Children and Youth Services Review 33 (2011) 23422346

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Children and Youth Services Review

j o u r n a l h o m e p a g e : w w w. e l s ev i e r. c o m / l o c a t e / c h i l d yo u t h

Children adopted from China: Attachment security two years later

Nancy J. Cohen , Fataneh Farnia
Hincks-Dellcrest Centre and Gail Appel Institute, Department of Psychiatry, University of Toronto, 114 Maitland Street, Toronto, Ontario, Canada M4Y 1E1

a r t i c l e i n f o a b s t r a c t

Article history: Background: This study continues the examination of the process of attachment formation of mothers and
Received 29 April 2011 their adopted Chinese daughters two years postadoption.
Received in revised form 4 August 2011 Method: 30 children adopted from China (mean age = 13.6 months at adoption) were assessed and followed
Accepted 7 August 2011 two years following adoption. They were compared to 31 nonadopted Canadian girls of similar age and family
Available online 12 August 2011
background. In earlier reported longitudinal studies of the adopted children, maternal reports of attachment
security were employed. In the current study the Strange Situation Procedure was used.
Keywords:
Adoption
Results: Adopted children show signs of having a secure attachment with their mothers two years following
Attachment adoption. There was some evidence that disorganized attachment characterized these children more so than
Infants for children in the comparison group.
China Conclusions: The moderate degree of emotional deprivation experienced by Chinese adoptees does not hinder
Institutionalization their ability to form a new attachment with adoptive mothers. Attachment appears open to change, even after
Strange Situation Procedure a time when children should have already formed an attachment relationship and the change is maintained.
2011 Elsevier Ltd. All rights reserved.

1. Introduction (van den Dries, Juffer, van IJzendoorn, & Bakermans-Kranenburg,

Over the past two decades, many Western parents have adopted
children from China (Selman, 2009). Until recently, the relatively young
age at the time of most of these adoptions (approximately one year of
age) is particularly appealing to adoptive parents as they assume that
these children experienced less severe deprivation and consequently
were less affected by institutional experiences. Findings from prospec-
tive studies have provided support for this in that children adopted from
China have been shown to make rapid gains in physical growth, and
cognitive, motor, and language development within the rst six months
following adoption (Cohen, Lojkasek, Yaghoub Zadeh, Pugliese, & Kiefer,
2008). We also previously reported growth in attachment security in
infants adopted from China from their arrival into adoptive homes until
2 years later using mothers' ratings of their attachment relationships
(Cohen & Farnia, 2011; Pugliese, Cohen, Farnia, & Lojkasek, 2010). Yet,
the validity of self-report data on attachment can be questioned. In the
current study we examined the observed attachment quality of the same
children using the Strange Situation Procedure (SSP).
1.1. Institutional care, international adoption and attachment
There is a paucity of research on the process of attachment
formation in infants adopted from China. However, a meta-analytic
review of studies of a wide group of internationally adopted children
Corresponding author.
E-mail addresses: nancy.cohen@utoronto.ca (N.J. Cohen),
ffarnia@hincksdellcrest.org (F. Farnia).
2009) concluded that children placed in an adoptive home before one
year of age exhibited few socioemotional difculties or attachment
disturbances and were as securely attached as their nonadopted
peers. The Asian children included in the meta-analysis were placed
before their rst birthday, which was seen as a protective factor.
With respect to adoptions from China specically, the One-Child
policy implemented by the Chinese government to control population
growth has led to a large number of children being abandoned shortly
after birth. These babies tend to be girls due to a strong cultural value
for sons in China. Raised in government institutions, only some
children are earmarked for international adoption based on the
perception that they are healthy. Moreover, in general, children
adopted from China may have been exposed to less prenatal adversity,
such as poverty or drug abuse, and better prenatal care because they
were abandoned largely because of the one-child policy (Miller &
Hendrie, 2000). Currently, increasingly more children adopted from
China are older and have other special needs. However, when we
collected our data Chinese adoptees were considered to have one of
the lowest disabilities rates among internationally adopted children
(Kreider & Cohen, 2009).
Nonetheless, the ndings from our research showed that children
adopted from China, on average at 13 months of age, experienced
institutional deprivation. When assessed within approximately one
month of arrival to Canada they were physically smaller than
nonadopted peers in height, weight, and head circumference and
exhibited delays in cognitive and motor functioning (Cohen et al.,
2008). The children made rapid developmental gains with scores
falling within the expected age range by 6 months postadoption

