Under the Same Label: Adopted Adolescents’ Heterogeneity in Well- Being and Perception of Social Contexts

Under the Same Label: Adopted Adolescents’ Heterogeneity in Well-Being and Perception of Social Contexts Carmen Paniagua*, Carmen Moreno*, Maite Román*, Jesús Palacios*, Harold D. Grotevant¥, & Francisco Rivera+. *Departamento de Psicología Evolutiva y de la Educación, Universidad de Sevilla, Seville (Spain). ¥Department of Psychology, University of Massachusetts Amherst, Massachusetts (United States of America). +Departamento de Psicología Experimental, Universidad de Sevilla, Seville (Spain). Abstract: This study compares a sample of 223 adopted adolescents with a non-adopted reference group representative of the Spanish adolescent population from the Spanish Health Behaviour in School-aged Children (HBSC) study. Variables related to the family context, peers, school context and emotional well-being are compared. Adoptees are analyzed as a group but also according to the type of adoption (domestic or intercountry) and the birth area of origin (Asia, Latin America, and Eastern Europe). The results showed more similarities than differences between the whole group of adoptees and the reference group, as well as heterogeneity within the adoptees depending on their origin. Introduction Until recently, research about adoption has been more focused on the difficulties, troubles, and sources of adversity faced by adopted children than on positive outcomes such as wellbeing and sources of support (Palacios & Brodzinsky, 2010). Furthermore, the study of adoptees has been more focused on the early years than on later stages of life (Matthews, Tirella, Germann, & Miller, 2016). However, life stages such as adolescence have a critical role in psychological well-being (e.g., Kessler, Petukhova, Sampson, Zaslavsky, & Wittchen, 2012), as well as in the adoption process. Many authors affirm that, in addition to the normative tasks of adolescence, adopted adolescents must face specific challenges during this stage related to the adoption status, such as the development of adoption identity and the search for origins (e.g., Askeland, Hysing, Aarø, Tell, & Sivertsen, 2015; Brodzinsky, Schechter, & Hening, 1993; Grotevant, Lo, Fiorenzo, & Dunbar, 2017; Smith, 2014). Furthermore, more difficulties in adopted adolescents have been reported in recent studies such as Wijedasa and Selwyn (2017), who identified this period as a critical one for adoption breakdown. Finally, the sources of information have frequently been adults (e.g., parents, teachers) more than the adoptees themselves. The present article addresses some of these limitations by giving voice to adopted adolescents in issues as relevant to them as their wellbeing and significant relationships (e.g., with parents and friends), issues with a high ecological validity. In addition, most of the research on adopted children has treated the adoptees as a homogeneous group, ignoring or paying little attention to their heterogeneity. There are a few studies that analyzed the diversity behind common generic labels. Several decades ago, Haugaard (1998) wrote about the risk of underestimating the inherent danger of some stories of high adversity pre-adoption, or the risk of exaggerating cases of more normalized developmental profiles. More recent publications (e.g. Grotevant & McDermott, 2014; Palacios, 2017) have paid special attention to the heterogeneity that exists among adoptees. Those authors affirm that adoptees can differ enormously from each other according to a great variety of criteria, such as their domestic or intercountry origin, or their different background of adversity; however, empirical evidence is still needed to know the scope of these ideas and affirm it with certainty. In a previous article, with a different sample treatment, data analysis, and final objective, we found differences between intercountry and domestic adoptees in family dimensions (blinded reference). In this paper, more adoption related variables are added for a more complete exploration of the adoptees’ heterogeneity. Therefore, this work is focused on the study of the existing diversity in contemporary adoption populations to analyze possible differences between adopted adolescents. Research comparing adoptees and non-adoptees dominated the scene during the initial years of adoption research (Palacios & Brodzinsky, 2010). ). This type of research was, and still is, abundant. According to the meta-analysis by