Adoptive motherhood (i.e., mothers who have adopted children) is a significant life transition, marked by completing the matching and placement process, which is often seen as a turning point (Adoption UK, 2019; Neil et al., 2019). However, some adoptive mothers have described the experience as challenging, with no honeymoon transition period and likened to a “baptism of fire” (Kohn-Willbridge et al., 2021).

Parenthood, including adoptive motherhood, is associated with various stressors that can lead to negative mental health (NegMH). NegMH is defined as the absence of positive mental health, characterized by the presence of psychological symptoms such as anxiety, depression, and distress, and the lack of mental well-being and life satisfaction (Keyes, 2020). NegMH has been linked to negative outcomes for the mother, her family, and child development, regardless of genetic relatedness (Natsuaki et al., 2014; Shrivastava et al., 2015).

Despite the extensive literature on the adjustment of birth mothers to motherhood, the mental health of adoptive mothers is not as well studied (Frost & Goldberg, 2020; McKay & Ross, 2010; Payne et al., 2010). The emotional and psychological impact of adoptive motherhood is often overlooked (Eanes & Fletcher, 2006), even though negative maternal well-being has been linked to negative child outcomes (Anthony et al., 2019; Goodman, 2011) and placement breakdown (Palacios et al., 2019; Selwyn et al., 2014). Many studies tend to focus on specific aspects of adoption, such as attachment or child development, rather than the overall adopter experience. Furthermore, where researchers involve adoptive parents, the focus is often placed on parenting outcomes rather than exploring the specific experiences of adoptive motherhood. More research is needed to gain a better understanding of the subjective experience of adoptive mothers, as well as the unique factors that contribute to their well-being.

CURRENT LANDSCAPE OF ADOPTION IN THE UNITED KINGDOM

Adoption is a legal process whereby an individual or a couple, usually referred to as adoptive parent(s), assume permanent parental responsibility for a child whose biological parents have relinquished their rights (Neil, 2012). Adoption aims to provide a child with a secure and stable family environment and offers adoptive parents the opportunity to form a loving bond with a child who is not biologically related to them.

According to a report by the U.K. government's Department for Education (DfE; 2022), as of March 2022, there were approximately 3,570 looked-after children in England waiting for adoption, and the average time a child spends waiting for adoption is 566 days. Most adoptions were carried out by heterosexual couples (72%), and the average age of children at the time of adoption was 3 years and 3 months (DfE; 2022). However, no sociodemographic information regarding adoptive parents is provided by the Department for Education.

It is important to note that there are significant differences in the adoption processes between the United Kingdom and the United States, which account for the majority of adoption literature. One major difference is the prevalence of private adoption agencies in the United States, which is not an option in the United Kingdom. All adoptions in the United Kingdom are facilitated by either a Local Authority or a voluntary agency, such as Barnardos or Parents and Children Together. Private adoption allows prospective adoptive parents to work collaboratively with agencies or attorneys to select a biological mother who has recently given birth or is yet to do so. In some cases, this method enables adoptive parents to learn more about the birth mother and the background of their prospective child. However, private adoption is costly, with an average cost of between $20,000 and $45,000 (CreatingaFamily, 2023), and not available to those engaging with public adoption agencies in either region.

Another significant difference is the timing of relinquishing parental rights by the birth mother. In the United Kingdom, birth mothers cannot relinquish parental rights and provide consent for adoption until the baby is at least 6 weeks old. If adoption is the preferred outcome, the Local Authority arranges a foster placement where the baby is cared for until the adoption process begins (Sensitive Matters, 2022). This delay is intended to provide birth mothers time to reflect on their options concerning adoption because the Local Authority is obligated to ensure that children remain with their birth families wherever possible. Prospective adopters can foster a child before adoption, which may allow the possible placement of an infant with an adoptive family. However, the placement is not secure because assessments of birth parents are not finalized (Adoption Focus, n.d.). In contrast, birth mothers in the United States can voluntarily relinquish their child while pregnant, allowing the prospective adoptive parent(s) to care for the baby directly from the hospital until the adoption process is completed (Adoption Focus, n.d.).

A final significant difference is the age of children at the time of adoption. In 2020, most children adopted through public agencies in the United States were 2 years old (8,194 children), with 1 year being the second most popular age (6,834; Adoption Foster Care Analysis Reporting System (AFCARS), 2022). Within private agencies, 62% of children were adopted within 1 month of birth (AFCARS, 2022). The age of the child at the time of adoption, particularly for those adopted through private means, is thus younger than the average in the United Kingdom and has implications for child attachment and development. This difference is significant because older age at placement is associated with greater risks to adoptive family adjustment and stability (Palacios et al., 2019; Selwyn et al., 2014). Research has indicated that children who have endured prolonged exposure to adversity before their adoption are at an increased risk of experiencing changes in their stress reactivity, brain functions, development, and behavior (Turecki et al., 2014). Furthermore, it has been suggested that such individuals may develop a cognitive schema in which others are perceived as hazardous and capricious, irrespective of the benevolent intentions of the adoptive parent (Gibb, 2002).

LITERATURE SPECIFIC TO ADOPTIVE MOTHERHOOD

Adoptive parent research has predominantly focused on mothers as opposed to fathers, leading to a limited representation of the experiences of adoptive fathers. As a result, findings from studies that focus on adoptive mothers have been consistent with those from the wider adoptive parent literature. These studies have identified a range of unique challenges faced by adoptive mothers, including heightened risk of negative mental health outcomes (Howard et al., 2013), feelings of isolation and stigmatization (Gibson, 2014), and difficulties navigating relationships with birth parents (Rushton & Minnis, 2010). Protective factors associated with positive adjustment and well-being among adoptive mothers have also been identified, such as social support and access to adoption-specific services (Grotevant & McRoy, 1998; Neil, 2015). Because of the overrepresentation of adoptive mothers in study sample populations, the current literature review includes findings from studies that examine the experiences of both mothers and fathers.

