Indiscriminate Friendliness in Children Adopted From China to the United States: A Mixed Methods Study

Yanhong Liu, Dan Li, Yanqing Xu

Indiscriminate friendliness (IF) is a prominent issue with children adopted from China to the United States. Through a mixed methods design, the authors explored four Chinese adoptees’ experiences of IF within their real-life context, investigated potential factors associated with IF, and examined the IF–attachment relationship. This mixed methods study consisted of a qualitative case study of four children adopted from China and a quantitative investigation into IF using a sample of 92 adoptive parents with Chinese adoptees. The qualitative findings revealed crucial propositions related to children’s IF, and the quantitative results provided further evidence to corroborate the qualitative findings. This study reinforced the stance that IF should be treated as a distinct construct from attachment. Researchers and professional counselors can benefit from the results of this study to better serve Chinese adoptive families.

Keywords: indiscriminate friendliness, children, China, adoptive families, mixed methods

According to intercountry adoption statistics, the United States welcomed 261,728 children across the world from 1999 to 2015 (U.S. Department of State, Bureau of Consular Affairs, 2016). Among these adopted children, 76,026 (approximately 30%) came from China, which made China the largest country of origin for intercountry adoption. A majority of Chinese adoptees were under 3 years old at the time of adoption (U.S. Department of State, 2016). Numerous issues have been detected related to the intercountry adoption process (Kreider & Cohen, 2009; van den Dries, Juffer, van IJzendoorn, & Bakermans-Kranenburg, 2009). A prominent issue is children’s indiscriminate friendliness (IF; Bruce, Tarullo, & Gunnar, 2009; Chisholm, Carter, Ames, & Morison, 1995; van den Dries, Juffer, van IJzendoorn, Bakermans-Kranenburg, & Alink, 2012). IF refers to children’s excessively friendly behaviors toward adults (other than their primary caregivers) without appropriate screening of the adults (Tizard, 1977). IF has been consistently identified in post-institutionalized children (Bruce et al., 2009; Chisholm et al., 1995) and has been viewed as pathological in nature (American Psychiatric Association [APA], 1994, 2013).

Previous research studies have yielded different post-adoption adjustment outcomes in Chinese adoptees compared to domestic adoptees or other internationally adopted children, including optimal behavioral adjustment (Cohen, Lojkasek, Zadeh, Pugliese, & Kiefer, 2008), successful attachment formation (Liu & Hazler, 2015), and positive academic performance (Tan & Marfo, 2006). The distinction between Chinese adoptees and their research counterparts entails a closer look at this population. Investigation into IF in children adopted from China became important, as the majority of them had experienced pre-adoption institutionalization in China. Consistent with earlier findings about post-institutionalized children (Bruce et al., 2009), IF has been identified as a significant issue in children adopted from China and was supported by the only study targeting Chinese adoptees in the United States (van den Dries et al., 2012).

A dearth of knowledge on IF in Chinese adoptees in the United States necessitated an in-depth qualitative investigation into this phenomenon in the adoptees’ real-life context (Yin, 2014). However, a single qualitative study cannot offer a comprehensive view of IF, nor can it thoroughly address all research questions for this study; thus, by adding a quantitative investigation, this study sought to compensate for the inadequacy of the qualitative methodology and allow researchers to triangulate and compare dissonant data between the two research approaches (Plano-Clark, Huddleston-Casas, Churchill, Green, & Garrett, 2008).

Indiscriminate Friendliness (IF)

IF, alternatively termed indiscriminately friendly behavior or indiscriminate overfriendliness, refers to a behavioral tendency for children to seek attention and approval from adults, including strangers (Hodges & Tizard, 1989; Tizard & Hodges, 1978). IF is also referred to as disinhibited attachment behavior or disinhibited social behavior, evidencing post-institutionalized children’s overfriendly behavior toward unfamiliar adult figures (Bruce et al., 2009). IF does not fall into the traditional sense of being friendly, which is associated with a positive human trait; instead, it is deemed behaviorally inappropriate when children actively approach strangers, without a reasonable assessment of whether or not it is safe to do so (Bruce et al., 2009; O’Connor et al., 2003).

Researchers have noted that children’s institutionalization experiences play a significant role in IF development, albeit adopted children are able to form strong attachments with their adoptive parents given adequate time (Chisholm, 1998; Hodges & Tizard, 1989; Tizard & Hodges, 1978). Post-institutionalized children with IF tend to approach, make personal comments to, and initiate physical contact with strangers, and children with a high level of IF are often willing to leave locations with strangers (Bruce et al., 2009). They also allow unfamiliar adults to put them to bed and comfort them when they are hurt (Tizard & Hodges, 1978). A multitude of adoptive parents have had concerns about their children’s safety as a result of their IF behaviors (Bruce et al., 2009).

In Tizard and Hodges’ (1978) follow-up study in the United Kingdom, one third of formerly institutionalized children exhibited excessive attention-seeking behaviors and a tendency to be overfriendly to adults. A few children, from ages 4 to 8, presented indiscriminate affection toward adults. In Bruce et al.’s (2009) sample of internationally adopted children in the United States following institutionalization, 65% displayed IF characteristics. Likewise, in Chisholm’s study (1998), Romanian adoptees in Canada exhibited significantly more IF behaviors than the two comparison groups: (a) Canadian-born, non-adopted, and non-institutionalized children; and (b) early-adopted Romanian children who were adopted before the age of 4 months. In contrast to institutionalization’s role as a risk factor of IF, adoptive parents’ responsive parenting was assumed to be a protective factor for children’s post-adoption behavioral adjustment (van den Dries et al., 2012). Responsive parenting entails a high level of warmth and nurturance in the process of caretaking, including offering timely attendance to children’s needs (Darling & Steinberg, 1993).


Theorists have examined the relationship between IF and attachment (Bowlby, 1982; Sabbagh, 1995). For example, Bowlby (1982), defining attachment as a child’s behavior to seek physical proximity to his/her primary caregiver, claimed attachment as a correlate to IF. Attachment, viewed as a social behavior, occurred as a result of certain behavioral systems activated when infants interact with the “environment of evolutionary adaptedness” and the mother figure in the environment (Bowlby, 1969, p. 179). The first two to three years are the most critical period for children to develop relationships with caregivers and to develop the aforementioned behavioral systems (Bowlby, 1969). Given an environment in which evolutionary adaptedness is absent, such as an institutional rearing environment, atypical discriminating attachments may ensue (O’Connor et al., 2003). Although many securely attached children displayed IF behaviors, their unattached counterparts demonstrated a higher likelihood of being overfriendly (Bowlby, 1982).

Evolution of Diagnostic Criteria

In addition to the heated dispute on whether or not IF is related to attachment patterns, the clinical perspective on IF has been evolving. In the Diagnostic and Statistical Manual of Mental Disorders (4th ed.; DSM-IV; APA, 1994), IF was termed the disinhibited type (i.e., indiscriminate sociability), as opposed to inhibited type (i.e., social withdrawal), under the Reactive Attachment Disorder diagnostic criteria. Similarly, the International Statistical Classification of Diseases and Related Health Problems (10th rev.; ICD-10; World Health Organization [WHO], 1992) named IF as a disinhibited attachment disorder. Both the DSM-IV and ICD-10 described IF as an abnormal pattern of relatedness that begins before the age of 5 years (APA, 1994; WHO, 1993). Nevertheless, the Diagnostic and Statistical Manual of Mental Disorders (5th ed.; DSM-5; APA, 2013) redefined IF as a disinhibited social engagement disorder, which is a trauma- and stressor-related disorder derived from severe neglect in the first two years of life. Hence, IF was separated from reactive attachment disorder, where it had been categorized.

