Yanhong Liu, Richard J. Hazler

International adoption provides U.S. families with parenting opportunities as well as with challenges accompanying adoptees’ post-adoption adjustment. The literature indicates differences in adjustment outcomes between Chinese and other international adoptees. Differences are found in behavioral adjustment, attachment formation and social-emotional development. Pre-adoption circumstances, including the political and cultural reasons for adoption, institutionalization experiences, and family stress, are relevant factors for adoptees’ post-adoption adjustment. A closer look at Chinese adoptees offers insights on components that may prohibit or contribute to post-adoption adjustment outcomes. Each component provides implications for professional counselors and the adoptive families they serve for nurturing the growth of international adoptees.

Keywords: international adoption, international adoptees, Chinese adoptees, post-adoption adjustment, professional counselors, adoptive families

International adoption, involving transferring children from a country of origin to a host country, creates a unique set of circumstances where adoptive parents and adopted children meet across lines of differences in biology, race, cultural heritage, nationality, socioeconomic status and more (Bartholet, 2006). World circumstances of war, poverty and lack of social welfare have created multiple scenarios in which countries now provide U.S. couples with additional parenting opportunities, while increasing infertility rates and other difficulties have reduced U.S. domestic adoption opportunities. These increases in international adoptions have both global significance and local importance for related countries, societies and communities (Hoshman, Gere, & Wong, 2006). Many advantages and challenges accompany the adoption process that counselors increasingly need to face in their schools, communities and private practices.


     International adoption provides many opportunities for the countries involved, for the individuals wanting to adopt and for the children needing adoption; however, the post-adoption process is accompanied by multiple challenges for adoptive parents, professional counselors and human service agencies. A meta-analysis by Juffer and van IJzendoorn (2005) showed that internationally adopted children exhibit more behavioral problems and receive more mental health services than non-adopted children. Higher rates of attachment and social-emotional problems also were found among internationally adopted children when compared to non-adopted and domestically adopted peers. As such, this group needs to be considered an at-risk population deserving of specific attention (Barcons et al., 2011; van den Dries, Juffer, IJzendoorn, & Bakermans-Kranenburg, 2010).


     Professional counseling journals currently provide little help to their readers about international adoptees and the resources needed to work effectively with them. Journal articles from psychology, social work, children and youth services, adoption, and sociology (e.g., Bruder, Dunst, Mogro-Wilson, & Tan, 2010; Cohen & Farnia, 2011; Pugliese, Cohen, Farnia, & Lojkasek, 2010) provide more information on these issues, and their findings can be utilized to meet the needs of professional counselors. This article will utilize the findings from related disciplines to demonstrate how professional counselors can more effectively support children and parents among this population.


     International adoptees from China have been shown to have better adjustment outcomes in comparison with international adoptees as a whole, making them an important subgroup to examine (Cohen & Farnia, 2011; Tan, Camras, Deng, Zhang, & Lu, 2012; Tan & Marfo, 2006). China also is the largest country of origin of children for international adoption, accounting for over one fourth of the 242,602 U.S. international adoptions between 1999 and 2012 (U.S. Department of State, 2012). The post-adoption adjustment of international adoptees from China and the wealth of literature regarding them provide important sources of information on what influences an international adoption. Consequently, this article gives significant focus to Chinese adoptees and, where possible, compares that information to studies of adoptees from other countries. This article transforms the information into practical implications for counselors and parents with international adoptees and those who are considering an international adoption.


