Family Intervention in the Initial Adaptation of Adoptive Families: Systematic Review

Intervenção Familiar na Adaptação Inicial das Famílias Adotivas: Revisão Sistemática

Intervención Familiar en la Adaptación Inicial de las Familias Adoptivas: Revisión Sistemática

Abstract

Considering the importance of mapping family interventions practices aimed specifically to adoption, this study sought to identify through a systematic review, how family intervention models for adoptive families are structured in initial adaptation with children from 0 to 6 years old. Four databases were consulted, which led to 9.143 results: Google Scholar (n=8.056), Science Direct (n=814), SciELO (n=43) and PsycINFO (n=230). Seven articles considered pertinent to the proposal of this study were included. As a result, it was identified that most part of the interventions were not systematically described. Although promising results were indicated, replication would not be viable due to the lack of detailing of the performed practices. There was no hegemony in the choice of intervention models. Also, it was indicated that the specificity for adoption in the interventions analyzed is not clear.

Keywords:
adoption (child); adopted children; adoptive families; family therapy; systematic review.

Resumo

Pensando na importância do mapeamento da prática de intervenção familiar voltada especificamente para a adoção, o presente estudo buscou identificar, por meio da revisão sistemática, como estão estruturados e aplicados os modelos de intervenção familiar para as famílias adotivas na adaptação inicial com as crianças de 0 a 6 anos. Para tanto, foram consultadas quatro bases de dados que levaram a 9.143 resultados: Google Scholar (n=8.056), Science Direct (n=814), SciELO (n=43), PsycINFO (n=230). Sete artigos foram considerados pertinentes à proposta deste estudo. Como resultado, identificou-se que as intervenções não estavam, em sua maioria, sistematicamente descritas. Apesar de resultados promissores serem indicados, a replicação não seria viável pela falta de detalhamentos das práticas realizadas. Ressalta-se que não houve homogeneidade na escolha dos modelos de intervenção. Por fim, destaca-se que não fica clara a especificidade voltada para adoção nas intervenções analisadas.

Palavras-chave:
adoção (criança); crianças adotivas; famílias adotivas; terapia familiar; revisão sistemática

Resumen

Pensando en la importancia de mapear la práctica de intervención familiar orientada específicamente a la adopción, el presente estudio buscó identificar, a través de una revisión sistemática, cómo se estructuran y aplican los modelos de intervención familiar para familias adoptivas en la adaptación inicial con niños de 0 a 6 años. Para ello, se consultaron cuatro bases de datos que arrojaron 9.143 resultados: Google Scholar (n=8.056), Science Direct (n=814), SciELO (n=43), PsycINFO (n=230). Siete artículos se consideraron relevantes para el propósito de este estudio. En su mayor parte, las intervenciones no se describían sistemáticamente. A pesar de los resultados prometedores, la replicación no sería factible debido a la falta de detalles de las prácticas realizadas. Cabe destacar que no hubo homogeneidad en la elección de los modelos de intervención. Por último, se señaló que no está clara la especificidad dirigida a la adopción en las intervenciones analizadas.

Palabras clave:
adopción (niño); niños adoptivos; familias adoptivas; terapia familiar; revisión sistemática

Introduction

Many years ago, in our society, adoption emerged as a way to enable parenting for couples who could not have children, and also as a means of guaranteeing the right to family life to children and adolescents who could no longer be with their biological families, either due to ill-treatment, neglect, abuse, or legal surrender of the children (Palacios, 2007; Simões, 2014). Considering the complexity of the formation of bonds in adoptive families, this systematic review sought to gather data from national and international literature on family intervention in this situation, in order to provide scientific input for the professional practice of therapists who work with parents and adoptive children.

When addressing the issue of adoption, it is essential to be aware of the devaluation of the rights of children and adolescents since the beginning of our history as a society. Much has been transformed and actions, in the form of laws, to ensure the safeguarding of childhood and adolescence, especially of abandoned children (Simões, 2014). However, even with such changes, adoption as a legal measure is still a relatively new and developing process in Brazil, with post-adoption services being an even newer proposal.

From a legal perspective, there is no rule determining post-adoption monitoring with interventional purpose in national adoptions (Law No. 8,069, 1990). Internationally, post-adoption services are recognized in their actions, but there is still criticism on those not being widespread and on the lack of conceptualization and methods (Palacios, 2007). Generally, they encompass a number of educational, material and support services to help adoptive families with difficulties related to the adoption situation (Teska, 2018). These measures meet the idea of Pedro-Viejo (2017) and of Sánchez-Sandoval et al. (2019) on the importance of a post-adoption work capable of promoting the necessary resources so families can face the adaptation challenges imposed by the condition of adoption, both in the initial adaptation and throughout the family life cycle. It should be noted that the literature on the initial adaptation time in adoptive families is scarce, and it is common to take the first years of family life, that is, the postpartum period of a biological parenthood, as reference for the study of this phenomenon (Kay et al., 2014). Corroborating this information, Resmini (2018) suggests, in its national investigation, that the initial adaptation in adoption occurs in the first two years of family living and adjustment.