The mixed findings on potential contributors to IF and the lack of in-depth qualitative input on IF reinforce the need to address IF in children adopted from China, which has rarely been discussed in counseling journals. Prevalence of IF in Chinese adoptees in the United States remains unknown, and no study was found exploring the experiences of children with IF. The purpose of this study was to better understand IF in children adopted from China by U.S. families. The authors conducted a case study on four Chinese adoptees through two in-depth semi-structured interviews with two U.S. adoptive mothers. To ensure the robustness of this study, the authors conducted a follow-up quantitative investigation into IF using a sample of 92 adoptive parents with children adopted from China. This study addressed three research questions—RQ1: How do parents perceive IF in children adopted from China?; RQ2: What are some potential factors that are associated with IF?; and RQ3: Is IF related to children’s attachment? The overarching goal of the current study was to provide an in-depth understanding of Chinese adoptees’ IF in its real-life context, to probe into the potential predictors of IF, and to examine the relationship between IF and attachment.



Participants for qualitative and quantitative investigations were drawn from U.S. adoptive parents with children adopted from China. Participants for the qualitative case study did not participate in the quantitative stage of investigation. The recruitment of participants represented a parallel relationship between qualitative and quantitative samples (Leech & Onwuegbuzie, 2010), ensuring the comparability of the two data sources. The same datasets have been investigated with different emphases, by one earlier submitted manuscript investigating child-parent attachment (Liu, 2017). The quantitative dataset was also used by another study that followed a hierarchical regression analysis on IF associative factors (Liu & Hazler, in press). Research questions for this study were distinctly independent from previous studies. Participants were recruited based on the following criteria: (a) participants were U.S. citizens who adopted children from China; (b) children adopted by participants were 3 years old or younger at the time of arrival (U.S. Department of State, 2016); and (c) children were younger than 6 years old at the time of data collection (APA, 1994, 2013; WHO, 1992).

Two White mothers, Amy and Tina, were recruited for a qualitative case study from the first author’s network from her previous work with adoptive families. Amy and Tina each adopted two children from China. The case study focused on the four children’s IF behaviors and related experiences. Parents, instead of the children, were selected as the participants, as all of the four children were under 6 years old and had limited ability in comprehending and articulating the phenomenon. Both participants were married and had tried to have biological children. Natural conception was not a possibility, so adoption became the alternative to fulfill the desire for parenthood. Amy was in her late 40s at the time of the interview. Amy had been a stay-at-home mother for her children, Amelia and Beatrice. Tina was around 50 years old at the time of the interview. Tina worked full-time at a research organization, while her husband had been the primary caregiver of their two children, Rebecca and Joshua. The ages of the four children at the time of arrival in the United States were: Amelia, 10 months; Beatrice, 3 years; Rebecca, 11 months; and Joshua, 2 years and 10 months.

Participants for the quantitative investigation consisted of 92 White parents who adopted children from China. Participants ranged from 31 to 59 years old (M = 46; SD = 6.4). Eighty-six (94%) of the participants were adoptive mothers of the children, and six (6%) were adoptive fathers. Sixty-two participants (67%) had two or more Chinese adoptees. A majority of participants (86%) held a bachelor’s degree or higher. More than half (70%) of the participants identified themselves as primary caregivers of the children, and the rest reported as equal caregivers (i.e., the participants and their spouses take an equivalent amount of caregiving responsibilities). Over half of the participants (53%) worked 20 hours or below per week or held no employment, and 47% of the respondents worked more than 20 hours per week. The average age of the children at the time of arrival in the United States was 19 months.

Sampling and Recruitment

Two separate Institutional Review Board approvals, for the qualitative case study and the quantitative investigation, were obtained from the first author’s institution where the study was conducted. The authors used the purposeful sampling method (Teddlie & Yu, 2007) to recruit the case study participants following the aforementioned screening criteria. The first author’s previous encounters with Chinese adoptees and adoptive families evoked her research interests in this population. The first author was transparent about her role as a researcher, distinct from her other roles (i.e., as a previous counselor for the children), when communicating with the participants. Amy and Tina each endorsed an informed consent form prior to their participation in the study. The form detailed the purposes and significance of this study, risk of participation, and confidentiality.

The 92 participants for the quantitative investigation were randomly recruited through adoption networks and professional organizations. The authors contacted all Children from China local chapters across all U.S. states, consisting of families with children adopted from China, and several online adoptive parent organizations. The study was endorsed by several Children from China chapters and one Chinese adoption agency. The study was also shared by administrators of several online organizations, including Chinese Adoptive Families, China Report, and Chinese Adoption. Parents who were interested in participating in the study e-mailed the first author; the first author then checked the eligibility of interested parents and provided a letter detailing the purpose, significance, risks, and confidentiality related to participation into this study. Participants were directed to the selected surveys (under the Instrumentation section) posted on PsychData. Participants of the study represented a wide geographic coverage.


A semi-structured interview was conducted with Amy and Tina, separately, to understand their children’s IF and to gain a totally fresh perspective toward IF, bracketing researchers’ worldviews (Creswell, 2013). Both interviews were performed by the first author, via phone with Amy, and in person with Tina. Each interview lasted for about one and a half hours. The interviewer asked open-ended interview questions to encourage participants to expand on answers related to IF (Creswell, 2013). The interview included five open-ended questions and allowed participants to expand on any area in which they felt it useful to communicate their understanding and children’s experiences of IF. For example, the interviewer asked: How has IF been demonstrated in your children?; What have you noted in terms of your children’s friendly behaviors?; and what has influenced your children’s behaviors based on your perceptions?

Quantitative data were generated from a self-report questionnaire posted on PsychData, consisting of measures for attachment and IF along with items measuring children’s former institutionalization experiences and parents’ caregiving quality. Attachment was measured by the adapted Attachment Q-Sort (AQS; Chisholm et al., 1995), which was based on the original AQS developed by Waters and Deane (1985). The adapted AQS contained 23 items measured by a 5-point scale, from 1 = very unlike my child to 5 = very like my child. A sample item from the adapted AQS was: “Your child clearly shows a pattern of using you as a base from which to explore, that is, he/she moves out to play, returns, and then moves out to play again.” Scores for the 23 items were summed, leading to a total attachment score. A higher attachment score means that a child was better attached with the respondent. Van IJzendoorn, Vereijken, Bakermans-Kranenburg, & Riksen-Walraven (2004) reported a modest stability of AQS for the first five years of children’s lives. In the Netherlands, Pool, Bijleveld, and Tavecchio (2000) applied the instrument to assess attachment security in 45 children with ages ranging from 2 to 6 years old. Good convergent validity of AQS has been established, with a .50 correlation (r score) between AQS and the Strange Situation Procedure (Vaughn & Waters, 1990). Reliability of the adapted AQS was manifested through Cronbach α coefficients, ranging from .65–.72 (Chisholm et al., 1995) to .77–.80 (Chisholm, 1998). The Cronbach α value for this study was .83.