BACKGROUND LITERATURE ON ADOPTIVE PARENTHOOD

Research into the experiences of adoptive parents suggest they often face unique challenges that can influence their mental health and parenting capacity (Barnett et al., 2019; Brodzinsky & Schechter, 1990; Gibbs, 2010). Abidin (1990) suggested that when parents' sense of well-being is threatened, their capacity to parent is diminished. The parent–child relationship is reciprocal, with the behavior and well-being of each influencing the other. Adopted children are at a higher risk for psychological problems, including externalizing behavior, such as acting out or aggressiveness, and internalizing behavior, such as depression or social withdrawal, compared with nonadopted children (McKay & Ross, 2010). This suggests that adoptive parents may also be at comparably high risk of parental stressors leading to NegMH (Eanes & Fletcher, 2006).

Several factors can impact adoptive parents' mental health, particularly early in the placement, including pressure to be a “perfect” parent (Daniluk & Hurtig-Mitchell, 2003), lack of appropriate parenting role models (Juffer et al., 2005), unrealistic expectations of self and child, low social support, and lack of emotional connection with the child (Foli, 2010; Rushton, 2003). Rates of adoptive parent depression are estimated to be as high as 32%, but this estimate varies greatly across studies and contexts (Foli et al., 2016; Gair, 1999; Senecky et al., 2009). Unlike the large number of children in the United States who are formally adopted by known carers, 85% of adoptive parents in the United Kingdom adopt their child as “strangers” (Selwyn et al., 2014). As such, they contend with establishing an emotional relationship with their child, who may not have had a stable, positive experience of family life and may struggle to understand their new family circumstances. Additionally, many face challenges such as adopting a child with special needs—that is, medical, developmental, or behavioral challenges that are often unforeseen at the time of adoption (Atkinson & Gonet, 2007; Barnett et al., 2019; Child Welfare Information Gateway, 2019; Tasker & Wood, 2016).

Studies of adoptive parent mental health have primarily focused on a few key areas, including the transition to adoptive parenthood (Boswell & Cudmore, 2014; Dance & Farmer, 2014; Kohn-Willbridge et al., 2021; Meakings et al., 2018), postadoption depression (Foli et al., 2016, 2017a, 2017b), contact with birth families (Grotevant et al., 2011), parenting programs (Harold et al., 2017; Sturgess & Selwyn, 2007), evaluation of postadoption support initiatives (Chobhthaigh & Duffy, 2019; Harlow, 2019; Harris-Waller et al., 2016), and factors associated with placement breakdown (Palacios et al., 2019; Randall, 2013; Selwyn et al., 2014). However, studies of the lived experience and emotional well-being of established adoptive parents, beyond the first 12 months postplacement, are uncommon (Palacios & Brodzinsky, 2010).

LITERATURE INTO THE WELL-BEING OF “ESTABLISHED” ADOPTERS

In the United Kingdom, Anthony et al. (2019) examined adopter depression and anxiety symptoms across the first 4 years after child placement. Findings suggest such symptoms remained relatively stable across time with depression scores declining toward the later years of placement (Anthony et al., 2019). The persistence of symptoms across the first years highlights the importance of professional awareness of adoptive parents' mental health beyond the first year and signal the need for further exploration into the mental health of established adoptive parents.

Large-scale surveys in the United Kingdom offer insights into the well-being of long-term adoptive parents. Although the majority of adopters express satisfaction with their adoption experience and report the joy and delight their children bring, reports of depression, anxiety, and posttraumatic stress disorder (PTSD)-like symptoms many years postplacement raise questions about overall satisfaction (Adoption UK, 2019; Neil et al., 2018; Selwyn et al., 2014). Adoption UK (2019) surveyed 3,500 adoptive parents, including more than 2,600 established adopters, finding that although many were satisfied, more than half reported significant or severe challenges. The most significant challenges included supporting children through education (68%), adapting parenting and family life to cope (41%), and dealing with violence and/or aggression from their children (35%). Neil et al. (2018) examined parental stress within established adoptive parents and found that 29 participants reported overall stress within the clinical range, 23 in the distress subscale, and 40 in the clinical range for the difficult child subscale. These studies suggest that many long-term adopters struggle with parental stress, depression, feelings of low parental competence, and anxiety related to adoptive parenting (Adoption UK, 2019; Neil et al., 2018; Selwyn et al., 2014).

Although the preceding survey data offer valuable insights into the well-being of long-term adoptive parents, methodological differences and cross-sectional data make the prevalence and factors influencing adopter mental health unclear. Although many adopters experience significant or severe challenges, including violent and/or aggressive child behavior, strains to intimate relationships, and depression-related parental stress, the emotional and psychological state of adopters is not universally explored as a primary outcome (Adoption UK, 2019; Neil et al., 2018; Selwyn et al., 2014). These challenges may have an impact on parents' emotional and psychological well-being beyond their parenting capability, particularly for parents of older children who report higher depression-related parental stress (>12 years; Neil et al., 2018). Furthermore, the survey-based methods used in many of the referenced studies raise concerns about social desirability bias, whereby respondents may present a more positive picture of their experiences (Opdenakker, 2006). Adopters may find it challenging to report their struggles, even anonymously, due to feelings of guilt and shame associated with depression symptoms and high expectations of themselves (Foli, 2010). Conducting face-to-face interviews may mitigate stigma and encourage respondents to use their own language to describe their experiences, responding spontaneously and with the support of positive social cues (Opdenakker, 2006).

CURRENT STUDY

Because the issue of adopter mental health remains largely underrecognized, the current study explores the emotional and psychological experiences of adoptive mothers as they reflect on their journey through adoptive motherhood. Study aims were to (a) identify and compare mothers' self-reported emotional state at 12 months after child placement to time of interview and (b) identify the factors that most challenge and support adopters' mental state.

METHODS

Participants

Participants were nine White, heterosexual adoptive mothers (see Figure 1). All mothers completed higher education and identified as having average or above household incomes. Inclusion criteria included sufficient fluency in English; residing in the United Kingdom; and having completed the adoption process within the United Kingdom through public, private, or international adoption. At the time of placement, eight of the 14 children were younger than 24 months (the remaining six were aged 3–5 years). Therefore, the majority of children were placed younger than the current average age of 3 years in the United Kingdom (DfE, 2022), and eight of nine families adopted a child of similar ethnic background. At time of interview, adopter's age averaged 45 years (range: 37–55 years) and had been a mother for, on average, 8 years (range: 3–15 years). Seven families consisted of more than one child, with four including adopted siblings and three including either an older nonadopted child and one who gave birth to a child several years after adopting a sibling pair.

