Mental health and behavioural difficulties in adopted children: A systematic review of post-adoption risk and protective factors

Abstract

Previous research suggests that adopted children are at a greater risk of experiencing psychological and behavioural difficulties or accessing mental health services than non-adopted peers and that post-adoption variables are significant risk and protective factors producing this situation. This review seeks to summarise the post-adoption variables associated with adopted children’s mental health or behavioural difficulties to inform future research and shape interventions. A search for publications that assess associated risk and protective factors using Web of Science, Psychinfo, Medline and Sociological Abstracts identified 52 studies that met rigorous methodological criteria. Children’s and adolescents’ mental health and behavioural outcomes were associated with parent, parent–child and wider family factors and by contextual variables. The findings highlight the importance of focusing on the multitude of systemic factors surrounding a child following adoption. Clinical implications and direction for future research are discussed.

Keywords

Adoption mental health behaviour risk factor

Introduction

When social workers decide that a child’s needs cannot be met by their birth parents within a reasonable timescale, current UK policy favours achieving permanence within another family setting, such as through adoption (Department for Education, 2016). But despite this relatively simple ambition, research on adoption is confounded by its many forms and the different contexts in which it is conducted. For example, children can be adopted by strangers or people they know, such as foster carers or relatives; adoptions can be domestic or intercountry and are often marked by a variety of transracial and cross-cultural aspects. In addition, factors such as the age and previous histories of the children have also been shown to affect outcomes. All of these variables have to be carefully considered when evaluating research studies and generalising findings.

In spite of these complications, numerous studies have demonstrated the positive impact of adoption on children’s physical, cognitive and psychosocial development following adversity (Juffer and van IJzendoorn, 2005; Palacios, Roman and Camacho, 2011; Rutter, 1998; Segatto and Dal Ben, 2013)¹. Findings from two meta-analyses suggest that most adopted children are well-adjusted (Bimmel, et al., 2003; Juffer and van IJzendoorn) but as a group show greater risk of psychological and behavioural difficulties and placement breakdowns that exacerbate their situation (Behle and Pinquart, 2016; Selwyn, Wijedasa and Meakings, 2014).

Based on these findings, research has begun to explore causal processes and probe more deeply into the risk and protective factors that predict children’s psychological adjustment. Pre-adoptive risk factors, such as the child’s age and previous history, have been identified as important (Anthony, Paine and Shelton, 2019; Hawk and McCall, 2010; Tan, Marfo and Dedrick, 2010) but do not account for the entire variability in subsequent psychological adjustment or explain the fact that many adoptees from inauspicious backgrounds appear well-adjusted (Bimmel; Juffer and van IJzendoorn).

Various explanatory models of adoptees’ difficulties have been fashioned (Peters, Atkins and McKay, 1999) but those that include both pre-adoptive and post-adoption factors seem to be the most fruitful. They also suggest that family and systemic processes have greater impact on children’s development than children’s pre-adoptive history and cite as especially important the adoptive family’s sense of coherence (Ji, et al., 2010) and the quality of prevailing relationships (Balenzano, et al., 2018). Similarly, parenting factors such as the quality of care the children experience have been found to mitigate some of the effects of pre-adoptive adversity on behavioural difficulties (Kriebel and Wentzel, 2011) and provide the basis for parenting programmes recommended by the UK National Institute for Clinical Excellence for children with attachment difficulties (NICE, 2015).

A more recent transdiagnostic model seeking to explain the link between childhood trauma and later internalising and externalising psychopathology offers a different perspective and highlights the role of changes in threat-related social and emotional processing, alongside an accelerated biological aging process (McLaughlin, et al., 2020). It emphasises the protective role of caregiving support in buffering threat-related challenges and highlights the importance of considering developmental processes over time, rather than cross-sectional associations at one timepoint.

While each research study tends to focus on specific variables, the overriding conclusion from this information is that the psychological adjustment of adoptees cannot be predicted by a single risk factor but reflects an accumulation of multiple risks interacting with protective factors (Roskam and Stievenart, 2014), hence the broad span of this current literature review. As little can be done to amend pre-adoptive risk factors, it focuses especially on post-adoption factors which provide a more promising basis for designing therapeutic services.