A Closer Look at Chinese Adoptees


     Chinese adoptees deserve particular research attention because they show more positive post-adoption outcomes in areas such as personal-social development, problem-solving skills, behavioral adjustment, child–parent attachment patterns and academic achievement (Cohen & Farnia, 2010; Tan, Marfo, & Dedrick, 2010; Welsh & Viana, 2012). Cohen and Farnia (2010, 2011) found a common trend in that Chinese adoptees display rapid growth in overall development within the first 6 months after adoption and increased attachment 2 years later. Their preschool years contain fewer behavioral problems compared even to U.S. preschool-age non-adopted girls from the normative sample (Tan et al., 2012). Behaviors exhibited by Chinese adoptees are comparable to those of U.S. non-adopted peers, which means Chinese adoptees demonstrate no more internalizing (directed toward oneself), externalizing (directed toward the environment) or total problem behaviors than all children in a similar age range (Tan et al., 2012). Internalizing problems, externalizing problems and overall behavior problems are the three subscales of the Child Behavior Checklist that Tan et al. (2012) used to measure preschool-age Chinese girls’ behaviors.


     A study from another Western culture compared the academic achievement of 77 Chinese adoptees with those of 77 Norwegian-born children of similar age and found no significant difference between the two samples (Dalen & Rygvold, 2006). These results differ from results of studies on international adoptees from other countries, in which these adoptees have been shown to exhibit lower academic performance than non-adoptees (e.g., Miller, Chan, Tirella, & Perrin, 2009; van IJzendoorn, Juffer, & Poelhuis, 2005). The combined results consistently indicated better post-adoption results for Chinese children. These results raise the following question: What is it about Chinese children and the process of their adoptions that might account for such differences?


Politics and Culture

     More than 90% of Chinese adoptees are female infants, a fact influenced by China’s political and cultural characteristics. Adoption from China to the United States was greatly affected by China’s one-child policy, first implemented in 1979. The policy was designed to control population growth by only allowing one child per couple. This policy, along with China’s cultural emphasis on sons over daughters, has caused the abandonment of many infant girls (Johnson, 2004). This abandonment practice is one way for a family to have a second child but still be a one-child family. Most of the abandonments happen in rural areas of China where households without a son are likely to experience discrimination for potentially losing their family name in following generations (Chen & Li, 2009). Family name has great cultural importance throughout China, but rural populations are the most concerned about these issues, making female children most vulnerable and more likely to be put up for international adoption.


     The one-child policy impacts more than the number and gender of adoptees. It is believed that this policy is an indirect factor in Chinese adoptees’ better physical and experiential conditions when adopted (Kreider & Cohen, 2009). The one-child policy, along with the cultural preference for male infants, indicates that healthy parents abandon the majority of Chinese children put up for adoption for poverty-related, political or cultural reasons, and not for health or disability reasons, as is often the case in other countries. Adoptees from Eastern Europe and Russia, for example, consistently experience pre-adoption adversities such as poverty and birth mothers’ alcohol and substance use during pregnancy (Kreider & Cohen, 2009; Welsh &Viana, 2012). The physical and emotional pre-adoption environments for non-Chinese children understandably make a significant difference for their potential to successfully develop as they meet the multiple demands of the adoption process.


Pre-Adoption Institutionalization Experience

     Approximately 85% of international adoptees have some level of institutionalization experience in their birth countries (Gunnar, van Dulmen, & the International Adoption Project Team, 2007). Along with pre-adoption parental quality and biological factors, the institutionalization experiences were found to be a significant factor in predicting post-adoption behavioral problems (Hawk & McCall, 2010; van den Dries et al., 2010). The quality of institutional care received by adoptees varies from country to country. The psychological aspect of institutional care is better in China because of the family-like atmosphere within institutions (Neimetz, 2010; Shang, 2002). A case study by Neimetz (2010) found that the director, codirector and other caregivers were called father, mother and siblings, respectively. This family-style psychological emphasis demonstrates recognition of a quasi-family environment aimed at counterbalancing the effects of the large number of children in an institution, which does not seem to appear in many other countries.