Askeland et al. (2017), much of the conclusions reached in the comparison depended on the studied groups (e.g., results show more positive outcomes when the adoptees are not part of a clinical sample) and on the source of information (e.g., parents usually highlight difficulties and adoptees have a more normalized view of themselves). Therefore, the first aim of the present study is to analyze the outcomes of adopted and non-adopted adolescents. As such, our interest here focuses not only on the comparison of adopted populations with the normative population, but also the comparison between different groups of adoptees based on characteristics related to the type of adoption and the area of origin. Comparative research with this perspective is not only scarce, but some results are also contradictory. Meta-analytic research has reported better adjustment among intercountry adoptees than in domestic adoptions (Juffer & van IJzendoorn, 2005). However, there is also some research that has not found significant differences between domestic and intercountry adoptees (e.g. van den Dries et al., 2009). On the other hand, different studies have found that a considerable number of adoptees, regardless their origin, have problems in establishing and maintaining relationships with peers due to a combination of different factors such as a higher incidence of externalizing behavior (Brown, Waters, & Shelton, 2017; Palacios, Moreno, & Román, 2013; Schofield & Beek, 2006). Research exploring the influence of birth regions in intercountry adoption has given rise to diverse results. The two regions of origin most studied have been Asia (mainly China) and Eastern Europe (especially Russia). It is common to find better adjustment in adoptees from China, as compared with Eastern European adoptees, because adoptees from China report better indicators in attachment (van den Dries et al., 2009) and are less often bullied (Raaska et al., 2012). However, more studies have identified problematic outcomes in Eastern European adoptees in different areas (e.g. Lindblad, Weitoft, & Hjern, 2010; Palacios et al., 2013; Raaska et al., 2012; Sonuga-Barke, Schlotz, & Kreppner, 2010). The differences have been attributed mainly to the fact that adoptees from China experienced better prenatal conditions, generally spent less time in orphanages and were adopted at younger ages; instead, the Eastern Europe adoptees experienced multiple risk factors prior to adoption (Landgren et al., 2006; Rutter, 1998; The St. Petersburg-USA Orphanage Research Team, 2005, 2008). Latin America as a birth area for adoptees has received less attention in prior research, with more scarce and contradictory data. For example, some studies have documented worse results in Latin American adoptees compared to other birth areas (e.g., Lindblad et al. 2010). However, other research has found better results in adoptees from Latin America compared to those from Eastern Europe in psychological adjustment (Palacios, Sánchez-Sandoval, & León, 2007). Social support and well-being Social support can be defined as social relationships that provide (or can potentially provide) material and interpersonal resources that are of value to the recipient (Thompson, 1995). Social support can be real or perceived and, in fact, several authors have defended the benefits of perceived social support in psychological well-being above real social support (e.g., Evans, Steel, & DiLillo, 2013). The effect of the positive relationship between social support and well-being, as well as its buffering influence when facing health and risk behaviors adversity, have been detected during adolescence (Bukowski, Laursen, & Hoza, 2010; Heimisdottir, Vilhjalmsson, Kristjansdottir, & Meyrowitsch, 2010; Marion, Laursen, Zettergren, & Bergman, 2013; Thompson, 2014). The main sources of social support during adolescence are family and peers. Although the family is still a reference of critical importance during adolescence, the influence of peers increases its importance (e.g., Brown & Larson, 2009; Oliva, 2015). Friends help to develop social skills and to create close relationships that may end up acting as attachment figures. Thereby, friendship has been linked to emotional well-being, including better selfesteem, less anxiety and depression, greater feelings of self-efficacy and improved social skills (e.g., Oliva, 2015; Thompson, 2014). However, peers are not only friends, but also classmates. School contexts have been identified as a