Long-term Health and Social Outcomes in Children and Adolescents Placed in Out-of-Home Care

Cardiovascular disease in adults with a history of out-of-home care during childhood: a systematic review and meta-analysis of prospective cohort studies

Background

While individuals who were separated from their biological family and placed into the care of the state during childhood (out-of-home care) are more prone to developing selected adverse health problems in adulthood, their risk of cardiovascular disease is uncertain. Our aim was to explore this association by pooling published and unpublished results from prospective cohort studies.

Methods

We used two approaches to identifying relevant data on childhood care and adult cardiovascular disease (PROSPERO registration CRD42021254665). First, to locate published studies, we searched PubMed (Medline) until November 2023. Second, with the objective of identifying unpublished studies with the potential to address the present research question, we scrutinised retrieved reviews on childhood out-of-home care and other adult health outcomes. Included studies were required to satisfy three criteria: a cohort study in which the assessment of care was made prospectively pre-adulthood (in the avoidance of recall bias); data on an unexposed comparator group were available (for the computation of relative risk); and a diagnosis of adult cardiovascular disease events (coronary heart disease, stroke, or their combination) had been made (as opposed to risk factors only). Collaborating investigators provided study-specific estimates which were aggregated using random-effects meta-analysis. The Newcastle-Ottawa Scale was used to assess individual study quality.

Findings

Twelve studies (2 published, 10 unpublished) met the inclusion criteria, and investigators from nine provided viable results, including updated analyses of the published studies. Studies comprised 611,601 individuals (301,129 women) from the US, UK, Sweden, Finland, and Australia. Five of the nine studies were judged to be of higher methodological quality. Relative to the unexposed, individuals with a care placement during childhood had a 51% greater risk of cardiovascular disease in adulthood (summary rate ratio after age- and sex-adjustment [95% confidence interval]: 1.51 [1.22, 1.86]; range of study-specific estimates: 1.07 to 2.06; I 2  = 69%, p = 0.001). This association was attenuated but persisted after adjustment for socioeconomic status in childhood (8 studies; 1.41 [1.15, 1.72]) and adulthood (9 studies, 1.29 [1.11, 1.51]).

Interpretation

Our findings show that individuals with experience of out-of-home care in childhood have a moderately raised risk of cardiovascular disease in adulthood.

Funding

Medical Research Council; National Institute on Aging; Wellcome Trust.

A Systematic Review of the Impact of Placement Instability on Emotional and Behavioural Outcomes Among Children in Foster Care

Foster care children are a highly vulnerable population and their experiences in care are considered crucial to their developmental and psychosocial wellbeing. Placement instability has been considered a possible risk factor for developmental difficulties due to its impact on the development of a reparative attachment relationship and sense of relational permanence. The current review synthesises the literature regarding the impact of placement instability on behavioural and mental health outcomes in foster care children. Three major databases and grey literature sources were searched for all relevant quantitative research published by July 2019. Titles and abstracts of 2419 articles were screened following searches, with full texts obtained for 51 studies and 14 included in the final review. All were subject to quality assessment by two independent reviewers. Results indicated that placement instability was a consistent predictor of externalising behaviour in children, although some evidence was counter-indicative in this regard. There was also evidence to suggest a relationship with internalising behaviours, and mental health difficulties, in particular PTSD symptoms. Methodological quality and design varied between studies which limited direct comparisons. Most notably, there was a lack of consensus on how to quantify and measure placement instability and many studies failed to control for potentially confounding care-related variables. The review highlights that instability seems to result in negative psychological outcomes, although the extent of this relationship remains unclear. The review's findings are discussed with reference to research and clinical implications.

Rates of out-of-home care among children in Canada: an analysis of national administrative child welfare data

INTRODUCTION

As a part of the public health approach to child welfare, data about children placed in out-of-home care are needed to assess population trends, understand drivers of social and health inequities, and examine outcomes for children and families. We analyzed administrative data from Canada to describe the population of children in out-of-home care, and estimate and compare rates of out-of-home care by province/territory, year, sex/gender, age group and placement type.