Procedure

Ethical approval was granted by the appropriate university committee before recruitment via a Local Authority Adoption Agency and online support groups. The Local Authority agreed to include a study flyer within an e-newsletter that was routinely emailed monthly to adopters. The online support groups were also provided with the study flyer that was posted to all members. The flyer included brief information about the study and invited those who might be interested in participating to email the research team for further details.

Participants were selected on a first-come, first-serve basis with consideration given to child age, number of children, and presence of birth children to enhance the representation of different family structures. Each participant received a participant information sheet (PIS) that provided details about the purpose and nature of the study, what would be expected of participants, and risks or potential benefits of participation, how confidentiality and privacy would be maintained, and contact information for the researchers in case participants had any questions or concerns. All mothers volunteered their time to participate in the study because funding was not available to offer compensation.

Data collection

The first author conducted semistructured interviews between April 2019 and June 2019. The interview focused on retrospective and current adopter experiences. Interviews were conducted within the participants home, lasted approximately 90 minutes, and were recorded and transcribed verbatim by the interviewer. Pseudonyms are used for names, locations, and identifiable organizations. An interview schedule was used to aid the interview; however, participants were probed to explore their emotional state/responses within their account. A sample of the type of questions asked include the following:

• Can you describe your adoption journey and how it has impacted your emotional well-being?
• What has been the most challenging aspect of being an adoptive mother?
• How have you coped with any emotional challenges that have arisen during the adoption process or since your child's arrival?
• Have you experienced any support or resources specifically for adoptive mothers, and if so, how have they helped you?
• What advice would you give to other adoptive mothers who may be struggling with emotional well-being issues?

Interviews provided a rich account of how the family evolved over the years from pre-placement to current day. Data focused on the adjustment to adoptive motherhood was analyzed and reported within a preliminary paper by the authors titled “Look After Me Too: A Qualitative Exploration of the Transition to Adoptive Motherhood” (Kohn-Willbridge et al., 2021). In that work, the focus was on the subjective emotional experience of mothers between pre-adoption through to 12 months post–child placement. Findings generated five key themes as impacting maternal mental health: Reality Not Living Up to Expectation, Uncertainty and Powerlessness, Emotional and Psychological Fatigue, Uniqueness and Isolation, and Love and Ambivalence (Kohn-Willbridge et al., 2021). The current work drew on these data to address the first objective, comparison of emotional state at time of transition to established adoptive parenthood.

This analysis rests on adoptive mothers' own assessment of their emotional and psychological states and factors that have contributed to such experiences.

Analysis

This qualitative research was founded from a constructivism, interpretivist stance, with inductive theme generation. Constructivism emphasizes the subjective nature of knowledge and learning, where individuals construct their own understanding of the world through experiences and interactions (Annansingh & Howell, 2016). The interpretivist stance is a philosophical perspective that emphasizes understanding the meanings people attach to experiences, viewing reality as socially constructed, and meaning created through social interactions (Finlay, 2002). Inductive theme generation is a method of analyzing qualitative data by identifying themes or patterns through a process of iterative coding (Braun & Clarke, 2006). This method allows themes to emerge from the data rather than using predetermined categories.

We used these concepts to explore the complex phenomena, adoptive motherhood, from participants' perspectives, which is sensitive to the subjective nature of knowledge and learning. Such an approach helps to understand the participants' experiences, the meanings they attach to them, and the patterns in their experiences. According to Finlay (2002), one of the main strengths of using such an approach is its ability to allow for the exploration of individuals' own perceptions of their lived experience. This is achieved by using methods such as in-depth interviews, which help to generate a detailed and rich understanding of these experiences.

Reflexive thematic analysis (TA) is an approach to qualitative data analysis that emphasizes the researcher's awareness of their own subjectivity and biases in interpreting and analyzing the data (Braun & Clarke, 2019). It is grounded in constructivist and interpretive perspectives, therefore arguing that the meaning of data is not fixed but rather shaped by the researcher's interpretation and understanding of the context in which it was produced.

Before commencing analysis, individual biographies of each participant were written to create a comprehensive profile of each participant before dividing the transcripts into “transition” and “established” parent experiences. This approach allowed for the reexamination of each mother's shared narrative in the context of her family system, which provided an opportunity for self-reflection and appraisal of interpretations within the analysis. Biographies are available upon request to the lead author.

Braun and Clarke's (2006) reflexive TA was employed because of its flexible structure for qualitative data analysis. This method enables the identification of patterns and themes within the data, similarly to other thematic analysis techniques. However, reflexive TA also acknowledges that the researcher actively constructs knowledge (Braun & Clarke, 2019). Therefore, analysis is regarded as a reflection of researchers' own interpretations of the data, which influence their perception of the data, theoretical assumptions, and analytical skills (Braun & Clarke, 2019). Thus, it is widely recognized that no two researchers will analyze a given dataset in the same way or achieve identical results, and exact reproducibility should not be expected.

Analysis was guided by Braun and Clarke's (2012) six-phase process:

1. Familiarization with the data—thorough reading of transcripts until the data is fully understood.
2. Initial code generation—development of initial descriptive and meaning-based codes for each transcript.
3. Theme generation—coding across the entire dataset, recognizing patterns of shared meaning, and grouping them around central concepts or themes.
4. Reviewing potential themes—recursively reviewing each transcript and comparing them to the created themes to ensure accurate representation of narratives.
5. Defining and naming themes—refining theme names and definitions based on both the dataset and the research question.
6. Producing the report—finalizing the results and presenting the analysis.

Themes were identified based on their impact on individual narratives and the mothers' experiences as a whole. NVivo software was employed as a useful tool for analysis. Throughout the analysis, transcripts, coding, and theme generation were shared with coauthors.

Because the lead researcher has personal experience as an adoptive mother, she has a connection with the group of individuals under investigation. Thus, it was necessary to recognize that this experience could influence her perception of the world, the concept of adoptive parenting, and the interpretation of data. Consequently, the research team highlighted this experience, and its possible bias, in the study's foreground. The research approach, delivery, and data analysis were all conducted from a reflective position with the coauthors providing critical evaluation. Although the researcher's personal experience facilitated the development of rapport and empathy with participants, it was crucial to acknowledge that there are differences between subjective experiences, interpretations, and worldview. This acknowledgment is vital to making sense of the participants' experiences (Sayers, 2018), preserving balance in data collection and analysis, and maintaining the research's integrity.