Method

Literature search strategy

The search terms used for the literature review comprised three clusters of factors: adoption/young people, mental health and risk and protective factors. Clinical psychologists working in adoption services were consulted to assess the completeness of the search terms.

Data sources

The following electronic databases were searched: Web of Science, Psychinfo, Medline and Sociological Abstracts. Google scholar was employed to identify any further studies. The final search was from inception to October 2019.

Inclusion and exclusion criteria

Criteria for inclusion in the review are outlined in Table 1. Studies were only considered if they sampled adopted children or adolescents using a case-control, longitudinal or cross-sectional methodology, if they focused on post-adoptive psychosocial risk or protective factors and if they measured mental health, behavioural or psychological adjustment as an outcome measure.

Table 1.

Inclusion and exclusion criteria.

Inclusion criteria	Exclusion criteria
Adopted children or adolescents	Studies of adult populations or non-adopted children
Post-adoption psychosocial risk or protective factors	Genetic or genetic-environment adoption studies
Measure of mental health, behavioural difficulties or psychological adjustment	Studies focusing on pre-adoptive risk or protective factors
Case-control, longitudinal or cross-sectional studies	Studies not published in English
	Non-empirical or general discussion papers

Study selection

The results of the literature search were downloaded and managed in an EndNote library, where duplicates were removed. Using the PRISMA guidelines, the titles were then screened against the inclusion and exclusion criteria and if the details were still unclear, the abstract was analysed. Once eligibility was determined, the full text was read and any further discrepancies were resolved by discussion among the researchers.

Data extraction and quality assessment

Information on each study was extracted and entered into a pre-designed template covering publication details, country of origin, methodology and participant characteristics. Further information included the post-adoption predictive factors, predictor measures, outcomes, outcome measures, key findings and limitations. The quality of the studies was assessed using the Standard Quality Assessment Criteria for Evaluating Primary Research Papers from a Variety of Fields (Kmet, Cook and Lee, 2004). The findings from each study were then narratively synthesised to summarise the risk and protective factors identified and articulate the key findings relevant to the subject of this article: the post-adoption factors associated with adopted children’s mental health and behavioural difficulties.

Results

Study selection²

Electronic database searches identified 2350 relevant studies of which 831 were immediately rejected because of duplication. From the remaining 1519, 919 were rejected following title screening and a further 477 after abstracts had been read, leaving 123 for close examination. After reading the full texts of these studies, 71 were rejected, leaving 52 for inclusion in this review.

Study characteristics

Of the 52 studies scrutinised, 29 used cross-sectional and 23 longitudinal methodologies. The number of participants ranged from 32 (Tarroja, 2015) to 2089 (Harwood, Feng and Yu, 2013), 30 studies focused on, or included, international adoptees and seven compared adoptive families with a matched non-adopter group. The risk factors examined varied; 23 studies looked at parent factors, 10 at parent–child relationships, 16 at family factors and 15 at contextual ones, with many studies looking at several of these.

The choice of outcome measures was equally varied. Those most used encompassed a broad spectrum of emotional and behavioural problems, such as the Child’s Behavioural Checklist, used in 26 studies, and the Strengths and Difficulties Questionnaire, used in four. Some studies focused on narrower subdomains of internalising and externalising behaviours or on specific symptoms and aspects of psychological difficulties.

Narrative synthesis

The overarching risk and protective factors associated with adopted children’s mental health or behavioural difficulties were summarised under common themes outlined in Figure 1; namely, parent factors, parent–child variables, family features and contextual influences; these will now be considered in more detail.

Figure 1.

Map of the post-adoption variables associated with adopted children’s mental health or behavioural difficulties.

Parent factors

The role of adoptive parent factors was explored in 17 studies covering parenting style, parental mental health and parental responsiveness.

Parenting style

Parenting style was the focus in most of the studies with 10 consistently highlighting it as an influence on children’s mental health or behavioural difficulties. A Belgian cross-sectional study compared 40 international adoptees with 34 non-adopted children and found that in both groups externalising and internalising behaviours were linked to lower parenting support (Roskam and Stievenart), a finding echoed in a US longitudinal study of 293 adoptive families (Simmel, 2007) and in a non-comparative Brazilian project involving 68 adoptees (Reppold and Hutz, 2009).

