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Outcomes of adoption from public care: research and practice issues

Alan Rushton is head of the Social Work and Social Care Section at the Institute of Psychiatry (Health Services and Population Research Department, PO32, Institute of Psychiatry, King’s College London, De Crespigny Park, London SE5 8AF, UK. Email: a.rushton{at}iop.kcl.ac.uk) and has for many years been the programme leader of the MSc in Mental Health Social Work. His research interests include adoption and fostering, child maltreatment and social work education.

	Abstract

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
The article covers the state of play of adoption from local authority care in the UK and research into the factors influencing placement outcomes. The major contentious issues about placement are discussed in relation to competing opinions and available evidence. Ways of intervening in adoptive families in difficulty are considered, together with current efforts to establish what makes for effective support services. This article recommends comprehensive assessments of the children to be placed and carefully targeted adoption-aware psychosocial interventions.

Box 1 Adoption statistics for England in 2004–2005 3800 children were adopted from care: this is 6% of children in care for more than 6 months 1000 more children were adopted than in 1999–2000: an increase of 38% 62% of children adopted from care were between 1 and 4 years old, 28% between 5 and 9 years old; very few were older than 9 The average age at adoption was 4 years 2 months (Department for Education and Skills, 2005)

 

Quite how these recently established adoptions are faring is a question that can only be answered with time. Some sceptical voices have asked whether pressure to arrange placements might result in more hurried, less well-matched placements and poorer outcomes. However, greater understanding of the needs of placed children and their adoptive parents and the availability of support services could well be making placements more secure and satisfactory.

It should be recognised that the recent direction of policy and practice in the UK (and in North America) would by no means be supported everywhere else (Warman & Roberts, 2002). Some countries take a strong stance on not severing ties with birth parents and not terminating parental rights when a child is in need or at risk. Instead they favour birth family preservation policies, or foster family placements but without adoption. Furthermore, extending the range of backgrounds and characteristics of adopters in order to increase recruitment would also not be generally acceptable, as will be discussed below.

	Placement stability and child mental health problems

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
The key question for policy makers and child welfare agencies is what are the outcomes for children adopted from care following abuse and neglect. Only recently has it been possible to begin to answer this question. Longitudinal studies have been needed to follow the children through the years of family placement and preferably on through leaving home and into young adulthood. In relation to non-infant placements, about a dozen studies have been published examining outcomes for children placed with non-relatives. One aspect assessed was the ‘disruption’ of placements, where the adoption irretrievably breaks down. Briefly, the studies have shown largely similar disruption rates of about 20% (range 10–50%) and rising with age of placement (for a detailed review see Rushton, 2003). Rates may differ depending on the composition of the sample and how ending of the placement is defined.

Two recent UK studies have delivered disruption rates and further information on the character of continuing placements. The Maudsley sample of children adopted from care in middle childhood and followed up to an average age of 13 (n = 99) showed that 23% of placements had disrupted (Quinton et al, 1998; Rushton & Dance, 2006). Of the continuing placements, nearly half were recorded as a positive experience by the adopters, but in 28% of the placements there were substantial difficulties even after 6 years in the adoptive family. These adoptive parents reported being challenged by continuing developmental, behavioural and social difficulties. In the Selwyn et al longitudinal non-infant adoption study (2006), 17% of placements disrupted and only two-fifths of the children followed up at an average of 7 years after placement were found to be free from behavioural problems. Both of the studies indicate that adoption can provide a stable home for the majority of the children although many problems do not disappear rapidly after placement and so the need for support may continue for many years.

Some of the problems of children placed from care (Box 2) challenge even experienced parents. More needs to be known about which of these developmental problems are ‘set’ and which are remediable when adverse environments are substituted with good-quality care.

Box 2 Typical emotional and behavioural problems of children placed from care Emotional distance Distortion of expression of feelings Slow development of a fresh attachment Indiscriminate sociability Over-activity Oppositional, defiant behaviour Rage reactions and serious aggression (less common)

 

Although these outcome studies show largely successful outcomes, even for ‘late-placed’ children, attention tends to be focused on the failures and problems in need of treatment. The following case example illustrates an adoptive placement with a positive outcome, although with some suggestion of enduring difficulties with close relationships and emotional expression.

