International Adoption, Behavior, and Mental Health

Adoption has been a part of human culture since earliest recorded times: Moses is perhaps the most famous adopted person in history.^{1 - 2} Fascination with adoption pervades literature (from fairy tales and myths to modern novels), psychology, and medicine. Researchers have long studied adoption in attempts to isolate the effects of “nature” and “nurture” on behavioral outcomes and mental health.³ Genetic factors, separation from birth parents, environmental exposures (both prenatal and postnatal), and aspects of the adoptive home environment have all been cited as possible contributors to adverse behavioral and mental health outcomes among adoptees.⁴

Although numerous articles have been published under the search headings of “adoption and mental health” or “adoption and behavior,” the use of disparate patient populations, diverse research questions, and varied methods make the results bewilderingly difficult to synthesize. Positive adoption outcomes are undoubtedly underreported.⁵ Furthermore, reports of increased prevalence of mental health problems among adoptees may be due in part to their adoptive family characteristics.^{6 - 8} Adoptive families are usually economically advantaged, well-educated, and familiar with available social and mental health services and are therefore likely to be overrepresented among populations receiving such assistance.

Another limitation in many studies of mental health and behavioral outcomes of adopted children is a focus on a single time point. Results of such cross-sectional studies may be misleading: evidence suggests that adopted children improve their behavior as adolescence progresses, especially if they have received earlier supportive or therapeutic services.⁹ Indeed, adoptees are underrepresented in juvenile court and adult mental health populations.¹⁰

Other research investigations do not differentiate between various types of adoption (private vs social services, international vs domestic), the age of the child at adoptive placement, the reasons for placement, and adoptive family characteristics. Criteria used to match children and parents are rarely examined critically.¹¹ For children placed after infancy, few investigations differentiate between problems noted at placement and those that manifest later. Studies of biological predictors of behavioral or mental health outcomes of adoptees are hampered by outdated or unreliable information about the birth parents. Moreover, few outcome studies take into account mental disorders and stress in the adoptive family, even though some research suggests that such families may have an increased incidence of these problems.¹² Furthermore, the cultural milieu of adoption has clearly evolved over time, greatly influencing the advice given to adoptive families about raising their children. Adoption has evolved from being a “shameful secret” to being celebrated—this change in attitude undoubtedly affects family dynamics, altering the outcome of children over time. Moreover, some adoption researchers believe that “normative crises” in adopted children and their families are incorrectly viewed as pathologic.^{13 - 15} Despite these and other difficulties, interest in mental health and behavioral outcomes of adoptees remains strong.

The popular image of adoption has changed considerably in recent years, especially as international adoption has become increasingly common. More than 230 000 children from other countries have been adopted by US parents since 1989.¹⁶ Parents in Europe (especially Scandinavia), Canada, Australia, and New Zealand also adopt children from outside their own countries. The stories of these children are dramatic: a child born to impoverished or otherwise disadvantaged parents in a faraway country comes to live a privileged life in the United States (or other country) after adoption. The increasing frequency of “visible” international adoptions—for example, the adoption of Chinese children by white parents—has also served to promote awareness of international adoption. As Pertman noted, “ . . . it’s getting increasingly difficult to find a playground without at least one little girl from China, being watched lovingly by a white mother or father.”² Moreover, sensationalized stories about severely disturbed children adopted from other countries have been widespread in the media. Many of these children lived in extremely difficult circumstances with their birth families or in institutions prior to adoptive placement.

Despite the increasing number of internationally adopted children in the United States, surprisingly little is known about their behavioral and mental health outcomes. Pediatricians, teachers, therapists, mental health personnel, adoption professionals, and prospective or adoptive parents are interested in better understanding the risks of complex or adverse behavioral or mental health outcomes among these children.

In this issue of JAMA, Juffer and van IJzendoorn¹⁷ report their findings from a meta-analysis of studies on behavioral problems and mental health referrals of international adoptees. Using careful selection criteria, the authors extracted data from 64 articles on behavioral problems and 34 articles on mental health referrals of internationally adopted children. The internationally adopted children were compared with nonadopted peers or domestically adopted children (ie, children adopted within the same country). The authors convincingly demonstrate that international adoptees have more behavioral problems than nonadopted controls, although the effect sizes were small. On the other hand, when compared with domestic adoptees, international adoptees had fewer total, externalizing, and internalizing behavioral problems and fewer mental health referrals.

Moreover, internationally adopted children who resided with their adoptive families for more than 12 years had fewer total behavioral problems than those living with their families for less time. Not surprisingly, the meta-analysis confirmed that preadoption adversity increased the risk of total and externalizing behavioral problems for international adoptees. Notably, age at adoption did not relate to behavioral problems, a finding of critical importance as the number of “older” children (often defined as >2 years of age) needing adoptive families continues to increase.

Although these conclusions are noteworthy, careful examination of some assumptions in this work is warranted. Most importantly, the characteristics of the comparison group of domestic adoptees are not completely defined. This heterogeneous group may include children placed as newborns or young infants, as well as school-age children or teenagers with extremely complex social and personal histories. Although the authors suggest that the reasons differ for relinquishment of children for international and domestic placement, some work suggests striking similarities.¹⁸ However, as the authors note, it is plausible that children selected for international placement are chosen because of favorable personal characteristics.

The relationship between family demographic characteristics and child outcomes also deserves further exploration. Some as-yet-undefined characteristics of parents who choose to adopt internationally may account for the favorable outcome of their children compared with that of domestic adoptees. Some evidence suggests that children placed in adoptive families with relatively lower socioeconomic status have more favorable outcomes than those placed with more privileged families.^{19 - 23}

The link between preadoption adversity and behavioral problems, while intuitively correct, should be examined in future studies. The meta-analysis coded studies for preadoption adversity if more than 50% of a sample experienced extreme deprivation. Lack of information about specific preadoption experiences and uncertainty about the various methods used to determine the quality of preadoption experiences prevent definitive conclusions. Furthermore, methodological requirements necessitated grouping of international and domestic adoptees for some analyses. These limitations need to be overcome in future investigations because a better understanding of the relationship of preadoption adversity to behavioral and mental health outcomes could provide helpful guidelines to design interventions in orphanages worldwide. Such interventions could benefit the countless children who remain institutionalized and do not benefit from adoptive placement.

Another curious finding of the meta-analysis was that studies conducted in North America described more total behavioral problems than studies reported from Europe or elsewhere. The authors do not speculate on the cause, although such possibilities as differential application of diagnostic standards, lower threshold for treatment, greater availability of services, reduced stigma of diagnosis or treatment, different expectations of adoptive parents, or placement of more behaviorally disturbed children in North America compared with other locales should be considered as possible explanations.

Although these and other intriguing questions remain unanswered, the meta-analysis by Juffer and van IJzendoorn is a welcome addition to the literature on international adoption, behavioral problems, and mental health outcomes. Their work allows refinement of future research questions and greatly enhances understanding of the risks faced by internationally adopted children and their parents. Researchers, adoption professionals, and families will use the information in this article to support family, social, and community factors that promote favorable outcomes; to identify, recognize, and ameliorate stressors within the adoptive family; and to strengthen family adjustment and attachment after adoption. Clearly, this report represents an important step toward the goals of reducing behavioral problems and promoting positive mental health outcomes for this vulnerable group of children.