Some studies delved deeper into parenting styles and investigated the effects of permissive versus authoritarian ones. In a cross-sectional US study comprising a longitudinal cohort of 133 adoptees, both styles correlated with behaviour problems with authoritarian parenting mediating³ the effect of non-child-related family stress on adoptees’ internalising behaviours and overall behavioural problems (Tan).

Among international adoptees, authoritarian parenting was observed more in families where the child learned of their adoption later rather than earlier and if parents had changed their child’s first name, a feature that was linked to raised levels of depression and low self-esteem (Reppold and Hutz). Another longitudinal study that compared 75 Romanian adoptees with 46 non-adopted Canadian children found that authoritarian parenting style was positively predictive of inattention and/or overactivity in adoptees with lower levels of deprivation, but negatively predictive in children with higher levels (Audet and Le Mare, 2011).

Positive parenting styles, such as child-centred approaches, unsurprisingly mostly showed more positive effects and have been found to be an adaptive behaviour that moderates the effects of cumulative risk in the pre-adoptive environments. Kriebel and Wentzel’s study of 70 domestic and international adoptees in the USA and Hornfeck, Bovenschen and Heene’s (2019) German study of 172 domestic and international adoptees demonstrate this by showing that positive parenting was linked to lower emotional and behavioural problems even when pre-adoption conditions were considered. This tendency is further confirmed in two other projects, one from Wales (Anthony) where parental warmth was found to moderate the association between the number of adverse early experiences and internalising symptoms three years post-adoption, and one from the US (Lawler, Koss and Gunmar, 2017) which followed up 68 adoptees and 52 non-adopted children and found that higher quality parental structure and limit-setting in the early period after adoption predicted lower child regulation difficulties. Especially significant was the fact that the style of parenting was not predicted by initial child regulation, so demonstrating the unique role of parenting quality.

Only one longitudinal study – of 74 Russian born adoptees in the US – found that behavioural outcomes showed no significant relation to parenting style as reported by mothers and fathers separately (Hein, et al., 2017). However, methodological weaknesses, such as discrepancies between each parent’s descriptions, question the wider applicability of the results.

In summary, it can be concluded that the evidence reviewed is consistent in indicating that parenting style is both a risk and a protective factor for adopted children’s mental health and behavioural problems, depending on its nature, and is clearly an important protective factor when the style moderates the impact of adverse pre-adoptive experiences. Negative parenting styles appear to have a detrimental impact on adoptees’ health and behaviour, whereas positive parenting is generally enhancing and, at minimum, has a positive buffering effect. However, the evidence is by no means robust as only four out of the 10 studies utilised observation of parenting as opposed to self-report, and only seven out of 10 studies controlled for child-led factors such as pre-adoption adversity or academic ability (Anthony; Audet; Hein; Kriebel; Lawler; Tan).

Parental mental health

The link between adoptive parent mental health and children’s behaviour or mental health was explored in seven studies (Colvert, et al., 2008; Gagnon-Oosterwaal, et al., 2012; Goldberg and Smith, 2013; Hails, et al., 2019; Hornfeck, Bovenschen and Heene, 2019; Liskola, et al., 2018; Smith-McKeever, 2004). One measured general parental mental health (Colvert), three focused on parental depression (Goldberg and Smith; Hails; Liskola), five explored parental stress (Gagnon-Oosterwaal; Miller, et al., 2009; Santos-Nunes, et al., 2018; Smith-McKeever; Smith, et al., 2018) and one assessed parent self-regulation (Hornfeck).

Only one study, a UK longitudinal scrutiny of 217 domestic and Romanian adoptees (Colvert), found no evidence of an association between parental mental health and the onset of children’s emotional disturbance. This contrasts with others where parental depressive symptoms were strongly related to higher levels of both externalising and internalising symptoms in the children (Goldberg and Smith; Hails), with indications that associations were stronger for paternal mental health issues on children's depressive symptoms than maternal health issues, which were not associated with children’s depressive symptoms (Liskola; Hails).