0190-7409/$ see front matter 2011 Elsevier Ltd. All rights reserved.
doi:10.1016/j.childyouth.2011.08.006
 N.J. Cohen, F. Farnia / Children and Youth Services Review 33 (2011) 23422346
(Cohen et al., 2008). These developmental ndings are comparable to
those reported in studies whose samples included but were not
restricted to Chinese adoptees (Pomerleau et al., 2005; van IJzendoorn
& Juffer, 2007; van Londen, Juffer, & van IJzendoorn, 2007; Wilson,
Weaver, Cradock, & Kuebli, 2008). While the children in our sample of
Chinese adoptees were functioning within the average range on
developmental measures within six months of arrival to Canada, they
did not catch-up completely to Canadian peers from a similar family
background until two years postadoption (Cohen et al., 2008).
The initial assessments in our research program took place very early
in the motherchild relationship, within a month of the adopted
children's arrival to Canada and before the basic elements of attachment
were established. The Chinese adoptees were initially rated by their
mothers as less securely attached but also made rapid gains in this
regard during the rst six months following adoption. Not only did they
show an increase in secure attachment behavior but also a decrease in
inhibited behaviors (e.g., not actively seeking and accepting comfort
when distressed, not regulating emotions well). Further, using
interview data, the adopted children did not show disturbances of
attachment. From six months postadoption through the ensuing two
years, ratings of attachment security on the Attachment Security
Questionnaire (Chisholm, 1998) remained stable and continued to be
similar to those obtained from mothers of nonadopted children (Cohen
& Farnia, 2011; Pugliese et al., 2010). Moreover, there was no indication
of an increased risk of insecure attachment behaviors (i.e., avoidant or
resistant behaviors) according to mothers' reports. Maternal ratings are
not considered to be comparable with observational data, such as the
Strange Situation Procedure (SSP) and their validity can be questioned.
In the present study, which took place two years after adoption, we used
direct observations of attachment behavior using the Strange Situation
Procedure (SSP) to examine attachment security.
1.2. Study objectives
The objective of the current study was to examine the quality of
attachment in children adopted from China and, in particular, to
determine whether the adopted children show an elevated risk for
insecure or disorganized attachment two years postadoption. More-
over we were interested in knowing whether these children showed
an elevated risk for disorganized attachment as has been reported by
some investigators of internationally adopted children (e.g., van
Londen et al., 2007) and in meta-analytic review of studies that
investigated attachment in adopted children (e.g., van den Dries et al.,
2009). In the present study, adopted children were compared to a
nonadopted Canadian sample of children of the same age. Based on
earlier ndings on measures of attachment taken at arrival to Canada
and six months later, we hypothesized that children adopted from
China would not differ from nonadopted children of similar age in
attachment security measured by the SSP.
2. Method
This study is part of a larger longitudinal study of the health and
development of children adopted from China (Cohen et al., 2008), which
examined 70 infant girls adopted from China during the rst two years
following adoption. A stratied comparison group of 43 Canadian-born,
nonadopted, never institutionalized infant girls, matched for age and
family demographics was also studied. Mother's age and education, in
years, were used as the predictors of attachment security.
Data collection for the present study began 24 months after the
larger project started. The subsample reported here consisted of 31
adopted and 30 nonadopted infants and their families that joined the
project from that point forward. Comparisons were made between the
subsample and larger sample (n = 70) on demographic variables
(children's age at adoption, parental age, education level and income
level) and developmental measures (physical growth, mental and
2343
motor functioning). Mean age of adopted children in the subsample,
13.6 (SD= 3.6) and adopted children in the larger project, 13.03
(SD= 3.1) was signicantly different, t (68) = 2.29, p = .05. Further-
more, mothers of adopted children in the subsample were older than
mothers in the larger project, t (68)= 2.39, p = .02. These differences
suggest a change in the trends of adoption from China during the four-
year period in which data were collected for the larger project. During
the two-year period of data collection on attachment measures for the
present study the adoptions from China were slightly older children by
older mothers. There were no any signicant differences between the
mental and motor abilities of adopted children in the subsample and the
children in the larger project.
The adopted sample was recruited through two collaborating
adoption agencies, while the nonadopted children were recruited
though community advertisements. Although recruited from different
sources, both groups were volunteer samples. No compensation was
provided for participation to either group.
2.1. Sample
2.1.1. Adopted children
Initially, there were 32 adopted Chinese girls in the sample. Of
these children, 84% had received orphanage care only, 16% (n = 5)
experienced both orphanage and foster care, and only one child
received sole foster care. The ve children who experienced both
types of care had spent approximately ve months in institutional
care. Diagnostic analysis and data plots indicated that while the
developmental and attachment scores of these ve children were
within the range of the rest of the sample and t the overall trend, the
proles of the child who received foster care only did not t the
overall trend. Therefore, her data were excluded from further
consideration to avoid overestimation of the results. The nal sample
for this study consisted of 31 adopted girls with a mean age of
14.9 months (SD = 3.6; range: 10.222.3 months) at the start of the
study. Most children entered an institution as newborns and spent the
majority of their pre-adoptive life in an institution. The mean length of
institutional care was 12.3 months.
2.1.2. Nonadopted children
The comparison sample included 30 nonadopted Canadian-born
girls with a mean age of 13.6 months (SD = 2.9; range: 9.1
19.0 months). The children lived in English-speaking families and
represented children to whom the adopted children would be com-
pared in their communities.
The rationale for choosing the comparison group was carefully
considered. Previous research on the developmental outcomes of
internationally adopted children has used both adopted and non-
adopted comparison groups. Ideally, a group of children adopted in
Canada at approximately one year of age would have been used.
However, domestic infant adoptions in Canada have dramatically
decreased in the past 10 years. In addition, private adoptions usually
occur shortly after birth, and adoptions through social services
sometimes involve children with an increased risk for health concerns
(i.e., exposure to drugs, alcohol or abuse). Therefore, the recruitment of
healthy later-placed infants adopted in Canada at approximately one
year of age was not a realistic option. We also did not consider families
with Chinese heritage or new immigrant families in Canada as these
families often speak a language other than English at home. Thus, the
experiences of Chinese families living in Canada would not necessarily
be comparable to Canadian families adopting children from China and,
therefore, would not represent an appropriate comparison sample. We
chose as the comparison group, a sample of nonadoptive Canadian
families to match the demographics and background experiences of
families adopting children from China, as well as the environment in
which the adopted children will be raised. The data from the
nonadopted comparison sample were used as an estimate of a
2344 N.J. Cohen, F. Farnia / Children and Youth Services Review 33 (2011) 23422346

