Promoting adoption clinical competence in mental health professionals

Full text

In M. Andolfi, M. Chistolini, & A. D’Andrea (Eds.) (2017), La famiglia adottiva tra crisi e
sviluppo. Milano: Franco Angeli.
Promoting Adoption Clinical Competence in Mental Health Professionals
David M. Brodzinsky, Ph.D.
Research Director, National Center on Adoption and Permanency
Professor Emeritus, Developmental and Clinical Psychology
Rutgers University
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Promoting Adoption Clinical Competence in Mental Health Professionals
Mr. and Mrs. R, a white, middle class couple, sought help for their 14 year old son,
Andrew, who had been adopted from Ethiopia at the age of two years. Following his
birth, he lived for four months with his maternal grandmother and two older siblings,
before she became unable to care for him and, consequently, placed him in an
orphanage. Both parents were reported to be deceased and no other biological family
members were available to raise him.
During the initial meeting with the parents, Mr. and Mrs. R stated that from the time of
his adoptive placement Andrew had been difficult to manage. Early on, he had problems
sleeping by himself and cried incessantly. When they brought him to their bed, he was
difficult to sooth and resisted being held. According to his parents, as he got older, he
started hoarding food and stealing toys from his siblings and friends. Separation anxiety
made it difficult for him to adjust to school. Frequent somatic complaints (e.g.
stomachaches and headaches) resulted in teachers calling his parents to bring him home.
Despite numerous pediatric evaluations, no medical basis was found for his physical
symptoms. His frequent school absence during first and second grade resulted in
academic and social difficulties. During third grade, psychological assessment revealed
that he was of average intelligence and had no learning disabilities. There was also no
indication of attention deficits or hyperactivity. Profound feelings of abandonment,
depression, and identity problems, however, were noted. Andrew was preoccupied with
trying to understand the reasons for his adoption and why his grandmother kept his older
siblings but not him. He believed that her decision was confirmation that something was
wrong with him. In addition, despite loving his parents, he also felt out of place in the
family because he was a different race from them and his younger brother, who had been
adopted from Russia. Mr. and Mrs. R recognized their son’s discomfort about his origins
and the racial differences in the family, but were unsure about how to manage them.
Over the years, Mr. and Mrs. R had sought counseling for Andrew, first when he was
seven years old and then again when he was 13 years old. Although some positive
changes had been made in Andrew’s behavior during the periods he was in therapy, his
parents indicated that depressive symptoms and preoccupation with his adoption, as well
as identity issues related to being of African origin, continued to plague him. When
asked how adoption related issues were managed by the previous therapist, Mr. and Mrs.
R noted that they were seldom raised in sessions with them. In addition, their son
indicated that he seldom talked with previous therapists about his feelings about being
adopted or being a different race from his parents. When the couple attended a local
adoptive parent workshop and realized that important issues were being ignored in their
son’s therapy, including more active involvement by them, they sought a referral to
another mental health provider, this time with someone who had a specialty in working
with adoptive families.
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The experiences of Mr. and Mrs. R are not unusual. Too often, adoptive families work with
mental health professionals who do not really understand how adoption impacts a person’s
identity and family dynamics (Atkinson, Gonet, Freundlich, & Riley, 2013; Brodzinsky, 2013;
Chistolini, 2010). Like Mr. and Mrs. R, many clients report that adoption is seldom, if ever,
raised in the course of therapy. Other parents suggest that therapists do not seem to understand
or validate their experiences or the experiences of their children. Some have even reported that
their experiences in working with mental health professionals have done more harm than good
because of unhelpful advice, judgmental attitudes, or inadequate treatment planning related to:
(a) failing to gather information about the child’s pre-adoption history, including experiences of
neglect and abuse, as well as knowledge about and involvement with birth family; (b) blaming
parents for their children’s problems; (c) pathologizing adoption and/or viewing the family as
pathological; (d) questioning parents’ motives for adoption, or for the particular type of adoption
they decided upon (e.g., transracial placement; special needs child; open adoption); (e) advising
parents not to talk about adoption with children because it will “stir things up”; (f) speaking out
against open adoption or seeking information about their child’s origins; (g) telling parents to
turn their child over to governmental authorities when problems become quite serious; (h) seeing
the child individually, without parental involvement in therapy, especially when there is a history
of attachment problems or trauma that may require specialized types of parental support
(Brodzinsky, 2013).
In short, one of the most frequent complaints of adoptive parents is their inability to find mental
health professionals who are adoption clinically competent. In this chapter, I discuss the reasons
why there is a need for more professionals to receive specialized training in working clinically
with members of the adoption kinship system (adopted persons, adoptive parents, birth parents).
I also discuss what it means to be adoption clinically competent and the different pathways for
achieving this goal.
Psychological Risk Associated with Adoption
Why is it important for mental health professionals to understand adoption and its impact on the
individual and her family1? This is a legitimate and important question that must be addressed
before any progress can be made in convincing mental health professionals of the need for
specialized training in this area.
For over a half century, social scientists have been investigating patterns of adjustment of
adopted children and youth compared to their peers who are raised by their biological parents
(Palacios & Brodzinsky, 2010). Early studies focused primarily on domestically born children
who were placed as infants into adoptive homes. Subsequent studies explored adjustment
patterns of domestically born children who had been removed from the care of their parents by
child welfare authorities because of neglect, abuse, or other difficult family circumstances, and
placed in foster care or institutional environments prior to being adopted. And still other
research focused on the adjustment of internationally adopted children who had experienced
varying levels of deprivation and who had often lived in an orphanage prior to adoptive
placement. The result of this extensive body of research is clear: adopted children show elevated
patterns of psychological and academic problems compared to their non-adopted peers. They are
1 To avoid grammatical awkwardness, I will alternative gender pronouns, section by section, throughout
the paper.
