Use of mental health services by adults who were adopted as infants.
Subject: Psychiatric services (Social aspects)
Adoption (Social aspects)
Adoption (Psychological aspects)
Adoption (Research)
Adoption (Statistics)
Adoptees (Psychological aspects)
Authors: Pearson, Frances
Curtis, Reagan
Chapman, Amanda Milligan
Pub Date: 04/01/2007
Publication: Name: Journal of Mental Health Counseling Publisher: American Mental Health Counselors Association Audience: Professional Format: Magazine/Journal Subject: Health; Psychology and mental health Copyright: COPYRIGHT 2007 American Mental Health Counselors Association ISSN: 1040-2861
Issue: Date: April, 2007 Source Volume: 29 Source Issue: 2
Topic: Event Code: 290 Public affairs; 310 Science & research; 680 Labor Distribution by Employer
Product: Product Code: 8000186 Mental Health Care; 9105250 Mental Health Programs NAICS Code: 62142 Outpatient Mental Health and Substance Abuse Centers; 92312 Administration of Public Health Programs SIC Code: 8093 Specialty outpatient clinics, not elsewhere classified
Geographic: Geographic Scope: United States Geographic Code: 1USA United States
Accession Number: 162790215
Full Text: Adults adopted as infants (N = 156) were surveyed to determine the degree to which they had sought help or guidance with psychological issues during adolescence and adulthood. Less than 12% reported seeking help and women sought help more frequently than men. When they sought professional help, they mostly utilized counselors, psychologists, and psychiatrists, but frequently sought help from other sources such as friends, family, and support groups. The results of the study are discussed in light of literature that suggests this population is more frequently referred for help and recommendations are made for practice and research.

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Adoption is an issue that affects 6 out of 10 people in the United States, either directly or indirectly (Evan B. Donaldson Adoption Institute, 1997). The statistics on adoption demonstrate the extent to which adoption permeates our society. There are roughly 120,000 adoptions in the United States every year (U.S. Department of Health and Human Services [USDHHS], 2004). In 2000, for the first time, the U.S. government recognized the importance of studying adopted children and collected information on this population in the U. S. census.

Even though adoption is common in the United States, the research on the long-term outcomes of adoption is scarce (Lears, Guth, & Lewandowski, 1998). Much of it has focused on adjustment of adoptees in childhood and adolescence. Some research has shown adoptees struggle with a variety of psychological issues (e.g. Brodzinsky, Schechter, & Henig, 1992; Common Clinical Issues Among Adoptees, 1995; Issues facing adult adoptees, n.d.; Leon, 2002; Nickman, 1996; Stevens, 1995) and that some of those issues may persist into adulthood (Melina & Roszia, 1993; Child Welfare Information Gateway, formerly National Adoption Information Clearinghouse [CWIG], 2004). Additional studies have shown that adoptees are more likely than the general population to be treated for academic, emotional, or behavioral problems and be over-represented in mental and psychiatric hospitals. (Lears et al.; Miller et al., 2000). In contrast, other researchers have argued that individuals who are adopted experience no more mental health problems than individuals who are not adopted (Benson, Sharma, & Roehlkepartain, 1994a, 1994b; Hochman & Huston, 1995) and that most issues are resolved by adulthood (Nickman). Furthermore, the literature is clear about the degree to which children and adolescents are referred for help (Grotevant, 2000; Miller et al.), but less information exists about adult help-seeking behavior.

With about 20% of adoptions in the United States being domestic infant adoptions by non-relatives (Stolly, 1993; USDHHS, 2004), and with the lack of control for age of adoption in existing research literature, we chose to focus on this population. In order to better understand the help-seeking behaviors of individuals who are adopted, we decided to study adults who were adopted during infancy to determine the degree to which they reported seeking help or guidance on psychological issues during adolescence and adulthood and where they sought help.

Demographics of Adoption

During the 2000 Census, the government collected data for the first time on the number of adopted children living in U. S. households and a number of variables related to their adoption. The data revealed that 2.1 million adopted children and 4.4 million step children were living in American households. A higher percentage of Black children than White children were adopted. Thirteen percent were foreign born. Girls were adopted more often than boys because women prefer adopting girls and more girls are available through international agencies. In general, adopted children lived in families that were better off economically, compared to children who lived with their biological parents, and their parents were more often married, more highly educated, and more likely to own homes. A higher percentage of the adopted children than non-adopted children under age 18 had at least one disability, especially a learning disability, Attention Deficit Disorder, or mental disabilities related to maternal drug use, alcohol fetal syndrome, or other medical conditions (Kreider, 2003).

