Adoption and foster care are important ‘solutions’ to identified problems or risks, but potentially they are also contributors to problem behaviours or emotional difficulties. In their problem-solving role, they are seen as potential solutions, not only to actual
or future mental health problems of children, but also to the adverse effects of involuntary childlessness.

This chapter concentrates on the impact of adoption and foster care on the children placed, but their role in problem solution or problem generation for adults is also touched on. Adoption is more often than not a satisfactory way of meeting the need to become parents for those childless couples who succeed in having a child placed with them (a tiny minority of the involuntary childless). It is very rarely a solution to the problems of a parent who gives up a child for adoption whether voluntarily or involuntarily. Studies of adults who relinquished children indicate that the reaction to the loss of their child may be associated with moderate distress or may lead to a long-term grief reaction, which in turn will potentially harm children subsequently born to that parent. One must also note that some parents who lose a child to adoption or foster care are themselves children, sometimes not yet in their teens, whose needs are often overlooked in the interests of providing for the infant.

Fostering and adoption started as very similar processes, diverged in Europe and North America in the first half of this century, and are now much closer together again. The ‘total severance’ model of legal adoption—the type that most people in Europe, the United States, and Australasia immediately recognize—has a short history. In the United Kingdom it was not until the passing of the 1958 Adoption Act that secrecy became the norm. The ‘sealing’ of birth information started in the United States around 1948 but it was not until 1991 that Alabama ‘sealed’ its adoption records.⁽¹⁾ This experiment of totally closed adoption was short-lived, and many countries have introduced legislation to allow adult adoptees and/ or birth relatives to access identifying information that allows them to seek each other out.⁽²⁾ ‘Open’ adoptions, in which some degree of contact between the adopters, the birth parents, and the children is maintained after placement, are increasingly common.

As countries have become richer, the need to place children for adoption has diminished and the number of infants placed at the request of their parents has fallen well short of the ‘demand’ of those wishing to start a family through adoption. In consequence, it has been possible to encourage potential adopters to ‘stretch’ their notions of parenthood, and to place older children, those with disabilities, and those with behavioural or emotional problems with adoptive parents as well as with foster parents. The main remaining difference between adoption and foster care is that the majority of children placed in foster homes live there for comparatively short periods before returning to their families of origin. They are best seen as supplementary rather than substitute parents, although in all ‘first world’ countries long-term or ‘permanent’ foster care is an important option for a minority of those entering public care, especially in those countries (the majority) who rarely use adoption as a route out of care.

Adoption and foster care will impact on the mental health of the children in different ways, which may be considered along six main dimensions (see Box 9.3.5.1). The dimensions interact differently for different children. An infant placed from an Asian country might be adopted by childless relatives in Europe and have had a positive early experience of parenting, or might have experienced very adverse early nurturing and be adopted by strangers of a different ethnic origin. The child placed at six may have had good care from one or both parents until some traumatic event led to the need for an adoptive placement, or the child may have been seriously maltreated and had several placements before finally joining a substitute family.

The actual or potential problems most obviously associated with child placement are those resulting from separation and loss. Brodzinsky et al.⁽³⁾ have made significant contributions to our understanding of the psychology of adoption. Put simply:

The impact of loss will also vary with the child’s temperament, and the work of Rutter,⁽⁴⁾ and of others who have written on ‘resilience’, are important sources. A ‘born worrier’ will go through life wondering what there was about him or her that was not worth keeping, and no amount of positive parenting will make this angst go away; a resilient child will shrug away the past and make the best of even not particularly good parenting by the substitute parents.

It is important, before considering the research findings, to take note of the limitations of our knowledge on the long-term outcomes of foster care and adoption. Turning first to the characteristics of the children, studies of family placement often include both infants and older children, those with emotional difficulties and those without. Some studies of foster care include children placed temporarily alongside others placed permanently, and in some US studies the term ‘foster care’ includes all children in out-of-home placements (for family placements the term ‘foster family care’ is used).

At the other end of the process a broad range of ‘outcome’ measures is used⁽⁵⁾ and ‘success’ rates vary depending on the measures used and the length of time between placement and reported outcome. The well-being of the young adult (using a range of standardized instruments) is the most reliable outcome measure but more often ‘output’ measures are used. (Was the child placed? Was legal adoption completed? Was a satisfactory reunion with the birth parents achieved during childhood or as an adult?). Measures of satisfaction of the different members of the adoptive family are also used. Unsurprisingly, therefore, reported ‘success’ rates have varied between below 50 per cent and around 95 per cent.

The placement process that researchers seek to evaluate is extremely complex. When, as with adoption or permanent fostering, the aim is for the child’s life chances to be improved by their becoming fully a part of the new family, it becomes impossible to unpick the very many variables that will have had an impact on the mental health of the young person between placement at 6 weeks and maturity at around 26. (There is some evidence that adopted people move towards emotional maturity at a slower pace—not surprisingly with at least two extra hurdles to surmount: that of separation and loss, and that of making sense of their adoptive identity). In longitudinal studies, if numbers are large enough, it is possible to control for the major variables such as age at placement, disability, and emotional or behavioural problems at the time of placement. However, the many aspects of parenting, and the nature of any therapeutic input may all have had an impact on the placement. The researchers may seek the opinions of parents and children as to what they found helpful, but clear causal relationships between outcomes and variables such as parenting styles, models of social work practice, and therapy cannot be claimed.

In summary, whilst researchers have, for many years, sought to bring academic rigour to their studies, family placement remains an ‘untidy’ subject. The more complex the placement circumstances and the longer the timescale, the more difficult it is to attribute success to any one factor, type of placement, or model of intervention.

The above section explains why, although there are some random controlled trials of treatment approaches and of short-term foster care models, the literature contains more research syntheses of the different aspects of family placement^{(5,6,7,8,9,10)} than ‘classical’ systematic reviews. The findings from the large volume of quantitative and qualitative research will be summarized under the broad headings of time-limited foster care placements and placements made with the intention that the child will become a full part of the adoptive or foster family. The emphasis will be on the second group, which will be further subdivided into placements of infants and placements of older children.