HE.S.T.A.F.T.A. - Scientific Society of Mental Health Professionals


  • Francesco VadilongaPsychologist, psychotherapist. Director of the CTA centre (Centro Terapia dell’Adolescenza – Milano – www.centrocta.it), in charge of the specialised service for support in difficult adoptions and case management of adoptive crises. Co-director of IRIS (Insegnamento e Ricerca Individuo e Sistemi) psychotherapy school

Towards a new model of adoption

In the last decade the context of adoption has profoundly changed. We are witnessing a transformation in the categories of children placed for adoption, and therefore the subsequent transformation of adoption, which is increasingly becoming an option for those children who have lived through traumatic experiences, maltreatment and sexual abuse, and who arrive in their adoptive family with a burden of suffering, distress and confusion.

The new adoptive scenarios

In the past, the adoptive family was conceived as completely similar to the biological family. The effort was to model adoption as much as possible according to the biological parental model. The differences between the biological family and the adoptive family were denied, with the consequence of ignoring the specific processes and difficulties that might arise in building emotional relationships within the adoption. What had happened before the adoption was not considered; specific support and treatment interventions were rarely put in place or proposed to the families. However, adoption is a social representation, and it evolves over time. Today the new model of adoption is based on the idea of continuity between the present  and  the  past.

The  idea  has  taken  root  that  even  children  with   difficult situations and special needs can be adopted. Hence, we are going through a period of transformations that in the future will probably bring about some changes in the aims, goals and practice of adoption; a process of conceptual transition of the adoption model is clearly underway. We are shifting from an adoptive model in which the child’s origins remain a secret, to one based on the recollection of the past, where the history of the child doesn’t start when s/he meets the adoptive family, whether this happens when the child is only some months old or when he is older, but instead begins when he is born. Therefore it is important that this part of his history might be recorded during the adoption and that his right to identity is safeguarded. The old adoptive model would pivot on this interruption, while today we have shifted to a model based on continuity. Also the metaphors once used (adoption as a second birth, the concept of a transplant or a graft) are today partial representations of adoption. We need to fully reinstate the idea of the adoptive triad[1] within which the three poles (children, biological parents and adoptive parents) are connected along a temporal continuum from the past to the future.

Risk factors

An idealised vision of adoption, namely the idea that adoption was like a “squaring of the circle”, and that through the child placement the different parts of the adoptive triangle would find their way to a “happy” life, caused an underestimation of the risk factors. Today the profile of adoptable children increasingly overlaps with that of special needs children: Italy is among the European countries with the highest  number of international adoption, and the one that places the highest percentage of special needs children.[2] We know that the adverse outcomes of adoption are the consequence of the build-up of risk factors; research on adoptive disruption usually shows that these are the result of circumstances where  certain adoptee features are combined with some specific features of adopting families, and with absent or inadequate professional intervention to support the adoption [3]. However we need to keep in mind that we shouldn’t only consider the risk factors, but also the protective ones. Even with high percentages of disruptions, such as the 24% illustrated in the research by Barth and Berry[4] on children adopted at the age of 12 or older, despite  this being quite a high percentage, we see that three quarters of these adoptions didn’t end in disruptions. The following table shows the main risk factors identified by Palacios[5] considering the features of the child, of the adoptive family and of the professional intervention:

Features of the children

  • High age at adoption (older than 6)
  • Externalised behaviours (severe behavioural problems)
  • Attachment difficulties

Features of fathers and mothers

  • Single mother
  • Previous children (biological or adopted)
  • Risk motivations
  • Severe disagreement within the couple about the adoptive project
  • Rigid, or less flexible parental style

Features of the professional intervention

  • Lack of specific training
  • General assessment of suitability
  • Inadequate matching
  • Pronounced discrepancy between the profile of the desired child and the real child
  • Scarce or absent post- adoptive support

In this research, as in the main studies, advanced age is one of the biggest risk factors. The data provided by the Commission for the International Adoptions  highlight that in Italy the arrival of children adopted in 2009 in the age range 5-9  exceeded the number of children aged 1-4: 55% of children coming to Italy compared to 45%. Therefore we have to start from the awareness that we are dealing with a population of children who have encountered traumatic experiences – before or after leaving their biological families – that have shaped their adaptive strategies; these are the children that will have a greater impact on the adoptive family where they are placed, and will relate in distinctive way to their new caregivers. Highlighting these aspects doesn’t mean discouraging adoption; on the contrary it means inviting all those involved, parents and professionals, to be aware of the possible difficulties and be prepared in order to ensure that the adoptive paths are adequately supported.