Returning to the idea of possible post-adoption services, family intervention is highlighted for its potential as a technique capable of helping adoptive families, especially in terms of adaptation. In a study with professionals working with post-adoption families, Lancaster et al. (2017) identified that the improvement of the bond between parents and adoptive children appears as the main objective of family intervention.

In addition to bonding, many studies have pointed out other difficulties commonly presented by adoptive children, among which are emotional, behavioral and health problems (Batki, 2018; Farr & Grotevant, 2019; Palacios, 2007; Sánchez-Sandoval & Palacios, 2012; Teska, 2018; Torres, 2017; Van IJzendoorn & Juffer, 2006; Vasquez & Stensland, 2016). Beyond the difficulties of the adopted children, there are the parents’ disappointments, especially in situations of infertility and possible previous losses (Palacios, 2007; Silva, 2018), and also the frustration of their expectations about the child that they idealized before the adoption. Some parents may experience high stress when they realize that they cannot erase, ignore, or change their children’s history and characteristics. The limitations they feel in “shaping” their children are commonly linked to reported difficulties and/or unrealistic expectations over the child’s arrival in the family (Moyer & Goldberg, 2015).

In these cases, there is also a perceived lack of support in their family adaptation processes (Moyer & Goldberg, 2015). With that, it can be thought that the demand for post-adoption assistance comes from the family and that the psychological symptoms presented are probably related to family conflicts of interactional nature (Minuchin et al., 2009), which put in conflict the expectations and characteristics of children and their adoptive parents. Andolfi (2011) indicates that generally children, through behaviors that are creative and suggestive of psychopathology, lead their parents to therapy, creating an opportunity for the family to review family roles and functions. According to this author, the child can be considered a gateway to the family system. However, one cannot lose sight of the fact that the family should be treated as a unit (Minuchin et al., 2009), considering that every child’s problem is a family problem (Andolfi, 2011). In summary, family intervention should serve as an opportunity for parents to process their parental challenges, especially those related to the bond, as well as assist in the development of effective parenting skills that help the family in resolving any conflicts, thus strengthening the relationship between parents and adoptive children (Pronchenko-Jain & Fernando, 2013; Waid & Alewine, 2018).

Some studies highlight the importance of professional competence, suggesting that in order to effectively serve adoptive families, it is necessary to have a lot of knowledge and understanding of adoption and the specificities of the family life cycle of those who adopt or are adopted (Atkinson & Riley, 2017; Farr & Grotevant, 2019; Lancaster et al., 2017; Pedro-Viejo, 2017; Waid & Alewine, 2018). Therefore, considering the importance of mapping the practice of family intervention, focused specifically on the context of adoption, this study sought to identify, through a systematic review of the literature, how family intervention models are structured and applied for adoptive families in the initial adaptation with children from 0 to 6 years of age.

Method

Outline

The present study used systematic review as outline. This method maximizes the search potential by providing as many results as possible in an organized way. Furthermore, the systematic review is recognized for its potential to minimize the bias of interest according to the initial hypotheses of the researcher, since it requires organization of the material found without interference of the authors’ perspective (Costa & Zoltowski, 2014).

The steps indicated by Costa and Zoltowski (2014) for the elaboration of a systematic review, followed in this study, were: (1) outlining the question to be researched; (2) choice of data sources; (3) choice of keywords for the search; (4) search and storage of the results; (5) selection of articles by their abstracts, according to inclusion and exclusion criteria; (6) extraction of data from the selected articles; (7) evaluation of the articles; (8) synthesis and interpretation of the data.

Search procedure

The search was carried out in four databases: Google Scholar, Direct Science, SciELO (Scientific Electronic Library Online) and PsycINFO, between the months of March and May 2021, with the last search date being May 01, 2021. The descriptors were defined according to the indications of the APA Thesaurus (American Psychological Association) and the terminology Bank of the BVS-Psi (Virtual Library of Psychology), and other keywords were used for their broad uses in the context of adoption researches. This openness to other terminologies follows the guidelines of Costa and Zoltowski (2014) that suggest that terminology banks should not be taken as definitive criteria in cases where researchers understand that other constructs are also important in the studied phenomenon.

