Exposure to out-of-home care in childhood and adult all-cause mortality: a cohort study

A Balancing Act: How Professionals in the Foster Care System Balance the Harm of Intimate Partner Violence as Compared to the Harm of Child Removal

The striking prevalence of child exposure to intimate partner violence (IPV) and its associated adverse health outcomes necessitates a robust response from professionals who must grapple with the ethical dilemma of how to serve and support children in these circumstances. In 2020, 42 participants from four different professional backgrounds (attorneys, nonprofit leadership, licensed therapists, and social workers) were interviewed or participated in a focus group discussion. All groups acknowledged the shortfalls of current intervention practices, which often result in child removal. Group 1, which included social workers that work for children's legal services, minor's counsel, and Los Angeles Department of Child and Family Services social workers, were more conflicted in their recommendations for change. Some Group 1 participants recommended more training, while others thought more training would make little difference and recommended more substantial changes to prevent child removal when possible. Group 2, which included parents' counsel, and Group 3, which included social workers, attorneys, and nonprofit leadership at IPV nonprofits, were more closely aligned in their recommendations, primarily focusing on systemic changes to the child welfare system. Participants whose employment required them to advocate for parents tend to view child removal from a non-offending parent as harmful for both the child and IPV survivor. These findings illuminate how the perspectives of these diverse participants are influenced by their professional and personal experiences.

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.

Rural mothers' beliefs and practices about diagnosis, treatment, and management of children health problems: A qualitative study in marginalized Southern Pakistan

Introduction

Appropriate health-seeking beliefs and practices are indispensable for the survival and development of children. In this study, we explore childcare beliefs and practices of rural mothers and analyze the different ways childhood illness is diagnosed and managed in a marginalized rural community in Southern Pakistan.

Methods

Using purposive sampling, in-depth interviews are conducted to obtain qualitative data from 20 illiterate and rural mothers in addition to 15 healthcare providers in the district Rajanpur of South Punjab.

Results and discussion

The findings reveal that rural mothers' access to healthcare and therapeutic programs is impeded due to geographical isolation, structural inequalities, poverty, and illiteracy. Consequently, evil eyes, witchcraft, and spirits are recognized as potential threats to children's health and nutrition. Therefore, the treatment of childhood morbidity and malnutrition is mostly performed with folk, domestic, herbal, magico-religious remedies, and spiritual healing methods. The current study also highlights that many low-income and rural mothers tend to normalize childhood illness when they become unable to advocate for their children's health and nutrition. Besides improving low-income mothers' access to healthcare facilities, health education and risk communication at the field level through field health staff could be most effective for health promotion.

Does time heal all wounds? Life course associations between child welfare involvement and mortality in prospective cohorts from Sweden and Britain

Child welfare involvement reflects childhood adversity and is associated with increased adult mortality, but it remains unclear how this association changes over the life course. Drawing on the Stockholm Birth Cohort Multigenerational Study (Sweden) and the National Childhood Development Study (Great Britain) this study examines whether inequalities within these cohorts diverge or converge. Involvement with child welfare services (ICWS) is divided into two levels ('child welfare contact' and 'out-of-home care'). For each cohort, we quantify absolute health inequalities as differences in cumulative probabilities of death (18-58 years) and temporary life expectancy; and relative inequalities as hazard ratios in ten-year intervals and ratios of lifetime lost. Persistently, ICWS was associated with premature mortality. The strength of the association varied by age, sex and level of ICWS. Consistently across both countries, the most robust relationship was between out-of-home care and mortality, with statistically significant age-specific hazard ratios ranging between 1.8 and 3.4 for males and 1.8-2.1 for females. Child welfare contact that did not result in out-of-home placement showed less consistent results. Among females the mortality gap developed later compared to males. Estimates attenuate after controlling for family socioeconomic and other background variables but patterns remain intact. Our results show that absolute inequalities widen with increasing age, while relative inequalities might peak in early adulthood and then stabilize in midlife. The relative disadvantage among looked-after children in early adulthood is heightened by overall low rates of mortality at this age. Absolute inequality increases with age, highlighting the weight of the accumulation of disadvantage in mortality over time. The bulk of excess deaths that could be attributed to ICWS occurs from midlife onwards. Mechanisms that uphold the disadvantage after childhood experiences require further exploration. This study highlights that the association between out-of-home care and premature mortality seems to transcend welfare systems.