place where adoptees experience frequent learning and social difficulties (Brown et al., 2017; DeJong, Hodges, & Malik, 2016; Palacios et al., 2013). Some studies have reported that the school is a context where adoptees suffer discrimination, racism and bullying due to the stigma around adoption or to their different appearance in transracial adoptions (Baden, 2016; Raaska et al., 2012; Soares, Barbosa-Ducharne, Palacios & Fonseca, 2017). This problem has been detected even in teachers (e.g., McGinnis, Smith, Ryan, & Howard, 2009), which is shocking given that social support from teachers has been identified as a fundamental factor for the achievement of positive outcomes and well-being (García-Moya, Bunn, Jiménez-Iglesias, Paniagua, & Brooks, 2018; Pössel, Burton, Cauley, Sawyer, Spence, & Sheffield, 2018). Adoption in Spain To understand the results of the present study it is necessary to frame it within the context of the country where the data have been collected. The demography of adoption has changed completely in Spain since 1996. Due to a combination of factors (Palacios & Amorós, 2006), special needs and intercountry adoptions became much more common than the adoption of healthy Spanish babies. Moreover, Spanish domestic adoption originates from the welfare system, which implies that the adoption occurs mainly in relation to experiences of neglect and abuse while in the birth family. In the years in which the greatest number of intercountry adoptions occurred in Spain (from 1997 to 2004, intercountry adoption increased by 273%, Selman, 2009), the intercountry adoptees’ average age at placement was between 2-3 years (Barcons-Castel, Fornieles-Deu, & Costas-Moragas, 2011; Palacios, Román, & Camacho, 2011). If we look at the area of origin, during those years the adopted children who came from Asia had a lower adoption age. Specifically, if we focus on China, the main country of origin within Asia, the average age was less than two years: 13.17 months in Abrines et al. (2012) and 19.76 months in Román (2007). Children adopted from both Eastern Europe and from Latin America had higher placement ages, with an average of approximately 3 years of age on arrival (Román, 2007). The participants in the current study, intercountry and domestic adoptees, belong to this period. Over time, there has been a change not only in the decreasing number of intercountry adoptions but also in increasingly higher adoption ages, as well as in a greater number of adoptions of groups of siblings or children with special needs (Observatorio de la Infancia, 2017). The demographic evolution of domestic adoption in Spain has been similar in terms of adoptee’s age at placement. In the 1990s, only 17% of adoptees were adopted over age 4 years (Sánchez-Sandoval, 2002); the percentage had risen to 43% in 2014 (Observatorio de la Infancia, 2016). HBSC study The Health Behavior in School-aged Children (HBSC) study is a collaborative study of the World Health Organization that has been carried out every four years since 1982. The last edition of the study in 2014 was completed by more than 40 countries. Spain is the only country in the international network (at least, at the moment) with a specific interest in adopted adolescents. The objective of the HBSC study is to analyze in depth the lifestyles of school-aged children, their health and well-being, and the quality of the developmental contexts in which they grow up, analyzing the influence of age (11 to 18 year old children are studied), sex (boys and girls) and socioeconomic conditions, and exploring the differences between countries that are part of the HBSC network. Taking into account the study objectives, and considering the boom Spain experienced in intercountry adoption in early 2000s and that many adopted children would currently be within the age range of the study, the Spanish HBSC team decided to incorporate in the questionnaire additional questions to identify adoptees. That decision has made it possible to study adoptees from a unique point of view in adoption research. First, the study focuses mainly on positive areas and the daily life of adolescent development, offering a broad, diverse and realistic view of these youngsters’ lives. Second, studying adolescent populations extends the adoption literature beyond childhood . In addition, the questionnaire is completed by the adoptees themselves, offering a vision on how adopted adolescents perceive themselves with great ecological validity and