The Boolean operator AND was used to refine the searches. The descriptors and equivalent terms in English and Spanish were: (a) adoção (criança) AND terapia familiar; (b) adoption (child) AND family therapy; (c) adopción (niño) AND terapia familiar; (d) crianças adotivas AND terapia familiar; (e) adopted children AND family therapy; (f) niños adoptados AND terapia familiar; (g) famílias adotivas AND terapia familiar; (h) adoptive families AND family therapy; (i) familias adoptivas AND terapia familiar; (j) adoção (criança) AND intervenção familiar; (k) adoption (child) AND family intervention; (l) adopción (niño) AND intervención familiar; (m) crianças adotivas AND intervenção familiar; (n) adopted children AND family intervention; (o) niños adoptados AND intervención familiar; (p) famílias adotivas AND intervenção familiar; (q) adoptive families AND family intervention; (r) familias adoptivas AND intervención familiar. Two independent judges conducted the search and selection of the studies based on the criteria presented below. The divergence cases were resolved by consensus among the judges. These judges performed data extraction in the selected articles and the disagreements were resolved in the same way.

The inclusion criteria were: the presence of keywords in the title and/or abstract of the articles; studies on interventions with families with adoptive children from 0 to 6 years old; empirical articles on intervention in the area of Psychology; the availability of full texts in databases referring to the period from 2004 to 2021. The delimited period is considered wide due to the difficulties in finding empirical studies of post-adoption intervention. Regarding the age range of the children, it is noteworthy that this study is connected to the investigations carried out on the research project “Transition to adoptive parenting: research and intervention” (Frizzo et al., 2016). According to the project and the proposal of the research group, this systematic review follows focuses on the development of families with children in early childhood - as suggested by the Law of early childhood legal landmark (Law No. 13,257, 2016) -, that is, from 0 to 6 years of age.

The exclusion criteria were: researches in book chapter format; books; monographies; master’s dissertations; doctoral theses; studies unavailable for reading of the complete material; studies with interventions in the period before adoption; studies with interventions after more than two years of adoption; studies with group interventions; studies with interventions only with children; studies with interventions with families of adopted adolescents; studies focused on the conjugality of adoptive parents; studies with foster families.

Data analysis

A descriptive analysis of the data was performed, given the purpose of this study to gather information on the topic and to map out the practice of family intervention specifically aimed at adoption. Data such as the theoretical contribution, the intervention itself and its objectives and procedures, as well as the number of meetings and the main results found, were exposed to provide scientific input for the professional practice of therapists of adoptive families.

Results

The search in the databases resulted in 9,143 studies, as shown in Figure 1: Google Scholar (n=8,056), Direct Science (n=814), SciELO (N=43), PsycINFO (N=230). Of these 9,143 studies, 9,079 were excluded because they did not contain the defined mandatory descriptors in the title or abstract and/or because they investigated other topics. Particularly in the results of Google Scholar, many studies that were not empirical articles and that listed in the search results were excluded due to the limitations of the Advanced Search option of this database. Of the 64 articles selected, 18 were excluded due to duplicity in the databases. In the next step, 46 articles were analyzed by reading the full texts and 39 were excluded because they did not meet the inclusion criteria defined in this systematic review. Finally, seven articles were considered relevant to the proposal of this study.

Figure 1
Database survey flow chart

Therefore, seven studies were analyzed, as described in Table 1. Most of the articles were published in the last 7 years. Among the places of origin of publications/interventions, European countries predominated. Moreover, the attachment theory was the predominant theoretical contribution chosen by the authors - references to psychoanalysis, neurodevelopment and family therapy based on mentalization were also found. The chosen design indicated a lack of research in this area, since the articles were defined in their intervention as pilot study, intervention study, single case study, preliminary intervention evaluation and clinical report. No randomized clinical trials were found. The type of data analysis varied widely - among the studies, two chose the mixed method, two used qualitative methods and three used quantitative methods.

