By Rick Weiss
Washington Post Staff Writer
Tuesday, July 15, 2008; HE01
Adolescents are expected to chafe at adult oversight, act impulsively and brood about the meaning of life.
But adolescents who were adopted in infancy are almost twice as likely as their non-adopted peers to end up in counseling for those kinds of behaviors, a fact that leaves many adoptive parents wondering: Do adopted children really have more adjustment problems in adolescence? Or do adoptive parents, hypervigilant as they famously are, overreact to the conventional struggles of young adulthood and refer their children to mental health professionals more often than need be?
Now research involving more than 1,000 adolescents is helping to settle those long-standing questions.
The work supports previous indications that, as a group, adopted adolescents really are more likely to wrestle with behavioral and mental health issues than those who are raised by their biological parents, exhibiting higher rates of attention-deficit hyperactivity disorder (ADHD) in particular.
But the new study also suggests that, for reasons that remain largely mysterious, those risks vary considerably, with children adopted from foreign lands adjusting considerably better, on average, than those adopted domestically.
Gratifyingly, the analysis also confirms that the vast majority of adoptees navigate the roiling waters of adolescence just as skillfully as their non-adopted friends and classmates.
"Adoption is a very emotional and politicized area," said Matthew McGue, a professor of psychology at the University of Minnesota, who led the study. "So it's important to recognize and emphasize that most of these kids are doing fine."
Adoption has been going on for a long time (think Moses, after all), and the extended family of adopted children grows bigger all the time. Last year, about 120,000 children were adopted in the United States alone, and U.S. adoptees younger than 18 now number about 1.5 million.
Although adoption has given most of those children spectacular opportunities, it is not surprising that at least some of them might have especially tough times during adolescence. By its nature, adoption raises in children precisely the kinds of doubts and insecurities already associated with that fast-changing time of life, including questions about personal identity, the meaning of family and the fine line between independence and abandonment.
That overlap has complicated efforts to disentangle the mental health issues specific to adopted adolescents, just as the lack of family history for many adoptees sometimes complicates medical diagnoses later in life.
Such complexities have only increased with the growth in international adoptions in the past few decades. Worldwide, about 40,000 children are adopted across national borders every year, through a network that encompasses more than 100 countries. In the United States, nearly a quarter-million children from overseas have been adopted in the past 20 years.
Bearing racial and ethnic traits clearly different from those of the parents who raise them, these children have little choice but to have their status as adoptees known to all before they themselves have begun to sort out the meaning of their situation, in many cases rushing their consideration of who they are, where they came from and why they were given up for adoption.
"Identity issues are pretty intense for adopted kids, but for kids adopted transnationally there is an added identity issue," said Joyce Maguire Pavao, founder and chief executive of the Center for Family Connections, an educational and counseling center in Cambridge, Mass., that specializes in adoption. "It's another level of feeling 'different.' "
In the new study, described in the May issue of Archives of Pediatric and Adolescent Medicine, researchers conducted mental health assessments on 692 adolescents, ages 11 to 21, who were adopted as infants (514 born outside the United States) and 540 non-adopted adolescents.
Over all, adoptees scored significantly higher on measures of what psychologists call "externalizing behaviors," a reference to various pathological ways of "acting out." Contrary to the widely held notion that many foreign adoptees have serious psychological problems because of undisclosed gestational complications or difficult early-life experiences, most of that excess of problem behaviors was in domestically adopted adolescents.
Among boys, for example, 25 percent of domestic adoptees were diagnosed as having, at some point in their childhood, "oppositional defiant disorder" (excessive arguing and fighting with authority), compared with 12 percent of non-adoptees and 20 percent of international adoptees. Similarly, 29 percent of domestically adopted boys had ADHD, compared with 8 percent of non-adopted adolescents and 19 percent of international adoptees. And 15 percent of domestically adopted boys had "conduct disorder" (often manifesting as delinquency), compared with 6 percent of non-adoptees and 8 percent of international adoptees.
Among girls, the proportions were similar, though the prevalence of each of those syndromes was about one-third lower than for boys. For boys and girls, rates of depression and separation anxiety disorder (known as "internalizing disorders" because they involve more inward suffering than outward acting) were roughly the same for all adopted and non-adopted adolescents.
The results resemble those from a 2005 reanalysis of more than 100 previously published studies of adoptee mental health. But the new study has advantages over previous ones. For one thing, it gathered participants with the help of large adoption agencies. That avoided the problem that often comes up with random, population-based surveys: namely, that some people don't know or don't admit that they are adopted.
Also, the diagnoses were based not just on parental descriptions but also on detailed interviews with the adolescents themselves and their teachers. That means the results are less likely to be skewed by the views of the adoptive parents, who tend to be highly educated, wealthier than average and extremely attentive -- a combination that can lead to exaggerated concerns about their children's behaviors and an over-pathologizing of normal adolescence.
Parental hypersensitivity does seem to be playing something of a role, Minnesota psychology professor McGue said, perhaps especially for girls adopted internationally.
About 18 percent of those girls were diagnosed with at least one of the disorders covered by the study, but 27 percent had had contact with a mental health professional, suggesting some parental predisposition to seek help for those children. (Parents referred about the same percentage of boys to mental health professionals, even though far more of them, it turns out, met the criteria for having a behavioral disorder.)
But overall, McGue said, the study shows that, by objective measures, adolescent adoptees do struggle with extra burdens. Adoptive parents, he said, "should be aware of that and be prepared to deal with it."
The study says little about what is behind the higher incidence of problems among adoptees or about the especially high rates among those adopted domestically. The presumption among many experts is that the problem represents a mix of several contributing issues, including genetic factors, substance abuse by mothers during gestation, or abuse or deprivation after birth.
"Children from orphanages come from orphanages," said Adam Pertman, executive director of the Evan B. Donaldson Adoption Institute in New York. "They experienced things that obviously had some impact on their developing psyche, on their being."
One thing, however, that surely does not cause problems is being raised by adoptive parents, Pertman emphasized. "Almost always what we're really talking about is what happened before the adoption."
One implication of that point is that the new study -- which drew upon adoptees in Minnesota who were interviewed as adolescents in the past five to 10 years, most of whom were adopted from Korea -- may have limited applicability to children adopted more recently or from different countries.
"Everyone wants to make generalizations," said Laurie C. Miller of the Tufts-New England Medical Center in Boston, "but it is hard to extrapolate." Indeed, she said, international adoptees often have their own varieties of psychological baggage linked to the circumstances of adoption in their home countries.
Korean adoptees, for example, were in many cases fathered by American service members. "That's a whole different sociopolitical background than the Chinese girls who are put up for adoption just because they are daughters," Miller said. That, in turn, is different "than in other countries where there is extreme poverty and perhaps a very loving family but where the poverty is so extreme that they cannot afford having another mouth to feed."
The new study also says nothing about whether the kinds of behavioral issues documented in adolescent adoptees will persist beyond adolescence.
"This is just a snapshot of one stage of life," McGue said. "The problems may go away, or they may amplify. We really don't know."
McGue plans to follow the subjects of the study for several years to help answer that question.
One message that would be wrong to take home from studies of adolescent adoptees is that counseling is evidence of failure, experts said.
"I would argue that if you're not giving these kids some mental health support, then you're continuing the abuse and neglect that led them to be in foster care in the first place," Pertman said.
Indeed, said Pavao of Family Connections, adoptees and their rearing parents need not wait until problems arise to justify an occasional heart-to-heart with a counselor or other professional.
"Sometimes you just need to have a little check-in to see what's going on in your family," Pavao said. "Think of it as the 50,000-mile checkup."