Children and Youth Services Review 77 (2017) 188–196

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Children and Youth Services Review

journal homepage: www.elsevier.com/locate/childyouth

Mental health and psychological adjustment in adults who were adopted MARK
during their childhood: A systematic review☆
Sandra Melero⁎, Yolanda Sánchez-Sandoval
Department of Psychology, University of Cádiz, Spain

A R T I C L E I N F O A B S T R A C T

Keywords: In the two last decades, research of the psychosocial needs of adopted children and adolescents has advanced
Adult dramatically. Nevertheless, less is known about their mental health when they reach adulthood. The aim of this
Adoption paper is to systematically review the evidence about mental health and psychological adjustment in adult
Mental health adoptees. A systematic search was conducted on Web of Science and PsycInfo. The review includes 27 studies
Psychological adjustment
that fulfilled the selection criteria (ages between 20 and 40, domestic adoptions and articles published since
Systematic review
1995). Evidence suggests that psychological adjustment in adult adoptees is more unfavourable (with higher
levels of depression, anxiety, personality and behavioural disorders and neuroticism) than in non-adoptees. A
small group of studies shows similar psychological adjustment of adoptees and non-adoptees. Moreover, there is
evidence that the adopted population is quite heterogeneous, involving individual and contextual variables.
There are clear diagnostic differences when gender is taken into account. Some family variables (e.g.,
attachment, parenting styles) emerge as mediating factors of the effects of the adoptive status on psychological
adjustment. Other risk and protective factors have been insufficiently studied (e.g., age at the time of adoption),
so additional research is needed.

1. Introduction dren have higher rates of psychopathology and maladjustment (Burns

Research on adopted people suggests which their main needs are at
early ages and during adolescence. Although research has demonstrated
that adoption is a measure to protect childhood that interferes on a
positive way on children's development and adjustment (Nickman
et al., 2005), some adopted children are at risk for some negative
outcomes, among which are mental health, psychological and neuro-
biological difficulties (Fisher, 2015). However, little is known about the
INTRO psychosocial needs of these people when they reach adulthood. This
article provides a systematic review of the research on mental health
and psychological adjustment of adults who were adopted during
childhood.
During the two last decades, there have been notable advances in
INTRO the study of the psychosocial needs of adopted children and adoles-
cents. Many studies have analysed whether adopted children have more
emotional, social, behavioural or intellectual problems. Empirical
research has confirmed a trend among adoptees of having more
psychological difficulties, and being overrepresented in mental health
services (Juffer & van IJzendoorn, 2005; Juffer, van
IJzendoorn, & Palacios, 2011). Research has found that adopted chil-
et al., 2004; Gagnon-Oosterwaal et al., 2012). The meta-analysis
performed by Juffer and van IJzendoorn (2005) showed that, although
adopted children have more emotional and behavioural problems than
their non-adopted peers, the effect sizes were small (d = 0.16–0.24).
This means that most adoptees are well adjusted, although they are
referred to mental health services more often than non-adoptees. Other
studies analysing indicators of psychological adjustment have shown
that, albeit somewhat lower, adoptees' self-esteem levels are similar to
those of their peers and higher than those of residential care adolescents
(Sánchez-Sandoval, 2015).
Why may adopted children and adolescents be at greater risk for
impaired mental health? Contemporary hypotheses about the reasons
for these problems follow multidimensional models: stress and re-
sources models; Sánchez-Sandoval and Palacios (2012) and models of
risk and protective factors; Del Pozo de Bolger, Dunstan, and Kaltner
(2016). Adoptees have had more life stressors during their early
childhood (e.g., exposure to substances in the prenatal period, subse-
quent neglect or abuse, inadequate nutrition, poor stimulation, separa-
tion and broken bonds because of numerous transitions among care-
givers). Early life stress may shape the development of brain areas

☆
This work was supported by the Ministerio de Economía y Competitividad from Spanish Government [Project PSI2014-52336-R, Young Adult Adoptees' Psychological Adjustment
and Developmental Tasks: a 20-year follow up and keys for intervention].
⁎
Corresponding author at: Department of Psychology, Faculty of Educational Sciences, University of Cádiz, Avenida Republica Saharaui, s/n, 11519 Puerto Real, Cádiz, Spain.
E-mail addresses: sandra.melero@uca.es (S. Melero), yolanda.sanchez@uca.es (Y. Sánchez-Sandoval).

