Research: Are adopted children really at a higher risk for needing therapy and attempting suicide?

    I will return to the blog with something that is both controversial and hard to talk about-- welcome back, right? Between having 6 different family members visit over the past month, a mysterious stomach virus, food poisoning striking our house, and planning a trip back to the midwest to see family, I have been a bit preoccupied! There are no new updates with our homestudy-- the paperwork is on someone's desk in some family court legal office somewhere awaiting approval. So, onto the research!

      I feel like this topic needs a bit more of an introduction than I normally give to research articles, and please allow me to make a blanket statement that I am going to try to cover this as delicately as possible and be conscientious of my wording so as not to offend members on any point of the adoption triad.  That being said, this is hard to discuss in a way that won't make anyone bristle.
      Here is the reality: there are some adoptive parents who are not good people-- at least in light of how they treat the biomoms who chose them as parents for their children. I have been reading firstmother blogs (particularly First Mother Forum and Musings of the Lame), and the stories that some people recount are beyond heartbreaking. I want to just throw this out there: when my husband and I say that we want to do an open adoption, we mean that we have every intention of staying in contact with the child's biomom and keeping her updated on the child's life, even if there are times where this is difficult, uncomfortable, or awkward. Our comfort does not take priority over our child's well-being, and keeping that option of contact open for the child is what appears to be best for adoptee well-being from an empirical standpoint. I'm not necessarily an optimist, but I guess I was kind of under a delusion that when potential adoptive parents say they want an open or semi-open adoption, that is what they mean. After reading some of these forums, that bubble of delusion has burst. Apparently, it is not uncommon for adoptive parents to agree to an open/semi-open adoption and then literally disappear from the biomom's life, given that in most states, open/semi-open contracts are not legally enforceable.  They will change their phone number and email address and sometimes even move so that the agency or biomom can't find them. A woman who entered an adoption arrangement thinking she would receive pictures of the child twice a year and get to visit at least annually now has no idea where the child is or even if s/he is even still alive and healthy. This is inexcusable, and it is no wonder that it has led to people who advocate against adoption. (If you are wondering how I am going to tie this into mental health and suicide, I'm almost there-- just follow me on this train of thought a bit longer)
     If you check out some of these firstmother blogs and forums, you will see a trend: many of them advocate against adoption, not for it. I'm going to interrupt my train of thought here to explain why I read these pages. I want to know about the women who have had bad experiences and what made them bad. Was it the agency they worked with? Their social worker? The adoptive parents? All of this information is valuable. If they feel that their agency was coercive, manipulative, and dishonest, that isn't an agency I want anything to do with. If it is an issue with the adoptive parents, knowing where hurt and conflict tend to arise can help us to shape our plan to prepare for how to handle these situations in a way that will allow us to maintain a good relationship with the biomom who chooses us. That's why I read these, and why I would encourage any other potential adoptive parent to read them, as well.
      Okay, back to why some women who have placed a child for adoption often speak against adoption. They talk about being deceived by the adoptive parents they chose, and being cut out of their child's life for no reason. I actually saw on an adoption forum something that reinforced the idea that many adoptive parents look for reasons to go back on their open adoption agreement. There was an adoptive mom who was frustrated that her child's biomom would post the pictures that she sent of the child on Facebook, often with the caption of "my daughter", and the biomom was trying to get the adoptive mom to exchange email addresses so that she could ask for updates more often than the letters she sent twice each year. She was talking about all of this, and concluded that she may have to invoke her right as a parent to stop contact with the biomom based on the best interest of the child. This is the problem: it seems like for some, "the best interest of the child" becomes synonymous with "what is comfortable for me." In other words "if it makes me uncomfortable, it must be bad for the child." This point was emphasized by all of the people who responded in support of that decision, with comments along the line of "You have to do what is best for your family." But these things aren't synonymous. I am under no delusion that our relationship with the bioparents will be this amazing friendship with no disagreements, no problems, and no discomfort (I know that this does happen, but is exceedingly rare). There will be issues that we will have to work through, but we are committed to doing that. Adoption has to be built on trust, and it is frustrating and saddening that there are so many stories of this trust being blatantly, intentionally violated-- stories which have made the whole process look like a scam and a classist effort to steal away babies. The biomoms in these cases become advocates against adoption,  often taking a view of the entire system as being corrupted (check out Musings of the Lame for a well-explained overview of this perspective) or assuming that happy open adoption arrangements are nothing more than a fairy tale. A quote from First Mother Forum illustrates that idea: "Far too many women are suckered into giving up their babies with the thought that the adoption will be open--there will be numerous visits, shared photographs and a continued, warm relationship through the years among all parties, and the child will grow up loving all corners as parents. Oh, someone send me a fairy tale like that; it would be a burst of good news." Please know that I am not dismissing this perspective or criticizing these women-- I can't even imagine being in this situation, and they have a point that many areas of the adoption system are in need of reform.
    One group of statistics that has been used frequently on such blogs is that adoptees have higher rates of mental health problems, counseling, and even suicide. The line of reasoning is, in summary, "Pregnant women are lied to in order to have their babies stolen from them, and it doesn't even end up being healthy for the children in the long run." Or, as worded in an article discussing a specific situation on the First Mother Forum: "The day will come that Catelynn and Tyler will learn that their struggle has been in vain; that their loses—and Carly’s [the baby they placed for adoption]—outweighed any gains." That quote exemplifies what that perspective often boils down to: the loss that you will experience and the loss that your baby will experience are going to end up being far greater than any benefit that child will have from the adoption. A popular pair of articles that I have see quoted on multiple sites to back up this point are these: "According to a 2000 study in the Journal of the American Academy of Child and Adolescent Psychiatry, 'adoptees were about twice as likely as nonadoptees to have received [mental health] counseling.' More worrisome, according to a 2001 study in the journal Pediatrics, 'attempted suicide is more common among adolescents who live with adoptive parents than among adolescents who live with biological parents.'" A 2007 article from the Journal of Mental Health Counseling that discusses therapy among those adopted as infants is also commonly mentioned. So, this review is going to look at these 3 articles in a bit more depth. Conveniently enough,  I have actually done research with the dataset used in both the 2000 and 2001 articles. One of my articles from this dataset has been published in an international, peer-reviewed journal, and I also did my dissertation from this data (which I haven't gotten around to breaking into smaller articles to publish yet). I don't say this in boast, but just to point out that I am very familiar with this data, how the questions were worded, and how things are coded. Now for the research!

