Mental health aspects of adoption and the role of mental health professionals: A Narrative review

Abstract

Background:

Adoption is the process through, which a child who is orphaned, abandoned, or surrendered is legally provided with parents who are not the biological parents of the child, thus ensures to ensure the child’s care and wellbeing. During the process of adoption and thereof, both adoptees and prospective adoptive parents (PAPs) face several psychosocial challenges. Assessment and timely intervention for these issues are paramount for the successful culmination of the adoption better longterm outcome.

Aim:

This narrative review aims to provide an overview of the adoption process in India, the psychological challenges faced by adoptees and adoptive parents, the role of mental health professionals, and future directions on this topic.

Methods:

For the current narrative review, a thorough literature search was performed using the PubMed and Google-scholar databases, along with a grey-literature search by visiting the websites of the relevant agencies, such Ministry of Women and Child Development, Govt. of India. The key terms used were adoption, mental health issues, adoptees, prospective adoptive parents (PAPs), and mental health professionals (MHPs).

Results:

Adoption is a difficult family construct that often gets neglected. India’s legal framework for adoption is limited by delays in declaring children legally free for adoption and the lack of mental health assessments for adoptive parents. Adopted children face complex psychosocial challenges, with higher rates of externalizing behaviors, yet well-designed community-based studies are lacking. Strengthening multidisciplinary policies and mental health support is crucial for improving adoption-related outcomes.

Conclusion:

The current research adds to the limited literature on this topic. This paper can sensitize MHPs, PAPs, and stakeholders of the adoption process, along with providing some critical insights about the topic, which in turn can help in the successful culmination of the adoption process both for the adoptees and PAPs.

INTRODUCTION

The Article 19 of the United Nations Convention on the Rights of the Child (UNCRC) mandates that “Government shall ensure that children are properly cared for and protected from any form of violence, abuse and neglect, while in care of legal guardian(s) or parent(s) or any other person(s) who has the care of the child.[1]” The Constitution of India has also provisioned, under Article 39(f), that “the state shall direct its policies to secure children from exploitation and moral and material abandonment” (The Constitution of India, 1950).[2] Adoption, as a process, offers care, security, and lifetime connections for adoptees (children), thereby helping to ameliorate the adverse experiences that a (adoptee) child underwent throughout his or her life. Alternatives of adoption like long-term foster care, orphanages, or unprepared or unwilling biological parents deprive children of the natural love and care of the parents. These alternatives often fail to provide the nurturing environment essential for emotional stability, leading to distress in adoptees. Through the system of adoption, (prospective) adoptive parents gain the opportunity to experience parenthood and, thus, life satisfaction.

Literature suggests that adopted children are at the higher risk of developing various psychological or adjustment related issues.[3] They often encounter mental health facilities for their adjustment problems or behavioral issues, which discourages the prospective adoptive parent (PAPs) from adopting these children, thereby reducing the formers’ chance of getting adopted.[3]

It must be emphasized that adoption is a challenging psycho-social context and process, however, it also brings opportunities for building resilience in both PAPs and adoptees.[4] Some of the critical factors associated with adoption include (various) pre-placement adversities faced by the adoptee and their attachment-related difficulties, social stigma experienced by the PAPs and the cumbersome process of adoption. Furthermore, outcomes of the adoption, including the psychological adjustment of the adopted children, are influenced by the adoptive family functioning (Parent-child relationship).

The psychological problems of both the parties involved in adoption need to be identified and addressed, particularly the mental health problems (doubt, grief, anxiety, adjustment issues, externalizing behaviors, etc.,) of the adoptees, which may not always be diagnosed as per the existing classificatory system. Hence, our threshold for intervening, including professional interventions, for the psychological problems of the adoptees should be lower.[3] Furthermore, targets for the intervention should not be limited to psychological disorders (disease model), but also distress and dysfunction related to adoption (problem model).

Despite the significance of this topic, including the psycho-social issues around it, and limited exposure of mental health professionals (MHPs) and trainees to this topic, little has been discussed about it in psychiatry literature, particularly from India. There are also, increased complexities such as pandemic, war like situations around the world making it more pertinent in the recent times.

