The nature of the evidence on the impact of adoption and fostering on child mental health

The actual or potential problems most obviously associated with child placement are those resulting from separation and loss. Brodzinsky et al.,(2) have made significant contributions to our understanding of the psychology of adoption. Put simply:

...for later-placed children, the loss of family or surrogate family connections is overt, often acute, and sometimes traumatic. In contrast, for children placed as infants, loss is, of necessity, more covert, emerging slowly as the youngster begins to understand the magnitude of what has happened In addition, there may be loss of a clear sense of genealogical connections and, in the case of transracial and inter-country adoption, loss of cultural, ethnic, and racial ties.

The impact of loss will also vary with the child's temperament. A 'born worrier' will go through life wondering what there was about him or her that was not worth keeping, and no amount of positive parenting will make this angst go away; a resilient child will shrug away the past and make the best of even not particularly good parenting by the substitute parents.

It is important, before considering the research findings, to take note of the limitations of our knowledge on the long-term outcomes of foster care and adoption. Turning first to the inputs to the process, studies of family placement often include both infants and older children, those with emotional difficulties and those without, and those whose parents consented to or opposed the placement or the adoption. Some studies of foster care include children placed temporarily alongside others placed permanently, some include children placed both for adoption and long-term or permanent fostering, and in some studies from the United States the term foster care includes children in what would in other countries be referred to as 'residential care'—the term 'foster family care' is used in the United States for family placements.

At the other end of the process the outcome may be measured in different way. Thoburn(3) listed 17 different outcome measures used with a cohort of 29 children referred for permanent family placement. These came under the categories of output measures (Was the child placed? Was legal adoption completed? Did the placement break down?), measures of satisfaction of the different members of the adoptive family, and measures of the well being of the adoptee. Depending on which outcome measure was used, success rates varied between 50 per cent and 100 per cent. Different research methods lend themselves to different outcome measures. The larger the numbers involved, the more likely it is that 'breakdown rates' or completion of legal adoption will be the only outcome measures used. Well being may be measured by standardized schedules including behavioural and emotional development scales, such as the parent and teacher schedules (4) used in several studies conducted in the United Kingdom, self-esteem scales, the incidence of delinquency or drug or alcohol abuse, attendance at child psychiatric clinics, and the need for out-of-home placement.

The placement process that researchers seek to evaluate is extremely complex. When, as with adoption or permanent fostering, the aim is to improve the long-term well being of the future adult, it becomes impossible to unpick the very many events and variables that will have had an impact on the life of a young person between placement at 6 weeks and maturity at 25 or 26. Moreover, there is some evidence that adopted young people move towards emotional maturity at a slower pace than those who have not been adopted—not suprisingly with at least two extra hurdles to surmount: that of loss and separation, and that of making sense of their adoptive identity. If numbers are large enough, it is possible, by the use of regression analysis, to control for the major variables such as age at placement, disability, and emotional or behavioural problems at the time of placement. However, the many aspects of parenting, the way in which children are told about their adoption, the different aspects of the placement process, and the nature of any therapeutic input may all have had an impact on the placement. The researchers may seek the opinions of parents and children as to what they found helpful, but clear associations between parenting styles and behaviours as well as social work practice and therapy cannot be claimed.

In summary, whilst researchers have, for many years, sought to bring academic rigour to their studies, family placement is a generally untidy subject. The more complex the placement circumstances and the longer the timescale, the more difficult it is to attribute success to any one factor or type of placement. As Triseliotis et al.(5) put it:

The notion of outcomes when human beings are involved is never a 'neat package' but one with plusses and minus. Total success or total failure can only be found with a few cases at the extremes. For the rest it is mainly a picture of 'benefits and losses' knowing that there are still many gaps in our knowledge about the answers to some important questions.

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