IF in this study was measured by the frequently used Five-Item Indiscriminately Friendliness Measure (i.e., the 5-item IF measure; Chisholm et al., 1995). The five items represent uncommonly friendly behaviors exhibited by children. The five items measure children’s friendliness level to strangers; whether or not the children were shy/behaved in a strange manner; children’s reactions to newly met adults; children’s willingness to go home with newly met adults; and children’s tendency to wander. Respondents selected 1 = Yes if the child showed the described behavior in the item; if no untypical friendly behavior was detected in the child, a 0 = No was chosen. A higher IF score indicates that the child displayed a higher level of IF behaviors. The Cronbach α coefficients of the measure were .58–.72 in Chisholm (1998) and .78–.81 in Pears, Bruce, Fisher, and Kim (2011). The Cronbach α value of the measure in this study was .58. The internal consistency was relatively low but acceptable based on similar values generated in earlier studies by the same measure (Chisholm, 1998; van den Dries et al., 2012).

In addition to the two existing measures, a demographic survey was included in the quantitative questionnaire, including questions asking children’s ages and institutionalization experiences. Children’s institutionalization experiences were assessed using questions on children’s physical growth statuses when arriving in the United States (i.e., weight), their length of institutionalization, and participants’ perception of the institutional care that their children had received prior to adoption (i.e., 1 = was not in an orphanage; 2 = high quality care; 3 = acceptable quality care; 4 = poor quality care). A higher total institutionalization score implied more positive institutionalization that a child had experienced. Parents’ caregiving quality/responsive parenting was measured by the authoritative parenting subscale of the Parenting Styles and Dimensions Questionnaire (Robinson, Mandleco, Olsen, & Hart, 2001), with a Cronbach α value of .84 for the present study.

Research Design

The current literature on IF indicates the complexity of the phenomenon because of its frequent occurrence in post-institutionalized children and its intertwined relationships with children’s nurturing environments (APA, 1994, 2013). A mixed methods study provides a better understanding of a complex phenomenon than either a single qualitative or quantitative study (Creswell, 2013). Specifically, this study utilized a sequential mixed methods design to explore Chinese adoptees’ IF within their real-life context. It comprised a two-part process, with an initial case study exploring four Chinese adoptees’ experiences of IF and a further quantitative investigation following the propositions generated from the case study. The authors consider a qualitative case study appropriate because a case study is a robust empirical approach investigating a case unit in its real-world context (Yin, 2014). The case unit includes, but is not limited to, an individual, a group, a family, a geographic region, or a particular phenomenon that is worthy of thorough investigation. It is considered an ideal methodology when “how” or “why” research questions are asked (Yin, 2014). The case unit for this study is the four Chinese adoptees’ experiences of IF. Yin (2014) defined a proposition as an essential component within a case study, guiding data collection and analysis to avoid superfluous information. Propositions are generated through literature review and/or experiences of the researchers and/or participants (Yin, 2014). The propositions from the qualitative case study guided the quantitative investigation. Both types of findings were triangulated and integrated in the Results section (Plano-Clark et al., 2008).


Trustworthiness. Researcher reflexivity, peer debriefing, and data triangulation ensured the trustworthiness of the qualitative case study (Hunt, 2011). The authors attained researcher reflexivity through examining and suspending personal beliefs (Hunt, 2011). Qualitative data in this study were triangulated through quantitative data (Leech & Onwuegbuzie, 2010). One procedure to ensure the trustworthiness of case study methodology is to incorporate data from multiple sources (Yin, 2014). Data from the two semi-structured interviews served as the primary data source, and memo writing by the first author offered a supplemental data source. Memo writing was a documentation of the researcher’s reflections or reactions while reviewing the raw interview transcripts (Creswell, 2013). The qualitative data were transcribed by the first author and were independently analyzed by the first, second, and third authors. All three authors then thoroughly reviewed each other’s coding and reached a consensus on data categorization. An expert in adoption research served as the external reviewer of the qualitative results to ensure that data interpretations were reasonable.

Data Analysis. The authors followed the recommended data analysis strategy of pattern matching (Yin, 2014). Synthesizing the current literature and information pertaining to participants’ experiences, the research team generated five propositions: (a) children immediately bonded with adoptive parents soon after adoption; (b) children initiated IF behaviors to newly met adults; (c) children responded to affectionate behaviors by newly met adults; (d) age, institutionalization, and adoptive parents’ love/responsive parenting were potentially associated with children’s IF behaviors; and (e) there was no clear conclusion on whether children’s IF was related to their attachment to parents, which warranted a further examination of the IF–attachment relationship.

Each of the authors used the propositions to organize raw data, perform coding and data reduction, and categorize meaningful units (Creswell, 2013). The authors carefully examined all meaning units and performed pattern matching to link the meaningful data units with the propositions (Yin, 2014). Full descriptions were provided on each of the propositions with supportive data from the two in-depth interviews. The researchers analyzed the quantitative data using SPSS Statistics 20. Researchers conducted univariate, bivariate, and multiple regression analyses on the quantitative dataset, examining potential factors associated with IF, as well as the IF–attachment relationship.


Results of this study included both qualitative and quantitative findings in response to the five propositions; both types of findings were triangulated, compared, and integrated into this section. Both datasets shed light on the three research questions. Each proposition was discussed and supported by qualitative data. Quantitative evidence was integrated into this section as a way to corroborate qualitative findings. Consistencies and discrepancies were identified between the two sets of data.

Research Question 1: How do parents perceive IF in children adopted from China?

Participants Amy and Tina reported IF as a prominent issue in all four of the children. The first three propositions were highlighted in the answer to Question 1. Quantitative results were consistent with qualitative findings, both of which are discussed in depth in the following paragraphs.

Children immediately bonded with adoptive parents soon after adoption. Adoptive parents were not considered as a child’s primary caregivers back to the time of adoption because of the brief time they had spent with the child. Adoptive parents, under that circumstance, were categorized as newly met adults. Amy shared that Amelia bonded immediately with her, followed by a successful adjustment. Amy further described that, in the very first night after they adopted Amelia, “she was laughing with us, smiling, giggling, and hugging us.” Tina shared similar patterns from Rebecca, who immediately bonded with her and her husband and presented as happy despite the fresh separation from her orphanage caregivers.

 Children initiated IF behaviors to newly met adults. Initiating affectionate behaviors to newly met adults was a significant indicator of IF (Tizard & Hodges, 1978). Amy and Tina shared this pattern as a common concern, with the fear that children were likely to be taken away by strangers. Participants characterized children’s behavior or tendency to show friendliness to strangers as boundary issues. These boundary issues were manifested vividly in Joshua. Tina reflected that Joshua would wander off and approach anybody, even though he was aware of the family’s presence. Tina provided several concrete examples to explain Joshua’s IF behaviors, including his actively seeking proximity specifically to women whom he first met. Tina recalled that Joshua approached a newly met woman at an airport. He also walked up to another woman at the beach, sat down next to the woman, and demonstrated a high level of physical affection toward her (e.g., running his hands through the woman’s hair). Tina added that Joshua was never hesitant to ask for food from strangers and often managed to get snacks from people from his stroller when they were in China.

Children responded to affectionate behaviors by newly met adults. Children’s friendly behaviors also were manifested through their reactions to strangers’ affectionate behaviors. Both participants indicated that although parents were sensitive to children’s initiation of friendly behaviors, children’s reactions to strangers were not given equal attention. It could be a risk factor depending on who the stranger is and the underlying drive that the stranger had in approaching a child. Participants noted that children would accept food from unknown adults. Tina responded that it was common to witness Joshua walking to strangers and returning with food or snacks. Affectionate reactions to strangers happened frequently among the four children at different places. Tina recalled that at a local grocery store, a cashier picked up Joshua and showed him her computer screen, and Joshua responded with excitement and joy, without any sense of reservation. The participants indicated that even though children’s friendly reactions to strangers may not necessarily mean that they were indiscriminately friendly to all adult figures, the unreserved friendliness revealed a sign of social limitation.

