Original Article

Developmental Child Welfare

Exploring links between early 2020, Vol. 2(1) 52–71
ª The Author(s) 2020

adversities and later outcomes Article reuse guidelines:

for children adopted from care: sagepub.com/journals-permissions

DOI: 10.1177/2516103220908043
journals.sagepub.com/home/dcw
Implications for planning post
adoption support

Elsbeth Neil1 , Marcello Morciano2, Julie Young1,

and Louise Hartley1

Abstract
This study explored how child maltreatment, alongside a range of other variables, predicted
adverse outcomes for children adopted from the foster care system in England. The participants
were 319 adoptive parents who completed an in-depth online survey about their most recently
adopted child. The mean age of children at placement for adoption was 28 months (range 0–11
years) and their ages at the time of the survey ranged from 0 years to 17 years (mean ¼ 7 years).
Detailed information was collected about children’s backgrounds, including their experiences in
the birth family and the care system before adoption. Adoptive parents also reported on how well
children were getting on in a range of areas of functioning and how well they felt the adoption was
going overall. Child maltreatment and child adverse outcomes were modeled as two factors in a
latent factor structural equation model. The relationship between these two factors was explored
alongside a range of covariates. Associated with worse outcomes for children were potentially
heritable factors (parental learning disability), the pre-birth environment (exposure to drugs or
alcohol in utero) and the period between birth and moving to the adoptive family (higher levels of
maltreatment, spending more than a year in care, having two or more foster placements). The
child’s distress on moving from the foster home to the adoptive family was also highly significant in
linking to poorer outcomes, suggesting the detrimental effect of poorly managed transitions.
Implications for child welfare practices before and after adoption are discussed.

1
University of East Anglia, UK
2
University of Manchester, UK

Submitted: 20 September 2019; Accepted: 31 January 2020

Corresponding author:
Elsbeth Neil, Centre for Research on Children & Families, University of East Anglia, Elizabeth Fry Building, Norwich
NR4 7TJ, UK.
Email: [email protected]
Neil et al. 53

Keywords
Adopted children’s outcomes, adoption, child maltreatment, early adversity, foster care

Introduction
This study focuses on children adopted from care, a form of adoption used in the United Kingdom
and several other jurisdictions including the U.S., Spain, Portugal, France, New South Wales, and
Canada (Fenton-Glynn, 2016; Palacios, Adrohar, et al., 2019; Thoburn, 2010). The goal of such
adoption is to provide legal, residential, and psychological permanence for children who cannot
remain within their birth family (Brodzinsky & Smith, 2019). In an extensive overview, Palacios,
Adrohar, et al. (2019) argue that when ethical and legal standards are properly adhered to, adoption
“may be one of the best alternatives for children who need a family life” (p. 32). For children who
have experienced adversity, adoption can be an “effective intervention,” providing opportunities
for developmental recovery (Van IJzendoorn & Juffer, 2006, p. 1240). In England, where this
study took place, the average age of children adopted from care when their adoption was legally
finalized was 3 years and 1 month in 2018/2019 (Department for Education [DfE], 2019). The
majority of such children are likely to have experienced abuse and/or neglect, as well as other
adverse childhood experiences, prior to adoption (DfE, 2019; Selwyn et al., 2014; Tregeagle et al.,
2019; Turney & Wildeman, 2017). Children’s developmental outcomes can vary widely (Grote-
vant & McDermott, 2014) and it is important that adoptive parents have realistic expectations
about children they are adopting (Moyer & Goldberg, 2017). The Adoption and Children Act 2002
in England requires agencies to make an adoption support plan prior to the child’s adoption.
Anticipating children’s support needs requires a good understanding of the impact of risk factors
on children’s development, and this knowledge is vital for professionals and prospective adopters.

The outcomes of adoption for children in care

The majority of adoptions provide residential permanence for children, although measuring the
incidence of adoption “breakdown” is dogged by problems of terminology and methodology
(Palacios, Rolock, et al., 2019). The rate of post-order adoption breakdown in England over a
12-year period has been estimated to be 3.2% (Selwyn et al., 2014). While adoptions that break-
down may be a small minority, a wider proportion of adoptive families where children are adopted
from care will experience persistent challenges (Thomas, 2013). For example, while one third of
adoptive parents surveyed by Selwyn et al. (2014) reported that their child’s adoption was going
well, another third said they experienced “highs and lows,” a quarter said they had major chal-
lenges, and 9% reported the adoption to have disrupted. A recent survey of over 2,638 adoptive
parents in the United Kingdom used similar rating categories. Under half of these parents (41%)
reported the adoption to be going “really well,” 38% said they had significant challenges but were
managing, 18% faced severe challenges, and 3% reported a disruption (Adoption UK, 2019).
Children adopted from care seem particularly at risk of experiencing emotional, behavioral, and
mental health problems (Adoption UK, 2019; Anthony et al., 2019; DeJong et al., 2016; Simmel,
Barth, & Brooks, 2007; Tarren-Sweeney, 2017; Tarren-Sweeney & Hazell, 2006). Adopted chil-
dren can have difficulties in attachment relationships with their adoptive parents and in relating to
peers (Hodges et al., 2005; Román et al., 2012; Rushton & Dance, 2006; Van den Dries et al.,
2009). In terms of their physical development, adopted children often show good recovery from
54 Developmental Child Welfare 2(1)