high personal meaning. Last, the large number of adolescents who participated in the 2014 edition of the study made it possible to obtain not only a powerful reference group, but also a sufficient number of adoptees to be able to explore their diversity based on birth area and allowing for different intra-group diversity. There are two aims of the present study. First, we aim to analyze the outcomes of adopted and non-adopted adolescents. According to Askeland et al. (2017), it is expected that the similarities are greater than the differences. The second objective is to analyze the diversity within the group of adoptees. According to the previous literature, we expect to find more favorable outcomes in intercountry adoptees than in domestic ones, but with a good amount of diversity within intercountry adoptions, where the Eastern European adoptees are expected to experience more difficulties than those adopted from Asia. We did not make predictions about Latin American adoptees, given the greater scarcity and lower consistency in the data from previous investigations. Method Participants This study is part of the Spanish 2014 edition of the HBSC study. The Ethical Research Committee of the University of Seville approved this survey, thus satisfying the fundamental ethical requirements for human research in accordance with current regulations in Spain and the European Union. The HBSC study procedure is governed by the international network guidelines, that establish three basic requirements (Currie et al., 2008): the questionnaire must be voluntarily answered by the school children themselves; the confidentiality and the anonymity of the participant’s answers must be assured and scrupulously respected; the questionnaires must always be completed in the school center itself and within school hours. In order to ensure the representativeness of the sample, random multi-stage sampling stratified by conglomerates was employed taking into account geographic area, type of school (private or state schools) and type of habitat (urban or rural). From the original sample (31,058 adolescents), 19,119 participants aged 11 to 18 years old were selected, removing adolescents who were living in a foster family, a welfare center or any other family situation related to the welfare system, as well as participants who did not reply to all the questions relevant in this paper. From this total sample, 223 were adopted adolescents (1.2%), and 18,896 adolescents formed a comparative non-adopted group (98.8%). The adoptees are part of the intercountry adoption boom mentioned above. Table 1 shows the demographic characteristics of participants and the different groups of which they are part. Within the intercountry group, the three main areas of origin with enough sample to analyze were selected: Asia, Eastern Europe and Latin America. Because there were significant differences between groups in sex and age, with a considerable effect size in age, the remaining analysis controlled for sex and age, as well as socioeconomic status. Due to the nature of the HBSC study, there is no information about the adolescents’ adoption history of abuse, neglect or institutionalization. Therefore, we were not able to include data for variables such as the reasons for adoption, their history of institutionalization or their age at placement. [Insert Table 1] Our second hypothesis was partially confirmed. Our results show that domestic adoptees obtained lower scores in well-being and adjustment to the social context than intercountry adoptees. In particular, the domestic adoptees reported more difficulties in family support and school satisfaction. However, although our results support the hypothesis that intercountry adoptees show more favorable results than domestic adoptees, it is also important to bear in mind that this difference was not present in all the studied areas. As in previous research (e.g. van den Dries et al., 2009) domestic adoptees also show some strengths compared to their intercountry peers, in our case in the satisfaction with the group of friends, as well as in perceived school support. To understand these results it is necessary to recall the characteristics of domestic adoption in our country. Spanish domestic adoption originates from the welfare system, which implies that the most adoptions happen follow experiences of significant neglect and abuse in the birth family (Palacios & Amorós, 2006). Moreover, age at adoption, a key factor in adoption