Psychological Issues

Some of the psychological issues that commonly occur among individuals who are adopted include a sense of loss, grief, shame, rejection, intimacy, control, identity formation, and depression (CWIG, 2004, 1995; Miller et al., 2000). A sense of loss seems to be inherent in adoption for all parties involved (Leon, 2002). Because adoptees lose their birth parents, they are deprived of health information, social history, cultural history, and status (Nickman, 1996). Feelings of loss are rarely completely resolved (Silverstein & Kaplan, 1982) and may intensify at milestone events, such as graduations, marriages, and childbirths. At these times, adoptees may wonder whether birthparents are thinking of them and how they would react to these milestones (Issues Facing Adult Adoptees, n.d.).

Loss often leads to grief, particularly if the adoptee has very little contact with the birth parents (Common Clinical Issues Among Adoptees, 1995; Hochman & Huston, 1995; Leon, 2002; Silverstein & Kaplan, 1982). Grief results from feeling unwanted and abandoned, as well as losing birth parents, possible siblings, culture, and religious heritage (Hayden, 1994). In children, unresolved grief may affect concentration, academics, self-esteem, identity, or peer relationships (Bower, 1994; Frank, 1991; Smith, 1993). The full impact of the grief may not be recognized until adolescence or adulthood when delayed or unexpressed grief can result in depression, delinquency, substance abuse, and aggressive behavior (Bower; Silverstein & Kaplan).

Feelings of rejection may result from adoptees' beliefs that their birth parents rejected them (Leon, 2002), and that they do not fit into their adopted family (Hochman & Huston, 1995). They may wonder whether there is something innately wrong with them that contributed to being un-chosen then chosen, and they may become convinced that they deserved to be rejected. This line of thought can result in resentment of the birth family, shame, or lowered self-esteem and self-concept (Bower, 1994; Common Clinical Issues Among Adoptees, 1995; Issues Facing Adult Adoptees, n.d.; Silverstein & Kaplan, 1982; Soria, 1984). As a result, they may avoid situations where they could potentially be rejected again (Silverstein & Kaplan).

The shame associated with adoption is often unrecognized by members of the adoption triad (birth parents, adoptive parents, adoptee) (Silverstein & Kaplan, 1982), yet feeling ashamed is a common feeling for adoptees (Common Clinical Issues Among Adoptees, 1995; Leon, 2002; Silverstein & Kaplan; Smith, 1993). Exacerbating this feeling is the secrecy sometimes associated with adoption practices (Silverstein & Kaplan).

A child who is adopted as an infant has no control over the decisions made at that time. The child does not choose to leave birth parents or choose the adopted family with whom to live (Common Clinical Issues Among Adoptees, 1995; Silverstein & Kaplan, 1982). If adopted children feel they have constantly been a pawn, they may be angry, engage in power struggles with authority figures, attempt to take control of their lives, and search for birth families (Hochman & Huston, 1995; Common Clinical Issues Among Adoptees, 1995; Hayden, 1994; Silverstein & Kaplan).

Adoption issues may become particularly salient during adolescence when adoptees enter Erikson's (1963) stage of identify formation (Silverstein & Kaplan, 1982). This is a time when all adolescents are struggling with issues of work and love, building relationships with role models and peers, making tentative steps into the adult world, and evaluating everything around them, including people, ideas, and values. For adolescents who are adopted, there are additional issues. They may begin to question their ancestry and search for identification figures (CWIG, 2006, 2005a). To complicate an already turbulent time, they must try to reconcile their relationships with two different sets of parents (Hochman & Huston, 1995). They may fantasize about what their lives would be like if they had stayed with their biological parents and rebel against their adoptive parents (CWIG, 2006, 2005a; Soria, 1984). As a result, they may be intensely reflective, emotional, and preoccupied with their adoptive status, and experience inner conflict, self-doubt, and guilt (Grotevant, 2001; Hochman & Huston). These strong emotions can translate into behavioral problems such as substance abuse, academic difficulties, preoccupation with the unknown, problems with or withdrawal from relationships, emotional shutdown, increased risk-taking, and suicide threats. At this stage of life, when they want to be like everyone else, they recognize they are different and feel the full impact of being adopted on a social, emotional, and intellectual level (Hayden, 1994; Stevens, 1995).

Because of their struggles with a variety of emotional issues and biological and genetic concerns, adoptees may face intimacy with trepidation. They may avoid closeness and commitment with others or may, consciously or unconsciously, sabotage or restrain emotion in relationships (Common Clinical Issues Among Adoptees, 1995; Silverstein & Kaplan, 1982). Many never feel close to anyone. Struggles with intimacy may result in depression, alcohol abuse or drug abuse, marital troubles, or problems with family and children (Issues Facing Adult Adoptees, n.d.).

According to the Search Institute Study, two-thirds of adoptees are interested in meeting their biological family (as cited in Bower, 1994). Often adoptees simply want information about their biological roots, their natural history, and their physical attributes, while some have a desire to understand the many possibilities lost to them (Bower; Hochman & Huston, 1995; Soria, 1984). Searching for remnants of the past can be a means of resolving many of the issues inherent in adoption.