RESULTS

Analysis of mothers' mental health generated three key themes: The continuation of NegMH throughout parenting, risk factors to mothers' emotional well-being, and protective factors to mothers' emotional well-being. (Table 1 provides a summary of generated themes.) Subthemes were identified within the risk and protective factor themes. References made to adopters' emotional well-being are made without clinical validation; no standardized measures were used, but rather they reflect mothers' own descriptions of their emotional state.

Theme 1: The continuation of NegMH throughout parenting

Across all nine narratives mothers spoke of “ups and downs” in what they imagined all parents face. Of the six mothers who reported experiences of depression, anxiety, or trauma symptoms within the first 12 months post-placement, all expressed continued strains on their emotional well-being due to parenting over the years. Perhaps unsurprisingly, factors directly related to transition to parenting, or the adoptive process itself, were not reported. However, factors including love, fatigue, and isolation were all identified as important influences on mothers' well-being.

Such results suggest that over time, mothers may have been realigning expectations as they became more familiar, and skilled, within their parenting task. Ultimately, the uniqueness and complexities of the mother–child relationship appeared to affected mothers' mental health. Despite the challenges, each mother reported a strong commitment to their child, and for three mothers, distress reduced over time.

Two mothers continued to be emotionally challenged by the “relentless” demands of parenting. These mothers “very much loved” their children, but parenting was “tiring, challenging, and very frustrating.” The task of love, commitment, and day-to-day parenting within an established family continued to take a toll on their well-being:

Christine: I now have severe anxiety because of them. It is not their fault but what they are going through, secondary trauma—all that trauma kind of stuff. … It is an emotional roller-coaster of what they throw at us and then I need counselling to help offload. … Sometimes I just have nothing left and I hit the wall.

Mary: I was suffering with anxiety. You were constantly living on eggshells. … I was getting a lot of panic attacks. … I was miserable and put on antidepressants … and it went on for a very, very long time. … In the end I ended up with PTSD … EMDR [eye movement desensitization and reprocessing] has really helped [but] it is still not within the realms of normal parenting. It is extreme parenting.

Not all mothers reported negative emotional well-being at 12 months post-placement. Three reported positive and smooth transitions. These positive experiences continued over time for two mothers, but the third had a very different experience. Sarah's transition into adoptive motherhood of siblings, Brandon and Sian, went better than she had hoped, but her relationship with Brandon changed considerably at age 8, approximately 7 years after adoption, and continued to deteriorate with increasingly aggressive and violent behavior toward Sarah before he moved out of home at age 15. Sarah's sense of emotional well-being was dominated by feelings of anxiety, isolation and fear for herself and concern for her son's future: “[It became like] walking on eggshells … I was trying to cope with living … surviving. … We are still a family … [but when he left home], I got my life back.”

Overall, mothers who experienced a degree of depression or anxiety during the transition period reported continued experiences throughout their parenting journey. The term “walking on eggshells” appeared to represent the daily anxiety and unpredictability shared by mothers, along with a sense of trying to “survive” the brunt of challenging child behavior. Although challenging child behavior continued to strain maternal mental health, for most mothers, the love, commitment, and resilience they had developed for their children appeared to moderate their emotional state somewhat, facilitating space for therapeutic understating of such behavior and the role it plays in their child's recovery from early life experiences.

With seven of the mothers self-reporting negative emotional well-being, either through anxiety or low mood, analysis identified factors that protected maternal mental health and those they felt presented challenges to it.

Theme 2: Factors contributing to negative emotional well-being

Three key factors were identified as contributing to mothers' experiences of negative emotional well-being: “Demands of ‘extreme parenting,’” “Strains within and across relationships,” and “Deprioritizing self-care.” Each subtheme is discussed in this section and illustrated by quotes from the interviews.

Theme 2a: Demands of “extreme parenting”

Eight mothers spoke openly about the difficulties associated with their continued challenging child behavior. Comments centered around children's emotional difficulties, developmental delay, child-to-parent violence and aggression, child need for control, and extreme inconsistency in child behavior. As Kate noted, “Her emotional needs are different … this is a lifelong thing … she was a child who was 4 presenting as 18 months and now she is 12 she is behaving like she is 8.”

Similarly, another participant described the following:

Helen: Even recently, I had to go out. … I was not in contact with Howard for half an hour and when I came home, he was really angry and upset … he said he thought I had left him at home to die. He was dramatic but not putting it on … he thought I had abandoned him.

In all cases but one, such characteristics and behavior had been present since child placement: Sarah was the exception, in which Brandon's challenging behavior started 7 years after placement.

Given the severity and complexity of behaviors, mothers spoke frequently of the exhaustion felt delivering the “extreme parenting” needed. The emotional energy required to constantly regulate their own emotional state (neutralizing feeling of anxiety, anger, frustration, irritation, shame, etc.), to attune emotionally with their child, understand the world from their eyes (as children who have experienced early trauma), and teach new strategies to cope with life's difficulties. Such responses often required mothers to comprehend the emotions driving challenging behavior (e.g., violence, aggression, control, rejection) putting aside the impact of such behaviors on themselves.

Molly: Sally can be exhausting and sometimes the support worker will leave here like “wow” because he has just dropped bombs on her and of course she is then very dysregulated and regresses and becomes a 3-year-old … it is exhausting regulating her all the time.

Mary: I mean the thing with “extreme parenting” is that everyone is stretched all the time… I think it would be true to say probably more than birth parents, and I don't mean because they are adopted but because of my duties, I wish I could just run away. … I would just like to put the load down and not have to deal with the mental load of appointments and fighting for therapy and getting the right support for them and having the right structure in the home.

Christine: At times I have nothing more to give. I have no emotional energy to give them. … I am operating three brains [Christine's, Dylan's, and Jane's] because they are offline at times … “the wall” comes very close at least once a month, and I probably hit it hard three or four times a year.

Mothers also spoke of a loss of work identity because of adoptive parenting, which required them to be available to advocate for their child or be at hand to regulate or moderate their child's behavior. Mothers experienced their inability to return to work as a loss of “independence” and “identity outside of being a mother,” reflecting their underestimation of how much “relentless attention” their child would need.

