Author Affiliations: Centre for Child and Family
Studies, Leiden University, Leiden, the Netherlands.
Context International adoption involves more than 40 000 children a year
moving among more than 100 countries. Before adoption, international adoptees
often experience insufficient medical care, malnutrition, maternal separation,
and neglect and abuse in orphanages.
Objective To estimate the effects of international adoption on behavioral problems
and mental health referrals.
Data Sources We searched MEDLINE, PsychLit, and ERIC from 1950 to January 2005 using
the terms adopt* combined with (behavior) problem, disorder, (mal)adjustment, (behavioral)
development, clinical or psychiatric (referral), or mental health;
conducted a manual search of the references of articles, books, book chapters,
and reports; and consulted experts for relevant studies. The search was not
limited to English-language publications.
Study Selection Studies that provided sufficient data to compute differences between
adoptees (in all age ranges) and nonadopted controls were selected, resulting
in 34 articles on mental health referrals and 64 articles on behavior problems.
Data Extraction Data on international adoption, preadoption adversity, and other moderators
were extracted from each study and inserted in the program Comprehensive Meta-analysis
(CMA). Effect sizes (d) for the overall differences
between adoptees and controls regarding internalizing, externalizing, total
behavior problems, and use of mental health services were computed. Homogeneity
across studies was tested with the Q statistic.
Data Synthesis Among 25 281 cases and 80 260 controls, adoptees (both within
and between countries) presented more behavior problems, but effect sizes
were small (d, 0.16-0.24). Adoptees (5092 cases)
were overrepresented in mental health services and this effect size was large
(d, 0.72). Among 15 790 cases and 30 450
controls, international adoptees showed more behavior problems than nonadopted
controls, but effect sizes were small (d, 0.07-0.11).
International adoptees showed fewer total, externalizing and internalizing
behavior problems than domestic adoptees. Also, international adoptees were
less often referred to mental health services (d,
0.37) than domestic adoptees (d, 0.81). International
adoptees with preadoption adversity showed more total problems and externalizing
problems than international adoptees without evidence of extreme deprivation.
Conclusions Most international adoptees are well-adjusted although they are referred
to mental health services more often than nonadopted controls. However, international
adoptees present fewer behavior problems and are less often referred to mental
health services than domestic adoptees.
Juffer F, van IJzendoorn MH. Behavior Problems and Mental Health Referrals of International AdopteesA Meta-analysis. JAMA. 2005;293(20):2501-2515. doi:10.1001/jama.293.20.2501