normative population because they presumably have already estab-
lished an attachment relationship with their mothers. These normative
data allow us to examine when during the trajectory the adopted
children form attachment relationships and catch-up to the nonadopted
children. As noted earlier, based on maternal report alone the
adopted and nonadopted children did not differ signicantly at
6-month follow-up.
2.2. Procedure
At each phase of the study, there were two appointments: (1) the in-
home parent interview and (2) the lab assessment. Adopted children
and their parents were visited within the rst month of arrival to Canada
(Initial) (or when recruited, in the case of nonadopted children) and
then again six, 12, and 24 months later. The adopted and nonadopted
groups underwent similar procedures at each time point. Children were
subsequently seen with their mothers in a research lab for the second
appointment where they participated in a developmental assessment
and at 24-month follow-up participated in the SSP.
The SSP was scored by a trained coder with 20% of the cases scored
by a second trained coder. Kappa statistics based on 20% of the data
are reported as evidence for inter-rater agreement, for all measures in
this study. Children were categorized as securely attached, insecurely
attached (avoidant, ambivalent), or disorganized. The Kappa statistics
yielded outstanding interrater reliability for secure attachment,
K = .981, p b .001, 95% CI [.842, 1.051], disorganized behavior,
K = .942, p b .001, 95% CI [.851, 1.043], and ambivalent, K = .952,
p = .001, 95% CI [.837, 1.045]. The two raters resolved coding issues
that emerged and came to a consensus through consultation.
3. Results
Distribution, skewness and kurtosis of the data were examined to
ensure that the assumptions for the different analyses were met.
Whenever the assumptions for parametric analyses were violated,
nonparametric tests were used.
3.1. Demographic characteristics of participants and their families