initial developmental delays for example with weight and height (Palacios, Roman & Camacho,
2010; Van Izendoorn & Juffer, 2006), but in the longer term early adversities may carry risks for
cardiometabolic disorders (Baldwin & Danese, 2019). The foster care population, and by extension
adopted children, are at high risk of fetal alcohol spectrum disorders (FASDs) (Astley et al., 2002;
Chasnoff et al., 2015; Gregory et al., 2015).

The impact of maltreatment and other factors affecting adopted children’s development
and adoptive family stability
The origin of adverse outcomes for adopted children may relate to a range of different factors
located within the child and their life history, birth and adoptive family factors and service factors
(Palacios, Rolock et al., 2019).

Age at placement and child maltreatment. Age at placement has often been studied, with older
children found to be at greater risk of later problems (Barth & Berry, 1988). However, age may
be predominantly a proxy for length of exposure to adverse experiences and may be less influential
per se than these other adversities (Howe, 1998; Palacios, Rolock et al., 2019; Rutter, 2005).
Children who are adopted at older ages may have had greater exposure to abuse and neglect, and
such maltreatment can have far-reaching developmental consequences (Egeland et al., 1983;
Rutter, 2005). Childhood maltreatment has been linked to a broad variety of neurological, beha-
vioral, emotional, health, and cognitive difficulties in looked after and adopted children (DeJong
et al., 2016; Hornfeck et al., 2019; Rushton & Dance, 2006; Tarren-Sweeney, 2017). The prefer-
ential rejection of one child in a sibling group is a further risk factor for some adoptees (Dance
et al., 2002; Rushton & Dance, 2006).

Pre-birth risks. Risks from maltreatment interact with genetic inheritance and pre-birth risks (Howe,
1998). Genetic risk factors include parent mental health problems (such as schizophrenia and
affective disorders) and intellectual disabilities (Cadoret, 1990; Ingraham & Kety, 2000; Smoller
& Finn, 2003; Vissers et al., 2016). Exposure to alcohol, opioids, and other drugs in utero has been
linked to neurobehavioral deficits in babies and children (Bandstra et al., 2010; Moe, 2002). It can
be difficult to determine the precise influence of various factors due to the complex interplay of
genetic, pre-birth, and post-birth factors (Rutter, 2005). For example, De Bellis et al. (2001) found
that parents/caregivers of maltreated children had significantly higher incidences of alcohol and/or
substance abuse, and greater incidences of mental health problems, thus their children may be
exposed to in utero harm, genetic risks, and maltreatment. This illustrates the overlapping nature of
risks that adopted children often experience, and hence the need for research designs that can
account for this complexity.

Risks encountered in care. Adopted children in England spend an average of 23 months in the foster
care system before moving to their adoptive family (DfE, 2019). This time can provide opportu-
nities for children’s recovery to begin, but additional moves, extended stays in care and poor
quality foster care, can all pose further risks (Biehal, 2014; Meakings & Selwyn, 2016; Rolock
et al., 2019; Simmel, Brooks, et al., 2001; Ward, 2009). In England, most children are adopted by
matched new families, so they experience separation from temporary foster carers, often at a very
sensitive age. This can be very distressing for very young children and those placed at older ages
(Thomas et al., 1999; Yarrow & Goodwin, 1973). The transition from foster to adoptive home is
Neil et al. 55

typically made over a short time period in England (7–14 days). The difficulties for children in
separating from foster carers can be a “blind spot” for adults focused on their own anxieties, and
children’s feelings and needs can be sidelined (Boswell & Cudmore, 2017). Transitions considered
by adoptive parents to be badly handled have been found to be associated with later adoption
disruptions (Selwyn et al., 2014).