studies, usually is higher in domestic than in intercountry adoption (Barcons-Castel et al., 2011; Observatorio de la Infancia, 2012, 2017; Palacios et al., 2011; Román, 2007; Sánchez- Sandoval, 2002). Regarding the intercountry adoptees’ heterogeneity according to their area of origin, we hypothesized that Eastern European adoptees would report more difficulties than Asian adoptees. This hypothesis was reinforced by the results showing statistically significant differences with a significant effect size in favor of Asian adoptees in most of the variables, with the exception of relationships with friends and school satisfaction, where there were no differences (difficulties with peers will be discussed later). In our study, adolescents adopted from Asia obtained higher scores in family support and satisfaction, even above the reference group. These results align with those reported by van den Dries et al. (2009), where Asian adoptees reported higher attachment scores than those from Eastern Europe. Better pre-adoption circumstances and an earlier age at placement could well explain the advantage of Asian adoptees reported here and in previous research. Adopted adolescents from Eastern Europe were the ones with the worst results in almost all the areas analyzed. These results are consistent with previous literature showing diverse problems in the adjustment of adoptees from Eastern Europe. These poorer outcomes have been related to the accumulation of pre-adoptive risk factors, such as alcohol abuse during pregnancy, poorer quality of institutional rearing and higher age at placement (Landgren et al., 2006; Rutter, 1998; The St. Petersburg-USA Orphanage Research Team, 2005, 2008; van den Dries et al., 2009). Compared to Latin American adoptees, both Asian and Eastern European adoptees have in common difficulties in relationships with friends and in the school contexts. As suggested by Meier (1999) for Korean adoptees, ethnic differences may lie at the heart of this outcome. In a very homogeneous ethnic society such as Spain, adoptees from Asia and Eastern Europe look different and this might become particularly important during adolescence. A similar problem has been reported in previous studies (e.g., DeLuca, Claxton, & van Dulmen, 2018; DeJong et al., 2016). Furthermore, this outcome may be also explained by the double stigma they face in social contexts (March, 1995; Steinberg & Hall, 2000): the stigma of looking different and the adoption stigma that could lead to marginalization and exclusion at school. Moreover, compared to those coming from Latin America, both groups come from clearly different cultures and could therefore experience a great variety of negative reactions in their extra-family environment (Grotevant, Dunbar, Kohler & Esau, 2007). Additionally, different studies reported that some adoptees present special difficulties in establishing relationships with peers because of the initial adversity they experienced (e.g., DeLuca et al, 2018). These difficulties could be related to the problems they had in establishing secure attachment in infancy (Schofield & Beek, 2006). Other studies have found that adoptees present more emotional and behavioral problems, as well as difficulties in social competence, which affect both their academic performance and classroom dynamics (Brown et al. 2017; Palacios et al., 2013), due to their greater difficulties in impulse control, maintenance of attention, affect regulation, and greater tendency to show disruptive behavior, etc. (Múgica, 2008). Our results give context to the work of Biehal, Ellison, Baker and Sinclair (2010) and Selwyn and Briheim-Crookhall (2017) who found a small presence of close friends in adopted children. The lack and inconsistency of previous research on those adopted from Latin America prevented us from making a prediction about their results. Contrary to what has been reported in the scarce studies with this population (e.g. Lindblad et al. 2010), our Latin American sample reported the most favorable results of the three groups of intercountry adoptees. In fact, in this group there were no negative characteristics that differentiated them from the non-adopted reference group. Furthermore, Latin American adoptees were the ones with the best scores in the school context. As discussed before, they were the ones more similar to the reference group in terms of physical appearance and culture of origin. Importantly, they did not have to learn a new language after their