http://dx.doi.org/10.1016/j.childyouth.2017.05.006
Received 6 January 2017; Received in revised form 4 May 2017; Accepted 4 May 2017
Available online 05 May 2017
0190-7409/ © 2017 Elsevier Ltd. All rights reserved.
S. Melero, Y. Sánchez-Sandoval
involved in socioemotional functioning (Hanson et al., 2015). Pre-
adoptive factors play an important role in a child's risk for developing
these problems. Some pre-adoptive risk factors are strongly related to
worse outcomes for adopted children (Wind, Brooks, & Barth, 2007).
Herrenkohl et al. (2016) have related mistreatment and abuse prior to
adoption to a higher risk of having mental health problems, although
some factors, such as social support, mediate that relationship. Sig-
nificantly, children who were adopted at older ages and those who
spent more time in institutions show more problems (Palacios, Sánchez-
Sandoval, & León, 2005b). However, children who were adopted at an
early age and those who had shorter institutionalizations prior to
adoption did not show significant differences with non-adoptees
(Rutter, Kreppner, & Connor, 2001). In conclusion, later adoptions
may imply the existence of more pre-adoptive risk factors and, there-
fore, a worse adjustment in those children.
It has been confirmed that the developmental levels of children at
the time of their adoption may be quite lower than expected according
to their biological age. Palacios, Sánchez-Sandoval, and León (2005a),
using Battelle's Developmental Inventory with a sample of 181 inter-
nationally adopted children, found that a high percentage (52.4%) of
those children showed serious developmental delay at the time of their
adoption. These results suggest that pre-adoptive risk factors and
childhood behaviour problems are salient predictors of some, but not
all, indicators of mental health in childhood and adolescence.
Cross-sectional studies have shown some disadvantage in adoptees'
psychological adjustment (somewhat worse results than their non-
adopted peers). However, adopted children show better adjustment
that those who remain in foster care. Moreover, longitudinal research
has shown that cohabitation in adoptive homes reduces difficulties in
adopted children. According to Juffer et al. (2011) an important
recovery takes place in these children's development, decreasing the
initial delay indexes. Some factors may have influenced that improve-
ment. Firstly, it is known that children can develop multiple attach-
ments to alternative caregivers (Cassidy, 1999). Accordingly, a good
relationship with adoptive parents can make attachment styles more
beneficial. Secondly, parental responsiveness and support are important
to restore an emotional context for children to learn to regulate their
affects (Simmel, 2007). Finally, parenting styles seem to explain the
different levels of resilience to the effects of their early negative
experiences (Simmel, 2007). According to Palacios et al. (2005a), those
adoptees with initial developmental problems, experimented an im-
portant recovery at the beginning of cohabitation with adoptive family.
However, that problems can still influence subsequent development.
Less is known about adoptees' psychosocial needs when they reach
adulthood. Research on this is more limited and less conclusive but it is
nonetheless important. These people, in addition to the new challenges
of becoming an adult, must solve added tasks due to the fact of being
adoptees (Brodzinsky, Schechter, & Henig, 2002).
The main purpose of this work is to perform a systematic review of
psychological adjustment and mental health in adults who were
adopted during childhood.
2. Method
To perform this systematic review, we followed the recommenda-
tions of the Preferred Reporting Items for Systematic Reviews and Meta-
Analyses, also known as PRISMA. PRISMA is an evidence-based method
that includes different aspects related to conceptualization and meth-
odology for systematic reviews and meta-analyses (Urrútia & Bonfill,
2010). PRISMA has some resources for orienting authors of systematic
reviews, for example a checklist to evaluate manuscripts and a flow
diagram to include on them to show information about the selection of
included articles graphically.
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Children and Youth Services Review 77 (2017) 188–196
Table 1
Keywords for bibliographical search.
Participants Intervention Result
Adult Adoptees Psychological adjustment
Adults Adoptee Mental health
Adulthood Adoption Psychological well-being
Adopted Emotional well-being
Psychological disorders
Psychiatric disorders
2.1. Formulation of the problem
In the first phase, the research question was adequately formulated
following PICOS protocol (Participants, Intervention, Comparisons,
Outcomes and Study design) recommended by PRISMA. It was drafted
as follows: How is the psychological adjustment (O) of adult people (P)
who were adopted during their childhood (I) in comparison to their
non-adopted peers and/or to other adult adoptees (C), according to
studies with experimental and correlational designs (S)?
2.2. Search strategy
A search of articles was carried out in the database PsycInfo and in
those included in the Web of Science. Those search engines were chosen
because of their relevance in psychological research, and in the case of
Web of Science in other sciences. In addition, a specialized journal,
Adoption Quarterly (not included in the Journal Citation Report), was
also searched. For this purpose, we selected some keywords related to
the fields which are included in our research question. Those keywords
are presented in Table 1.
2.3. Selection criteria
All the studies that presented results related to mental health and
psychological adjustment in an adult population with a previous history
of adoption and that fulfilled the following conditions were included: (i)
sample aged between 20 and 40 years, (ii) sample from national
adoption (adopted in their own country of origin) and (iii) articles
published since 1995. Systematic Reviews and Meta-Analyses were
excluded.
2.4. Assessment of bias
In order to prevent bias during the elaboration process of the
systematic review, the following actions were performed:
The search was done in English and in Spanish in order to prevent
language bias. Studies were reviewed independently by two different
people and subsequently shared, as recommended by Sánchez-Meca
and Botella (2010) and Perestelo-Pérez (2013). Our first step was to
select articles based on the titles. Next, we reviewed abstracts. Then we
read each article to resolve any disagreements about inclusion. The last
phase, the complete reading of all the pre-selected articles, was also
done by two independent reviewers.
The quality of evidence of the included studies was assessed using
the method created by the Scottish Intercollegiate Guidelines Network
(SIGN 50: A guideline developer's handbook., 2015). This method
scores every paper, from one (best score) to four (worst score),
depending on its evidence level (level 1 is for meta-analyses and
systematic reviews, level 2 is for case control or cohort studies, level
3 is for non-analytic studies, and level 4 is for experts' opinions). In
addition, a symbol “-, + or ++” is given to each study according to the
risk of bias (“-” means a high risk of bias, “+” means low risk of bias,
and “++” means very low risk of bias). All the articles included have
an evidence level of 2+ (well conducted case control or cohort studies
with a low risk of confounding or bias and a significant risk that the
S. Melero, Y. Sánchez-Sandoval
Fig. 1. This flow diagram shows the process followed by the authors to select the studies for this systematic review. After various exclusion phases, 27 works were selected.
relationship is not causal).
3. Results
3.1. Included studies
At the beginning, the search provided a total of 391 references
(Fig. 1). After rejecting 343 because of duplication or not being related
to the topic (despite the fact those studies included the keywords, they
used them with other meaning or in other context). Only 38 reached the
first screening stage (consisting of Abstract reading). In this phase, 10
more studies were excluded because they did not meet all the selection
criteria. Finally, during the reading of the complete texts, one more was
excluded because it did not satisfy the age selection criterion for the
sample. Hence, the systematic review included 27 studies that met all
the selection criteria mentioned before.
All the included studies have a quantitative methodology in
common but there are some differences among them, as can be
observed in Table 2. Most of them use samples between 100 and 300
participants in both groups (adoptees and non-adoptees). However, the
range goes from 46 to 36,788 participants for adoptees, and from 49 to
246,198 non-adoptees. Likewise, all of them address early adulthood
(18 to 40 years), although they can reach older age groups (41 to
98 years). The majority are from the USA but some of them were
carried out in Australia, Israel, India, Denmark, Greenlandic, Sweden,
Finland, England and New Zeeland. Fourteen of the 27 works used a
comparison group design (subjects with similar characteristics, non-
adopted twins, biological children of the adoptive family, friends) to
compare to the adopted group.
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Children and Youth Services Review 77 (2017) 188–196
3.2. Analysis and synthesis
3.2.1. Mental health and psychological adjustment indicators
The first analysis consisted of identifying the variables considered as
indicators of psychological adjustment in all the articles. The indicators
had been grouped into the following blocks (see Table 3 for details):
- Absence/presence of psychiatric and/or psychological problems.
- Type of disorder.
- Specialized treatment in mental health.
- Addictions/delinquency.
- Psychological well-being.
- Quality of adopted family relations.
3.2.2. Psychological adjustment and mental health of adopted and non-
adopted people.
3.2.2.1. Psychological adjustment and symptomatology. Analysing
general psychological adjustment, Loehlin, Horn, and Ernst (2007)
reported that, although there were some cases of maladjustment,
adoptees' psychological adjustment was adequate and comparable to
that of their peers. One of the studies found better adjustment in
adopted females, showing that they were less represented in higher
levels of psychological problems than were non-adopted females
(Collishaw, Maughan, & Pickles, 1998). Five studies showed poorer
psychological adjustment in adult adoptees than in the comparison
groups (Cubito & Brandon, 2000; Levy-Shiff, 2001; Oke, Groza, Park,
Kalyanvala, & Shetty, 2015; Smyer, Gatz, Simi, & Pedersen, 1998;
Sullivan, Wells, & Bushnell, 1995).
Depression was the most frequently studied symptomatology.
According to Passmore, Feeney, Peterson, and Shimmaki (2006),
 Table 2
Included studies and their characteristics.