Theme 2b: Strains within and across relationships

Perhaps unsurprisingly, mothers often spoke of strains to fundamental relationships within their immediate family, extended family, and wider circle of friends. Eight mothers were in long-term relationships, with one relationship breaking down after child placement. Four mothers noted the quality of their partner relationship had decreased because of the strains of parenting. For example, Alexia explained her children could no longer be babysat by family or friends due to their behavior, resulting in “not having time for each other,” so they tended to go out separately.

More prominent was the continued strain within mother–child relationships and the impact of strained sibling relations. Despite loving their children, three mothers continued to feel a strain in their attachment or bond at time of interview.

Alexia: It would be quite nice for Rebecca to have a, you know, a go-to person where she can actually do no wrong in their eyes … like my friend who she had a real connection with and … yeah, I never thought I would say that about one of my own children.

Sarah: You know we have really tried hard, and it has been really difficult to try and build a relationship with him. Um, he is not the boy I recognize, he has tried to morph into—he has changed.

For others, it was not their own relationship but the strain between siblings that left mothers “disappointed” and “questioning” whether adopting a second child, or siblings, was the right decision. Of the seven mothers who adopted their second child, five expressed guilt. For those who adopted two children, either simultaneously or separately, the strain on meeting the needs of two children with differing needs left mothers reflecting on the merits of single adoption. For example, Christine said, “one could be just as fulfilling.”

Two mothers who were motivated to adopt, at least in part, from a desire to provide a sibling for a nonadopted child also reflected on the choice of sibling and expressed guilt that perhaps the choice to adopt had not been as advantageous for their first born as previously hoped. As Angie, stated, “Since adopting Chris, we do question something if the struggles we are having with Lachlan are because we did adopt Chris.”

Outside of the immediate family, strain was reported between mothers and members of the wider family. This often centering on differences in parenting techniques by grandparents. Although grandparents were mentioned as a source of support, mothers also spoke of the difficulty in adjusting the parenting values and beliefs held by their own parents to accommodate the needs of their children.

Molly: Sally was kicking off last week and mum struggles with her values and ideals to deal with Sally's behavior when she's behaving like that. And I still can't get through to my mum that, you know, she is a child of trauma, but she thinks “no, she is just misbehaving.”

Others spoke of difficulty in educating their parents and wider families about their children's behavior and why their parenting is different. Interviewees reported that grandparents often struggled with the terminology of adoption and understanding there is more than “one style of parenting.” There was an apparent tension between wanting family involvement and support but also feeling that it was “easier to leave it,” resulting in a distancing in family relationships.

Such experiences within the family, coupled with the reduction of support offered by face-to-face friendships, led some mothers to report feelings of “isolation” and emotional distance from others. Mothers described situations in which contact with close friends “completely stopped,” support networks “kind of disintegrated,” and even long-term friends opting out of babysitting because the child “is a bit too much.” Angie said that this “has led to a lot of isolation because we chose not to open ourselves up to people, we felt didn't understand, because it was too difficult to then deal with their insensitivities about it.” Another mother described the following:

Mary: They thought “of course we will babysit all the time, we love kids”, and even our referees have said “She is too much,” and they have never babysat. … Um, very isolating. My parents also haven't really got it despite their experience, so yeah it has been isolating.

Theme 2c: Deprioritization of parent self-care

The final subtheme explored is arguably the most reinforced message shared by mothers: that the deprioritization of maternal self-care by adopters and adoption processionals is harmful not only to parents but to children and the wider family. Angie described it this way: “This self-sacrificing parenting where you don't matter, and it is only about the child: there comes a time when you realize that if I don't matter then they will only suffer.”

Although most mothers spoke of accessing some form of professional help over the years, often this was a result of a child referral with the parent “piggybacking” support. Without exception, every mother spoke of the need for self-care, in various forms, to keep their own sense of well-being intact and to “have enough emotional resources to parent.”

At times, self-care was referred to as “making time for myself,” enjoying time with friends/family outside of parenting duties. However, for all but one, self-care included professional help that was adoption-informed and accessible. It is therefore important to note that most mothers reported experiencing difficulties accessing the support, including long waits, funding issues, or parent well-being issues not being recognized by professionals.

Christine: We can't afford to pay for counselling sessions, so I have to wait for charity sessions to come up. The [Adoption Support Fund] budget goes too quickly on the kids … and counseling is not something you get through the Adoption Support Fund.

Some mothers reported accessing support for themselves through the Adoption Support Fund (ASF) but doing so “under the radar” so not to be “caught out.” The ASF is a government-funded initiative in the United Kingdom that aims to provide financial support to adoptive families to access therapeutic services for their children's development and emotional needs (DfE, 2019). Mary's EMDR therapy for PTSD was one example of this:

Mary: It is not what the fund is for which I think is a big flaw … what I experienced is relatively common and I think it needs to be recognized within the ASF that sometimes it is the parent that needs the help in order to parent the children.

For Sarah, requests for personal support were left unanswered during the breakdown of Brandon's placement. She explained all support was withdrawn as soon as Brandon chose to disengage, despite her request for some personal support, and added “there is nothing for parents unless the kids are partaking.”

Theme 3: Factors contributing to positive emotional well-being

Three key factors were identified as supporting mothers' emotional well-being: development of love, attachment, and sense of family identity; learning, competence, and “therapeutic parenting”; and the ability to “offload”: sources of formal and informal support. Each of these subthemes is discussed in this section with illustrative quotes from the interviews.

Theme 3a: Development of love, attachment, and sense of family identity

All nine mothers spoke of the love they felt for their children. If not throughout the entire parenting journey, at least at times, mothers reflected on their attachment or bond with their child, the importance of feeling needed by them and a sense of agency in creating “our family.” Unsurprisingly, mothers who reported “better than expected” adoption experiences also offered many reflections of love and attachment between themselves and their child. The ease with which some mothers bonded and identified as “mother” related to lower reports of emotional distress and strains to well-being across time. As Helen noted, “He is lovely, he is my boy, and we will always have that. … Everything else seems to be secondary to that.”