Table 1
Characterization of selected articles

Id	Article title	Authors	Year	Country	Outline	Analysis	Theoretical Base
A1	Duplicity and illusion in families formed by international adoption	Loncan, A.	2004	France	Clinical Report	Qualitative	Psychoanalysis
A2	The importance of parenting in the development of disorganized attachment: evidence from a preventive intervention study in adoptive families	Juffer, F., Bakermans-Kranenburg, F. J., & Van IJzendoorn, M. H.	2005	Netherlands	Randomized intervention study	Quantitative	Attachment theory
A3	The Marte Meo method as a means of supporting new adoptive parents	Osterman, G., Möller, A., & Wirtberg, I.	2010	Sweden	Intervention study	Qualitative	Attachment theory
A4	Parent-Child Interaction Therapy as an attachment-based intervention: Theoretical rationale and pilot data with adopted children	Allen, B., Timmer, S. G., & Urquiza, A. J.	2014	United States	Pilot Study	Quantitative	Attachment theory
A5	A proposal for a brief-term post-adoption intervention in the attachment-perspective: a single case study with a late-adopted child and his adoptive mother	Pace, C.S., D’Onofrio, E., Guerriero, V., & Zavattini, G. C.	2016	Italy	Single case study and follow up after 7 years	Quantitative and qualitative	Attachment theory
A6	Clinical improvements in adopted children with fetal alcohol spectrum disorders through neurodevelopmentally informed clinical intervention: A pilot study	Zarnegar, Z., Hambrick, E. P., Perry, B. D., Azen, S. P., & Peterson, C.	2016	United States	Pilot Study	Quantitative	Neurodevelopment
A7	Adopting Minds - a mentalization-based therapy for families in a post-adoption support service: preliminary evaluation and service user experience	Midgley, N., Alayza, A., Lawrence, H., & Bellew, R.	2018	United Kingdom	Preliminary evaluation of an intervention	Quantitative and qualitative	Mentalization-based family therapy

Four studies involved international adoption (A1, A2, A3 and A5), and the other three studies (A4, A6 and A7) did not offer information on the type of adoption carried out by the participants. The time of living with the adoptive child before the start of the intervention varied greatly, with the shortest time reported being 2 months and the longest time was more than 10 years together. The inclusion criterion of this study was that the interventions took place in a maximum of 2 years after the arrival of the child in the family. However, study A7, with cases of more than 10 years of living together, was included since in its sample there are also cases of less than 2 years. Similarly, study A4 was also open to families with a longer living time, but included cases of arrival of the adopted child less than 2 years prior. One of the studies (A2) is unclear as to the definition of time of living with the family, despite addressing adoptions of children under 6 months of age. Therefore, it is inferred that the time of intervention did not exceed the limits defined in this systematic review. Most of the interventions took place before 6 months of living with the adoptive family (A2, A3, A5 and A6). One study (A1) presented cases in which families underwent interventions close to 2 years after the child’s arrival.

In the following paragraphs we will describe the interventions with their objectives, techniques, location and number of meetings, as well as the measures/instruments of analysis and the main findings of the seven studies. It should be noted that only two of the articles (A1 and A7) use the term family therapy to refer to their interventions. Coincidentally, these are the studies that present participation of all family members (A1) and triads in most meetings (A7). Studies A4 and A6 refer to parent-child interaction therapy and parent-child psychotherapy, respectively. Articles A2, A3 and A5 use the term intervention.

The authors of study A1 defined their intervention as psychoanalytic family therapy. There is no description of applied techniques. In this study (A1), no assessment instruments were defined that lead to the results found. According to Article A1, the treatment meant to contribute to the redevelopment of the psychic space of family involvement which was in formation. According to the authors, there was an improvement in the symptoms of the child, the identified patient, in addition to greater prominence of the sister who was targeted by fraternal rivalry. Moreover, the increased bond and the establishment of intimacy between family members was pointed out.

Studies A2 and A3 reported that their interventions were based on video-feedback techniques. Data from both articles defined their interventions as preventive. Both presented similar intervention objectives, indicating the intention to promote improvement of sensitive responsiveness, aiming to meet the needs of children in order to help them in their development, in addition to enabling secure attachment relationships.

In study A2, a control group received a booklet with information on adoption, one intervention group received a book - called “personal book” - with information focused on sensitive parenting and the other intervention group received the same book with the combination of three meetings with interventionists applying video-feedback techniques. The authors reported that, during the meetings of application of the technique, they sought to verbalize the children’s reactions to their mothers, as well as strengthen their sensitivity to the behaviors of their child/children. More information on the handling of the meetings was not available. The pre-and post-intervention measures that helped to find the quantitative results of this study were: sociodemographic variables; Sensitivity and Cooperation (Ainsworth et al., 1974); Strange Situation Procedure (SSP) (Ainsworth et al., 1978); Procedures for identifying infants as disorganized/disoriented during the Ainsworth Strange Situation (Main & Solomon, 1990); Dutch Temperament Questionnaire (Kohnstamm, 1984). The authors found decreased rates of disorganized attachment in the group that received the combined intervention of “personal book” and video-feedback, as well as improvement in maternal sensitive responsiveness. Furthermore, they could conclude that the intervention in “personal book” alone, with information centered on sensitive parenting, was not effective enough to result in changes in disorganized attachment. The authors of A2 provide evidence that parental interventions can change the disorganized attachment of foster children.