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significantly overrepresented in both outpatient and inpatient mental health facilities
(Brodzinsky, Santa, & Smith, in press; Elmund, Lindblad, Vennerljung & Hjern, 2007; Howard,
Smith & Ryan, 2004; Keyes, Sharma, Elkins, Iancono & McGue, 2008), and are more likely to
be diagnosed with a range of externalizing and internalizing psychological symptoms than are
children raised by their biological parents (Juffer & van IJzendoorn, 2005; Rosnati, Montirosso,
& Barni, 2008). On the other hand, the magnitude of adjustment differences between adopted
and non-adopted children and youth, while generally significant, is small in effect size, except
for mental health referral rates, for which there is a larger group difference. This finding
suggests that most adopted children are within the normal range of adjustment, even though as a
group, they are more likely to manifest adjustment difficulties and be treated by a mental health
professional.
Not all adoptions are the same or are associated with the same level of psychological risk. For
example, children placed as infants are at less risk for adjustment problems than those placed as
older children (Tan & Marn, 2013). Children placed from domestic foster care or institutions,
and those placed from abroad, usually are older when entering their adoptive family. They also
are more likely to have experienced prenatal complications associated with exposure to drugs
and alcohol, heightened maternal stress, and in utero malnutrition, as well as postnatal adversities
such as neglect, abuse, domestic violence, parental psychopathology, multiple foster care
placements, orphanage life, and exposure to other traumatic events (e.g., war and civil strife).
These experiences, rather than adoption per se, are believed to account for the majority of
psychological and learning problems manifested by adopted children. In short, although adopted
children and youth are at increased risk for a range of adjustment difficulties, most of their
problems can be accounted for by factors that predate their entrance into the adoptive family. In
fact, adoption can be a healing experience. Research suggests that placement into a stable and
nurturing adoptive family has often been found to promote significant (albeit, sometimes
incomplete) psychological and physical recovery among children whose previous life was
seriously compromised by grossly inadequate child care conditions and other traumatic life
experiences (McCall, van IJzendoorn, Juffer, Groark, & Groza, 2011; Palacios, Román, Moreno,
León, & Peňarrubia, 2014; van IJzendoorn & Juffer, 2006). In keeping with this conclusion,
Harwood, Feng & Yu (2013) noted that the impact of pre-placement adversities on children’s
long-term adjustment is significantly mediated by the quality of adoptive parent-child
relationships.
Adoption-Related Family Tasks.
Adoption is not only associated with a higher rate of early life adversity, it also presents parents
with normative challenges at each stage of the family life cycle that can impact children’s self-
esteem, identity, family relationships, and psychological adjustment (Brodzinsky, 1987;
Brodzinsky, Schechter & Henig, 1992). When these challenges are handled well by parents,
children are better able to integrate the adoption experience into their lives in a healthy manner;
when they are ignored or poorly managed, children’s emotional adjustment and family
relationships can suffer.
At around six years of age, Maria began asking questions about her birth and whether
she had grown inside her adoptive mother. Mr. and Mrs. S were unsure what to say. On
the one hand, they wanted to be truthful with their daughter and share information about
her birth family and the reasons for her adoption. Yet each time Maria asked questions,
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Mrs. S felt such deep sadness about her inability to conceive a child, and the lack of a
biological tie to her daughter, that she could not bring herself to talk about the adoption.
Sensing that her mother was avoiding her questions, Maria persisted with them,
ultimately leading to an emotional scene in which the mother, crying uncontrollably,
acknowledged that she had been born to another woman, following which they had
adopted her. Mr. and Mrs. S reported that Maria appeared more upset with her mother’s
distress than with the news that she had been adopted. Realizing that they needed
support, the parents sought counseling from a therapist who specialized in working with
adoptive families. Mrs. S was helped to manage her grief related to infertility and to
understand how it had complicated the process of sharing even basic adoption
information with her child. The couple was also provided with support regarding
sharing background information with Maria, how best to help her understand and cope
with her adoption, and how to reframe some of the more sensitive background
information in a way that did not disparage the birth family.
One of most important tasks for adoptive parents is acknowledging that raising an adopted child
is a different experience from raising a child born into the family (Brodzinsky & Pinderhughes,
2002), if for no other reason that their child will always be connected to two families – one that
gave them life and one in which they were raised. The ability of parents to understand and accept
this reality helps them support their children in their efforts to integrate adoption into their
emerging sense of self. For example, once children are told that they were adopted, it is
inevitable that they will have thoughts, feelings, and perhaps questions about their birth family
and the circumstances that led to their adoption. Parents who acknowledge the differences of
adoptive family life will be better prepared to validate, normalize, and support their children’s
curiosity about adoption. But doing so requires that parents create an environment where
children feel free to share their thoughts and feelings and seek answers to questions about their
origins, even in situations when there is little information available about the birth family, which
is often the case in intercountry placements. In other words, regardless of whether an adoption is
open or closed in terms of contact with birth family, or whether there is little or much
information known about them, all families should strive toward being communicatively open
with respect to adoption issues (Brodzinsky, 2005). Research has shown that open
communication about adoption enhances children’s self-esteem, supports more positive parent-
child relationships, and facilitates healthier psychological adjustment (Brodzinsky, 2006, 2011;
Hawkins, Beckett, Rutter, Castle, Colvert, et al., 2007; Ferrari, Ranieri, Barni, & Rosnati, 2015;
LeMare & Audet, 2011).
Mrs. W reported that from the time her daughter was five years old, she had been
extremely curious about her origins. Born in China and placed at the age of 19 months,
Lia, who was currently 11 years of age, wanted to know what her birth parents looked
like, why they didn’t raise her, and whether she had any brothers or sisters. Not having
any knowledge about her birth family or the nature of her life prior to entering an
orphanage at six months of age, Mrs. W was unable to provide the information that Lia
sought. But, intuitively, she recognized the normality of her daughter’s questions, and
was not threatened by them. With a deep sense of empathy, she acknowledged how
difficult it must be for Lia not to have information about her birth family. Furthermore,
in many conversations that emerged over time, she explored with Lia different
possibilities about what might have happened that resulted in her adoption. She made
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sure that Lia knew that all questions were welcomed and respected, and that she would
support all efforts to help her daughter find answers to them, including planning a family
trip to China for Lia’s 13th birthday.