In addition to the friendly behavioral patterns, Amy and Tina offered further explanations on the four children’s IF behaviors. The two participants offered three rationales in explaining these behaviors: (a) children’s personalities; (b) their developmental stages; and (c) their desire to have basic needs met. Being an extrovert was linked to children’s friendly behaviors, as Tina expressed that Joshua may be the most extroverted person that she could think of, just based on the fact that he always enjoyed being with people. Both participants defined some of the children’s friendly behaviors as developmentally appropriate. Particularly, expressing a high level of friendliness was not atypical for younger children. In other words, it was reasonable that children under 5 years old consistently exhibited more friendly behaviors than those who were 8 years old or above. Both participants noted that the children mostly regarded themselves as the center of the universe and assumed that others would always be interested to hear everything they had to say. Amy indicated that friendliness may simply serve as a tool for children to have their basic needs met. The friendly tendency was obvious in Beatrice, as whenever she was hungry, she would request food from strangers. Participants did not view this tendency as pathological in speaking of children’s desire to meet their internal drive.

Responses from participants for the quantitative stage echoed the qualitative findings. IF indicators were reinforced by participants’ responses to the 5-item measure. Eighty-five percent of the participants (n = 78) selected 1 for item 1, indicating that their children were friendly (i.e., sometimes or always very friendly) with new adults. Fifty-seven percent of the participants (n = 52) reported the lack of shyness or misbehaving in the presence of strangers. Twenty-five percent of the participants (n = 23) identified 0, meaning “the child has always been shy or behaved in a strange manner,” and approximately 18% (n = 17) indicated that children exhibited a reasonable level of shyness since their arrival in the United States but could not speak to children’s former friendly behaviors back in China.

For item 3, examining children’s behaviors when meeting with new adults, 27% of the participants (n = 25) selected 1, specifying that children always approached new adults, showing toys, speaking or asking questions. About 60% of parents (n = 54) indicated that children would screen new adults (i.e., observing and evaluating) prior to taking actions. The remainder (n = 13; 13%) indicated fears or indifference toward new adults. For item 4, approximately 41% of the participants (n = 38) chose 1, identifying that their children have exhibited some tendency of going home with a newly met adult. With regard to item 5, 23% of the participants (n = 21) reported that their children displayed a tendency to wander, without being subsequently distressed after realizing they were away from their parents.

Research Question 2: What are some potential factors that are associated with IF?

The fourth proposition guiding the qualitative case study was that age, institutionalization, and adoptive parents’ love and responsive parenting were potentially associated with children’s IF behaviors. Amy and Tina asserted that children’s behavioral adjustments were related to children’s ages at the time of arrival in the United States; specifically, younger children demonstrated better behavioral adjustments compared to children adopted at an older age. Comparing the behaviors of Amelia and Beatrice, Amy mentioned that Beatrice, who was adopted at the age of 3, experienced a more challenging time bonding and adjusting in comparison to Amelia, who was adopted at a younger age. Both participants maintained that children adopted at a younger age generally transitioned smoothly and quickly, because children adopted as infants were not old enough to remember their previous experiences, despite the fact that adoption involves separation and loss and itself could be considered as trauma.

The participants connected children’s institutionalization experiences with their later IF behaviors. Children’s IF behaviors were speculated to be a consequence of earlier institutionalization that children had experienced. Amy and Tina viewed IF as one of the institutionalization issues rather than an attachment issue. Amy suggested that children who were previously institutionalized mostly lacked child-parent relationships and failed to form a routine early on in life. It was assessed that something might have happened in children’s brains that made it difficult to learn to interact in later relationships. Tina assumed that Joshua’s IF behaviors represented his life experiences at the orphanage from which he was adopted. She speculated that the overfriendliness had become a pattern in his first three years in the orphanage where he had no clue about whom his next caregiver would be, and a rational way for him to gain attention from others was to be friendly (e.g., giving a hug).

The participants also tied children’s IF behaviors with the news report about suspected child abuse in the orphanage where Joshua was adopted. There was a lack of knowledge and evidence regarding the institutional care that children had received prior to adoption, but the participants held the assumption that children’s weight could be an indicator of the quality of care provided at orphanages, which might be indirectly tied to children’s behaviors of reaching out to strangers for food or other basic needs. All four children’s weight was below the average when adopted, according to the participants. This was the most evident for Joshua, as he weighed only 23 pounds when he was 2 years and 10 months old. His numbers fell off the growth chart for his developmental stage.

Both Amy and Tina highlighted the role of love and responsive parenting as a protective factor of IF behaviors and in counteracting children’s previous institutionalization experiences. In this study, parents’ love and responsive parenting were delivered through understanding of the complexity of IF, accepting the child, and attending to the individual needs of the child. Both participants perceived IF as a concern, yet understood that going through abandonment and institutionalization may have contributed to children’s IF behaviors. Adopting a child meant, according to Amy, not only bringing a child home, but also caring for the child in one’s heart. Strong emotions were provoked when participants recalled children’s atypical experiences compared to their non-adopted peers. The participants reiterated that love should be unconditional to all children, no matter by birth or adoption. Amy firmly believed that whether a child is biological or adopted, it should make no difference in terms of parenting because each child deserves high-quality love. All children should be considered as “our children, and the love is “our” love.

Separation is what adoptees go through. With strong emotions, Amy highlighted the goodbyes that the adoptees had to say in their lives, all of which apparently were out of their control. Amy elaborated that a child’s life started in the mother’s room for months, and the child was used to the mother’s presence and voice, and then had to tell the mother goodbye. That was the child’s first loss in life. The child was then delivered to the orphanage, labeled as one of many orphans, and taken care of by orphanage staff. Shortly after forming an attachment with orphanage staff and peers (referred to as “crib-mates” by Amy), the child was matched with an adoptive family from overseas and had to say goodbye again. The multiple losses and separations solidified the critical role that adoptive parents may play, so that the child is nurtured in a steady and consistent environment.

Participants believed that showing responsive parenting was vital in helping children work on IF behaviors because changes could not be made on children’s pre-adoption experiences, but could be made on post-adoption caregiving. Tina reinforced that parents should not just take a child away from strangers; a more compelling need for the child was to learn how to act appropriately with strangers. The participants emphasized the importance of selective attending, meaning that parents attend to a child when he/she was in true need (e.g., when a child wanders off without checking in) and ignore behaviors that did not matter to the child’s safety or growth. Participants suggested several techniques for fostering parental attending to children’s needs, including singing children’s tunes, encouraging eye contact, strictly following routines, and offering hugs. These techniques helped instill in the children security and stability.

Age, institutionalization, and love and responsive parenting were included in the quantitative investigation. Bivariate analyses were conducted between each of the variables and IF scores. A higher institutionalization score was significantly correlated with a lower IF score (r = -.24; p < .05); namely, the more positive institutionalization experiences a child had, the fewer IF behaviors the child exhibited (Liu & Hazler, in press). No significant correlations were identified between age and IF (r = -.10; p > .05) or responsive parenting and IF (r = -.04; p > .05). A multiple regression analysis yielded a significant model, with institutionalization as the significant predictor of IF. The results showed that institutionalization explained 9% variance in IF scores (R2 = .09, F (1, 88) = 4.16, p < .05) (Liu & Hazler, in press). Responsive caregiving was nonsignificant in predicting IF.

