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Transition to adoptive parenthood: a concept analysis

10 January 2022

Tracey Long, Catriona Jones, Julie Jomeen and Colin R Martin define transition to adoptive parenthood and identify associated experiences and challenges, when becoming parents by adoption. 

Research summary

  • This paper aims to conceptualise transition to adoptive parenthood.
  • The transition is acknowledged in universal health services and recognised in the role played by community practitioners, in particular health visitors, within ‘high-impact area 1’.
  • The specific needs of transition to adoptive parenthood can be overlooked or conflated with transition to biological parenthood. 
  • A literature review was undertaken and, in line with Rodgers (2000), antecedents, attributes and consequences were identified. 
  • Understanding the transition to adoptive parenthood through concept analysis has been useful in highlighting to community practitioners the importance of context when considering adoption and also the circumstances preceding adoption (antecedents) as a route to parenthood.
  • The transition to adoptive parenthood is contextual and should therefore be understood in the context of the situation and circumstance of those becoming parents.

Introduction

Becoming a parent is a key life transition, often referred to as transition to parenthood. Transition to parenthood is a commonly used term within child and family literature (Barimani et al, 2017; Parfit and Ayres, 2014; Deave et al, 2008), and refers to the period following the birth of the first baby (Doss and Rhoades, 2017) and the early weeks (Institute of Health Visiting (IHV), 2021). It is also acknowledged in universal health services (Local Government Association, 2019) and recognised in the role played by community practitioners, in particular health visitors (HVs) within high-impact area 1 and supporting the transition to parenthood (Public Health England – PHE, 2021a) and preconception care (IHV, 2019). In the case of adoption, when parents don’t experience ‘preconception’ or the ‘birth of the first baby’, and when the ‘early weeks’ are experienced differently, the transition to parenthood is less clear.   

The transition to adoptive parenthood is lacking in definition, and risks being grouped with the transition to biological parenthood. This could result in specific needs being overlooked or not understood in the context of preconceived ideas or assumptions. An example is made by Purse (2019), who reported not being asked about how they were coping or their feelings, but was instead considered to be coping because they had been “carefully selected for the adoption task”. Instead, feelings of being an outsider and in crisis were experienced (Purse, 2019). This highlights the importance of understanding the transition to adoptive parenthood as a distinct experience.

This paper shares findings from a concept analysis undertaken to advance knowledge of transition to adoptive parenthood. Concept analysis is an activity whereby “concepts, their characteristics and relations to other concepts are clarified” (Nuopponen et al, 2010), and the basic elements of a concept are examined (Walker and Avant, 2019). Different frameworks of concept analysis have been used to inform nursing or healthcare practice, including Morse (2000), Rogers (2000), and Walker and Avant (2019). This concept analysis offers a working definition of the transition to adoptive parenthood, which should inform services for children, young people and families. It is deemed relevant for HVs, school nurses, looked-after children’s nurses, community nursery nurses, and other practitioners working with adoptive parents. 


Method 

This concept analysis uses the evolutionary approach of Rodgers (2000), thought relevant for the development of knowledge in nursing science (Tofthagen, 2010) and when considering a concept that can change over time and be influenced by the context in which it is used (Rodgers, 2000). This was important when understanding the ‘transition to adoptive parenthood’, related to policy, law and understanding within different disciplines, including health and social care. 

The six primary activities of Rodgers (2000) are followed. They are cited as: 1. Identify the concept of interest and associated expressions (including surrogate terms). 2. Identify and select an appropriate realm (setting and sample) for data collection. 3. Collect data relevant to identify: a) the attributes of the concept; and b) the contextual basis of the concept, including interdisciplinary, sociocultural, and temporal (antecedent and consequential occurrences) variations. 4. Analyse data regarding the above characteristics of the concept. 5. Identify an exemplar of the concept, if appropriate. 6. Identify implications, hypotheses, and implications for further development of this concept (Rodgers, 2000). According to Rodgers, these activities are carried out simultaneously throughout the concept analysis, and are therefore not steps in a process but rather tasks to be undertaken. This reflects how this concept analysis was developed; however, it is important to note that for the purpose of this paper, the primary activities are presented in a sequential manner.    

The first primary activity, identification of the concept of interest, was a relatively easy first step in the concept analysis process, informed by practice and academia. Understanding the ‘transition to adoptive parenthood’ was deemed important to underpinning subsequent research. Due to a lack of definition of the transition to adoptive parenthood, words were reviewed separately. This identified: transition “a change from one form or type to another, or the process by which this happens”; adoptive “an adoptive parent is one who has adopted a child”; and parenthood “the state of being a parent” (Cambridge Dictionary, 2021). These, when considered alongside their synonymous words (Figure 1) gave insight into the concept and promoted wider understanding.   