Study/Country Sample Age Measures Design Findings

(Westermeyer et al., 2015) 378 adoptees and 42,504 + 18 AUDADIS-IV CompG Adoptees showed more personality disorders.
U.S.A. non-adoptees
(Grotevant et al., 2011) 169 adoptive families 20–30 ASR, ABCL L Family satisfaction is related to externalizing behaviour of emerging
U.S.A. adults.
S. Melero, Y. Sánchez-Sandoval

(Feeney et al., 2007) 144 adoptees, 131 non- Mean about Interview, ASQ, PBI, Risk in Intimacy, Socio and Emotional CompG and Low satisfaction with reunion with birth mothers and impaired
Australia adoptees 37 years Loneliness, Trust in Close Relationships L relationships are related to more anxiety and avoidance. Later
adoptions are related to a higher risk in intimacy and loneliness.
(Levy-Shiff, 2001) 91 adoptees, 91 non- About 28 Tennessee Self-Concept Scale, SCL-90-R, Family Environment Scale L and Adoptees had worse self-concept and higher pathological
Israel adoptees CompG symptomatology.
(Borders et al., 2000) 100 adoptees, 70 friends Mean 43–44 Interview, SWLS, SDS, PIL, Life Regrets, Mid-life identity concerns CG Adoptees showed higher scores on depression, lower self-esteem and
U.S.A. scale, MSR, Kansas marital satisfaction scale, AAS, Family/Friend less secure attachment. More problems in searchers' group between
APGAR, CES-D, SES Rosenberg, Risk Prediction Scale adoptees.
(Cubito & Brandon, 2000) 716 adoptees 21–61 BSI, SDS2, ACS, PDQa Norm. Except for men anger, adoptees have worse adjustment than
U.S.A. normative samples, even worse in the case of searchers.
(Oke et al., 2015) 46 adoptees 20–32 SF-36, BSD Norm. Adoptees scored under clinical samples but higher than general
India population on depression. Worse mental health in adoptees.
(Yoon et al., 2012) 378 adoptees and 42,504 + 18 AUDADIS-IV CompG Substance use disorder is more common on adoptees.
U.S.A. non-adoptees
(Laubjerg & Petersson, 2011) 36,788 adoptees, 246,198 15–27 National registered data CompG Adoptees have higher risk of delinquency. Even more if they were
Denmark non-adoptees adopted after are 1 or if they are step-children.
(Laubjerg & Petersson, 2010) 594 adoptees, 11,109 non- 32 or less National registered data CompG Adoption does not increase the risk of psychiatric inpatient admissions
Greenland adoptees but being a step-daughter does. Psychiatric contact is more frequent in
adoptees and step-children.
(Caspers et al., 2006) 208 24–66 AAI, SSAGA-II L More likelihood of substance disorders for all kinds of attachment
U.S.A. except for the continuous secure.

