Mental health outcomes in adopted children - a longitudinal register-based study

International adoption involves both risk and protection for later adjustment. International adoptees often experience adverse conditions in the time before adoption, placing them at risk of developing mental health problems. The adolescent years can be especially challenging, as questions related to identity and unknown origins emerge. Adoption can also be protective, with fewer problems among adoptees than among children who are left in subpar conditions in the country where they were born. Such findings have led researchers to claim that international adoptees show remarkable resilience. Nevertheless, resilience factors and their associations with mental health problems have not been investigated in internationally adopted adolescents previously. Likewise, little is known in this group about alcohol and drug use, which is associated with mental health problems in adolescence and which may be an important marker of maladjustment. The main objective of the present thesis was to investigate the adjustment of international adoptees in the adolescent years, focusing on mental health problems. More specifically, the objectives were to a) compare the occurrence of mental health problems in internationally adopted adolescents to their non-adopted peers and b) investigate resilience (e.g. family cohesion and personal competence) and problematic alcohol and drug use, and whether these factors are related to mental health problems. To accomplish this, the mental health of internationally adopted adolescents was investigated using a meta-analytic approach and by obtaining new data from an epidemiological study. In the meta-analysis, findings from a heterogeneous set of 11 studies were included. In the epidemiological study, data from the youth@hordaland-survey was linked to the Norwegian Central Adoption Registry. A total of 12,257 adolescents aged 16-19 years old participated, of whom 45 were identified as internationally adopted. Information on demographics, mental health problems, resilience factors, and indicators of alcohol and drug use were collected via self-report. Results both from the meta-analysis and the youth@hordaland-survey indicated that internationally adopted adolescents reported more mental health problems than non-adopted peers. The combined effect estimates for 11 studies included in the meta-analysis were 0.16 (95% CI 0.03-0.28) for questionnaire-based studies and 0.70 (95% CI 0.50-0.90) for registry studies when comparing adoptees to their non-adopted peers. The results varied significantly according to outcome measure. Studies using categorical measures, indicating more serious mental health problems, yielded larger effect estimates than studies investigating symptoms through the use of continuous measures. The sample of international adoptees from the youth@hordaland-survey reported more symptoms of depression, obsessive compulsive disorder (OCD), attention-deficit/hyperactivity disorder (ADHD) and perfectionism than their non-adopted peers, while no difference was found for anxiety. Although they reported more mental health problems, the adoptees displayed similar levels of resilience to their non-adopted peers and there were no significant group differences in the associations between resilience and mental health problems. The adopted adolescents reported more problematic alcohol and drug use, although there were no significant differences in the pattern and frequency of use. The differences in problematic alcohol and drug use could largely be explained by differences in mental health problems, measured as symptoms of depression and ADHD. These findings confirm adolescence as a potentially difficult period for internationally adopted adolescents, who display more mental health problems than their non-adopted peers and more problematic alcohol and drug use. Importantly, the international adoptees reported a similar level of resilience to their peers. The resilience factors identified in this thesis are strengths that can form the basis for preventive efforts. It is important to acknowledge both the increased risk and the resilience these adolescents demonstrate, and to provide adequate help when needed. All three papers were published in international peer-reviewed journal, and were also included in Kristin Gärtner Askeland?s PhD/doctoral thesis, which was publicly defended in January 2017. A forth paper using data from the HUNT3-study linked to the adoption registry was submitted for publication in January 2017, focusing on both somatic and mental health among adult national adoptees, compared to stepchild adoptees and non-adopted.

Adoption can be viewed as an intervention for children with a difficult start in life, with a goal of improving their potential for positive development. Prior studies report major improvements in children's early development following adoption, however, adoptees are considered to be at risk for developing mental disorders. They also show poorer school performances than their non-adopted peers, though their cognitive competence is similar. We suggest that mental health problems can be one of the factors u nderlying these differences. There is little information available on mental distress among adoptees, and the possible relationships between mental distress, resilience and educational outcomes. The aim of this project is to examine these relationships, and how they develop over time. This project has the advantage of identifying adoptees by utilizing the Norwegian Central Adoption Registry, ensuring that adoptees are correctly identified, which has traditionally been a challenge in adoption research. T he adoption registry will be linked to several large population-based health surveys. Four of the papers will be based on data from the longitudinal Bergen Child Study (BCS). The first waves of BCS include about 7000 participants, while the fourth wave (a lso called ung@hordaland) include 10 200 participants. Data from BCS will also be linked to official data on school absence and grade point averages provided by Hordaland County. Two papers will be based on data from the two most recent waves of the Nord- Trøndelag Health Studies, including about 74 000 participants in HUNT2 and 48 289 in HUNT3. Findings from this project could help improve educational and health related services given to adoptees and adoptive parents, and form the basis for preventive int erventions aimed at helping adopted children. In addition, it can shed light on some of the factors that promote positive development in adopted children through the study of resilience.