METHODS

We conducted a cross-sectional analysis of point-in-time data from all provinces and territories for the period 2013/2014 to 2021/2022. We used frequencies and percentages to describe the population of children (and youth up to age 21 years) in out-of-home care and estimated overall and stratified rates and rate ratios.

RESULTS

An estimated 61 104 children in Canada were in out-of-home care on 31 March 2022. The national rate of out-of-home care was 8.24 children per 1000 population. Rate variations by province/territory were substantial and changed over time. Rates were highest among males and children aged 1 to 3 and 16 to 17 years. Foster homes were the most common type of placement, although kinship homes accounted for an increasing share.

CONCLUSION

This analysis demonstrated that administrative data can be used to generate national indicators about children involved in the child welfare system. These data can be used for tracking progress towards health and social equity for children and youth in Canada.

Cumulative risk factors for injuries and poisoning requiring hospital care in youth with prenatal substance exposure: A longitudinal controlled cohort study

Aim: To investigate whether the youth with prenatal substance exposure (PSE) (aged 15-24 years, n = 615) had been in hospital care more often due to injuries and poisoning in comparison with unexposed matched controls (n = 1787). Methods: Data from medical records (exposure) and national health and social welfare registers (outcome and confounders) were combined and youths were monitored from birth until either outpatient or inpatient hospital care for injury or poisoning, death or the end of the study period (December 2016). Cox regression models were used in the analyses accounting for associated child and maternal risk factors. Results: Half (50.4%) of the exposed group and 40.6% of controls had been in hospital care due to injury or poisoning during the follow-up (p < 0.001). The difference between groups was diminished after controlling for postnatal child and maternal risk factors (hazard ratio [HR] = 0.88, 95% confidence interval [CI] 0.72-1.07, p > 0.05). Cumulative adversity, especially out-of-home care in combination with a diagnosed attention or behavioural dysregulation problem, posed the highest risk in both groups (exposed: HR = 1.65, 95% CI 1.24-2.19, p < 0.001; controls: HR = 1.84, 95% CI 1.33-2.56, p < 0.001). Conclusion: Hospital care for injury and poisoning is more common in youth with PSE, but this is largely explained by the related postnatal child and maternal factors. Long-term support to families with maternal substance abuse problems could prevent injury and poisoning among youth with PSE.

Parental Mental Illness and the Likelihood of Child Out-of-Home Care: A Cohort Study

OBJECTIVES

To detail the relationship between parental mental illness and the likelihood of out-of-home care (OHC) among their children, and to identify factors which modify this relationship.

METHODS

Using Swedish national registers, children born in 2000 to 2011 (n = 1 249 463) were linked to their parents. Time-dependent parental mental illness (nonaffective and affective psychosis, substance misuse, depression, anxiety and stress, eating disorders, personality disorders, attention deficit hyperactivity disorder, autism, and intellectual disability), was identified through International Classification of Diseases codes.

RESULTS

After adjustment for socioeconomic factors, children living with mentally ill parents were 4 times as likely to be placed in OHC than children without (95% confidence interval [CI] 4.24-4.61). The highest hazard ratio (HR) was in the youngest children aged 0 to 1 year (5.77, 95% CI 5.42-6.14), exposed to maternal illness (HR 4.56, 95% CI 4.37-4.76), and parental intellectual disability (HR 4.73, 95% CI 4.09-5.46). Children with parental mental illness with multiple risk factors were at particularly high risk. Compared with children without parental mental illness, and those with university-educated parents, children whose parents had mental illness and only had education to age 16 had a 15 times higher risk of OHC (95% CI 13.75-16.54).

CONCLUSIONS

Children with parental mental illness are considerably more likely to be removed from home into care during childhood, particularly during the first year of life and if they are from socially disadvantaged families. Greater knowledge of these risks should lead to increased support for vulnerable new families.