Research Question 3: Is IF related to children’s attachment?

In answering this question, data were matched with the fifth proposition: there was no clear conclusion on whether children’s IF was related to their attachment to parents, which warrants a further examination of the IF–attachment relationship. Neither qualitative nor quantitative results provided evidence to support a relationship between children’s attachment and IF behaviors. Amy and Tina shared an interesting fact that the children seemed to attach well with them in spite of frequent IF behaviors directed to adults other than the primary caregivers. All four children were reported to form successful attachment with their adoptive parents; in the meantime, they displayed different levels of IF toward strangers. The two participants held the opinion that IF may not necessarily be categorized as an attachment disorder. This was echoed by previous analysis concerning institutionalization, in which parents speculated that IF behaviors might be more appropriately treated as an institutionalization versus attachment issue. Tina disclosed that Joshua’s IF behaviors were described by a clinical practitioner as “nowhere near the attachment disorder.”

A bivariate analysis was conducted between attachment and IF scores using the quantitative data, which yielded a nonsignificant result (r = .12, p > .05). Therefore, no significant correlation was detected between attachment and children’s IF behaviors. A direct interpretation of the quantitative result was that an adoptee’s attachment with adoptive parents was not correlated with the level of the child’s IF. Positive attachment and IF can coexist in a child, which was consistent with the case study findings.


This mixed methods study revealed qualitative themes and quantitative evidence in addressing the three research questions. Consistent with previous findings, this study reinforced that IF appears to be a prevalent issue in Chinese adoptees. Children’s IF was demonstrated through quick bonding to new adoptive parents soon after adoption, initiating excessively friendly behaviors to strangers, and responding to strangers’ affectionate behaviors without hesitance. A child’s affectionate behaviors toward adoptive parents were deemed a sign of IF, as the child and adoptive parents did not have previous encounters with each other. Under attachment theory (Bowlby, 1969), a child selectively shows affection to and seeks proximity from the mother or the primary caregiver, and the attachment relationship is based on frequent behavioral exchanges between the child and the mother or primary caregiver (Sroufe & Waters, 1977). Naturally, children’s excessive friendliness to strangers, without the selection process under the attachment theory, is considered atypical behavior.

IF behaviors were described as a manifestation of pathology and either classified as a subtype of attachment disorder under the DSM-IV (APA, 1994) or renamed as disinhibited social engagement disorder in the most recent DSM-5 (APA, 2013). The 5-item IF measure utilized in the study was consistent with the screening questions within the DSM, which concretized the IF through specific behaviors such as wandering off and going home with strangers. Although the items provided a simplified interpretation of IF, qualitative findings revealed multiple layers tied to IF that have not been adequately attended to by researchers and professional practitioners. The DSM-IV and DSM-5 classifications were based on the presumption that IF was an outcome of pathogenic care or maltreatment that children had experienced earlier in life (APA, 1994, 2013).

There has been a lack of investigation into personal factors that may explain children’s IF behaviors. Qualitative findings of this study illuminated the complex nature of IF and directed attention to other alternative criteria, in addition to pathogenic care, including children’s personality types, developmental stage, and drive to meet personal needs. These findings were consistent with Bennett, Espie, Duncan, and Minnis’ (2009) qualitative study that explored IF through children’s lenses. Bennett and colleagues highlighted children’s two internal drives underlying their IF behaviors: seeking love/attention and striving to meet personal needs. A comprehensive literature review by Love, Minnis, and O’Connor (2015) also challenged the pathogenic care criterion within the DSM by proposing several additional factors associated with IF, including genetic differences, inhibitory control, cognitive ability, and post-adoption caregiving.

Children’s former institutionalization experiences were proposed to be a salient factor associated with children’s behaviors (Bruce et al., 2009). The significant role of institutionalization in relation to IF was supported by numerous earlier studies conducted with internationally adopted children (Bruce et al., 2009; van den Dries et al., 2012). IF has been reported as a salient issue with previously institutionalized children in comparison with children raised in their birth families (Chisholm, 1998; Tizard & Hodges, 1978). Findings seem to be unanimously significant across the literature in regards to the association between children’s institutionalized experiences and children’s IF behaviors. The quantitative results of this study echoed previous findings, with institutionalization significantly associated with children’s IF. Qualitative findings also highlighted the role of institutional care as a factor associated with children’s IF behaviors. For example, children who received inadequate care from pre-adoption institutions may appear to be friendlier or seek food and/or attention from adults, as they had to compete with other children in the institution for a limited amount of available resources.

Another variable that revealed inconsistent findings between the qualitative and quantitative datasets was responsive parenting. Quantitative results of this study did not support the significance of caregiving by adoptive parents, which was supported by Zeanah and Smyke (2008), and IF was confirmed not to be associated with post-adoption caregiving quality. Qualitative findings of this study, on the other hand, demonstrated the importance of love and responsive parenting in working with children’s behavioral adjustment. Similar findings can be retrieved from the study by van den Dries et al. (2012), which indicated that children receiving better maternal care after adoption presented less IF behaviors.

The relationship between IF and attachment has been repeatedly investigated in the literature, with two antithetical views: (a) IF is a form/subtype of attachment (APA, 1994; O’Connor et al., 2003); and (b) IF needs to be treated as a unique behavioral issue, separate from attachment (APA, 2013; Lyons-Ruth, Zeanah, & Gleason, 2015). A common theme between the two views is that IF behaviors are developmentally inappropriate. The quantitative results of this study were aligned with the latter view that IF is not significantly correlated with attachment. Qualitative responses from this study were congruent with the quantitative results, as participants indicated that positive attachment and IF behaviors indeed coexist in children. The qualitative findings furthermore challenged the pathological stance that has been historically held about IF, with an alternative explanation that children’s personalities, developmental stages, and internal drives to meet personal needs may be associated with their IF behaviors.


This study has three main limitations. The comparatively low Cronbach alpha value of the 5-item IF measure was the first concern, which brought about the question of whether or not the 5-item IF was adequate in measuring IF, although low level of internal consistency is noted to be common in short scales (Streiner, 2003). The second limitation was related to participants and self-report surveys, in which reporter bias and social desirability could confound the results; namely, participants might have chosen to respond to the items based on what they believed to be socially desirable responses. Further, using parents as the only participants is likely to arouse doubt on whether or not parental perceptions of children’s IF behaviors were accurate. The third limitation was related to data saturation. Although sample size is not emphasized in qualitative research, data saturation has been consistently suggested, meaning that data collection should continue until the point that no new information arises. A practical concern is that qualitative results based on the four Chinese adoptees’ experiences may not reach data saturation (Creswell, 2013; Teddlie & Yu, 2007), thus potentially affecting the analytical generalization of qualitative findings. Nevertheless, Teddlie and Yu (2007) offered further justification for the need of representativeness and saturation trade-off sampling in mixed methods research. This sampling technique entails unequal emphases of qualitative and quantitative sampling within a mixed methods study; namely, when quantitative representativeness is emphasized, less emphasis is directed to the qualitative saturation of the study.