Adoption as rehabilitation

Bowlby[6], in his studies on orphans in Europe after the war, stated that institutional care lacks the essential ingredients for healthy development; he portrayed adoption as one of the best alternatives, although his intuition was not supported by empirical evidence. Van Ijzendoorn and Juffer’s[7] major meta-analysis provided scientific evidence that today enables us to conceptualise adoption as a powerful intervention, representing a remarkable rehabilitation tool for critical development areas: physical growth, cognitive development, school achievement, self-esteem and behavioural problems, and secure attachment. The results of these research projects show in particular a higher percentage of secure attachment in non-adoptees (adoptees 45%- non-adoptees 62%). While differences are not significant in the insecure, ambivalent (adoptees 10% - non-adoptees 9%) and avoidant attachment styles (adoptees 12%- non-adoptees 14%), it is striking that in the adoptees group, the disorganised attachment style percentage (33%) is more than double compared to non-adoptees (15%).  Overall  if  we  compare  the  adoptees  to  the  group  of  previous  peers who remained in the orphanage or in their biological family, adoption appears to be a healing intervention and a protective factor, while if we compare them with their current group of peers (non-adopted children raised in “regular families”), adoption could be considered as a risk factor.

These data suggest that adoption is a privileged treatment area for traumatised children. However, the significant increase in adoptions of children at a later age and with traumatic histories – despite undoubtedly offering a chance of life to many children that were previously destined to remain in institutions – raises new problems for the adoptive parents. In the light of clinical evidence, our experience in the last  ten years suggests that a significant number of parents of children adopted at a later age are encountering more relational and behavioural difficulties with their sons and daughters, particularly during pre-adolescence and adolescence. Therefore we can speculate that this group of children is the one that will encounter the greatest difficulties in the adoptive process.

3 What makes adoption difficult

For the positive outcome of adoptions, it is critical that professionals and adoptive families are able to understand how these children function in their new  care  contexts, in order to have a wide enough framework of meanings from which the resources for the comprehension of their behaviours can be drawn, avoiding any misunderstanding. The “transactional model” proposed by Stovall and Dozier[8] can be useful for this purpose: the model enables us to overcome a linear, cause-effect definition that identifies specific parental behaviours as the foundation of the child’s trauma; the child and the environment co-determine the progress and the direction of development within a circular model. In other words, a child’s growth trajectory along a particular developmental path is determined by the transactions that happen between  the  child  and  his  caregivers;  not  only  are  children  influenced  by  their environment, but the social milieu is influenced by the children, their needs and behaviours. Applied to the adoptive context, this model tells us that each child’s trajectory depends on the kind of abuse, neglect and rejection he experienced and on the specific reactions of the adoptive parents, which in turn are influenced by the children’s post-traumatic behaviours[9].

In addition, it helps us understand that, once in the new environment, children continue to use the strategies that they developed to survive in situations of abuse and neglect, despite the fact that they are now in a safe family environment. We know  that the creation of new relationships, and in particular the one with adoptive parents, cannot but be influenced by past attachment models, established in previous dramatically deficient and distorted relationships.[10] The development of behavioural patterns based on the responses of the attachment figure can be considered a way to adapt to the environment, with the aim of maintaining a contact with the caregiver. Therefore not only will the adoptee bring the adaptive strategies learned in previous relationships back up in the relationship with the adoptive parents, but he will also  use representations originating from his past experiences to anticipate other people’s behaviours. In the light of their experience, the adoptees expect that the new caregivers will have the same features (they will be frightening, damaging, unpredictable, violent or confused) as those they have experienced in the past[11]. If  the adoptive parent is sensitive and responsive enough, s/he will try to provide care and protection; however this caring approach might produce intense arousal states with behavioural reactions such as freezing, fear, anger and confusion. Although the strategies learned in their context of origin might have helped the children to survive in a very difficult environment, they also mean that these children are poorly- equipped to draw benefit from loving, responsive and good quality care.