Adopted Adolescents' Overrepresentation in Mental Health Counseling

      This first article was published in 2000. The analysis for the article was done using data from Wave 1 of the AddHealth (The National Longitudinal Study of Adolescent Health). These data were collected in 1994-1996, when the participants were in 7th-12th grade. This means that if they were adopted as infants, they would have been adopted in the mid-70's to early-80's. Open adoption didn't really become popular until 1982, meaning that many (if not most) of these children probably had closed adoptions. 

    This study considered whether or not adolescents had received counseling. They looked at whether or not the teen had ever been in therapy by asking the question: “When did you last have counseling, psychological testing, or any other mental health or therapy service?” Anyone who gave any answer other than "I've never had any of these services" was considered to have been in therapy. There was a second question asking: "Within the last year, have you received psychological or emotional counseling." This question was answered by a simple yes or no. 

     Something to be aware of in terms of how the study was set up is that teens were classified as either "adopted" or "not adopted." Those who were adopted into 2 parent homes were considered with those who were adopted by a single parent, and that wave of dataset does not contain the information to make it possible to know anything further about the adoption. We don't know if they were infants or if they were 10 years old at the time of adoption. We don't know if they came from foster care. We don't know if they were adopted by a relative. We don't know if they had contact with their bioparents. All we know is were they adopted, yes or no.

   You can see why this is a significant issue. About 33% of children are placed into foster care because of abuse (physical, sexual, or emotional), with many people believing that this statistic is inaccurately low. Children stay in foster care for an average of nearly 3 years (right around 31 months) and live in an average of 3 different homes before being adopted-- transitions which have been labeled as "profoundly unsettling."  Over 60% of children in foster care have tested as having a developmental delay. It is obviously not accurate to be placing a child who was adopted as an infant in the same category as a child who was adopted after being abused and then spending 3 years in the system living with multiple families. Basically, you aren't creating a group that gives you reliable information about the actual variable of influence since there is so much within-group variability.

    That being said, yes, this study did show that adopted children are one and-a-half to two times more likely to have been in some form of counseling than non-adopted children. There is no other way to interpret the results-- that was there. But keep in mind that there are many things that could explain this finding, such as all of the information about resources that adoptive parents receive about counseling services available, or even adoptive parents being more comfortable with the idea of counseling and holding less stigma about it since they, themselves, might have sought counseling to help cope with their infertility. Other studies using this exact same data have shown that adoptive parents in this sample had higher levels of education and higher income, which are two factors that are associated with being more willing to seek counseling. Also remember that we don't know any other details about what motivated the counseling for these teens. And again, we also don't know the breakdown of the specific situations. We do know from other research that children who have been in foster care are more likely than children who have not to have been in therapy and have some sort of mental health diagnosis, so it is definitely possible that this was having an influence on these results.