When children come from backgrounds filled with trauma and adversity, especially when birth
parents are known to have been neglectful, abusive or suffering from mental illness or substance
abuse, adoptive parents often find it difficult to engage their sons and daughters in discussions
about their origins. Sometimes children’s questions are ignored or dismissed by parents as
unimportant – “that’s in the past … let’s focus on now”; sometimes, in an effort to protect their
children, parents lie about what is known about the birth parents or the circumstances leading to
the adoption; and in some cases, parents share the difficult background information, but do so
with comments that unnecessarily denigrate the birth parents. To be sure, the task of sharing
difficult background information with children is a challenging one, with no easy answers. But it
is a task that must be accomplished if parents want to help their children understand their
adoption experience in a healthy and supportive manner. Success in achieving this goal often
requires input and guidance from professionals who understand the complexities of adoption and
how best to share difficult background information with children of varying ages (Brodzinsky,
2011).
Adoption involves loss. In fact, the loss is much more pervasive than is generally realized
(Brodzinsky, 1990, 2011) and includes, but is not limited to, loss of: (a) birth parents, birth
siblings, and extended birth family; (b) previous non-biological caregivers and supports such as
foster parents, foster siblings, teachers, peers; (c) social status, associated with adoption-related
stigma; (d) “fitting in” with one’s family, as a result of genetic-based differences in physical,
intellectual, and personality characteristics; (e) racial and ethnic heritage; and (f) identity. In
addition, adoption related loss is often difficult to resolve because of a lack of information about
the past, the ambiguous nature of the loss, and the lack of recognition and support for the loss by
others, both within and outside of the family. Too often children hear comments that emphasize
“being grateful for what they have” and minimize that which they have lost. When this occurs,
the ability to grieve is compromised, leading to disenfranchised grief (Doka, 2002), which
increases the risk for adjustment difficulties. Professionals can support parents in helping their
children understand and cope with their unique family status by offering guidelines for talking
about adoption. Some of the points to be addressed include (see Brodzinsky, 2011 for additional
details):
•Discussing adoption with children is a process, not an event. Sharing
information unfolds over time and is geared toward children’s cognitive and
emotional readiness to integrate what they are learning about their family status
and history and to make appropriate use of it. In short, parents should take their
time with this process and recognize that children will need to hear their adoption
story again and again.
•Sharing adoption information should be a dialogue with children, not a
process of talking to them. Parent should give children the opportunity to ask
questions and be responsive to them. By listening to what children are asking,
parents will be in a better position to understand their needs and whether their
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comprehension of the information presented has been reasonably accurate or not.
In short, parents should talk less, listen more, and encourage a give-and-take
discussion about the child’s adoption story.
•Begin the adoption story with birth and family diversity, not adoption. By
explaining the birth process and connecting it to the birth family, parents reinforce
the idea that “everyone is the same;” i.e., we all enter this world through the same
biological process. Once the “simple” facts of birth and reproduction are
discussed, parents can then talk about how families are formed. To reinforce the
fact that adopted children are not alone in living in a non-traditional family,
parents should then talk about the many different kinds of families that exist. In
short, even before identifying adoption as the means by which the child became
part of the family, parents should normalize, and even celebrate, the many faces of
family life, with adoptive families being just one of many diverse types that exist.
•Validate and normalize children’s curiosity, questions, and feelings about
their adoption, birth parents, and birth heritage. Parents often feel anxious in
response to their children’s questions about adoption. In turn, sensing their
parents’ discomfort, children often withhold additional questions and become
emotionally withdrawn regarding adoption issues. By normalizing children’s
curiosity about adoption, parents give them permission to ask questions about
their background and validate their connection to both their current family and the
one that gave them life.
•Be aware of your own feelings and values related to infertility, birth parents,
and the child’s history. Unresolved feelings related to infertility and the lack of
a biological tie to one’s children, as well as the difficulties faced by birth family
members that led to the adoption often create confusion and anxiety for adoptive
parents in their efforts to be open and supportive during the “telling” process.
Parents will often need help from a therapist in working through their own sense
of loss associated with infertility, as well as how best to share difficult
background information with their child.
•Avoid negative judgments about birth parents or the child’s heritage. To feel
worry as a person, children need to believe that they come from worthwhile
beginnings. Accordingly, as adoptive parents share background information with
their children, they must avoid negative descriptions or derogatory comments
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about the birth family. Otherwise, children’s identity and self-esteem could be
compromised.
•Reframe difficult background information. Parents are frequently unsure
about when and how to talk about the early adversity and trauma experienced by
their child prior to the adoptive placement. Professionals need to stress several
points about sharing difficult background information. First, do not lie! It is
better for parents to acknowledge that they know some information about the
child’s background that they believe is best shared when the child is older –
because of its complexity – rather than to avoid saying anything or lying about
having additional information. Secrets are difficult to keep and can undermine
family relationships. Although perhaps feeling frustrated and even a bit angry
about not having all their questions answered immediately, children will learn to
trust their parents when they follow through with promises to share additional
adoption information as the child gets older.