For some, attachment and bonding took time. Being able to build a reciprocal relationship appeared to be of great help, allowing mothers “feel true love” for their child and identify positives in the child's character where challenges previously felt overwhelming.

Angie: He was always clinging to me … screaming. I felt trapped and claustrophobic. The day after this third birthday he was poorly and just slept on me, and it was the first time I didn't want him to go somewhere else. I didn't want him to not be with me because actually you need me. And that was fundamental in creating that bond.

Kate: It has taken years, and it is an ongoing process and I am not sure if we will ever, ever get there really but, I mean … [crying] … now I adore her, I adore her but it took me ages to even like her. I didn't like her at all. She was a nightmare, and it was really hard to see any positives. … It took about 2 years for me to absolutely love her.

For two mothers who continued to experience NegMH, comments such as “I just want to help them” and “it's been harder than I thought” but the children are “very much loved” may go some way to show how a loving relationship can help to overcome the challenges of “extreme parenting.”

The initial bond Sarah felt with Brandon was severely tested over the years. Despite the progressive breakdown of relationship, Sarah reflected on the many “memories in the bank” she had acquired from the earlier years, which helped not only to manage the breakdown with her son emotionally but continue to “have a relationship … still [be] a family.”

Theme 3b: Learning, competence, and “therapeutic parenting”

Growth in parental competence, knowledge, and skills were associated with positive or improved mental health. Eight of the nine mothers referred to their increase in knowledge and understanding of their child's behavior feeling more skilled at responding to it. With time, mothers accepted their children's behavior, recognizing the “need to be treated differently” and becoming an “expert of [their] own family.”

Angie: [Before] I wouldn't have known what was right or not. Now I know my son, I know—not all the time but most the time—what is going on underneath … we are more able to deal with things … [and] have more tools in our toolkit.

Likewise, Helen said, “Oh, now I can read her like a book, but at the time I couldn't keep up with her.”

Many commented on the belief that adoptive parenting was “more than pure parenting,” often making reference to being a “therapeutic parent” and the realization they needed to diverge from more familiar or traditional methods of parenting. Specifically, such parenting does not shame the child, use reward charts, or expect the child to self-regulate or feel empathy and remorse for their behavior (Naish, 2018). Rather, parents recognize that all behavior is communication, often based on fear, and therefore parenting needs to respond to the child's emotional and developmental, as opposed to chronological, age, using empathy and connection to guide behavior (Hughes, 2012).

Christine: I am a therapeutic parent, not just a parent … [I'd] say “it's time to brush your teeth” and he would brush his teeth, instead of standing there and saying, “come on, you must know what you are supposed to do … you have been doing it twice a day for the past few years.” But of course, he really didn't know what he was supposed to do and the more I went on about it, the more he froze and the more incredibly frustrated I would get. Now I understand … PACE parenting, think toddler. [The term PACE parenting refers to a trauma-informed model of parenting based on the principles of Playfulness, Acceptance, Curiosity, and Empathy (Golding & Hughes, 2012).]

Conversely, Sarah's narrative showed a decreased sense of parenting confidence and competence as Brandon's behavior continued to challenge her: “[I] had no idea anything else was going on … we didn't realize until afterwards that this [Brandon's difficulties] was obviously attachment related.” Perhaps if Sarah had received support to better understand Brandon's behavior, she may have been able to increase her confidence in parenting and avoid, or decrease, the emotional distress experienced over many years.

Theme 3c: The ability to “offload”: Sources of formal and informal support

The eight mothers who access professional, adoption-related support considered it “a lifeline” to “save” families. Mothers accessed a range of professional support from adoption parenting programs to clinical interventions. Four mothers spoke highly of one-to-one talking therapy, with reference to being able to receive direct clinical care for themselves during these sessions, without the presence of their child or partner. As Kate noted, “If we go separately then at least we can sort of talk about the other person, it sounds horrible but, we can express ourselves free and openly … and that is really good.” Regardless of the degree of emotional distress a mother faced the experience of “being listened to” allowed them to “offload” their emotional baggage. Christine stated, “Basically, I had gone beyond the wall. … I had been on anxiety medication for four years, but it triggered me into counselling and getting more help for me … counseling helps me to find me.”

Although most mothers had attended courses aimed at providing information about child development and parenting techniques, it was largely felt to be unhelpful compared with more tailored, one-to-one support.

Angie: It has been very theoretical and information heavy, which you then have to try and work out how it applied to your child … the family therapist has been better because it has physically been with us … without this support I think I would have been really struggling.

Reflecting on her experience, Sarah recalled the introduction of several therapeutic interventions that focused on Brandon's needs, but she complained that help was withdrawn if a child did not wish to engage. Like other mothers, she called for more support to be available for parents independently, without the child's engagement.

Beyond formal support, all mothers commented on the value of other adoptive parents “normalizing extreme behavior” leading to feeling “understood by someone who knows.” For some, meeting peers was the most beneficial aspect of the post-adoption interventions provided to them. As Christine recalled, “Looking back now, 50% of the course was useless but the biggest thing was meeting other adopters and I suddenly realized that we were the same as other adopters' worlds.”

Others noted the value of purposely engaging in support activities such as in-person adoptive parent support groups and family meet-ups, use of social media groups or engaging in a buddy initiative via social services.

Angie: I think that informal support has increased my confidence to put my hand up maybe earlier than I would have done and ask for help. This has been hugely beneficial … with the parents on the group things are unsaid and just accepted.

Connecting with other adopters appeared not only to increase parental confidence but also decrease their sense of isolation. These impacts appear to evolve over time as mothers expressed a higher confidence in utilizing and valuing such informal support as their parenting experience increased. Furthermore, mothers appeared to gain parenting confidence not only from receiving support but also by providing it to others and normalizing their experience.

Molly: Before, I didn't really share with them in a way I would now, and I do now. You know, like I posted the other day how lonely and isolated I was feeling … because now I know if I do post something, I will get support back…There was a lady recently who is going through severe Post Adoption Depression, and it was really nice to say, it is ok to her we have all been through it.

For Tracey, who has experienced an overall positive adoption journey, the use of peer support had been valuable, but she cautioned “they can give you a skewed view” if everyone in the group is struggling and the positives about adoption are lost.