Parental stress was another aspect of mental health commonly associated with children’s internalising and externalising behavioural problems (Gagnon-Oosterwaal; Miller; Smith-McKeever) and difficulties at school (Miller). Furthermore, in two Canadian longitudinal studies of international adoptees (Gagnon-Oosterwaal; Smith), it was found to mediate the relationship between children’s characteristics and early risk factors, such as age at adoption and behavioural problems. From a slightly different angle, a Portuguese cross-sectional mediation study of 116 adoptees found that discrepancies between parents’ expectations and real experiences post-adoption were linked to increased parental stress, which in turn had a negative influence on the child’s adjustment (Santos-Nunes). The stress was often manifested in relational indicators, such as the amount of positive time parents and children spend together and how often the parent thinks of the child when they are separated (Smith-McKeever). In another study (Hornfleck), stress was incorporated into a broader concept of parent self-regulation that comprised self-efficacy, perceived stress and psychological distress, and this too was found to be related to greater emotional and behavioural problems among the children.

Together, these findings highlight the important role of adoptive parental mental health as a risk factor for children’s adjustment, and further suggest that parental stress, and not just diagnosable mental health issues, are important risk factors. An association was found in many studies, with some highlighting the direction of effect, with parental depressive symptoms predicting later internalising behaviours. However, as they do not include non-adopted comparison groups, it is difficult to determine whether the results are specific to adoptive families or common among all.

Parental responsiveness

Three longitudinal studies focused on maternal sensitivity or self-reflectiveness as a risk factor. This refers to a parent’s ability to mentalise their child’s state of mind and the quality with which they respond to their child’s cues in a timely and appropriate manner (Priel, et al., 2000; van der Voort, et al., 2013, 2014). Each study examined the specific rather than the general effects of this, so Priel and colleagues’ Israeli study found an association between low maternal self-reflectiveness and a higher rate of externalising behaviours among both adopted and non-adopted children, while van der Voort and colleagues found maternal sensitivity to be an important predictor of internalising problems and delinquent behaviour, but not aggression at age 14.

These studies extend findings about the importance of parental factors for children’s mental health and behaviour, this time noting the protective effect of adoptive parents’ ability to mentalise and respond to their child.

Parent–child relationship

The nature of the parent–child relationship, mostly measured through observational methods, was consistently linked to children’s behavioural problems, and in particular adolescent behavioural difficulties (Groza and Ryan, 2002; Groza, Ryan and Cash, 2003; Harwood, Feng and Yu, 2013; Klahr, et al., 2011; Koh and Rueter, 2011; Santos-Nunes).

Harwood and colleagues’ longitudinal study of 2089 domestic and international adoptees in the US found both direct and indirect paths between pre-adoptive adversities and mental health outcomes, with the majority of associations mediated or partially mediated by the quality of parent–child relationships. The same effects were charted by Groza and by Klahr and colleagues for children’s behavioural difficulties.

Ethnic socialisation in transracially adopted families was an important aspect of parent–child relationships associated with adoptees’ well-being for many adopted children in two US studies (Yoon, 2000, 2004).

Improved parent–child attachment is a common aim of many post-adoption interventions (Kerr and Cossar, 2014) and two studies linked attachment difficulties to ADHD symptoms more strongly than pre-adoptive risk factors, such as deprivation and prenatal alcohol exposure (De Maat, et al., 2018). In Roskam’s study, externalising behaviours were linked to anxious-avoidant attachment and low parenting support in both adopted and non-adopted children.

These findings demonstrate that within adoptive families, like non-adoptive families, the parent–child relationship is associated with children’s mental health and behavioural outcomes. However, there are adoption-specific effects in the parent–child relationship to consider, such as the effect of difference, as highlighted by ethnic socialisation effects.

Family factors

Family environment

Studies of the family environment all focused on cohesion, expressiveness and conflict within the adoptive family. A positive family environment was related to children’s adaptive adjustment in five studies (Ji; McGuinness and Pallansch, 2007; McGuinness, Ryan and Robinson, 2005; Simmel; Tung, et al., 2018), one (Ji) suggesting that family coherence affected adoptees’ adjustment considerably more than pre-adoptive risk factors. Another (Tung) specifically explored children’s temperamental sensitivity and later family cohesion and found that adoptees with an early reactive temperament did not exhibit greater sensitivity to maltreatment or later adoptive family cohesion; however, adoptive family cohesion demonstrated a marginally significant and protective effect on later criminal behaviours and arrest rates.