Case example 1

Leanne was placed unusually late (at 10 years of age) into a child-free family. At 16 she was described by her adopters as very settled and she herself said that life with her adoptive parents was like life with any other family. The parents gave a very positive account of her progress and said many problems had resolved in the early years of the placement. She was described as a bright, likeable and confident girl and they were proud of her academic achievements. Any minor conflicts over attitude or dress were seen as typical adolescent behaviour.

Leanne had grown up with her mother, who had depression and severe alcohol problems and was a neglectful parent. After adoption, Leanne did not seek contact with her nor with any member of her birth family. The adoption social worker provided intensive and fairly long-term post-adoption support, including ‘life story work’.

The adopters described Leanne’s attachment to them as strong, but had concerns that she could sometimes cut herself off from relationships and had difficulty in expressing her emotions. She was also described as highly active, over-talkative in school, always in a rush and perhaps over-busy. This could be seen as her defensive style, perhaps constructed to manage painful feelings about the past.

	Predictors of placement outcome in late adoption

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
Some degree of consensus has now been achieved on the factors that raise the risk of poor outcome in late adoption (Rushton, 2004). The most frequently replicated finding is the relationship between older age at placement and poorer outcome. Also influential are the behavioural, emotional and social difficulties the child brings to the placement and the challenges these pose for the adopters. Other factors have been reported as predictors, but have not found universal support. The available research tends to focus on environmental factors (e.g. exposure to risk during the pregnancy due to poor nutrition or to the mother’s substance misuse or stress levels) and their relationship with outcome and tends to downplay the possible genetic contribution. Information on these and other perinatal factors that might help to explain current behavioural problems is not often available to practitioners nor to adoption researchers.

As part of the Maudsley adoption study referred to above, a colleague and I collected data prospectively (1990–2002) from a representative sample of domestic adoptive placements at the start of placement, at 1 year and at 6 years later (Rushton & Dance, 2006). Most of the children entered care because of abuse and neglect. Box 3 shows predictors of outcome in adolescence that the study revealed. We concluded that late adoption can be successful, as half the children made good progress, but the extent of disruptions and difficulties in continuing placements gave rise to concern. Knowledge of the predictors and the extent of continuing problems should help in devising pre- and post-placement support services.

Box 3 Outcome predictors in the Maudsley adolescent follow-up study Four factors contributed independently to a higher risk of disruption: older age at placement a longer time in care a high level of behavioural problems having been singled out from siblings and rejected by birth parents (Rushton & Dance, 2006)

 

Our study highlighted the influence of a history of ‘preferential rejection’: where a child in a sibling group is singled out for negative treatment and comes into care while the siblings remain with the birth parents. It is possible that carrying a negative self-image following rejection, plus growing awareness that siblings were not so treated, can place special obstacles in the way of settling into a new family and forming new, trusting relationships. Practitioners should be alerted to the phenomenon of preferential rejection in the child’s history and consider the possible effects on the child’s subsequent relationships in order to devise more specific adoption support plans (Rushton & Dance, 2003). However, not all children who experienced this form of emotional abuse had poor outcomes, so it should not automatically be considered a contraindication to adoptive placement.

	Mental representations of attachment

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
Another stream of work examining children’s progress in adoptive placements has focused not simply on reports and observations of the children’s behaviour, but on their mental representations of attachment relationships. Hodges et al(2005) have attempted to understand how maltreated children construct ‘internal representational models’ of the world and of significant people, how this influences how they perceive and react to their new family and how this might change over time.

By means of narrative techniques (the story stem assessment) these authors sought more subtle indicators of movement towards secure attachment. In so doing they explored some common representations of maltreated children: often of unresponsive or rejecting adults and child figures who do not acknowledge the need for help. In their 2-year follow-up of late adoptive placements, they report some positive changes although the children’s negative representations had by no means disappeared. This research explores a more complex picture of developmental recovery in which new developments do not completely erase, but may live alongside, early established and more persistent representations.