Adoptive family factors and the child’s increasing age. In terms of adoptive family structure, single
parent adoption does not appear to pose additional risks, and for some children may be advanta-
geous (Brodzinsky & Pinderhughes, 2005; Tan & Baggerly, 2009). However, social workers may
still hold views about married couples being “ideal” adopters (Farmer & Dance, 2015). Family
process variables such as parents’ motivation and expectations regarding adoption, the stability of
couple relationships, parental warmth, and parenting abilities (including adoption communication
openness) may all impact on outcomes (Anthony et al., 2019; Brodzinsky, 2005; Grotevant &
McDermott, 2014; Palacios, Rolock, et al., 2019).
Adopted children can show good developmental catch-up over time (Van Ijzendoorn & Juffer,
2006) which would suggest that longer time in the adoptive family would be associated with better
outcomes. However, adolescence often heralds an increase in emotional and behavioral difficulties
for adoptees (Brodzinsky, 2011; Neil et al., 2015; Sonuga-Barke et al., 2017), and the majority of
post-order disruptions occur in adolescence (Selwyn et al., 2014). Stability, improvement, or
deterioration in mental health over time are all possible outcomes (Tarren-Sweeney, 2017); hence,
it is unclear whether length of time in the adoptive family (which will correlate with the increasing
age of the child) acts as a risk or protective factor.

The current study

Untangling the relative effects of different adversities on children’s development is challenging
because of the complex and overlapping nature of risk factors. Few studies of children adopted
from care have had large enough samples to manage this complexity and hence identify the
independent contributions of correlated risk factors. This study aimed to address this gap in the
research through using in-depth survey data from a sample of 319 adoptive parents to explore
links between children’s pre-adoption experiences (in utero, at home with their birth family and
in foster care) and their progress in the adoptive home (across a range of domains) using a latent
factor structural equation approach. Child maltreatment and children’s outcomes are multidi-
mensional concepts so we modeled them as two factors in a latent factor structural equation
model. This approach allows researchers to test the validity of hypotheses about both measure-
ment and structural relationships simultaneously and within a single framework (MacCallum &
Austin, 2000). It is suitable for dealing with multicollinearity (where many covariates of interest
are highly correlated) which can potentially create problems in interpreting findings. It also
recognizes that constructs such as child maltreatment and outcomes cannot be observed directly
in surveys but must be constructed or inferred from a set of answers to survey questions. It
recognizes that the survey indicators are also prone to measurement errors resulting from their
self-reporting nature, such as differing interpretations of the questions based on respondents’
experiences, attitudes, and knowledge.
The four key components of the model we employed are the two latent constructs (children’s
experiences of maltreatment; children’s adverse outcomes) and two sets of mediating factors
(factors influencing maltreatment such as length of time at home, parental pathology; factors
56 Developmental Child Welfare 2(1)

influencing adverse outcomes such as length of time in the adoptive family, adoptive family
structure). Our hypotheses were that (1) that higher values on the maltreatment index would be
associated with more adverse outcomes, (2) values on the maltreatment index would be greater for
children who stayed in the home environment longer, whose birth parent(s) had learning difficul-
ties, mental health problems, and/or substance misuse problems, and (3) a range of other covariates
would also impact children’s outcomes independent of their experiences of maltreatment.

Methodology
Participants
The participants were 319 adoptive parents who completed an in-depth online survey in 2016–
2017 (See Neil, Young & Hartley, 2018 for full details of the survey). They were recruited through
21 adoption agencies in one region of England. Respondents indicated their consent to participate
by completing and submitting the survey. The study received ethical approval from The University
of East Anglia, School of Social Work Research Ethics committee.
Eighty-five percent (n ¼ 268) were mothers and 15% (n ¼ 48) fathers. A minority (17%, n ¼
53) were from single parent households. Three-quarters (n ¼ 238, 76%) were part of a heterosexual
couple and 7% (n ¼ 22) part of a gay or lesbian couple. The majority of adoptive parents (n ¼ 217,
93%) were White British or Irish. Most (88%, n ¼ 281) had adopted a child previously unknown to
them; two parents knew their child from their professional or family network and 36 (11%) were
foster carer adopters.
One parent per family completed the survey about one child (their most recently adopted child,
or the oldest of siblings placed together). Children were aged 0–17 at the time of the survey, the
average age being 7. Age at placement ranged from 0 years to 11 years (mean ¼ 28 months). Just
over half (53%) were boys and 47% were girls; 89% were White (British, Irish, or “other”) and 8%
were from Black and ethnic minority groups.