There is some controversy and disagreement in the literature about the extent to which adoptees have mental health problems. For example, Stevens (1995) noted that agencies, members of the adoption triad, and researchers are beginning to understand that adjustment difficulties related to adoption can affect children, even when those children were adopted as infants. In one study by Howard, Smith, and Ryan (2004), parents of welfare adoptees (n = 340), domestic infant adoptees (n = 481), international adoptees (n = 89), and birth children (n = 175) were surveyed to determine the number of problems the children experienced. The results showed differences between birth children and children who were adopted. The birth children had a mean of 6.2 problems, while the means for those who were adopted were as follows: domestic infant adoption (M=9.1); international adoption (M=9.4); child welfare (M=11.9). Thus, those who were adopted as infants fared better than those adopted through international adoptions or child welfare systems, but still experienced more difficulties than birth children. This is consistent with Silverstein and Kaplan's (1982) claim that "Adolescent adoptees are overrepresented among those who join sub-cultures, run away, become pregnant, or totally reject their families" (Identity section, paragraph 4).

As noted by Cubito and Brandon (2000), the literature shows higher levels of maladjustment in adopted children than non-adopted children, but the level of maladjustment in adults is less clear. Cubito and Brandon examined the history of using mental health services by adult adoptees and found higher levels of maladjustment compared to normative data, but the levels were not as high as out-patient norms. They also demonstrated that non-searchers and those who were reunited with their biological parents were less maladjusted than those who were searching. Levy-Shill (2001) also discovered higher levels of maladjustment among adult adoptees than non-adoptees, but noted that age of adoption and openness to adoption were associated with adjustment. In particular, their study showed that adoption after 6 months caused separation distress and increased maladjustment, but that general family functioning was an important factor as well. One study of psychiatric illness among adults adopted as infants was conducted in Scandinavia using national health insurance data and showed higher psychiatric illness, alcohol and drug use, and personality disorders among adoptees compared to non-adopted controls (Bohnar & yon Knorring, 1979). Milligan (2003) found that over 50% of respondents who were adopted as infants reported that psychological issues, such as grief, isolation/intimacy, identity, and loss, were experienced in adolescence and in adulthood.

Other research shows the long-term impact of the adoption experience is minimal, especially for those adopted in infancy. A Search Institute study (as cited in Bower, 1994) of the use of alcohol, tobacco, and drug use; sexual acts; depression and suicide attempts; delinquent and violent acts; school problems; and bulimia among adoptees concluded that 75% of adoptees have good mental health. In addition, Grotevant (2000) has shown adoptees perform normally on self-esteem scales. Benson, Sharma, and Roehlkepartain (1994a) studied 881 adolescents who were adopted as infants and noted they were as likely as their peers to report a positive identity, saw adoption as a fact of life, and had strong bonds with their parents. Three-quarters of them were psychologically healthy due to early adoption and family support. The same authors also discovered that adolescents in transracial adoptions were doing well because of parental support, goodness of fit within the family, and family management of factors that affect their well-being (Benson et al., 1994b). Age and gender seem to make a difference--girls may think about adoption more than boys, and older adolescents may consider it more than younger adolescents (Benson & Sharma, 1994). Hochman and Huston (1995) believed adoptees can resolve their issues in the same way as their non-adopted peers while Nickman (1996) indicated the majority of mental health problems experienced by adoptees in childhood and adolescence were resolved by adulthood. Although the information about adults is limited, a study of adopted and non-adopted adults from the National Child Development Study found positive adjustment in adult adoptees, except that adopted men had more difficulty finding employment and social support (Collishaw, Maughan, & Pickles, 1998). In this sample, emotional problems among adopted women were actually lower than among non-adopted women. According to the authors of the study, the children in the study were from disadvantaged groups and, therefore, the adopted individuals may have had more advantages than those who were not adopted.

Help-seeking

Although the degree to which adoptees have mental health problems in comparison to their non-adopted peers is unclear, the research shows adoptees receive mental health services more than the general population. For example, the Search Institute study (as cited in Bower; 1994) revealed that a third of adoptees are involved in counseling or psychotherapy. While less than 2% of the United States population are adopted, studies indicate that 5 to 10% of those in counseling are adoptees and that 15 to 25% of patients in residential psychiatric facilities are adopted (Bower, 1994; Kaye, 1998). Further, children who have been adopted were estimated to be two to five times more likely to receive psychological treatment than their nonadopted peers (Grotevant, 2000; Miller et al., 2000). None of this research specifically focused on individuals who were adopted as infants compared to other groups (birth children, international adoptions, child welfare adoptions after infancy).