4 The distress of adopted children

Many adoptees seem unable to elicit or respond to protective parenting and care.  They don’t feel safe when they are in care contexts characterised by intimacy and protection. Some of these children have learnt to feel safer relying only on themselves. Their distress is reactivated in warm and protective care relationships. Others have learned to use unpredictable behaviour to control attachment figures, and tend to behave as if the new caregivers might be a potential source of hostility, maltreatment and neglect. In reaction to all this, it is highly likely that the caregivers in turn might feel helpless, angry and confused, since they are obliged to cope with hostility, aggression, rejection and sudden changes of mood. In the most difficult cases, the adoptive parents are tempted to give up to their role as caregivers, since they feel they don’t want or are no longer able to provide care for their children. Without the support and help of an expert, many parents feel trapped in the child’s distorted vision about the way relationships work. We can consider the distress of adoptees as a sort of precondition, of “psychic difficulty” that might be a sign of psychopathological development; the adoptive path might get the children’s developmental trajectory back into a normal range, or on the contrary keep it moving in the direction that will lead to psychopathological outcomes. This is determined by the intersection of risk factors borne by the children and the protective and risk  factors connected to the features of the adoptive parents, and the promptness and efficacy of support interventions. In the above-mentioned transactional model proposed by Stovall and Dozier[12], the adoptive parents’ responses enable the evolution of the child’s representations. The adoption of a traumatised child requires the parent’s ability to direct this process and gradually govern the change; otherwise the response of the adoptive parent might confirm the child’s representations or trigger their development. The transformative force of adoption consists in offering the  child  new  nurture  experiences  that  will  be  significantly  different  from  his previous experience. If these new experiences occur with a certain repetitiveness and strength, the child will be obliged to create new scripts, connecting them with the existing ones. Thus, adoption can be a new experience, able to generate change in the child’s mental organisation; starting from individual daily nurture experiences, the gradual change will affect the general attachment representation. In contrast, when  the care experience that the child receives in the adoptive placement follows the insecure models experienced in the past, his scripts will be confirmed and change will not influence the overall representation of attachment. This formulation strongly embraces a vision of adoption centred on the child’s needs, and adds value to the crucial contribution that adoptive parents can offer.

Preventing adoption disruption

In the light of what has been discussed, in order to enable adoptions to evolve positively, careful attention must be dedicated to assessing risk in adoptions and intervening at an early stage in order to support them. In high-risk adoptions we have to prevent the onset of the crisis, in the crucial phase when the relation is built, rather than try to remedy a full-blown crisis. However, it is important to have some specialised and “ecological”[13] preconditions that might direct the assessment and the case management, always keeping in mind the specificity of the adoptive experience. The nuclear family as a whole should be considered as the main focus of the intervention, considering adoption the first and most important “therapeutic” intervention aimed at changing the mental models and representations within the relationship between the parents and the child[14].

Risk assessment

Reinforcing the protective factors by providing support that takes into account the specificity of adoption is critical in order to guide the development of children towards a trajectory of normality.

In order to be able to plan an appropriate supportive intervention we need to know what situation we are dealing with, and in particular to assess the interaction between risk factors and protective factors. Being equipped with assessment models for early identification of “at risk” adoptive situation is quite useful, particularly considering that often information is not available.

The model should provide information at many levels and include:

identification of risk indicators for the child, in particular the presence of specific past trauma;

identification of risk factors for the couple[15];

assessment instruments and procedures to perform early screening of the risk situations identified.

The assessment must include observation of the ongoing change pertaining to both  the child and the parents, after the child’s arrival in the family; if there are siblings, their relationship must also be assessed. In addition, the initial adoptive encounter must be reconstructed, together with the mechanisms that were activated at the basis of the match of the mental models, and the relational and mental dynamics activated with the placement of the child in the family unit.

Specialized support

The tendency of adoptive families to view adoption as an exclusively private matter should be opposed: in the light of existing evidence it appears to be a risk factor[16]. Historically the support intervention in the post-adoption period has coincided with the year of pre-adoptive foster care, provided for by the law for national adoption.

However, considering that adoption is a long-term process and that critical aspects  can emerge at different moments, the duration of the support should be guaranteed beyond the first year after the child’s arrival. Considering adoption as a process that goes on over time leads us to conceive the post-adoption period in a different way: difficulties might emerge at different moments during the adoptive path, and the support should not be limited in time, but rather accompany the child’s growth according to the intersection of developmental stages with the specific characteristics of the adoption; support interventions should be aimed at supporting the developmental tasks of children and parents in the different stages of the adoptive family cycle. The family should have access to the support at the critical stages or turning points of the life cycle, or when specific needs emerge.

Why it is important to see children in the post-adoption period

Professionals are often reluctant to directly involve the child; the fear of “traumatising” children, of being intrusive, of discriminating against adoptive families, of being perceived as “controllers”, might cause them to underestimate the need to observe and assess children. Considering the increasing number of adoptions that give rise to problematic situations, there are no reasons important enough to withhold from children who have already had enough trials in life, all the necessary help in order to avoid any further trauma. The children can give significant contributions to reconstructing their history and understanding any traumatic experiences in which they were involved. The main representatives of the adoptive process cannot be any other than the child’s caregivers; therefore, when involving the children we need to respect the parents’ central role, without replacing them or divesting them of the competence and knowledge they have about their child. It is possible to understand the child’s mental functioning in a more specific way, and to transfer it to the parents so as to orient them better on the attachment styles and adaptive strategies used.