Measures
Indicators of maltreatment. There were six questions about pre-adoption abuse (physical abuse,
emotional/psychological abuse, sexual abuse involving contact, sexual abuse not involving con-
tact, witness to domestic violence, singled out for rejection) and five about neglect (medical
neglect, nutritional neglect, emotional neglect, physical neglect, supervisory neglect). In complet-
ing this section (and other questions about the child’s history pre-adoption), adoptive parents were
likely to have drawn on a range of sources including the child’s permanence report prepared by the
social worker prior to adoption, plus other information passed on by professionals, foster carers, or
birth family members. Adopters were provided with detailed definitions of types and levels of
severity of maltreatment.
For all maltreatment variables except “singled out for rejection,” data were coded as follows:
don’t know (score as missing), not experienced (Score 0), experienced at mild level (Score 1),
likely experienced/unsure what level (Score 2), experienced at moderate level (Score 3), and
experienced at significant level (Score 4).
With “singled out for rejection,” we created a dummy variable taking the value of one when
experienced (encompassing “mild,” “likely,” “moderate,” and “severe”) and zero when this was
not known to have been experienced (encompassing the previous codes “don’t know” and “not
Neil et al. 57

experienced”). This approach was taken because the preferential rejection or scapegoating of one
child in the family was considered to be not an additional type of maltreatment (it may have
manifested, e.g., as physical, sexual, or emotional abuse or neglect), but a factor making maltreat-
ment psychologically worse for the child (because it was directed mainly or wholly at them and not
at their siblings).
These 11 dimensions were then aggregated to 4 for the statistical analysis: neglect (medical
neglect, nutritional neglect, emotional neglect, physical neglect, supervisory neglect); physical
abuse; emotional abuse (emotional/psychological abuse, witness to domestic violence, singled
out for rejection); and sexual abuse (sexual abuse involving contact, sexual abuse not involv-
ing contact).
The highest score on any one of the relevant subscales was used as the score for the neglect,
physical abuse, and sexual abuse indicators. The emotional abuse indicator was constructed using
the highest score on “emotional/psychological abuse” and “witness to domestic violence” and
adding an extra score of 1 for “singled out for rejection” (if the child had experienced this). If data
were missing for one or more of the subscales, the overall score for each of the four dimensions was
still calculated using the highest score from remaining subscales. Pairwise correlation coefficients
between maltreatment factors were high (all correlations being significant at the .05 level—see
Table S4 in the supplementary materials), and the internal consistency was very high (Cronbach’s
a statistics: .8025).

Indicators of adverse outcomes. The outcome indicators used in the model were adoptive parents’
reports of the adoption overall and of their child’s progress in eight different areas of development.
How was the adoption faring overall? Five options were given. This variable was recoded as
follows: 1 ¼ going really well, 2 ¼ managing challenges, and 3 ¼ struggling (combining three
options struggling, possible that the child won’t remain in the family, and adoption has broken
down).
Child behavior, well-being, and relationships. Parents were asked to indicate whether their child
showed strengths or challenges in eight different areas: general behavior in the home, general
behavior outside the home, general physical health, emotional well-being, self-esteem, relationship
with the parent completing the survey, social interaction with adults outside the family, and
making and maintaining friendships. Respondents could tick one of the four options and these
were assigned scores as follows: serious challenges (3), moderate challenges (2), no challenges
(1), and a particular strength (0). Pairwise correlation coefficients between all outcome factors
were all significant at the .05 level (Table S5 in supplementary materials). Values associated with
the internal consistency were high (Cronbach’s a ¼ .9049). These results, together with the results
relating to the latent maltreatment index, support the use of a latent factor approach.

Covariates. The first set of covariates included factors found previously to be associated with child
maltreatment:
The child’s sex. Male ¼ 0, female ¼ 1.
Exposure to drugs or alcohol in utero. 0 ¼ not known that the child had been exposed to either drugs
or alcohol (don’t know, not experienced) and 1 ¼ known exposure to drugs or alcohol or both
(mild, likely/unknown level, moderate, significant).
58 Developmental Child Welfare 2(1)

Learning disability of birth parents. This was coded as 0 where neither birth parent was known to
have a learning disability, 1 ¼ where one parent was known to have a learning disability and 2 ¼
both birth parents were known to have a learning disability.
Serious mental illness of birth parents. A variable for the presence of bipolar disorder and/or
schizophrenia in birth parents was included. This variable was scored as 0 (neither parent known
to have these mental illnesses), 1 ¼ one parent is known to be affected, or 2 ¼ both parents known
be affected.
The age of the child when finally removed from the birth family. To account for potential nonlinearity
in the relationship between the length of time the child was exposed to the birth parent environment
and the maltreatment index, five different dummy indicators were defined, with cutoffs for the age
of the child set at 3, 5, 11, 17, and 23 months old. The reference category was therefore a child that
was finally removed from the birth parent(s) after 23 months.
A second set of covariates were those found in previous studies to be associated with child
outcomes:
Time in foster family(ies) (time in care). This was approximated by subtracting age at final removal
from birth family from age at placement with adopters (or with foster carer adopters). To allow for
nonlinearities, two binary variables were generated: the first took the value of 1 if the child spent
less than 12 months in care; the second took the value of 1 if the child spent between 12 months and
24 months in care. The reference category was therefore a child that spent more than 24 months (2
years) in care (not with the family who adopted them).
Child’s distress on moving from the foster home. A binary indicator was generated from the question
“Overall, how did your child find the process of moving to your household?” with five possible
responses given. “Extremely difficult” and “somewhat difficult” were recoded as “difficult move”
(1) and the other categories of response (neither easy nor difficult, somewhat easy, and extremely
easy) were coded as (0).
Number of foster homes. 0 ¼ no or one previous foster home and 1¼ two or more foster homes
before moving to the adoptive family.
Adoptive family—single or dual parenting. A binary variable was generated taking the value of 1 if
the parent was single and 0 otherwise.
Child’s length of time in the adoptive family. This was calculated by subtracting the child’s age at
placement in the adoptive family from their age in years at the time of the survey.