In addition, research has shown that adoptive families and school personnel seek psychological services earlier and more readily for adoptees than non-adopted children. Often, this is based on the assumption that adoption may have impacted the child or the child may be biologically susceptible to mental disturbance (Bower, 1994; Lears et al., 1998; Miall, 1998; Miller et al., 2000; Stevens, 1995). Some researchers found that seeking help was related to family variables, as well as psychological problems. They concluded that although adoptees may not have more psychological problems than their peers, they are referred more often because their adoptive parents are educated and familiar with social services, and are therefore more willing to seek professional help. They also found that white parents and parents who had insurance were more likely to seek help because it was socially acceptable and they could afford to do so. Among the adopted individuals, those with higher grades and higher scores on measures of self-worth were less likely to seek counseling; while those who had more trouble in school, substance abuse, emotional distress, suicide ideation, and depression were more likely to seek help (Kaye, 1988; Lears et al.; Miller et al.).

Although research shows that adopted children are referred for professional help more often than non-adopted children, the degree to which adults who were adopted seek assistance is less clear. According to Kreisher (2002), the need for support after adoption is a lifelong process. She noted that adopted adolescents typically seek help with identity issues, while adults are more likely to seek counseling when they are starting a family or struggling with questions about their biological and cultural background. According to Cubito and Brandon (2000), adults may also seek help when they are searching for their birth parents. In their study, those who were seeking their birth parents had higher levels of out-patient and in-patient care than those who were not searching.

In addition to age differences in help seeking, research on the general population has shown gender differences in attitudes toward counseling (Good, Dell, & Mintz, 1989; McCarthy & Holliday, 2004; Rule & Gardy, 1994). Some studies indicated that women were more likely to seek professional help from a doctor or counselor while men were more likely to self-medicate and use alcohol (Cotton, Wright, Harris, Jorne, & McGorry, 2006; Daughtry & Paulk, 2006). Among college students, women are more likely to seek counseling and use self-help groups than men (Meissen, Warren, & Kendall, 1996; Sheu & Sedlacek, 2004). Although there is very little literature on gender differences among adoptees, Cubito and Brandon's (2000) study showed that men who were searching for their birth parents received alcohol treatment more than women who were searching. Additional research on gender differences among those who were adopted is notably lacking.

The Children's Welfare Information Gateway (2006, 2005a) and Kreisher (2002) made a strong case for the need for assistance after a family adopts a child and noted that many families seek assistance. According to the CWIG, the most common type of assistance is outpatient psychotherapy, but talking to friends is also typical. Kreisher commented that groups are particularly helpful as a venue for venting concerns, seeking advice, answering questions, and getting support from others. The CWIG (2005b) encouraged families to select a therapist who is knowledgeable about adoption because sometimes psychological issues are associated with adoption and sometimes they are not. Because many therapists do not receive training in adoption issues and often do not consider adoption relationships when treating individuals, it becomes imperative that training on adoption dynamics be increased (Kreisher; CWIG, 2006, 2005b, 2005a, 1995; Miller et al., 2000). According to the CWIG (2004) individuals may seek help with interpersonal relations, integration of adoption experiences, struggles around adoption, healing processes, grief and loss, and preparation for a reunion with a birth parent, therefore therapists must be prepared to help with those issues. Miller et al. recommended that counselors receive training on the following: the uniqueness of the adopted family, control issues, parents' sense of entitlement, adoptive identity, and perception of compatibility. They also recommended that therapists become familiar with adoption laws and post-adoption services.

Summary and Research Questions

After reviewing the literature on adoption, we discovered there are many questions and inconsistencies in the research. For example, most of the research suggests that individuals who were adopted struggle with a variety of psychological issues such as loss, grief, shame, feeling rejected, and difficulty with identity and intimacy. They also display maladaptive behaviors such as poor performance in school, alcohol and drug use, suicide ideation, and acting out against their adoptive parents. Furthermore, the literature suggests they are referred for mental health treatment more often than those who were not adopted. In contrast, other literature suggests that adopted individuals have no more problems than others and that adolescent and adult adjustment is positive. But the literature is limited in the following ways: (a) it focuses primarily on children and adolescents, rather than adults; (b) it fails to account for the variety of possible adoption types (open vs. closed, domestic infant adoption, international adoption, interracial adoption, adoption by family members, and adoption at various ages); and (c) there is very little information about help-seeking behaviors by gender, type of adoption, or age at adoption. Because adoption impacts the lives of most people in this country and the research literature has not focused on adults adopted as infants, it seems imperative that more information be obtained about this population. Therefore, we conducted a study to determine the extent to which adults who were adopted as infants sought help on specific psychological issues during adolescence and adulthood; whether there were gender differences in their help-seeking behavior; whether there was a relationship between their help-seeking in adolescence and adulthood, and who they turned to for help. This study begins to fill an important gap in the research literature that must be closed to provide mental health practitioners the empirical base from which to guide their practice and appropriately support individuals who have been adopted.