191
(Kelly et al., 1998) 49 adoptees, 49 non- Mean FES, MSEI, SDTLI CG Adoptees have lower self-esteem and lower moral self-approval. Non-
U.S.A. adoptees 18–20 years adoptees show higher self-concept and expressiveness.
(Caspers et al., 2005) 148 adoptees 28–62 AAI, Assessment for the Genetics of Alcoholism, Social Provisions Non Comp Illegal substance use is more likely in insecure attachments, which
U.S.A. Scale also have less social support.
(Kendler et al., 2015) 18,115 adoptees, 171,989 22–65 National registered data CompG Environmental and biological factors influence the presence of an
Sweden non-adoptees and 107,696 alcohol use disorder.
step-parents
(Westermeyer et al., 2014) 378 adoptees and 42,504 + 18 AUDADIS-IV CompG Adoptees have more likelihood of having a mood or anxiety disorder.
U.S.A. non-adoptees
(Spinks et al., 2007) 742 adoptees Mean SSAGA-II CG Men have more health problems. Alcohol group have more health
U.S.A. 40–42 years complaints. High exposure to alcohol influences earlier appearance of
cardiovascular diseases.
(Wahlberg et al., 2004) 109 adoptees T1: 18 years Rorschach L The risk of psychiatric disorder increases when adoptees have genetic
Finland T2: 39 years risk and communication deviance in their adoptive parents.
(Curtis & Pearson, 2010) 130 23–98 Interview Non Comp Those who had contact with birth parents showed more problems
U.S.A. than those who did not.
(Collishaw et al., 1998) 84 adoptees, 1626 non- 33 Interview, Malaise Inventory, CAGE L and Adopted men have less job stability and less social support.
England adoptees CompG
(Smyer et al., 1998) 60 pairs of twins (only 1 28–84 Interview, Moos FES, LOC, Versions of Eysenck Scales, Cooke Medley CompG Adoptees grew up in more privileged environments and with more
Sweden adopted) Ho Scale, LSI-Z, CES-D, OARS control. They have higher educational level, less alcohol problems but
worse mental health.
(Loehlin et al., 2007) 324 adoptees, 142 biological About 30 Scale created by authors L and Biological children are considered better in education and other
U.S.A. CompG variables, but this does not mean adoptees have more problems. They
just have a lower mean. There are more similarities between parents
and biological children.
(Passmore et al., 2005) 100 adoptees, 100 non- 18–74 Interview, Rosenberg SES, ISI3, PBI CompG Adoptees reunited with birth family have lower self-esteem, less
Australia adoptees maternal care and overprotection than non-reunited or non-adoptees.
(Sullivan et al., 1995) 1498 18–64 DIS CompG Adoptees have more problems with drugs and alcohol, more
New Zeeland behavioural problems and more antisocial personality. In addition,
(continued on next page)
Children and Youth Services Review 77 (2017) 188–196
S. Melero, Y. Sánchez-Sandoval Children and Youth Services Review 77 (2017) 188–196

Satisfaction Index. MEIM = Multigroup Ethnic Identity Measure. MSEI = Multidimensional Self-Esteem Inventory. MSQ = Motives for Searching Questionnaire. MSR = Sensitivity to Rejection Scale. No Comp = No comparison with other group.
Note. AAI = Adult Attachment Interview. AAS = Adult Attachment Scale. ABCL = Adult Behavior Checklist. ACS = Anger Content Scale. ADQ = Adoption Dynamics Questionnaire. AIQ = Adoption Identity Questionnaire. AIWS = Adoptive

Inventory. CAGE = Cuttingdown, Annoyed, Guilt, Eyeopen. CES-D = Center for Epidemiologic Studies Depression Scale. CompG = comparison group. DASS-D = Depression Anxiety Stress Scales. DIS = Diagnostic Interview Schedule.
FES = Family Environment Scale. CG = Control group. IES-R = Impact of Events Scale-Revised. IPPA = Inventory of Parent and Peer Attachment. ISI3 = Identity Style Inventory. L = longitudinal. LOC = Locus of Control. LSI-Z = Life
Identity Work Scale. ASQ = Attachment Style Questionnaire. ASR = Adult Self Report. AUDADIS-IV = Alcohol Use Disorder and Associated Disabilities Interview Schedule- DSM-IV. BDS = Brief Screen for Depression. BSI = Brief Symptom

Norm = comparison to general population. OARS = Older Adults Resources and Services. PBI = Parental Bonding Instrument. PDQ = Personal Data Questionnaire. PIL = Purpose in Life Test. PSI = Parental Style Index. SCL-90-R = Symptom
Distress Checklist-90-Revised. SDS = Semantic Differential Scale. SDS2 = Self-Rating Depression Scale. SDTLI = Student Developmental Task and Lifestyle Inventory. SES = Self- Esteem Scale. SF-36 = Health Survey Short Forms. SSAGA-
associated with depression. More overprotection, lower age and being
Parental variables (e.g., overprotection), age and adoptive status are

higher self-esteem and life satisfaction. The more similar they are to
Preoccupation is more frequent in people with an unsolved identity.

differences between people adopted when they were born and those
adopted up to age 5, but differences were found with those adopted
Table 3

People with a reflexive exploration have more positive feelings, in

Close attachment, high income and having siblings are related to

Mental health and psychological adjustment indicators.

Less depression in people with higher educational level. No

Indicators Variables Number of

contrast to people with a more behavioural exploration.

studies found

Absence/presence of psychiatric Using standardized tests 15

and/or psychological Clinical interviews 9
problems. Information from state 3

adopted predict higher levels of depression.

records

their parents, the closer the attachment.