Research and Clinical Implications

Results of this study provide crucial implications for future research and practice by professional counselors who work with Chinese adoptees and adoptive parents (e.g., counselors working in school or family settings). Controversies on the categorization of IF (as attachment or other mental health disorders) in the DSM, along with the additional factors proposed by participants, indicate a compelling need to develop a more mature measure for IF, considering a wider range of behaviors beyond the five items. One goal of the new measure is to offer a justification on whether IF truly exists in a child and the severity of the IF tendency. Future research studies should be considered regarding the underlying causes of IF. Researchers should consider involving children in future investigations in order to acquire diverse perspectives on IF and to obtain more generalizable results from the first-person lens.

A clinical implication from this study is that professional counselors working with adoptees and adoptive families need to attend to the complexity of IF. IF behaviors certainly need to be monitored and screened because of the risks associated with the behaviors; however, no quick diagnosis should be reached without adequate evidence on the frequency and magnitude of the behaviors. Practitioners need to reassess the criteria defining pathology—whether or not children’s friendly behaviors are truly indiscriminate and to what extent a friendly behavior should be classified as abnormal (Zeanah & Smyke, 2008). These clinical needs call for practitioners’ familiarity with evidence-based research and more exposure to the target population, IF-related training programs, and a more comprehensive clinical questionnaire asking for further evidence to support children’s IF occurrence and severity.


This study enriched the knowledge of IF through a mixture of qualitative and quantitative findings. Results of this study unveiled Chinese adoptees’ experiences of IF and shed light on factors associated with IF, strengthening the significance of institutionalization as an important factor in children’s IF behaviors. The authors also generated a significant regression model that accounted for 9% of the variance in IF (Liu & Hazler, in press). In alignment with recent research studies (Love et al., 2015; Lyons-Ruth et al., 2015) and the DSM-5, this study provided evidence to support the distinction of IF from attachment. It also introduced alternatives to the pathological perspective toward IF from previous research and diagnostic standards. The results of this study enabled a better understanding of IF and offered research recommendations and critical implications for professional counselors serving adoptive families.

Conflict of Interest and Funding Disclosure

The authors reported no conflict of interest or funding contributions for the development of this manuscript.


American Psychiatric Association. (1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author.

American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Washington, DC: Author.

Bennett, J., Espie, C., Duncan, B., & Minnis, H. (2009). A qualitative exploration of children’s understanding

of indiscriminate friendliness. Clinical Child Psychology and Psychiatry, 14, 595–618. doi:10.1177/1359104509339137

Bowlby, J. (1969). Attachment and loss, Vol. I: Attachment. New York, NY: Basic Books.

Bowlby, J. (1982). Attachment and loss: Retrospect and prospect. American Journal of Orthopsychiatry, 52, 664–678.

Bruce, J., Tarullo, A. R., & Gunnar, M. R. (2009). Disinhibited social behavior among internationally adopted children. Development and Psychopathology, 21, 157–171. doi:10.1017/S0954579409000108

Chisholm, K. (1998). A three year follow-up of attachment and indiscriminate friendliness in children adopted from Romanian orphanages. Child Development, 69, 1092–1106.

Chisholm, K., Carter, M. C., Ames, E. W., & Morison, S. J. (1995). Attachment security and indiscriminate friendliness in children adopted from Romanian orphanages. Development and Psychopathology, 7, 283–294. doi:10.1017/S0954579400006507

Cohen, N. J., Lojkasek, M., Zadeh, Z. Y., Pugliese, M., & Kiefer, H. (2008). Children adopted from China: A prospective study of their growth and development. Journal of Child Psychology and Psychiatry, 49, 458–468. doi:10.1111/j.1469-7610.2007.01853.x

Creswell, J. W. (2013). Qualitative inquiry & research design: Choosing among five approaches (3rd ed.). Los Angeles, CA: Sage.

Darling, N., & Steinberg, L. (1993). Parenting style as context: An integrative model. Psychological Bulletin, 13, 487–496. doi:10.1037/0033-2909.113.3.487

Hodges, J., & Tizard, B. (1989). Social and family relationships of ex-institutional adolescents. Journal of Child Psychology and Psychiatry, 30, 77–97. doi:10.1111/j.1469-7610.1989.tb00770.x

Hunt, B. (2011). Publishing qualitative research in counseling journals. Journal of Counseling & Development, 89, 296–300. doi:10.1002/j.1556-6678.2011.tb00092.x

Kreider, R. M., & Cohen, P. N. (2009). Disability among internationally adopted children in the United States. Pediatrics, 124, 1311–1318. doi:10.1542/peds.2008-3206

Leech, N. L., & Onwuegbuzie, A. J. (2010). Guidelines for conducting and reporting mixed research in the field of counseling and beyond. Journal of Counseling & Development, 88, 61–69.

Liu, Y. (2017). Child-parent attachment in U.S. families with Chinese adoptees: What does mixed methods research say? Manuscript submitted for publication.

Liu, Y., & Hazler, R. J. (2015). All foreign-born adoptees are not the same: What counselors and parents need to know. The Professional Counselor, 5, 238–247. doi:10.15241/efh.5.2.238

Liu, Y., & Hazler, R. J. (in press). Variables associated with indiscriminate friendliness displayed by Chinese adoptees in U.S. families. The Family Journal.

Love, L., Minnis, H., & O’Connor, S. (2015). Factors associated with indiscriminate friendliness in high-risk children. Infant Mental Health Journal, 36, 427–445. doi:10.1002/imhj.21520

Lyons-Ruth, K., Zeanah, C. H., & Gleason, M. M. (2015). Commentary: Should we move away from an attachment framework for understanding disinhibited social engagement disorder (DSED)? A commentary on Zeanah and Gleason (2015). Journal of Child Psychology and Psychiatry, 56, 223–227. doi:10.1111/jcpp.12373

O’Connor, T. G., Marvin, R. S., Rutter, M., Olrick, J. T., Britner, P. A., & the English and Romanian Adoptees Study Team. (2003). Child-parent attachment following early institutional deprivation. Development and Psychopathology, 15, 19–38.

Pears, K. C., Bruce, J., Fisher, P. A., & Kim, H. K. (2011). Indiscriminate friendliness in maltreated foster children.

            Child Maltreatment, 15, 64–75. doi:10.1177/1077559509337891

Plano-Clark, V. L., Huddleston-Casas, C. A., Churchill, S. L., Green, D. O., & Garrett, A. L. (2008). Mixed

methods approaches in family science research. Journal of Family Issues, 29, 1543–1566. doi:10.1177/0192513X08318251

Pool, M. M., Bijleveld, C. C. J. H., & Tavecchio, L. W. C. (2000). The effect of same-age and mixed-age grouping in day care on parent–child attachment security. Social Behavior and Personality, 28, 595–602.

Robinson, C. C., Mandleco, B., Olsen, S. F., & Hart, C. H. (2001). The parenting styles and dimensions question-naire. In B. F. Perlmutter, J. Toulioatos & G. W. Holden (Eds.), Handbook of family measurement techniques: Vol. 3. Instruments & index (pp. 319–321). Thousand Oaks, CA: Sage.

Sabbagh, R. (1995). Attachment and behavior towards strangers in Romanian preschoolers into Canadian families. (Unpublished master’s thesis). University of Toronto, Ontario, Canada.

