close friends. Her work dispels common misconceptions that Chinese families do not adopt children from outside of family lines and do not adopt girls. More importantly, her research identifies a group of domestic adoptive parents willing to assume the care of normal, abandoned children, permitting Social Welfare Institutions to concentrate their efforts on those who are disabled. However, domestic adoption has not been promoted or supported to the same extent as international adoption, presumably because those abandoned have been viewed as being over-quota births first and children second.

The major problem encountered by Chinese families adopting outside the framework is official recognition of their child, which ensures access to such entitlements as education and healthcare. Within the group of Chinese adoptive families described by Dr. Johnson, two-thirds were able to legally register their adopted child by appealing to the good will of officials or paying a modest fine. However, a number were burdened with huge fines or suffered forced sterilization. Under some circumstances, even after enduring these sanctions, children were not officially registered. As noted by Dr. Johnson, the plight of these unregistered “black children” is ironic since China has insisted on guaranteeing that Chinese children adopted abroad have full citizenship and fully equal treatment in their adoptive families.

Primary Disabilities
A disproportionate percentage of children who reside within Social Welfare Institutions are those abandoned because of primary medical disabilities. While many of these children have conditions that are easily treated within a sophisticated medical system, they pose enormous problems for families who have neither access nor financial resources to pay for this care. Therefore, even though the one-child policy exempts children with disabilities, Chinese families with handicapped children face powerful forces that encourage abandonment.

I have participated in a number of training courses in China and observed significant progress in pediatric rehabilitation over the past six years. Until recently, the disabled in China suffered the same segregation from the able population as individuals with disabilities in Western society. With the exception of the blind, for which the profession of masseuse was traditionally reserved, the focus was on the family attending to the needs of the disabled rather than promoting self-sufficiency. However, the past two decades have witnessed the establishment of centers of excellence in rehabilitation medicine as well as architectural adaptations that permit disabled individuals to participate more fully in society.

A driving force behind this change is Deng Pufang the eldest son of the former Chinese leader Deng Xiaoping. During the Cultural Revolution, he was persecuted so vigorously that he sustained a severe cervical spine injury and since then has been wheelchair bound. Due in large part to the prominence of his family and his position as the President of the Chinese Federation for the Disabled, it is common to see ramps, handicapped restroom facilities, and redesigned streets and sidewalks that have eliminated curbing at crosswalks. Coded tiles incorporated into sidewalks and audible signals at intersections help the blind navigate more independently and safely. These accommodations are not limited to the major cities. In 1999, I participated in a rehabilitation course in a remote location in Inner Mongolia where new street and sidewalk construction incorporated these changes.

Access to and expertise in Western rehabilitation medicine is generally localized to large cities with sophisticated medical infrastructures. However, some treatments for chronic disabilities, including acupuncture, massage and natural compounds from the pharmacopoeia of traditional Chinese medicine, are generally available throughout China. Training programs are needed to develop the required expertise that will permit application of both new and traditional treatments to the benefit of disabled children.

Many communities have developed rehabilitation programs associated with Social Welfare Institutions. One facility that I visited, the Nanjing Social Welfare Institute, was specifically designed for the rehabilitation of severely handicapped orphans. However, many children from the community participate in the excellent therapy and vocational training programs available through the center. Another impressive program, the Children’s Rehabilitation Center in Qingdao, was designed primarily for children with hearing, vision and cognitive impairment living in the community. Universal access of families to such services is a critical step in reducing the number of abandoned disabled children.

Secondary Disabilities
Secondary disabilities may prove even more daunting for institutionalized children. Less obvious than a cleft lip or clubfoot, these problems are brought about by lack of a nurturing environment during the early formative years of life. Secondary disabilities affect both normal and disabled children within orphanages, and may include irreversible deterioration in growth, cognitive, language and social skills, and emotion regulation (15). In the case of children who remain within Social Welfare Institutions, particularly those with disabilities, the key needs involve a comprehensive package of medical, cognitive and social rehabilitation designed to teach skills that will permit their integration into Chinese society as independent adults.

I am pleased to serve on the board of an organization that is attempting to directly prevent the development of secondary disabilities within Social Welfare Institutions. Half the Sky Foundation (named for the Chinese adage "Women hold up half the sky") was created in 1998 by adoptive families who desired to maintain a tie to China, the country that was their daughters' first home (16). The organization is committed to helping the children who remain in China's orphanages do more than merely survive. The mission is to enrich the lives and enhance the prospects for these forgotten children by providing infant nurture and early childhood education centers inside orphanage walls.

