A review of the research evidence on outcomes

Recent comprehensive reviews of the literature on adoption are those of Triseliotis et al.,(6) Sellick and Thoburn,(7) Howe,(8) and Brodzinsky et al.(2) The findings from the large volume of research will be summarized under the broad headings of time-limited foster care placements and placements (with either adoptive or foster parents) made with the aim of providing the child with 'a family for life'. The emphasis will be on the second group, which will be further subdivided into placements of infants and placements of older children.

Time-limited placements

In general terms, short-term foster care is used along with other services in an attempt to improve family functioning so that the child may benefit from increased stability in the family home or as a short-term crisis intervention measure. In a major British study of over 3000 short-term foster family placements, Rowe et al.(9) listed the purposes for which time-limited foster placements were used (B,ox2).

Box 2

The aims of short term foster-care

• Temporary care (accounting for 46% of the placements)

• Preparation for long-term placement (14%)

Triseliotis et al.(5) and Berridge(!9 provide overviews of foster care research that concentrate on task-centred foster care. Generally it is successful in that few placements actually break down and most parents express satisfaction with the service. This is especially so if the placement is well planned and follows careful preparation for the child, the birth parents, and the foster parents. Packman ^i1,» found that, regrettably, a 'keep them out of care at all costs' attitude tends to prevail, thus leading to too many ill-planned and ill-matched emergency placements, which in turn led to placement breakdown and to unnecessary moves in care. Aldgate et al. (12> found that children were initially less positive about regular planned breaks with respite foster families than were their parents but over the research period, began to appreciate its benefits for themselves as well as their parents.

Hazel and Fenyo(13> and Hill et alSl4) have reviewed the main British and North American studies of specialist foster care for troubled adolescents. Though placement stability is a problem, these schemes are well rated by most of the young people and there is evidence of limited improvements in well being. Researchers report a problem of 'over-staying' for some of the young people. But this should perhaps be reframed as a success, in that some young people settle in so well that, against the odds, the task-centred foster family becomes a 'secure base' and the foster parents continue to provide support to the young adults as they start their own families.

With short-term foster care, strong associations have been found between the quality of social work practice and the successful return home of the child. Practitioners who facilitate good contact between the birth parents, foster parents, and the child, provide support to the foster parents and the birth parents. They also co-ordinate a multiagency approach to treatment of the child and parents before, during, and after placement, which is more likely to avoid multiple moves in care and to facilitate a safe and stable return to the family home or relatives.

Adoption and long-term foster-family placement

Whilst adoption is recognized as the major substitute-family placement option for most young children who cannot remain with their birth parents, opinion is divided (often along country lines) as to the importance of foster care as a placement of choice. Practice also varies in different countries in respect of placement with relatives. In the United Kingdom it is the exception rather than the rule for relatives to adopt (foster care, or residence order, or informal arrangements being preferred), whereas in the United States legal adoption by relatives tends to be encouraged. (!5)

Outcomes for children placed as infants

The largest volume of research on the long-term outcome of adoption concerns children placed as infants. However, inevitably, the practice referred to in these studies is already dated by the time they appear some 25 years or so after the child was placed. Most of these studies concern infants, placed for adoption at the request of their parents, who were placed relatively quickly with their new families. Although some may have been born to mothers who had poor antenatal care, most of these early placed children will not have experienced neglect or maltreatment. Most will have left the care of their mothers shortly after birth and experienced the single loss of a short-term foster parent at the time of placement with their adopters, usually when under 6 months of age. However, with the growth of intercountry adoptions, studies of infants placed more recently are more likely to include substantial numbers of children who have experienced adverse conditions during their early months. It is likely that disruption rates will be higher than they have been in the past.

The impact of placement in the short term

An important source of detailed information on short-term outcomes of infant placements is the longitudinal study by Rutter et al.,(l6) which compares young Romanian children placed with United Kingdom families with a cohort of United Kingdom infants placed in 'stranger' adoptive families by British adoption agencies. Reactions to placement of the United Kingdom infants who had generally good postnatal care are predictable in the light of knowledge about child development, attachment, separation, and loss. Those placed quickly settle with no obvious signs of stress; those with adverse early experiences including institutionalization (most of the Romanian infants) also appear to settle well if placed in their early months. Those placed when older than 6 months are more likely to show stress reactions at the loss of a carer to whom they are beginning to be attached, or to show adverse reactions resulting from early maltreatment, neglect, or institutionalization.

Signs of stress during childhood

The more robust studies of adopted or long-term foster children in their middle years and early adolescence are those that prospectively follow adopted infants as they grow up. This allows links to be made between early measurements and the well being of the children at various stages. The most important longitudinal studies are those of Bohman and Siguarson(17) in Sweden, Hoopes^ in the United States, Maughan and Pickles^9 in the United Kingdom, and Fergusson et al.(20) in New Zealand. The conclusion drawn from these studies is that adoptive children do better at each stage than non-adopted peers living in the generally adverse environments in which the children were likely to have lived had they remained with their birth parents. However, it is unclear whether this difference can be associated with adoption per se or with the more advantaged home circumstances of the adopted children.