Parents are also encouraged to differentiate between the birth parents’ intent and
desire in relation to their child as opposed to their actions. Often birth parents
intend to nurture their children and want to be loving and attentive parents, but
fail to do so for reasons that may be beyond their control (e.g., poverty,
psychiatric disturbance). With the help of professionals, adoptive parents should
try to reframe the difficult life circumstances encountered by the birth family in
ways that allow the child to have a balanced and healthier view of them. One
possibility is through the use of an illness model. Birth parents who could not
meet their children’s needs because of drug or alcohol addiction or who suffered
from a psychiatric disorder can be described as experiencing an illness that made
it impossible for them to make consistently good parenting decisions. Similarly,
neglectful and abusive behavior can be reframed as judgment problems, impulse
control problems, or inadequate knowledge about children’s need that prevented
them from being the type of parents they hoped and expected to be. Adoptive
parents need to be calm, empathic, self-confident, and reassuring when engaged in
these types of discussions with their children.
•Be prepared to help children cope with adoption-related loss and grief.
Parents often misunderstand children’s reactions to adoption-related information.
Too often when they see confusion, anxiety, embarrassment, sadness, and/or anger
manifested by their son or daughter, they panic and interpret the emotional
reactions and accompanying behaviors as reflecting significant psychological
problems. This conclusion often leads to a premature referral to a mental health
professional. Adoption experts can help parents by redefining the children’s
reactions – when it’s appropriate to do so – as a normal grief process. Doing so
often allows parents to more accurately understand their children’s experiences
and feel more empowered to help them manage their emotional distress.
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•Promote open, honest, and respectful parent-child communication about
adoption. Children are better able to work through adoption-related grief when
parents create a home environment that is characterized by openness, honesty,
trust, and respect. When children feel understood and accepted, even in the midst
of their confusion, sadness, and anger related to adoption, they will eventually
find ways of integrating this life experience into a healthy and secure sense of
self.
Another dilemma faced by parents who have adopted across racial, ethnic and/or cultural lines is
supporting their children’s self-esteem and identity. Although research suggests that transracially
adopted children show similar patterns of psychological adjustment compared to those who are
the same race or ethnicity as their parents, difficulties in racial/ethnic self-esteem and identity
can, and often do, occur (Smith, McRoy, Freundlich, & Kroll, 2008). Sometimes children
experience discomfort because of the physical dissimilarities between themselves, family
members, friends, and neighbors. Experiences of overt prejudice and discrimination, as well as
the experience of micro-aggressions related to race and/or adoption (Sue et al., 2007; Rosnati &
Ferrari, 2013), are not uncommon. Coping with racial differences in the family poses another
layer of challenge for parents and children, which often benefits from specialized preparation,
education, community support, and professional guidance. For example, parents will need to
examine their thoughts and feelings about race, ethnicity, and culture. Those who have prided
themselves on being “color blind” will need to recognize that this personal perspective may not
serve their children well. Being open to their children’s experiences of being a different race or
ethnicity than their parents, extended family, and others in the community, will help parents
understand what steps must be taken to ensure that their children are not only well integrated into
the family, but are developing security and pride in their birth heritage.
“I don’t look like anyone in the family … they’re white and I’m black … I love them of
course, but they just don’t understand what it’s like for me. I don’t know if they see the
stares of others when we are in a restaurant or at stores, but I do. Those people are
wondering, ‘what’s their story … guess they adopted him.’ And then maybe they start to
think about what happened to me before my adoption … maybe even feel sorry for me …
I don’t care if people know I’m adopted, but being black and having white parents means
that I can’t control whether they know or not. They just have to look and then they see
that I don’t really belong to this family … And I don’t like that people might be thinking
about the problems that my birth family had … that’s private stuff … Maybe it’s all in my
head and they aren’t thinking about my adoption … But I can’t help wondering about it
…” [Justin, 14 years old; born in Ethiopia and placed for adoption at 3 years of age]
Seeking information about, and contact with, birth family is becoming increasingly common, not
only in the U.S., but in many European countries. Although contact is typically easier in
domestic adoptions, it is also occurring in intercountry adoptions. For example, a study by
Tieman, van der Ende and Verhulst (2008) of 1,417 international adoptees in The Netherlands
found that 32% of adult adoptees, 24 to 30 years of age, had searched for birth relatives or
information about them, with 14% reporting that they had reunited with one or more members of
their birth family. Another 32% expressed interest in their origins, but had not yet taken steps to
search for birth family members. Whereas searching was once viewed as a reflection of
psychopathology among adopted individuals or a disturbed adoptive parent-child relationship, it
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is now understood to be a normal extension of identity development (Brodzinsky, et al., 1992;
Grotevant, 1997; Schechter & Bertocci, 1990). Moreover, with the development of the internet
and the rise of social media, searching has become not only easier, but more common, not just
among adopted individuals, including adopted youth, but also among birth family members
(Howard, 2012; Whitesel & Howard, 2013). Adoptive parents frequently need professional
preparation, guidance and support related to search issues, including but not limited to:
understanding the motives of their children’s interest in searching; how best to support those
interests; the benefits and risks associated with contact with birth family; understanding and
working through their own feelings regarding their children’s desire for contact with birth
family; managing their children’s search interests and behavior on the internet; preparing for
unplanned contact by birth family; and managing unmediated contact between their children and
birth family members, if it occurs.
In summary, there is a wide range of personal, interpersonal, and situational factors that are
commonly faced by adopted children and their parents that can be challenging and increase the
risk for adjustment difficulties. Whether the issues experienced by the adoptive family are tied to
the type of adverse pre-adoption experiences noted in the prior section, the more normative post-
adoption issues described in the current section, or a combination of factors, adoptive parents not
only need effective pre-placement preparation and education, but readily available post-adoption
professional support (Brodzinsky, 2008). In other words, they need access to mental health
professionals who are adoption clinically competent.
Adoption Clinical Competence
There is no widely accepted definition of what constitutes adoption clinical competence,
although numerous adoption scholars and adoption practitioners have contributed to the ongoing
discussion about this issue (Atkinson, et al., 2013; Brodzinsky, 2013; Casey Family Services,
2003; Center for Adoption Support and Education, 2012; Janus, 1997; National Child Welfare
Resource Center for Adoption, 2007; Tarren-Sweeney, 2010; Tarren-Sweeney & Vetere, 2013).