Healthcare beliefs and practices of kin caregivers in South Africa: implications for child survival

BACKGROUND

Appropriate health-seeking practices may have a positive influence on child survival, particularly when practiced by kin caregivers of children who are below the age of 5 years. While literature has shown that children who are raised in kinship care often present with poor health outcomes and often have unmet healthcare needs, the health-seeking behaviours and practices of the children's kin caregivers that ultimately influence these health outcomes remain largely unknown. In this paper, we explored the healthcare beliefs and practices of kin caregivers in South Africa on child survival.

METHODS

Overall, 12 structured interviews were conducted with all the participants. Six [6] interviews were conducted in the Eastern Cape province and 6 were conducted in the KwaZulu-Natal province. The sample of participants was obtained by seeking permission from the child welfare authorities in the KwaZulu-Natal and Eastern Cape Department of Social Development (DSD) to assist in identifying a sample of the kin-caregivers who have provided primary care to children below the age of 5. The structured interviews were transcribed and analysed using thematic content analysis. After thematic content analysis was carried out, transcripts were given case numbers and then imported into NViVo version 11 for analysis and interpretation of the findings.

RESULTS

The healthcare seeking behaviours and poor use of healthcare services of the caregivers were largely influenced by their notions and perceptions of health and illness. The notions and perceptions that the caregivers hold about the health statuses of the children placed under their care and illness were found to be largely culturally determined and largely influenced by preconceptions and certain healthcare beliefs. Increased reliance on traditional herbs, Notion of witchcraft and Faith healing emerged as key factors that influence health-seeking practices and beliefs of kin caregivers, thus influencing under-five mortality.

CONCLUSION

Kin caregivers should be equipped with the necessary guidance, resources and training that facilitate the successful fulfilment of the caregiving role, given the number of unmet needs and challenges that they face. This will in turn translate into positive child health outcomes.

Association of Child Placement in Out-of-Home Care With Trajectories of Hospitalization Because of Suicide Attempts From Early to Late Adulthood

Importance

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.

Objective

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.

Design, Setting, and Participants

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.

Exposures

Childhood experiences of OHC based on information from the Social Register (age 0-19 years).

Main Outcomes and Measures

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).

Results

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.

Conclusions and Relevance

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.

Out-of-home care in childhood and biomedical risk factors in middle-age: National birth cohort study

Objective

With there being an apparent impact of experience of out‐of‐home care in childhood on chronic disease and mortality, we examined how such adversity might be embodied such that it has a measurable impact on human biology, so mediating this relationship.

Methods

We used data from the UK National Child Development Study in which exposure to public care was prospectively gathered on three occasions up to age 16. Study members also participated in a social survey at age 42 and a clinical examination at age 44/45 when cardiovascular, inflammatory, neuroendocrine, and respiratory risk markers for mortality were collected, 19 of which were included as endpoints in the present analyses.

Results

Of the 8012 participants in the biomedical survey, 4% (n = 322) had been in care at some point in childhood and/or adolescence. We found the expected marked differences in the early life characteristics of poverty, health, and disability in children with experience of public care relative to their unexposed counterparts. After controlling for these confounding factors, however, care in childhood was essentially unrelated to biomarkers in middle‐age. We also found no consistent links between these biomarkers and the duration, timing, or type of care.

Conclusions

Our results suggest that the biomarkers captured in the present study are unlikely to mediate the link between public care in childhood and later chronic disease or mortality. Processes involving mental health, socioeconomic position, and health behaviors would seem to be a potential alternative pathway warranting investigation.

Troubled childhoods cast long shadows: Childhood adversity and premature all-cause mortality in a Swedish cohort

Experiences of childhood adversity are common and have profound health impacts over the life course. Yet, studying health outcomes associated with childhood adversity is challenging due to a lack of conceptual clarity of childhood adversity, scarce prospective data, and selection bias. Using a 65-year follow-up of a Swedish cohort born in 1953 (n = 14,004), this study examined the relationship between childhood adversity (ages 0-18) and premature all-cause mortality (ages 19-65). Childhood adversity was operationalized as involvement with child welfare services, household dysfunction, and disadvantageous family socioeconomic conditions. Survival models were used to estimate how much of the association between child welfare service involvement and mortality could be explained by household dysfunction and socioeconomic conditions. Results show that individuals who were involved with child welfare services had higher hazards of dying prematurely than their majority population peers. These risks followed a gradient, ranging from a hazard ratio of 3.08 (95% CI: 2.68-3.53) among those placed in out-of-home care, followed by individuals subjected to in-home services who demonstrated a hazard ratio of 2.53 (95% CI: 1.93-3.32), to a hazard ratio of 1.81 among those investigated and not substantiated (95% CI: 1.55-2.12). Associations between involvement with child welfare services and premature all-cause mortality were robust to adjustment for household dysfunction and disadvantageous family socioeconomic conditions. Neither household dysfunction nor socioeconomic conditions were related with mortality independent of child welfare services involvement. This study suggests that involvement with child welfare services is a viable proxy for exposure to childhood adversity and avoids pitfalls of self-reported or retrospective measures.