   So, the bottom line is that this study did find that adopted children are more likely than non-adopted children to seek counseling, but we don't know the reasons why and we can't break these findings down any further by specific situations. Is this study valuable? Absolutely! If for no other reason than for therapists to be aware of this and have greater training in adoption issues-- both for individual and family counseling. Is this study something that can be used to say that adoption is unhealthy for the adoptees? No. It just doesn't give us enough information for that. Some adoptees do have terrible experiences, and please believe me when I say that I am in no way minimizing or dismissing that. But, this statistic can't be used as a blanket statement to say that adopted children will likely need therapy. 

   On to the next study!

Adoption as a risk factor for attempted suicide

     Suicide is a hard topic, and it is difficult to write about in this setting in a tone that doesn't feel dismissive. Both in my role as a grief counselor and from personal experience, I have seen the heart-wrenching effects that suicide has on a family. I am not taking this topic likely, or downplaying the issue of suicide in any way. But, it is important to clarify the influences that do (and do not) tend to lead to suicide. My goal here is to review this article that has been used to claim that adoptees are at a greater risk for suicide, and evaluate if this claim is accurate.  

       This study also used the AddHealth data set, so keep in mind what was said earlier about the time period. One thing that I didn't mention about AddHealth earlier is that the first wave also gave a short questionnaire to the parents. For this study, a teen was considered adopted if the mother identified herself as the adoptive mother on the questionnaire. Again, no further information is available about the age at the time of adoption or the circumstances leading to the adoption. Only families where the mother was married and had never been divorced (i.e., the household represented a nuclear two-parent family) were included in the study.

    In these data, 16 adopted teens and 197 non-adopted teens reported a suicide attempt in the past year. Notice how small that number is for adopted teens-- 16.  Where it gets significant is the ratio. I'm going to spew off some numbers here, so bear with me. There were 6,577 adolescents in this particular segment of the dataset: 214 (3% of them) lived with adoptive parents, and 6,363 (97% of them) lived with biological parents.  Out of these 6,577 teens, 213 (3%) reported a suicide attempt. So, 7.6% of the adopted teens reported a suicide attempt in comparison to 3.1% of non-adopted teens, even though the raw numbers make it look like suicide attempts among adopted teens were lower.

      Did the study show that adopted teens are more likely to commit suicide? Yes. But again, this needs a bit more detail rather than just leaving it at that. In statistics, there is an important number called an odds ratio-- it is the number that tells you just how much more (or less likely) something is. In this study,  adoption had a 1.98 odds ratio, which translates that an adopted adolescent was 1.98 times (lets just say two times) more likely to have attempted suicide. But to provide some context, I want to mention some of the other odds ratios that were given. Depression had an odds ratio of 3.41, cigarette use of 2.31, and delinquency of 2.17. This means that depression, smoking, and delinquency had a more dramatic impact on the likelihood of suicide attempt than being adopted. And, family connectedness decreased the likelihood of suicide risk, whether or not the child was adopted. See what that means? Whether or adopted or biological, the actual relationships within the family are powerful means of support. Basically, adoption was not some ultimate predictor of suicide attempts above and beyond other risk or protective factors. Is it associated? Sure. But keep in mind that other research studies have found that having parents who are divorced or being raised by a single parent are, as well, and both of those groups had higher statistics than the adoption ones found here (men of divorced parents were 3x as likely, children of single parents were more than twice as likely). The point of saying that is to reinforce that suicide is a vastly complex issue that cannot be narrowed down to one cause, especially if you try to make that cause family structure. If you want to warn people that placing a child for adoption will increase their risk of suicide, you better also be warning everyone who you know who is divorced or a single parent, since if you just look at the numbers those are bigger issues.  It's a bit of an oversimplification, isn't it?

   Alright, time for the last study!

  Use of mental health services by adult adoptees

          This study was pretty straightforward. The researchers found 156 adults (age 21 or over) who had been adopted before age 2, and surveyed them about if they had "sought help" for psychological issues during either adolescence or adulthood.  It is important to note that the mean age was 43 years (median=40), so about half of these participants were adopted during the Baby Scoop Era. The researchers asked about open versus closed adoption, and only 3 of the participants had open adoptions; the rest were closed, with the child not even knowing who the bioparents were. This automatically puts this study in a different perspective than the situation that we (and I'm sure many of you) are considering. All but 15 participants had searched for their bioparents (of those 15, 5 had plans to begin searching soon), and 71 had successfully found and had contact with their bioparents.

      Before getting started on the findings, it is important to note how the question was worded. They weren't asked if they had been in "counseling" or "therapy," but were asked if they had "sought help or guidance." Examples that they were provided of seeking help or guidance on the questionnaire did include therapists, psychologists, and psychiatrists, but also religious leaders, social workers, and "other." This is significant because one of the avenues for finding participants was adoption support groups. If I go to a support group and ask how many people have ever "sought guidance," that is going to get me a pretty high number based on the very fact that I am at a place where people come to seek guidance. 