Figure 1. Synonymous words 

It was important to understand significant literature and therefore a review of books was undertaken, identifying seminal work and key authors considered important for the concept analysis. Kirk (1984), whose findings included role handicaps of adoptive parents when adopting children, Goldberg (2010), who explored the differing parenthood trajectory for adoptive parents, and Goldberg (2012), which highlighted the experiences and challenges for adoptive dads identifying as gay. 

A review of the literature was also undertaken, shown in Figure 2. No date limiter was applied, because all literature, regardless of age, was included if it contributed to increasing the knowledge of transition to adoptive parenthood as a concept or supported the development of a definition. English language papers were however selected; 40 academic papers were identified. 

Figure 2. Literature review flow chart 

Table 1. Papers included in the concept analysis 


 


Data analysis

Rodgers (2000) suggests that the concept analysis is undertaken using thematic analysis. This concept analysis utilised thematic analysis, chosen because it was considered a flexible yet structured approach to conceptualise transition to adoptive parenthood by identifying major themes (Figure 3). It incorporated six phases: data familiarisation, initial code generation, searching for themes, reviewing themes, defining and naming themes, and report production (Braun and Clarke, 2006). Related or surrogate terms, antecedents, attributes and consequences were identified (Figure 3, Table 2). This process required reflection and continuous review. 

Figure 3. Conceptualisation of transition to adoptive parenthood  

Table 2. Related or surrogate terms 


Antecedents

In line with Rodgers (2000), antecedents are identified. Rodgers (1989) describes antecedents as events or situations preceding an instance of the concept occurring. Understanding the antecedents of the transition to becoming adoptive parents is important for informing discussions with adoptive parents during the needs assessment process, and is supportive of the community practitioner in considering parental experience prior to the placement of a child. The following are antecedents of transition to adoptive parenthood:

Identity transformation 

A priority of becoming parents was present (Moyer and Goldberg, 2017), with parenthood being desired from the start of marriage (Bejenaru and Roth, 2012) and for some expected as a sequel to marriage (Daly, 1988). The influence of family, friends, neighbours, service providers, religion and media (Willis-Hepp and Hrapczynski, 2019) is acknowledged. Daly (1988) suggests that before adoptive parents can identify with adoptive parenthood they need to relinquish biological parenthood, requiring a transformation of identity. 

Decision to become a parent by adoption

The decision to become a parent by adoption must occur before the transition to parenthood takes place. This decision was highlighted in numerous papers (Messina and D’Amore, 2018; Dance and Farmer, 2014; Bejenaru and Roth, 2012; Weir, 2003; Daly, 1988). Weir highlighted infertility as the main reason for the decision to adopt.

Application, assessment and training 

Dance and Farmer (2014) highlighted the application process and the adoption process. The latter was also referred to in several other papers. (Messina and D’Amore, 2018; Gianino, 2008; Ryan and Whitlock, 2007; Daniluk and Hurtig-Mitchell, 2003).

Exclusive decisions 

Adoptive parents are required to make decisions, exclusive to adoption, including child characteristics (Tasker and Wood, 2016; Gianino, 2008), level of disability, behaviour, and the number of children (Dance and Farmer, 2014), regarding the adoption agency (Gianino, 2008) and pertaining to parental history of drug or mental health. 

Attributes  

Attributes are defined as characteristics which provide a distinguishable description of the concept (Rodgers, 2000). The “identification of the attributes of the concepts represents the primary accomplishment of concept analysis” (Rodgers, 2000) and therefore are considered central to the analysis. Understanding the attributes of the transition to adoptive parenthood is considered important and beneficial for community practitioners, because it differentiates it from transition to parenthood, by birth. Several attributes were identified.

Becoming parent by order of court

Unlike biological parents, adoptive parents become parents by order of court. This forms a ‘legal relationship’ (Ryan and Whitlock, 2007), requiring assessment of parental fitness (Senecky et al, 2009). 

Becoming parent without pregnancy

Adoptive parents are denied the pregnancy experience. Issues with this were identified, including a lack of due date (Sandelowski et al, 1991), no cues afforded by pregnancy (Brodzinsky and Huffman, 1988) and lack of scans and other sources of information (Sandelowski et al, 1993).

