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PUBLIC HEALTH: INTERNATIONAL ADOPTEES AND MENTAL HEALTH

The following points are made by F. Juffer and M.H. van IJzendoorn (J. Am. Med. Assoc. 2005 293:2501):

1) International adoption is an increasing phenomenon involving more than 40,000 children a year moving between more than 100 countries.[1,2] By setting uniform norms and standards, the 1993 Hague Convention[3] endorsed and facilitated international adoption. International adoption may offer the advantage of a permanent family to a child for whom a family cannot be found in the country of origin. In 2004, most international adoptions in the United States (22,884) were from China, Russia, Guatemala, South Korea, and Kazakhstan,[4] whereas most international adoptions in Europe (15,847 in 2003) were from China, Russia, Colombia, Ukraine, and Bulgaria.[2] Since the 1970s, domestic adoptions in North America and Europe drastically decreased, whereas at the same time the number of international adoptions increased.[1]

2) International adoptees often experience inadequate prenatal and perinatal medical care, maternal separation, psychological deprivation, insufficient health services, neglect, abuse, and malnutrition in orphanages or poor families before adoptive placement.[5] Animal models have shown that early maternal separation and deprivation can seriously harm infant functioning and later development. Psychological deprivation in orphanages can result in maladjustment in children. In addition, after adoptive placement, adoptees have to cope with integrating the loss of their culture and birth family into their lives. In contrast to domestic adoptees who are adopted within the same country, international adoptees may face problems regarding their divergent identity, as most international adoptees are raised by parents who do not share their racial and cultural background.

3) Adoption usually offers improved medical, physical, educational, and psychological opportunities for institutionalized children, and research has documented children's substantial recovery from deprivation after adoption, which may partly be due to the possibility that some adopted children were selected for adoption because they seemed brighter or had better social skills. Nevertheless, several studies found that adopted children were overrepresented in mental health populations and showed more externalizing disorders. Some studies found more mental health problems in international adoptees compared with nonadopted controls, in particular in male adoptees, in adolescence, and in children placed beyond infancy. However, the majority of adoptees were functioning well. In a large national cohort study in Sweden involving more than 11,000 international adoptees, a significantly higher risk of suicide, psychiatric illness, and social maladjustment was found compared with nonadopted controls, although most adoptees were doing well.

4) The authors report the first meta-analyses on behavior problems and mental health referrals of international adoptees comparing them to nonadopted controls and domestic adoptees. The authors hypothesized that international adoptees present more behavior problems and are referred to mental health services more often than nonadopted controls16 or domestic adoptees.[5] The authors hypothesized that those with preadoption adversity, older ages at international adoptive placement (greater than 12 months), and males would have an increased risk for behavior problems and mental health referrals. International adoptees were also expected to show more behavior problems in adolescence compared with the years before adolescence. The authors studied domestic adoptions in Western countries only because the increasing domestic adoptions in developing countries, eg, India, have not been systematically studied yet.

5) From their results, the authors conclude: Most international adoptees are well-adjusted, although they are referred to mental health services more often than nonadopted controls. However, international adoptees present fewer behavior problems and are less often referred to mental health services than domestic adoptees.

References (abridged):

1. Selman P. Intercountry adoption in the new millennium; the "quiet migration" revisited. Popul Res Policy Rev. 2002;21:205-225

2. Selman P. The demographic history of intercountry adoption. In: Selman P, ed. Intercountry Adoption: Developments, Trends and Perspectives. London, England: British Agencies for Adoption and Fostering; 2000

3. Duncan W. The Hague Convention on protection of children and co-operation in respect of intercountry adoption. In: Selman P, ed. Intercountry Adoption: Developments, Trends and Perspectives. London, England: British Agencies for Adoption and Fostering; 2000

4. Immigrant visas issued to orphans coming to the U.S. US State Department Web site. Available at: http://www.travel.state.gov/family/adoption/stats/stats_451.html. Accessed April 3, 2005.

5. Gunnar MR, Bruce J, Grotevant HD. International adoption of institutionally reared children: research and policy. Dev Psychopathol. 2000;12:677-693

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