To fulfill this mission, Half the Sky, in cooperation with the China Population Welfare Foundation and the China Social Work Association, both Beijing NGOs, creates and operates two programs: Baby Sisters Infant Nurture Centers and Little Sisters Preschools. The Baby Sisters Infant Nurture Centers employ HTS-trained “Nannies” from the local community to cuddle, love and provide orphaned babies the physical and emotional stimulation essential to the normal development of the brain and psychological well-being.

In the Little Sisters Preschools, HTS-trained teachers use a unique and progressive curriculum that blends principles of the Reggio Emilia approach to early childhood education with contemporary Chinese teaching methods. The program is designed not only to prepare the children to succeed in Chinese schools, but also to help develop the “whole child”—to help her attain the positive sense of self so often missing in institutionalized children.

By the end of 2002, HTS will be offering services to over 1200 children in eight institutions: Hefei and Chuzhou in Anhui Province; Changzhou in Jiangsu Province; Chengdu in Sichuan Province; Chongqing Municipality, Shanghai Municipality: and two institutions in Guangdong Province. On Children’s Day, June 1, 2002, HTS, CPWF, and CSWA in cooperation with the Ministry of Civil Affairs opened a national model center and training facility at the Shanghai Children’s Home, facilitating outreach to institutions across China.

Half the Sky’s long-term plan calls for establishing and maintaining programs in at least two children’s welfare institutions in each Chinese province where there are substantial numbers of children living in institutions. Each center will serve as a provincial model and will offer regional training workshops and a base for the network of caregivers to exchange ideas and experience. The rapid expansion of HTS programs would not have happened without exceptional support and cooperation from the directors of each facility and local and provincial officials. I view this teamwork as further proof of a sincere desire to improve conditions for abandoned children as rapidly as possible.

Conclusion
On March 7, 1996, I participated in a congressional briefing sponsored by Senator Paul Simon that was organized in response to the Human Rights Watch report on alleged abuse and neglect in the Shanghai Children’s Welfare Institution. The meeting began with a statement by Dr. Ewing Carroll, Executive Secretary of the Asia/Pacific Region of the General Board of Global Ministries of the United Methodist Church. Acknowledging the size and complexity of Chinese society, he stated that everything we would hear during the briefing would be true “somewhere” in China. In this spirit, I acknowledge that the situation may well be different “somewhere” in China, but my personal experience has been thoroughly positive. From my perspective, few countries have made as much headway over such a short period of time in improving conditions for institutionalized children and providing an ever-increasing array of interventions for those who are disabled. International adoption benefits not only those who are placed but also those who remain by improving conditions within orphanages. The adoption process itself goes as smoothly as it does anywhere in the world and outcomes, from the perspective of adoptive parents and adoption professionals, are overwhelmingly positive.

Despite great progress on many fronts, problems within this realm of children’s issues do exist. Population control policy has been undeniably linked with increased abandonment of healthy infant girls since the late 1980s and a marked expansion of the population within Social Welfare Institutions. While some of these abandoned children succumb, probably many more are adopted by Chinese families in violation of adoption laws designed principally to prevent over-quota births rather than to ensure the well being of children. Consequently, hundreds of thousands of children, principally girls, exist in situations where they are deprived of entitlements such as education and health care due to their parent’s inability to gain official governmental recognition of their adoption. As noted by Dr. Johnson, adoption laws should be further modified so that they serve first the needs of children, and domestic adoption should be promoted and supported as vigorously as international placement.

In 1999, the adoption law in China was changed, lowering the legal age of adoption to 30 and permitting adoption of orphans from within state welfare institutions by families who already had children as long they could obtain certification of compliance with birth planning regulations from local authorities. During the year following liberalization of the law, the number of officially registered adoptions in China increased from approximately 6-8,000/year to 52,000. While the number of children adopted from orphanages increased, a larger portion of this number probably represented registration of foundlings adopted outside of orphanages as well as official recognition of “black children” adopted outside of legal channels. In these events I see progress and gain hope that domestic adoption will be supported, and that those homeless children welcomed into Chinese families outside the letter of the law will enjoy the full rights and privileges guaranteed in China’s own constitution.

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