adoption, as was the case with the Asian and Eastern Europe adoptees. Compared to these groups, those adopted in Latin America were less exposed to the stigma of looking -and in some aspects behavingdifferent. In conclusion, the results observed in intercountry adoptees were different depending on the match between the child’s birth country and country of adoption. Under the same label "adoptees," different realities can occur both in origin and destination, which highlights the importance of avoiding over-generalizations. Our data have clearly shown more similarities than differences between adoptees and the non-adoptee reference group. Nevertheless, the data also show that the most notable differences are observed in adolescents’ relationships with peers. Furthermore, our data have also shown that these results can be misleading if heterogeneity within the adoptees is not considered. For example, while there were no differences in life satisfaction scores between adopted and non-adopted adolescents, this outcome was nuanced when the sample was divided between domestic and intercountry adoptees, where we observed that domestic adoptees reported a significantly lower life satisfaction score than non-adoptees. At the same time, differences were observed within the intercountry adoptions according to their geographic birth zones, with the lowest scores in those adopted from Eastern Europe compared to the other two intercountry-adopted groups. In fact, the scores reported by Eastern European adoptees were more similar to domestic adoptees than to the other intercountry-adopted groups. Despite the novel approach of this study, the present work has limitations in at least three relevant aspects. First, the lack of information regarding the past of the adopted sample (e.g., the age at placement, which is an important variable in the study of adoption) prevented us from studying the relationship between their current outcomes and their preadoptive information. It is possible that the sample of adoptees studied here was adopted at ages similar to those mentioned in the introduction for groups of adoptees by place of origin, but we have not been able to confirm adoption age. The second limitation derives from the nature of the HBSC study and other correlational investigations, which prevents the establishment of causal relationships between variables. Additionally, similar to past research on adoption, the sample and, therefore, the results, are limited to the context of the country where the study was conducted. Although the context of Spain could have been an advantage in our case, for example, when analyzing the adoption of children of Latin American origin, however, caution is still warranted. The latter leads to insist on the caution to be had when generalization of the findings are made. Our data suggest that the country of adoption should be assessed in studies that measure the country of adoption origin. Despite these limitations, the present study has clear strengths. First, this study highlights the possibility of approaching the scarcely studied population of adopted adolescents, without limiting ourselves to "ad hoc" samples or clinical populations. In addition, the data obtained come from adopted adolescents themselves, something that adds interest to the results obtained. Furthermore, the characteristics of the sampling allowed to study a representative Spanish adopted adolescent sample. The present study also assessed variables not often analyzed in previous research, such as the relationship with friends (beyond classmates) and emotional well-being. Finally, in this study, we have included an understudied group in the adoption literature-- adoptees from Latin America. Based on the presented results and discussion, some future lines of research are suggested. In the first place, future work proposals should take into account diversity in adoptees, considering heterogeneity in the conclusions and methodological designs. Furthermore, to understand in depth the reality of different adopted groups one needs to be more cautious in generalizing results. On the other hand, our results also highlight the need to carry out more research focused on Latin American adoptees in order to determine if having been adopted in Spain influenced our results, or whether positive findings are also found with this adopted population in other countries. Likewise, it is also necessary to address the reality of each country that conducts research in