Identifying newborn discharge to child protective services: Comparing discharge codes from birth hospitalization records and child protection case files

PURPOSE

Newborn removal by North America's child protective services (CPS) disproportionately impacts Indigenous and Black families, yet its implications for population health inequities are not well understood. To guide this as a domain for future research, we measured validity of birth hospitalization discharge codes categorizing newborns discharged to CPS.

METHODS

Using data from 309,260 births in Manitoba, Canada, we compared data on newborns discharged to CPS from hospital discharge codes with the presumed gold standard of custody status from CPS case reports in overall population and separately by First Nations status (categorization used in Canada for Indigenous peoples who are members of a First Nation).

RESULTS

Of 309,260 newborns, 4562 (1.48%) were in CPS custody at hospital discharge according to CPS case reports and 2678 (0.87%) were coded by hospitals as discharged to CPS. Sensitivity of discharge codes was low (47.8%), however codes were highly specific (99.8%) with a positive predictive value (PPV) of 81.4%, and a negative predictive value (NPV) of 99.2%. Sensitivity, PPV and specificity were equal for all newborns but NPV was lower for First Nations newborns.

CONCLUSIONS

Canadian hospital discharge records underestimate newborn discharge to CPS, with no difference in misclassication based on First Nations status.

Cardiovascular Disease Events in Adults with a History of State Care in Childhood: Pooling of Unpublished Results from 9 Cohort Studies

Background

Individuals who were separated from their biological family and placed into the care of the state during childhood (out-of-home care) are more prone to developing selected physical and mental health problems in adulthood, however, their risk of cardiovascular disease (CVD) is uncertain. Accordingly, we pooled published and unpublished results from cohort studies of childhood care and adult CVD.

Methods

We used two approaches to identifying relevant data on childhood care and adult CVD (PROSPERO registration CRD42021254665). First, to locate published studies, we searched PubMed (Medline) until November 2023. Second, with the aim of identifying unpublished studies with the potential to address the present research question, we scrutinised retrieved reviews of the impact of childhood state care on related adult health outcomes. All included studies were required to have prospective measurement of state care in childhood and a follow-up of CVD events in adulthood as the primary outcome (incident coronary heart disease and/or stroke). Collaborating investigators provided study-specific estimates which were aggregated using random-effects meta-analysis. The Newcastle-Ottawa Scale was used to assess individual study quality.

Findings

Thirteen studies (2 published, 11 unpublished) met the inclusion criteria, and investigators from nine provided viable results, including updated analyses of the published studies. Studies comprised 611,601 individuals (301,129 women) from the US, UK, Sweden, Finland, and Australia. Relative to the unexposed, individuals with a care placement during childhood had a 50% greater risk of CVD in adulthood (summary rate ratio after basic adjustment [95% confidence interval]: 1.50 [1.22, 1.84]); range of study-specific estimates: 1.28 to 2.06; I2 = 69%, p = 0.001). This association was attenuated but persisted after multivariable adjustment for socioeconomic status in childhood (8 studies; 1.41 [1.15, 1.72]) and adulthood (9 studies, 1.28 [1.10, 1.50]). There was a suggestion of a stronger state care-CVD association in women.

Interpretation

Our findings show that individuals with experience of state care in childhood have a moderately raised risk of CVD in adulthood. For timely prevention, clinicians and policy makers should be aware that people with a care history may need additional attention in risk factor management.

Psychopathology and mental health service use among youth in foster care admitted to a psychiatric inpatient unit: a 4-year retrospective controlled study

