Narrative Case Study: Adoption

Narrative Case Study: Adoption

Linda L Hill, MD, MPH

Winter 2007 - Volume 11 Number 1

Regularly in the course of my practice, I’ll take a family history and receive the reply “I don’t know, I was adopted.” In the past, I viewed this lack of genetic information as an annoying gap in the patient history. However, I recently became involved in reuniting my father, David, with his birth family, an experience that has changed my perspective.

Birth, Adoption, Life

In 1926, Marion Babbage, a single Irish Catholic maid in London became pregnant at the age of 23 by the son of an unmarried English gentleman who owned the house where she was working. A few months after a single liaison with her employer, she found her abdomen swelling, but had already left his employment. She had met a photographer who proposed marriage, but only if she was unencumbered. On May 31, 1927, she gave birth to a healthy boy, who she named Ralph after his father. He went straight to a nursing home, while she looked for suitable parents. Marion placed an ad in a local ‘personals’ column, asking for someone to adopt this boy.

The ad was answered by Dorothy Hill, a married but childless woman who had a hysterectomy in 1921 for tuberculosis of the uterus. Marion picked Ralph up from the nursing home when he was age five weeks and took him to the home of Dorothy and her husband William. She dropped the baby off with her picture and the birth certificate. That was the last time she saw or heard from Ralph for 70 years. She married the photographer one month later.

William and Dorothy renamed the baby David. He wasn’t told he was adopted until age 11. The family spent the war years in England living on a mere $500 a year. David, like many teen boys during the war years, worked in the local factory full time during the war, also going to school, supplementing that meagre income by catching rabbits. David was soon the sole supporter of the family when William died of lung cancer in 1943. In 1947, at the age of 20, he won a scholarship to a university in the US. He married, had three children and subsequently, three grandchildren. He enjoyed a successful and rewarding career and continues to consult at the age of 78.

Searching for Roots

There were several things that bothered my father about his adoption. Why did his mother give him up? Was he so unlovable, that she just left him with Dorothy and William? Why didn’t she list the father’s name on the birth certificate? Was she a prostitute? David had developed hypertension at an early age. What else was in the cards? Were there other genetic diseases, like Huntington’s Chorea or premature heart disease lurking in his gene pool? Lastly, he missed having an extended family.

In early 1996, my daughter, then age 13 years, was assigned a ‘Coming to America’ project in the eighth grade—a school-imposed ‘searching for roots.’ Intrigued by the project (in contrast to my daughter), I initiated a search for my father’s birth family with only the birth certificate and picture.

I began by contacting agencies in the United Kingdom that specialize in birth family reunions, hoping that the birth family had registered and were waiting for David. However, that was not the case. I was referred to a woman in the UK who employed herself by searching the microfiche of the Family Records Centre in London. Over the next 18 months the clues trickled in: the birth mother Marion Babbage had married William Trigg in 1927, and had a son three years later. Any trace of the Triggs ended there. In the meantime, I was using the Internet to search for Triggs, sending out e-mails and letters, and even meeting with Triggs, making new friends but not finding my father’s family. Finally, a lucky break occurred. William Trigg’s sister, who had signed his marriage certificate in 1927, had died in the 1950s, and the name and address and phone of the closest relative was listed on the death certificate, which my grandmotherly detective had found. That relative answered the phone and willingly spoke of the family and gave the last known address (from the 1960s) of Marion and William Trigg, in Sydney Australia. Using a reverse directory, I got the number for the address and placed a cold call. On December 27, 1997, Marion Trigg, aged 94 years, answered the phone; she was lucid and talkative.


Sadly, Marion was not interested in a family reunion. She did not wish her second son, or his wife and their children, to find out about David. On the other hand, she understood his wishes to know his roots and eventually disclosed the identity of David’s father. She seemed to welcome my phone calls of which there were many and even agreed to talk to David. They had one conversation of about 45 minutes. She asked his forgiveness and he declared there was nothing to forgive. They had little more to say to each other and never spoke again.


While this was disappointing to my father, several of his questions were answered. His father was upper class and intelligent, and his mother was alert and alive at the age of 94. I spent the next two years searching for a handsome man named Ralph Oliver Raphael, born around 1890, with a limp. Finally, after hundreds of Internet letters, mail queries and Internet phone book searches, the family was found. In March 1999, I went to London to meet with two first cousins of David, and received a family history and pictures of his birth father. David is the spitting image of his father Ralph, who died in 1945. The Raphael family, though previously unaware of their illegitimate cousin, believed the story and welcomed the family.

Over the next few years David met four of his five cousins, and the families have gotten to know each other. He learned that his father never had other children, married twice, was born to a prominent London family, and was a talented and accomplished man. Like my father, Ralph Raphael had an interest in corporate psychology. Although his death certificate listed ‘renal failure’ as the cause of death, the family had no specific genetic problems and the cousins were bright, healthy, and successful.


The sole remaining dilemma was, following the death of his mother, whether to contact his half brother. In August of 2003, after being unable to find Marion’s name any longer at her address in the Sydney online white pages, I put in a call to Eric, David’s younger half brother. Eric was delighted and welcoming. His mother had reluctantly told him the story from her nursing home bed before her death two years earlier; however, he doubted the veracity of the tale. In addition, she had destroyed all of the correspondence between us and Eric didn’t even know David’s name nor have any way of contacting his brother.

On December 1, 2003, we flew to Sydney to meet Eric. The reunion was joyful and rewarding. In the course of the next five days, Eric admitted that his parents were not easy people to live with; they forced him to quit school and begin work at age 16, packed his bags for him on his 21st birthday, and went to the beach instead of attending his wedding. Any thoughts my father had harbored that life with his birth-mother would have been better were soon dissolved. The brothers’ five days together provided my father with his first sibling experience in a loving and supportive environment. He and his brother have plans to continue meeting for the rest of their lives.