this field. Both the characteristics of each country and their adoption policies can influence their results, requiring the conclusions to be interpreted in their own context. This paper also has clear practical implications. In the first place, adoption interventions should not be generic for all profiles, but rather should consider the existing specificity and diversity when addressing the weaknesses and potentialities of each adopted person. It would be mistaken to approach this subject thinking that all adoptees present difficulties with peers while forgetting other characteristics, such as emotional wellbeing. For example, Eastern European adoptees evaluated in this study would benefit equally from interventions carried out in the family context and in the school context. However, Asian adoptees require interventions in the school more than in the family. Funding The HBSC study was supported in Spain by the Spanish Ministry of Health, Social Services and Equality through a research contract with the University of Seville. This work was also supported by the Spanish Ministry of Economy and Competitiveness through the project PSI2015-67757-R. Carmen Paniagua’s work was supported by the V Plan Propio de Investigación de la Universidad de Sevilla (Spain) 2014, under the action “II.2. Contrato Predoctorales o de Personal Investigador en Formación (PIF) para el Desarrollo del Programa Propio de I+D+i de la US”. References Abrines, N., Barcons, N., Marre, D., Brun, C., Fornieles, A., & Fumadó, V. (2012). ADHD-like symptoms and attachment in internationally adopted children. Attachment and Human Development, 14(4), 405-423. Askeland, K. G., Hysing, M., Aarø, L. E., Tell, G. S., & Sivertsen, B. (2015). 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(2016). Growing up unequal: Gender and socioeconomic differences in young people’s wealth and Well-being. Health Behaviour in School-aged Children (HBSC) study: International report from the 2013/2014 survey. WHO Regional Office for Europe. Copenhagen: Health policy for children and adolescents. Juffer, F., & Van IJzendoorn, M. H. (2005). Behavior problems and mental health referrals of international adoptees. Journal of the American Medical Association, 293(20), 2501. Kessler, R. C., Petukhova, M., Sampson, N. A., Zaslavsky, A. M., & Wittchen, H. U. (2012). Twelve‐month and lifetime prevalence and lifetime morbid risk of anxiety and mood disorders in the United States. International Journal of Methods in Psychiatric Research, 21(3), 169-184. Landgren, M., Andersson Grönlund, M., Elfstrand, P. O., Simonsson, J. E., Svensson, L., & Strömland, K. (2006). Health before and after adoption from Eastern Europe. Acta Paediatrica, 95(6), 720-725. Lindblad, F., Weitoft, G. R., & Hjern, A. (2010). ADHD in international adoptees: A national cohort study. European Child Adolescent Psychiatry, 19(1), 37–44. March, K. (1995). Perception of adoption as social stigma: Motivation for search and reunion. Journal of Marriage and the Family, 57(3), 653-660. Marion, D., Laursen, B., Zettergren, P., & Bergman, L. R. (2013). Predicting life satisfaction during middle adulthood from peer relationships during mid-adolescence. Journal of Youth and Adolescence, 42(8), 1299-1307. Matthews, J. A., Tirella, L. G., Germann, E. S., & Miller, L. C. (2016). International adoptees as teens and young adults: family and child function. Early Child Development and Care, 186(9), 1453-1465. McGinnis, H., Livingston, S., Ryan, S., & Howard, J. A. (2009). Beyond culture camp: Promoting healthy identity formation in adoption. New York: Evan B. Donaldson Adoption Institute. Table 2. Mean comparison and effect sizes in the non-adoptee reference group and adoptees. N Mean Mean 95% CI SD t p d Lower Upper Life satisfaction Reference 18896 0.02 0.01 0.04 0.96 1.92 .149 0.12 Adoptees 223 -0.10 -0.28 0.05 1.24 HRQL Reference 18896 0.02 0.01 0.03 0.99 2.07 .052 0.14 Adoptees 223 -0.12 -0.27 0.02 1.12 Family support Reference 18896 0.02 0.01 0.04 0.97 -0.05 .965 0.01 Adoptees 223 0.03 -0.11 0.15 0.97 Family satisfaction Reference 18896 0.02 0.01 0.04 0.96 1.86 .149 0.12 Adoptees 223 -0.10 -0.26 0.06 1.22 Friend support Reference 18896 0.02 0.01 0.04 0.98 2.08 .063 0.13 Adoptees 223 -0.11 -0.26 0.03 1.09 Friend satisfaction Reference 18896 0.02 0.01 0.03 0.96 4.63 .002 0.31* Adoptees 223 -0.28 -0.47 -0.11 1.34 School satisfaction Reference 18896 0.01 -0.01 0.02 0.99 -2.37 .015 0.15 Adoptees 223 0.16 0.03 0.29 1.00 Classmate support Reference 