Youth in foster care (FC) are at increased risk of poor psychosocial outcomes. The aim of this study was to assess psychopathology and mental health service use among youth living in FC who require psychiatric hospitalisation. All individuals admitted to our Children and Adolescent Inpatient Psychiatry Unit between 2014 and 2017 who were in FC were systematically reviewed. The control group was defined as all youth living with their immediate family and hospitalised in our unit throughout 2016. We identified 89 patients placed in FC and 247 controls. Socio-demographic and clinical data were retrospectively collected from computerised charts. A survival analysis of emergency department visits and readmission to the hospital was conducted. Compared to controls, the FC group presented significantly higher rates of conduct disorder (78.7% vs 14.6%; p < 0.001) and substance use disorder (49.4% vs 27.5%; p < 0.001), mainly cannabis use (34.8% vs 16.6%; p < 0.001); higher rates of comorbidity (96.6% vs 55.9%; p < 0.001) and mean number of comorbid diagnoses (3.3 ± 1.1 vs 2.3 ± 0.5; p < 0.001). The FC group had a higher number of emergency room visits before and after admission than controls. FC youth were also 2.77 times more likely to visit the emergency department after discharge, and in a shorter time period, than controls (p = 0.004). Disruptive behaviours, substance use disorder, and comorbid psychopathology were all more prevalent among FC youth than controls. Specific strategies are needed to optimize community mental health resources and address the increased use of emergency services by these youth before and after hospitalisation.

Out-of-home interventions for adolescents who were treated according to the Open Dialogue model for mental health care

BACKGROUND

The Open Dialogue approach (OD) emphasizes community-based psychiatric treatment for adolescents, but its success in achieving this is poorly documented.

OBJECTIVE

To analyse out-of-home intervention usage in a national sample of adolescent psychiatric patients and determine if OD is linked to increased time until out-of-home intervention.

PARTICIPANTS AND SETTING

The register-based cohort study included all adolescents aged 13-20 who received psychiatric treatment in Finland between 2003 and 2008. The research group (n = 780) included adolescents whose treatment was initiated in the Western Lapland catchment area, where OD covered the entire psychiatric service. The comparison group (n = 44,088) included the rest of Finland. National register data encompassed the period from treatment onset until the end of the 10-year follow-up or death. The primary outcomes of interest were the times to the first and second out-of-home intervention, including foster care, supportive housing, and hospitalization. The secondary outcomes included the clinical/demographic characteristics of adolescents treated out-of-home.

METHODS

The hypothesis was tested via an inverse probability of treatment-weighted Cox hazard model, plus within- and between-group comparisons to analyse the secondary outcome.

RESULTS

OD was associated with increased time to the first (adjusted hazard ratio [aHR]: 0.61, 95%CI: 0.52-0.72) and second (aHR: 0.75, 95%CI: 0.58-0.96) out-of-home interventions. In both service types, there was a subgroup of adolescents with repeated out-of-home interventions, who also demonstrated poorer long-term outcomes.

CONCLUSION

OD-based psychiatric services for adolescents are associated with fewer out-of-home interventions. The clinical significance of the findings warrants further research.

Child protective services involvement and exclusionary school discipline

The study examined the impact of child protective services (CPS) contact on out-of-school suspensions for 49,918 Wisconsin students (followed from ages 5-6 to 14-15; [school years 2010-2019; 74% White; 7% Black; 11% Hispanic; 8% other; 49% female]). A quasi-experimental design comparing recent CPS contact to upcoming (future) CPS contact shows that both recent CPS contact without foster care and future CPS contact predict higher odds of suspension compared with no contact. Higher odds of suspension emerged prior to CPS contact and did not substantially increase during or after CPS contact, suggesting that system-induced stress is not a primary driver of behavioral problems leading to suspension. Foster care reduced the odds of suspension among White children and children in special education.

Outcomes and experiences after child custody loss among mothers who use drugs: A mixed studies systematic review

BACKGROUND

Mothers who use drugs are more likely to experience child custody loss than mothers who do not use drugs. The negative impact of removal on children has been well characterized in current literature while less is known about the impact of custody loss on mothers. The purpose of this mixed studies systematic review is to describe the state of science on the maternal outcomes and experiences after child custody loss among mothers who use drugs.

METHODS

PubMed, PsycINFO, CINAHL, and Social Work Abstract databases were systematically searched between June 2022 to January 2023. Article eligibility criteria centered on the outcomes and experiences of mothers who use drugs after losing child custody. Studies were analyzed using results-based convergent synthesis methodology for mixed studies reviews. Study quality was assessed using the Mixed Methods Appraisal Tool (MMAT). A visual synthesis model was derived from combined results across all studies.