Becoming parents to an infant or child (not baby)

Sandelowski et al (1993) highlight that adoptive parents understand that their child would not be a newborn. McKay and Ross (2010) highlighted that adoptive parents can have any aged child placed with them. Several age groups for children adopted were identified, including under or mostly under one-year-olds (Daniluk and Hurtig-Mitchell, 2003; Keopkee et al, 1991), an average age at placement being two years and seven months (Meakings et al, 2016). Ages were wide-ranging, from newborn to 15 years old (Moyer and Goldberg, 2017), two months of age to 11 years old (Messini and D’Amore, 2018) and between five months and five years of age (Bejenaru and Roth, 2012). 

Becoming parents to a child not biologically their own

This attribute could raise issues about meeting the child (Lewis, 2018; Bejenaru and Roth, 2012), parental legitimacy (Daniluk and Hurtig-Mitchell, 2003) and child responsibility (Bejenaru and Roth, 2012; McKay and Ross, 2010). Furthermore, ‘issues’ or ‘needs’ may present with the children, from historical trauma (Foli et al, 2017), past abuse or neglect (Meakings et al, 2016, Tasker and Wood, 2016; Brodzinsky and Huffman, 1988) or in utero exposure to drugs, alcohol and domestic violence, or from having different homes prior to placement (Meakings et al, 2016). Issues or needs identified include “serious and enduring health problems or disability”, alongside development, emotional and behavioural wellbeing needs (Meakings et al, 2016), development and behaviour issues (Gianino, 2008) and health needs (Moyer and Goldberg, 2017; Bejenaru and Roth, 2012).   

Unpredictable timeline 

An unpredictable timeline was highlighted in several papers, (Goldberg et al, 2014; Gair, 1999), from sudden and unpredictable (McKay and Ross, 2010) to being experienced over years (Ryan and Whitlock, 2007). Examples of this varied timeline were identified (Frost and Goldberg, 2020a; Dance and Farmer, 2014; Weir, 2003; Sandelowski et al, 1993; Sandelowski et al, 1991), highlighting several issues, including management of short-notice adoptions and adoptions occurring over a longer time.

Exclusive support requirements

As with non-adoptive parents, adoptive parents were found to have needs associated with children’s health and development – for example, eating, sleeping and toileting (Meakings et al, 2016). However, exclusive support needs were evident, relating to the child’s history and therapy (Goldberg et al, 2014), identity (Daniluk and Hurtig-Mitchell, 2003), foster carers (Lewis, 2018; Bejenaru and Roth, 2012), and communication with the child, (Bejenaru and Roth, 2012). Specialised support needs, including neurological (Moyer and Goldberg, 2017), psychological (Bejenaru and Roth, 2012), speech and language, physiotherapy, podiatry, audiology, ear nose and throat and ophthalmology (Meakings et al, 2016), attachment and behavior (Goldberg et al., 2014) and adoption specific communications (Daniluk and Hurtig-Mitchell, 2003) were also highlighted, alongside the promotion of a child’s identity, birth family contact, financial and legal issues (Meakings et al, 2016).  

Transition to adoptive parenthood, in context 

In line with Rodgers (2000), it was important to understand the context of the transition to adoptive parenthood. The interdisciplinary context was identified in various disciplines, including applied sciences and medicine; however, it was prevalent within health papers, especially psychology and nursing. 

From a sociocultural context, several dimensions were identified. Adoptive parents were found to be typically older than biological parents (Canzi et al, 2019b, Keopke et al, 1991; Levy-Shiff et al, 1990), demonstrated by Calvo et al (2015), who highlighted a mean age for 38.3 for adoptive couples.  Adoptive parents were found to have positive educational achievement and employment. They had above-average education and occupational status levels (Daly, 1988) and were highly educated (Gianino, 2008; Ryan and Whitlock, 2007). 

There was a predominance, when considering ethnicity, of Caucasian, white or white British adoptive parents (Frost and Goldberg, 2020b; Foli et al, 2017; Moyer and Goldberg, 2017; Martin et al, 2016; Tasker and Wood, 2016; Calvo et al, 2015; Goldberg et al, 2014; Lavner et al, 2014; McKay and Ross, 2010; Brown et al, 2009; Gianino, 2008; Ryan and Whitlock, 2007; Daniluk and Hurtig-Mitchell, 2003; Weir, 2003). 