The diminishing effects of pre-adoptive risk factors and the growing protective contribution of family environment to children’s well-being were noted in three longitudinal studies by McGuinness and Pallansch, McGuinness and colleagues and Simmel.

Conflict and family relationships were explored in three studies (Balenzano; Goldberg and Smith; Tan) and found in cross-sectional analysis to be associated with children’s behavioural problems (Tan) and greater internalising symptoms (Goldberg and Smith).

Although the study of family environments is something of an academic minefield, overall, the findings are consistent in suggesting that cohesion, expressiveness and conflict serve as important risk and protective factors for children’s behavioural and mental health difficulties and that healthy family environments can serve to mitigate the impact of pre-adoption adversity and have an impact over and above pre-adoption risk factors. However, as before, without data from non-adopted comparison groups, it is difficult to know how far the findings are adoption specific.

Communication openness

The impact of communication openness where the adoptive parents recognise rather than deny the inherent differences associated with being an adoptive family was explored in six studies (Aramburu Alegret, et al., 2020; Brodzinsky, 2006; Grotevant, et al., 2011; Le Mare and Audet, 2014; Soares, et al., 2017; Tarroja) and was found to be a generally positive association.

Several cross-sectional studies of international adoptions found that communicative openness was associated with lower adolescent behavioural problems (Aramburu Alegret; Le Mare and Audet; Tarroja) and emotional lability and negativity (Soares).

But the relationship between openness and children’s health and behaviour was less marked in Brodzinsky’s study which found that although family structural and communication openness were positively correlated, only communication openness independently predicted children’s adjustment. There appears to be a role for adoptive parents being able to recognise and communicate about the inherent differences associated with being an adoptive family, but the evidence on the benefits of communicative openness is inconclusive.

Adoption satisfaction

Family members’ satisfaction with adoption was measured in two studies (Balenzano; Nilsson, et al., 2011). Nilsson and colleagues found that higher levels were related to fewer conduct problems among adolescents and Balenzano linked the parents’ satisfaction with the adoption process, regarding open arrangements to young people’s psychological distress. These findings highlight the importance of family factors, including the process of adoption and satisfaction with it, for children’s mental health and behaviour.

Contextual factors

Ethnic identity and discrimination

Six studies explored the relationship between psychological adjustment, ethnic identity development and experiences of discrimination, mostly among internationally adopted children (Juffer and van IJzendoorn; Lee, 2010; Qin, et al., 2017; Schires, et al., 2020; Yoon). Three US studies found that discrimination was linked to greater internalising and externalising problems, depressive symptoms and psychological distress (Lee; Schires; Qin) with another showing that discrimination was greater for parents of Asian and Latin American children than for white Eastern European children. Moreover, the perceived discrimination reported was uniquely related to greater problem behaviours for adopted children from Asia and Latin America than white Eastern European children, highlighting a specific effect of racial discrimination (Lee).

These findings indicate the importance for transracially adopted children of racial factors and experiences of discrimination. The psychological mechanism by which discrimination operates for adoptees is not yet well understood. It does not appear to be related to emotional regulation styles, which did not moderate the association between perceived discrimination and adjustment (Qin). Schires found that the negative effects of discrimination were especially marked for children whose parents did not teach their children about racial identity or prepare them to cope with experiences of racism. Similarly, Yoon’s studies of Korean born adoptees also found better psychological adjustment resulted from parents supporting their child’s ethnic identity development and sharing ethnic socialisation experiences. One study of transracially adopted children found greater adjustment difficulties in children who internalised the perceived dominant skin colour of the host country as more desirable (Juffer and van IJzendoorn).

Mohanty’s (2015) study found a curvilinear relationship between adoptees’ sense of ethnic identity and self-esteem, in that a moderate level of identification with ethnicity of origin is associated with positive esteem whereas low and high levels are related to low self-esteem. However, Le Mare and Audet found that exposure to culture of origin did not relate to behavioural problems.

This set of studies is specific to transracial adoption and cannot easily have a non-adopted control group. The studies highlight the importance of considering the cultural and racial contexts and adults’ and children's experiences of discrimination when seeking to improve the well-being of internationally adopted children.