RESULTS

Of 2434 articles screened, 22 relevant scientific articles were selected for inclusion. Longitudinal, cohort studies (n=4) and a cross-sectional study (n=1) identified positive associations between custody loss and poorer mental health, increased drug use and overdose risk, less treatment engagement, and worsened social factors. Qualitative studies (n=17) identified themes that described re-traumatization after child custody loss and the development of coping mechanisms through identity negotiation.

CONCLUSION

Our findings indicate that child custody loss associated with drug use may exacerbate trauma and worsen maternal health. Immediate implications are provided for maternal health policy and practice in healthcare, child welfare, and legal professions.

Medical Professional Reports and Child Welfare System Infant Investigations: An Analysis of National Child Abuse and Neglect Data System Data

Background

Medical professionals are key components of child maltreatment surveillance. Updated estimates of reporting rates by medical professionals are needed.

Methods

We use the National Child Abuse and Neglect Data System (2000-2019) to estimate rates of child welfare investigations of infants stemming from medical professional reporting to child welfare agencies. We adjust for missing data and join records to population data to compute race/ethnicity-specific rates of infant exposure to child welfare investigations at the state-year level, including sub-analyses related to pregnant/parenting people's substance use.

Results

Between 2010 and 2019, child welfare investigated 2.8 million infants; ∼26% (n=731,705) stemmed from medical professionals' reports. Population-adjusted rates of these investigations stemming doubled between 2010 and 2019 (13.1-27.1 per 1000 infants). Rates of investigations stemming from medical professionals' reports increased faster than did rates for other mandated reporters, such as teachers and police, whose reporting remained relatively stable. In 2019, child welfare investigated ∼1 in 18 Black (5.4%), 1 in 31 Indigenous (3.2%), and 1 in 41 White infants (2.5%) following medical professionals' reports. Relative increases were similar across racial groups, but absolute increases differed, with 1.3% more of White, 1.7% of Indigenous, and 3.1% of Black infants investigated in 2019 than 2010. Investigations related to substance use comprised ∼35% of these investigations; in some states, this was almost 80%.

Discussion

Rates of child welfare investigations of infants stemming from medical professional reports have increased dramatically over the past decade with persistent and notable racial inequities in these investigations.

Child Abuse, Misdiagnosed by an Expertise Center: Part I-Medico-Social Aspects

Child abuse is a dangerous situation for an infant. Professionals need to weigh the risk of failing to act when children are seriously harmed against the serious harm done by carrying out safeguarding interventions. In severe cases, foster care might be advisable. The negative effects for the child's psychosocial development requires that such placement must be based on very solid evidence. Our aim is to identify why Dutch parents whose child may have a medical condition that could mimic symptoms of child abuse have a significant chance of being erroneously convicted and losing custody of their child. As a method, we describe and analyze the following case. An Armenian-Dutch newborn (uncomplicated term vaginal delivery), starting at two weeks after birth, developed small bruises on varying body locations. At two months, a Well-Baby Clinic physician referred the girl to a university hospital, mentioning that there were no reasons to suspect child abuse and that her Armenian grandmother easily bruised as well. However, before consultation by a pediatrician of the hospital-located Expertise Center for Child Abuse, the parents were suspected of child abuse. Based on the expertise center's protocols, skeletal X-rays were made, which showed three healed, asymptomatic rib fractures, while invalid statistics suggested, incorrectly, a 10-100 times more likely non-accidental than accidental cause of the symptoms (discussed in Part II of this series). The expertise enter physician ignored any argument that could show parental innocence, including the positive parent-child relationship reported by the Well-Baby Clinic and the general practitioner. The girl and her older brother were placed in a family foster home and then in a secret home. The case radically resolved when a large bruise also developed there, and an independent tissue disease specialist diagnosed a hereditary connective tissue disorder in the mother, implying that the girl's bruises and rib fractures could well be disease-related. In conclusion, if child abuse is suspected, and foster care placement considered, the patient and the parents should be thoroughly investigated by an independent experienced pediatrician together with an experienced pediatric clinical psychologist or psychotherapist to produce an independent opinion. Children deserve this extra safeguard before being separated from their parents.

