Psychosocial Issues: Mental Health and Behavioral Issues in International Adoptees
By Mary Allen Staat, MD, MPH, International Adoption Center
Each year, more than 40,000 children are internationally adopted around the world with more than 20,000 adopted in the US alone. Given the many potential known and unknown pre-adoption circumstances both before and after birth, there is concern that internationally adopted children may be at increased risk for mental health and behavioral issues.
In an ambitious study conducted by researchers from the Netherlands more than 50 years of data and 137 studies on the outcomes of adopted children were analyzed using meta-analysis methods.
The results of the study were recently published in the Journal of the American Medical Association in May 2005. The combined studies included 25,281 adopted cases and 80,260 controls.
The effect size (d) was calculated for each study comparing non-adopted children to either domestically adopted or internationally adopted children. An effect size of <0.20 is considered to be a small effect, 0.50 a moderate effect and 0.80 a large effect.
Surprising to many, internationally adopted children were found to only be slightly more likely than non-adopted children to have behavioral problems (d=0.11) and had fewer problems than domestically adopted children (d=0.20).
While the majority of internationally adopted children were found to be well-adjusted, more international adoptees were referred for mental health services compared to the control group of non-adopted children (d=0.37) but less than domestically adopted children (d=0.81).
In all variables examined, internationally adopted children were found to be at increased risk for the mental health outcomes studied [total behavior problems (d=0.11), externalizing problems (d=0.10), internalizing problems (d=0.07) and mental health referrals (d=0.37)] compared to non-adopted children but at significantly lower risk compared to domestically adopted children [total behavior problems (d=0.20), externalizing problems (d=0.34), internalizing problems (d=0.23) and mental health referrals (d=0.81)}.
The reason for the differences between international and domestic adoptees is unclear. Since many of the international adoption studies were conducted after 1990, the researchers did a sub-analysis only using studies conducted after 1990 and found the same results. The age and gender composition of the groups were similar as well.
The authors hypothesized that since many families who adopt internationally are transracial, adoption was less likely kept as a secret perhaps resulting in better communication and trust within the family compared to domestic adoptions where adoption may have been kept a secret or not as freely discussed.
While internationally adopted children may have experienced inadequate prenatal and perinatal medical care, maternal separation, psychological deprivation, neglect, abuse and malnutrition, the notion that these children are irreversibly emotionally damaged has now been challenged.
While international adoptees did have more mental health issues than non-adopted peers, the rate of behavioral problems was low, suggesting most international adoptees are doing well.
In further analyses of studies in internationally adopted children, a history of extreme preadoption adversity was a predictor of more behavioral problems (d=0.18), especially externalizing problems when compared to international adoptees without this history (d=0.09).
In contrast to the findings of some other studies, neither the age at adoption nor gender of international adoptees appeared to be important factors for the development of behavioral problems.
However, adopted children who had been with their adoptive family for a longer period of time were less likely to have behavior problems compared to those who had been together for a shorter time period.
An interesting finding of this meta-analysis was that studies conducted in North America found more total behavior problems in internationally adopted children compared to studies conducted in other countries. The authors were unable to identify reasons for this finding and felt this area needed further study.
While this was a very well done study, there are some limitations. There is some concern that adoptive parents may have a lower threshold for seeking mental health services compared to birth parents.
Adoptive parents often have a higher socioeconomic status, are aware of the potential mental health issues surrounding adoption and may have different expectations of their adoptive child compared to birth parents.
Thus, perhaps the rate of mental health referrals does not really equate to the rate of mental health issues in adoptees compared to birth children.
Also, there is concern that the studies conducted to date have not included the large number of children adopted from China in recent years.
The authors credit these positive outcomes to the characteristics of adoptive families describing them to be "highly motivated to raise children" and willing to invest in their children's development.
While the risk for mental health issues in this study appears to be small, the authors conclude that clinicians should be aware of this small, but increased risk, especially in those children who experienced neglect or maltreatment preadoptively, and recommend that families be promptly referred for mental health services if there are any concerns.
Resources
Jemmer, F, van IJzendoorn MH. Behavior problems and mental health referrals of international adoptees: A meta-analysis. JAMA. 2005;293:2501-2515.