2.3. Measures Table 1 depicts descriptive analysis of demographic characteristics of

2.3.1. Attachment
Following the standard procedure for the Strange Situation Procedure
(SSP), the examiner read the instructions to the mother who then sat in a
chair and for 3 min read while the child explored. The mother responded
if the child approached her but did not initiate interaction. A stranger
then entered the room, sat silently for one minute, conversed with the
mother for a minute and then approached the child and invited her to
play. The mother then departed the room leaving the child with the
stranger (Episode 4). After 3 min the mother returned, greeted and
comforted the child if necessary and then returned to the chair to read.
After 3 min there was a second separation (Episode 6); the mother left
after saying good bye or providing some reason for leaving and the child
was left alone. After 3 min the stranger entered and comforted the child,
if necessary (Episode 7). After 3 min the mother returned and comforted
the child if necessary (reunion). The only difference in the procedure for
preschool children is that the 3 min separations were extended to 5 min.
Trained coders used the MacArthur Preschool Attachment Coding
system (Cassidy & Marvin, 1992) to score the SSP. It is important to
note that there were three instances in the adopted sample where the
SSP protocol could not be coded. These three children were so
distressed that the mother never left the room.
participants and their families. Parents in both the adopted and
nonadopted groups were generally university educated and within the
middle to upper socioeconomic levels. Adoptive mothers and fathers were
signicantly older than nonadoptive parents, mothers: t (62)=6.57,
p=.001; fathers: t (49)=2.94, p=.01. In addition, almost all parents of
the nonadopted sample (97%) were married, two-parent families,
whereas 38% of adoptive parents were single mothers, Z (64)=3.39,
p=.001. Our sample of older, highly educated parents of middle to upper
socioeconomic levels were characteristic of adoptive parents reported in
the literature (e.g., Hellerstedt et al., 2008; O'Connor et al., 2003; van den
Dries, Juffer, van IJzendoorn, & Bakermans-Kranenburg, 2010).
3.2. Distribution of attachment categories
For the most part children in the adopted and comparison groups
were categorized as securely attached. The majority of adopted
children were securely attached (n = 20; 71%).
Of the remaining adopted children, 6 (21%) were classied as
disorganized, and 2 (7%) were classied as ambivalent two years
postadoption. Data from three cases of adopted children were
uncodable and are not included in the subsequent analyses. None of
the adopted children was classied as avoidant. Similar to the adopted

Table 1
Demographic characteristics of participants and their families.

Adopted Nonadopted
(n = 31) (n = 30)

Variable M SD M SD F (1, 59)

Age at adoption (months) 13.6 3.6

Length of time in institution (months) 12.3 4.9
Age at initial (months) 14.9 3.6 13.6 3.0 2.34
Age at 2-year follow-up (months) 38.9 3.9 37.6 3.6 1.89
Mother's age 42.3 5.0 34.6 4.9 36.75
Father's agea 42.1 6.4 37.2 6.0 7.35
Mother's education (years) 15.6 2.0 15.1 1.9 .97
Father's education (years) 15.1 2.6 13.9 1.5 4.50