The majority also spoke of turning to friends for emotional support, rather than practical child-orientated support. This offered some comfort and attention to the emotional needs of the mother. For example, Angie said, “No, they don't get it. They don't understand it, but at least they are aware of that impact on us.”

Overall, there was a sense that mothers had to fight to receive personalized support and have their emotional experiences validated. All mothers who were able to receive therapeutic intervention, expressed gratitude for the help and indicated an improvement in their emotional well-being. For those challenged on a day-day-basis by “extreme parenting,” the engagement with counseling, or other forms of therapy, provided an essential space to “offload” emotional baggage accumulated during their routine parenting function. Parent-focused therapeutic support appeared to restore the vital reserves needed to effectively meet the demands of “therapeutic parenting.”

DISCUSSION

The first aim of this study was to explore mothers' self-reported emotional state beyond the first year after child placement until time of interview. Overall, mothers' reports of NegMH remained stable across time. Those who reported struggling with low mood, anxiety, or “trauma” at 12 months after placement reported some degree of NegMH years later. Our findings extend the work of Anthony et al. (2019), which suggest that such experiences can continue for many years post-placement. Interestingly, other studies suggest factors such as child age at placement, adoption of a single child or sibling group are associated with higher risk of parental NegMH (i.e., Canzi et al., 2019; Goldberg, 2010; Selwyn et al., 2014); however, such predications were not seen in this sample. Regardless, as adoptees developed into middle childhood and adolescence, adoptive mothers faced new challenges with issues such as identity and social relationships coming to the forefront. Our findings—and others'—underscore the need to support parental mental health over the early years of parenting and for this to continue across the life span of the adoptive family beyond the early years (Palacios & Sanchez-Sandoval, 2006; Sanchez-Sandoval & Palacios, 2013).

The second aim was to identify factors that challenge and support parents' psychological well-being. One key finding was mothers' tenacity and love for their children, despite the cost to themselves. Unsurprisingly, there was a positive relationship between mothers' emotional well-being and the increase in mothers' sense of parenting competency and sense of identity as “mother” (Eanes & Fletcher, 2006; Foli, 2010). This could be understood as mothers continuously realigning expectations of themselves and their child in response to real experiences of parenting. Foli et al.'s (2017a, 2017b) mid-range theory of post-adoption depression helps to explain such changes, suggesting that mothers' levels of depression decrease as alignment between expectation and reality increases. However, our findings indicated that mothers continue to experience NegMH even when expectations of self and child are adjusted, suggesting factors associated with the daily function of adoptive parenting put mothers at risk of NegMH, such as the experience of “extreme parenting.”

The acknowledgment and impact of extreme parenting on maternal mental health was a novel, if not understandable, offering of the findings. In contrast to recent parent perspective studies, mothers described the level of exhaustion and isolation they felt at meeting the demands of their parenting task. Extreme parenting refers to the unique challenges and demands faced by parents who have adopted children with complex and challenging needs, such as those who have experienced trauma or have developmental or behavioral issues (Turney & Pocklington, 2011).

These challenges may include managing challenging behaviors, navigating complex systems of care, and dealing with the emotional and psychological impact of the adoption process as a whole (Turney & Pocklington, 2011). As evident from the accounts provided within this analysis, extreme parenting can be characterized by a high level of stress and emotional strain, which can lead to negative mental health outcomes such as depression, anxiety, and PTSD (Morvwen, 2020). It may be that through the experience of engaging in extreme parenting, a requirement to parent many adopted children positively, that adoptive mothers are at higher risk of feelings of isolation and lack of support, which can further exacerbate their stress and mental health problems.

Another interesting finding was the value mothers placed on formal and informal support for their well-being. Previous research has noted that connections between adopters, in the form of peer support, is a valuable source of practical and emotional support (Adoption UK, 2019; Neil et al., 2018 Tasker & Wood, 2016; however, it was the experience of professional one-to-one, adult-specific support, focusing on the psychological well-being of mothers that proved more highly valued. The overarching message was a need to “offload” their own emotional baggage incurred by their parenting role. In this sense, it was not the child's behavior itself that was seen as the greatest challenge (cf., Adoption UK, 2019; Neil et al., 2018), but rather the task of “therapeutic parenting” and the “emotional energy” it took to process such behavior internally in the absence of support from the wider family to deliver such parenting. Mothers made an important distinction between the impact of child behavior and the demands of responding to child behavior. This slight, but significant, distinction may be lost within survey-style reporting, as survey response options relating to parenting stress or child behavior may not allow for or encourage such detailed reflection.

An appropriate term in this context appears to be parental burnout, defined as a state of intense exhaustion related to one's parental role, in which one may become emotionally detached from one's children and doubtful of one's capacity to be a good parent (Roskam et al., 2017). This concept is different from depression or stress and emphasizes the need to consider physiological and psychological responses to parenting tasks. Roskam et al. (2017) suggested that parents are at greater risk of burnout in today's climate due to increased pressure to bring up healthy, secure, and successful children while time spent parenting decreases due to the necessity or desire to return to work. Adoptive mothers may be at heightened risk due to the challenges associated with trauma-related child development, along with the social stigma often attached to adoption (Brodzinsky, 1987; Daniluk & Hurtig-Mitchell, 2003; Van Gulden & Bartels-Rabb, 2001).

Mothers' emphasis to prioritize their own mental health stood in contrast to much of the parent perspective literature, which describes adopters often deprioritizing their own emotional needs and placing a higher value on child well-being (Adoption UK, 2019; Neil et al., 2018). However, within such studies parents also spoke of dealing with challenging child behavior, and tension in personal relationships (Adoption UK, 2019; Neil et al., 2018).

A major barrier to accessing parent-focused therapeutic support is its exclusion from Adoption Support Fund criteria (DfE, 2019). Recent systematic reviews of post-adoption interventions indicate a primary focus on child outcomes and the practicalities of the parenting task (Chobhthaigh & Duffy; 2019; Drozd et al., 2017). Formal support, in the form of parenting groups, parent–child therapy, or training, is frequently provided for new adaptors (Chobhthaigh & Duffy; 2019; Drozd et al., 2017); however, it is clear that such support is often not available at a time further on in the adoption, and perhaps more important, access to direct therapeutic support, independent of the child, appears to remain a lottery. Consequently, many adoptive parents report feeling as if they have “fallen off a cliff” in terms of support after the first year of placement (Adoption UK, 2019). There is a clear parental need for counseling or psychological therapy after the period of early child placement (Atkinson & Gonet, 2007).

