Elsevier

The Lancet

Volume 360, Issue 9331, 10 August 2002, Pages 443-448
The Lancet

Articles
Suicide, psychiatric illness, and social maladjustment in intercountry adoptees in Sweden: a cohort study

https://doi.org/10.1016/S0140-6736(02)09674-5Get rights and content

Summary

Background

Many intercountry adoptees are reaching adolescence in western Europe and the USA, and the mental health and social adjustment of these individuals as adolescents and young adults has now become an important issue. We aimed to assess mental health disorders and social maladjustment in adolescence and young adulthood in intercountry adoptees in Sweden.

Method

Our data was obtained from the Swedish national registers for the cohort born in 1970–79. We used multivariate Cox's regression models of person-years to compare indicators of suicide death (1986–95), court sentences (1986–93), and discharges for psychiatric illness, suicide attempts, and substance abuse (1987–94) in 11 320 intercountry adoptees with 2343 Swedish-born siblings, 4006 immigrant children, and a general population of 853 419 Swedish-born residents.

Findings

After adjustment for major sociodemographic confounders, intercountry adoptees were more likely than other Swedish-born children to die from suicide (odds ratio 3·6, 95% Cl 2·1–5·9); attempt suicide (3·6, 3·1–4·2); be admitted for a psychiatric disorder (3·2, 2·9–3·6), drug abuse (5·2, 2·9–9·3) or alcohol abuse (2·6, 2·0–3·3); or to commit a crime (1·6, 1·5–1·7). Siblings in adoptive homes had lower odds ratios for most outcomes than did adoptees, whereas adoptees and immigrant children had much the same odds ratios.

Interpretation

Adoptees in Sweden have a high risk for severe mental health problems and social maladjustment in adolescence and young adulthood. We advise professionals to give appropriate consideration to the high risk of suicide in patients who are intercountry adoptees.

Introduction

The mental health and social adjustment of intercountry adopted children as adolescents and young adults has become an important issue in western Europe and the USA in recent years because many intercountry adoptees are reaching adolescence in their host countries. In Sweden, adoption of children born abroad became common practice in the late 1960s when the number of Swedish children available for adoption diminished rapidly. Since the 1960s, about 40 000 foreign-born children have been adopted in Sweden, mainly from Korea, India, and Colombia.1 Thus, Sweden has the largest population of intercountry adoptees in Europe, and the largest number per capita (1·0–1·5% of the total population born after 1965) in the world.2

Results of studies3, 4 of early adjustment have shown that intercountry adoptees adapt well during their preschool and early school years after the first months of initial adjustment in the adoptive family. Many children arrive in a poor nutritional and health state, but improve rapidly in their adoptive homes.5 However, the health, wellbeing, and social adjustment of intercountry adoptees during adolescence and young adulthood is not as well understood. Although results from a Dutch interview study6 of 1500 intercountry teenage adoptees showed that many children had not adapted well to their new homes and had depressive disorders, other Scandinavian1, 7, 8 and US studies9 have recorded few differences in behaviour problems, quality of life, and self-esteem between intercountry adoptees and other adolescents and young adults. Intercountry adoptees are referred to child psychiatric clinics more frequently than would be expected from population data.10 Such practice is probably because adoptive parents have a more active help-seeking behaviour than other parents rather than because adoptees have worse mental health.11, 12, 13

We aimed to assess mental health disorders and social maladjustment in adolescence and young adulthood in a national cohort of intercountry adoptees in Sweden. The inconsistent findings in previous studies14, 15 could be accounted for by difficulties in obtaining large representative samples of adoptees (absence of, or erratic, records; confidentiality laws; and the low proportion of adoptees in most populations) and finding relevant groups for comparison. Here, we used Swedish National Registers to tackle both these difficulties.

Section snippets

Patients

Sweden has national registers with high-quality data for socioeconomic and health indicators of the entire Swedish population, which use unique personal identification numbers that follow each Swedish resident from birth to death. We used data from the Swedish Population and Housing Census of 1985, the Swedish National Parent Register, and the Register of the Total Swedish Population to identify adoptees and the three comparison groups. We included people born in 1970–79 who were still alive

Results

The intercountry adoptee group consisted of 8700 children born in Asia and 2620 in Latin America. The sibling group consisted of 2343 children, the immigrant group 4006, and the general population group 853 419. 8406 (74%) of the adopted children were adopted at age 0–1 years, 1862 (16%) at 2–3 years, and 1052 (9%) at 4–6 years. These results contrast with those of the immigrant group, in which 2343 (58%) arrived at age 4–6 years. Asian adoptees were mostly girls (5743 [66%] of 8700), whereas

Discussion

Our results show that intercountry adoptees are three to four times more likely to have serious mental health problems such as suicide, suicide attempts, and psychiatric admissions; five times more likely to be addicted to drugs; and two to three times more likely to commit crimes or abuse alcohol than other children in Swedish society living in similar socioeconomic circumstances. Our study differed from others in the design of the cohort, the large size of the population, and the use of

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