Type of disorder. The most Depression 9
studied symptomatology in Anxiety 3
this population. Personality disorders 2
Externalizing behaviour 2
they have more depression.

Anger, neuroticism and 1 each one

psychotic disorder
Mental health generally 8
Specialized treatment in mental Care in specialized mental 6
health. health services or psychiatric
after age 6.

inpatient admittances
Findings

Addictions/delinquency Substance abuse 11

Criminal behaviour 1
Psychological well-being General psychological well- 1
being.
Self-esteem 4
No Comp

No Comp

No Comp

Identity 3
CompG
Design

Life satisfaction 2
Self-concept 2
Quality of family relations. Family relation generally 6
Scale, Rosenberg SES, Current adoption experiencea, Thinking about
Interview, DASS-D, Scale of Emotional Arousability, PBI, PSI, MSQ

Interview, IPPA, Communication about adoptiona, Life-Satisfaction

Attachment 5
Support 3
Partner relationships 2
II = Semi-Structured Assessment for the Genetics of Alcoholism-II. SVEAL-PEL = Stressful Life Events Scale. SWLS = Satisfaction with Life Scale.

Communication 2

adoptive status per se did not predict different depression levels.

According to these authors, it is necessary to include familiar variables
MEIM, AIWSa, AIQ, ADQ, Rosenberg SES

in the analysis to obtain a significant prediction of depression. When

differences were found, results indicated higher levels of depression in
adoptees in comparison to their friends (Borders, Penny, & Portnoy,
2000), general population (Oke et al., 2015; Westermeyer, Yoon,
Tomaska, & Kuskowski, 2014) and children who enter their families
by birth (Loehlin et al., 2007; Sullivan et al., 1995), although this last
study only found differences in females, coinciding with the results of
Decker and Omori (2009). Besides these findings, Westermeyer et al.
birthparentsa

(2014) indicated that two mood disorders are associated with adoptive
Interview
Measures

status: major depression disorder and bipolar disorder I. Furthermore,

despite the higher levels of depression in adopted people, these levels
were lower in this population than in clinical samples (Oke et al.,
2015).
The works that compare anxiety levels in adult adoptees with
comparison groups showed higher anxiety in adoptees on average
About 38

(Loehlin et al., 2007; Westermeyer et al., 2014). In particular, adopted

18–75

18–70

19–71
Age

people were more likely to have some anxiety disorders, such as panic
disorders without agoraphobia, specific phobias and generalized anxi-
ety disorder. The remaining anxiety disorders seemed to be unrelated to Resto
144 adoptees, 131 non-

adoptive status (Westermeyer et al., 2014).

Focusing on personality disorders, some authors concluded that all
the types were more prevalent in adult adoptees, except for dependent
141 adoptees

345 adoptees

personality disorder (Westermeyer, Yoon, Amundson,

N1 = 196
N2 = 119
N3 = 217

adoptees

Warwick, & Kuskowski, 2015). In accordance with previous results,

Sample

Self-created scale by article authors.

Sullivan et al. (1995) found that antisocial personality was more likely
in adopted adult males than in non-adopted ones. However, it was even Rotas
more prevalent in a third group of people, those from disrupted families
(referred to people whose biological parents died, separated or divorced
(Decker & Omori, 2009)

(Passmore et al., 2006)

or who were raised by extended family), highlighting the importance of

(Müller et al., 2002)

environmental factors. Some of those factors, like parents' divorce or

Table 2 (continued)

(Colaner, 2014)
Study/Country

family disruption, mediated that relationship.

Australia

Regarding other symptomatology studied more exceptionally,

U.S.A.

U.S.A.

U.S.A.