Data from Article A3 indicated that the video-feedback intervention was named, by the authors, as the “Marte Meo” method. The authors obtained the results through qualitative interviews. It was identified that the participants were satisfied with the intervention experience. In addition, the authors pointed out that most parents take too fast a pace for their child. Still, there were gender differences in the response of parents to the rhythm of the child. According to them, men were more ready to wait for the child’s initiative than women, when the latter seemed to hinder the child’s initiative or response, since they were very close to them. Still, fathers expressed interest in focusing on seeing the children, while mothers were more concerned about seeing the relationship with the child.

In addition to these studies, article A5 has an intervention meeting with video-feedback. Both Article A5 and Article A4 have objectives similar to those of studies A2 and A3, since they seek to increase parenting skills. In particular, the latter (A4) sought to reduce children’s behavior problems and parental stress, in addition to improving the parent-child relationship. Study A5 aimed to promote reflection on the mental states of attachment and their influence on the mother-baby relationship.

Study A4 uses parent-child interaction therapy, an intervention in the mirror room, according to the authors, in which hidden therapists direct the actions of parents with their children. The techniques are briefly described by the authors, divided into two phases: improvement of the parent-child relationship and improvement of children’s obedience. The instruments that demonstrated the effects of the intervention were: Child Behavior Checklist (CBCL) (Achenbach, 1994a, 1994b, 2001; Achenbach & Rescorla, 2000); Eyberg Child Behavior Inventory (ECBI) (Eyberg & Pincus, 1999); Parenting Stress Inventory-Short Form (PSI-SF) (Abidin, 1995); Dyadic Parent-Child Interaction Coding System (DPICS) (Eyberg et al., 2013). There was improvement in positive parenting techniques, reduction of parental stress and of externalizing and internalizing behaviors of the children.

Study A5 was defined as a brief clinical intervention oriented to attachment. The authors considered the evaluation as part of the mother-child dyad care. Five meetings were organized in a clinical center: two evaluation meetings, two intervention meetings and one of feedback, in addition to a follow-up meeting after 7 years. The evaluation material contained the Strange situation procedure (Ainsworth et al., 1978) and the Adult attachment interview (Main et al., 2008). In the intervention meetings, the evaluation material was used as a basis: in the first one, the video-feedback technique was used and in the second the results of the Adult attachment interview were discussed. Other measures that helped to reach the results were: Manchester Child Attachment Story Task (MCAST) (Barone et al., 2009; Green et al., 2000); Friend and Family Interview (FFI) (Pace, 2014; Steele et al., 2009); Current Relationship Interview (CREATE) (Crowell & Owens, 1996); Life Stress Questionnaire (LSQ) (Holmes & Rahe, 1967). The results of Article A5 pointed to a modification of the child’s attachment style towards greater safety. The authors highlighted the importance of intervention aimed at adoptive families in the first months after adoption and the fact that adoption, on its own, represents an intervention for the children.

In studies A6 and A7 are tested the adaptations of two models of interventions in adoptive families. In the first (A6), there is a combination of the neurosequential model of therapy, parent-child psychotherapy and conscious parental education. In the second (A7), systemic family therapy is associated with mentalization-based treatment for families.

In Article A6, adoptive dyads or triads received a combination of regulatory, somatosensory, relational and cognitive enrichments through the neurosequential model of therapy. In addition, the participants had meetings of parent-child psychotherapy and conscious parental education. These techniques were briefly explained by the authors, and there was no clear description of the organization of the meetings. The instruments that served as intervention evaluation measures were: Battelle Developmental Inventory-Second Edition (Newborg, 2005); Parenting Stress Index-Short Form (PSI-SF) (Abidin, 1990); NMT Metrics (Perry, 2006). The findings of this study showed improvement in the scores of various measures of Child Development functioning, improvement of parental care skills and reduction of parental stress.

In study A7, systemic family therapy with adapted treatment based on mentalization aimed to help build trust, improve family relationships and help parents and children better understand each other. The instruments used for further analysis were: sociodemographic questionnaire; questionnaire of strengths and difficulties; Brief Assessment Checklist (BAC) (Tarren-Sweeny, 2013), Child Behaviour Check List (CBCL) (Achenbach, 1994a, 1994b, 2001; Achenbach & Rescorla, 2000); Brief Parental Self Efficacy Scale (BPSES) (Woolgar et al., 2013); Experience of Service Questionnaire (ESQ) (Attridge-Stirling, 2002); adapted Experience of therapy Interview (Midgley et al., 2011). Improvement in mental health and self-efficacy of parents was among the main results found. In addition, parents reported high levels of satisfaction with the mentalization-based family therapy service. The interviews revealed that the families found a space that was supportive and not judgemental. They said the service helped them cope with the struggles they faced, as well as their children’s past experiences. However, some adoptive families felt that this short-term service, lasting six sessions, was not enough to solve all the difficulties that led the family to seek help.