Risk Factors for Adoptee Adjustment


Cognitive Development

     The status of adoptees’ cognitive development at the time of adoption has been noted as predictive of attachment outcome and social-emotional reactivity. Recent literature has indicated a positive relationship between international adoptees’ post-adoption adjustment and their cognitive level when they arrived in the host country (Cohen & Farnia, 2010). Cohen and Farnia (2011) found that mental development index scores are significant predictors of Chinese adoptees’ later social-emotional activities and attachment outcomes, which in turn affect cognitive development. After 6 months, adoptees with higher mental development index scores were associated with better social-emotional adjustment and faster rates of forming attachment relationships with their adoptive mothers. Cohen and Farnia (2010) speculated that a lack of cognitive resources is associated with adoptees’ difficulty in post-adoption adjustment.


Behaviors at Time of Adoption

Positive relationships have been found between rejection behaviors at the time of adoption and both internalizing and externalizing behavioral problems of preschool-age and school-age Chinese adoptees (Tan & Marfo, 2006). Rejection behaviors are adoptees’ resistant behaviors toward adoptive parents during the initial period after adoption (Tan & Marfo, 2006). Tan and Marfo (2006) found that the behaviors present at the time of adoption were better predictors of later adjustment outcomes than adoptees’ age on arrival. Therefore, initial behaviors are more influential for adoption outcomes than the maturity that comes with age (Tan et al., 2010).


Family Stress

     Tan et al. (2012) studied the post-adoption adjustment of 133 preschool-age Chinese adoptees and found that the level of stress in the adoptive family positively correlated with the child’s presenting behavioral problems. The higher the level of stress that a family encounters, the more behavioral problems are identified in the child. Maternal depression prior to adoption, as well as high parental expectations of problems (i.e., expecting a high rate of occurrence of the child’s behavioral problems), were significant predictors for post-adoption family stress (Viana & Welsh, 2010). Familial stress is a significant factor in child–parent relationships and a risk factor for overall child psychopathology (Deater-Deckard, 1998).


Parental Sensitivity and Authoritative Parenting

Parental sensitivity refers to parents’ ability to sense various cues that an infant exhibits and to respond to those cues consistently (Karl, 1995). Sensitive parenting provided by adoptive parents is related to better developmental growth following adoption (Palacios & Brodzinsky, 2010). Parents who are consistently sensitive in caregiving develop more secure attachment with adoptees, and changing from insensitive to sensitive caregiving results in a transition from insecure to secure attachment (Beijersbergen, Juffer, Bakermans-Kranenburg, & van IJzendoorn, 2012).


Parental sensitivity in the literature refers generally to parents’ responsiveness to infants, but the concept of parenting styles takes on greater significance when it concerns young children. Baumrind (1978) proposed three primary parenting approaches: authoritative parenting, authoritarian parenting and permissive parenting. Authoritative parenting was highlighted positively for its emphasis on parents’ setting up reasonably high expectations while showing support for children’s interests. Tan et al. (2012) studied the role of authoritative parenting in adoptive families with Chinese children and found that authoritative parenting was associated with fewer behavioral problems in Chinese adoptees in the study.


     A closer look at Chinese adoptees’ pre-adoption circumstances and post-adoption protective factors offers insights about the critical components that may prohibit or contribute to positive adjustment outcomes. Political and cultural influences, institutionalization experiences prior to adoption, adoptees’ cognitive development level, and parents’ sensitive care and authoritative parenting in post-adoption all appear to be important factors in post-adoption adjustment. Each component provides implications for professional counselors and the adoptive families they serve in facilitating adoptees’ development.


Implications for Parents and Counselors


     Post-adoption protective factors such as parental sensitivity and appropriate parenting approaches can mitigate adoptees’ adverse experiences and promote resilience (Barcons et al., 2011; Scroggs & Heitfield, 2001; van den Dries et al., 2010). The impact of pre-adoption conditions diminishes as the influence of the adoptive family becomes more salient (Gagnon-Oosterwaal et al., 2012). Studies showing significantly better results for Chinese adoptees’ adjustment provide insights related to key issues deserving attention from professional counselors and their parent clients. Examining pre-adoption conditions and experiences of international adoptees can be a challenging issue due to the distance from countries of origin and confidential nature of the information.