The sexual orientation that adoptive parents identified with included gay or lesbian (Goldberg and Smith, 2011 Brown et al, 2009), lesbian (Ryan and Whitlock, 2007), gay (Gianino, 2008) or lesbian, gay and heterosexual couples (Goldberg and Smith, 2009; Goldberg et al, 2010; Goldberg et al, 2014). Some adoptive parents experienced infertility prior to adoption (Bejenaru and Roth, 2012; Brodzinsky and Huffman, 1988; Daly, 1988; Sandelwoski et al, 1991; Sandelowski et al, 1993; South et al, 2019; Tasker and Wood, 2016). It is considered likely that contextual variables will affect decisions made by the parents, pre and post adoption (Willis Hepp and Hrapczynski, 2019), therefore, the examples given could be used to inform community practice, when considering the parents holistically.  


Consequences  

Consequences follow the occurrence of the event (Rodgers and Knafl, 2000), important for community practitioners when supporting adoptive parents to care for their children. The consequences of transition to adoptive parenthood include the following: 

Appreciation of parenthood

Several papers identifying consequences of the transition to adoptive parenthood were identified, including Canzi et al (2019a), Bejenaru and Roth (2012), Brown et al (2009), Gianinio (2008), Daniluk and Hurtig-Mitchell (2003), Levy-Shiff et al (1990) and Brodzinsky and Huffman (1988), highlighting anticipation, the dream of parenthood as a lifelong goal being achieved, and the associated satisfaction and sense of accomplishment. It is argued, however, that this can lead to adoptive parents minimising difficulties (Canzi et al, 2019a) and rationale for not reporting challenges (McKay and Ross, 2010). 

Wide-ranging emotions and feelings

Wide-ranging emotions and feelings identified included being thrilled (Keopke et al, 1991), happiness (Daniluk and Hurtig-Mitchell, 2003), and joy (Tasker and Wood, 2016) to feeling pressurised (Dance and Farmer, 2014), dismissed (Daniluk and Hurtig-Mitchell, 2003) and reassured (Meakings et al, 2016). Other parents experienced guilt (Messina and D’Amore, 2018), fear and anxiety (McKay and Ross, 2010), and worry (Meakings et al, 2016), while others reported stress (Canzi et al, 2019a; Canzi et al, 2019b; Lewis, 2018; Lavner et al, 2017; Moyer and Goldberg, 2017; Martin et al, 2016) and sadness (Gianino, 2008). Of particular note was missing out on ‘cradle years’ (Moyer and Goldberg, 2017), behaviour-related feelings (Frost and Goldberg, 2020a) or lagging behind others because of infertility (Weir, 2003), considered instances of the ‘unique emotions and concerns’ experienced during transition to adoptive parenthood (Fontenot, 2007). 

Mental health effect

Mental health consequences were cited in several papers (Foli et al, 2017; Lavner et al, 2014; Goldberg et al, 2010; McKay et al, 2010; Levy-Shiff et al, 1991;). Contrasting views were highlighted, from being quite a happy time (Levy-Shiff et al, 1991) to being of no great difference when considering adoptive and biological mothers (Keopke et al, 1991) and no significant difference in the rates of depression (Senecky et al, 2009). Comparisons to postnatal depression were however made (Gair, 1999), with mothers reporting severe feelings, including that of killing the baby. 

Physical health impact

Physical health was poorly documented and was only cited in a few papers (Foli et al, 2017; South et al, 2012; Daniluk and Hurtig-Mitchell, 2003; Gair, 1999; Keopke et al, 1991). 

Relationship influence

Relationship influence was identified as a consequence of the transition to adoptive parenthood, including changes to the relationship (Frost and Goldberg et al, 2020a), relationship quality (Canzi et al, 2019a) and relationship focus (Gianino, 2008). Other positive consequences were however highlighted. Ceballo et al (2004) discussed the chosen act of adoption causing less disharmony, and Martin et al (2016) found marriages had positive perception and satisfaction in the early months following adoption.  


Towards a definition

Considering the findings from the concept analysis, alongside the defining attributes, transition to adoptive parenthood is defined as: ‘a transitional period, for an unspecified period of time, whereby a childless person (or couple), or a person (or couple) wishing to enlarge a pre-existing family, following a formal application and period of assessment, become the legal parent/s of a child/ren, not biologically their own’. 

This definition may be useful when considering the transition to adoptive parenthood within community practice, as it differentiates it from that experienced by birth parents. HVs in particular may reflect upon on this, within their role within high-impact area 1 and supporting the transition to parenthood. 