There is a lack of longitudinal studies examining the long-term psychological outcomes of adoptees, leaving gaps in understanding their developmental trajectories.[5] Additionally, research on single-parent adoption (SPA) and LGBTQ+ adoptions in India is scarce despite increasing acceptance of these social and family structures.[6] Most studies fail to explore how cultural norms, stigma, and societal attitudes shape adoption-related mental health concerns, highlighting the need for qualitative research on adoptees’ lived experiences.[7]

Having a comprehensive literature on the process of adoption, psycho-social issues experienced by the adoptee child and prospective adoptive parents, the impact of the disaster, such as the COVID-19 pandemic, the role of the MHP to facilitate adoption process and improve the adoption-related outcome, and recommendations on how to address the care gap can be a useful addition to the existing literature. Therefore, the current narrative review aims to bridge the current service delivery gaps and research gaps related to this this topic.

This narrative review aims to provide an overview of the adoption process in India, psychological challenges faced by adoptees and adoptive parents, the role of mental health professionals (MHPs), and future directions on this topic.

MATERIALS AND METHODS

The inclusion criteria for this review include—articles (original or non-original) related to the mental health aspects of adoption, including its process in India, published in English, and whose full text is available. However, papers that have not explicitly dealt with mental health aspects of adoption were excluded from the study. We did not set any time frame for the literature search. The key terms used for this review were adoption, adoptees, prospective adoptive parents (for adoption), and mental health, psychological issues, and mental health professionals (for mental health). Since this is a narrative review, we limited our focus to databases that are readily accessible—the PubMed and Google Scholar. Moreover, we also performed a grey literature search, relevant records from the Government of India, Ministry of Women and Child Development, to identify crucial reports, viewpoints, and unpublished work on this topic. A comprehensive literature search was conducted by using the above-mentioned keywords. The search initially yielded 2,279 articles, which were screened based on relevance, inclusion and exclusion criteria, and duplication. Ultimately, 20 articles were found eligible for the current review. The identified records were screened by suitability of the paper for the reviewers (JJ and SG) for suitability of the paper for the review. The eligible papers were reviewed in the context of the aims and objectives of the review; however, we did not set any priori-variables list (also since ours was a narrative review, not a systematic review) to populate the findings of the individual papers. Likewise, quality of the study was not analyzed considering it was out of the scope of a narrative review, and the included studies were not only restricted to the original papers.

DISCUSSION

Adoption and its process in India

Although the need for adoption is enormous in India, a decline in adoption statistics has been observed in the last decade, both domestic as well as inter-country adoption. The number of adoptions dropped from 5,693 domestic and 628 inter-country adoptions in the year 2010–2011 to 3,580 domestic and 449 inter-country in the year 2023–2024.[8] This decline is due to fewer available adoptee infants, a preference for children without special needs, kinship adoption, and increased access to assisted reproductive techniques. Political and legal factors, such as the Hague Convention, ethnic matching challenges, legal delays, and the COVID-19 pandemic, have also contributed.[8]

In US, the downward trend has been seen since 2018 and 2019, the number of children adopted from foster care in 2022 was 53,665. This was only a 1% decrease from the year prior, but over an 18% decrease from 2019.[9]

In UK, the number of looked-after children, who were adopted during the year went down from 3,000 in 2022 to 2,960 in 2023.[10] Globally, there has been an overall decline in adoption rate.

In India, the Central Adoption Resource Authority (CARA) functions as the regulatory body for adoption, including in-country and inter-country adoptions. It primarily deals with the adoption of orphan, abandoned and surrendered children through its recognized adoption agencies. Juvenile Justice Act, 2015 (JJAct, 2015) and Adoption Regulations, 2017 (followed by Adoption Regulation (2022)) are the key legislative frameworks for adoption.[11] Details of the eligibility criteria for PAPs are mentioned in the Supplementary Table 1.

Supplementary Table 1.