It is therefore concluded that there is no prevailing model of family intervention for adoptive families in the available scientific literature in the form of empirical articles. The studies of psychoanalytic family therapy (A1) and systemic family therapy based on mentalization (A7) were the most successful in bringing together fathers, mothers and children in the therapeutic space. Interventions involving video-feedback were present in three articles (A2, A3 and A5) that counted on the mother-baby dyads or only the parents at the meetings. Parent-child interaction therapy was the basis of one study (A4), while parent-child psychotherapy was part of the intervention proposed in another article (A6). Both studies (A4 and A6) had dyads and triads as participants, and in one of them (A4) dyads prevailed in the meetings while the other (A6) did not disclaim information on predominance. Therefore, we believe that some of the authors of the articles analyzed understood that they were dealing with adoptive families, since they used this reference, even when they could not perform direct work with some of these family members.

Discussion

Considering the importance of the practice of family intervention in the context of adoption, this systematic review sought to identify how family therapy models are structured for adoptive families in the initial adaptation with children. It was verified, through this study, that empirical articles on the topic are incipient. This is easily observed through the design descriptions of the studies analyzed (Table 1), which indicate, in various ways, the exploratory character of the researches involving interventions with adoptive families.

In general, it was identified that the interventions were not, for the most part, systematically described, something already identified by other studies that conducted systematic reviews in the context of adoption (Drozd et al., 2018; Harris-Waller et al., 2018). The study that indicated psychoanalytic family therapy (A1) did not report the applied techniques or planning in relation to intervention meetings. The studies that had as main basis the video-feedback intervention (A2 and A3) did not offer further information on the management of meetings. In particular, article A2 mentioned techniques for verbalizing children’s reactions to their mothers and strengthening their sensitivity to their children’s behavior, but without providing further details on the application of these techniques. Study A7 also did not explain the systematization of the meetings.

In Article A6, the neurosequential model of therapy, parent-child psychotherapy and conscious parental education are conceptually explained, however, their application is not sufficiently characterized. Articles A4 and A5 offer a considerable description of the intervention procedures, and in study A4 are mentioned phases of the intervention meetings, with two different focuses, but with very brief description of techniques; in study A5 the two intervention meetings are specified in relation to the base materials for discussion, video-feedback and interview about attachment in adults, with the participating dyad. Therefore, it can be thought that the empirical studies analyzed did not offer, effectively, information about their intervention procedures, a relevant aspect to be considered by those who aim to present interventions in the scientific literature. It is emphasized that the lack of information makes it impractical to replicate interventions, a finding that is corroborated by the notes of Palacios (2007) on the lack of conceptualization and methods in post-adoption services.

Information on the location of the intervention and the number of meetings were not uniform. The contexts for intervention reported by the authors were: participants’ home (A2 and A3); research laboratory (A2); outpatient health clinic (A4 and A6); clinical center (A5); and a non-governmental organization’s space (A7). One of the studies did not report where the intervention occurred (A1). The number of meetings ranged from a minimum of 3 to a maximum of 48 meetings, considering all the articles analyzed. Therefore, it is understood that the data presented do not allow identification of a single physical environment of reference for these interventions, as well as demonstrate that meetings with adoptive families may vary in terms of frequency and duration according to the intervention proposal. In this sense the suggestion of Palacios (2007) is reaffirmed, that the practices of post-adoption interventions should be better disseminated and, for this, it is believed that empirical studies in this context should be presented in their entirety, detailing significant aspects of their intervention proposals.

In addition, we sought to verify the demands of the families participating in the studies, since it is understood that this is an important point for family intervention. In general, it was observed that the complaints were mostly related to the children, and in only two studies (A3 and A5) questions of interaction and parental skills are identified. This goes against the statement of Andolfi (2011) about children being, commonly, responsible for taking their parents to therapy, through their behaviors which are suggestive of psychopathology. Furthermore, the findings are in line with the literature that indicates significant complaints related to emotional and behavioral difficulties usually presented by adoptive children (Batki, 2018; Farr & Grotevant, 2019; Palacios, 2007; Sánchez-Sandoval & Palacios, 2012; Torres, 2017; Van IJzendoorn & Juffer, 2006).