Adoption clinical competence represents a range of knowledge, skills, and experiences related to
the assessment and treatment of members of the adoptive kinship system. This competence
begins with graduate level training in one or more disciplinary areas related to mental health and
child/family welfare (e.g., psychiatry, psychology, social work, marriage and family therapy,
etc.). Although typically providing a broad-based understanding of clinical theory,
individual/family assessment, and treatment approaches that are commensurate with practice
guidelines for their respective disciplines, these programs, by themselves, are usually insufficient
for fostering adoption clinical competence. In fact, most programs seldom provide any
meaningful training related to the psychology of adoption and foster care. For example, in a U.S.
national survey of licensed psychologists, Sass and Henderson (2000) found that two-thirds of
respondents reported having no graduate coursework related to adoption, and less than one third
believed they were very well prepared or well prepared to treat adoption issues. Similarly, in a
U.S. survey of 224 directors of clinical training programs in marriage and family therapy, social
work, or counseling, Weir, Fife, Whiting, and Blazewick (2008) found that very few programs
offered specific coursework in adoption (4.8% to 16.3%) or foster care (2.6% to 22.1%),
although these topics were sometimes incorporated into other courses. In addition, the impact of
the limited training received by clinicians can be seen in a study of family therapists conducted
by McDaniel and Jennings (1997). Presented with a simulated case study of an adoptive family
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that explicitly highlighted adoption issues as a presenting problem, only 16% of the family
therapists focused aspects of their intervention on adoption-related issues. Limited graduate
training related to adoption has also been reported for medical students, including pediatricians
(Henry, Pollack & Lazare, 2006), as well as teachers (Stroud, Stroud, & Staley, 1996; Tayman,
Marotta, Lynch, Riley, Ortiz, et al., 2008), two groups of professionals who routinely interact
with and are responsible for the well-being of adopted children and adolescents, and their
families.
Issues in Assessment
Clinicians working with adoption kinship members benefit from maintaining a bio-psychosocial
perspective in their assessment and understanding of the individuals and families they serve
(Bronfrenbrenner, 2005; Palacios, 2009). Although all people exist within, and are impacted by,
a complex array of interacting systems, this reality is even more so for adopted children and their
parents. In forming their families, adoptive parents require the aid of the legal and child welfare
systems. As they raise their children, they more often require the help of mental health
professionals, medical professionals, and special education professionals. Furthermore, adopted
children, and by extension, their adoptive parents, are parts of a complex, extended kinship
system involving birth families and, in some cases, previous foster families. When parents adopt
children who are biologically unrelated, or come from different cultural heritages, the extended
kinship system grows even larger and becomes more complex. Integrating birth (or foster)
family members into the lives of the adoptive families, as well as children’s cultural and ethnic
heritages, can pose challenges for adopted individuals and their parents. Even when there is no
actual contact with these individuals, birth family members can have a significant psychological
impact on the emotional lives of adoptive family members (Brodzinsky, 2014). Clinicians who
adopt an ecological perspective of adoptive family life, with an appreciation of the complex
array of interacting systems that impact them, will be in a much better position to effectively help
their clients.
To understand of how adoption issues impact the psychological dynamics of the child and family,
it is important for therapists to integrate adoption related information into the clinical intake
process. Some of the key areas to explore when interviewing parents include:
•Motives for adopting. Did one or both parents experience infertility? If so, how
has fertility loss been dealt with by the individual or couple? What other motives
led to the adoption?
•Motives for a specific type of adoption. Why did parents choose to a specific
type of adoption – e.g., a newborn baby or an older child; a healthy child or one
with special needs; a child of the same race/ethnicity or one from a different
race/ethnicity; a child born domestically or from another country? Have their
experiences of integrating the child into the family been consistent with their pre-
adoption expectations?
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•Information on the child’s background. Given that adopted children often
experience early adversity and trauma, clinicians need to inquiry in detail about
the child’s life experiences prior to entering his new family. Did the child
experience multiple caregivers and/or orphanage life, and, if so, for how long? Is
there evidence of previous neglect, physical abuse, sexual abuse, or other trauma?
Is there information about the birth parents’ mental health, the prenatal experience
of the child, and post-natal care by birth family or others? Knowledge about these
types of background experiences allows clinicians to have a better understanding
of the challenges faced by the child and his parents and to develop more effective
treatment plans.
•Experiences during the adoption process. Did the parents feel supported and
welcomed during the adoption process or was it more stressful than expected?
Did they receive pre-placement preparation and education related to adoption, in
general, and, in particular, with regard to the unique issues associated with their
adopted child (e.g., managing attachment issues, transracial placement, etc)? Was
the preparation and education sufficient for their needs and the needs of their
child?
•Experiences in sharing adoption information with their child. What are the
parents’ attitudes regarding talking about adoption with their child? Have they
been comfortable doing so or not? What background information have they
shared and what hasn’t been shared? What are their reasons for not sharing
specific background information? Do they encourage discussions about adoption,
and, if so, how? Are they aware of their child’s view about being adopted, and, if
so, what do they believe he understands or feels about the adoption? Has their
child’s reaction to being adopted changed over time, and, if so, how has it
changed? Has their child’s reaction to being adopted been different than they
expected, and, if so, in what way? How have they tried to help their child cope
with his adoption?
•Parental attitudes about, and contact with, their child’s birth family. What
do parents know about the birth family, including the circumstances leading to the
child’s separation from them? What are their feelings about the birth family?
Prior to being adopted, was their child in contact with birth family members, and,
if so, with whom? Which family members, if any, does the child remember or
talk about? Does the family have any form of contact with birth family members,
and, if so, with whom, in what way, and how frequently? Has their child shown
interest in contact with birth family, and, if so, have any plans been discussed
regarding making contact with them or visiting the child’s birthplace?