In line with Rodgers’ (2000) approach, which suggests providing (where appropriate), an exemplar/s of the concept to practically demonstrate the concept, a number could be offered to address the differing contextual elements. These include (but are not exclusive to) first or second child adoptions, single or sibling group adoption, foster to adopt adoptions, international or welfare adoption, same-sex couple or heterosexual adoptions, step parent or foster parent adoptions, mixed race adoptions, and the adoption of children with health needs. The exemplar (Table 3) for this concept analysis seeks to offer a practical example that can be considered alongside the definition, useful for those working with adoptive parents. 

Table 3. Exemplar (not based on a real couple) 

David (39) and Nicky (38) had dreamt of becoming parents when they married in their late 20s, and following an extensive period of trying to conceive naturally, they sought medical help. 

Following a diagnosis of infertility, David and Nicky were referred for in vitro fertilisation (IVF). Nicky became pregnant following three IVF treatments but unfortunately miscarried in early pregnancy. David and Nicky took time to decide what they wanted to do next but they could not imagine their lives without children in it. David shared with Nicky how he could no longer watch her going through any more treatment, nor could he watch her experience further pain form losing their babies. They made a decision to become adoptive parents and made an appointment to discuss this further. 

David, now 41 and Nicky, now 40, completed the application, underwent a period of assessment and training and were subsequently approved as adoptive parents. David and Nicky felt they could adopt more than one child as they did not want undertake the adoption process twice. They were matched quickly with sisters, Jenny aged three and Julie aged five. Nicky took time off from work and David returned to work following his adoption leave. Supported by social workers, they shared that they were matched with their daughters, reflecting upon becoming parents quickly. They discussed the challenges associated with negotiating shopping, housework, alongside pre-existing routines that the children arrived with. They shared that, following the court order, apart from some minor behavioural difficulties, no further support was required.

 


Discussion

The concept analysis, using Rodgers’ (2000) evolutionary approach, offers a practical example of the transition to adoptive parenthood alongside the development of an operational definition of the transition to adoptive parenthood. It identified antecedents (identity transformation; the decision to become a parent by adoption; application, assessment and training; exclusive decisions), attributes (becoming parents by order of court without pregnancy, to an infant/child and not a baby, not biologically their own, with unpredictable timelines and exclusive support requirements), and consequences (the appreciation of parenthood; wide ranging emotions and feelings; the effect on mental health; the physical health impact; relationship influence) when becoming parents by adoption.  

It has highlighted the unique nature of transition to adoptive parenthood, giving insight into the distinctive experiences and exclusive decisions facing adoptive parents. An example is becoming parents by order of court, as this is the polar opposite to the experience of biological parents who, generally, become parents without any legal intervention. The concept analysis highlighted ‘context’, recognising that no two experiences will be the same, but vary depending on multiple factors, including type of adoption, child/parental characteristics and demographics. Similarities are made here with transition to parenthood for biological parents.  

HVs are ideally placed to support the ‘unique experiences and challenges as a result of becoming parents through adoption, not biology’ (Long et al, 2021). They have ‘in-depth knowledge and advanced skills of assessment, therapeutic communication and care management’ (Public Health England, 2021b), fundamental for the assessment of adoptive parents’ mental health and wellbeing. Their value is also recognised when supporting adoptive parents to understand what is normal, by providing context to the concerns raised (Meakings et al, 2016). However, it is important to reflect on this further, considering when HVs begin their contact with adoptive parents: is this before or after family formation? It is highly likely that they first see adoptive parents after family formation. If so, this is problematic, as the creation of a family by adoption remains the creation of a family, like that through biology, requiring assessment and support. 


Recommendations

Transition to adoptive parenthood is contextual and should therefore be understood in the context of the situation and circumstance of those becoming parents. Further research, considering transition to adoptive parenthood from a health perspective, should explore the individual context in which this is positioned. Furthermore, transition to adoptive parenthood should be reflected in contemporary health practice and policy. 


Conclusion

This paper has conceptualised transition to adoptive parenthood, offering a definition which differentiates it from other forms of transition to parenthood. In the same way as first-time biological parents, first-time parents by adoption make a transition from being ‘childless’ to being ‘with child’, resulting in change. This change can impact on identity, relationships, roles, finance and for some have a detrimental effect on health and wellbeing, all of which could impact on child, family and adoption outcomes. It is of paramount importance that the health needs of parents are fully considered, and addressed through robust health needs assessment, supporting parents to make a safe transition and be prepared for this important and significant life event.  


Acknowledgement

The authors would like to acknowledge all community practitioners, who through their dedication and commitment, skillfully and professionally support parents across the transition to parenthood period. 


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