“Long-Term Health and Social Outcomes in Children and Adolescents Placed in Out-Of-Home Care”, 2021-10-25 (; backlinks; similar):
Question: What is the risk of experiencing adverse social and health outcomes in adulthood among children and adolescents placed in out-of-home care?
Results: In this cohort study, risk of adverse social and health outcomes in adulthood were elevated 1.4–5× among children placed in out-of-home care compared with their siblings who had never been placed in out-of-home care. By comparing differentially exposed siblings, the study was able to account for shared genetic and environmental preplacement factors.
Meaning: Although it may be necessary to remove children from parents who expose them to severe maltreatment, neglect, or abuse, out-of-home care placement is associated with important outcomes that need careful review.
Importance: Children who are placed in out-of-home care may have poorer outcomes in adulthood, on average, compared with their peers, but the direction and magnitude of these associations need clarification.
Objective: To estimate associations between being placed in out-of-home care in childhood and adolescence and subsequent risks of experiencing a wide range of social and health outcomes in adulthood following comprehensive adjustments for preplacement factors.
Design, Setting, & Participants: This cohort and cosibling study of all children born in Finland 1986–14200024ya (n = 855,622) monitored each person from their 15th birthday either until the end of the study period (December 2018) or until they migrated, died, or experienced the outcome of interest. Cox and Poisson regression models were used to estimate associations with adjustment for measured confounders (from linked population registers) and unmeasured familial confounders (using sibling comparisons). Data were analyzed from October 2020 to August 2021.
Exposures: Placement in out-of-home care up to age 15 years.
Main Outcomes & Measures: Through national population, patient, prescription drug, cause of death, and crime registers, 16 specific outcomes were identified across the following categories: psychiatric disorders; low socioeconomic status; injuries and experiencing violence; and antisocial behaviors, suicidality, and premature mortality.
Results: A total of 30,127 individuals (3.4%) were identified who had been placed in out-of-home care for a median (interquartile range) period of 1.3 (0.2–5.1) years and 2 (1–3) placement episodes before age 15 years.
Compared with their siblings, individuals who had been placed in out-of-home care were 1.4–5× more likely to experience adverse outcomes in adulthood (adjusted hazard ratio [aHR] for those with a fall-related injury, 1.40; 95% CI, 1.25–1.57 and aHR for those with an unintentional poisoning injury, 4.79; 95% CI, 3.56–6.43, respectively). The highest relative risks were observed for those with violent crime arrests (aHR, 4.16; 95% CI, 3.74–4.62; cumulative incidence, 24.6% in individuals who had been placed in out-of-home care vs 5.1% in those who had not), substance misuse (aHR, 4.75; 95% CI, 4.25–5.30; cumulative incidence, 23.2% vs 4.6%), and unintentional poisoning injury (aHR 4.79; 95% CI, 3.56–6.43; cumulative incidence, 3.1% vs 0.6%).
Additional adjustments for perinatal factors, childhood behavioral problems, and traumatic injuries, including experiencing violence, did not materially change the findings.
Conclusions & Relevance: Out-of-home care placement was associated with a wide range of adverse outcomes in adulthood, which persisted following adjustments for measured preplacement factors and unmeasured familial factors.
…We categorized individuals who had been placed in out-of-home care by child welfare services at least once before their 15th birthday as having been exposed to out-of-home care. There are 4 main types of out-of-home care settings in Finland: family foster care (kinship or nonrelative care), professional group homes, institutional care, and other or unclassified care. We assigned each child to the type of care setting to which they had been exposed for the longest period.
…Two previous studies, based on a total of 1,384 siblings and examining within-family associations between long-term foster care placement and social and health outcomes in adulthood, found that those who were placed either did not differ from their siblings or had worse outcomes.17,18 However, the limited statistical power in these studies likely explains the lack of associations. Investigations using other natural experimental approaches, such as child welfare policy reforms19 and rotationally assigned child welfare investigators,20,28,29 have reported mixed results. An advantage of our study compared with these is that we were able to study the placement trajectories of the individuals in our sample throughout their entire childhood and adolescence to obtain more precise estimates of the associations with a large number of health and social outcomes in adulthood.