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•Parental sensitivity to racial, ethnic, and cultural issues (for transracial
families). To what extent are parents aware of and sensitive to racial, ethnic, and
cultural differences between themselves and their child? Do they approach these
issues from a “color blind” or “color awareness” perspective? Have they taken
steps to learn more about their child’s racial/ethnic/cultural birth heritage, and, if
so, in what way? Have they taken steps to support their child’s connection to his
racial/ethnic/cultural heritage, and, if so, in what way? Has their child had
experiences of being teased because of his race or ethnicity, and, if so, have
parents taken steps to help their child learn how to cope with racial/ethnic
prejudice? How has their child coped with being a different race/ethnicity from
them?
•Social support and feedback from others about adoption. What was the extent
and quality of support from family, friends, and neighbors regarding adoption,
and, in particular, for the specific type of adoption the parents decided upon (e.g.,
older, special needs child; transracial/transethnic placement)? Are family
members aware of others who have adopted a child? Is the family connected to
community supports for adoption (e.g., groups for parents and/or children;
adoption education programs)? What has been the family’s experience in working
with other mental health, medical, and/or educational professionals in relation to
adoption issues?
When interviewing children, professionals are advised to explore additional adoption issues,
including, but not limited to:
•Children’s knowledge and feelings about being adopted. What is the meaning
of being adopted for the child? How does she understand it and what are her
feelings about being adopted? Have her feelings changed over time, and, if so, in
what way? How has being adopted impacted the child? What is her sense of
being similar to or different from other children because of her adoption? What is
her sense of connection to her parents? Was she old enough at the time of
placement to remember becoming part of the family? What was it like for her
during this time? How easy or difficult was it for her to feel that she was part of
the family?
•Communication about adoption. Is the child comfortable talking about
adoption with her parents, and with others? Does the child believe that her
parents are comfortable discussing adoption issues with her? Does the child
believe the parents are aware of her feelings about being adopted?
•Knowledge, beliefs, and feelings about birth family. What information does
the child know about her birth family, and the circumstances leading to the
13

adoption? Does the child have memories of birth family members or other
previous caregivers, and, if so, what feelings are associated with these memories?
To what extent is the child curious about the birth family and birth heritage?
What fantasies does she have about them? Does the child have contact with any
birth family members, and, if so, with whom? If not, does the child have interest
in finding out more about the birth family and possibly making contact with
them? Has the child taken any steps on her own to try to find them, such as
conducting an internet search or seeking them through social media?
•Support and feedback from others about adoption. Does the child feel
supported by the parents regarding her interest in adoption, including information
about the birth family? To what extent does the child experience support from
extended family, friends, and others? Has the child ever been teased about being
adopted or about being a different race/ethnicity from her parents? Does the child
have contact with others who are adopted, and, if so, has contact been helpful?
Issues in Diagnosis, and Treatment
With the emergence of empirically validated treatment approaches for specific clinical problems,
clinicians are increasingly concerned with identifying the nature of a client’s problems and
implementing interventions that have been shown to be effective in reducing them. Traditional
diagnostic systems in mental health (e.g., DSM-V and ICD-10), however, are often inadequate
for describing the complexity of symptoms manifested by adopted, foster, and institutionalized
children or in guiding clinicians toward helpful interventions (Casey Family Serices, 2003;
DeJong, 2010; Tarren-Sweeney, 2008, 2010; Tarren-Sweeney & Vetere, 2013). The multiple
adversities experienced by so many boys and girls prior to adoption often lead to an array of
symptoms that too frequently become an “alphabet soup” of diagnoses (ADHD, FAS, ODD,
CD), as parents take their children from one professional to another. Patterns of diagnostic co-
morbidity are extremely common among children with disruptive and traumatic histories, which
can create confusion and pose challenges not only for parents, but also for therapists who are
responsible for formulating and implementing an effective treatment plan. Mental health
professionals working with this population of children and families need to adopt a more
nuanced and systemic perspective in their assessment and treatment planning.
Given their histories of neglect, abuse, relationship disruptions, and other early adversities, many
adopted, foster, and institutionalized children are likely to benefit from specialized interventions
that are empirically validated or represent promising practices for treating trauma and attachment
difficulties, such as, but not limited to: trauma-focus cognitive behavior therapy (Dorsey &
Deblinger, 2012), eye movement desensitization and reprocessing therapy (Adler-Tapia & Settle,
2009), child-parent relationship therapy (Bratton, Landreth, & Lin, 2010; Carnes-Holt, 2012),
dyadic developmental psychotherapy (Becker-Weidman & Hughes, 2008), ARC: attachment,
self-regulation, and competence (Blaustein & Kinniburgh, 2010), theraplay (Booth & Jernberg,
2010, Weir, Lee, Canosa, Rodrigues, McWilliams, & Parker, 2013), narrative therapy (Lacher,
Nichols, & May, 2005; Vetere & Dowling, 2005), and multi-dimensional family therapy (Liddle,
2010). Although mental health professionals cannot be expected to be experts in all of these
interventions, they are advised to become proficient in some of them. As adoptive parents
14

become more informed advocates for their children, they will seek clinicians who are
knowledgeable and skillful in implementing trauma and attachment informed treatment plans.
Children and families also benefit from adoption-specific interventions, which are often
integrated into a broader therapeutic treatment plan (see Brodzinsky, Smith, & Brodzinsky, 1998
for a review of some of these approaches). Lifebook work, pictorial timelines, journal writing,
written role play, and therapeutic rituals are variations of narrative theory and focus on helping
the adopted person understand and process his significant life events, as well as his thoughts and
feelings related to adoption. Although space does not allow for a description of these types of
interventions, an example of written role will highlight its utility for addressing adoption issues.
