Adult Mortality in Children Exposed to State Care: Systematic Review and Meta-Analysis of Prospective Cohort Studies

Abstract

Background: Removal from family of origin to placement in state care is a highly challenging and increasingly prevalent childhood experience. The purpose of this report was to synthesise published and unpublished prospective evidence on adult mortality in people with a history of state care in early life. Methods: For this systematic review and meta-analysis, we searched PubMed and Embase from their inception to May 31st 2021, extracting standard estimates of association and variance from qualifying studies. We augmented these findings with analyses of unpublished individual-participant data from the 1958 and 1970 Birth Cohort Studies (total N = 21,936). Study-specific estimates were aggregated using random-effect meta-analysis. The Cochrane Risk of Bias Tool was used to assess study quality. This review is PROSPERO-registered (CRD42021254665). Findings: We identified 209 potentially eligible published articles, of which 11 prospective cohort studies from the UK, Sweden, Finland, the USA, and Canada met the inclusion criteria (2 unpublished). In 2,273,998 individuals (10 studies), relative to those without a care history in childhood, those who were exposed had 2.5 times the risk of total mortality in adulthood (summary rate ratio; 95% confidence interval: 2.58; 1.96 to 3.39), study-specific estimates varying between 1.53 and 5.77 (I2=92%). Despite some attenuation, this association held following adjustment for other measures of early life adversity; extended into middle- and older-age; was stronger in higher quality studies; and was of equal magnitude according to sex and geographical region. There was a suggestion of sensitive periods of exposure to care, whereby individuals who entered public care for the first time in adolescence (3.54; 2.00 to 6.29) experienced greater rates of total mortality than those doing so earlier in the life course (1.69; 1.35 to 2.12). In five studies capturing 1,524,761 individuals (5 studies), children in care had more than three times the risk of competed suicide in adulthood (3.37; 2.64 to 4.30) with study-specific estimates ranging between 2.42 and 5.85 (I2=68%). The magnitude of this relationship was weaker after adjustment for multiple covariates; in men versus women; and in lower quality studies. Interpretation: The excess rates of total and suicide mortality in children exposed to state care suggest child protection systems and social policy following care graduation are insufficient to mitigate the effects of the adverse experiences of care itself and the social disadvantage that preceded it. Funding: GDB is supported by the UK Medical Research Council (MR/P023444/1) and the US National Institute on Aging (1R56AG052519-01; 1R01AG052519-01A1); MK by the Wellcome Trust (221854/Z/20/Z), the MRC (R024227, S011676), NIA (R01AG056477), the Academy of Finland (329202), and Helsinki Institute of Life Science (H970); and PF by the UK Economic and Social Research Council & Biotechnology and Biological Sciences Research Council (Soc-B Centre for Doctoral Training). Declaration of Interest: None to declare. Ethical Approval: Data collection for the 1958 cohort study was approved by the National Health Service Research Ethics committee, and for the 1970 cohort study by the London Central Research Ethics Committee. No ethics was needed for this study.