Difficulties related to the physical and mental health of the adoptive children were indicated as the main demand in only one of the studies analyzed (A6), which differs from the literature that points to the frequent presence of concerns about the health of adoptive children (Palacios, 2007; Sánchez-Sandoval & Palacios, 2012; Teska, 2018; Vasquez & Stensland, 2016). Given these findings, it is important to think how often the demand for psychotherapy falls on adoptive children, especially because of a parental belief that the experiences prior to adoption (such as mistreatment, neglect and abuse) can cause difficulties. However, it is necessary to remember that parents also go through emotional processes before the decision for adoption and this should be taken into consideration, even in cases in which the initial demand for therapy seems to focus only on the child. As stated by Minuchin et al. (2009), one cannot lose sight of the fact that the family needs to be treated as a unit and that any and all problems of the child, or perhaps expressed by the child, is a family problem (Andolfi, 2011).

Still related to the results of the demands from the participants in the interventions, it is interesting to contrast this data with the intervention objectives described by the authors of the articles. Despite the demands being especially focused on the difficulties of children, the therapeutic objectives focused, for the most part, on improvements in parental skills and the parent-child relationship. It is important to keep in mind that, just as it is prioritized in family therapy, the problem is seen as a difficulty of the family and not only of one of its members (Andolfi, 2011; Minuchin et al., 2009). In the studies of this review, the authors proposed interventions designed for the family unit and not only for the child. Even when the demand described was for care of the emotional and behavioral symptoms of the children, in the objective of the intervention this appeared transformed into a proposal to help parents in their parental skills, to deal with these difficulties. This meets the literature notes that describe family therapy as an opportunity for adoptive parents to process their parental challenges as they are responsible for the formation of an individual, especially with regard to the building of bonds and parental skills that promote child development (Pronchenko-Jain & Fernando, 2013; Waid & Alewine, 2018).

Finally, it is important to consider that, from the description of the interventions and their techniques (Table 2), it is not clear that the analyzed interventions were specifically aimed at adoption. Many of the proposals applied by the authors are already widely used in interventions with biological families. Apparently, the type of problem presented by adoptive families is taken into account, and so is their need for management, but it brings up the question of how much the adoption experience itself was worked out in the meetings with the participating adoptive families. The importance of considering social factors around families, which imply their structure and functioning, in family intervention processes is highlighted (Minuchin et al., 2009), as is the case with adoption. For this, it is necessary to consider aspects such as, for example, the waiting time for adoption, which can be connected to important emotional processes - such as mourning - that impact the way these individuals relate.

Table 2
Description of relevant aspects of the interventions of the selected articles