Eligibility criteria for “ Who can adopt” as per CARA

Eligibility criteria	Description
Prospective Adoptive Parent (PAP)	Physically, mentally, emotionally, and financially capable, they shall not have any life-threatening medical condition(S) and they should not have been convicted in criminal act of any nature or accused in any case of child rights violation.
Marital status- If married	a) The consent of both the spouses for the adoption shall be required. b) Stable marital relationship for at least 2 years. c) Composite age of married couple does not exceed 110 years except in case of stepparent or relative adoption.
Marital status- if Single (With or without biological/adoptive child)	a) A single female can adopt a child of any gender. b) A single male shall not be eligible to adopt a girl child. c) Age of a single parent should not exceed 55 years. d) Must have less than 4 children (unless adopting child with special needs or hard-to-place child* etc.)
Age difference In general age difference between the PAP and the child should not be less than 25 years	a) Up to 2yrs: Couple- 85yrs; Single- 40yrs b) 2-4yrs: Couple-90yrs; Single- 45yrs. c) 4-8yrs: Couple-100yrs.; Single-50yrs. d) 8-18yrs: Couple-110yrs; Single-55yrs

*refers to a child who has not been placed in adoption after going through the following procedure: a) a normal child under age of 5 who has not been placed in adoption within 60 days after referral, or b) a child over the age of five or siblings has not been placed in adoption within 30 days after referral, and children of category a & b, who have not been placed in adoption within the prescribed time limit and even following making another placement attempt for 7 days with all the PAPs

Mental health aspects of adoption for child and parent

Mental health aspects of the adoptee children

Grieving is a normal response to loss and the process of mourning helps in recovery.[3] Adoption-related loss is unique in many ways but often remains unrecognized. Kinship adoption is rare, and individuals are often at risk of feeling different from others in the family. Unlike death, adoption-related loss is not permanent instead it evolves with time. As individuals grow to know their status of adoption, their wish to unite with birth parents and family also increases (referred to as “root search”). This seeds a sense of confusion, among the adoptees related to their identity. To overcome the latter issue, the open adoption process has been practiced; however, it has also failed to eliminate confusion among the adoptees. Strained relationships with biological parents and circumstances around separation instill negative viewpoints about self-image and parenting among the adoptees. An immature mind of the adoptee often finds difficulty in processing the loss and often projects themselves to be a cause of loss (“Parents voluntarily left him or her, or they were not a good child” etc.). Instead of addressing the above issues, emphasis is often laid on finding a caring family for the child and achieving adoption, a process of legal permanence. Many times, these adoption-related complexities remain invalidated and misunderstood. This is known as “Disenfranchised grief,” which is more difficult to remit than socially acknowledged other forms of grief.[3]

Epidemiological studies suggest that adopted children are more likely to be referred to mental health services and special education programs. This could be attributed to the social stigma associated with adoption as they are perceived as a threat to the (adoptive) family’s integrity and identity. Moreover, adoptive families are more accustomed to using social services they are linked with the agencies, social workers and health professionals involved in the process of adoption.

Similarly, clinical studies show that adoptees have a higher rate of externalizing behaviors including aggression, oppositional and defiant behaviors, hyperactivity, stealing, lying, running away, etc. Moreover, they have been found to manifest a higher rate of problematic personalities (e.g. Antisocial Personality Disorder, Borderline Personality Disorder), substance use disorder, eating disorders, delinquent behaviors, neurodevelopmental disorders, like attention deficit hyperactivity disorder (ADHD), learning disabilities etc.[12] In contrast, Internalizing disorders, such as anxiety disorders, depression, and psychotic disorders are lower among the adoptees or at par with the non-adoptive population. Likewise, research showed that adoptees (Vs. non-adoptees children and adolescents) were younger to get admitted to a psychiatric facility, would stay for longer, and were more likely to run away from the facility.[4] However, community-based studies did not find increased psychological problems or other deviant patterns of behavioral and personality characteristics.[13,14] Such varied results can be attributed to various methodological issues, such as retrospective or cross-sectional study design, small sample size, the lack of validated tools, selection of inappropriate control groups, convenient sampling, greater studies from the clinical population or hospital setting than those involving non-clinical population or community-based studies etc.[15]

