Research roundup: Working with adults adopted as children
This issue addresses clinical considerations for psychologists who see adult patients who were adopted during their childhood.
November is National Adoption Awareness Month. While most of this month’s efforts focus on children and youth currently in foster care awaiting permanent placement, it’s also a good time to review the literature on adoption as a life-long process. Higher proportions of adopted persons attend therapy (17.71%) than nonadopted persons (8.76%; Miller et al., 2000), and some adopted individuals may struggle with certain issues as adults, such as loss and grief particularly during milestone events like marriage and childbirth (Nydam, 2007; Silverstein & Kaplan 1988); building and maintaining close relationships (Corder, 2012); distress over lack of genetic information; and issues with identity development (Child Welfare Information Gateway, 2004).
The following studies sought to better understand the psychosocial needs of adopted individuals when they reach adulthood, explore their reasons for seeking treatment, and their thoughts about the mental health service they received; and to delve into what an adoption-competent clinical practice looks like.
In addition to reviewing the following research summaries, psychologists are encouraged to explore the literature more completely to determine what may be useful to them in practice.
Melero, S., & Sánchez-Sandoval, Y. (2017). Mental health and psychological adjustment in adults who were adopted during their childhood: A systematic review. Children and Youth Services Review, 77, 188–196. http://dx.doi.org/10.1016/j.childyouth.2017.05.006.
While numerous studies have examined the mental health and psychological adjustment of children and adolescents who have been adopted, the authors of this systematic review sought to better understand the psychosocial needs of these individuals when they reach adulthood. A search of articles in PsycInfo and the Web of Science resulted in the inclusion of 27 studies published after 1995 with sample populations of adults aged 20 to 40 years who were adopted in their own country of origin as children.
Evidence from the reviewed studies suggests increased risk of mental health difficulties for adult adoptees. Higher levels of depression and anxiety (particularly panic disorder without agoraphobia, specific phobias and generalized anxiety disorder) were indicated by several studies, as were higher levels of certain personality and behavioral disorders, and neuroticism.
Adopted adults were no more likely to be admitted to a psychiatric inpatient unit, and while they were more likely to seek counseling, little difference was found compared to nonadoptees regarding their reasons for counseling. Self-esteem, self-concept, self-control, and moral self-approval were lower in adult adoptees, but life satisfaction was consistent between both groups in the moderately high range. Results regarding addiction were inconclusive. Further, adopted adults rated their bonds with their families lower than nonadoptees (e.g., higher insecure attachment, higher levels of overprotection), and were more likely to experience dissolvement of marital or cohabitating partnerships.
Looking at group differences, adopted women showed higher levels of internalizing issues (e.g., depression) while men presented more externalizing issues (e.g., delinquency and substance abuse), which is similar to results found in the general population. Being older at the time of adoption was associated with less positive adjustment possibly due to increased time spent in unstable situations. Adoptees who were searching for their birth family had higher levels of pathological symptomatology and depression; however, the causal direction is unclear, requiring additional research.
Numerous mediating or protective factors promoting better psychological adjustment also emerged in the literature, including the presence of biological or adoptive siblings; parenting styles characterized by organization, expressiveness, recreational, and intellectual activities; open communication about adoption in the home; and having a secure attachment with adoptive parents.
Baden, A.L., Kitchen, A., Mazza, J.R., Harrington, E.S., & White, E.E. (2017). Addressing adoption in counseling: A study of adult adoptees’ counseling satisfaction. Families in Society, 98(3), 209–216. http://dx.doi.org/10.1606/1044-3894.2017.98.26.
Higher proportions of adopted persons have been found to attend therapy (17.71%) more than nonadopted persons (8.76%; Miller et al., 2000), however, little is known about the counseling needs and experiences of adult adoptees. This study sought to explore adult adoptees’ reasons for seeking treatment, their mental health service preferences, their satisfaction with the therapy they received, and their perception of how much emphasis was placed on adoption during their treatment.
Using a mixed-methods design, 118 adult adoptees aged 18 to 78 years old (M=44, SD=13) participated in an online survey completing questions regarding their demographics, adoption history, reasons for seeking counseling and reports of those experiences, and ratings of their relationships with significant others. Participants also completed measures regarding their satisfaction with therapy, adoptive identity status, and self-esteem.