Healthcare utilization and psychiatric morbidity in violent offenders: findings from a prospective cohort study

PURPOSE

Although persistent offenders with histories of imprisonment and violence have disproportionate high rates of psychiatric disorders, little is known of their psychiatric healthcare utilization (HCU) and HCU-associated factors. This study aimed to explore psychiatric HCU, psychiatric morbidity, and psychotropic prescription drugs in violent offenders with a history of incarceration.

METHODS

Male offenders aged 18-25 (n = 266) imprisoned for violent and/or physical sexual offenses were clinically assessed in 2010-2012 and prospectively followed in Swedish national registries through 2017. Register-based information regarding HCU, psychiatric morbidity, and psychotropic drugs was tracked and compared with a general population group (n = 10,000) and across offending trajectory groups. Baseline risk factors were used to explain prospective psychiatric HCU in violent offenders.

RESULTS

Violent offenders used less general healthcare and psychiatric outpatient care, but more psychiatric inpatient care and were more often given psychiatric diagnoses and psychotropic drugs than the general population. Participants previously assigned to persisting offending trajectory groups had higher rates of psychiatric HCU than those assigned to a desisting trajectory. In multivariable regression models, psychiatric HCU was associated with anxiety disorders, prior psychiatric contact, placement in a foster home, psychopathic traits, low intellectual functioning, and persistent offending.

CONCLUSIONS

Violent offenders are burdened by extensive and serious psychiatric morbidity and typically interact with psychiatric healthcare as inpatients rather than outpatients. Knowledge about their backgrounds, criminal behaviors, and psychiatric statuses can aid the planning of psychiatric services for this troublesome group.

Childhood adversity is associated with hospitalisations and survival following external causes and non-communicable diseases: a 46-year follow-up of a Stockholm birth cohort

BACKGROUND

Childhood adversity indicated by involvement with child welfare services (ICWS) is associated with increased risks of disease and injuries in young adulthood. It is yet unknown whether such risks are limited to external causes and mental and behavioural disorders or whether they extend beyond early adulthood and to non-communicable diseases (NCDs) with later onset. Moreover, it has not been explored whether ICWS associates with decreased survival prospects following hospitalisation.

METHODS

Based on prospective data for a 1953 Stockholm birth cohort (n=14 134), ICWS was operationalised distinguishing two levels in administrative child welfare records (ages 0-19; 'investigated' and 'placed' in out-of-home care (OHC)). Hospitalisations and all-cause mortality (ages 20-66) were derived from national registers. Hospitalisation records were categorised into external causes and NCDs, and nine subcategories. Negative binomial regression models were used to estimate differences in hospitalisation risks between those with and without experiences of ICWS and Cox survival models to estimate mortality after hospitalisation.

RESULTS

Placement in OHC was associated with higher risks of hospitalisation due to external causes and NCDs and all investigated subcategories except cancers. Risks were generally also elevated among those investigated but not placed. ICWS was further linked to higher mortality risks following hospitalisation.

CONCLUSION

Differential risk of morbidity and differential survival may explain inequalities in mortality following childhood adversity. We conclude that the healthcare sector might play an important role in preventing and mitigating the elevated risks of externally caused morbidity, disease and premature mortality observed among those with a history of ICWS.