Typically, written role play is used with adolescents and adults, although I have successfully used
it with children as young as nine years of age. The adopted person is asked to write a letter to
one of his birth parents or another birth family member, sharing whatever thoughts or feelings he
wishes. The person is informed that the letter is not intended to be sent to the recipient, but is
only a means of expressing his thoughts and feelings. Once the letter is completed, the person is
then asked to pretend that he is the recipient of the letter (e.g., the birth parent) and to write a
response, including any thoughts or feelings that he imagines the recipient might choose to share.
When the second letter is finished, the person then is asked to imagine receiving the letter and to
write another one in response. In essence, written role play involves a “correspondence with the
self” regarding unanswered questions, hopes, desires, and fears of the adopted person in relation
to the imagined or symbolic birth family member. This type of intervention can occur in a single
session or across sessions; it can be a single intervention or one that the therapist and client
occasionally returns to over the span of therapy. The goal, of course, is to help the adopted
teenager or adult to externalize that which has been internalized for too long, so as to able to
more effectively process the issues raised and find a healthier way of integrating them into the
emerging sense of self. Considering the following excerpts from Danielle, at 16 year old girl,
adopted at the age of three years from Guatemala.
Dear (blank),
Yesterday was my birthday. I’m now 16. I wonder if you thought about me yesterday.
I’ve often wondered whether you think about me … do you even remember me? … do you
remember what I looked like as a baby? … I can’t remember you … we have pictures of
Guatemala and the village where I was born but none of you or others in my family … it
makes me sad sometimes … Don’t get me wrong though. I expect that there was a good
reason why you didn’t keep me … probably too poor to raise me. I know that I’m
supposed to be grateful for being adopted, and I am in many ways … but it still makes me
sad that I don’t know who you are.
Your daughter (by birth),
Danielle
In the same session, she responded:
Dear Danielle,
Of course I remember you … A mother never forgets, never stops feeling love for her
child …I wish I had a picture of you too, so I could see what you look like now … it must
15

be hard for you not to know about me … it’s hard for me too. I’m thankful that you have
a good life and know that you love your parents… that’s good … I wish I could see you
and have you meet all of your family here … maybe someday.
Your birth mother
Two weeks later, Danielle shared the following brief letter which she wrote at home:
Dear (blank),
I don’t know what it would be like visiting you … I don’t know if I would feel comfortable
… I don’t know how to speak Spanish … sometimes I try to imagine that I grew up with
you … I try to imagine what my life would be like … I probably would be a completely
different person in so many ways … so it makes me wonder who I really am … it’s
confusing.
For Danielle, it is clear that she longs for information about her birth mother and hopes that her
feelings are reciprocated. Her letters also reflect the awareness that adoption probably has
benefited her life circumstances, for which she is grateful. Yet it has left her feeling unsure of
who she really is, as well as disconnected from her origins in terms of her native language. By
processing the issues raised in these and subsequent letters, written role play, in conjunction with
other forms of intervention provided opportunities for Danielle to integrate her life experiences,
stories, and fantasies into a more cohesive sense of self.
Adoption-Specific Training
Being adoption competent also means having in-depth knowledge about the ways in which
adoption impacts members of the adoptive kinship system. As previously noted, most graduate
training program provide little, if any, training in this area. So what are these areas of
knowledge? Although numerous professionals and organizations have addressed this issue, the
work of the Center for Adoption Education and Support (C.A.S.E.) represents the most
thoughtful and thorough attempt to define the core content areas for achieving adoption
competence (Atkinson et al., 2013; see also Brodzinsky, 2013). Key content areas for adoption
training were identified by a task force convened by C.A.S.E. that was comprised of adoption,
child welfare, and mental health researchers, practitioners, and policymakers, as well as members
of the adoption kinship system. These areas include, but are not limited to:
•Historical and contemporary perspectives on adoption practice
•Adoption law and its impact on family formation and family stability
•Nature and functions of the child welfare system and its impact on family life
•Different types of adoption and the issues and processes associated with each of them
•Lifespan developmental perspective on adoption, including how being adopted is
understood and experienced by adopted persons from infancy through adulthood
16

•Parenting tasks and adoptive family dynamics at various phases of the life cycle
•Adoptive parent preparation and post-adoption support needs
•Impact of infertility on adoptive parenting
•Impact of neglect, abuse, multiple caregivers, institutionalization, and other trauma on
neurological, social, emotional, and cognitive development
•Role of attachment and relationship disruption on children’s development and family
dynamics
•Nature of adoption-related loss and grief
•Issues in transracial, transethnic, and transcultural adoption, including ways of
supporting positive racial, ethnic and cultural identity in children and youth
•Issues in adoption by sexual-minority individuals and couples
•Psychology of search and reunion, including the role of the internet and social media as
tools for searching
•Impact of adoption and child loss on birth parents
•Support needs of birth parents during the adoption decision making phase and following
adoption placement
•Open adoption, including helping participants in their evolving relationships
•Ethical issues in adoption practice and counseling
Becoming Adoption Competent
Brodzinsky (2013) has emphasized that there is no single pathway to becoming adoption
clinically competent. Moreover, given that graduate programs in the helping professions focus
most of their training on core issues in their respective disciplines, with limited resources
available to provide in-depth training in the many specialized areas that impact individuals and
their families, it is unlikely to expect that most clinicians will finish their programs with a solid
knowledge base and well developed practical skills related to the psychology of adoption. So
how can a professional become sufficiently knowledgeable, skillful, and experienced to offer
sensitive and effective clinical services to members of the adoption kinship system?
One means is through post-graduate adoption certificate training programs. At least 16 such
programs are operating in the U.S. at the present time (Brodzinsky, 2013). Some have been in
existence for over two decades; others are brand new. Such programs are also available in some
European countries, including Italy. Although some post-graduate adoption training programs
are offered through universities, many are offered through private agencies or institutes.
Approximately half of the programs in the U.S. are based on the Training for Adoption
Competence (TAC) curriculum developed by the Center for Adoption Support and Education.