Participants reported seeking therapy for a variety of reasons with depression, anxiety, self-esteem, and family issues each reported by at least 50% of respondents. Adoption competence was ranked as the most important factor in choosing a therapist (24% ranked it as the highest factor), followed by other specialty areas of competence, personal recommendation, and type of degree or license. The majority of participants sought therapy with psychologists, but social workers and other credentialed therapists were also seen.
With regards to satisfaction with therapy, those individuals who rated their therapists as emphasizing adoption to any degree from somewhat to completely had significantly higher levels of satisfaction than those whose therapist gave it no emphasis. When asked what participants found to be most helpful in therapy, the two most common responses were validation and empathy, and a focus on issues of racial/ethnic, sexual, and adoptive identities.
Interestingly, adoptees’ satisfaction with their relationships with their birth mothers (or lack thereof) also predicted satisfaction with therapy. Contact with birth mothers alone was not predictive nor had all participants made contact with their birth mothers. It seems that for adoptees who seek therapy, they may assess the success of their counseling more highly when they feel higher levels of satisfaction or comfort with whatever relationship or lack of relationship they have with their birth mothers.
Atkinson, A.J., Gonet, P.A., Freundlich, M., & Riley, D.B. (2013). Adoption competent clinical practice: Defining meaning and development. Adoption Quarterly, 16, 156–174. http://dx.doi.org/10.1080/10926755.2013.844215.
In the study discussed previously, adoptees ranked adoption competence as the most important factor in their choosing a therapist, but what does being “adoption competent” entail?
In this article, the authors report on two related studies. The first looks at how clinicians in an evidence-based adoption competency training program demonstrate these competencies in practice, and the second surveys adoptive families for their opinions on what defines an adoption competent mental health professional.
The first study examined responses from 185 adoption competency training participants to determine if specific aspects of clinical practice were impacted by the information or insights they received as a part of the competency training. The aspects of practice most frequently influenced by training were:
- The collection of more background information, particularly related to adoption, trauma, grief, and loss, during intake and the initial assessment (94%)
- The incorporation of new assessment questions and procedures such as genograms and eco-maps (85%)
- The use of clinical approaches that are informed by a greater understanding of attachment issues (85%)
- The increase in usage of a greater variety of techniques with children and youth, including hands-on activities and tools such as lifebooks, loss boxes, and masks (82%)
The second study surveyed adoptive families online and asked them to rate their degree of agreement, on a 5-point scale, of 14 components of adoption competency. The survey also included questions regarding their adoption-related role and personal experiences with mental health professionals.
The 485 respondents consistently rated that they agreed with all 14 components of the definition of adoption competency, with agreement ratings ranging from 90.9% to 97.5%. The components that were most strongly rated were those having to do with understanding the impact of separation and loss, understanding of the developmental challenges of adoptive families, understanding of family development and multiple service systems, understanding of how families are formed, and working effectively with persons who have experienced abuse, neglect, or trauma.
Additionally, about 81% of participants reported working with one or more mental health professionals, but less than 25% of those who had seen a mental health professional reported that the professional was adoption-competent. Nearly a quarter of participants further described that they found that therapists had a lack of adoption knowledge in areas including attachment, trauma, loss and use of appropriate language.
Adoptive families can be good settings to meet the social, personal, and individual needs that adoptees face, but some difficulties (e.g., depression, anxiety, issues with self-esteem and interpersonal relationships) have the potential to remain into adulthood. When initiating a relationship with a patient, questions regarding adoption status could be included in intake interviews so as not to assume biological connections among family members.
Regardless of initial reasons for seeking treatment, psychologists may wish to address the adoption status of adult adoptees, as well as their satisfaction with the condition of their relationship with their birth mothers, to increase adoptees’ satisfaction with therapy.
Additionally, these studies highlighted the importance of adoption competency training for those who work with adoptees and/or their families. Professional development opportunities that focus on understanding adoption as a lifelong process, explore better understanding of grief and loss, emphasize the ways early trauma affects attachment, use evidence-based interventions, and stress the need to address adoption issues directly may be of most benefit to psychologists working with adults who were adopted as children.
A good resource for psychologists who wish to explore the literature on adoption more deeply is the 2017 article “Adoption research, practice and societal trends: Ten years of progress” published in American Psychologist by Mary O’Leary Wiley.