Structural openness of adoption

Three studies assessed the impact of the structural openness of adoption, referring to post-adoption contact with birth families (Agnich, et al., 2016; Neil, 2009; Grotevant). Overall, contact was not related to emotional or behavioural difficulties, but a US study (Agnich) found higher rates of children in open adoptions receiving a diagnosis of ‘attachment disorder’ although this was based on a limited methodology. A more promising explanatory factor than focusing on contact per se was the presence of proactive co-operation between the adoptive and birth families. This supports Grotevant’s finding that satisfaction with contact is an important influence on the effects of open adoption on children’s mental well-being. Children in open arrangements are more likely to have family relationships characterised by trust and adoptive parents’ willingness to recommend adoption to others (Agnich). However, there may be uncontrolled differences in the birth family characteristics for those in closed and open adoptions. The findings on the role of structural openness are limited, with no longitudinal study assessing the specific role of contact on behavioural or mental health outcomes. Longitudinal data on structural openness is vital as many clinicians and adoptive parents are understandably concerned about the positive or negative impact of contact with birth families.

Schools

Relationships between parents and schools were investigated in only one study (Goldberg and Smith). It found that parental school involvement was negatively related to later internalising symptoms in the child. While this finding highlights the importance of the network around the child being taken into consideration, evidence from one study means that any conclusions can only be tentative.

Discussion

Our aim has been to review scientifically robust evidence to consolidate and expand current knowledge about adoptees’ mental health and behavioural difficulties and to identify ways forward for research and practice. The findings of the narrative synthesis support previous research by highlighting the importance of focusing on the multitude of systemic factors surrounding the child and how these can be usefully divided into clusters according to their source of influence. Four areas were analysed in this review: parent, parent–child relations, family and context.

Overall, the findings of the analysis support the psychosocial and transdiagnostic developmental models described earlier. They indicate that post-adoption factors are associated with, and often predictive of, adoptees’ difficulties and that some post-adoption factors have a greater effect than pre-adoptive ones, which were often measured as cumulative history of maltreatment. It is important to hold in mind the possible genetic and perinatal factors, not explored within the primary studies that are likely to hold long-term consequences alongside post-adoptive factors.

Consistent evidence was found for the significance accorded to the role of adoptive parents, including their parenting style, mental health and responsiveness, all of which were linked to children’s behavioural and emotional mental health. Importantly, parenting style and mental health were more strongly related than pre-adoptive risks, measured as cumulative history of maltreatment, to later child difficulties. However, such studies did not consider the genetic or perinatal factors that may have long-term consequences, such as exposure to drugs or alcohol within the womb. Interestingly, Audet’s study showed that the impacts were not universal as authoritarian parenting had differential effects depending on the level of deprivation experienced by the child. Although it cannot establish causality, the study suggests that for severely deprived children, such parents may display sensitivity and responsiveness to their child’s needs, aware that they are more likely to flourish in a structured environment.

Another important consideration was the quality and impact of adoptive parents’ relationships with the child; this linked to children’s behavioural problems and appeared to mediate the influence of pre-adoptive adversities and child outcomes. Family factors incorporated family environment, cohesion, expressiveness and conflict, which were all related to the presence and extent of children’s behavioural and mental health difficulties. Importantly, over time pre-adoptive risk factors declined in significance, whereas aspects of family environment became more salient, highlighting the importance of perceiving post-adoptive variables as an intervention, particularly as the age of the child increases. Communication openness within the family system also predicted children’s later adjustment, buffering the impact of early adversity although this varied according to the level of maltreatment experienced by the child, with greater adversity being linked to lower openness. This highlights the importance of supporting families and parents with the information relating to their child’s previous history and skills in communicating it.

A further finding of the review was the importance of contextual factors related to adoptees’ behavioural or mental health difficulties. Open adoptions where contact with birth families is maintained were not associated with later difficulties but there is evidence that proactive co-operation between the adoptive and birth families accounts for any variations in outcomes. Further important contextual factors for many adopted children include the role of parental support in ethnic socialisation, developing racial identity and experiences of discrimination.