     A few participants had, in fact, sought help for psychological issues-- 12% to be exact. An interesting point is that the participants were asked who they sought help from, and the majority of those who sought help in adolescence and about 1 in 4 who sought help in adulthood said "other" (in adulthood, it was "other" or religious leaders). When asked to elaborate about what "other" meant, the answers received were friends, other adoptees, their adoptive parents, another support group they may have belonged to (such as AA or NA), support groups, "spiritual avenues,"or even just reading books about adoption. So, "seeking help" in these cases really can't be accurately translated to "using mental health services," as the title of the article implies. If I am feeling stressed and read a book about managing stress or chat with my mom about it, I would be offended if someone labeled that as me "seeking mental health services" for stress. The title is a bit misleading there.

      Speaking of the reasons they sought help, there were 17 participants (15 of these were women) who had sought help for isolation/intimacy issues, and 9 (7 were women) who had counseling to try to work through feelings of shame/guilt. No one sought help for issues related to identity or anxiety, and no other issue was significantly enough represented that the author's found need to include it in their reported findings. 

     

So what does all of this mean?

      Adoption is certainly fraught with loss, and it definitely has the potential to create unique issues that children, adolescents, and young adults will have to work through. Adoption is a relationship that is born out of loss, and no matter how happy of a home the child is adopted into, that fact can never be erased. Loss leads to grief-- it is the nature of human emotions-- and unresolved grief in turn can lead to a variety of problems. As I've discussed in the other research article reviews, every child copes with this loss differently and there are huge ranges seen in the degree of difficulty it causes. Is it true that many adoptees have experienced unfortunate, sometimes even emotionally abusive adoption situations? Absolutely. Are there women out there who have been manipulated and coerced into placing a child for adoption when they probably could have been able to parent, themselves, if given the proper supportive resources? Sadly, yes. Is adoption bad for children and their mental health? No, not universally. There are many things about a family that influence a child's emotional and psychological well-being, so to interpret these findings in a way that suggests that it is the adoption that causes negative outcomes is extraordinarily oversimplified.

      My reason in wanting to address this issue wasn't just as a response to some of the other blogs I have been reading, but due to the phenomena of self-fulfilling prophecy and behavioral confirmation effect. The idea behind these phenomena is that when you believe something (particularly about a child), that belief changes your behaviors, even if you are not aware of it. Those behavioral changes actually cause the belief to come true in many cases, because you are behaving as though it is already true. The famous example of this that we use in developmental psychology is Rosenthal's school study in the 1960's. Teachers in an elementary school gave their students a test that they were told would predict which students had the potential to greatly increase their I.Q. over the course of one school year. After the tests were given, the researchers then picked a group of students at random, and told their teachers that these were the potential "academic spurters." These students didn't actually have any special indications on their I.Q. tests, their teachers were just told that they did (yes, that is lying, sometimes we have to do that to get good research!). At the end of the year, the researchers retested everyone's I.Q. Guess what? The students who had been randomly chosen as having high I.Q. growth potential had their score raise by several more points than their classmates. What the researchers found was that the teacher's expectations of those students greatly affected how they interacted with them. These interactions, in turn, actually brought about the result that they had expected to see. 

      Where I am going with this is that if we adopt a child and go into the process of parenting that child with the expectation that s/he will likely develop problematic behaviors and need counseling and experience grief and depression to the point of attempting suicide, those beliefs will influence how we interact with that child. We would probably be quicker to seek therapy for the child, because any behavior or expression of emotion that would be slightly troubling could easily be interpreted as a "red flag." (I'm not saying that seeking counseling for a child when they exhibit problematic behaviors is a bad idea or something to hold with stigma.) So, while a big part of why I am doing this research is to become more aware of the difficulties and struggles that adoptees tend to go through as they are coping with their losses and forming their identity in order to more effectively parent and support my future child, I can't just assume that my child will be fated for psychological problems due to being adopted. The parent in me won't allow that kind of pessimism towards my child, and the researcher in me screams about how the studies don't support that broad of a generalization.

The articles in this post:

Miller, B.C., Fan, X., Grotevant, H.D., Christensen, M., Coul, D., & Van Dulmen, M. (2000). Adopted adolescents' overrepresentation in mental health counseling: Adoptees' problems or parents' lower threshold for referral? Journal of the American Academy of Child & Adolescent Psychiatry, 39, 1504-1511.

Pearson, F., Curtis, R., & Chapman, A.M. (2007).  Use of mental health services by adults who were adopted as infants. Journal of Mental Health Counseling, 29,  163-185.

Slap, G., Goodman, E., & Huang, B. (2001). Adoption as a risk factor for attempted suicide during adolescence. Pediatrics, 108(2), E30.