although adoptees seemed to show psychotic disorders in higher

proportions, differences with non-adoptees were not significant
a

(Westermeyer et al., 2014). Referring to behavioural disorders, adop-

192
 S. Melero, Y. Sánchez-Sandoval
tees had a higher likelihood of presenting one of these disorders in
comparison to non-adoptees (Sullivan et al., 1995). Finally, adopted
people scored higher in neuroticism than their non-adopted twins
(Smyer et al., 1998).
3.2.2.2. Presence on clinical samples. With regard to the presence of
adopted adults in clinical samples, we found that being adopted did not
increase the risk of psychiatric inpatient admissions
(Laubjerg & Petersson, 2010). However, in the case of psychiatric
contact, the findings pointed in the opposite direction, showing that
adoptees seek counselling more than non-adoptees (Borders et al.,
2000; Laubjerg & Petersson, 2010). However, little difference was found
in the two groups in the reasons for counselling (Borders et al., 2000).
3.2.2.3. Behavioural problems. Referring to addictions, Borders et al.
(2000) found that adoptees and their friends both scored under the cut-
off point, indicating a minimum risk of dependency. These results were
consistent with the findings of Collishaw et al. (1998) who did not find
any differences, in this case, in alcohol consumption, between adoptees
and non-adoptees compared with the general population. Nevertheless,
a study with sets of twins in which one of them was adopted and the
other was not showed that the ones who remained with their biological
family drank significantly more than their adopted siblings, although
both groups reported doing so rarely (Smyer et al., 1998). Contrarily,
other studies have found a higher prevalence of legal and illegal
substance abuse and dependency in adopted people (Sullivan et al.,
1995; Yoon, Westermeyer, Warwick, & Kuskowski, 2012). In addition,
in the case of high exposure to alcohol, these people had more health
complaints and a lower onset age of cardiovascular disease (Spinks
et al., 2007). Finally, only one of the studies showed results about
delinquency. Those results concluded that adopted people had a 30%
higher risk of conviction than the non-adoptees in the cohort
(Laubjerg & Petersson, 2011).
AUTOCONCEPTO,
AUTOESTIMA
3.2.2.4. Well-being. Analysing mental health from the positive
variables of well-being, adoptees had lower levels of self-esteem
(Borders et al., 2000; Passmore, Fogarty, Bourke, & Baker-Evans,
2005), self-concept (Levy-Shiff, 2001), self-control and moral self-
approval (Kelly, Towner-Thyrum, Rigby, & Martin, 1998). However,
other works did not show differences in self-esteem between adoptees
and non-adoptees (Kelly et al., 1998), or in life satisfaction, where both
groups scored moderately high (Borders et al., 2000). Finally, identity
achievement has rarely been considered as an indicator of adjustment
in adults. From the review, we can only conclude that preoccupation
was higher in adults with an unsolved identity, whereas exploration
(behavioural and reflective) was more common in adults with an
achieved identity (Colaner, 2014).
3.2.2.5. Family relations. Considering the quality of adoptive family
relations as a possible indicator of adjustment, there have been various
conclusions because they were analysed from many different variables.
According to Levy-Shiff (2001), adopted adults rated their family
relations more negatively than non-adopted ones, although these
relations were worse in disrupted families, where there was also a
greater likelihood of alcohol abuse or dependency, behaviour disorders
and antisocial personality (Sullivan et al., 1995). When attachment has
been analysed, the findings showed that insecure attachment was more
common in adult adoptees (Feeney, Passmore, & Peterson, 2007),
whereas secure attachment was more frequent in non-adoptees
(Borders et al., 2000). Overprotection was also higher in adopted
Sobrepr people (Passmore et al., 2005), increasing their levels of depression and
oteccion
emotional arousability (Passmore et al., 2006).
Finally, other similarities have been highlighted between adult
adoptees and non-adoptees regarding their own family size, lone
parenthood (Collishaw et al., 1998) and sensitivity to rejection, where
both of them present medium levels, and marital satisfaction, moderate
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Children and Youth Services Review 77 (2017) 188–196
in both groups (Borders et al., 2000). However, adopted adults were
more likely to experience a marital or cohabitation breakdown and to
Ruptura
become involved in subsequent romantic relationships. Adopted fe-
males tended to start their first partner relationships and to have
children later in life. Additionally, adopted females presented fewer
unwanted pregnancies (Collishaw et al., 1998). Menos
3.2.3. Implied variables
Included works analysed the role of certain variables that are
associated with adoptees' mental health and psychological adjustment.
In relation to sociodemographic and personal variables and starting
with gender, some investigations did not find any differences in mental
health between adopted males and females (Levy-Shiff, 2001; Oke
et al., 2015) or in more specific variables such as depression or
emotional arousability (Passmore et al., 2006). In other studies, females
tended to have more psychiatric diagnoses (Kendler et al., 2015), more
depression (Decker & Omori, 2009; Sullivan et al., 1995), more psy-
chiatric contact (Laubjerg & Petersson, 2011), more father-overprotec-
tion (Passmore et al., 2005), they thought more frequently about their
birth mothers (Müller, Gibbs, & Ariely, 2002) but they were considered
better students (Loehlin et al., 2007) and they had more social support
than males (Collishaw et al., 1998). On the contrary, men presented
more antisocial personality (Sullivan et al., 1995), more delinquency
and alcohol and drug abuse (Kendler et al., 2015; Laubjerg & Petersson,
2011; Loehlin et al., 2007) and they were more estranged from their
fathers (Loehlin et al., 2007), although they had a closer attachment to
their mothers (Müller et al., 2002). In addition, gender as a variable had
mediating effects. For example, there were differences in depression
between men who were searchers (people who have started the search
or contact with their birth family) and non-searchers, but this did not
occur in women (Cubito & Brandon, 2000). Furthermore, in another
work, there were emotional and counselling differences between
adopted and non-adopted females, but not between males (Collishaw
et al., 1998).
Taking into account the current age of adopted people, whereas in
some studies, it seemed unimportant (Feeney et al., 2007; Smyer et al.,
1998), other studies underlined that younger adult adoptees (18 to
29 years) were more likely to have personality disorders (Westermeyer
et al., 2015), more loneliness (Feeney et al., 2007), more emotional
arousability (Passmore et al., 2006) and they thought more frequently
about their birth mothers (Müller et al., 2002). On another hand, older
adoptees (more than 40 years) had been informed later about their
adoption (Müller et al., 2002).
In relation to age at adoption, there were not many conclusive data.