Poor Family Relationships in Adolescence and the Risk of Premature Death: Findings from the Stockholm Birth Cohort Study

Poor family relationships during childhood have been shown to have long-term negative effects on an offspring's health. However, few studies have followed the offspring to retirement age, and relatedly, knowledge about the link between poor family relationships and premature death is scarce. The aim of this study was to examine the association between poor family relationships in adolescence and the risk of premature death, even when considering other adverse childhood conditions. Prospective data from the Stockholm Birth Cohort study were used, with 2636 individuals born in 1953 who were followed up until age 65. Information on family relations was based on interviews with the participants' mothers in 1968. Information on mortality was retrieved from administrative register data from 1969-2018. Cox proportional hazards regressions showed that poor family relationships in adolescence were associated with an increased risk of premature death, even when adjusting for childhood conditions in terms of household social class, household economic poverty, contact with the child services, parental alcohol abuse, and parental mental illness (Hazard Ratio (HR), 2.08, 95% Confidence Interval (CI), 1.40-3.09). The findings show that poor family relationships in adolescence can have severe and long-lasting health consequences, highlighting the importance of early interventions.

Do trajectories of economic, work- and health-related disadvantages explain child welfare clients' increased mortality risk? A prospective cohort study

Background

Past research has shown that individuals who have had experiences of out-of-home care (OHC) in childhood have increased risks of premature mortality. Prior studies also suggest that these individuals are more likely to follow long-term trajectories that are characterised by economic, work-, and health-related disadvantages, compared to majority population peers. Yet, we do not know the extent to which such trajectories may explain their elevated mortality risks. The aim of this study is therefore to examine whether trajectories of economic, work-, and health-related disadvantages in midlife mediate the association between OHC experience in childhood and subsequent all-cause mortality.

Methods

Utilising longitudinal Swedish data from a 1953 cohort (n = 14,294), followed from birth up until 2008 (age 55), this study applies gender-specific logistic regression analysis to analyse the association between OHC experience in childhood (ages 0–19; 1953–1972) and all-cause mortality (ages 47–55; 2000–2008). A decomposition method developed for non-linear regression models is used to estimate mediation by trajectories of economic, work-, and health-related disadvantages (ages 39–46; 1992–1999), as indicated by social welfare receipt, unemployment, and mental health problems. To account for selection processes underlying placement in OHC, an alternative comparison group of children who were investigated by the child welfare committee but not placed, is included.

Results

The results confirm that individuals with experience of OHC have more than a two-fold increased risk of all-cause mortality, for men (OR: 2.10, 95% CI: 1.42–3.11) and women (OR: 2.23, 95% CI: 1.39–3.59) alike. Approximately one-third (31.1%) of the association among men, and one-fourth (27.4%) of the association among women, is mediated by the long-term trajectories of economic, work-, and health-related disadvantages. The group who were investigated but not placed shows similar, yet overall weaker, associations.

Conclusions

Individuals who come to the attention of the child welfare services, regardless of whether they are placed in out-of-home care or not, continue to be at risk of adverse outcomes across the life course. Preventing them from following trajectories of economic, work-, and health-related disadvantages could potentially reduce their risk of premature death.

A decade lost: does educational success mitigate the increased risks of premature death among children with experience of out-of-home care?

Background

Past research has consistently identified children with out-of-home care (OHC) experience as a high-risk group for premature mortality. While many have argued that educational success is a key factor in reducing these individuals’ excessive death risks, empirical evidence has hitherto been limited. The aim of the current study was therefore to examine the potentially mitigating role of educational success in the association between OHC experience and premature mortality.

Methods

Drawing on a Stockholm cohort born in 1953 (n=15 117), we analysed the associations among placement in OHC (ages 0–12), school performance (ages 13, 16 and 19) and premature all-cause mortality (ages 20–56) by means of Cox and Laplace regression analyses.

Results

The Cox regression models confirmed the increased risk of premature mortality among individuals with OHC experience. Unadjusted Laplace regression models showed that, based on median survival time, these children died more than a decade before their majority population peers. However, among individuals who performed well at school, that is, those who scored above-average marks at the age of 16 (grade 9) and at the age of 19 (grade 12), the risks of premature mortality did not significantly differ between the two groups.

Conclusion

Educational success seems to mitigate the increased risks of premature death among children with OHC experience.