Finally, an interesting point of consideration is the impact of sibling relationships on adoptive mothers' well-being. Our findings indicate where sibling relationships remained strained, mothers' reported feeling guilt and uncertainty about their decision to adopt. Strikingly, there is little research on how the characteristics of a second adopted child may impact the adoptive family (Berge et al., 2006; Selwyn, 2019) or how strained sibling relationships may impact maternal well-being (Frost & Goldberg, 2020). Further research is needed to better understand the impact of such relationships and experiences.

Limitations

Before considering the wider implications of these findings, it is important to consider the limitations associated with the data. First, all participants were members of an online support group, often used by parents who are having difficulties within their adoptive family. As such, their experiences may have been less positive than those of other adoptive families. It should also be noted that participants reported higher than average levels of education and income: These are two factors that are often protective against poor mental health, but, as noted earlier, no sociodemographic information regarding adoptive parents is provided by the Department for Education, so it is not possible to determine how well the sample reflects the broader population of adoptive parents.

Second, the sample consisted of nine heterosexual White mothers. The study aimed to recruit both adoptive mothers and fathers; however, only adoptive mothers expressed interest in taking part at time of recruitment. Although 86% of children are adopted by heterosexual adopters (CoramBAAF, 2019), the experiences of fathers, coparents, members of the LGBTQ+ community, or people with non-White ethnicities were not included. Although the sample size of nine was appropriate for a phenomenological study (Creswell, 1998; Morse, 1994), it does not allow generalization to all adoptive parents.

Third, adoption practices may differ across geographic areas and time. There were many changes to social work policy and practice over the period that participants adopted their children (between 2004 and 2016). These might have influenced access of post-adoption parent-focused interventions. It is beyond the scope of this work to offer a full commentary of such changes (see DfE, 2016).

Fourth, it is important to consider recall biases. The time since transition to parenthood ranged from 3 to 15 years. For some, the accuracy and volume of memories relating to this time may be influenced by subsequent events and experiences, and emotional distress felt at the time (Hassan, 2005).

Finally, the interviewer's own status as an adoptive mother was made known to interviewees both within the information sheet and within interviews (when asked). This disclosure may have created a more open environment, facilitating fuller disclosure of negative emotional experiences than offered in other studies, but it may have also meant that some “taken for granted” information was not shared. Reflexive TA was used because it acknowledges and utilizes the interviewer's own experience to increase the value and depth of analysis. The interviewer analyzed findings with the close involvement of the coauthors to reaffirm the conclusions drawn. These factors are important because they acknowledge the possibility of bias within the sample and within the experiences being shared.

Future research

For more in-depth analysis, it is useful to consider other family characteristics that may influence mental health experiences, including quality and satisfaction with partner relationship, experiences of fathers and/or coparent, child characteristics, sibling characteristics, diversity within family member ethnicity and socioeconomic status, and mothers' response, knowledge and understanding of child characteristics.

Exploration of the characteristics of established adoptive parents, with explicit attention on parental well-being, using clinical well-being measures (including the use of the Parental Burnout Inventory; Roskam et al., 2017) would provide stronger evidence of the experience of NegMH.

It would be advantageous to explore the benefits of extending the Adoption Support Fund to include funding for parent specific therapeutic interventions on adoptive parent well-being, child well-being and placement outcomes.

Future research is needed into the characteristics and impact of adopted and nonadopted siblings within adoptive families with attention given to the impact of strained sibling attachment on adoptive parent well-being. Rosenberg and Robinson (2014) found that nonadopted children in adoptive families may experience a range of emotions related to their adoptive siblings, including jealousy, guilt, and resentment. Research has explored the phenomenon of adopted children being viewed as accessories or playmates for existing nonadopted children within adoptive families (Senecky & Chaimovitz, 2020). Senecky and Chaimovitz (2020) found that adoptive parents often expected their nonadopted children to play a major role in the socialization of the adopted child and to help in the assimilation process. Such a dynamic could result in adoptive parents feeling less responsible for the care and socialization of the adopted child, which could contribute to a sense of detachment (Senecky & Chaimovitz, 2020). Development of specific interventions for adoptive families focusing on strengthening sibling relationships and its impact on the wider family dynamics may provide a protective factor to overall family well-being.

Further prospective longitudinal research into the trajectories of adoptive parent mental health would enable better understanding of protective factors that challenge the stability of parental well-being and family outcomes. In addition, research into the emotional experiences of adoptive parents throughout the breakdown of an adoptive placement is needed, along with identification of parental support needs during and post-breakdown.

Conclusion

For all mothers, the experience of parenting adoptive children brought joy to their lives. Time allowed many to develop strong and positive relationships with their children, often in the face of continued behavioral challenges and strains on maternal mental health. Mothers spoke of their commitment to their children, growth and adjustment within the family and the value of turning to other adopters for emotional support. However, mothers also identified the need for their own emotional and psychological well-being to be considered as important as that of their child. The demands of “extreme parenting” and therapeutic parenting led mothers to feel exhausted and isolated from those around them.

Implications

If adoptive mothers in the United Kingdom experience negative mental health outcomes years after adopting, there are important implications for adoption policy and practice. First, adoption agencies should provide adoptive parents with comprehensive information about the potential challenges they may face after adopting a child. This information should include the possible impact on the parents' mental health, the support services available, and the long-term implications for the family (Selwyn et al., 2014). Second, adoption agencies should provide adoptive families with ongoing support, including access to adult-specific mental health services. This support should be tailored to meet the individual needs of each family and should be available for as long as required (Biehal et al., 2015). Third, adoption agencies should conduct regular follow-up assessments of adoptive families to monitor their well-being and identify any emerging mental health issues. This assessment should be ongoing, and support services should be provided as required (Selwyn et al., 2014).

Overall, adoption policy and practice should be informed by the experiences of adoptive mothers and their mental health outcomes years after adopting. Adoption agencies should take a proactive approach to addressing the mental health needs of adoptive families, providing comprehensive information, ongoing support, and regular assessments (Biehal et al., 2015; Selwyn et al., 2014).