METHODS

Participants

The study was limited to adults over the age of 21 who were involved in domestic adoptions prior to their second birthday. The participants were 156 individuals whose ages ranged from 22 to 98, with a mean age of 43.2 years and a median age of 40.5 years. Of these respondents, 135 were female and 21 were male. Participants were predominately White (n = 149), with the remaining individuals identifying themselves as Filipino, Native American, Hispanic, mixed, or unknown. Education level varied, but was generally high: 41 had a graduate degree, 48 had a bachelor's degree, 56 had some college, 10 had a high school diploma or GED, and one did not complete high school. Slightly more participants were placed by private (n = 90) than public (n = 64) adoption agencies (2 declined to state). The vast majority of the adoptions were closed (birthparents identities and locations were not revealed to adoptees or adoptive parents) with only 3 of the participants reporting open adoptions.

The 156 participants were volunteers garnered from an adoption advocacy Internet website. Participants were either subscribers or were referred to the survey by a subscriber. Because of referrals, participants were garnered from several adoption advocacy, support, and search groups. Not surprisingly, given our recruiting methods, the vast majority of participants had searched for their birth parents. Only 15 participants had not searched, and of those 15, five indicated that they had specific plans to search for their birth parents. In fact, 71 of the 156 participants had been in touch with their birthparents, even though the vast majority had been placed in closed adoptions.

Measures

Respondents were instructed to complete a survey consisting of demographic/general adoption information (age at adoption, siblings, whether they have searched for birth parents, type of adoption) and 20 survey questions regarding psychological issues. Nine prominent psychological issues that adoptees face were culled from the literature through document analysis: anxiety, control, depression/suicide, grief, isolation/intimacy, identity, loss, rejection/abandonment, shame/guilt, and a tenth catchall category (other issues not specifically named) was included. Each psychological issue was defined in layman's terms to aid participants' interpretation (see Appendix for definitions). The respondents checked whether the issue "was a problem" or "was not a problem," for each issue both "as an adolescent" and "as an adult," yielding two dichotomous items for each psychological issue. They also indicated whether they "sought help or guidance" as an adolescent and as an adult, and were given a list of mental health providers (counselor/therapists, psychologists, psychiatrists, religious leaders, school counselors, social workers, other) and asked to check who they turned to for help ("check all that apply"). Cronbach's index of internal consistency (a = .92) indicated high reliability based on data from the 20 items measuring psychological issues, with subscale reliabilities for the 10 adolescent and 10 adult oriented questions also satisfactory (a = .87 for both). The content validity of each item was assessed as adequate by the authors based on a content analysis of research literature on psychological issues related to adoption (a full version of the survey is available from the authors upon request).

Procedures

All procedures were approved by the Institutional Review Board at Northwestern State University of Louisiana. The survey was placed on a Web site created by an independent design company. The link to this survey was sent to subscribers of an adoption advocacy website for three weeks. Participants were informed of the identity of the researcher, the purpose of the study, requirements for participation, confidentiality and anonymity safeguards, who would view their data, the length of the survey, researcher contact information, and safety measures for possible psychological risk. Finally, they were advised that submission of the survey indicated their consent for the use of their data in the study. The data went to a computer database hosted by the independent website design company to ensure anonymity. When the survey was removed from the Internet, the company emailed the database for use in statistical analyses.

RESULTS

Very few of the participants reported they sought help during adolescence with psychological issues. None of them indicated they sought help with identity or anxiety, and a few (one to three women) reported seeking help on the other issues. The men reported no incidence of psychological help or guidance during adolescence. Most respondents did not seek help or guidance in adulthood. Among those who did, the numbers were fairly evenly distributed across the various issues, with isolation/intimacy issues the highest (n = 17) and shame/guilt the lowest (n = 9). The number of women who sought assistance was highest for isolation/intimacy (n = 15) and lowest for shame/guilt (n = 7). The men reported much lower incidence of seeking help. None of the men reported seeking help on control issues; one or two reported getting help on each of the other issues.

Pearson's Chi-Square tests of independence with gender as the independent variable and whether or not help was sought as the dependent variable revealed no statistically significant effects by gender during adolescence or adulthood. Data for men and women were then combined and a McNemar test indicated a statistically significant difference between the number of participants who sought help as adolescents and those who sought help as adults [[c.sup.2] (N=156) = 52.66, p<.05]. Of the 156 respondents who answered the help or guidance question for both adolescence and adulthood, 65 did not seek help at either age. Of those respondents who did not seek help in adolescence, 68 sought help as adults. Five respondents sought help as adolescents, but did not seek help or guidance as adults. Only 16 survey participants sought help both as adolescents and as adults.

Table 1 shows the helpers from whom respondents sought help or guidance as adolescents and adults. The data show that as adolescents, respondents most often used psychiatrists (n = 8), counselors/therapists (n = 11), and "other" (n = 29) for help or guidance. As adults, they mostly used, psychiatrists (n = 10), psychologists (n = 12), "other" (n = 24), and counselors/therapists (n = 49). Overall, respondents sought very little help from religious leaders, school counselors, or social workers. Adolescent males never sought help from those sources.

