Adoption and Mental Illness

  Arline Kaplan

January 26, 2009 / Psychiatric Times

The mental health of adoptees has become an increasingly important issue as the number of adoptions in the United States continues to rise. According to the National Council For Adoption,1 there were 130,269 domestic adoptions and 21,063 intercountry adoptions in 2002. (In 1996 there were 108,463 domestic adoptions and 11,303 intercountry adoptions.) US Census figures in 2000 indicated that nearly 1.6 million children and teenagers under 18 years in the US and Puerto Rico are adopted.²

The adoption study compared a random sample of 540 adolescents born in Minnesota, who were not adopted, with a representative sample of adoptees (514 international adoptees and 178 domestic adoptees). The children had been placed by the 3 largest adoption agencies in Minnesota.³

“All of the kids were adopted within the first 2 years of life, but the great majority were adopted within the first year,” said Margaret A. Keyes, PhD, lead author of the study and a research psychologist. “The average age at placement was 4 months. So it is not as if you are looking at 3- and 4-year-olds coming over on a plane from a faraway country.”

At the time of the assessments, the study participants ranged in age from 11 to 21 years. The assessments were rigorous and involved use of the Diagnostic Interview for Children and Adolescents-Revised (DICA-R) and the Structured Clinical Interview for DSM-III-R (SCID-II). (Both had been updated to cover DSM-IV criteria.) The modified DICA-R was also administered to mothers of participants to assess disorders in their children.

Disorders assessed over the lifetime of the adoptees included oppositional defiant disorder (ODD), attention-deficit/hyperactivity disorder (ADHD), conduct disorder, major depressive disorder, and separation anxiety disorder.

Because of its design, the study makes a major contribution to the medical literature, Keyes told Psychiatric Times. It is one of the first to investigate the prevalence of common DSM-IV childhood disorders in a population-based sample of adopted adolescents. In addition, it improved on the methodology of prior studies.

While previous studies had relied extensively on parent reports and checklist descriptions of problems the kids had, Keyes said, “We had parents and children come into our laboratory at the University of Minnesota and complete individual clinical interviews . . . then we also collected teacher reports.” Two individuals with advanced clinical training reviewed the interviews, according to Keyes, and “they had to come to consensus about every single symptom. That information was then entered into the computer, and the diagnoses were assigned by computer algorithms.”

The odds of having ADHD or ODD were about twice as high in all adopted adolescents. For example, Keyes said, 7 to 8 out of 100 nonadopted adolescents had ADHD compared with 14 to 15 out of 100 of the adoptees. In addition, domestic adoptees had higher odds of having conduct disorder than nonadopted adolescents. Consistent with a meta-analysis by Juffer and van Ijzendoorn,⁴ the University of Minnesota researchers found that international adoptees had fewer externalizing behavioral problems than domestic adoptees. This finding is somewhat provocative, because some researchers5 have speculated that international adoptees would be at increased risk for mental health problems because they are more likely to have been placed in the adoptive home at a later age, to have experienced preplacement adversity, or to have been exposed to postplacement discrimination.

In contrast, Juffer and van Ijzendoorn (authors of the meta-analysis) suggested that adoptive parents of international adoptees may be better prepared to rear an adopted child than the adoptive parents of domestic adoptees. They also suggested that domestic adoptees may experience greater prenatal exposure to teratogenic substances or have a greater genetic risk for mental health problems than international adoptees.

International adoptees were significantly more anxious than nonadopted adolescents and, according to their parents, had significantly more symptoms of major depressive and separation anxiety disorders.

Despite the study’s findings, Keyes emphasized that most of the children adopted as infants are well-adjusted and psychologically healthy.

“That point gets lost in a discussion of a paper like this,” she said.

Mental health contacts
The adoption study also found that all adopted adolescents were significantly more likely to have had contact with a mental health professional than nonadoptees. “We have known for a long time that adoptees are over-represented in mental health settings,” Keyes said. “One hypothesis is that it relates to referral bias—that adopted parents on average have greater economic resources, are a little bit better educated, and have experience with social services agencies through the process of adopting, so they are more likely to refer their kids to a mental health setting. Now, we think that at least part of that over-representation is due to the fact that the adoptees are experiencing more of the kinds of behavioral problems for which parents refer their kids.”

1. National Council For Adoption. Adoption Factbook IV. Sterling, Va.: National Council For Adoption; 2007.
2. Kreider RM. Adopted Children and Stepchildren: 2000. US Census Bureau. Issued October 2003. www.census.gov/prod/2003pubs/censr-6.pdf. Accessed October 6, 2008.
3. Keyes MA, Sharma A, Elkins IJ, et al. The mental health of US adolescents adopted in infancy. Arch Pediatr Adolesc Med. 2008;162:419-425.
4. Juffer F, van Ijzendoorn MH. Behavior problems and mental health referrals of international adoptees: a meta-analysis. JAMA. 2005;293:2501-2515.
5. Hjern A, Lindblad F, Vinnerljung B. Suicide, psychiatric illness, and social maladjustment in intercountry adoptees in Sweden: a cohort study. Lancet. 2002; 360:443-448.