Various factors influence the adjustment in children thereby affecting their mental health issues (as depicted in Table 1). Various theories have been put forth to explain the adjustment issues in children like Psychodynamic theory, Attachment theory, Social role theory/Family systems theory, Stress and coping model theory.[5] The primary assumption under the “Stress and Coping Model” is children’s adjustment to adoption is largely determined by how they appraise their adoption experience as depicted in Figure 1. Thus, adoptees use various cognitive behavioral approaches to cope with these issues. Coping techniques like assistance-seeking and problem-solving are associated with better adjustment outcomes; in contrast, cognitive-behavioral avoidance approach (avoiding thoughts or conversations related to adoption) leads to poorer adjustment outcomes, with a higher incidence of psychological problems.[5]

Table 1.

Enlisting factors influencing adjustment in Adoptive children

Factors	Description
• Age of the child	• At the age around 5–7 years, children start understanding about meaning of being adopted, so their feelings of anxiety and confusion about their family status deepens.
• Gender differences	• Boys, adopted or nonadopted, are more vulnerable than girls to psychological problems (especially disruptive disorders and academic problem) related to adoption
• Family Structure	• Mixed results. • Studies on presence of biological child or ordinal position of adoptee on their social adjustment or mental health remain inconclusive.
• Family communication patterns	• A more open, “acknowledgment-of-difference” style of communication about adoption among family members facilitates healthier adjustment in adoptees than a closed, “rejection-of-difference” approach.
• The role of parenting style, parental emotional adjustment, attributions, and expectations	• Acceptance and satisfaction with the adoptive parenthood, with a warm and accepting attitude toward the child, is predictive of more positive adoption adjustment. • Emotional problems in parent are often reflected as adjustment issues in child.
• Preplacement history involves both the prenatal and postnatal experiences	• Prenatal: Adverse prenatal experiences like heightened maternal stress, poor maternal nutrition, fetal exposure to alcohol or drugs, are linked to increased developmental problems in childhood • Post-natal: Age at placement has been found older the child at the time of placement, the greater the risk of postplacement adjustment issues.

Source: adopted from Brodzinsky 1990

Figure 1.

Depicting the “Stress and coping model” of Adoption Adjustment (Adopted from Brodzinsky, 1990)

Notably, adoption has various positive outcomes such as, improved quality of life, better emotional and social development, opportunities for growth and success.[16]

The critical aspects related to research on mental health issues of the adoptees include clinical studies focusing on children referred for mental health services, leading to an overrepresentation of psychological and behavioral challenges while community-based studies include a more diverse population, showing a wider range of outcomes, including many well-adjusted adoptees.[15] Therefore, findings of the former setting of the studies cannot be generalized to the latter group of participants or setting.

Mental health aspects of the adoptive (and prospective adoptive) parents

The parenthood experience of PAP and adoptive parents is also unique. It can be associated with a negative experience with infertility, experiencing first-time parenthood at an older age, parenting a child with pre-existing emotional or behavioral problems, or racial differences or dealing with the stigma attached to the adoption.[17] Due to the above reasons, the parenting experiences of biological and (prospective) adoptive parents are substantially different.

Cultural expectations about biological parenthood can significantly influence the mental health of PAPs. In many cultures, biological parenthood is seen as a key aspect of identity and personal fulfilment, and there can be societal pressure to have biological children. These expectations may shape how PAPs view their ability to be “real” parents, leading to various mental health impacts like feelings of inadequacy or Guilt etc.[18]

According to the “family stress theory” (Patterson and Garwick), the transition period of parenthood adjustment is an interactional process between demands (stressors, strains, daily hassles) and capabilities (resources, coping behavior).[11] Parenthood is experienced positively when demands and facilitating factors are well balanced; conversely, adjustment becomes difficult when demands outweigh resources. Mental health, physical health, and intimate partner relationships often get influenced by (prospective-) and adoptive parents during the process of adoption and thereof. Although physical health-related distress is less experienced among adoptive parents as compared to a biological parent, psychological problems are much more common in them. For instance, post-adoption depression is relatively common in adoptive parents, which further affects intimate partner relationships.[11]

Several factors influence post-adoption adjustment in the adoptive parents: child-related variables (Temperament, pre-adoption history, neurodevelopmental disorders, or behavioral disorders), Parent-related variables (coping skills, personality-related factors, resilience, sleep deprivation etc.), and adoption-related (legal status of the adoption, adoption of inter-racial or child with special needs).