Respondents were allowed to explain their specific venues of help and guidance when choosing a response of "other." For adolescents, "other" referred to seeking help from friends, other adoptees, and their adoptive parents. As adults, adoptees indicated they received help from Alcoholics Anonymous, adoption literature, support or advocacy groups, family members, friends, Narcotics Anonymous, and spiritual avenues.

DISCUSSION

The first question addressed by this study was the degree to which individuals who were adopted as infants sought help or guidance for psychological issues as adolescents or as adults. Very few respondents (fewer than 12%) indicated they sought help or guidance either as adolescents or adults. Although previous research has shown that adopted individuals are over-represented in mental health institutions and referred more frequently by parents and school officials for psychological help (Leafs et al., 1998; Miller et al., 2000), our data did not show a high incidence of help-seeking. These data were collected in conjunction with a larger study in which over 50% of the same respondents reported struggles with psychological issues during adolescence and adulthood (Milligan, 2003), so their lack of help-seeking is particularly surprising. It cannot be assumed that they did not seek help because they were not having problems.

Of the respondents who indicated they sought help with psychological issues, most indicated they sought help during adulthood. Help-seeking was particularly low during adolescence, with several zeros and a maximum of three who sought help on various issues. Interestingly, none of the adults reported they sought help with identity issues during adolescence, which is the one issue that the literature indicates is most salient during adolescence (Silverstein & Kaplan, 1982) and which Erikson's (1963) theory of psychosocial development suggests is the primary developmental task for this age group. The incidence of help-seeking increased in adulthood, but was still not high. The highest number of respondents (n = 17) indicated they sought help for isolation/intimacy issues in adulthood, which is consistent with previous research (Silverstein & Kaplan) and Erikson's theory of psychosocial development.

One reason for the discrepancy between our sample and the literature may be that previous studies were frequently about children (e.g., Grotevant, 2000; Miller et al., 2000), while our study focused on adolescence and adulthood. Obviously, parents and school personnel watch children for signs of difficulty and make referrals; this would not be the case with adults. But that explanation does not explain why adolescent help-seeking would be so low; adolescents are largely under the supervision and observation of parents and teachers, so one would expect them to be referred for professional help when they experienced difficulty. We can assume one of three things: (a) they received help during childhood which protected them against later problems; (b) they did not experience enough difficulty to warrant seeking help; or (c) the parents and teachers failed to refer them when they ran into trouble. Due to the age of some of our adult respondents, it is also possible that mental health help was not as common or accepted when they were adolescents.

The sample used in this study may be another reason for the discrepancy between our results and previous studies. The respondents were individuals who were adopted as infants and may not have experienced the same trauma as individuals who were adopted later in life. Previous research on adoptees has failed to consistently differentiate between individuals who were adopted as infants and individuals who were placed in several foster homes prior to being adopted, so it is difficult to draw conclusions about the resiliency of those adopted as infants. The few studies on those adopted as infants are inconclusive regarding the degree to which they experience later problems. Some research has demonstrated that individuals adopted as infants have a higher incidence of psychiatric illness than individuals who were not adopted (Bohnar & yon Knorring, 1979; Levy-Shiff, 2001), especially if the adoption occurs after the age of 6 months (Levy-Shift), but other research shows individuals adopted as infants have a lower incidence of ADHD than those placed in multiple foster homes (Hinshaw, 2002). Some studies have shown positive outcomes for adolescents (Benson et al., 1994a) and adults (Collishaw et al., 1998) adopted as infants, which seems to be consistent with our sample. Research has also shown that general family functioning is important in determining whether individuals adopted as infants experience trauma (Levy-Shift) and that they do well if they grow up in families with strong bonds, good parenting, and effective management of adoption issues (Benson et al, 1994b), so perhaps our sample received more family support for dealing with issues associated with adoption. The respondents in our study indicated they had experienced difficulties (Milligan, 2003), but it is possible their problems were not severe enough to warrant them seeking help or they felt supported in other ways.

The fact that this sample of adoptees sought counseling infrequently is even more surprising because many of them were searching for their birth parents. Literature in the field suggests adoptees searching for their birth parents are more likely to seek treatment for mental health issues related to adoption and show higher levels of outpatient, in-patient, and alcohol treatment than non-searchers (Brodzinsky et al., 1992; Cubito & Brandon, 2000), but some researchers believe the act of searching itself may be therapeutic (Bower, 1994; Hochman & Huston, 1995; Russell, 1994). Our finding appeared to provide support for the notion that searching is therapeutic in that 71 of our 156 participants had been in contact with their birth parents and we found a relatively low incidence of help seeking in this sample.

The sample being obtained from adoption Web sites might partially explain the relatively low overall help-seeking in this sample in that, it is possible the respondents obtained their information and help through the World Wide Web and used informal support instead of therapy. In fact, many of them indicated that they get help from friends, Alcoholics Anonymous, adoption literature, support groups, family members, or spiritual venues.

