Abstract
Children placed in out-of-home care (OHC) have higher rates of suicidal behaviors, including suicide attempts, compared with those who grow up in their family of origin. Several studies have shown that this elevated risk persists into young adulthood. Yet, our knowledge about any longer-term associations of OHC with suicide attempts is limited. To examine how childhood experiences of placement in OHC are associated with trajectories of hospitalization because of suicide attempts (HSA) from early into late adulthood. This prospective birth cohort study that was conducted in Stockholm, Sweden, and analyzed in March 2020 included 14 559 individuals born in 1953 who were living in the greater metropolitan of Stockholm in November 1963 and followed through registers up until December 2016. Childhood experiences of OHC based on information from the Social Register (age 0-19 years). Hospitalization because of suicide attempts based on in-patient care data from the National Patient Register. Group-based trajectory modeling was used to cluster individuals according to their probabilities of HSA across adulthood (age 20-63 years). In this cohort of 14 559 individuals (7146 women [49.1%]), 1320 individuals (9.1%) had childhood experiences of OHC, whereas 525 individuals ( 3.6%) had HSA. A Cox regression analysis showed a substantially higher risk of HSA among those with childhood experiences of OHC (hazard ratio, 3.58; 95% CI, 2.93-4.36) and after adjusting for a range of adverse childhood living conditions (hazard ratio, 2.51; 95% CI, 2.00-3.15). Those with at least 1 HSA were grouped into 4 trajectories: (1) peak in middle adulthood (66 [12.6%]), (2) stable low across adulthood (167 [31.8%]), (3) peak in early adulthood (210 [40.0%]), and (4) peak in emerging adulthood (82 [15.6%]). A multinomial regression analysis suggested that those with experiences of OHC had higher risks of following any of these trajectories (trajectory 1: relative risk ratio [RRR], 2.91; 95% CI, 1.61-5.26; trajectory 2: RRR, 3.18; 95% CI, 2.21-4.59; trajectory 3: RRR, 4.32; 95% CI, 3.18-5.86; trajectory 4: RRR, 3.26; 95% CI, 1.94-5.46). The estimates were reduced after adjusting for adverse childhood living conditions. The findings suggest that the elevated risk of suicide attempts among former child welfare clients does not cease after young adulthood, indicating the necessity for clinical attention to childhood experiences of OHC as a risk marker for suicidal behavior across the life span.
Highlights
Suicidal behaviors among children and young people have been identified as a major public health problem.[1]
The findings suggest that the elevated risk of suicide attempts among former child welfare clients does not cease after young adulthood, indicating the necessity for clinical attention to childhood experiences of of-home care (OHC) as a risk marker for suicidal behavior across the life span
While the association between OHC and hospitalization because of suicide attempts (HSA) becomes reduced in the adjusted model, it remains strong and statistically significant (HR, 2.51; 95% CI, 2.00-3.15)
Summary
Suicidal behaviors among children and young people have been identified as a major public health problem.[1] The prevalence of such behaviors is prominent among individuals placed in foster family or residential care (out-of-home care [OHC]). A recent systematic review and meta-analysis showed that children and young people in OHC are more than 3 times more likely to attempt suicide compared with noncare populations.[2] A few prospective studies have demonstrated that this difference does not cease after exiting care but rather extends further into young adulthood.[3,4] Whether the same holds true for later phases in life remains to be explored. There are good reasons to expect this to be the case, considering that the elevated risks of mental and behavioral disorders among individuals with childhood experiences of placement in OHC have been found to last well into midlife.[5,6,7] We find support for this notion in the research focusing on adverse childhood experiences (ACEs), a concept that overlaps with experiences of OHC in theory and practice, and lifetime suicide attempts.[8,9,10,11] Yet, with some notable exceptions,[12] most studies have based their measurements of ACE on retrospective data, which are known to be sensitive for recall bias.[13]
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