For example, Decker and Omori (2009) did not find any differences in
levels of depression, incomes, divorces or likelihood of owning a home,
but they found that people adopted after age six were less likely to
graduate from high school or college. Other authors found that later age
at adoption was related to a more pathological symptomatology (Levy-
Shiff, 2001), a higher risk in intimacy and more family loneliness
(Feeney et al., 2007), more delinquency and higher frequency of
psychiatric contact (Laubjerg & Petersson, 2011). All the included
studies proceeded from domestic adoptions, so the role of the origin
in adopted people was not very important in them. Unusually, Amer-
ican studies showed that being Hispanic increased the risk of having a
substance use disorder (Yoon et al., 2012), and being of Asian or from
the Pacific origin increased the prevalence of mood disorders
(Westermeyer et al., 2014). In addition, the presence of psychiatric
disorders was four times higher in adoptees with a high genetic risk
(Wahlberg et al., 2004). Moreover, people who believed that adoption
involves social stigma tended to think more about it and they felt
unhappier about being adopted (Müller et al., 2002).
Achieved educational level was related to the adjustment of this
population and, as in the case of depression, it was higher in under-
graduates (Decker & Omori, 2009), although adoptees were considered
worse students and with lower educational levels by their families in
 S. Melero, Y. Sánchez-Sandoval
comparison with biological children. This does not necessarily mean a
worse adjustment for them (Loehlin et al., 2007) because, when they
were compared with non-adopted twins, adoptees reached a higher
educational level (Smyer et al., 1998). However, some authors reported
that income is an important variable to predict life satisfaction in adult
adoptees (Müller et al., 2002), which, along with job instability
(Collishaw et al., 1998; Loehlin et al., 2007), could make adult adoptees
feel less satisfied with their lives.
Some characteristics of the adoptive family unit were related to
adoptees' psychological adjustment. The presence of biological or
adopted siblings increased life satisfaction (Müller et al., 2002) or, for
example, being married decreased the risk of substance use disorder in
adoptees (Yoon et al., 2012). Organization, expressiveness and intel-
lectual or recreational orientations in the family increased adoptees'
self-control and moral self-approval (Kelly et al., 1998). Even physical
similarities with the adoptive mother, together to the value granted to
this fact, caused more positive feelings about adoption (Müller et al.,
COMUNICACIÓN
2002). Open communication about adoption at home is important,
because communication deviance (communication that distract and
Confunde befuddle listeners) can triple the risk of presenting a psychiatric
disorder in adoptees (Wahlberg et al., 2004).
Attachment style emerged as a mediating factor of the effects of the
adoptive status on adults' psychological adjustment (Feeney et al.,
2007). Secure attachment, more frequent in adoptees as the psycholo-
gical similarities they have with their adoptive parents increases, led to
more positive self-esteem (Müller et al., 2002). In contrast, insecure
styles increased the likelihood of alcohol and drug abuse or dependency
(Caspers, Cadoret, Langbehn, Yucuis, & Troutman, 2005; Caspers,
Yucuis, Troutman, & Spinks, 2006). Furthermore, people with ambiva-
lent insecure attachment had less social support (Caspers et al., 2005)
and more psychiatric contact. Finally, avoidant attachment was asso-
ciated with lower adherence to treatment (Caspers et al., 2006).
As a function of parenting styles, control was a mediating variable in
the existence of mental problems and the level of neuroticism in
adoptees (Smyer et al., 1998). However, parental educational expecta-
tions were not related to adoptees' mental health (Oke et al., 2015),
although other variables, such as the presence of alcohol use disorder, a
mental illness or delinquency in parents or siblings (biological and
adoptive) increased adoptees' odds of having alcohol use disorder
(Kendler et al., 2015).
One last difference in the adoptee group was being searchers or non-
searchers of their birth family. In this case, results showed that
searchers had higher levels of pathological symptomatology
(Cubito & Brandon, 2000) and depression than non-searchers (Borders
et al., 2000; Cubito & Brandon, 2000). In addition, the adoptees who
contacted their birth family also had more problems during their
adulthood than those who did not. Some examples of these problems
are depression, suicide, guilt (Curtis & Pearson, 2010), lower self-
esteem (Passmore et al., 2005) and problems with certain family
variables (Passmore et al., 2006). Externalizing behaviour seemed to
be unrelated (Grotevant, Rueter, Von Korff, & Gonzalez, 2011). As for
anxiety, people who did not had very satisfactory reunions with their
biological families had more anxiety (Feeney et al., 2007). Moreover,
Cubito and Brandon (2000) found that non-searchers and those re-
united with their birth families tended to present lower levels of anger
than searchers. Finally, searchers had less social support (Borders et al.,
2000), more mental health contacts and they took more psychiatric
medication (Cubito & Brandon, 2000). Even the adoptive family's
dissatisfaction with the contact with the biological family was related
to higher externalizing problems in the adoptee (Grotevant et al.,
2011).
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Children and Youth Services Review 77 (2017) 188–196
4. Discussion
4.1. Conclusions
The reviewed studies indicate some risk of mental health difficulties
during adoptees' adulthood. These results are in line with the findings
with children and adolescents, who show a worse psychological
adjustment than their non-adopted peers (Burns et al., 2004; Fisher,
2015; Gagnon-Oosterwaal et al., 2012; Juffer & van IJzendoorn, 2005;
Sánchez-Sandoval, 2015).
The analysed studies lead to the conclusion that adoptees' psycho-
logical adjustment is less favourable, as their levels of depression,
anxiety, personality and behavioural disorders and neuroticism are
higher than those of non-adoptees. Moreover, there are no differences
in some symptomatologies, like psychoticism. Being adopted increases
the risk of psychiatric contacts but not of psychiatric inpatient admis-
sions. In addition, self-esteem, self-concept, self-control and moral self-
approval are lower in adult adoptees but not life satisfaction, which is
moderately high in both groups. Regarding addictions, results are not
conclusive. While some studies do not show differences in addictive
behaviour between adoptees and non-adoptees, others identify a higher
risk of consumption for adopted adults. The study of psychological
adjustment through the analysis of adoptive family relations is less
frequent. When there are differences, adoptees rate their bonds with
their families lower (for example, there is more insecure attachment
among adoptees). Although there are many familiar indicators, they
present the same quality as in non-adoptive population. This might
mean that some adoptive familiar variables contribute to the recovery