Statistical analysis
The structural model implemented (shown in Figure 1) comprised the following four different
components that were being estimated simultaneously.

Child maltreatment. The exposure to and severity of maltreatment was modeled as a latent construct
that cannot be directly observed but can be estimated by making use of parents’ responses to the
questions about maltreatment. This maltreatment variable is shown as an oval on the left-hand side
of Figure 1. The square boxes to the left indicate the four maltreatment aggregated indicators
described earlier.
 Figure 1. Latent factor structural equation model: Child maltreatment and adoption outcomes.

59
60 Developmental Child Welfare 2(1)

Factors influencing maltreatment. The underlying (latent) maltreatment index is allowed to covary
with the set of covariates documented earlier. Because these factors are assumed to influence the
child maltreatment score derived, they are shown in the model on the left-hand side, above the
latent maltreatment index.

Measuring children’s adverse outcomes. Children’s outcomes were also modeled as a latent factor,
measured using adoptive parent’s ratings of their child’s behavior, well-being, relationships, and
how the adoption was faring overall. Higher scores on this index represented poorer outcomes;
hence, we labeled this the “adverse outcome index.” This latent construct is shown on the right-
hand side of Figure 1 in the oval figure, with the square boxes (to the right) representing the
observed indicators used to estimate it.

Factors influencing outcomes. The adverse outcome index is then allowed to be influenced by a
set of factors, including the maltreatment index. Other covariates included time in foster
family(ies), number of placements in care, the child’s distress on moving from the foster
home, length of time in the adoptive home, child’s sex, and whether the child was in a single
or two-parent family.

Results
Descriptive statistics
The descriptive statistics for all the variables used in this analysis are provided in Tables S1 to S3
in the supplementary materials.
Neglect was the most prevalent form of maltreatment, with 59% of children having experienced
this at a moderate or significant level. Almost half of the children (47%) had experienced moderate
to very severe emotional abuse. In contrast, physical abuse was less commonly experienced (18%
physical abuse at moderate or significant levels) and only 4% of children were reported to have
experienced moderate or significant sexual abuse. All four types of maltreatment were signifi-
cantly correlated with each other at the 5% level or higher, with the highest correlations being
between emotional abuse and neglect.
In terms of how the adoption was going overall, 44% of parents said things were going well,
35% said they had challenges but were managing, and 21% said they were struggling. The most
common child adverse outcomes reported by adopted parents were related to behavior in the home
and emotional well-being with fewer concerns being shown about the child’s physical health,
relationships with the adoptive parents, and social interaction with adults outside the home (see
Tables S2 in supplementary materials).
Over half of the children (54%) were reported to have been exposed to harmful levels of drugs
or alcohol in utero (see Tables S3 in supplementary materials). Almost one third of children (31%)
had at least one parent with a learning difficulty. In contrast, just 5% of children had at least one
parent known to have a bipolar or schizophrenic disorder. In terms of age at removal, almost half
(48%) were removed from home in the youngest age band (under three months), but over one in
five children (22%) were not finally removed until they were 2 years or older. The descriptive
statistics also show that one third of children (33%) had lived with two or more different foster
families before moving to their adoptive family.
Neil et al. 61

Emotional abuse

Physical abuse

Neglect

Sexual abuse

0 .2 .4 .6 .8 1 1.2 1.4 1.6 1.8 2

Factor loading

Figure 2. Estimated factor loadings associated with the maltreatment index.

Regression results
Factor loadings. Figure 2 shows estimated factor loadings for the maltreatment index. All abuse
indicators had a significant and positive effect in determining the overall level of the maltreatment
index. The most significant factors were emotional abuse and neglect. In other words, children who
experienced these types of maltreatment had particularly higher levels/severity of maltreatment
overall (see Figure 2). Note that for identification purposes we set the residual variance of both the
latent factors equal to 1.
Figure 3 shows the estimated factor loading for the adverse outcome index. Similarly, indicators
on parents’ ratings of outcomes in the different areas loaded onto the adverse outcome index highly
significantly. Some indicators were more relevant than others in determining the latent outcome
index: the highest correlations were found for emotional health, self-esteem, and behavior at home.
The overall adoption outcome indicator was also significantly correlated with the latent index
derived (see Figure 3).