U.S. programs vary in their length from approximately 45 to 96 class hours. Although there is
17

considerable overlap in course content from program to program, those that are longer provide
more in-depth and broader coverage of key adoption related areas. In addition, some programs
offer a stronger clinical focus than others. Unfortunately, few require clinical supervision of
adoption related cases during the training period.
Adoption competence can also be fostered through continuing education workshops, online
training courses, and through participation in adoption conferences. Although these types of
training opportunities are becoming increasingly common, not only in the U.S. but throughout
Europe, they generally focus on selected adoption topics and are not part of an integrated and
comprehensive effort to enhance adoption clinical competence. To address this problem, at least
in the U.S., the federal government, in 2014, funded a five year National Training Initiative to
develop online, programmatic and comprehensive training in adoption competence for child
welfare and mental health professionals. This project, which is in development, is being headed
by the Center for Adoption Support and Education and its partners – see
http://adoptionsupport.org/adoption-competencyinitiatives/national-training-initiative-nti.
To remain adoption competent, even for those individuals who have gone through adoption
certificate training programs, professionals must be aware of current research and practice issues
related to adoption through regular attendance at continuing education workshops and
conferences. Knowledge about adoption and related areas has changed rapidly in the past decade
or so. Reliance on knowledge and skills gained through graduate school training, and even
previously attended post-graduate certificate programs, may be insufficient to meet the ongoing
needs of clients. As an example, consider the growth of knowledge over the past decade
regarding the influence of early life trauma on the developing brain and its impact on child health
and functioning (Lanius, Vermetten, & Pain, 2010; McCall, et al., 2011). Professionals who
remain unaware of this new information and its relevance for parenting and clinical intervention
will be poorly prepared to create an effective treatment plan. Commitment to ongoing
professional development through continuing education is a responsibility for clinicians in all the
helping disciplines. Adoption professionals must make a similar commitment and remember that
competence is an evolving process that must be nurtured through ongoing learning.
Becoming a competent clinician, whether in adoption or in other areas of child welfare and
mental health, requires more than in-depth, comprehensive classroom or distance instruction in
core content areas. It also requires putting newly developed knowledge and skills into practice,
under the supervision of a more experienced professional. Supervision is a core component of
professional development and needs to be incorporated into adoption clinical training. It
supports the less-advanced professional in forming an identity as an adoption clinical specialist
and facilitates more sensitive, effective, and ethical application of clinical knowledge and skills
in the service of meeting the needs of adoption kinship members. Competent clinical
supervision not only leads to better trained therapists, but also improved quality of care and
protection for the public. Unfortunately, few post-graduate training programs, at least in the
U.S., incorporate ongoing clinical supervision as part of adoption clinical training, and those that
do, offer it for a time limited period and as group supervision rather than individual supervision.
Mental health professionals who wish to improve their adoption knowledge and skills can also
benefit from being mentored by a more experienced colleague and/or through peer group
support/supervision. In my own practice, for example, I routinely mentor or supervise
18

colleagues as they work with adoption kinship members. In some cases, these are relatively
inexperienced individuals who have completed an adoption training program or taken one or
more adoption workshops but have not yet been supervised in applying their knowledge in
clinical practice; in other cases, they are experienced clinicians, but insufficiently trained in
adoption, who are interested in better understanding adoption issues that have emerged in a client
they are seeing. Furthermore, my own skills as an adoption clinician are continually enhanced
through regular participation in a peer support group composed of other professionals working in
the fields of adoption and foster care. The give and take of peer feedback and support ensures
that professionals, myself included, not only gain new insights into the clinical issues facing their
clients, but are better able to manage their own stress in confronting trauma and loss that are
routinely apart of adoption clinical work.
Finally, being adoption competent, like in any other professional field, means being aware of
one’s limitations. Being adoption competent does not inherently mean that someone is qualified
to meet the mental health needs of all members of the adoption kinship system. Adoption issues
are often difficult to disentangle from other presenting problems. A clinician may be well trained
to treat adoption issues and some mental health disorders, but not sufficiently trained to treat
other disorders. Unfortunately, one of the inherent biases among adoption professionals, in my
opinion, is to view clients primarily through the lens of adoption. This could very well lead them
to ignore certain presenting problems or misinterpret them as reflecting an issue related to
adoption adjustment. Adoption professionals need to maintain a balanced perspective in working
with their clients, recognizing that although adoption frequently plays an important role in the
psychodynamics of the individual and family, it is not always at the core of the presenting
problem. In addition, adoption clinicians need to be humble and recognize when a client’s
problems are beyond their area of competence and require a referral to another professional.
Summary and Conclusions
With the changes in adoption practice that have occurred over the past quarter century or more,
the makeup of adoptive families has become more complex and the challenges facing them have
increased. Although the majority of adopted individuals are within the normal range of
psychological functioning, as a group, they are at increased risk for a variety of negative
adjustment outcomes. As a result, adoptive families are more likely to seek the help of mental
health professionals. Unfortunately, many of these professionals do not understand the
psychology of adoption and are poorly prepared to meet their clients’ needs. In short, they are
not adoption clinically competent. Yet there is reason to believe that this pattern is slowly
changing. Throughout the U.S. and in many parts of Europe, including Italy, efforts are being
made to promote adoption competence among mental health professions. And there are a
number of ways in which professionals can become adoption clinically competent. In fact, to
become and remain competent, it is probably necessary to follow more than one path. Even
those who complete a post-adoption training program will still need to keep abreast of new
knowledge and techniques that are constantly emerging in the field. Remaining current with the
research, practice, and policy literatures in adoption and foster care, attending continuing
education programs in the field, and maintaining contact with other professionals who work in
the area are some of the ways of ensuring that one remains adoption competent, which, in turn, is
the best way of meeting the needs of members of the adoptive kinship system.
19

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