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New Study on Adoptee Mental Health Issues

May 13, 2008
By .
Adoption

Last week the Archives on Pediatric and Adolescent Medicine published a new study on the comparative mental health of adoptees. The findings are of concern to everyone involved in the adoption process.

The study tracked children adopted in infancy. It compared results in a control group of non-adopted kids with kids adopted domestically as well as kids adopted internationally. The purpose was to determine whether kids adopted in infancy and lacking problem factors were more at risk for mental health issues:

Despite the popularity of adoption, there is a persistent concern that adopted children may be at heightened risk for mental health or adjustment problems.3 Previous research has shown that adopted children with a history of prenatal substance exposure4 or preplacement deprivation5 and those who were placed relatively late in their adoptive homes6 are at heightened risk of social, intellectual, and emotional problems. Nevertheless, existing research has not resolved the extent to which those adoptees with a good preplacement history and an early age at placement are at increased risk for clinically relevant mental health problems.

The linked article describes the methodology and results in considerable detail. In brief, the study found statistically significant differences in the prevalence of mental health issues between adopted and nonadopted adolescents. Adopted children — both domestic and international — were significantly more likely to have contact with a mental health professional. Adoptees were more likely to exhibit "externalizing" mental health issues such as Oppositional Defiant Disorder and Attention Deficit Hyperactivity Disorder. Domestic adoptees were more likely to exhibit such externalizing behaviors; international adoptees were more likely to exhibit internalizing behaviors like social anxiety disorder and depression.

The statistics are a matter of concern for any adoptive parent. I'm not a statistician, mental health professional, or social scientist, but I have some questions:

  • To what extent does socioeconomic status impact the study? The study notes that adoptees' families averaged wealthier. Is it possible that more affluent parents are more likely to report concerns about mental status, whether or not they exist? Does higher socioeconomic status generally correlate with tendency to visit mental health professionals?
  • The study is largely based on reported behavior by teachers, parents, and adoptees. I know it's not an exact science, but particularly with over-diagnosed conditions like ADHD, how reliable is that? Are there any more objective criteria that could be used? Is it possible that adoptive parents are conditioned to be hypervigilant, and that teachers are conditioned to see adopted children differently?

I'll see if I get my wife, the child psychologist, to read and discuss it. Meanwhile, the study emphasizes that most adopted kids are psychologically healthy. The statistical differences between domestic and international adoptees is fascinating; I'm wondering what theories they have for that disparity.

This has been picked up by the national press, which, being the press, has chosen to lead with the Brad and Angelina angle.

Last 5 posts by Ken

4 Comments
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4 Comments

  1. Brandon  •  May 13, 2008 @8:17 am

    Thanks for posting this, Ken. This appears to be a fairly well-done and interesting study. To address your questions:

    1) Although the authors did some interesting mathematical conversion of their SES measures, my reading of the data in Table 1 is that the "average" participating family was middle class. The parents of international adoptees was somewhat higher SES than those of domestic adoptees (darn, money-grubbing lawyers! :) ) The classic finding with SES and mental health services suggests that lower-SES populations tend to access care through hospitals while higher-SES populations tend to access care through office-based practices. Additionally, lower-SES populations tend to have less access to care than higher-SES populations. However, this difference is confounded by lack of infrastructure and funding, and may not actually be because lower-SES folks don't want mental health care.

    2) I love this question about the applicability of the outcome measures; it's a good one to ask of any study. The measures used in this study are widely accepted, standardized measures that were (for the most part) created expressly to be able to answer research questions about inherently subjective diagnostic concepts. Now, whether or not you buy into the DSM-IV and the American Psychiatric Association's concept of how to define a mental disorder is another debate for another day.

    As I read the study, I was struck by two impressions:

    1) Given the purpose of the study and the population of children examined, the absence of Reactive Attachment Disorder as one of the diagnoses is somewhat puzzling. Granted, it is a somewhat controversial diagnosis, but it is included in the latest DSM-IV.

    2) Effect sizes, effect sizes, effect sizes! In mental health studies, these have rapidly become as important an index of the meaningfulness of results as statistical significance. Depending on the effect size statistic used, a "strong" effect size is anything above the range of 0.50-0.80. The authors did report how they calculated effect size, but I'm not fresh out of school enough to remember which statistic their description is. Maybe Noah or Amy will know better than me. By the authors' admission, though, the vast majority of their effect sizes were in the small to moderate range. Looking at Table 2, the only "KA-POW!" effect sizes are for the externalizing stuff and ODD between domestic adopted and nonadopted adolescents, and for ODD and inattention between domestic and international adoptees. Thus, I think characterizing adopted children as "a troubled population in general" (which, to be fair, the authors do NOT do) is a bit of a stretch.

  2. Ansley  •  May 13, 2008 @11:54 am

    Brandon, to address the absense of RAD diagnosis… ODD, ADHD, depression, and the mentioned mental health issues in the study are all symptoms of trauma and RAD in adopted adults. So, although the study did not group the symptoms together as a specific syndrome, RAD is definitely in the mix, IMO.

    Thanks for your thoughful answer.

  3. Brandon  •  May 13, 2008 @5:46 pm

    Ansley, that is a good point about RAD, and precisely why (now that you've jogged my memory) my mentors in graduate school trained us to consider it a "controversial" diagnosis. Now that I read your comment, I specifically remember by Child and Adolescent Psychopathy professor poo-pooing RAD by dismissing it as indistinguishable from a combination of several symptoms of already extant internalizing and externalizing disorders. Thanks for clearing that up!

    Since you're on a roll, do you want to have a shot at deciphering which effect size statistic they used? It doesn't seem like Cohen's f-squared… is it Hedges' g?

  4. Ansley  •  May 13, 2008 @9:35 pm

    "Since you’re on a roll, do you want to have a shot at deciphering which effect size statistic they used? It doesn’t seem like Cohen’s f-squared… is it Hedges’ g? "

    Dude, I ain't that good!