Sroufe, L. A., & Waters, E. (1977). Attachment as an organizational construct. Child Development, 48, 1184–1199. doi:10.2307/1128475

Streiner, D. L. (2003). Starting at the beginning: An introduction to coefficient alpha and internal consistency. Journal of Personality Assessment, 80, 99–103. doi:10.1207/S15327752JPA8001_18

Tan, T. X., & Marfo, K. (2006). Parental ratings of behavioral adjustment in two samples of adopted Chinese girls: Age-related versus socio-emotional correlates and predictors. Journal of Applied Developmental Psychology, 27, 14–30. doi:10.1016/j.appdev.2005.12.004

Teddlie, C., & Yu, F. (2007). Mixed methods sampling: A typology with examples. Journal of Mixed Methods Research, 1, 77–100. doi:10.1177/2345678906292430

Tizard, B. (1977). Adoption: A second chance. London, UK: Open Books.

Tizard, B., & Hodges, J. (1978). The effect of early institutional rearing on the development of eight year old children. Journal of Child Psychology and Psychiatry, 19, 99–118. doi:10.1111/j.1469-7610.1978.tb00453.x

U.S. Department of State, Bureau of Consular Affairs. (2016). Intercountry Adoption Statistics. Retrieved from

van den Dries, L., Juffer, F., van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2009). Fostering security? A meta-analysis of attachment in adopted children. Children and Youth Services Review, 31, 410–421. doi:10.1016/j.childyouth.2008.09.008

van den Dries, L., Juffer, F., van IJzendoorn, M. H., Bakermans-Kranenburg, M. J., & Alink, L. R. A. (2012). Infants’ responsiveness, attachment, and indiscriminate friendliness after international adoption from institutions or foster care in China: Application of Emotional Availability Scales to adoptive families. Development and Psychopathology, 24, 49–64. doi:10.1017/S0954579411000654

Van IJzendoorn, M. H., Vereijken, C. M. J. L., Bakermans-Kranenburg, M. J., & Riksen-Walraven, J. M. (2004). Assessing attachment security with the Attachment Q Sort: Meta-analytic evidence for the validity of the Observer AQS. Child Development, 75, 1188–1213. doi:10.1111/j.1467-8624.2004.00733.x.

Vaughn, B. E., & Waters, E. (1990). Attachment behavior at home and in the laboratory: Q-sort observations and strange situation classifications of one-year-olds. Child Development, 61, 1965–1973. doi:10.1111/j.1467-8624.1990.tb03578.x

Waters, E., & Deane, K. E. (1985). Defining and assessing individual differences in attachment relationships: Q-methodology and the organization of behavior in infancy and early childhood. Monographs of the Society for Research in Child Development, 50, 41–65.

World Health Organization. (1992). International statistical classification of diseases and related health problems (10th rev.). Geneva, Switzerland: Author.

Yin, R. K. (2014). Case study research: Design and methods (5th ed.). Thousand Oaks, CA: Sage.

Zeanah, C. H., & Smyke, A. T. (2008). Attachment disorders in family and social context. Infant Mental Health Journal, 29, 219–233. doi:10.1002/imhj.20176


Yanhong Liu, NCC, is an assistant professor and the School Counseling Program Coordinator at The University of Toledo. Dan Li is a doctoral candidate in counselor education at the University of Iowa. Yanqing Xu is an assistant professor at The University of Toledo. Correspondence may be addressed to Yanhong Liu, 2801 W. Bancroft St., MS 119, Toledo, OH 43606,


All Foreign-Born Adoptees Are Not the Same: What Counselors and Parents Need to Know

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.



Barcons, N., Abrines, N., Brun, C., Sartini, C., Fumadó, V., & Marre, D. (2011). Social relationships in children from intercountry adoption. Children and Youth Services Review, 34, 955–961. doi:10.1016/j.childyouth.2012.01.028.

Bartholet, E. (2006). International adoption. In L. Askeland (Ed.), Children and youth in adoption, orphanages, and foster care: A historical handbook and guide (pp. 63–78). Westport, CT: Greenwood Press.

Baumrind, D. (1978). Parental disciplinary patterns and social competence in children. Youth & Society, 9, 239–276. doi:10.1177/0044118X7800900302

Becker-Weidman, A. (2006). Treatment for children with trauma-attachment disorders: Dyadic developmental psychotherapy. Child and Adolescent Social Work Journal, 23, 147–171. doi:10.1007/s10560-005-0039-0

Beijersbergen, M. D., Juffer, F., Bakermans-Kranenburg, M. J., & van IJzendoorn, M. H. (2012). Remaining or becoming secure: Parental sensitive support predicts attachment continuity from infancy to adolescence in a longitudinal adoption study. Developmental Psychology, 48, 1277–1282. doi:10.1037/a0027442

Bledsoe, J. M., & Johnston, B. D. (2004). Preparing families for international adoption. Pediatrics in Review, 25, 242–249.

Bowlby, J. (1969). Attachment and loss, Volume. I: Attachment. New York, NY: Basic Books.

Brennan, C. (2013). Challenging behaviors in infant and toddler non-parental care: An exploration of caregiver beliefs and response strategies (Doctoral dissertation, University of Washington). Retrieved from

Bruder, M. B., Dunst, C. J., Mogro-Wilson, C., & Tan, T. X. (2010). Continuity of parental behavioral ratings of children adopted from China and parenting competence, confidence and enjoyment. Adoption and Fostering, 34(4), 3–16. doi:10.1177/030857591003400402

Chen, Y., & Li, H. (2009). Mother’s education and child health: Is there a nurturing effect? Journal of Health Economics, 28, 413–426. doi:10.1016/j.jhealeco.2008.10.005

Cohen, N. J., & Farnia, F. (2010). Social-emotional adjustment and attachment in children adopted from China: Processes and predictors of change. International Journal of Behavioral Development, 35, 66–67. doi:10.1177/0165025410371602

Cohen, N. J., & Farnia, F. (2011). Children adopted from China: Attachment security two years later. Children and Youth Services Review, 33, 2342–2346. doi:10.1016/j.childyouth.2011.08.006

Dalen, M., & Rygvold, A. L. (2006). Educational achievement in adopted children from China. Adoption Quarterly, 9(4), 45–58. doi:10.1300/J145v09n04_03

Deater-Deckard, K. (1998). Parenting stress and child adjustment: Some old hypotheses and new questions. Clinical Psychological Science and Practice, 5, 314–332. doi:10.1111/j.1468-2850.1998.tb00152.x

Ehrenreich, J. T., Santucci, L. C., & Weiner, C. L. (2009). Trastorno de ansiedad por separación en jóvenes: fenomenología, evaluación y tratamiento [Separation anxiety disorder in youth: Phenomenology, assessment, and treatment]. Psicol Conductual, 16, 389–412.

Gagnon-Oosterwaal, N., Cossette, L., Smolla, N., Pomerleau, A. Malcuit, G., Chicoine, J. F., . . . Séguin, R. (2012). Pre-adoption adversity, maternal stress, and behavior problems at school-age in international adoptees. Journal of Applied Developmental Psychology, 33, 236–242. doi:10.1016/j.appdev.2012.04.002.

Grant, K. E., Compas, B. E., Thurm, A. E., McMahon, S. D., & Gipson, P. Y. (2004). Stressors and child and adolescent psychopathology: Measurement issues and prospective effects. Journal of Clinical Child and Adolescent Psychology, 33, 412–425. doi:10.1207/s15374424jccp3302_23

Grossmann, K. E., Grossmann, K., Winter, M., & Zimmermann, P. (2002). Attachment relationships and appraisal of partnership: From early experience of sensitive support to later relationship representation. In L. Pulkkinen & A. Caspi (Eds.), Paths to successful development (pp. 73–105). Cambridge, United Kingdom: Cambridge University Press.