Awareness of Gender Differences and Health Status

The availability of more female than male infants for adoption, created by China’s one-child policy and cultural emphasis on males over females, is related to a healthier status of most adopted Chinese children (Kreider & Cohen, 2009). These gender and health differences provide insights into caregiving by adoptive parents and the counseling services offered to adoptive families. Designing and implementing preventative and intervening approaches should be carefully examined and adapted based on considerations of male versus female adoptees, and of healthy children versus children with special needs.


     Implications for parents. Parents need to understand the context of countries from which they wish to adopt a child. Families differ in their reasons for adoption, the countries they choose from which to adopt and characteristics of the child whom they wish to adopt. These differences make it important for parents to conduct a self-analysis and rationalize the adoption choice by specifying characteristics of an adopted child such as gender, age, race and health conditions prior to the international adoption process (Gunnar, Bruce, & Grotevant, 2000). Becoming familiar with the context of countries of origin facilitates the family’s matching process with a potential child. For example, parents may choose to adopt from a country with more female infants on the waiting list, such as China, if they prefer adopting a female child and have no specific restrictions on other characteristics.


     Parents also need to be aware of potential relationships between abandonment and the gender or health of the child so as to provide appropriate post-adoption care. Obtaining pre-adoption information about the child and the country of origin is an important step (Gunnar et al., 2000). Additionally, adoptive parents should understand that health and medical information, including family and prenatal history, is probably more comprehensive for a child from some countries than others. Families may follow up with the adoption agency by making specific requests for information that is more detailed than the standard information provided (Bledsoe & Johnston, 2004).


     Implications for counselors. When considering the gender and health of the adoptee, two main types of services are suggested for professional counselors working with internationally adoptive parents and adopted children—information interpretation (Gunnar et al., 2000) and pre- and post-adoption counseling services (Welsh, Viana, Petrill, & Mathias, 2007). The connection between the adoption process and the individual characteristics of the child to each country’s policy and culture make it necessary for counselors to take into consideration the context of the country of origin and to help families interpret adoption-related information (Gunnar et al., 2000). Quality interpretation increases the likelihood of the child’s positive post-adoption development. At the same time, the interpretation of information also has the potential to prevent a child from being adopted due to possible physical and mental health concerns of the child, expenses involved, and additional requirements about parents’ age, income or sexual orientation regulated by specific countries of origin (Gunnar et al., 2000).


     Counselors may utilize pre-adoption information (e.g., health and behavioral information, diagnosis) in designing interventions for adopted children. Most counselors do not receive professional training in adoption or working with adoptive families and children, so establishing a professional network with adoption agencies, social workers and psychologists becomes essential. This network will provide more accurate information and ensure necessary referrals, access to available medical and health data, appropriate consultation, and professional collaboration that will best serve adoptees and families.


 Recognizing Adoption-Point Behaviors

     Tan et al. (2010) reported in a longitudinal study of preschool-age Chinese adoptees that behaviors exhibited at the time of adoption predict adjustment outcomes regardless of the age at adoption. Risk indicators were identified as refusal/avoidance and crying/clinging behaviors, and more internalizing and externalizing behavioral problems were found in children exhibiting more physical risk indicators at the time of adoption (Tan et al., 2012).


     Implications for parents. International adoptive parents should be aware of the behaviors exhibited at the time of adoption by adoptees, which can be particularly helpful for recognizing potential adjustment issues. To deal with noncompliance and clinging related to problem behaviors and social-emotional learning, it is suggested that parents provide timely comfort and be attuned to the child’s needs (Brennan, 2013). Parents also are encouraged to recognize changes from the environment of the adoptee’s origin to a U.S. environment and consider preparing resources to help with children’s transitions. These can include music or stories in languages of birth countries along with toys and other sources of origin environment comfort.