Estimated relationships for the maltreatment index. The first column of Table 1 provides estimated
coefficients for the maltreatment index—the factors that influence the child’s experience of mal-
treatment. The latent maltreatment index significantly increased with the length of time the child
was exposed to the birth family. Note that the effect was not linear: children who were removed
from the birth parents when under 3 months had, as expected, significantly lower maltreatment
index scores than those removed when aged 17 months or above. This group may stand out as it
contained a large number of children removed either at birth or within their first month of life, so
the length of exposure to the birth family environment was very minimal. Children removed from
the birth family in all groups up until 18 months of age experienced less severe maltreatment than
children who remained in the birth family for 2 years or longer. The maltreatment index was
significantly higher for those children exposed to drugs and/or alcohol in utero. The maltreatment
index was also higher for those children with birth parents affected by major psychiatric problems
and learning disabilities. The effect, however, was significant at 5% level for learning difficulties
62 Developmental Child Welfare 2(1)

Overall adoption outcome

Behaviour at home

Behaviour outside home

Physical health

Emotional health

Self Esteem

Relation with parents

Relationships with other adults

Peer relationships

0 .25 .5 .75 1 1.25 1.5 1.75 2 2.25 2.5

Factor loading

Figure 3. Estimated factor loadings associated with the adverse outcome index.

Table 1. Estimated coefficients for the latent maltreatment index and the latent outcome index.

Covariates Latent maltreatment index Latent outcome index

Latent maltreatment 0.175***

Prenatal toxic exposure to drugs/alcohol in utero 0.330**
Birth parents with learning disabilities 0.240**
Birth parents with bipolar disorder/schizophrenia 0.214
Removed from birth parents when under 3 months old 2.273***
Removed from birth parents when 3–5 months old 0.875**
Removed from birth parents when 6–11 months old 0.786***
Removed from birth parents when 12–17 months old 0.612**
Removed from birth parents when 18–23 months old 0.217
Female 0.035 0.071
Time spent in foster care less than 12 months 0.314*
Time spent in foster care 12–24 months 0.128
Length of time in adoptive family 0.02
Child found move to adopters difficult 0.581***
Two or more foster homes before moving 0.283**
Adoptive family single parenting 0.02

Note. Sample size: 319. Robust standard errors. Goodness-of-fit statistics: log-likelihood ¼ 3,608.3; degrees of freedom ¼ 73;
Akaike information criterion ¼ 7,362.6; Bayesian information criterion ¼ 7,639.3.
***p < .01. **p < .05. *p < .1.

only. Psychiatric problems were not associated significantly, when controlling for exposure to
alcohol/drugs.

Estimated relationships for the outcome index. The second column of Table 1 provides estimated
coefficients for the adverse outcome index. As expected, the latent adverse outcome index was
Neil et al. 63

significantly higher (i.e., worse) for children with a high value on the maltreatment index. The time
that children stayed in foster care was negatively linked to the outcomes observed, all other factors
being equal. Those children who stayed in foster care (in a different family to the one that adopted
them) for less than 12 months had, on average, better outcomes than those who spent a longer
period in care. Beyond 12 months, however, there were no significant associations between the
outcome index and the time in care. Children who had two or more foster placements before
moving to their adoptive family had significantly poorer outcomes than those who had just one
foster placement or who were placed directly with their adoptive parents. Controlling for other
characteristics, the length of time in the adoptive family (which was strongly linked to current age)
had no significant association with the latent outcome. Those children who experienced the move
to adopters as difficult were more likely to have poorer outcomes, when all other factors were taken
into account. No significant differences between boys and girls were found either in terms of the
latent maltreatment index or the adverse outcome index. Finally, it appeared that family structure
was not significantly associated with outcomes: the coefficient associated with being a single
parent was small in magnitude and not statistically significant.

Sensitivity analysis. Results from a fuller set of variations of the latent factor structural model in
Figure 1 are available in the supplementary information (pp. 7–8). The most salient result was
that exposure to drugs or alcohol in utero and learning disability of birth parents were both
found to be positively and significantly associated with the adverse outcome index at 5% and 1%
levels, respectively, indicating that these factors were independently associated with worse child
outcomes.