Limitations

The current review was confined by the limitations of the 52 included studies. Twenty-nine of them were cross-sectional and so could not draw conclusions about developmental processes and effects over time; only seven studies compared adoptive and non-adoptive families, making it hard to know whether the findings are specific to adopted children and the data based on parental reports which could inflate the relationship between variables and outcomes.

In addition, the studies were conducted across 14 countries, each with its own adoption process and context, making it difficult to compare like with like. In the US, for instance, the majority of adoptions are by foster carers known to the child whereas in the UK most children are adopted by strangers. Given this diversity, it is difficult to generalise the findings and reach global conclusions about adoption; it is possible that the concept needs disaggregation if research is to be more fruitful.

The review was further limited by missing information or bias in the studies. Thirty focused on international adoptions but information on sending countries was often scant and was completely missing in two. In addition, over half of these 30 failed to describe the ethnicity of the adopters. Only one study (Brodzinsky) provided full details of the child’s country of origin, the country where they were adopted and whether the adoption was transracial. This is a major omission given that parental support of ethnic socialisation is positively linked to children’s adjustment, self-esteem and sense of belonging in their new home. Furthermore, due to variation between study design and methodology and missing information, it was not possible to compare effect sizes to understand the relative strength of association between the post-adoption variables.

Future research

The review has shown that the available research tends to focus on one or two factors deemed to be important for adoptees’ mental health and behaviour. Only one study (Balenzano) explored all of the four areas of influence suggested in this article, namely parent, parent–child, family and contextual factors. More work is needed to explore the relationship between these influences and their impact on different types of children at different ages. Similar attention needs to be made to the diversity of adoptive families, especially with the widening of eligibility criteria to include single people and same-sex couples.

Implications for clinical practice

These findings indicate important systemic areas for developing interventions to support adoptive families. It demonstrates the importance for clinicians to hold in mind the varied systems surrounding a child when assessing and formulating strategies. However, the supportive evidence often focuses on one factor, such as psychological interventions for parents or attachment therapies for children, and is limited to assessments of efficacy.

Although the current review highlighted that there are some adoption-specific issues, pertaining to ethnic socialisation in transracial adoption, many of the risk and protective factors are similar to those found in non-adopted families, such as the role of parental mental health and family factors. This is important given the tendency to divert adoptive families away from standard care pathways to specialised ones which are not always available locally. Where specialist care pathways for adoptive families are not available, standard care pathways should be readily trained in the complexities of pre- and post-adoption factors specific to the experience of adoptive families. This may include identifying possible risks highlighted in the present review to guide intervention and individualised support to adoptive families. Furthermore, the review found that pre-adoptive risk factors are often less important than later family factors, which suggests that adoptive families need continuing support to the point where these family factors are more important. Long-term follow-ups with adoptive families where early adversity occurs is vital.

Footnotes

Declaration of conflicting interests

The author(s) declared the following potential conflicts of interest with respect to the research, authorship, and/or publication of this article: This research was undertaken as part of a DClinPsy degree by Morvwen Duncan.

Funding

The author(s) received no financial support for the research, authorship, and/or publication of this article.

Notes

Morvwen Duncan is a Clinical Psychologist, Department of Clinical Educational and Health Psychology, University College London.

Matt Woolgar is a Consultant Clinical Psychologist and lead researcher, National Academy of Parenting Research, Kings College London.

Rachel Ransley is a Clinical Psychologist with the Tavistock and Portman NHS Trust, London.

Pasco Fearon is Professor and Chair in Developmental Psychopathology, Department of Clinical Educational and Health Psychology, University College London.

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Mental health and behavioural difficulties in adopted children: A systematic review of post-adoption risk and protective factors

Abstract

Keywords

Introduction

Method

Literature search strategy

Data sources

Inclusion and exclusion criteria

Study selection

Data extraction and quality assessment

Results

Study selection 2

Study characteristics

Narrative synthesis

Parent factors

Parenting style

Parental mental health

Parental responsiveness

Parent–child relationship

Family factors

Family environment

Communication openness

Adoption satisfaction

Contextual factors

Ethnic identity and discrimination

Structural openness of adoption

Schools

Discussion

Limitations

Future research

Implications for clinical practice

Footnotes

Declaration of conflicting interests

Funding

Notes

References

Study selection²