Finding out about his birth family has eased some of David’s nagging questions and worries. While he again experienced rejection from his birth mother, knowing her story eased some of his pain and curiosity. The rest of his family has been warm and welcoming, and people with whom he will have lifelong relationships.

Issues for Adopted Children

Some of the issues plaguing David throughout his life may be universal to adopted children. Questions about genetics, family stories, immigration experiences, and reasons for adoption placement are frequent. Other issues may be unique, and may depend on the adoption child/parent fit. These include fantasies of what life would have been like with the birth family, imagining reunions, and guilt over a lack of bonding with the adoption family.

The effect of adverse childhood experiences on adult health has been well documented.1,2 The characteristics of pre-adoption experiences, the age of adoption, and the nature of the adoptive families all determine whether adopted children experience their childhood as “adverse.”3 Adoptive families may provide a more supportive environment for children. An adoption study of twins separated at birth found that adoptive families increased the socioeconomic status of the children compared to their biological families.4 This is particularly significant in international adoptions of institutionalized children.5 One study found increased rates of behavioral problems in adopted children compared with biological two-parent families, but fewer behavioral problems than with biological one-parent families.6 The twin study4 found that adoptees had greater education, less alcohol abuse, though somewhat higher psychological distress (neuroticism and alienation), than children in single-parent families.

An analysis of adopted child personality and behavior problems found that “ego resilience” was associated with the least behavior problems, while “ego overcontrol” was associated with internalizing problems and “ego undercontrol” with externalizing problems. Adopted boys were found to have more behavioral issues than girls.7 A large study in the US using National Health Interview survey data found that foster children age 5-11 years, but not age 12-17 years, had more behavioral problems than nonadopted children. Only 12% of adopted children had any behavioral problems. Eighty-eight percent had scores similar to nonadopted children. They concluded that the small number of problem adoptees could likely be explained by genetic predisposition, prenatal drug or alcohol exposure, and pre-adoption adverse experiences.8 In one meta-analysis of adoption studies, the authors concluded that while adopted children show a trend towards global disturbances, this is related to specific variables, especially neglectful or abusive pre-adoptive experiences, such as may occur with prolonged fostering. They also concluded that there was no evidence for adverse outcomes with adoption of children by gay or lesbian individuals or couples.9 The trends towards open adoption raises other issues for adoptees, but may generally provide adoptees with a reduced sense of loss, and improved self esteem.10 Data on in-vitro fertilization, surrogate mothering with subsequent adoption, and other complex arrangements have not been adequately studied to determine whether they are associated with increased behavioral problems.11

Considerations for Physicians

When encountering adult patients with an adoption history, physicians need to look beyond the lack of genetic history. The pre-adoption/adoption experiences may have a profound affect on the lives of the individual, both positively and negatively. Age at adoption, abuse before or after adoption, the number of foster care placements before adoption, characteristics of the adoptive family, and relationship with the birth family are all important determinants of adjustment. On the other hand, most adoptive parents can be reassured that adoptive children have very similar amounts of behavioral issues as nonadopted children. I have expanded my adoption history to provide a more extensive understanding of an individual’s experiences. The Internet has greatly improved the chances of locating birth families with minimal information and expense. My father’s experiences, both positive and somewhat distressing, have led me to strongly support those patients who express interest in pursuing their birth origins.

1. Felitti VJ, Anda RF, Nordenberg D, et al. Relationship of childhood abuse and household dysfunction to many of the leading causes of death in adults. The Adverse Childhood Experiences (ACE) Study. Am J Prev Med 1998 May;14(4):245-58.
    2.    Dube SR, Anda RF, Felitti VJ, Chapman D, Williamson DF, Giles WH. Childhood abuse, household dysfunction, and the risk of attempted suicide throughout the life span: findings from the Adverse Childhood Experiences Study. JAMA 2001 Dec 26;286(24):3089-96.
    3.     Logan F, Morrall P, Chambers H. Identification of risk factors for psychological disturbance in adopted children. Child Abuse Review 1998;7:54-64.
    4.    Smyer MA, Gatz M, Simi NL, Pederson NL. Childhood adoption: long-term effects in adulthood. Psychiatry 1998 Fall;61(3):191-205.
    5.    O’Connor TG, Bredenkamp D, Rutter M, The English and Romanian Adoptees (ERA) Study Team. Attachment disturbances and disorders in children exposed to early severe deprivation. Infant Ment Health J 1999;20(1):10-29.
    6.     Fergusson DM, Lynskey M, Horwood LJ. The adolescent outcomes of adoption: a 16-year longitudinal study. J Child Psychol Psychiatry 1995 May; 36(4):597-615.
    7.    Juffer F, Stams GJ, van Jzendoorn MH. Adopted children’s problem behavior is significantly related to their ego resiliency, ego control, and sociometric status. J Child Psychol Psychiatry 2004 May;45(4):697-706.
    8.    Brand A, Brinich P. Behavior problems and mental health contacts in adopted, foster, and nonadopted children. J Child Psychol Psychiat 1999 Nov;40(8):1221-9.
    9.    Nickman S, Rosenfeld A, Fine P, et al. Children in adoptive families: overview and update. J Am Acad Child Adolesc Psychiatry 2005 Oct;44(10):987-95.
    10.    Baumann C. Examining where we were and where we are: clinical issues in adoption 1985-1995. Child Adolesc Social Work J 1997 Oct;14(5):313-34.
    11.    Golombok S, MacCallum F. Practitioner review: outcomes for parents and children following non-traditional conception: what do clinicians need to know? J Child Psychol Psychiatry 2003 Mar;44(3):303-15.


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