Marital status (% married) 65% 97% 9.97

Child's placement in family (% of only child) 72% 69% 1.02

Note.
a
n = 20 in adopted group as 11 families were single-mother households.
Correlation is signicant at the 0.05 level (2-tailed).
Correlation is signicant at the 0.01 level (2-tailed).
Correlation is signicant at the 0.001 level (2-tailed).
 N.J. Cohen, F. Farnia / Children and Youth Services Review 33 (2011) 23422346
sample, the majority of nonadopted children were securely attached
(n = 24, 80%). Of the remaining nonadopted children, 2 (7%) were
classied as disorganized, 2 (7%) were classied as ambivalent and 2
(7%) were classied as avoidant.
3.3. Mothers' age and education and attachment behaviors
Logistic regression analyses were performed to examine the
association between mothers' age and education with their ratings
of their children's attachment behaviors. Results are shown in Table 2.
As can be seen, neither mothers' age nor education contributed to
their ratings of their children's attachment behaviors.
3.4. Behavior during stress episodes
Child behavior during the four stress episodes was rated on a 5-
point scale with 1 indicating display of a low amount of distress.
MannWhitney Test for two independent samples was used to
compare ratings of observed attachment behaviors of adopted and
nonadopted children under the three stressful episodes (Episodes 4, 6,
and 7) of the SSP. There were no signicant group differences in any of
the three episodes. Generally, reactivity to stress decreased over the
successive episodes.
3.5. Type of care and distress episodes
MannWhitney test for two independent samples was used to
compare observed attachment in stressful episodes of the SSP in
adopted children who received institutional care only (n = 26) with
those who experienced both institutional and foster care (n = 5). No
signicant differences were found between the two groups on any of
the three stress episodes two years postadoption, Z = 1.046,
p = .295, Z = .341, p = .733, Z = .707, p = .479 for episodes 4, 6,
and 7, respectively.
4. Discussion
Our previous research showed that even in the rst six months
following adoption mothers reported that attachment security
increased sharply. Moreover, by that time, maternal ratings of
attachment security in adopted and nonadopted children were
similar. This pattern was sustained over the rst two years following
adoption (Cohen & Farnia, 2011; Pugliese et al., 2010). Thus, children
newly adopted from China entered an attachment-making phase
during the six months postadoption and exhibited an increase in
attachment-related behaviors, as would a younger child who is in the
process of becoming attached. These conclusions were based on
maternal report of child behavior. In this present study, using an
independent measure of attachment, the SSP, the results were similar
to those obtained from maternal report. Thus, information provided
by mothers in their ratings of attachment was accurate. By and large
adopted and nonadopted children do not differ in attachment security
two years postadoption. Moreover, the distribution of attachment
Table 2
Mothers' age and education and attachment behaviors.
B Wald statistics
Secure attachment
Mothers' age .143 1.692
Mothers' education .310 .879
Disorganized
Mothers' age .086 .270
Mothers' education .148 .093
Ambivalent
Mothers' age .350 2.355
Mothers' education .806 1.458
2345
categories was similar to that reported in a meta-analytic review
(van IJzendoorn, Schuengel, & Bakermans-Kranenburg, 1999).
It is important to consider the present ndings on attachment in
relation to both those observed in normative samples and to those
observed in the comparison sample of nonadopted examined in this
study. With respect to the normative distribution of attachment
categories, a somewhat higher proportion of adopted children in the
present study was classied as disorganized (21%) than the norm (15%),
and fewer were classied as insecure (7%) than the norm (24%).
The ndings are also important in light of recent ndings that at two
and six months postadoption, previously institutionalized adopted
Chinese children were at greater risk for insecure and disorganized
attachment (van den Dries et al., in press) in relation to normative
distribution of adoption (van IJzendoorn et al., 1999). The present
results suggest that the future may bode well for the children in this
younger sample when they are followed over a more extended time
period.
In relation to the comparison sample, children in the present sample
show a signicantly higher proportion of disorganized attachment than
the comparison children (21% vs 7%) but not insecure attachment (7% vs
14%). Thus, we cannot rule out the possibility that a proportion of our
sample is at risk for socialemotional problems, something that can only
be determined with further follow-up.
When we consider the overall picture for Chinese adoptees,
combining the current ndings with those we reported previously
(Cohen et al., 2008; Cohen & Farnia, 2011; Pugliese et al., 2010), Chinese
adoptees fare well with respect to attachment and other aspects of
development even though, on average, they were adopted somewhat
later than one year of age. The most likely explanation for the rapid
growth of attachment in these children is that despite having
experienced privation, they had relatively favorable early conditions
prior to adoption placement and less exposure to the severe forms of
deprivation and neglect typical of some other international adoptees,