All studies have found that, even for those with poor antenatal and birth history or who experience adverse circumstances in their early months, subsequent physical and cognitive development is generally good. However, children adopted as infants appear to be at a slightly higher risk of experiencing problems in their social, emotional, and behavioural development compared with other children raised in similar socio-economic circumstances. This is particularly the case with adopted boys. Information from longitudinal studies is supplemented by studies of clinical populations, such as those whose parents seek psychiatric help for them. In a non-representative sample of 122 mainly baby adoptees, Howe(8) found that 76 per cent had a trouble-free adolescence but that 24 per cent had exhibited at least one problem behaviour, and in the most severe cases this had resulted in school exclusion and delinquency. Rates of maladjustment appear to be higher around the age of 11, and decrease as the children move into later adolescence. Some studies suggest that adopted children are more vulnerable on some measures of behavioural and emotional development than others, including an inability to settle, restlessness, a tendency to lie or fantasize, and difficulties in getting on with their peers and teachers. Low self-esteem and feelings of insecurity are also more likely to be present amongst children in their middle years and adolescence.

Long-term outcomes

There is consistency among researchers that around 5 per cent of those placed as infants will leave their adoptive families before the age of 18, in circumstances of conflict which can be described as 'breakdown'. Around 80 per cent of both adopters and adoptees express broad satisfaction with the growing-up experience. When problems do emerge, the issue of adoptive identity often underlies a range of presenting symptoms. Amongst the 80 per cent of adopted adults who are satisfied with the experience of growing-up adopted are some who continuously or episodically have a sense of unease around questions of identity and the reasons why their birth parents gave them up for adoption.

When well being is the outcome measure used, adults who were adopted as infants tend to be healthier, have higher IQ scores, lower rates of criminal behaviour, and fewer psychiatric symptoms than non-adopted peers from similar backgrounds to those into which they were born. However, rates of antisocial behaviour are still higher than for non-adopted children raised in generally advantaged homes (as is usually the case with adopters who have to go through an 'approval' process).

Older children

Researchers and clinicians tend to agree that beyond 6 months of age, the risks of moving children increase, and the older the child at placement, the more likely it is that there will be difficulties in the child's behaviour, which increase the risk of placement breakdown. Some delays in placement are caused by incompetence or poor practice. However, the main reason for delay in placement (sometimes referred to as 'drift') is contested legal proceedings. In most countries it is only possible in extreme circumstances to place a child for adoption without the consent of the birth parents; in others (including the United States and Britain) it is not uncommon for parental consent to be dispensed with by court order. In many countries the law and guidance require attempts to be made to place a child with a family of the same ethnic and cultural background, unless this is not possible or demonstrably not in the child's interest. Consequently, if an adoption is contested, even if plans to place the child start to be made before he or she is born, as may be the case when a parent has been convicted of a serious physical or sexual assault against other children, 'due process' usually means that it is rare for a child to be placed under the age of 6 months. International adoptions are sometimes delayed because of the search within the country of origin for an incountry placement, or because of legal formalities. Some countries do not allow overseas adoption until the child is 2 or 3 years of age.

Medium-term outcomes

Many of the children placed when older bring problems with them into placement, to which may be added those discussed earlier, which are specifically associated with being adopted or fostered. For those placed from overseas, the difficulties are those commonly associated with institutionalization and privation of affection and consistent care. For a large proportion of those placed from care, the problems are those associated with maltreatment or neglect, including attachments with parent figures that may have been anxious, ambivalent, or avoidant, followed by the loss of those attachment figures. They may also have been separated from siblings and experienced multiple changes of carer.

High rates of emotional and behavioural disturbance are found amongst late-placed children during the preteen period as well as during adolescence. Rushton et al.(21) describe a prospective study of boys placed after 5 years of age, the majority of whom had suffered neglect or abuse prior to placement. During the first year after placement the mean number of problems had halved, although overactivity and problems in attaching to their new parents were noted. After 8 years 19 per cent of the placements had broken down and a higher proportion were showing behaviour problems, especially in terms of relationships with their peers.

The prospective longitudinal study of Hodges and Tizard, ^ of a group of adopted children who had spent their early years in institutions, may be particularly helpful in understanding the problems that may be experienced by those placed from overseas who have had similar early experiences.

Long-term outcomes for late-placed children

Whilst some children placed in positive environments that provide committed and loving parenting and stability will recover from the adverse effects of early significant harm, developmental recovery cannot be anticipated in all cases. From a study of over 1100 'hard-to-place' children placed in adoptive or permanent foster homes, Thoburn found that one in five of the placements had disrupted between 2 and 6 years after placement—a consistent finding from United Kingdom studies. There was a strong and statistically significant association between disruption and the age at placement (see Fig 1).(23) Of those aged between 7 and 8 years at placement, one in five experienced breakdown; this proportion rose to almost one in two for those placed between the ages of 11 and 12. The graph is less stable for teenagers, in part because numbers are smaller and statistics less reliable, and in part because families are more likely to 'hang on in' if they know the young person can be helped to leave home 'respectably' at 16 years of age.

Fig. 1 Age at placement and percentage of placements disrupting. (Reproduced with permission from J. Thoburn (1991). Evaluating placement: survey findings and conclusions. In Permanent family placement: a decade of experience (ed. J. Fratter, J. Rowe, and J. Thoburn), pp. 34-57. BAAF, London.)

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