Gunnar, M. R., Bruce, J., & Grotevant, H. D. (2000). International adoption of institutionally reared children: Research and policy. Development and Psychopathology, 12, 677–693.

Gunnar, M. R., van Dulmen, M. H. M., & the International Adoption Project Team. (2007). Behavior problems in postinstitutionalized internationally adopted children. Development and Psychopathology, 1, 129–148. doi:10.1017/S0954579407070071

Halford, W. K., & Petch, J. (2010). Couple psychoeducation for new parents: Observed and potential effects on parenting. Clinical Child and Family Psychology Review, 13, 164–180. doi:10.1007/s10567-010-0066-z

Hawk, B., & McCall, R. B. (2010). CBCL behavior problems of post-institutionalized international adoptees. Clinical Child and Family Psychology Review, 13, 199–211. doi:10.1007/s10567-010-0068-x

Hoshmand, L. T., Gere, S., & Wong, Y.-S. (2006). International adoption and the case of China: Implications of policy, theory, and research for psychoeducation and counseling. Asian Journal of Counselling, 13, 5–50.

Johnson, K. A. (2004). Wanting a daughter, needing a son: Abandonment, adoption, and orphanage care in China. St. Paul, MN: Yeong & Yeong Book.

Juffer, F., & van IJzendoorn, H. M. (2005). Behavior problems and mental health referrals of international adoptees: A meta-analysis. The Journal of the American Medical Association, 20, 2501–2515. doi:10.1001/jama.293.20.2501

Karl, D. (1995). Maternal responsiveness of socially high-risk mothers to the elicitation cues of their 7-month-old infants. Journal of Pediatric Nursing, 10, 254–263. doi:10.1016/S0882-5963(05)80022-3

Kisilevsky, B. S., Hains, S. M. J., Lee, K., Muir, D. W., Xu, F., Fu, G., …Yang, R. L. (1998). The still-face effect in Chinese and Canadian 3- to 6-month-old infants. Developmental Psychology, 34, 629–639.


Kotchick, B. A., & Forehand, R. (2002). Putting parenting in perspective: A discussion of the contextual factors that shape parenting practices. Journal of Child and Family Studies, 11, 255–269.

Kreider, R. M., & Cohen, P. N. (2009). Disability among internationally adopted children in the United States. Pediatrics, 124, 1311–1318. doi:10.1542/peds.2008-3206

Kriebel, D. K., & Wentzel, K. (2011). Parenting as a moderator of cumulative risk for behavioral competence in adopted children. Adoption Quarterly, 14, 37–60. doi:10.1080/10926755.2011.557945

Krishnakumar, A., & Buehler, C. (2000). Interparental conflict and parenting behaviors: A meta-analytic review. Family Relations, 49, 25–44.

Meins, E., Fernyhough, C., Fradley, E., & Tuckey, M. (2001). Rethinking maternal sensitivity: Mothers’ comments on infants’ mental processes predict security of attachment at 12 months. Journal of Child Psychology and Psychiatry, 42, 637–648.

Miller, L., Chan, W., Tirella, L., & Perrin, E. (2009). Outcomes of children adopted from Eastern Europe.International Journal of Behavioral Development, 33, 289–298. doi:10.1177/0165025408098026

Morris, A. S., Cui, L., & Steinberg, L. (2013). Parenting research and themes: What we have learned and where to go next. In R. E. Larzelere, A. S. Morris, & A. W. Harrist (Eds.), Authoritative parenting: Synthesizing nurturance and discipline for optimal child development (pp. 35–58). Washington, DC: American Psychological Association.

Neimetz, C. (2011). Navigating family roles within an institutional framework: An exploratory study in one private Chinese orphanage. Journal of Child and Family Studies, 20, 585–595. doi:10.1007/s10826-010-9431-2

Palacios, J., & Brodzinsky, D. (2010). Review: Adoption research: Trends, topics, outcomes. International Journal of Behavioral Development, 34, 270–284. doi:10.1177/0165025410362837

Pugliese, M., Cohen, N. J., Farnia, F., & Lojkasek, M. (2010). The emerging attachment relationship between adopted Chinese infants and their mothers. Children and Youth Services Review, 32, 1719–1728.


Purvis, K. B., Cross, D. R., & Pennings, J. S. (2009). Trust-Based relational intervention™: Interactive principles for adopted children with special social-emotional needs. Journal of Humanistic Counseling, Education and Development, 48, 3–22. doi:10.1002/j.2161-1939.2009.tb00064.x

Roberson, K. C. (2006). Attachment and caregiving behavioral systems in intercountry adoption: A literature review. Children and Youth Services Review, 28, 727–740. doi:10.1016/j.childyouth.2005.07.008

Scroggs, P. H., & Heitfield, H. (2001). International adopters and their children: Birth culture ties. Gender Issues, 19, 3–30.

Shang, X. (2002). Looking for a better way to care for children: Cooperation between the state and civil society in China. Social Service Review, 76, 203–228. doi:10.1086/339671

Tan, T. X., & Camras, L. A. (2011). Social skills of adopted Chinese girls at home and in school: Parent and teacher ratings. Children and Youth Services Review, 33, 1813–1821. doi:10.1016/j.childyouth.2011.05.006

Tan, T. X., Camras, L. A., Deng, H., Zhang, M., & Lu, Z. (2012). Family stress, parenting styles, and behavioral adjustment in preschool-age adopted Chinese girls. Early Children Research Quarterly, 27, 128–136. doi:10.1016/j.ecresq.2011.04.002

Tan, T. X., & Marfo, K. (2006). Parental ratings of behavioral adjustment in two samples of adopted Chinese girls: Age-related versus socio-emotional correlates and predictors. Applied Developmental Psychology, 27, 14–30. doi:10.1016/j.appdev.2005.12.004

Tan, T. X., Marfo, K., & Dedrick, R. F. (2010). Early developmental and psychosocial risks and longitudinal behavioral adjustment outcomes for preschool-age girls adopted from China. Journal of Applied Developmental Psychology, 31, 306–314. doi:10.1016/j.appdev.2010.04.002

U.S. Department of State, Bureau of Consular Affairs. (2012). Intercountry adoption statistics. Retrieved from

van den Dries, L., Juffer, F., van IJzendoorn, M. H., & Bakermans-Kranenburg, M. J. (2010). Infants’ physical and cognitive development after international adoption from foster care or institutions in China. Journal of Developmental and Behavioral Pediatrics, 31, 144–150. doi:10.1097/DBP.0b013e3181cdaa3a

van IJzendoorn, M. H., Juffer, F., & Poelhuis, C. W. K. (2005). Adoption and cognitive development: A meta-analytic comparison of adopted and nonadopted children’s IQ and school performance. Psychological Bulletin, 131, 301–316. doi:10.1037/0033-2909.131.2.301

Viana, A. G., & Welsh, J. A. (2010). Correlates and predictors of parenting stress among internationally adopting mothers: A longitudinal investigation. International Journal of Behavioral Development, 34, 363–373. doi:10.1177/0165025409339403

Welsh, J. A., & Viana, A. G. (2012). Developmental outcomes of internationally adopted children. Adoption Quarterly, 15, 241–264. doi:10.1080/10926755.2012.731029

Welsh, J. A., Viana, A. G., Petrill, S. A., & Mathias, M. D. (2007). Interventions for internationally adopted children and families: A review of the literature. Child and Adolescent Social Work Journal, 24, 285–311.



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,