Counseling Considerations when Working with Adopted Individuals

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Adoptive families embody a growing portion of the population in the United States. Approximately 136,000 children are adopted yearly, adding to the current estimate of 2 million adoptees (Opiola & Bratton, 2018). However, prior to being adopted, children’s experiences may vary on a spectrum; ranging from supportive and nurturing, to neglectful and abusive. Children whose early experiences included abuse, neglect, and inconsistent caregiving often exhibit intense emotional and behavioral challenges and may reject adoptive parents’ efforts to connect and form a close relationship.

Additionally, even though adoption is common in the United States, the research on the long-term outcomes of adoption is scarce (Pearson, Curtis, & Chapman, 2007). Pearson, Curtis, & Chapman suggest that some research has shown adoptees struggle with a variety of psychological issues, and that some of those issues may continue into adulthood (citing Brodzinsky, Schechter, & Henig, 1992; Common Clinical Issues Among Adoptees, 1995; Issues facing adult adoptees, n.d.; Leon, 2002; Nickman, 1996; Stevens, 1995). On the other hand, there is also research that argues that individuals who are adopted experience no more mental health problems than individuals who are not adopted, and that most issues are resolved by adulthood (as cited in Benson, Sharma, & Roehlkepartain, 1994a, 1994b; Hochman & Huston, 1995).

In 2000, for the first time, the U.S. government recognized the importance of studying adopted children and collected information on this population in the U. S. census (Pearson, Curtis, & Chapman, 2007). The following review of literature consists of multiple empirically validated studies, looking at how being adopted can affect the mental health and development of an adopted individual in childhood and later on in adulthood. This review of the research done on adopted individuals will provide implications from a multicultural perspective for mental health professionals working with this population.

Child Parent Relationship Therapy for Adopted Children

A secure attachment experience during the 1st year of life is integral to a child’s emotional well-being and holistic development. For many children involved in foster care, or who have been adopted, their initial relationships may fail to provide a sense of security (Carnes-Holt & Bratton, 2014). Children who have experienced repeated changes in caregivers, repetitive neglect, and abuse can experience difficulty feeling safe in relationships. Consequently, adopted children; especially those who have been subjected to foster care or a form of institutional care, are more likely to have encountered these experiences. Unfortunately, this can compromise their ability to form secure attachments in their adoptive family (Carnes-Holt & Bratton, 2014).

A pilot study done in 2014 by Kara Carnes-Holt and Sue C. Bratton, sought to examine the effectiveness of child parent relationship therapy (CPRT) with 61 adoptive families. Although counseling professionals advocate the use of CPRT with adoptive and foster families, an in-depth review of the literature revealed no published outcome studies focused on CPRT with this population (Carnes-Holt & Bratton, 2014). CPRT uses a small, supportive group format merging together didactic and supervision experiences. The model is designed for an average of six to eight parents meeting together in 2-hour groups for 10 weeks (Carnes-Holt & Bratton, 2014). Furthermore, parents also conduct weekly supervised play sessions with their children as a means of applying CCPT attitudes and skills aimed at fostering a more attuned and empathic parent-child relationship and reducing child behavior problems (as cited in Landreth, 2002). Carnes-Holt and Bratton (2014), looked at two primary research questions:

  1. Was there a mean reduction in children’s behavior problems over time for the experimental group compared with the wait-list control group?
  2. Was there a mean increase in observed parental empathy over time for the experimental group compared with the wait-list control group?

A randomized control group design was utilized to examine the effects of CPRT on adoptive families for this study. A total of 39 women (19 in the experimental group, 20 in the control group) and 22 men (13 in the experimental group, nine in the control group) participated in the study (Carnes-Holt & Bratton, 2014). Moreover, 88.5% of parents reported European American as their ethnicity. The children of the parents who participated in the study ranged in age from 2 to 10 years, with the average age of 5.8 years for the experimental group and 5.6 years for the control group (Carnes-Holt & Bratton, 2014).

There were two main instruments used in this study to measure parent empathy and children’s behavior problems. The Child Behavior Checklist-Parent tool (CBCL) measures parents’ reports of children’s behavioral and emotional problems based on children’s social relationships, activities, and school performance (Carnes-Holt & Bratton, 2014). Whereas, to measure empathy from the caregivers, the Measurement of Empathy in Adult-Child Interaction (MEACI) was given. The MEACI is a direct observation measure designed to operationally define empathy as related to parent-child interactions in spontaneous play sessions (Carnes-Holt & Bratton, 2014). Subsequently, to score the MEACI, trained observers rate the three dimensions of adult-child interactions (Communication of Acceptance, Allowing the Child Self-Direction, Involvement) at 3-minute intervals for six consecutive rating intervals (Carnes-Holt & Bratton, 2014).

All participants were administered the CBCL, then for the purpose of obtaining pretest data for the MEACI, completed a 20-minute recorded play session with their adoptive child. Next, participants were randomly assigned to one of two group, either the experimental CPRT group or the waitlist control group (Carnes-Holt & Bratton, 2014). The 32 participants who were part of the experimental group then underwent the 10-week CPRT intervention described earlier.