Out-of-home care placement and mortality rate in early adulthood: identifying vulnerable subgroups in a nationwide cohort study

Out-of-home care has been linked to excess mortality across the lifespan. We examined whether this association is modified by the age at first out-of-home care placement and the number of placements. In this population-based cohort study, we used register data covering all children born in Denmark between 1 and 1980 and 31 December 1999, totalling 1,111,193 individuals followed until 31 December 2018. We divided participants according to sex, out-of-home care status, age at first placement, and the number of placements. We estimated adjusted hazard ratios and hazard differences per 10,000 person-years for all-cause mortality and mortality due to suicide, accidents, and cancer between ages 18 and 39. 53,015 (4.8%) of the participants were placed in out-of-home care before age 18. The adjusted hazard ratio for all-cause mortality was 3.4 (95% CI 3.1-3.7) for males and 4.7 (4.0-5.4) for females, corresponding to 20.6 (19.0-22.2) and 10.3 (9.1-11.5) additional deaths per 10,000 individuals annually among males and females, respectively. Associations did not vary substantially according to age at first placement or the number of placements. Both males and females with a history of out-of-home care were more likely to die from suicide, accidents, and cancer compared with their peers. We show a markedly higher all-cause and cause-specific mortality among children who have been placed in out-of-home care, but contrary to our hypothesis, age at first placement and the number of placements did not modify this relation. These results warrant further investigation into potential target points for interventions that may prevent premature mortality in this group of disadvantaged individuals.

Prenatal cocaine exposure and substance use disorder in emerging adulthood at age 21

BACKGROUND

Prenatal cocaine exposure (PCE) has been associated with child and adolescent externalizing behaviors and early substance use, yet few studies investigated its association with substance use disorder (SUD) in emerging adults. The present study examined the association of PCE with SUD in emerging adulthood, and whether childhood externalizing behaviors and adolescent substance use mediated the relationship.

METHODS

Participants were 367 (187 PCE; 53% female) adults at age 21, primarily urban African American who were recruited at birth. PCE and exposure to alcohol, tobacco, and marijuana were determined using biologic assays for drug metabolites and/or maternal self-report at birth. Offspring externalizing problems were assessed using the Youth Self-Report at age 12, substance use and substance use-related problems via biologic assays and/or self-report at age 15, and SUD determined using DSM-5 diagnostic criteria at age 21.

RESULTS

About 32.3% of the emerging adults were determined to have marijuana use disorder, 30.3% tobacco use disorder, and 15.5% alcohol use disorder. PCE was related to greater externalizing behaviors at age 12 (β = 0.12, p = .042), which in turn was related to SUD (β = 0.22, p = .008). PCE was also related to substance use, mainly marijuana, at age 15 (β = 0.22, p = .011), which was related to SUD (β = 0.51, p < .001). Total indirect effects including these two pathways were significant (β = 0.19, p = .002).

CONCLUSIONS

PCE may increase risk for SUD in emerging adulthood through childhood externalizing behaviors and adolescent substance use.

Adverse childhood experiences do not moderate the association between aggressive antisocial behavior and general disinhibition in a forensic psychiatric inpatient sample

Adverse childhood experiences (ACE) and high levels of disinhibition have been associated with a variety of negative outcomes such as aggressive antisocial behavior (AAB). However, forensic psychiatric populations remain an understudied group in this field of research. This study aimed to fill that gap by investigating associations between ACE, AAB, and disinhibition in a forensic psychiatric sample. Furthermore, we aimed to explore such findings by investigating whether ACE might have a moderating effect on the association between disinhibition and AAB. A sample of forensic psychiatric patients (n = 89) was recruited from a high-security forensic psychiatric facility in Sweden. All study variables were moderately to strongly related to each other, although we found no moderating effect of ACE. Post hoc analysis indicated that our ACE items had differential effects on AAB scores, with placement outside the family home, absent parents, and parental drug abuse producing the largest effect on AAB levels. Our findings are in line with previous research demonstrating a significant and robust relationship between ACE, AAB, and disinhibition. Forensic psychiatric populations are exposed to high levels of both self-reported and documented ACE. This calls for trauma-informed care and highlights the importance of considering ACE in risk assessment, preventive work, and policy making.

Mental Disorders Into Adulthood Among Adolescents Placed in Residential Care: A Prospective 10-Year Follow-up Study

Background

Child welfare and juvenile justice placed youths show high levels of psychosocial burden and high rates of mental disorders. It remains unclear how mental disorders develop into adulthood in these populations. The aim was to present the rates of mental disorders in adolescence and adulthood in child welfare and juvenile justice samples and to examine their mental health trajectories from adolescence into adulthood.