such as those adopted from Romania (e.g., O'Connor, Marvin, Rutter
et al., 2003). Although there are no data on the Chinese institutions from
which children in the study were adopted, there are reasons to believe
that at least some of the children had experienced fairly favorable early
beginnings (Pugliese et al., 2010). For instance, the orphanage
caregivers were reported by some parents to be tearful as they handed
over children to their adoptive parents, suggesting that there may have
been an opportunity for at least some children to form relationships. In
addition, Chinese children were less compromised prior to institution-
alization; because children were abandoned due to the one-child policy
rather than maternal risk factors, they were more likely to be healthy.
Moreover, there is a selection bias inherent to adoptions from China
where only the healthiest and most appealing children are eligible for
international adoption. Those selected are also likely to be the most
resilient children. This combined with the relatively young age at
adoption, implies less exposure to the stressors of institutional life,
which likely results in more favorable attachment outcomes. As noted
earlier, recently there has been a sharp increase in older and other
special needs adoptions from China and the current ndings may not
apply to these children.
4.1. Theoretical and clinical implications
The literature indicates that infants placed for adoption at a young
p-value age and without the confounding effects of deprivation, exhibit few
attachment disturbances (e.g., Ames & Chisholm, 2001; Juffer &
.192 Rosenboom, 1997; O'Connor et al., 2003; Stams, Juffer, & van IJzendoorn,
.349
2002; van den Dries et al., 2009). In children adopted later than six to
.603 eight months of age the process of attachment may be slower and not as
.761 easily established and be disordered or atypical (e.g., Ames & Chisholm,
2001; O'Connor et al., 2003; van den Dries et al., 2009).
.125
Thus, on a theoretical level, the study of Chinese adoptees
.227
contributes to a broader understanding of the impact of moderate
2346 N.J. Cohen, F. Farnia / Children and Youth Services Review 33 (2011) 23422346
forms of early deprivation on child development. It also contributes to
the understanding of how changes in the environment, through the
intervention of adoption, can alter a child's developmental trajectory
and minimize the effects of early deprivation. In addition, this
research contributes to broadening the larger body of research on
attachment of internationally adopted children, as well as the
adoption literature in general.
On a practical level, this study is informative to a variety of
stakeholders including of course families who have adopted children
from China. Understanding the effects of early experiences on
attachment development informs adoption agencies and government
organizations involved in the adoption process generally. While the
long-term outcomes of Chinese adoptees are unknown, the preliminary
ndings from this small group of children adopted from China suggest
that these children do reasonably well with respect to attachment
24 months following adoption. Of course, large-scale longitudinal
studies of this nature are needed to provide further information as
children develop. Moreover, new studies will need to be undertaken
now that the policies surrounding adoption from China have shifted.
4.2. Limitations of the study
The conclusions need to be tempered by limitations of this study. For
instance, a relatively small sample was used for this study. Moreover, the
fact that the adopted group and comparison groups were self-selected
convenience samples is a limitation. This is a common constraint when
conducting natural experiments. Although it cannot be determined, it is
possible that the adoptive parents who volunteered to participate may
represent a different group than those who chose not to participate. This
could limit the generalizability of the ndings.
As with many new areas of research, unanswered questions remain
regarding attachment in Chinese adoptees. It is possible that the effects
of early adversity had yet to show up in the toddler years and emerge
later in development as relationships become more complex. It has been
found that that children who spent their rst years in institutions before
being adopted by loving families still suffered long-term damage to their
immune systems as a result of early emotional stress and showed
difculties with both physical and socialemotional health some years
later (Fries, Ziegler, Kurian, Jacoris, & Pollak, 2005; Fries & Pollak, 2004).
Longer term follow-up of these children into middle childhood and
adolescence also is important.
5. Conclusion
The outcomes from this study support Bowlby's assertions
regarding the development of attachment that attachment develop-
ment typically begins at six months of age. Secure attachment can be
delayed until after the rst birthday if the child has an insecure
attachment history and little opportunity for a secure attachment
relationship to form during this period. Moreover, he maintained that
corrective attachment experiences are possible during the rst ve
years (Bowlby, 1988), something that was observed in the present
sample. These ndings are both optimistic and encouraging.
Acknowledgment
This research was supported by a grant from Canadian Institutes of
Health Research.
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