	The key contentious issues in placement choice

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
Many factors are held to be crucial in placement choices, for example race matching, continued contact with birth parents, and the sexual orientation and age of adoptive parents. Research can help to answer some questions, although the debate is often entangled with beliefs, moral values, political and ideological positions rather than outcomes. The child’s best interest should be held up as the main concern, although since many factors contribute to a child’s interests sometimes these may be pitted against each other.

Same-sex partners as adopters
The Adoption and Children Act 2002 for England and Wales regards applications to adopt as acceptable by ‘two people of different or the same sex living as partners in an enduring family relationship’ (section 50). However, attitudes towards same-sex adopters vary enormously across countries, within countries and within ethnic and faith groups. One French psychiatrist, when hearing me present the current UK position said ‘But haven’t they suffered enough!’.

The possible effect on child development of the sexual orientation of the parents is bound to be a key question, but it has been studied more in same-sex partnerships where one partner is the birth parent. A comprehensive review of children raised by lesbian mothers or gay fathers (Anderssen et al, 2002) found that such children do not differ significantly from those raised by heterosexual parents in comparisons on seven types of outcome, including psychological disorder and sexual identity confusion.

So far little research is available on comparative outcomes of same-sex and heterosexual adoptive parents, as the former is still relatively rare (Brooks & Goldberg, 2001). But such placements have been made for many years by some adoption agencies as they increase the pool of families for children awaiting placement. Lesbian and gay families wanting children may well face discrimination in the adoption process and possibly in receiving services capable of understanding the unique circumstances of the adopters and the child.

James (2002) describes gay and lesbian parenting in the context of a possibly hostile community and the need of practitioners to be alert to this. He also warns against continuing prejudice and ignorance in the therapeutic community. He identifies themes common to all adopters and to same-sex parents and draws attention to issues particular to gay and lesbian adoption. When clinicians are asked to advise on the suitability of gay adopters or to provide support, they may also need to reflect on and perhaps reconsider their own assumptions about sexual orientation and parenting.

Transracial placements
I concentrate here on domestic transracial adoptions, although the growing number of children placed transnationally, and therefore usually transethnically, is an important topic, especially in the USA, where this is much more common than in the UK. Many voices have been raised, and continue to be raised, in heated debates on this topic, including those of the potential adopters, who protest at the barriers raised to adopting a child of a different race; those of Black and minority ethnic children raised in White families and their experiences, good and bad; and the range of views of Black families and Black professionals in regard to child welfare practices. It is worth remembering that views differ not only across but also within these groups. The debate continues, with no easy solutions and with swings of opinion over time. In the UK, transracial placements have become less common and placing agencies try to make an ethnically matched placement if possible and if the time waiting for such a placement is consistent with the interests of the child.

As far as outcome research is concerned, traditional psychological measures have revealed no difference in placement stability nor in other outcomes for transracial placements (Rushton & Minnis, 1997). In comparing outcomes of transracial placements with same-race placements, it is important to clarify whether it is the ethnicity dimension itself that is related to outcome and not some associated factor such as the child’s pre-placement experience and level of difficulty or having waited longer for permanent placement. In these studies, measures of outcome have been rather narrow, minimising the social context, and some allege that their selection is ideologically influenced. Acknowledgement is growing that multiple measures are needed to capture the children’s and young people’s experiences and all round adjustment (Burrow & Finley, 2004). Other issues, such as discomfort with being different, identity conflicts and confusion, dislocation from the community of origin and experience of racism, clearly need to be considered if the full consequences are to be understood. These are complex issues for the practitioner and researcher alike.

Clinicians working with transracial adoptive families may need to help young people from mixed ethnic backgrounds to come to terms with their unusual history and to explore their identity, self-concept and life choices. Transracial adopters may need help, especially in dealing with the turbulence arising from adolescent conflicts possibly compounded by concerns about ethnic origins.

Contact with the birth family
Policy and practice has moved from closed adoption, where it was thought best for adopted children to make a ‘clean break’ from their birth parents, to some degree of contact now being put in place for most cases in the UK. This will often be by telephone or letter contact rather than frequent face-to-face meetings.