The study found that in regard to an overall reduction in behavior problems over time, parents who participated in the experimental group reported a statistically significant decrease in children’s overall behavior problems from pretest to posttest when compared with parents in the control group (Carnes-Holt & Bratton, 2014). Results further indicated that in regard to parental empathy over time, all 32 experimental group parents increased in empathic interactions with their children as evidenced by their individual mean change scores on the MEACI. These results are particularly noteworthy because the independent raters were blinded to participants’ treatment group assignment and whether they were scoring pre, or post-data for the MEACI (Carnes-Holt & Bratton, 2014).

According to the American Psychological Association (2002), a single experiment from one setting does not provide sufficient evidence of efficacy. Therefore, Opiola and Bratton (2018) conducted a randomized controlled replication study of Carnes-Holt’s and Bratton’s original 2014 pilot study; examining the effectiveness of child parent relationship therapy (CPRT) with 49 adoptive families. The predominant goal of the replication study was to replicate findings from Carnes-Holt and Bratton’s (2014) study using the same protocol and methods to establish CPRT as an evidence-based intervention for adoptive families (Opiola & Bratton, 2018). Specifically, Opiola and Bratton’s (2018) study addressed three primary research questions:

  • Research Question 1: Do children of adoptive parents who participated in CPRT exhibit a reduction in behavioral problems?
  • Research Question 2: Do adoptive parents who participated in CPRT report a reduction in stress in the parent-child relationship?
  • Research Question 3: Do adoptive parents who participate in CPRT demonstrate an increase in empathic interactions with their children?

Furthermore, the replication study took in to account Carnes-Holt and Bratton’s recommendation to compare CPRT with treatment as usual (TAU), to overcome the limitations inherent to no-treatment wait-list control groups (Opiola & Bratton, 2018). Additionally, the Parent Stress Index, Fourth Edition (PSI-4) was a third additional instrument utilized in conjunction with the CBCL and MEAICI. The PSI-4 measures parents’ perceptions of their stress related to the parent-child relationship (Opiola & Bratton, 2018).

The CPRT group consisted of 25 participants, whereas the TAU group consisted of 24 participants. The TAU group was based on typical postadoption services offered by the adoption agencies and ministries the participants were recruited from. These services included brief individual parent consultation focused on child behavior management and crisis intervention conducted by phone or in person (Opiola & Bratton, 2018). Therefore, parents assigned to the control (TAU) group were offered individual parent consultation once per week for 30 minutes. Depending on their preference, they had the option to receive the services face to face or via phone (Opiola & Bratton, 2018). Participants in both groups were then given the three pre and posttest instruments (PSI-4, CBCL, and MEAICI), and reevaluated after the 10-week CPRT group had concluded.

The results indicated that, according to parent report, adoptive children whose parents participated in the CPRT groups demonstrated a statistically significant decrease in global behavior problems over time compared with children whose parents received TAU (Opiola & Bratton, 2018). Moreover, CPRT parents demonstrated a statistically significant increase in empathy responses and behaviors, compared with parents in the TAU groups. Finally, in regard to parent stress, the results indicated that adoptive parents who participated in CPRT reported a statistically significant decrease in stress in the parent-child relationship, compared with the TAU parents. These findings confirm Carnes-Holt and Bratton’s (2014) results and provide strong support for CPRT as a responsive intervention for adoptive families (Opiola & Bratton, 2018).


  1. American Psychological Association. (2002). Criteria for evaluating treatment guidelines. American Psychologist, 57, 1052-1059. doi: 10.1037/0003-066X.57.12.1052
  2. Baden, Amanda L., et al. “Reclaiming culture: reculturation of transracial and international adoptees.” Journal of Counseling and Development, vol. 90, no. 4, 2012, p. 387+.
  3. Benson, P. L. & Sharma, A. R. (1994). The truth about adopted teenagers. Adoptive Families, 38, 16-20.
  4. Benson, P. L., Sharma, A. R., & Roehlkepartain, E. C. (1994a). New study identifies strengths of adoptive families. Source, 10(2), 1-3.
  5. Benson, P. L., Sharma, A. R., & Roehlkepartain, E. C. (1994b). Growing up adopted: A portrait of adolescents and their families. Search Institute: Minneapolis, MN.
  6. Brodzinsky, D.M., Schechter, M.D., & Henig, R.M. (1992). Being Adopted: The Lifelong Search For Self. New York: Anchor Books.
  7. Carnes-Holt, Kara, and Sue C. Bratton. “The efficacy of child parent relationship therapy for adopted children with attachment disruptions.” Journal of Counseling and Development, vol. 92, no. 3, 2014, p. 328+.
  8. Landreth, G. L. (2002). Play therapy: The art of the relationship (2nd ed.). New York, NY: Routledge.
  9. Langrehr, Kimberly J., et al. “Implications of transnational adoption status for adult Korean adoptees.” Journal of Multicultural Counseling and Development, vol. 43, no. 1, 2015, p. 6+.
  10. Opiola, Kristie K., and Sue C. Bratton. “The Efficacy of Child Parent Relationship Therapy for Adoptive Families: A Replication Study.” Journal of Counseling and Development, vol. 96, no. 2, 2018, p. 155+.
  11. Pearson, Frances, et al. “Use of mental health services by adults who were adopted as infants.” Journal of Mental Health Counseling, Apr. 2007, p. 163+.
  12. Penny, Judith, et al. “Reconstruction of adoption issues: delineation of five phases among adult adoptees.” Journal of Counseling and Development, vol. 85, no. 1, 2007, p. 30+.
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Counseling Considerations When Working with Adopted Individuals. (2021, May 17). Retrieved from

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