Some Adoptions May Increase Risk of Mental Illness

Above the door of every adoption agency, said psychiatrist Gordon Livingston, M.D., should rest a sign reading: “Life is not perfect.”

Whatever the joys adoption brings to parents, they must also recognize their new child's greater vulnerability to psychiatric disorders.

“Adoptees are overrepresented in mental health care, and for understandable reasons,” said Livingston.

He speaks from experience, not only out of his practice in Columbia, Md., but as an adopted child who also adopted a son from Vietnam. “They were abandoned by their birth parents and raised by others, and are more likely to be only children. Their adoptive parents may have struggled with infertility issues, so adoption may be seen for them and for their children as a `second-choice' parenthood.”

Now a new report from a long-term study by Dutch researchers confirms that children adopted from foreign countries show higher rates of anxiety disorders and substance abuse as young adults than do their nonadopted peers.

Boys adopted in the Netherlands from foreign countries were almost four times more likely to have a mood disorder as young adults than their nonadopted peers, according to Wendy Tieman, M.S., Jan van der Ende, M.S., and Frank Verhulst, M.D., in the March American Journal of Psychiatry. Both male and female adoptees also showed higher rates of anxiety disorders and substance abuse.

Experts in the U.S. agree that the experiences of these children prior to adoption have a lingering effect on their well-being.

“These kids are a high-risk group by any standard,” said Dana Johnson, M.D., Ph.D., director of the International Adoption Clinic and director of the Division of Neonatology at the University of Minnesota.“ Abandonment by a destitute, single parent with poor prenatal care and inadequate diet is the most common reason why a child is available for adoption. The second most common reason is neglect or physical or sexual abuse.”

Early months or years in an institution can also have lasting effects, said Johnson. “Lack of stimulation and consistent caregivers, suboptimal nutrition, and physical/sexual abuse all conspire to delay and sometimes preclude normal development. All institutionalized children fall behind in large and fine motor development, speech acquisition, and attainment of necessary social skills.”

Even the most basic postadoption questions can influence a child's developing identity, said Livingston. Most adoptive parents don't really know why birth mothers give up their children.

“Today, they usually tell their children, `She wanted you to have a better life,' but that equates love with relinquishment,” he said, adding that trans-racial adoptions in a homogeneous country like the Netherlands may further affect the child's confidence and sense of self.

Adoption from outside the Netherlands is a relatively recent phenomenon, and the first generation of intercountry adoptees is now reaching adulthood. There are about 28,000 intercountry adoptees there, mostly from Asia or Latin America. The young people in the current study were drawn from 2,148 foreign-born children (65 percent of the total of 3,519) adopted between 1972 and 1975. The children were interviewed in 1986 and in 1989-1990, and again in 1999 and 2002, the basis for the current report.

The 1,484 adoptees available for study were aged 22 to 30 years at the time of last follow-up. The researchers compared them with 695 young Dutch adults who were not adopted. Adoptees who dropped out of the sample before the last round of inquiry had high levels of parent-reported problems at the start of the study, so the current results may well underrepresent prevalence of mental disorders.

Using DSM-IV criteria and the Composite International Diagnostic Interview, the researchers obtained data on the prevalence of anxiety, mood and disruptive disorders, and substance abuse or dependence. Their research was supported by a grant from the Dutch Ministry of Justice.

Adopted children had 1.52 times the likelihood of meeting criteria for anxiety. About 16 percent of adoptees had anxiety disorders, compared with 11.2 percent of the nonadoptees. Women in both groups were 3.37 times more likely to have an anxiety disorder than men. About 8 percent of adoptees met the criteria for substance abuse or dependence, compared with about 4 percent for nonadoptees.

Nonetheless, there was no significant difference between female adoptees and nonadoptees regarding mood disorders. Adopted men, however, were 3.76 times more likely to have a mood disorder than men who were not adopted (7.8 percent versus 2.2 percent).

“This suggests that males but not females show greater vulnerability to early negative life experiences or to adoption specifically, resulting in affective problems,” wrote the authors. There was a similar but nonsignificant trend for anxiety disorders. Boys and girls in the same cohort displayed similar gender-related patterns of anxiety and depression when the researchers studied them at ages 14 to 18.

Gender differences in later vulnerability were not explained by early childhood experiences. Males were not older at placement or more neglected or abused, compared with female adoptees. Genetic differences between boys and girls in the origins of psychiatric disorders were possible, said the researchers, but unlikely.

“It seems likely that environmental influences associated with adoption played a role in the emergence of mood disorders in males and less so in females,” the researchers wrote. They suggested that depressions in childhood and adolescence have different origins that vary also by gender.

While poorer socioeconomic status is usually associated with worse medical outcomes, Tieman and colleagues found that children adopted into low and middle socioeconomic families did not differ from their nonadopted counterparts. However, those in high socioeconomic families were more likely to report any disorder than their comparison peers.

Experts offered several hypotheses for why these children are more likely to see mental health professionals. International adoption is expensive, so parents who can afford to adopt also have good health insurance or can afford to pay for care on their own, said Livingston.

Johnson suggested that some high socioeconomic families may give up on extremely difficult adoptees. Those children may then be re-adopted by lower-income families who are better able to tolerate their behavior rather than bring them into the clinic for treatment.

Tieman, van der Ende, and Verhulst suggested that better preparing adoptive parents and increased support for adoptees and their families may mitigate some of these problems. However, adverse circumstances in the child's original country, moving to a new country, placement in a new family, and ethnic differences may raise the risk for mental health problems, even with preparation and help, they said.

While the vast majority of adoptees do well, parents, primary care physicians, and psychiatrists should keep these issues in mind.

“These children are not coming out of favorable childhood experiences,” said Charles H. Zeanah Jr., M.D., a professor of psychiatry and pediatrics and director of child and adolescent psychiatry at Tulane University School of Medicine in New Orleans. “They may have been abandoned or neglected, in an institution or in foster care. Adoption produces substantial changes and gains, but the effects of early adversity are not erased by their later experience.”

“Psychiatric Disorders in Young Adult Intercountry Adoptees: An Epidemiological Study” is posted online at<http://ajp.psychiatryonline.org/cgi/content/full/162/3/592>.“ Adopting an Institutionalized Child: What Are the Risks?” by Johnson is posted at<www.adoptionresearch.org/risks.html>.▪

Am J Psychiatry 2005 3 592