Discussion
Adopted children’s outcomes (in terms of the overall progress of their adoption and the adopters’
ratings of the child’s progress in eight areas covering physical, emotional, and behavioral devel-
opment and relationship with parents, peers, and others) were affected by range of risk factors each
of which were significant when controlling for a comprehensive set of other factors. These factors
included possible heritable factors (parental learning disability), the pre-birth environment (expo-
sure to drugs or alcohol in utero), and the period of their life between birth and moving to their
adoptive family (higher levels of maltreatment, spending more than a year in care, having two or
more foster placements). The child’s distress on moving from the foster home to the adoptive
family was also highly significant in linking to poorer outcomes. This confirms the findings of
Selwyn et al. (2014) but demonstrates that this factor (arguably a risk created by the adoption
system itself) is significant even when other factors are taken into account. Children’s outcomes
did not appear to be significantly affected by their sex, whether they were in a single-parent or two-
parent family, whether their birth parents had a mental illness (schizophrenia or bipolar disorder),
or the length of time in their adoptive family. Although the older children in this study (and
therefore those who had been in their adoptive family for longer) had much higher problems than
the younger ones (Neil, Young & Hartley, 2018), our analysis suggests these differences were
primarily to do with the higher levels of other risks factors for such children rather than their older
age at the time of the survey.
Many of the factors identified as a risk for adopted children’s development concur with findings
of previous research (Palacios, Rolock, et al., 2019). However, this novel analytical approach,
previously not applied in adoption research, has enabled the relationship between the latent
64 Developmental Child Welfare 2(1)

variables (maltreatment and child outcomes) to be examined alongside further observed variables
simultaneously and within a single framework, providing more robust evidence about the individ-
ual impact of various factors.

Implications for policy and practice

Risks experienced before entering care, even before birth, impact significantly on children’s like-
lihood of experiencing maltreatment and directly on their adoption outcomes, pointing to the
importance of supporting and protecting children in their families of origin before they enter care.
Primary risk factors such as parental substance misuse need to be understood in the context of
secondary risk factors such as poverty, ill-health, and housing problems (Brown et al., 2016;
Bywaters et al., 2016; Sidebotham et al., 2006) but, in the United Kingdom, austerity policies
have led to drastic cuts in family support services (Kelly et al., 2018). Alongside family support,
timely safeguarding of children, and where necessary proactive planning for permanence, is also
needed to prevent or reduce children’s exposure to maltreatment and promote their long-term
welfare (Davies & Ward, 2012). While a policy focus on adoption support is much needed, this
must considered alongside (not at the expense of) the provision of interventions at an earlier stage
that support families and safeguard children.
Once a child enters care it is important to avoid unnecessary delay in permanency planning
and to reduce the number of pre-adoption foster homes, preferably to one or none (i.e., where the
child is adopted by foster carers). Concurrency or foster for adoption placements can reduce
children’s time and moves in care (Dibben & Howorth, 2017; Monck et al., 2004). Purposive
court and social work intervention and interdisciplinary practice with birth parents prior to and
during the child’s placement in care can also reduce disruption for children and help parents
tackle their problems, Family Drug and Alcohol Courts being one example (Harwin et al., 2018).
Our analysis suggested the key difference for children was spending less than 12 months in care;
there were no significant differences between those who stayed 12–24 months or more than 24
months. This may suggest that for children who have already waited a year, speed is not
necessarily the most important factor—the quality of the in-care experience, the appropriateness
of the match with adopters, and careful preparation of the child may be more significant. Our
analysis found that child outcomes did not differ by family structure (one- or two-parent fam-
ilies). This suggests that when matching children, decisions should be based on the capacity of
the parent(s) to meet the child’s needs, rather than on unfounded assumptions that couples can
offer more than single parents.
When children do move from foster care to their adoptive family, the focus may need to switch
from reducing time delays to moving at a pace that is comfortable for the child. There was little
diversity in how transitions were handled in this study. The vast majority of moves were short (12
days on average from the child first meeting the adopters to them assuming full-time care).
Whether or not foster carers stayed in touch after the move was very variable, and adoptive parents
frequently described transitions as intense and exhausting (Neil, Young & Hartley, 2018). Transi-
tions may be easier if there is greater temporal and relational overlap between the foster and
adoptive family systems. This can be achieved by adopters and foster carers working together
and at the child’s pace, and foster carers providing early support to the child and adopters after the
move (Neil, Beek & Schofield, 2018; Boswell & Cudmore, 2017; Lewis, 2018).
Information about risk factors known to agencies at the point of placing children for
adoption should be used to identify which children might need further specialist assessment
Neil et al. 65