What effect does contact have on the adjustment of adopted children? We now have the benefit of a study of voluntarily relinquished infants placed for adoption and followed to adolescence in a non-randomised comparison of open with closed adoptions (Von Korff et al, 2006). This has shown no significant associations between contact and adolescent adjustment problems, although more adolescents in closed adoptions had scores in the clinical range. Contact arrangements are more complicated, however, with older children adopted from care if the parents have abused them, or want to undermine the placement, or might put them at risk during a contact arrangement or who give further proof of rejection. Definitive results are lacking on the benefit of contact for older children adopted from care and have proved hard to research (Quinton et al, 1997). Clinicians will want to examine the potential benefits of contact as a way of helping the child to have a coherent sense of their history, while considering case by case what the impact might be of different types and frequency of contact on all the parties of the ‘adoption triangle’ (child, birth family and adopters).

Older couples seeking to adopt
The age of adopters has not generally proved to be a predictor of poor placement outcome. In studies which suggest that this is so, it may be because more problematic children are placed with more experienced, and therefore older, parents. As with other types of parent, it is the suitability for the task that counts. Adoptive parenting of disturbed children clearly requires sufficiently energetic caring and capacity to deal with the likely stresses. The obvious downside of a placement with older adopters is that the adopted children may lose their parents at a stage in their lives when they are still vulnerable.

	Assessment and adoptive placement

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
Given the well-established raised incidence of problems in looked after children (Meltzer et al, 2003) and how some of these problems remain in a proportion of children after adoption, comprehensive assessments of the children are needed before placement – but often not conducted. The specialist multi-disciplinary team (representing child psychiatry, psychology, and education and adoption specialists from the local authority) should be able to assemble the most reliable and accurate history of the child and conduct an assessment of current functioning. The most relevant standardised measures, observations, file searches and interviews should be used to describe a profile of the child’s key experiences, strengths and weaknesses. This should capture physical and psychological development, the quality of relationships, educational progress and speech and language. The best possible understanding of any current problems should then form the basis of recommendations for specifically targeted, evidence-based therapeutic interventions.

Establishing and supporting adoptive placements
Adopters have frequently complained, in their search for support, that they have felt blamed, or that services were not ‘adoption aware’, or that only brief assessments or short-term interventions were available. For many years calls have been made for better recognition and expansion of adoption support services (Lowe et al, 1999). Legislation in England now recognises this, albeit offering very cautiously constructed provisions (Children and Young Persons, England: The Adoption Support Services (Local Authorities) (England) Regulations 2003). Section 4 of the Adoption and Children Act 2002 requires the local authority to carry out an assessment following a request for adoption support. This is an obligation to provide an assessment, but not a right to a service. If a service is warranted, including therapeutic intervention, this may be arranged through services outside the local authority. Many question whether the legislation will in fact secure more effective and available support. Efforts to expand support services are being made, but there are also obstacles in terms of the availability of professional skills and adoption-aware practitioners and accessibility, especially outside the major cities (Rushton & Dance, 2002).

The following case illustrates the need to establish a good working partnership with adoptive parents seeking support.

Case example 2

A single adoptive mother sought help in dealing with her 9-year-old son’s strong need for control and the frequent conflicts it engendered. This mother first wanted to be reassured about the stance of the specialist adoption advisor and the nature of the help she was offering. As her confidence in the advisor grew, she became more honest about the difficulties and more open to considering alternative parenting approaches. Over a sequence of sessions, the mother was helped to see the child’s intense need for control as a strategy to keep himself safe in a world he had not been able to trust. The mother was encouraged to identify which situations seemed to bring on this controlling behaviour. The mother’s greater understanding and modifications of her approach to engaging with her son led, in time, to a reduction in conflict.

	The effectiveness of interventions

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
The search is under way to find the effective ingredients in adoption support and in more specialised psychotherapeutic intervention. Many questions need an answer. Can intervention, in addition to stable placement, help to compensate for early poor relationships? What features of an intervention are thought to promote fresh attachment? What is the adopters’ contribution? More investigation is needed into the effectiveness of a variety of interventions (family-based, group-based, child-based and parent–child based) that could contribute to placement stability and to favourable outcomes. New developments in adapting play, art and drama therapy to the adoption context need to be systematised and evaluated.