Methods

Seventy adolescents in shared residential care, placed by child welfare (n = 52, mean age = 15 years) or juvenile justice (n = 18, mean age = 17 years) authorities, were followed up into adulthood (child welfare: mean age = 25 years; juvenile justice: mean age = 27 years). Mental disorders were assessed based on the International Classification of Diseases 10th Revision diagnoses at baseline and at follow-up. Epidemiological information on mental disorders was presented for each group. Bivariate correlations and structural equation modeling for the relationship of mental disorders were performed.

Results

In the total sample, prevalence rates of 73% and 86% for any mental disorder were found in adolescence (child welfare: 70%; juvenile justice: 83%) and adulthood (child welfare: 83%; juvenile justice: 94%) respectively. General psychopathology was found to be stable from adolescence into adulthood in both samples.

Conclusions

Our findings showed high prevalence rates and a high stability of general psychopathology into adulthood among child welfare and juvenile justice adolescents in Swiss residential care. Therefore, continuity of mental health care and well-prepared transitions into adulthood for such individuals is highly warranted.

State care in childhood and adult mortality: a systematic review and meta-analysis of prospective cohort studies

BACKGROUND

Removal from family of origin to state care can be a highly challenging childhood experience and is itself linked to an array of unfavourable outcomes in adult life. We aim to synthetise evidence on the risk of adult mortality in people with a history of state care in early life, and assess the association according to different contexts.

METHODS

In this systematic review and meta-analysis, we focused on four health outcomes hypothesised to be associated with exposure to early state care: total mortality, cardiovascular disease, cancer, and suicide. We searched the electronic databases PubMed and Embase from inception to Jan 21, 2022, for studies fulfilling the following criteria: it was a prospective study in which the assessment of care was made up to 18 years of age; it included an unexposed comparator group; the focus of the study was temporary out-of-home care and not adoption; mortality surveillance was extended into adulthood; standard estimates of association (eg, relative risk, odds ratios, or hazard ratios) and variance (eg, CIs and SE) were provided; the study appeared in a peer-reviewed journal; and the study was published in English. An adapted Cochrane Risk of Bias Tool was used to assess study quality. We extracted estimates of association and variance from qualifying studies and augmented these findings with analyses of unpublished data from individual participants in two UK birth cohorts-ie, the 1958 and 1970 studies (total n=21 936). We computed hazard ratios with accompanying 95% CIs for care and each health outcome separately for each study, and then pooled the results using a random-effects meta-analysis. This review is registered at PROSPERO, CRD42021254665.

FINDINGS

We identified 210 potentially eligible published articles, of which 14 met our inclusion criteria (two studies were unpublished). Of 3 223 580 individuals drawn from 13 studies, those who were exposed to care in childhood had twice the risk of total mortality in adulthood relative to those without a history of care in childhood (summary risk ratio 2·21 [95% CI 1·62-3·02]), with study-specific estimates varying between 1·04 and 5·77 (I² =98%). Despite some attenuation, this association remained 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, geographical region, and birth year. There was some suggestion of sensitive periods of exposure to care, whereby individuals who entered state care for the first time in adolescence (2·47 [0·98-6·52]) had greater rates of mortality than those doing so early in the life course (1·75 [1·25-2·45]). In four studies including 534 890 people, children in care had more than three times the risk of completed suicide in adulthood relative to their unexposed peers (3·35 [2·41-4·68]), with study-specific estimates ranging between 2·42 and 5·85 (I²=72%). The magnitude of this association was weaker after adjustment for multiple covariates; in men than in women; and in lower-quality studies.

INTERPRETATION

Our results for adult mortality suggest child protection systems, social policy, and health services following care graduation are insufficient to mitigate the adverse experiences that might have preceded placement into care and those that might accompany it.

FUNDING

None.