The second question we explored was whether there were gender differences in help-seeking among this group of respondents. Very few women reported they sought help for their psychological issues during adolescence, but men reported they did not seek help at all. Even in adulthood, the numbers were not high. The numbers for women ranged from a high of 15 for isolation/intimacy to a low of seven for shame/guilt. Only one or two men reported getting help on any of the issues. Although the difference by gender was not statistically significant, the fact that more women than men sought help is consistent with the literature on gender differences in help-seeking among the general population (Good et al., 1989) and may also reflect the fact that more women than men are adopted (Kreider, 2003).

Results of this study indicated an increase in help seeking for both men and women from adolescence to adulthood, which could be explained in a variety of ways. Previous research indicated that the mental health problems experienced by adoptees in childhood and adolescence were often not resolved by adulthood and psychological tasks such as identity and intimacy may be relevant beyond the years with which they are traditionally associated, so it is not surprising adoptees would seek help in adulthood (Brodzisky et al., 1992; Milligan, 2003; Nickman, 1996). In addition, intimate relationships, parenthood, and other life milestones may cause them to revisit previously resolved stages (Issues Facing Adult Adoptees, n.d.). Furthermore, adults may be more willing and able to seek help than adolescents. As adults, they may be developmentally more capable of introspection and self-evaluation, recognize psychological issues that can be attributed to adoption, and seek help. In addition, as they age, they may feel less obliged to protect their adoptive family from any negative stigma associated with their adoption. On the other hand, the increase in help-seeking during adulthood could be the direct result of the lack of help during adolescence. If that is the case, we have to wonder why they did not get help earlier. Perhaps the issues were not severe enough in adolescence, but they were compounded by family and work responsibilities, life milestones, or the process of searching for biological parents in adulthood.

Although the numbers were too small for inferential statistical analysis, there seemed to be some differences in the types of issues for which the respondents sought help. During adolescence, the men did not seek help on the issues identified on the survey, but a few (one to three) women sought help on all issues except anxiety and identity. As adults, men's help-seeking was still low, but one or two sought help with all issues except control. Adult women sought help on all the issues, with isolation/intimacy being the highest (n = 15) and shame/guilt being the lowest (n = 7). It is obvious that women sought help more frequently than men, but both groups sought help on the issues identified in the literature.

The respondents in this study used counselors, psychologists and psychiatrists most often when they sought professional help for psychological issues, but much of their help seemed to come from informal sources such as friends, family, support groups of various types, and printed information. Again, this is consistent with literature (CWIG, 2006, 2005a). A few received help from religious leaders as adolescents and adults, but it was only in adulthood that they worked with social workers.

Because mental health counselors are one of the primary sources of help, it is important to examine the degree to which they are trained to work with adoptees. One respondent stated he had used the survey's link for the National Board of Certified Counselors' Web site and found no counselor specializing in adoption issues. We also had difficulty locating educational facilities and continuing education specifically relevant to adoption. This lack of mental health counselors specializing in adoption and of specialized training in adoption is troublesome because adoptees are referred more often and treated more often in the mental health settings than their non-adopted peers (Bower, 1994; Grotevant, 2000; Kaye, 1998; Miller et al., 2000).

It appears that the need for professional assistance in resolving issues with the adoption experience cannot be ignored. Research indicates that adoptees are more likely to be referred to mental health counselors in childhood and adolescence than their non-adopted peers (Bower, 1994; Grotevant, 2000; Hochman & Huston, 1995; Kaye, 1988; Leafs et al., 1998; Miall, 1998; Miller et al., 2000; Silverstein & Kaplan, 1982), yet the lack of help or guidance reported by respondents in this study suggests they did not receive much mental health treatment even as adolescents. The lack of psychological help or guidance in adolescence may be one of the reasons the psychological effects of the adoption experience appear to increase or remain unresolved in adulthood.

Limitations

We designed this study as an exploratory foray into an area where little empirical research has been done; it is therefore important to recognize the limitations and intended scope of this investigation. The survey was constructed by the researchers based upon a content analysis of the literature, and while the observed reliability was high (Cronbach's [alpha] = .92) validity studies are warranted. The survey relied on self-report and some respondents indicated they had difficulty with the lack of specificity in the language used. The sample was also limited in specific ways. The majority of the respondents were white, well educated, and searching for their birthparents. They all used the internet. Because data were not collected from a control group of non-searchers or individuals who did not have access to adoption Web sites, the results cannot be generalized to those groups. The education level fits with adoption demographics from the 2000 Census, but we know that we have not represented the ethnic makeup of adoptees (Kreider, 2003). Also, caution must be exercised in assuming that the psychological issues reported by the respondents are tied to the adoption experience because there can be many confounding variables, such as the adoption practices utilized at the time they were adopted compared to adoption practices more recently, the inherited characteristics of the individual, and the characteristics of the family in which they were raised.