and intervention. Screening for the possibility of FASDs where prenatal exposure to alco-
hol is known is important, as early diagnosis and appropriate treatment can help adopters to
better understand their child’s needs and prevent secondary disabilities (Lange et al.,
2013). Children who are showing signs of attachment difficulties or whose experience of
adversity puts them at risk of such problems should be assessed for attachment disorders
and parenting interventions such as video feedback or therapeutic play sessions should be
offered (National Institute for Health and Care Excellence, 2015). Other common mental
health problems, especially behavior problems, neurodevelopmental difficulties, trauma,
and mood disorders, may also need to be considered and assessed by specialists (Woolgar
et al., 2018).
Information about children’s risks should be used in the recruitment and preparation of
adoptive parents. Adoptive parents commonly report feeling ill-equipped for the realities of
parenting an adopted child; they are likely to value specialist clinical information and oppor-
tunities to connect to others with relevant personal experiences as well as access to services
and parenting tools and strategies (Lee et al., 2018). Providing prospective adopters with more
information about the impact of risks factors on children may help build their empathy and
increase their confidence in considering a child with special needs such as FASD (Edelstein
et al., 2017). Better initial preparation and training for adoptive parents can normalize expec-
tations about the need for support and increase willingness to seek help later on (Wind et al.,
2007). A focus on a wide range of risk factors beyond age at placement is important, as the
support needs of children placed as babies and toddlers can be overlooked (Meakings et al.,
2018). Simplistic or deterministic predictions about children’s development need to be
avoided as sensitivity to risk varies and children’s outcomes are diverse (Woolgar & Sim-
monds, 2019), but building a realistic understanding of potential challenges balanced with a
sense of optimism is important (Lee et al., 2018).

Limitations
Our analysis was able to include a good range of variables but the sample size, although large for
an adoption study, limited the number that could be included. Other variables that could be studied
in future research include, for example, the impact of structural and communicative openness,
placement with siblings, the child’s development (disability and emotional and behavior devel-
opment) at the time of placement, and adoptive parenting stress. It is also vitally important to study
adoption outcomes as perceived by adoptees themselves.
A key limitation of the analysis is that adoptive parents reported both on the child’s history
prior to adoption and their current outcome. In the light of the child’s current progress, parents
may have (re)interpreted information given about the child’s past, or vice versa. We attempted to
reduce this potential bias by including detailed definitions of the types and levels of severity of
maltreatment. To attenuate the risk of “shared method bias,” future research should consider the
use of triangulated information about children’s backgrounds and/or their progress (e.g., from
adoptees, social workers, or teachers) although this yields the problem of dealing with poten-
tially discordant reports. Adoptive parents were recruited via adoption agencies, and parents of
older children may have been those who were actively seeking or receiving support, hence over
representing adolescents with difficulties. This shows the importance of controlling for age at
placement and other risks factors when analyzing cross-sectional samples of adopted children
and adolescents.
66 Developmental Child Welfare 2(1)

Conclusion
This study found that adopted children’s adverse outcomes across several domains rated by their
adoptive parents were negatively affected by a wide range of risk factors. The relatively large
sample size enabled the novel use of latent factor structural equation modeling methods, allowing
us to examine the independent effects of often highly correlated variables. Children were found to
have experienced higher levels of maltreatment when they lived at home for longer and when their
birth parents had learning difficulties and/or drug or alcohol problems. These problems of birth
parents also negatively affected children’s outcomes regardless of levels of maltreatment experi-
enced. Higher levels of maltreatment predicted worse outcomes for children after adoption, but the
child’s duration in care and the number of foster homes were also influential. A new finding was
that children who were distressed on moving from their foster home had worse outcomes, showing
the importance of thinking about and addressing loss and separation for adoptees.
Improving outcomes for adopted children requires a focus on child welfare practices before and
after adoption. Children adopted from care encounter many hazards in their lives before adoption,
not just in their families but within the care system. Family support and child protection services
are vital in reducing risks of maltreatment. Further harm due to multiple moves in care and poorly
managed transitions into the adoptive family are preventable risks, and reducing these should also
be a priority. Policy makers, practitioners, and prospective adopters need to use information about
risk factors to make realistic and properly resourced plans for the support children may need,
continually or episodically, after they have been adopted.

Acknowledgements
The authors acknowledge the contribution of Dr. Irina Sirbu who assisted with production of the online survey
and preliminary data analysis.

Declaration of conflicting interests

The author(s) declared no potential conflicts of interest with respect to the research, authorship, and/or
publication of this article.

Funding
The author(s) disclosed receipt of the following financial support for the research, authorship, and/or publi-
cation of this article: This research was supported by a grant from Barnardo’s on behalf of the Yorkshire and
Humberside Adoption Consortium; Dr. Morciano’s contribution was supported by the Economic and Social
Research Council, United Kingdom, through the Business and Local Government Data Research Centre
Grant (grant number ES/L011859/1).

ORCID iD
Elsbeth Neil https://orcid.org/0000-0001-5655-7498

Supplemental material
Supplemental material for this article is available online.
Neil et al. 67

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