Some interventions with children are now being described and their theoretical justification set out (e.g. Dozier, 2006; Howe, 2006). Lieberman (2003) points out that adoptive parents can miss or misinterpret subtle clues, perhaps seeing temper tantrums and oppositional, defiant behaviour as negative communications towards them rather than the child’s expressions of anxiety and fear of loss. She advises that adopters of disturbed children need special skills ‘to decode and respond appropriately to the child’s psychological needs’. However, all interventions focused on adoptive parenting need to take care to steer clear of implying blame or criticism in favour of the joint search for understanding and for devising appropriate responses.

The development of more intensive, structured and tailor-made parenting interventions is one promising approach. A randomised controlled trial is currently being conducted to investigate the cost-effectiveness of two 10-week, home-based interventions to enhance adoptive parenting (Rushton et al, 2006). Behaviour management advice is being compared with an educational programme to aid understanding of the children’s problems and both are compared with services as usual. However, some adopted children with enduring behavioural problems and attachment difficulties may need longer-term therapeutic help, together with appropriate, readily available supportive services for the adoptive parents, who are not seeing great evidence of their child’s recovery from poor early experience.

	Adoption and mental health

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
Mental health practitioners may be involved in a variety of ways in adoption. They may advise on the needs and psychosocial profile of the children looking for a new family. They may be involved in the assessment and selection of adoptive parents capable of providing warm, sensitive care who have the understanding and parenting skill to manage difficult behaviour and are able to promote physical, psychological, social and educational progress. Practitioners may be involved in assessing the suitability and timing of an adoptive placement, in adopter preparation and matching, in interventions with placements in difficulty and in managing the painful consequences of adoption disruptions. Adopted adults may seek counselling, and support may be required in the context of adoption reunions (Triseliotis et al, 2005). There needs to be a greater bringing together of findings in the field of developmental psychopathology, changes in adoption policy and skilled adoption-sensitive practice.

In terms of future research of importance to practitioners, the factors that impede some children from making fresh attachments in their new families need to be better understood and to be linked to ethically and theoretically sound interventions. In time, evidence will need to be gathered on the cost-effectiveness of a variety of child- and adopter-based interventions in order to reduce the risk, and to increase satisfactory outcomes, for these permanent family placements.

	Declaration of interest

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
None.

	MCQs

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 

1. The percentage of children placed from care for adoption in England is:
   1. 1%
      
   2. 6%
      
   3. 20%
      
   4. 50%
      
   5. 80%.
      
   
   
2. On average, the percentage of late adoptive placements that break down is:
   1. 1%
      
   2. 8%
      
   3. 20%
      
   4. 50%
      
   5. 80%.
      
   
   
3. In late adoptive placments, the strongest predictor of disruption the placement is:
   1. the gender of the child
      
   2. the child’s age at placement
      
   3. the adoptive father’s employment
      
   4. the child’s IQ
      
   5. the age of the family’s social worker.
      
   
   
4. As regards transracial placements:
   1. children are being placed transracially in ever-increasing numbers in the UK
      
   2. hundreds of follow-up studies have now been conducted to compare transracial with same-race placement outcomes
      
   3. those opposed to transracial placements argue that the children will be confused about their identity and their ethnic group
      
   4. ideology and politics are irrelevant in the transracial debate
      
   5. many more international adoptions occur in the UK than the USA.
      
   
   
5. As regards legislated adoption support in England:
   1. all parties to an adoption have a legal entitlement to a service of their choice
      
   2. comprehensive assessment of the child is recommended when considering placement choices and adoption support
      
   3. brief intervention following placement should be sufficient to support all adoptive families
      
   4. many scientifically conducted evaluations have identified ‘what works’ in post-adoption support
      
   5. direct intervention with the child is always the treatment of choice when adoptions are in difficulty.
      
   
   

MCQ answers

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	References

Top Abstract Placement stability and child... Predictors of placement outcome... Mental representations of... The key contentious issues... Assessment and adoptive... The effectiveness of... Adoption and mental health Declaration of interest MCQs References

 
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Dozier, M. (2006) Attachment based treatment for vulnerable children. Attachment and Human Development, 5, 253–257.

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