of initial delays (Simmel, 2007), bringing some adult adoptees nearer to
level of adjustment of non-adoptees.
Far from being a homogeneous variable, psychological adjustment
in adult adoptees presents some variability. Some individual character-
istics, such as being older at adoption time, are associated with some
less adjusted psychological profiles. According to Anthony et al. (2016)
a longer wait in care before being placed for adoption, is related to: a
developmental delay, externalizing behaviour, health problems and
domestic violence. That confirms the longitudinal influence of pre-
adoptive risk factors (Del Pozo de Bolger et al., 2016; Palacios et al.,
2005a). Fowler, Toro, and Miles (2009) found that foster youth living in
continuously unstable situations were more likely to suffer emotional or
behavioural diseases, and adolescents with mental health disorders are
at higher risk of having negative outcomes in their transition to
adulthood (Havlicek, Garcia, & Smith, 2013). People who were adopted
at an older age might had experienced unstable situations like those
people in foster care, so that could influence their mental health
conditions during adulthood.
Gender is another important variable. As in the general population,
adopted women show higher levels of internalizing problems (e.g.,
depression) and men present more externalizing problems (e.g., sub-
stance abuse). Though the results about the influence of the origin
determine some risk for parts of the population, Villegas and Pecora
(2012) found that ethnicity is unrelated to adults' mental health. Other
variables, such as an affective and educational climate in the adoptive
family, seem to act as a protective factor of adults' mental health.
Parenting styles characterized by organization, expressiveness, recrea-
tional, and intellectual activities, open communication about adoption, IMP
and the absence of disorders in other family members seem to promote
better psychological adjustment in adopted people.
Findings show poorer adjustment in searchers for their birth
families. This should be investigated in depth, because the causal
direction between both variables is unclear: Is the search for origins a
universal need, shared by all adopted adults and its failure to be
resolved generates conflicts? Or are adoptees with worse adjustment
the ones who start the search to resolve their dissatisfactions and
personal conflicts? When this topic was studied with adolescents, it was
confirmed that people who started the search during adolescence
 S. Melero, Y. Sánchez-Sandoval
presented more difficulties (Sánchez-Sandoval, 2002).
Taking everything into account, adoption seems to be a good way to
improve people's adjustment. Some researchers found poorer adjust-
ment in people from foster care in comparison to adoptees. Most
adoptive families are good contexts to satisfy social, personal and
specific needs that adoptees have to face, but some difficulties remain
over the life cycle.
4.2. Implications for practice and future research
The lack of information about these people's mental health needs
when they reach adulthood and the variables related to their adjust-
ment, represents a relevant gap to prevention and intervention. Even
when it is known that some parts of the brain develop well into the
twenties and the competence in some functions improve. Additionally,
the transition to adulthood is an opportunity to alter developmental
trajectories, so specified programs in early adulthood might offer an
opportunity to optimize health and development (Havlicek et al.,
2013).
Brecha There are also significant gaps in some services, especially given the
current economic conditions that limit many young adults' self-suffi-
ciency (Stott, 2013). Taking that into account, it is essential to prevent
future difficulties in this population and organize the services to address
them. In some countries, there are programs to improve the mental
health of young adults with poorer adjustment, for example, Ohio's
Behavioural Health Juvenile Justice Initiative (BHJJ), which helps
young people who were justice-involved or who were substance
consumers (Kretschmar, Butcher, Kanary, & Devens, 2015). Even
though it is not specific for adoptees, this program highlights some
important aspects in which adoptees are more represented. The
conclusions of this review would also have to be taken into account
by post-adoption support services in their professional work.
This review has revealed the existence of limited research of the
adjustment of adult adoptees in comparison with the large amount of
research of adopted children and adolescents. Only through the design
Ya sea of studies with adult population, either cross-sectional or longitudinal,
is it possible to reach conclusions about the effects of adoption during
the entire life cycle and the real possibilities of developmental recovery
in early adverse situations. This paper also provides a list of psycho-
logical measures that can be used in future research with adult adopted
population.
4.3. Limitations
The review draws attention to the diversity of variables related to
psychological adjustment and the large amount of measures used to
assess every one of them. This may influence the comparability of the
different studies. In addition, the number of included studies that
examine some variables is sometimes not enough to establish definitive
conclusions about them. Furthermore, most of the studies did not
include information about adverse childhood experiences of those
people, although it is known, because of existent research with children
and adolescents, that those factors have an important influence in their
adjustment. Recently, research showed that being exposed to adverse
experiences in childhood has an influence in adult mental health,
increasing the risk for some disorders (Merrick et al., 2017).
Brecha On the other hand, there is an important gap on the knowledge
about the influence of possible changes on the structure of adoptive
IMP
families in psychological adjustment. For example, little is known about
the role of additional adoptions in different times, about the role of
other people in the family, or about the influence of divorce. There is a
limitation when we compare adopted individuals to people from
disrupted families. Taking into account the high percentage of divorces,
some adoptees might have had to face a double challenge, the fact of
being an adoptee and if their parents were no longer together.
Another limitation of systematic reviews is that they only include
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Children and Youth Services Review 77 (2017) 188–196
published works. There may be other researchers with unpublished
works who did not find differences between adoptees and non-adoptees
or other studies in which the hypothesis was rejected. Studies with
statistically significant results are more likely to be published than
those that do not find group differences. This implies a publication bias
(Dwan, Gamble, Williamson, & Kirkham, 2013).
Señalar
Finally, we must highlight that drawing definitive conclusions is
really difficult because we included different studies with different
purposes in different ways and with different samples.
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