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This is a plain English summary of an original research article. The views expressed are those of the author(s) and reviewer(s) at the time of publication.

Thousands of children are adopted from care every year in the UK. Most have had a difficult beginning, but little is known about which early adverse experiences are most likely to lead to post-traumatic stress (PTS).

Adverse experiences include abuse, neglect, and household dysfunction including exposure to drugs, alcohol, and violence. A new study found these experiences were common among adopted children. One in two children had experienced neglect; one in three had multiple adverse experiences. 

Adopted children in this study were more likely to show symptoms of PTS than others in the population. But PTS is not a single condition. Some people with PTS feel emotionally numb (avoidance), others are jumpy and tense (arousal) or have nightmares and flashbacks (intrusive thoughts).  

The researchers found five distinct groups of early adverse experiences. The PTS symptoms children were most likely to develop differed between groups. For example, children with multiple different experiences (including exposure to drugs or alcohol in the womb) were most likely to develop avoidance and arousal. 

The types of adversity children experienced might therefore determine the type of tailored mental health support they need. The research suggests that offering evidence-based services before and after adoption could help families better support their adopted children. 

This Alert features in our evidence Collection: Adverse childhood experiences: what support do young people need? Read the Collection

What’s the issue?

During the year 2019 to 2020 in England, 3,440 children were adopted from care. Most had lived through adverse experiences in their early life that could affect their mental health and development. 

Adverse childhood experiences (ACEs) include exposure to alcohol or drugs while in the womb; emotional, physical, and sexual abuse; neglect; living with substance abuse or violence; having parents with learning difficulties or mental health problems. 

Adopted children are more likely to need specialist care for mental health issues. Few studies have investigated PTSD in adopted children, but children in foster care are twice as likely as war veterans to have symptoms of PTSD.

There are three main groups of PTSD symptoms:

    • arousal, such as jumpiness, tension, difficulty concentrating, and problems sleeping
    • avoidance, such as feeling emotionally numb or “cut off” from their feelings.
    • intrusion, such as nightmares, flashbacks, and being upset by traumatic memories.

A better understanding of how adopted children’s early experiences link to mental health symptoms like PTSD would help policymakers and practitioners design post-adoption support that is tailored to a child’s needs.

Past research has often simply counted the number of adverse experiences a child has been exposed to. It has not taken into account the type of event/s, their interactions, or their specific impact on the child. This study explores individual children’s experiences, and how patterns of adversity are linked to symptoms of PTSD.

What’s new?

The study included social worker records of all 374 children placed for adoption in Wales in the year 2014 to 2015. These reports provide information about the children’s birth parents and the reasons they were placed for adoption.

A sub-group of 58 adoptive parents filled in a series of questionnaires in the four years after adoption. Parents reported on their child’s and their own mental health, and family relationships. 

The researchers found that between 7% and 14% of the children displayed clinically relevant symptoms of PTSD. Arousal symptoms were the most common, followed by avoidance, and intrusion.

Researchers looked at the types of adversity recorded in social worker records. They identified five groups of adverse experience. 

    • Multiple risks: One in three children (36%) had experienced adversity both before birth (mother’s substance abuse) and afterwards. Children in this group spent the most time with their birth parents and in care. 
    • Low exposure: Another one in three children (35%) were removed from their parents’ care at birth and were unlikely to have experienced adversity before adoption. 
    • Before birth: One in seven children (14%) was, for example, exposed to drugs or alcohol in the womb, born early (premature) or small (low birthweight). This group of children spent only a month on average in the care of their birth parents. 
    • Early life: One in 12 children (8%) had experienced adversity in the first months of life (17 months on average), typically abuse, neglect, or witnessing domestic violence. Unlike the multiple risks group, these children were not exposed to substance abuse before or after birth. 
    • Parental difficulties: One in 16 children (6%) had a parent with learning difficulties and experienced neglect that may have been unintentional when parents were unable to recognise their child’s needs. Some of these children experienced physical abuse. 

Children who had experienced multiple risks were most likely to show signs of PTS; symptoms of avoidance and arousal were highest in this group. Intrusion symptoms were highest in the group which had experienced adversity in early life. 

Why is this important?

This study found that the type of early adversity children lived through was linked to the type of PTS symptoms they went on to develop. This finding has implications for care planning for individual children.  

For example, children in the “multiple risk” group displayed more avoidance and arousal symptoms. It may be that the combination of exposure to toxins in the womb plus adverse experiences in childhood, alters the development of body and brain. This includes mental skills such as self-control and working memory.

Children in the “early life” group could be most likely to have intrusive symptoms because they had experienced all types of abuse, neglect, and household dysfunction, particularly witnessing domestic violence. 

This research suggests that adopted children need tailored support, based on the types of adversity they have experienced. Early intervention for PTSD – along with continuity of care – could prevent or reduce mental health and developmental issues. 

Although adopted children were more likely to show PTS symptoms (7-14% children) than the general population (7-8%), the authors note that it is reassuring that most adopted children did not show signs of PTS.

What’s next?

This research highlights the need for targeted, evidence-based, services before and after adoption. Parents and teachers also need access to appropriate training. 

The researchers hope to follow the children in this study to see how their symptoms change over time. They would like to explore whether aspects of adoptive homes (such as parental warmth), or interventions the children have received, lead to a reduction in symptoms.

Future work could explore factors that promote resilience and might explain why many children stay healthy even after adverse experiences early in life. 

You may be interested to read

The full paper: Anthony RE, and others. Patterns of adversity and post-traumatic stress among children adopted from care. Child Abuse & Neglect 2020;104795 

Cardiff University's Wales Adoption Cohort Study: A research study exploring the elements of early placement success for adopted children and their families. 

A piece from Child Trends: Adverse childhood experiences are different than child trauma, and it’s critical to understand why.  

Related paper from the same authors: Anthony RE, and others. Early adversity predicts adoptees’ enduring emotional and behavioral problems in childhood. European Child & Adolescent Psychiatry 2021;30 

Funding: This research was supported by grants from the Welsh Government and from The Waterloo Foundation. The Wales Adoption Study was initially funded by Health and Care Research Wales. 

Conflicts of Interest: The study authors declare no conflicts of interest.

Disclaimer: Summaries on NIHR Evidence are not a substitute for professional medical advice. They provide information about research which is funded or supported by the NIHR. Please note that the views expressed are those of the author(s) and reviewer(s) and not necessarily those of the NHS, the NIHR or the Department of Health and Social Care.

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