Despite the significance of the problem, the current research on adoption is marred by several methodological challenges. This is partly related to the lack of the validated instruments, the stigma surrounding this topic, the lack of interest, and expertise of the researchers in this area, and the adoption being considered more a sociological framework than a socio-medical framework. Therefore, further research is required in this area, particularly those aiming at developing instruments that tap the unique parenthood experiences of adoptive parents, establishing their psychometric properties, adoptee child characteristics, type of adoption method, and legality surrounding the adoption process and how do they affect the experiences of adoptive parent. Additionally, more longitudinal studies are required to differentiate the transitional issues vis-à-vis’ persistent psychological distress among the parties so that support an be provided to them and specific interventions can be developed and implemented to manage their psychological problems.[19]

Role of the MHPs in Assessing and Managing Psychological Issues of the Adoptee Children:

Literature suggests that adoptees are at higher risk of developing various externalizing disorders and have unique psychosocial issues related to the adoption. As discussed above, before adoption, children in difficult family contexts are vulnerable to neglect and abuse. Government and various welfare organizations which earlier used to consider adoption-related adjustment issues as primarily a social problem, now recognize their psychological underpinnings and need for psychological interventions. Therefore, the above issues necessitate a multi-disciplinary approach/program.

One of the multi-disciplinary initiatives adopted by the National Health Service, United Kingdom (NHS-UK) is the “Working Together” program under Child Adolescent Mental Health Services (CAMHS). It is a guide to conducting collaborative work among local authorities, clinical commissioning groups, and MHPs to safeguard the interests of children at risk of neglect and maltreatment. It emphasizes childcare on a public health preventive model and prescribes prevention at three levels, viz. primary prevention, secondary prevention, and tertiary prevention. Primary prevention aims at preventing childhood maltreatment and involves education and health promotion among at-risk populations (requiring CAMHS involvement to a much lesser extent). Secondary prevention deals with early interventions in helping the child directly, e.g., cognitive behavioral interventions for psychological issues of the child or by working on the parent-child relationship based on the framework of attachment theories). Tertiary prevention targets children who have suffered abuse and neglect and intends to reduce suffering, promote quality of life and prevent the onset of mental disorders. It involves screening of looked-after children (children in child care institutes) for developmental disorders and psychiatric disorders, strengthening care for these children and capacity building of the agencies/organizations serving as short and long-term placements for these children.[20]

Psychosocial issues with (Prospective and-) adoptive parents

The psycho-social issues of the (Prospective and-) adoptive parents are unique and occur at both the pre-adoption and post-adoption stages [Table 2]. MHPs’ are required to address these issues for better adoption-related outcomes.

Table 2.

Role of psychiatrist in addressing psychosocial issues in parents seeking adoption

Psychosocial issues	Description
Pre-adoption psychosocial Issues	• Understanding worries, and handling expectations of the PAPs. • Dealing with the concerns of the extended family members of the adoptive parents. • Involving biological-children of the adoptive parents in the adoption-related discussion.
Post adoption Psycho-social Issues	• Preparations and arrangements (adoptive parents to be advised to gradually transit from institution systems to their family structure or functioning) • Early stimulation of the adoptee children • Supporting in disclosure process • Aiding in dealing with emotional issues of the PAPs and challenges faced during and post adoption.

Pre-adoption psychosocial issues of PAPs

Adoption is often sought when a couple/individual (single parent) wishes to be a parent; however, due to the infertility, genetic reasons, or unmarried status, they cannot beget a child. Adoption is an act of love and should not be considered a form of charity. It should not be undertaken for illegal or immoral reasons like getting a legal heir for property disputes, obtaining a future caregiver or out of social and family pressures. Informing about the eligibility criteria and the process of adoption helps in the preparation of PAPs for adoption. Kinship adoptions also need to go through similar legal processes as outlined by CARA.[21,22]

Individuals involved during the adoption process need to be aware of the adoption-related (including its outcome) worries or fears of PAPs. Often PAPs have a negative perception (or Stigma) of adoption due to a lack of adequate information, or prevailing cultural beliefs around adoption such as “attaining parenthood through adoption means a couple is infertile.” Addressing these negative beliefs is of paramount importance.