     Implications for counselors. Professional consultation with adoption agencies can provide the basis for understanding specific behaviors that the child presents and how the behaviors can affect development. Some behaviors displayed by an adoptee may be related to his or her developmental stage, and frequently avoidance and clinging behaviors are identified as major symptoms of separation anxiety disorder in children (Ehrenreich, Santucci, & Weiner, 2009). Counselors may work with parents to track the frequency of the behaviors during the initial period after adoption. Appropriate interventions can then be designed and implemented according to the presentation of behaviors and/or specific diagnosis made by qualified professionals.


Facilitating Secure Attachment Development

Understanding the mutually influential factors of social-emotional reactivity and attachment security of adopted children are of practical significance (Cohen & Farnia, 2010). According to attachment theory, children with secure attachment are more likely to develop strong internal working models with salient self-efficacy, enabling them to be empathic and more capable of maintaining relationships, whereas children with insecure attachment may develop weak internal working models that lack social competency in relationships (Bowlby, 1969). Internationally adopted children experience a variety of transitions in culture, language and living environment, which present as separation and loss, adding difficulty to the development of attachment to new caregivers (Bowlby, 1969).


     Implications for parents. Parental sensitivity, or providing appropriate, timely and consistent responses, is a major contributor to secure child–parent attachment. It is a protective factor for international adoptees and can counteract otherwise problematic pre-adoption risk factors. Parents can increase their sensitivity by utilizing a form of mind-mindedness as an effective strategy for helping infants form secure attachments (Meins, Fernyhough, Fradley, & Tuckey, 2001). The technique involves naming children’s feelings, wishes, intentions and thoughts in situationally appropriate ways. The act of naming encourages active recognition of the need to respond to the child and the time to do so, thereby building a pattern of productive, sensitive, parental behaviors.


     Implications for counselors. Counselors may emphasize adoptee–parent relationships in which trust is a fundamental element (Barcons et al., 2011; Tan & Camras, 2011). Parent training and psychoeducation based on individual family needs can help establish the necessary parental desire and skills required. Trust-Based Relational Intervention is one sample of a program developed for adoptive families of children with social-emotional needs (Purvis, Cross, & Pennings, 2009). This program emphasizes the following two main principles in developing a family-based program: (a) awareness (i.e., understanding adoptees’ responses and feelings) and (b) engagement (i.e., interacting with adoptees in a way that makes them feel safe). Modeling eye contact and imitating the child’s body position are recommended for working with internationally adopted children for whom extreme changes in culture, environment and other factors can make developing trust more difficult. Counselors should be cautious when using these strategies before getting to know the child and parents in-depth. Active eye contact and body gestures may intimidate children due to cultural reasons or previous traumatic experiences (Becker-Weidman, 2006).


Coping With Family Stress

     Numerous studies have demonstrated a positive correlation between family stress and child psychopathology (Grant, Compas, Thurm, McMahon, & Gipson, 2004; Tan et al., 2012), and have shown that a significant sign of parental stress is maternal depression prior to adoption (Viana & Welsh, 2010). Parents must consider the parenting role differences in balancing family stress because parenting is not just the responsibility of a single parent.


     Implications for parents. Parents must evaluate the impact of family stress that can inhibit family function, thereby increasing children’s behavioral problems, and the family’s ability to deal with those problems. In two-parent households, parents are encouraged to participate in a parenting process in which one parent provides more emotional support to children by encouraging them to be independent and to explore unknown things (i.e., proactive approach), while the other provides emotional support through sensitive caring and responding to the child’s distress (i.e., reactive approach; Grossmann, Grossmann, Winter, & Zimmermann, 2002). Adoptive parents must consider a self-check on overall mental health as individuals, as a couple and as a family. Seeking support from a pre-adoptive preparation program focusing on evaluating self-wellness and promoting family resilience is an extremely valuable step (Viana & Welsh, 2010).