Id	Participants	Demand	Intervention	Objective of the intervention	Techniques used	Location and number of meetings	Main results
A1	1 Family: parents and their adopted daughters (biological half-sisters).	Mother’s complaint of anger, frustration and fraternal rivalry presented by one daughter (identified patient).	Psychoanalytic Family Therapy.	Contribute to the redevelopment of the psychic space of the family involvement in formation.	Not informed.	Not informed.	Improvement of the symptoms of the child (identified patient); greater prominence of the sister targeted by fraternal rivalry; improvement of the bond and establishment of intimacy between family members.
A2	130 dyads (mother-baby): with first adopted child under 6 months of age.	Not informed (participants recruited through adoption agencies).	Book and video-feedback.	Improve sensitive responsiveness and promote secure attachment relationships between babies and parents and child competence.	Book with suggestions for sensitive parenting; Meetings with video-feedback.	In the family home and in the research laboratory: 5 meetings: pre- and post- tests plus 3 video-feedback interventions.	Decreased disorganized attachment rate through combined book and video-feedback intervention; improvement in maternal sensitive responsiveness.
A3	7 fathers and mothers with one adopted child aged 5 to 15 months.	General information and advice on parenting and how to come to a better understanding of your children. Moreover, more specific help on issues regarding attachment, hyperactivity or how to help your child at mealtime.	Marte Meo method: an intervention with video-feedback.	Helping parents in the needs of their child at the different stages of their development and stimulate them to modify their behavior in a way that aims to promote the development of the child.	Meetings with video-feedback.	In the family home: between 3 and 7 meetings per family (about 6 months of intervention).	The parents perceived the intervention as positive; it was observed that most parents adopt a too fast pace for the child; the fathers expressed interest in focusing on seeing the children, while the mothers were more concerned about seeing the relationship with the child.
A4	Number of families not reported: dyads or triads (85 adopted children aged 2 to 8 years old).	Children referred for treatment due to disruptive behaviors and behaviors that are difficult to manage.	Parent-child interaction therapy: an intervention in the mirror room, with hidden therapists directing parents’ actions with their children.	Increase positive parenting skills, reduce children’s behavior problems, reduce parental stress, and improve parent-child relationship.	Didactic Training; Behavior guided, through listening apparatus, by therapists.	In the outpatient clinic of a University hospital: the average number of appointments (including evaluations) was 17.26 (SD=6.7), lasting from 14 to 20 weeks.	Significant improvements in positive parenting techniques; reductions in parental stress and reductions in children’s externalizing and internalizing behaviors.
A5	1 Dyad (mother and son of 6 years).	The mother thought she was becoming more and more distant from her son.	Brief attachment-oriented clinical intervention, focused on a multi-method evaluation of attachment, relationships, and representations.	Help the mother increase her maternal sensitivity and reflect on her mental states of attachment and their influence on the mother-child relationship.	Video-feedback; feedback of the interview on attachment in adults.	In a Clinical Center: 5 visits (2 evaluations, 2 interventions and 1 feedback), plus 1 appointment for follow-up after 7 years.	Modification of the adopted child’s attachment pattern for greater security. Highlighting the importance of intervention in the first months after adoption.
A6	Number of families not reported: dyads or triads (10 adopted children, aged between 10 and 53 months).	Young children with Fetal Alcohol Syndrome Spectrum Disorder and with comorbid experiences of mistreatment or loss.	Combination of techniques: series of regulatory, somatosensory, relational and cognitive enrichments.	Help parents make decisions based on clinical knowledge of a child’s current developmental functions.	Neurosequential model of therapy; parent-child psychotherapy; conscious parental education.	In a community mental health outpatient clinic: from 24 to 48 meetings, over 6 months).	Improved scores of various measures of child development; parental care skills improved while stress decreased.
A7	36 families: dyads or triads - 32 cases with available data (59 parents and 42 children, aged 2 to 17 years old).	Referred families: social and emotional concerns, emotional regulation and challenging behavior of the child.	Systemic family therapy with adapted treatment based on mentalization.	Help build trust, improve the relationship and help parents and children understand each other.	Adaptation of mentalization-based treatment for families	In the space of a non-governmental organization (NGO): 6 meetings.	Positive results in parental mental health and self-efficacy; reports of high levels of satisfaction with therapy; helped parents in the struggles they faced, such as their children’s past experiences.

Final Considerations

A large part of the studies highlighted the importance of intervening in the initial adaptation period of adoptive families, which meets national investigations on adoption (Resmini, 2018; Schwochow & Frizzo, 2021; Silva, 2018). The results of these studies showed improvements in parenting skills, changes related to greater attachment security, change in children’s symptoms/behaviors, as well as less stress and improvement in parental mental health. Improvement in the bond and establishment of intimacy between family members were also observed, and improvement in the scores of various measures of the child development. Participants in one of the articles highlighted that the listening space in family therapy made it possible to bring to awareness some of the emotional processes of the families. The articles included in this systematic review, therefore, pay attention to the potential, already indicated by the literature, of psychological interventions in the initial adaptation of adoptive families (Lancaster et al., 2017; Pronchenko-Jain & Fernando, 2013; Waid & Alewine, 2018).

However, even in the face of these results, it is necessary to indicate a certain limitation of information in this systematic review. It is understood that there was significant difficulty in explaining the intervention processes, particularly due to the lack of systematic description in the analyzed articles. Other systematic review studies in the context of adoption, exploring different objectives and criteria, demonstrated difficulty in performing meta-analyses of interventions, as is the case of the study by Drozd et al. (2018) and by Harris-Waller et al. (2018). These authors found problems, also existing in the present study, of unclear reports of methods, procedures and findings of the interventions with adoptive families. For this, it is suggested that empirical articles may be dedicated to presenting of the conceptualization and methods of the applied interventions, thus promoting their dissemination.

Given the results of this systematic review, the importance of professional specialization for the effective care of adoptive families is also highlighted, since the literature points to the need for knowledge and understanding of adoption and the specificities of the family life cycle of those who adopt or are adopted, aiming at an effective practice (Atkinson & Riley, 2017; Farr & Grotevant, 2019; Lancaster et al., 2017; Pedro-Viejo, 2017; Waid & Alewine, 2018). With these findings, we expect to encourage research in the context of adoption, especially with regard to intervention practices with these families. It is believed that family intervention has significant potential and should therefore be an area of investment for those seeking to improve psychological care to adoptive families. For this, it is encouraged that empirical studies present their practices with rich details, thus making them viable for replication.

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Publication Dates

• Publication in this collection
  14 Apr 2023
• Date of issue
  Jan-Mar 2023

History

• Received
  24 June 2021
• Reviewed
  29 Sept 2021
• Accepted
  01 Nov 2021