Similarly, it is crucial to moderate PAP’s expectations, as many times the PAPs demand adoptee children to have certain looks or features, child to be grateful to them, well-behaved, and accepted by others. Adoption preparation must also include making these expectations realistic. Parents should be informed about the likelihood of their child being exposed to malnutrition that may affect their appearance, or adverse placement experiences which contribute to mistrust towards the adoptive parents and emotional-behavioral issues. Furthermore, PAPs should be empowered as to how to deal with extended family and community as their family members may also have a lot of questions and they may be unwelcoming to the notion of adoption. So, PAPs should be prepared for such circumstances, express their excitement about the adoption and the adoptee child, and let their family members know how their support would be vital. If biological children also exist, they should be involved in discussion and preparation for adoption, validating their concerns and questions, emphasizing their new roles as big sisters or brothers in the upcoming family structure and their participation in the disclosure process.

Post-adoption psycho-social issues of adoptive parents

During the initial days, PAPs are very enthusiastic about creating new spaces for the adopted children (e.g., placing various feeding and social interaction practices) that may be starkly different from what the child is accustomed to in the child-care institution. These gestures can inadvertently act as a stressor or overwhelming for the child. In contrast, parents are required to give adequate time to the child to adjust to the new environment gradually. The MHPs can help PAPs identify these potential issues and help them prevent or overcome these matters. Orienting PAP by the MHPs about the child’s needs and gradual transition from the childcare institutes to the new home is critical. It can be of great help if PAPs contact child-care institutions to find out the patterns/practices the child has been accustomed to; continue with the institutional arrangements for the initial few days in the home and then slowly progress to parents’ ways of doing things. Similarly, for example, while planning for a name change of the child; it is advisable if a child ages more than one and identifies with the given name, it’s better to retain it.[4]

A child’s environment influences the development of his young mind. An early sensory and motor stimulation facilitates a child’s growth; in contrast, inadequate stimulation can result in developmental delays and learning difficulties. Therefore, MHPs (child psychologists, psychiatry social workers, or psychiatrists) involved during the adoption process should encourage adoptive parents to early stimulate the child in the five key areas viz Physical/Locomotor, Social, Speech and Language, Cognitive, and Emotional development.

Another vital area post-adoption is adoption disclosure. It cannot be overemphasized that adoption-disclosure is a dynamic process, characterized by an active exchange between parents and children. Children should be asked about their understanding related to Adoption and rectify misunderstandings, if any. During this process, parents should normalize the child’s curiosity, queries, and feelings about their biological parents and heritage. Parents should be aware of their feelings about the adoptee’s heritage. One should discuss the psycho-social difficulties the biological parents had or the child had with them, this will facilitate disclosure. This helps in avoiding the formation of negative judgments about birth parents too. PAPS need to appraise how the child is coping emotionally and discern if the child requires any additional support. Early disclosure (when a child is 2–4 years of age) is advantageous by normalizing the “Adoption” status and parents become desensitized from anxiety around the disclosure process. The narration of the adoption story should be about birth being a biological process, how families are formed, family diversity and normalized adoption as it reduces risk. Always use age-appropriate language and be aware of the developmental level of the child.[3] One such program or depiction developed by the National Institute of Mental Health and Neuro Sciences (NIMHANS), Bengaluru is SAMVAD (Support, Advocacy and Mental health Interventions for children in Vulnerable Circumstances and Distress). This national initiative provides resource for various child protection, mental health, and psychosocial care. With regards to adoption disclosure, it shares a story series called as “Mimi series” that exemplifies and models how adoption issues can be handled sensibly according to developmental age.[23]

PAPs should be available emotionally especially when the child is in distress and facilitate the child to cope with adoption-related loss and grief. Open and honest communication between parent and child should be promoted. MHPs involved during the adoption process and thereof should screen adoptive parents for any psychological issues, which often remain unattended. Non-address all the above issues may result in adoption (disruption or) dissolution.

Role of MHPs in addressing psychosocial issues of the (Prospective and-) adoptive parents

The MHPs can play a crucial role in identifying and managing the psychological issues of the (prospective and) adoptive parents. This would not only reduce the latter’s distress but also positively influence the adoption outcome. Some of the pertinent issues have been tabulate in Tables 2 and 3.

Table 3.

Recommendations and future direction concerning adoption and its mental health aspects

Recommendations	Details
Process of Adoption
• Time limited custody	Implement time-limited temporary custody with regular follow-ups to ensure timely legal freedom for adoption
• Counselling	Provide developmentally appropriate counselling, especially for older children to prepare them for adoption and address adjustment issues
• Child report	Social counsellors should include the Mental health examination of the child to identify and address developmental or emotional issues before declaring the child legally free for adoption
• Home study report	It should comprise a reasonable mental health assessment of PAP’s. Counselling of parents should be done on the relevant aspects of the adoption like, early stimulation of the child, looking into their developmental needs, disclosure etc.
Extended Follow up	Planned follow-ups with CARA beyond the current two-year time frame to better understand adjustment issues for both child and parent
Policies and Program	Better policies should be framed to address the adoption related issues, should focus on capacity building, Human Resource development, better referral system and multidisciplinary approach
Research on adoption	Research on adoption has been scant. Research from India must be undertaken to promote intra-country adoption of the children with special needs, challenges and experiences of adoptive parents and predictors of successful adoption of such children Longitudinal studies, Qualitative studies and intervention-based research should be conducted.
Learnings from COVID 19	The pandemic revealed significant flaws in India’s adoption and child protection systems, exposing gaps in policies and infrastructure. Urgent reforms are needed, including increase in number of child-care institutions, addressing human resource deficits, and improving training, adoption encouraging friendly legal frameworks, time bound legal processes, better scrutiny of adoption centers
Training of the students/professionals of mental health	Formal training for the MHPs and allied disciplines (e.g., psychologists, psychiatry social workers) on adoption and related mental health aspects in their post-graduate curriculum or during the continuous medical education/rehabilitation education (CRE). Focused workshops on this issue, maybe under the umbrella of social psychiatry, can promote knowledge and skills of the MHPs or trainees in this area. Upgradation of policy frameworks in this sub-field is required.

A systematic review[24] described various interventions based on the various psychological theories (including attachment, trauma, child development, transactional and family systems theories,) found that specific interventions like Child-Parent relationship therapy (CPRT) and Trust based relational intervention (TBRI) uses principles like therapeutic play, active listening, empathy, non directive approach, differential reinforcement which improves parent-child dyad psychological and behavioral outcomes.

Recommendations

We have provided some recommendations [Table 3]and future direction concerning adoption and mental health aspects around it.

Limitation

1. Limitations related to screening of only two databases.

2. The quality of the study not being assessed may result in poorly evident findings, and

3. Focusing only on the English language article may lead to missing out on important works.

CONCLUSION

Adoption is a difficult family construct that often gets neglected. India has a legal framework governing the adoption process, but factors such as delays in declaring a child legally free for adoption and the absence of mental health assessments for prospective adoptive parents hinder its effective utilization. This review highlights the increased likelihood of adopted children being referred to mental health services due to the complex psychosocial challenges they face, with clinical studies reporting higher rates of externalizing behaviors. Despite the existence of a legal framework for adoption in India, factors such as delays in declaring children legally free and the lack of mental health assessments for prospective adoptive parents limit its effectiveness. Additionally, there is a significant gap in well-designed community-based studies on this population. MHPs play a crucial role in addressing pre- and post-adoption psychosocial issues and screening adopted children for mental health disorders. These findings underscore the need for policies supporting a collaborative, multidisciplinary approach, and further research in this area.

Conflicts of interest

The authors do not have any conflicts of interest to declare. This is to highlight that RS is an Expert member of the committee for the Central Adoption Regulatory Authority (CARA), Ministry of Women and Child, Govt. of India; however, his association with the stated organization has no bearing or influence on this research work.

Funding Statement

Nil.