We have a set of instruments that enable us to collect the representations the children have about themselves, their attachment figures and family relationships1[17], that provide material we can use to speculate with a certain precision about the perception of family roles and relational patterns with caregivers. We must consider the knowledge we can acquire about the child as a way to increase the parent’s awareness about the expectations and distorted perceptions that the child has about parental  care. We can then use it as a “map” of some  of the child’s vulnerability areas, in  order to guide the adoptive parents in the possible difficulties they might encounter.

Supporting adoptive parenting

Through specific parental support programs[18], we can promote positive interaction between the parents and the child, increasing the parents’ sensitivity and responsiveness, developing their ability to communicate with children, increasing their mentalisation and reflective function. These interventions aim at acting on the risk factors, thus becoming protective factors; we can use different kinds of intervention according to the chosen focus or the features of the risk data set to which they are applied; they are differentiated according to the duration (number of sessions), age of the children and place of intervention. The majority of programmes have the goal of intervening in risk situations, supporting parental skills and facilitating the evolution of attachment bonds towards greater levels of security.

An important meta-analysis[19]  emblematically entitled “Less is more” shows that   the effectiveness   of   interventions   is   inversely  proportional   to  the   duration;  those interventions including a number of sessions between 5 and 16 were more effective  in producing changes in parental sensitivity compared to interventions with a higher number of sessions.

Adoption and psychotherapy

The research mentioned above[20] found that adoptive parents show a higher number of visits to childhood mental health services. The higher percentage of adoptees’ use of services can be explained in two alternative ways. The first is that the adoptive  parents might have a lower threshold level to seek support and to turn to the help provided by services; the second is that the higher percentages might in fact predict more severe (behavioural or cognitive) problems in adopted children. On the basis of these data, even if we acknowledge a greater capacity to ask for help on the part of adoptive families, we can assert that a significant minority of adoptive children are vulnerable to development-related problems, and therefore we have to speculate that families welcoming these children need specialised support. However, therapeutic intervention once the adoption has already started is a complicated procedure: if we conceive adoption as a process able to restructure the child’s mental models and representations, pivoting on the relationship with adoptive parents, as we suggested  in this article, the “real” care is adoption; if adoption doesn’t work we need to take care of adoption itself, so as to re-enable it to fulfil its therapeutic role for  the children. The therapeutic intervention must focus on the relationship between the adoptee and the adoptive parents; in addition, it should aim at working in parallel on both sides in order to understand the child’s models and representations and modify the parents’ defensive responses that tend to mirror the negative image the child has  of himself; it wouldn’t be functional to offer the child a course of therapy where he feels adequately understood and mirrored by the therapist, while leaving his relationship with his parents unchanged. The therapy must lie within the circular model described by Stovall and Dozier[21], and promote more functional responses by the parents when confronted with the inadequate strategies the children have learnt in their context of origin. Therefore the adoptive parents must be included in therapeutic projects with the role of co-therapists and, if necessary, helped to change themselves in order to change the relationship with their child[22].

Adoption as a safe base

Adoption research[23] rejects the concept of determinism; it shows the plasticity of the child’s development and the possibility of an exceptional recovery, even when starting from extremely adverse situations experienced in the early years of life. However, a new attachment relationship with the adoptive parents can’t simply be established on a blank slate. The attachment experiences with maltreating, abusive or inadequate caregivers before the separation from the biological parents or in the period between the separation and the adoptive placement will continue to influence the new attachment. It is crucial to support adoptive parents in dealing with the demands of developing an attachment bond with the adoptees. In many situations the adoptive parents must not only be able to offer sensitive and responsive reactions to their children; bearing in mind the coercive or avoidant defensive strategies  developed by the children, the parents must also be able to give voice to the non- expressed or distortedly-expressed needs of their children. It is documented that relatively brief interventions focused on attachment are effective in supporting the adoptive parents in their complicated task and in backing their efforts to create a relationship of trust with the adopted child. Overall, interventions should  be organised so as to help and guide the child and the parent through a corrective experience  of  attachment.  It  is  necessary  that  parents, with  the proper support, reclaim their own parental competences, becoming a sufficiently secure base for their child.

[1] A., D., Sorosky, A. Baran, R., Pannor, “The adoption triangle: the effects of the sealed record on adoptees, birth parents and adoptive parent”. Anchor Press, New York, 1978.