In addition to the limitations inherent in the study, we found many limitations and inconsistencies in the literature. Of particular interest to us was the lack of information about adults who were adopted as infants and gender differences and help-seeking behaviors among that population. In general, the literature on psychological issues of adoptees fails to discriminate by type of adoption, gender, age of adoption, and many of the other variables that can affect outcomes. Furthermore, most of the research is on children rather than adults.

Recommendations for Practice and Research

Results of our literature review reiterated the need for the mental health community, parents, and school personnel to effectively anticipate and address psychological issues specific to adoption, especially when working with children. It was recommended that mental health professionals become familiar with the issues associated with adoption, be able to differentiate between normal developmental difficulties and those exacerbated by adoption, and be able to communicate this knowledge to adoptive parents and schools. The literature also recommended that the mental health field develop some guidelines and training opportunities for those who want to specialize in adoption so they can recognize the uniqueness of adoptive families and psychological issues associated with adoption, and understand the laws and services that impact adoption families (Miller et al., 2000). Furthermore, the Child Welfare Information Gateway (2004) proposed that mental health counselors should be able to recognize and assist with the interpersonal issues and struggles related to the adoption experience, issues of grief and loss, the healing process, and the process of seeking birth parents and preparing for a reunion.

Because of the psychological issues associated with adoption, individual and group counseling are recommended. Individual counseling with adoptees should address issues such as anxiety, grief, control, depression, and suicide in this population using some of the same methods as would be used with the general population. Support and therapy groups could be especially beneficial to this population, removing much of the isolation and stigma often associated with adoption (CWIG, 2004). As Kreiser (2002) indicated, support groups are useful for getting answers to questions, getting advice, and sharing concerns with others who are in similar circumstances. In all cases, it is critical to explore links between psychological issues and the experience of adoption.

Based upon the data from our preliminary study, it appears that many adolescents and adults do not seek help with psychological issues associated with adoption. Therefore, we recommend further research be conducted to determine the extent to which they struggle with psychological issues and the extent to which they seek help. If they have problems and do not seek help, it would be helpful to understand why. Then, perhaps mental health counselors could do outreach (possibly through the Internet) to reach this population or work to overcome barriers that exist. Some research suggests there are very few long-term effects from adoption. If that is the case, then the question of seeking help becomes moot.

The long-term impact of adoption is not known because of a lack of adequate understanding of when issues appear and when issues are resolved. Obviously, more research needs to be conducted on the experiences of adolescents and adults who have been adopted as rigorous studies of this population are notably lacking. Future studies could help to tease out the effects of age of adoption (infancy through adolescence), race (interracial adoptions and intraracial adoption), nationality (international adoptions), type of adoption (amount and type of contact with birth family), foster care, and characteristics of the adoptive family (socioeconomic status, educational background of parents, number of siblings) on the psychological issues and help-seeking behavior of adopted individuals. Studies could also focus on whether the adopted child had been abused, the age and health of the mother, and the relationship of the child to the adoptive parents (biological relationships, stepchild). Further research on the incidence of help seeking in these various subgroups of this population would be helpful, as well as research on the long-term effects of counseling or therapy.

APPENDIX

Psychological Issues as Defined for Participants on the Survey

Anxiety: Do you ever feel excessively tense or nervous when thinking about or talking about your adoption or things related to your adoption?

Control: Does your adoption ever lead you to feel the need to control your environment and people around you OR as though you had no control over your environment and people around you?

Depression/Suicide: Do you ever feel depressed or suicidal when thinking about or talking about your adoption?

Grief: Do you ever feel sad about the events surrounding your birth?

Isolation/Intimacy: Do you ever feel alone or different from others as a result of being adopted? Does feeling alone or different affect your relationships whether by distancing yourself or clinging?

Identity: Do you ever feel as though your identity was shaped by or could not be shaped because of your adoption?

Loss: Do you ever feel a sense of loss for the life or parents you did not have?

Rejection/Abandonment: Do your ever feel as though your adoption was really a form of rejection or abandonment?

Shame/Guilt: Do you ever feel ashamed of any part of your adoption or experience guilt related to your adoption?

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Correspondence regarding this article should be sent to fpearson@memphis.edu.

Frances Pearson is associate professor o fin the Department of Leadership at at the University of Memphis. Reagan Curtis is professor of educational psychology at West Virginia University. Amanda Milligan Chapman is a private counselor in Alexandria, Louisiana.
Table 1
Helpers from Whom Respondents Received Help or
Guidance as Adolescents and Adult

              Private
             Counselor
             Therapist   Psychiatrist   Psychologist

Adolescent      11            8              3
   Female       10            8              3
     Male        1            0              0

    Adult       49            10             12
   Female       46            9              10
     Male        3            1              2

             Religious      School      Social
              Leaders     Counselor     Worker   Other

Adolescent       3            3            0       29
   Female        3            3            0       25
     Male        0            0            0        4

    Adult        3            2            7       24
   Female        2            1            5       20
     Male        1            1            2        4
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