     Implications for counselors. Meeting the needs of adoptive families often requires implementing techniques to help recognize and deal with the sources of family stress. Parents must have an understanding of the family stress issues before they can effectively move on to developing and implementing interventions for adoptees’ behavioral problems, which can be exacerbated or even created by the stress. Counseling services for parental depression, anxiety, and other relevant feelings and symptoms are critical (Viana & Welsh, 2010).


     Conflict within a couple’s relationship is a key factor that predicts family stress because low-conflict couples are positively associated with satisfying parent–child interactions (Krishnakumar & Buehler, 2000). A variety of psychoeducational programs focus specifically on improving couple relationships for new parents (Halford & Petch, 2010). Counselors must consider the importance of parents’ focusing on conflict management and pre-parental anxieties of internationally adopting prior to the child’s arrival.


Cultivating Authoritative Parenting

     Parenting and attachment are two parallel behavioral systems that facilitate effective caregiving and attachment relationships in adopted children (Roberson, 2006). Results of hierarchical multiple regression analyses by Kriebel and Wentzel (2011) indicated that adoptees’ cumulative risk from pre-adoption circumstances is a negative predictor for later adaptive behaviors, whereas authoritative parenting is a positive predictor of children’s adaptability. Authoritative parenting also was found to be associated with fewer behavioral problems in Chinese adoptees, whereas authoritarian and permissive parenting styles were correlated with more behavioral problems exhibited by the children (Tan et al., 2012).


     Implications for parents. Cultivating authoritative parenting refers to promoting parents’ supportive role accompanied by consistent rather than harsh discipline. Parents with an authoritative parenting style tend to show warmth, affection and responsiveness and support children’s interests, but they also set up reasonably high demands and expectations for children (Baumrind, 1978). Inconsistent, overly harsh or emotionally vacant parenting has deleterious effects on children’s development. A lack of parental control or consistency in discipline is associated with greater behavioral problems at all child developmental stages.


     The concept of parenting styles is the same in all cultures, but its application may vary by race, culture or socioeconomic status. For example, Kisilevsky et al. (1998) maintained that parenting methods of Chinese parents differ substantially from those of U.S. parents, so adopted children from China experience different parenting before and after they are adopted. Parents with internationally adopted children are encouraged to take all social and cultural variables of parenting into consideration (Kotchick & Forehand, 2002), while using an authoritative parenting style as the principal guideline.


     Implications for counselors. Psychoeducational programs can be intervention strategies for counselors to better serve adoptive families’ parenting needs. Programs may include a miniature of Baumrind’s (1978) work with emphasis on how current parent themes align with the parenting typologies (i.e., authoritative, authoritarian and permissive). Counselors also may consider providing parenting examples; specifically, as suggested by Morris, Cui, and Steinberg (2013), they may provide examples related to intercultural parenting. Group counseling is another option that counselors can consider for families. Parental networks of families with children adopted from the same country of origin were found to be an effective intervention for post-adoption adjustment of families (Welsh et al., 2007), as international adoptive parents tend to listen to and seek help from informal networks whose participants have experienced similar challenges. Focus can be on feedback or experiences that families can gain from each other, while lessening the facilitating role of the counselor.




     A close review of the unique international circumstances related to adoption from China draws attention to risk and protective factors of post-adoption adjustment. Parents of all international adoptees and counselors working with adopted children and adoptive families may want to take the multicultural characteristics of each child into consideration. There are vast differences within international adoptees as a group. Children’s health, attachment and adjustment patterns vary based on their countries of birth, and each individual differs from others in the post-adoption adjustment process due to personal reasons other than cultural factors.



Conflict of Interest and Funding Disclosure

The authors reported no conflict of

interest or funding contributions for

the development of this manuscript.



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Yahnong Liu, NCC, is a doctoral student at the Pennsylvania State University. Richard J. Hazler, NCC, is a Professor and the Program Coordinator of Counselor Education at the Pennsylvania State University. Correspondence may be addressed to Yahnong Liu, 317 Cedar Building, The Pennsylvania State University, University Park, PA 16802, yxl257@psu.edu.