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Mental health of adopted children: risks and protective factors

Adoption is becoming increasingly popular; however, there is an underlying concern that adopted children are at greater risk for mental health problems. Studies have found that adopted children are more likely to develop social, intellectual, or emotional problems. Exposure to substances in the womb including drugs and alcohol, subsequent abuse or neglect, lack of structure in the family environment, poor nutrition, and reduced stimulation, along with placement at a later age, can all place a child at risk for developing these problems.

A recent study published in the Archives of Pediatric and Adolescent Medicine found that adolescents adopted as infants were twice as likely as nonadoptees to be diagnosed with externalizing disorders such as attention-deficit/hyperactivity (ADHD) and oppositional defiant disorder. This did not surprise Dr. Margaret Keyes, the study's lead author.

"We have always known adoptees are overrepresented in mental health settings, often at two-and-a-half to six times the rate of children from the general population," says Keyes, who conducts research at the University of Minnesota's Department of Psychology. The question is why.

Adoptive parents more likely to seek help

"In the past, many people suggested that adopted children were seen in mental health settings more often than other children because of a referral bias," says Dr. Keyes, explaining that adoptive parents might be more likely to seek professional help because they tend to be better educated, have more economic resources, and they have had experience with accessing social services during the adoption process. If this were the case, it could in part explain the increased number of diagnoses in this population.

Although Keyes' study found that the odds of seeking help for externalizing disorders conditions were twice as high in adopted adolescents, she does not attribute this increase to a referral bias. Rather, the "increase mirrors an increased risk for externalizing disorders in this group."

However, Dr. Keyes also points out that while twice as many ADHD cases sounds like a huge increase, "it means that whereas seven out of every 100 children in the general population are diagnosed with ADHD, for adopted children it was more like 15 out of every 100." Although this increased number is significant, it is important to note that 85 out of 100 adopted children did not receive this diagnosis.

Problems are not unique to adopted children

"Most adopted kids are doing fine and I don't think adoptive parents need to be particularly concerned," says Dr. Keyes. Instead, all parents should be appropriately vigilant because these problems are not unique to adopted children. Dr. Keyes advises that, "if you see your kid having problems as an adolescent, seek help as you would for any child, regardless of whether you are a parent through adoption or biology."

Tips for parents: Helping your adopted child

Although adoptive parents have no control over risks their child was exposed to before adoption, there is much that adopted parents can do to provide their child with a stable, mentally healthy environment from the moment he joins the family. "One of the strongest protective factors is adoption into a positive family environment and the opportunity to form a secure attachment relationship," emphasizes Nancy Cohen, PhD, and Director of Research at the Hincks-Dellcrest Centre for Children's Mental Health in Toronto. Creating a positive family environment is something biological children will benefit from as well.

A constant figure to look up to

"All children need to know that regardless of how they act, they have a person they can turn to," says Cohen. When given a constant attachment figure, "children quickly learn that there is someone who can read their verbal and nonverbal cues and respond sensitively to them." Although attachment relationships typically are formed in the first year of life, Cohen explained that "studies show children adopted late form an attachment with parents, do well, and generally have a quite positive outcome."

"Sometimes when an older child enters an adoptive home, everyone is on their best behavior and it is a kind of honeymoon," explains Dr. Cohen. "However, as the child begins to form an attachment and they realize the family is something special and how nice the environment is, they might get scared and start to act out, wondering, 'if I act out, will you still love me?'"

Be sensitive to how your child's environment has changed

Parents also need to be sensitive to how circumstances might have changed for their child and respond appropriately.

For example, North American parents rarely sleep with their children. But in China, children often sleep in groups, in nurseries, or with their foster families. "When the child joins their adoptive family, they are typically put to sleep alone in their own room. When they wake up alone in a dark room that looks and smells different from what they are used to, it can be frightening for the child," says Cohen, "so parents need to go immediately into the room when the child cries. The child will soon learn that 'when I cry, my parents respond.'"

Do not overwhelm your child

Hold off on big family parties or filling your child's new room with lots of toys. Instead, gradually introduce your child into their new home and family. Buy toys based on your child's developmental stage rather than their chronological age.

Respect your child's birth parents

"Parents adopting infants usually introduce the word 'adoption' at age three," says Dr. Cohen. This gives children familiarity with the word adoption early on , even though children typically do not truly understand the meaning of adoption until around age seven or eight.

Some, but not all children are upset when they learn that they are adopted. Children may be upset because they feel a sense of loss or that their birth parents did not care for them. When this happens, how adoptive parents portray biological parents is important.

"It is damaging to say things such as: your parents didn't want you, or they drank and were no good," warns Dr. Cohen. Instead, she recommends saying things like: "Your parents wanted to make sure you were safe, it doesn't mean that they don't love you. We are so happy you are our child."

Providing perspective on why the birth parents gave up the child can also help.

For example, China has a one-child policy. Some parents cannot afford to pay the fine the government forces them to pay for having more than one child. If this is the case, an adoptive parent can explain that although their child's birth parents could not pay the fine, it does not mean that her birth parents did not love her.

Adoptive parents also need to respect the child's time of mourning as they experience the loss of their birth parents. "If your child becomes upset, cries, or gets angry, the best thing you can do, although it can be hard, is to encourage them to talk about their feelings and empathize with them," says Dr. Cohen.

Mental health of parents

Although biological parents are exempt from the mental health screening process that adoptive parents must undergo, Dr. Cohen believes both should hold themselves to the same standards. "Everyone should be concerned about mental health," she says. "Promoting mental health should be part of everyone's agenda."

To that end, all prospective parents - whether adoptive or biological - may want to ask themselves these questions:

  • Do I have the patience and perseverance to raise a child?
  • Do I have a good sense of humour and a talent for keeping life in perspective?
  • Do I have the ability to accept without judging and to love unconditionally?
  • Am I aware that that healing does not always come quickly?
  • Do I have a stable relationship or social network to support me?
  • Do I have the financial security to raise a child?

Your own childhood in perspective

Some parents idealize their childhood. Others, according to Dr. Cohen are "still angry at their mother or father for some reason or another." Neither is a healthy perspective.

Ask for help when you need it

"Everyone has a fantasy of what it is to be a mom or dad, then reality sets in," says Dr. Cohen. "Yes, there are lovely moments, but there are stresses too. That is the time when families need help." Dr. Cohen says one thing holds true for all parents: "A supportive parent with good mental health themselves who reacts to the child appropriately can make all the difference."

Kimberly Humphreys
Medical Writer/Editor,


Keyes MA, et al. The mental health of US adolescents adopted in infancy. Archives of Pediatric and Adolescent Medicine. 2008;162(5):419-25.

Cohen NJ, et al. Children adopted from China: a prospective study of their growth and development. The Journal of Child Psychology and Psychiatry. 2008;49(4):458-68.

Mather M. Intercountry adoption. Archives of Disease in Childhood. 2007;92(6):479-82.

Cohen NJ, Coyne J, Duvall J. Adopted and biological children in the clinic: Family, parental and child characteristics. Journal of Child Psychology and Psychiatry. 1993;34(4):545-62.

Juffer F, van Ijzendoorn MH. Behavior problems and mental health referrals of international adoptees: a meta-analysis. Journal of the American Medical Association. 2005;293:2501-2515.

Dave Thomas Foundation. [cited December 12, 2008]. Available from: