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. Author manuscript; available in PMC: 2025 Oct 30.
Published before final editing as: Parent Sci Pract. 2024 Oct 30:10.1080/15295192.2024.2412266. doi: 10.1080/15295192.2024.2412266

Post-adoption perinatal grief and parenting future children in the home: The moderating roles of social support and parental substance use

Erick V Perez 1, Misaki N Natsuaki 2, Camille C Cioffi 3, Jenae M Neiderhiser 4, Daniel Shaw 5, Jody M Ganiban 6, Amy L Whitesel 7, Leslie D Leve 8
PMCID: PMC12373400  NIHMSID: NIHMS2027232  PMID: 40881850

SYNOPSIS

Objective.

The aim of this study was twofold: (a) to examine the impact of birth mother’s post-adoption perinatal grief – stemming from ambiguous loss – on their perceptions of their parenting years later and the relationship quality they have with the children who they raise; and (b) to evaluate the potential contribution that social support and substance use severity play in moderating the impact of post-adoption perinatal grief.

Design.

We applied an adoption design that consisted of a sample of birth mothers (N = 53) who placed one child for adoption at birth and parented another child in their home following the voluntary adoption placement of the adoptee. At 3–6 months postpartum of the adopted child, we measured birth mother’s post-adoption perinatal grief, substance use severity, and level of social support received by their friends, family, and community. When the child the birth mother was parenting reached age 7, birth mothers reported on their relationships with that child, including parent-child conflict, parent-child closeness, parenting satisfaction, and sense of efficacy as a parent.

Results.

Findings revealed that high post-adoption perinatal grief was associated with increased parent-child conflict. High post-adoption perinatal grief was also associated with low parenting satisfaction, albeit this effect was mitigated in the context of high social support.

Conclusions.

Findings suggest that grief following adoption may result in effects that are sustained years later, including compromised relationships and low parenting satisfaction with the child they later raise, although social support may mitigate the potential negative effects of post-adoption perinatal grief on parental satisfaction. Future work should examine the mechanisms linking post-adoption perinatal grief with future parenting.

Keywords: ambiguous loss, perinatal grief, adoption, social support, substance use

Introduction

Ambiguous loss is a blurred and impermanent form of loss that results from not knowing the whereabouts of a loved one due to special circumstances (e.g., the person is missing), which can cause family members to simultaneously feel an absence and the presence of the missing person (Boss, 2007). Although ambiguous loss is often dismissed as less traumatic than actual permanent loss (Knight & Glitterman, 2018), research has shown that people who experience ambiguous loss often undergo a grieving process similar to that experienced after the death of a loved one (Boss & Yeats, 2014), and severe grief after ambiguous loss is linked to maladaptive functioning (Lang et al., 2011). The uncertainty surrounding ambiguous loss can make it a particularly distressful loss, leading to symptoms that are painful yet often missed or misdiagnosed (Pauline & Boss, 2009).

In this study, we focus on an understudied population that has a high likelihood of experiencing ambiguous loss: parents who decide to place their child for adoption. Following the placement of a child for adoption, birth parents may experience post-adoption perinatal grief pertaining to the ambiguous loss of their child (Aloi, 2009). While loss in general brings feelings of pain and suffering, birth mothers also report feelings of uncertainty and a complicated relationship with the adoptee, reporting that their love for the child remains strong despite being unable to see or become close to them (Sova, 2021). Due to lack of definitiveness in ambiguous loss and the chronicity of uncertainty, post-adoption perinatal grief after ambiguous loss has the potential to have long-lasting effects on the birth parent that could permeate into the future relationships that birth parents have with their future children. The overarching aim of this study is to advance our understanding on birth parents’ post-adoption perinatal grief stemming from the experiences of ambiguous loss by evaluating its prospective effects on subsequent family relationships and parenting with a special attention to the moderating roles of personal (substance use) and contextual (social support) factors.

Birth Parents’ Post-Adoption Perinatal Grief and Parenting

Although there is considerable research examining the family-related challenges and parenting difficulties parents face after losing a child due to death (Lehman et al., 1989; McClowry et al., 1987; Warland et al., 2011; Gilmer et al., 2012), much less attention has been given to parenting of birth parents who place a child for adoption and then parent other children at home. However, it is reasonable to assume that birth parents who place a child for adoption face a unique set of challenges in the relationship with children they parent at home. For instance, due to the ambiguous form of loss in which the adoptee is physically absent but psychologically present, the emotional impact of placing a child for adoption may resurface throughout the birth parent’s life, resulting in grief that may be more persistent and complex (Coleman & Garratt, 2016). Such loss and grief have the potential to affect how parents interact with other children who they may parent post-adoption. Specifically, there is a potential “spill-over” effect from grief felt after placing a child for adoption that may compromise parent-child relationships with a child (or children) they are parenting. For example, in a study of birth mothers ages 30–46 that placed a child for adoption approximately a decade prior, those who decided to have more children often reported distancing themselves from the child(ren) they were raising, ultimately struggling to form a secure attachment (Claridge, 2014).

Additionally, complex emotions that birth parents potentially carry into their parenting of children they are raising (e.g., lingering guilt from the adoption experience, anxiety about being perceived as a “good” parent) may lead to overcompensation in parenting behaviors (e.g., overly protective or strict) that strain the parent-child relationship (Neil, 2006). Deykin et al. (1984) found that birth mothers often report overprotective behavior, compulsive worry about their children’s health, and difficulty accepting their children’s growth and independence. Overall, while studies have examined the long-term effects on birth parents themselves after post-adoption perinatal grief, very little work has directly examined how parenting and parent-child relationships are affected by birth parents’ experience of post-adoption perinatal grief.

Heterogeneity in Post-Adoption Perinatal Grief Outcomes: Moderation by Social Support and Substance Use History

It is important to note that there is heterogeneity in how individuals are affected by grief after the loss of loved ones, in part due to the personal and circumstantial factors surrounding their loss. Social support from friends, family, and the community has been identified not only as an enhancement for faster and healthy coping in the grieving process, but also as a promoter of resilience and redemption (Kavanaugh et al., 2004). For example, high social support from friends, family, and significant others is associated with a strengthening of bonds with those who remain, whereas poor support or lack of support can lead to strained bonds (Burke et al., 2010). However, the effects of social support may depend on the type of social support. Following a loss, Schut & Stroebe (2010) found that social support aimed at dealing with the grief work and processing of loss did not seem to provide a protective effect; however, more general social support (e.g., support that one may receive regardless of bereaved status such as help with daily activities) did seem to aid adjustment. This outcome is likely because in addition to the emotional toll of loss, there are many secondary stressors either stemming from the loss directly (e.g., financial burdens), or indirectly such as the daily activities and tasks unattended to due to emotional toll of loss (Stroebe and Schut, 2010).

In regard to perinatal grief following an adoption placement, Winkler and van Kepple (1984) reported that lack of social support in the months after adoption placement was a major contributing factor to poor post-adoption adjustment, including one’s peer and family relationships. Conversely, another study examining post-adoption adjustment as many as 20 years later failed to support their hypothesis that social support would be a protective factor (De Simone, 1996); however, the timing of social support (e.g., during adoption placement or even decades later) was highly variable, leaving the question of how general support during the initial grieving process of post-adoption perinatal grief may impact long-term adjustment, including relationships with children they are parenting. While there are studies highlighting the effects of factors such as social support when one grieves for the death of a loved one (Taylor, 2011), there is a dearth of studies examining these factors when facing ambiguous loss.

An important but understudied personal factor that may pose a risk or complicate the grieving process is an individual’s history of substance use. Most of the research focused on substance use on birth parents’ experiences of custody loss and does not include an examination of substance use among parents who voluntarily place their child for adoption (Russelle et al., 2022; Dellor & Freisthler, 2018; Smith, 2003). However, there is a small body of research documenting that birth parents’ substance use history may serve as an additional risk for heightened the grief, aggravating the post-adoption family life adjustment. In a review by Parisi et al. (2019), a higher rate of complicated grief was found among people who used substances compared to those who did not. More relevant, Masferrer et al. (2016) found that as many as 61% of people with heightened substance use severity were at risk of suicide following the loss of a significant person (i.e. family, best friend, partner).

Studies on grief and substance use have mainly focused on the direct effect of substance use history on grief, but it is plausible that birth parents’ substance use history may act as a moderator in the association between grief and subsequent family relationships. Substance use history may indicate a general tendency for maladaptive coping, which has been associated with social withdrawal, wishful thinking, self-criticism (Caparros et al., 2021), and relationship difficulties (Hans, 2002). Healthy grieving of the lost loved one calls for the activation of adaptive coping skills, such as meaning-making and attending to life changes (Stroebe & Schut, 2010). However, with avoidant and maladaptive coping tendencies, oft-observed in individuals with substance use (Smyth & Wiechelt, 2005), the ill effect of grief stemming from the loss of a child may be potentially amplified.

Present Study

The goal of this report is to illuminate the impact of grief after ambiguous loss on family relationships years later, and identify factors that may facilitate the healthy adjustment of the grieved and their family members. The specific aims of this study are two-fold: (a) to examine the impact of birth mother’s post-adoption perinatal grief on her perceived parenting and relationship quality with other children whom she raises, approximately 8 years later; and (b) to evaluate the roles that social support and substance use severity play in moderating the impact of post-adoption perinatal grief on perceptions of parenting and the parent-child relationship quality. We hypothesized that higher post-adoption perinatal grief would be associated with more negative perceptions of parenting and lower parent-child relationship quality. In addition, we expected that increased substance use would exacerbate the effects of grief while high social support would mitigate it.

Methods

Participants

Early Growth and Development Study (EGDS):

This study utilizes data from a subset of birth mothers who participated in the Early Growth and Development Study (EGDS; Leve et al., 2019). The EGDS is a prospective, longitudinal adoption study comprised of families linked through voluntary adoption (N = 561 families), each of which consists of an adopted child, their adoptive parents, and their birth mother (and father when possible – 34% were recruited). The EGDS has followed two cohorts of adopted children (cohort I n = 361, cohort II n = 200) since infancy (i.e., 3–6 months of age). Important for this study, EGDS subsequently expanded its scope by recruiting a sample of biological siblings of EGDS adoptees who are raised by the EGDS birth mothers (known as the Early Parenting of Children Project [EPoCH; see Leve et al., 2019 and Reiss et al., 2022 for more details]. The current investigation uses data from cohort II and the EPoCh data, which includes the assessment of the birth mother’s parenting and parent-child relationships with the child in her home.

The EGDS participating families were recruited via 45 adoption agencies, including public, private, religious, secular, open, and closed adoptions. These adoption agencies were located in 15 states spanning the Mid-Atlantic, West/Southwest, Midwest, and Pacific Northwest regions of the United States. All children were adopted immediately after birth with a median age of 2 days (SD = 12.45 days, range = 0 to 91 days). Eligibility criteria in the EGDS project included (a) participated in a domestic adoption, (b) placement occurred within 3 months postpartum, (c) the infant was placed with an adoptive family that was not biologically related to the child, (d) there were no known major medical conditions such as extreme prematurity or extensive medical surgeries, and (e) the birth and adoptive parents were able to understand English at the eighth-grade level. Full details regarding recruitment and sample characteristics are provided in Leve et al. (2019). Informed consent was appropriately obtained prior to assessment.

Current Sample.

While the full EGDS sample consists of 561 birth mothers, only a smaller subset of birth mothers met the inclusion criteria specific to this study. The inclusion criteria for this study’s analytical sample include birth mothers: (a) whose data on post-adoption perinatal grief is available at 3–6 months after the birth of the adoptee child (only Cohort II birth mothers had this information; N = 200); and (b) from Cohort II who had another child(ren) she was raising at home and who participated in the EPoCH parenting assessment (which includes all of the outcomes included in this study) when the child she was raising at home reached age 7 (N = 53). The ethnic and racial makeup of birth mothers was 70% White non-Latinx, 13% African American, 7% Hispanic/Latinx, 5% multiracial, and 5% other, and were 24 years of age on average (SD = 6.00) at the time of the adopted child’s birth. At the start of the study, birth mothers had a median household income of less than $15,000, typically had completed up to high school education (41%), and 6% were married. The median child age at adoption placement was 2 days (M = 5.58; SD = 11.32). The EGDS recruited birth fathers too, but given that only 34% of birth fathers of the full EGDS participated in the study, only 15 birth fathers met the inclusion criteria for this study’s analytical sample. Due to the small sample size, they were not included in this study.

Measures

Post-Adoption Perinatal Grief

At 3–6 months postpartum of the adopted child, the level of grief birth mother’s experienced post-adoption was quantified via the Perinatal Grief Scale, which was designed by the project team to measure specifically post-adoption perinatal grief by adapting Toedter’s et al. original Perinatal Grief Scale (2001). Birth mothers reported on 33 items (e.g., I am grieving for the baby, I cry when I think about him/her, the best part of me died when the baby was placed), indicating the extent to which they agree or disagree with each statement on a 5-point Likert scale (1 = strongly agree, 3 = neither agree nor disagree, 5 = strongly disagree). The total of 33 items was computed, with higher scores reflecting more grief (α = .95). An international comparison of studies using the original perinatal grief scale has demonstrated the use of the scale within adoption populations to have comparable alpha coefficients (i.e., α = 92–96; Toedter et al., 2001).

Social Support

At 3–6 months postpartum of the adopted child, we assessed how satisfied birth mothers were with the level of available support through intimate relationships, friendships, and neighborhood or community support VIA the General Life Satisfaction Questionnaire (Crnic et al., 1983). Using a 4-point Likert scale (1 = very dissatisfied, 2 = somewhat dissatisfied, 4 = very satisfied), birth mothers reported on 8 items (e.g., “how satisfied are you with the amount of times you visit your friends”, “how satisfied are you with the amount of phone contact with friends and family”, and “how satisfied are you with your opportunities to share your most private feelings with someone”). The average score was computed with higher scores reflecting greater satisfaction with available social support (α = .81). Previous studies using this measure have yielded comparable alpha coefficients (α = .76–88; Laurent et al., 2014; Brotnow et al., 2015).

Substance Use Severity

At 3–6 months postpartum of the adopted child, the level of lifetime alcohol, tobacco, and other drug (ATOD) severity was assessed via a modified version of the Composite International Diagnostic Interview – Short Form [CIDI-SF] (Kessler et al., 1998). The CIDI is a comprehensive, fully standardized interview to assess 17 major diagnostic areas according to the definitions and criteria of the tenth revision of the International Classification of Diseases (ICD; World Health Organization 1992). The original CIDI-SF questions were modified for this study to pertain to lifetime severity rather than 12-month severity, and to include a set of tobacco-use severity questions. Birth mothers reported whether they have ever engaged in the use of various substances (i.e., alcohol, sedatives, tranquilizers, amphetamines, prescription painkillers, inhalants, marijuana, cocaine, LSD, or heroin) and endorsed symptoms arising from substance use (e.g., “During your lifetime, did you have any emotional or psychological problems from using alcohol – such as feeling uninterested in things, feeling depressed, suspicious of people, paranoid, or having strange ideas”; “How often has your use of marijuana interfered with your work at school, at a job, or at home?”). The indicators of lifetime problem use of alcohol, tobacco, marijuana, and other drugs were each standardized and then combined to form a composite substance use severity score (see Leve et al., 2010 for more details), with higher scores indicating greater substance use severity (range = −0.88 to 1.60; α = .71).

Parent-Child Relationship Quality

When the birth mother’s child raised in her home reached age 7, the relationship between the birth mother and her child at home was assessed via the Adult Child Relationship Questionnaire, which was adapted from the Student-Teacher Relationship Scale (Pianta & Steinberg, 1991). Using a 5-point scale, (1 = definitely not,, 2 = not really, 3 = yes and no or not sure, 4 = somewhat, 5 = definitely), birth mothers reported on 10 items that assessed their perceived conflict with the child (e.g., “This child and I always seem to be struggling with each other”; “This child gets angry at me easily”; “ Even though I’ve tried hard, I don’t feel good about how the two of us have gotten along”) and 5 items that assessed the their perceived closeness with their child (e.g., “This child likes telling me about him/herself”; “It is easy to be in tune with what this child is feeling; this child is open with me about sharing feelings and telling me how things are”). Higher scores indicate greater conflict (range = 5 to 50; α = .88) and greater closeness (range = 5 to 25; α = .65).

Parenting Satisfaction and Efficacy

When the birth mother’s child raised in her home reached age 7, birth mothers reported on how satisfied they were with their parenting and their sense of efficacy regarding their parenting of the child at home via the Parenting Sense of Competence Scale (Johnson et al., 1989). Using a 6-point scale, (1 = strongly agree, 3 = mildly agree, 6 = strongly disagree), birth mothers reported on 9 items regarding parenting satisfaction (e.g., “My talents and interests are in other areas, not in being a parent”; “Being a parent makes me tense and anxious”; “My parent was better prepared to be a good parent than I am”) and 7 items for parenting efficacy (e.g., “Being a parent is manageable and problems are easily solved”; “I meet my own personal expectations for expertise in caring for my child”; “If anyone can find the answer to what is troubling my child, I am the one. Higher scores for the satisfaction subscale indicate greater satisfaction (α = .73), and higher scores for the efficacy subscale indicate greater efficacy (α = .89).

Covariates

Several covariates were considered. First, we controlled for household income (1 = less than $20,000, 2 = $20,000-$39,000, 3 = $40,000-$59,000, 4 = $60,000-$79,000, 5 = $80,000-$99,000, 6 = $100,000 or more) because individuals from different socioeconomic backgrounds often have varying levels of access to resources including social support. Second, we considered openness in the adoption (1 = very closed, 2 = closed, 3 = semi-open, 4 = moderately open, 5 = open, 6 = quite open, 7 = very open) since openness has been shown to influence how birth mothers grieve, with a review of the effect of openness in adoption showing that more openness is typically associated with more positive outcomes (Townsend, 2003). Lastly, while there was variability in the time since placement among birth mothers (M = 7.50 years, SD = 2.00), time since placement was not significantly correlated with any study variables and was therefore not included as a covariate in favor of model parsimony.

Analytic Strategy

First, descriptive statistics and bivariate correlations among all study variables were computed. Secondly, a series of linear regression was performed to test for the effect of post-adoption perinatal grief at 3–6 months post-adoption on age 7 relationship quality between birth mothers and their children whom they were raising at home, parenting satisfaction, and parenting efficacy. The regression models also included social support and lifetime substance use severity as moderators of post-adoption perinatal grief while controlling for household income and openness in the adoption. The regression model was run separately for each of four outcomes (i.e., closeness, conflict, parenting satisfaction, and parenting efficacy). If moderators emerged as significant, the interactions were probed with conditioning values set to the 16th percentile (i.e., low), 50th (i.e., moderate), and 84th percentile (i.e., high) as recommended by Hayes and Matthes (2009).

Given that this study uses longitudinal data, it is important to pay attention to attrition. Missingness ranged from 3.5% to 12.3% across study variables. Little’s Missing Completely at Random (MCAR) was conducted, and results supported that the data were MCAR (χ2(37)= 35.24, p = .552). Data that meet the MCAR assumption reduces bias (Dong & Peng, 2013) even when the proportion of missingness is as high as 90% (Madley-Dowd et al., 2019). Therefore, full information maximum likelihood (FIML) was used to treat missingness in the analyses.

Results

Descriptives

Means, standard deviations, and bivariate correlations among the study variables are presented in Table 1. On average, birth mothers reported moderate post-adoption perinatal grief with a mean of 74.68 (SD = 29.00, range = 33–153). Post-adoption perinatal grief was positively correlated with parent-child conflict (r = .42, p = .002) and negatively correlated with parenting satisfaction (r = −.47, p = .001)

Table 1.

Means, standard deviation, and bivariate correlations among study variables.

1 2 3 4 5 6 7 8 9 10
1 Post-adoption perinatal grief - - - - - - - - - -
2 Social support −.44** - - - - - - - - -
3 History of substance use severity .19 −.12 - - - - - - - -
4 Parent-child conflict .42** −.26 .12 - - - - - - -
5 Parent-child closeness −.25 .49*** −.05 −.50*** - - - - - -
6 Parenting satisfaction −.47*** .50*** −.28 −.52*** .38** - - - - -
7 Parenting efficacy −.17 .22 −.23 −.51*** .48*** .36* - - - -
8 Openness .13 .17 .23 .12 −.04 .12 .17 - - -
9 Household income −.10 .25 −.11 −.05 .17 .17 −.12 .39** - -
10 Time since placement .06 .16 .27 −.17 −.20 .12 .24 −.23 −.54* -
M 74.68 3.11 −0.15 20.21 23.03 40.87 33.54 −.30 12.67 7.5
SD 29.00 0.50 0.67 7.70 2.32 8.84 2.45 .89 1.69 2.00
N 53 49 53 52 52 48 48 53 51 53
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Note: Full information maximum likelihood and pairwise deletion yielded consistent results.

*

p < .05.

**

p < .01.

***

p <.001

Evaluation of the Effect of Post-adoption Perinatal Grief on Parent-Child Relationships

Results from regression analyses are summarized in Table 2. Results revealed that high post-adoption perinatal grief was significantly associated with greater conflict between birth mothers and the child they are parenting (b = .11, p = .026). Social support and substance use severity failed to reach statistical significance as moderators of the association between post-adoption perinatal grief and parent-child conflict. Post-adoption perinatal grief was not significantly associated with how birth mothers perceived closeness with their child (b < −.001, p = .966), although social support was positively associated with closeness (b = 2.04, p = .006). Neither social support nor substance use severity moderated the effect of post-adoption perinatal grief on closeness.

Table 2.

Impact of post-adoption perinatal grief on parental outcomes as moderated by social support and substance use severity.

Parent-child conflict Parent-child closeness Parenting satisfaction Parenting efficacy
b(SE) b(SE) b(SE) b(SE)
Intercept 20.96(1.18) 25.71(1.32) 41.88(4.40) 35.35(3.82)
Post-adoption perinatal grief .11(.04)* −.002(.01) −.08(.04)* −.02(.03)
Social support −.21(2.57) 2.04(.70)* 7.06(2.26)* 1.32(1.96)
History of substance use severity −.20(1.77) .10(.49) −3.62(1.61)* −1.41(1.40)
Perinatal grief x social support .04(.09) .03(.02) .21(.07)* −.03(.06)
Perinatal grief x history of substance use severity −.03(.07) .002(.02) .04(.06) −.02(.05)
Openness .52(1.51) .35(.40) −.29(1.25) 1.89(1.07)
Household income −.25(1.15) −.44(.31) −1.30(1.06) −.80(.91)
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Note:

*

p <.05.

Evaluation of the Effect of Post-adoption Perinatal Grief on Parenting Satisfaction and Efficacy

As shown in Table 2, birth mothers’ post-adoption perinatal grief was associated with parenting satisfaction (b = −.08, p = .031). This effect was also moderated by the level of social support they received 3–6 months after the birth of the adoptee. As shown in Figure 1, when birth mothers received low (b = −.20, p < .001) to moderate (b = −.10, p = .017) levels of social support, high post-adoption perinatal grief was negatively associated with how satisfied they were with their parenting; however, when they received high social support, post-adoption perinatal grief was no longer significantly associated with their parenting satisfaction (b = .01, p = .87). Additionally, the main effect of substance use severity was negatively associated with parental satisfaction (b = −3.62, p = .031), but it did not moderate the effect of post-adoption perinatal grief. Post-adoption perinatal grief was not significantly associated with birth mother’s parenting efficacy (b = −.02, p = .51).

Figure 1. Association between post-adoption perinatal grief and parental satisfaction as moderated by social support.

Figure 1

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Note. Low = 18th percentile, Mean = 50th percentile, High = 84th percentile.

Discussion

Limited research has explored the effects ambiguous loss stemming from placing a child for adoption can have on parenting practices and parenting efficacy nearly a decade later. This study used a sample of birth mothers who previously placed a child for adoption and subsequently parented a child to explore how post-adoption perinatal grief affected later parenting and parent-child relationships. We found that high post-adoption perinatal grief after placing a child for adoption can prospectively lead parents to feel less satisfied with their subsequent parenting, as well as report increased conflict with the child they are parenting. However, the adverse effect of post-adoption perinatal grief on parental satisfaction was mitigated when birth mothers received higher social support from their community, friends, and intimate relationships as they navigated the grief associated with the ambiguous loss. We did not find substance use severity as a significant exacerbator of post-adoption perinatal grief on family functioning.

The Power of Social Support

Although post-adoption perinatal grief experienced after the adoption process predicted post-adoption family life, our results demonstrated an optimistic finding: social support from families, friends, and community can alleviate the ill effects of grief on parenting satisfaction. The importance of this finding should be discussed in the context of birth parents’ experiences of navigating adoption. Birth mothers are often unfairly stigmatized as being selfish or not loving their children or are erroneously assumed to quickly move on with their lives post-adoption (Jerome & Sweeney, 2014). Due to this misconception, they have often reported cases in which social support was withheld as a punitive measure (Fessler, 2007). Doka (2002) points out that individuals at elevated risk of experiencing disenfranchised grief, including birth mothers, might be discouraged from seeking support. This is unfortunate because, as our findings suggest, social support from friends, family, and the community can significantly aid in the grieving process and lead to positive growth (Lenhardt, 1997). Consistent with prior work (Kavanaugh et al., 2004; Schut & Stroebe, 2010), our study also highlights how social support can aid birth mothers’ post-adoption adjustment as they subsequently parent a child(ren).

Substance Use and Parenting

In line with previous literature on parental substance use and grief (Masferrer et al., 2016; Hans, 2002; Parisi et al., 2019), this study hypothesized that a history of substance use severity would exacerbate the downstream associations between post-adoption perinatal grief and subsequent parent-child relationships and birth mothers’ perceptions of their own parenting. Our data failed to find support for this hypothesis. History of substance use severity did not emerge as a significant moderator for the effects of post-adoption perinatal grief, nor was history of substance use severity significantly correlated with post-adoption perinatal grief, social support, parenting satisfaction and efficacy, and parent-child relationships. Although null findings are not strong evidence of nil effect, our findings, if valid, may implicate that following adoption placement, mothers with a history of substance use severity are no more “at risk” than mothers without such a history to create a challenging family environment for future children.

Clinical Implications for Birth Mothers

Loss has historically – and erroneously – been treated as an experience to eventually forget and recover from (Rothaupt & Becker, 2007). More recent literature on bereavement has recognized loss as an experience that individuals move forward with and has the potential to create long-lasting effects – potentially negative effects in cases of higher and more complex grief (Eisma et al., 2019; Burke et al., 2010). Thereby, grief is now recognized as an experience that can benefit from clinical interventions aiding the bereaved (Shear et al., 2016). However, birth mothers’ experience of post-adoption perinatal grief is often left unheard and unacknowledged, subject to comments such as being told that they will get over it or forget all about it when they have another baby (Lauderdale & Boyle, 1994), which downplays the negative effects of post-adoption perinatal grief. Conversely, our findings show that birth mothers experience, on average, moderate levels of post-adoption perinatal grief, which can indeed have long-term negative effects, particularly in regard to their parenting and parent-child relationships with other children that they parent. These findings highlight the need for birth mothers to receive adequate intervention and support. Our findings identified that strengthening social support can be an effective and accessible strategy for intervention. For example, support groups for birth mothers can be organized, as peer support group is an effective form of intervention in general for bereaved individuals (Robinson & Pond, 2019; Picton et al., 2001). Educating friends and family members about post-adoption perinatal grief and the birth mother’s needs may aid in fostering a supportive childrearing environment for both the child and the mother. Lastly, connecting birth mothers with resources such as community centers and mentorship programs may also serve to increase one’s social support as they create safe spaces, receive emotional support, and receive practical advice, potentially even from birth mothers who are also parenting children post-adoption.

Strengths, Limitations, and Future Research

The findings and implications of this study are bolstered by several unique features of this investigation. First and foremost, this study capitalized on an adoption design to investigate post-adoption perinatal grief stemming from ambiguous loss, which is an understudied form of loss. Second, the timely post-adoption data collection allowed for an assessment of post-adoption perinatal grief during the grieving process. Retrospective assessment of grief is especially subject to memory bias due to the meaning making process associated with grieving (Park, 2008). Lastly, the longitudinal design of the study yielded the evaluation of long-lasting effects of post-adoption perinatal grief stemming from ambiguous loss on parenting and relationships between parents and their subsequently born children.

These strengths notwithstanding, our findings should be viewed alongside several limitations. First, given the unique nature of the population, the sample size was considerably small, significantly reducing the study’s power to detect significant associations. This may have resulted in our null findings concerning substance use severity. However, substance use severity was significantly associated with parenting satisfaction, indicating that additional power or more precise measurement of substance use severity may have resulted in different findings. Secondly, our sample included only birth mothers who voluntarily made adoption placements, limiting our generalizability to the broader population of birth mothers experiencing ambiguous loss of their children. Future research should also incorporate birth fathers – another understudied population – to examine how ambiguous loss may affect paternal parenting. Third, we did not examine any child outcomes, limiting our insight into the potential intergenerational effects of grief. Future research should include child reports of parenting and child outcomes to further examine the intergenerational effects of ambiguous loss. Fourth, all measures used in this study were reported by birth mothers, possibly causing inflation due to shared method variance. This concern is somewhat attenuated by the fact that there is a long-time gap between the grief assessment (3–6 months post adoption) and parent-child relationship reports (when the child the birth mother was parenting was age 7, approximately 8 years after the initial adoption placement), but shared method variance may still operate to cause inflation. Fifth, substance use was measured by assessing lifetime substance use severity, limiting our ability to examine the effect of timing of substance use. Sixth, this study included minimal analysis and assessment of adoption openness, limited to a single to a timepoint shortly after adoption placement; however, openness changes over time. Future research should incorporate multiple assessments of adoption openness to see what role changing levels of openness may have on post-adoption perinatal grief and parenting. Last, while grief is a long-term and potentially lifelong experience, we only assessed post-adoption perinatal grief shortly after birth mothers placed their child for adoption, limiting our ability to assess the dynamic nature of post-adoption perinatal grief. Future research should incorporate multiple assessments of post-adoption perinatal grief, as well as evaluate potential mechanisms linking post-adoption perinatal grief with future parenting.

Implications

This study revealed that loss can have significant, lasting effects on parents, even when the loss is more ambiguous in nature. This finding suggests the importance of acknowledging and aiding those who experience ambiguous loss post-adoption (Kaur-Aujila et al., 2022). This study found that one of the ways to aid those facing ambiguous loss is by providing social support as friends, family, and a community. Additionally, while this study did not reveal a history of substance severity to be a significant exacerbator of the effects of post-adoption perinatal grief, it is still important to further explore and understand the experiences of mothers with a history of and current substance severity to best support them (Weatherall & Duffy, 2008). Overall, this study supported the notion that even for ambiguous loss, individuals do not simply ‘move-on,’ but they move forward - how they move forward can depend on how socially supported they are.

Acknowledgements

This project was supported by grant R01 DA020585 from the National Institute on Drug Abuse, the National Institute of Mental Health and OBSSR, NIH, U.S. PHS (PI: Jenae Neiderhiser, Ph.D.) and by grant R01 DA035062 from the National Institute on Drug Abuse, NIH, U.S. PHS (PI: Leslie Leve, Ph.D.). The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institute of Child Health & Human Development or the National Institutes of Health. This project was supported by grant R01 DA035062 from the National Institute on Drug Abuse, NIH, U.S. PHS (PI: Leslie Leve, Ph.D.).

We thank the families and adoption agencies that participated in this study. We gratefully acknowledge the assistance Sally Guyer provided, as well as the rest of the staff of the Early Growth and Development Study for their contributions towards recruitment and data collection. Special gratitude is given to David Reiss who was centrally involved in this work prior to his retirement.

Contributor Information

Erick V. Perez, University of California, Riverside

Misaki N. Natsuaki, Department of Psychology, University of California, Riverside, California.

Camille C. Cioffi, University of Oregon

Jenae M. Neiderhiser, Pennsylvania State University

Daniel Shaw, University of Pittsburgh.

Jody M. Ganiban, George Washington University

Amy L. Whitesel, Nationwide Children’s Hospital.

Leslie D. Leve, University of Oregon

Data availability statement

The data supporting this study’s findings are available from the corresponding author upon request.

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Associated Data

This section collects any data citations, data availability statements, or supplementary materials included in this article.

Data Availability Statement

The data supporting this study’s findings are available from the corresponding author upon request.

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