18896 0.02 0.01 0.04 0.97 1.24 .238 0.08 Adoptees 223 -0.06 -0.20 0.07 1.05 Teacher support Reference 18896 0.01 0.00 0.03 0.98 0.63 .556 0.04 Adoptees 223 -0.03 -0.16 0.12 1.07 Note. HRQL = Health-Related Quality of Life. *small effect size. Table 3. Mean comparison and effect sizes in the non-adoptee reference group (R), domestic adoptees (D) and intercountry adoptees (I). N Mean Mean 95% CI SD Posthoc p d Lower Upper Life satisfaction Reference 18896 0.02 0.01 0.03 0.96 R-I .467 0.06 International 142 0.08 -0.10 0.25 1.01 R-D .010 0.47* Domestic 81 -0.43 -0.78 -0.10 1.51 I-D .008 0.42* HRQL Reference 18896 0.02 0.01 0.03 0.99 R-I .958 0.00 International 142 0.02 -0.14 0.19 1.01 R-D .006 0.37* Domestic 81 -0.35 -0.65 -0.10 1.25 I-D .018 0.34* Family support Reference 18896 0.02 0.01 0.04 0.97 R-I .208 0.09 International 142 0.11 -0.04 0.25 0.89 R-D .228 0.14 Domestic 81 -0.12 -0.37 0.10 1.07 I-D .080 0.24* Family satisfaction Reference 18896 0.02 0.01 0.04 0.96 R-I .815 0.02 International 142 0.00 -0.20 0.17 1.14 R-D .069 0.30* Domestic 81 -0.27 -0.59 0.04 1.36 I-D .137 0.22 Friend support Reference 18896 0.02 0.01 0.04 0.98 R-I .048 0.18 International 142 -0.16 -0.35 0.01 1.09 R-D .653 0.05 Domestic 81 -0.03 -0.27 0.21 1.07 I-D .412 0.12 Friend satisfaction Reference 18896 0.02 0.01 0.03 0.96 R-I .011 0.28* International 142 -0.25 -0.46 -0.04 1.29 R-D .026 0.36* Domestic 81 -0.33 -0.65 -0.03 1.41 I-D .651 0.06 School satisfaction Reference 18896 0.01 -0.01 0.02 0.99 R-I .003 0.24* International 142 0.25 0.08 0.41 0.97 R-D .977 0.01 Domestic 81 0.00 -0.23 0.22 1.03 I-D .070 0.25* Classmate support Reference 18896 0.02 0.01 0.04 0.97 R-I .026 0.20* International 142 -0.17 -0.35 0.00 1.05 R-D .303 0.13 Domestic 81 0.15 -0.08 0.36 1.03 I-D .029 0.31* Teacher support Reference 18896 0.01 0.00 0.03 0.98 R-I .862 0.02 International 142 0.03 -0.13 0.20 1.01 R-D .262 0.14 Domestic 81 -0.13 -0.38 0.12 1.17 I-D .282 0.15 Note. HRQL = Health-Related Quality of Life. *small effect size. Table 4. Mean comparison and effect sizes in the non-adoptee reference group (R) and three birth areas selected: Asia (A), Latin America (L), and East Europe (E). N Mean Mean 95% CI SD Posthoc p d Lower Upper Life satisfaction Reference 18896 0.02 0.01 0.03 0.96 R-A .218 0.14 Asia 56 0.15 -0.07 0.37 0.80 R-L .174 0.27* R-E .327 0.17 Latin America 30 0.28 -0.15 0.66 1.09 A-L 1.000 0.14 A-E 1.000 0.31* East Europe 40 -0.14 -0.51 0.19 1.14 L-E .457 0.38* HRQL Reference 18896 0.02 0.01 0.03 0.99 R-A .575 0.08 Asia 56 0.10 -0.19 0.36 1.02 R-L .550 0.12 R-E .127 0.23* Latin America 30 0.14 -0.28 0.52 1.09 A-L 1.000 0.04 A-E .515 0.32* East Europe 40 -0.21 -0.52 0.08 0.95 L-E .815 0.35* Family support Reference 18896 0.02 0.01 0.04 0.97 R-A .030 0.23* Asia 56 0.24 0.02 0.42 0.73 R-L .450 0.12 R-E .801 0.04 Latin America 30 0.14 -0.21 0.44 0.90 A-L 1.000 0.13 A-E .601 0.30* East Europe 40 -0.02 -0.40 0.28 1.02 L-E .909 0.17 Family Reference 18896 0.02 0.01 0.04 0.96 R-A .588 0.08 satisfaction Asia 56 0.10 -0.21 0.34 1.01 R-L .963 0.02 R-E .386 0.17 Latin America 30 0.04 -0.49 0.45 1.26 A-L 1.000 0.06 A-E .792 0.22* East Europe 40 -0.14 -0.49 0.20 1.18 L-E 1.000 0.15 Friend support Reference 18896 0.02 0.01 0.04 0.98 R-A .038 0.27* Asia 56 -0.24 -0.50 0.01 0.98 R-L .334 0.18 R-E .120 0.30* Latin America 30 0.20 -0.18 0.52 0.99 A-L .205 0.45* A-E 1.000 0.03 East Europe 40 -0.27 -0.65 0.09 1.23 L-E .079 0.42* Friend satisfaction Reference 18896 0.02 0.01 0.03 0.96 R-A .016 0.37* Asia 56 -0.34 -0.65 -0.08 1.07 R-L .632 0.11 R-E .214 0.25* Latin America 30 0.13 -0.40 0.54 1.36 A-L .114 0.40* A-E 1.000 0.10 East Europe 40 -0.22 -0.66 0.14 1.29 L-E .218 0.27* School satisfaction Reference 18896 0.01 -0.01 0.02 0.99 R-A .048 0.24* Asia 56 0.25 -0.01 0.49 0.89 R-L .069 0.34* R-E .484 0.11 Latin America 30 0.35 -0.04 0.72 1.09 A-L 1.000 0.10 A-E 1.000 0.14 East Europe 40 0.12 -0.21 0.43 1.02 L-E 1.000 0.22* Classmate support Reference 18896 0.02 0.01 0.04 0.97 R-A .413 0.11 Asia 56 -0.09 -0.40 0.17 1.09 R-L .681 0.07 R-E .006 0.45* Latin America 30 0.09 -0.23 0.41 0.89 A-L .779 0.18 A-E .341 0.31* East Europe 40 -0.42 -0.77 -0.10 1.03 L-E .043 0.53** Teacher support Reference 18896 0.01 0.00 0.03 0.98 R-A .898 0.03 Asia 56 0.04 -0.24 0.27 0.97 R-L .061 0.30 R-E .203 0.19 Latin America 30 0.30 -0.01 0.62 0.88 A-L .213 0.28* A-E 1.000 0.22* East Europe 40 -0.18 -0.52 0.13 1.04 L-E 0.57 0.50** Note. HRQL = Health-Related Quality of Life. *small effect size. **medium effect size