[2] Personal communication by Laura Martinez Mora. Coordinator of the technical assistance program for adoption – The Hague convention of Private International Law.

[3] Palacios, “Adozioni che falliscono”, in F. Vadilonga (edited by), Curare l’adozione. Modelli di sostegno e presa in carico della crisi adottiva. Cortina, Milano, 2010

[4] R.P. Barth, M. Berry, "Preventing adoption disruption". In Prevention in Human Services, 1990, 9 (1), pp. 205-222.

[5] Palacios, Y. Sanchez-Sandoval, E., Leon, "Intercountry adoption disruptions in Spain". In Adoption Quarterly, 2005 9, pp. 35-55


[7] M., Van Ijzendoorn, F., Juffer, “The Emanuel Miller memorial lecture 2006: Adoption as intervention. Meta-analytic evidence for massive catch-up and plasticity in physical, socio-emotional and cognitive development”. In Journal of Child Psychology and Psychiatry, 2006, 47, pp. 1228-1245. Si tratta di una serie di meta-analisi svolte su più di 270 casi che includono più di 230000 bambini adottati e non adottati e i loro genitori.

[8] K.C., Stovall e M., Dozier, “Infants in foster care: An attachment theory perspective”. In Adoption Quarterly, 1998, 2, pp. 55-88.

[9] D., Howe, S., Fearnley, “Disorder of attachment in adopted and fostered children: Recognition and treatment”. In Clinical Child Psychology and Psychiatry, 2003, 8, pp. 369-387.

[10] G. Attili, “Relazioni familiari, adozione e sviluppo psicologico del bambino: il ruolo dell’attaccamento”, in F. Vadilonga (a cura di), Curare l’adozione. Modelli di sostegno e presa in carico della crisi adottiva. Cortina, Milano, 2010

[11] D., Howe, S., Fearnley, 2003, Op.cit.

[12] K.C., Stovall,  M., Dozier, 1998, Op.cit.

[13] U. Brofenbrenner, 2002, Ecologia dello sviluppo umano Il Mulino, Bologna.

[14] F. Vadilonga, “Il bambino nella famiglia adottiva”, in F. Vadilonga (a cura di), Curare l’adozione. Modelli di sostegno e presa in carico della crisi adottiva. Cortina, Milano, 2010

[15] In this regard, even though the couple will have been assessed for suitability, in the light of clinical experience we  think that the assessment must be reviewed following the encounter with the child, which might  highlight  vulnerabilities that didn’t emerge before or resources that might be enhanced in connection with the specific problems manifested by the child.

[16] Palacios, Y. Sanchez-Sandoval, E., Leon, 2005, Op. Cit.

[17] This means facilitating the children’s narrative of their histories, giving them a way to show their perceptions and expectations about attachment figures or family relationships. See: J., Hodges, S., Hillman, M., Steele, and K. Henderson, “‘Little Pig’ narrative story stem coding manual”. Anna Freud Project on Attachment in Adoption. Unpublished manuscript, 2002, The Anna Freud Centre, London. Centre/Great Ormond Street/Coram Family Research and F. Vadilonga (in press), L’utilizzo dello Sceno-test nella valutazione e nel sostegno della genitorialità.

[18] Among the programmes designed to support parenting I will mention the VIPP (Video Intervention to promote Positive Parenting – F. Juffer, M. J. Bakermans-Kraenenburg, M. van Ijzendorm, 2008, Promoting Positive Parenting. An Attachment based intervention. Mahwah, NJ: Lawrence Erlbaum), specifically oriented to adoptive parenting. In this programme the mother and child are recorded in daily life situations while they play together; recording sessions alternate with other sessions when professionals and parents watch selected segments of the video together. The video- feedback offers the opportunity to trigger in the parents a greater ability to observe the child’s behaviour.

[19] J. Bakermans-Kranenburg, M. H. Van IJzendoorn, F. Juffer, 2003, Less is more: Meta-analyses of sensitivity and attachment interventions in early childhood. Psychological Bulletin, 129, 195-215.

[20] M., Van Ijzendoorn, F., Juffer, 2006, Op. Cit.

[21] K.C., Stovall,  M., Dozier, 1998, Op.cit.

[22] F. Vadilonga (a cura di), “Curare l’adozione.Modelli di sostegno e presa in carico della crisi adottiva”. Cortina, Milano, 2010

[23] R., Rosnati (a cura di), 2010, “Il legame adottivo: Contributi internazionali per la ricerca e l’intervento”. Unicopli, Milano.

Read the next article:

ARTICLE 4/ ISSUE 10, April 2017

Working therapeutically with the adolescent and his/her family: A case of combined psychotherapy

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