Suicide and suicide attempts in children and adolescents in the child welfare system

Background:

Few population studies have examined the psychiatric outcomes of children and adolescents in the child welfare system, and no studies have compared outcomes before and after entry into care. Our objective was to assess the relative rate (RR) of suicide, attempted suicide, admission to hospital and visits to physicians’ offices among children and adolescents in care compared with those not in care. We also examined these outcomes within the child welfare population before and after entry into care.

Methods:

We used population-level data to identify children and adolescents 5 to 17 years of age who were in care in Manitoba for the first time between Apr. 1, 1997, and Mar. 31, 2006, and a comparison cohort not in care. We compared the two cohorts to obtain RRs for the specified outcomes. We also determined RRs within the child welfare population relative to the same population two years before entry into care.

Results:

We identified 8279 children and adolescents in care for the first time and a comparison cohort of 353 050 children and adolescents not in care. Outcome rates were higher among those in care than in the comparison cohort for suicide (adjusted RR 3.54, 95% confidence interval CI] 2.11–5.95), attempted suicide (adjusted RR 2.11, 95% CI 1.84–2.43) and all other outcomes. However, adjusted RRs for attempted suicide (RR 0.27, 95% CI 0.21–0.34), admissions to hospital and physician visits decreased after entry into care.

Interpretation:

Children and adolescents in care were at greater risk of suicide and attempting suicide than those who were not in care. Rates of suicide attempts and hospital admissions within this population were highest before entry into care and decreased thereafter.In Canada, about 76 000 children and adolescents are under the care of provincial child and family services.¹ In Manitoba, more than 7000 children and adolescents were in the care of child and family services in 2008. Many of them had experienced abuse and neglect, or death or conflict in their families, along with disability or emotional problems.^2–13 Concerns have been raised that the Canadian child welfare system does not provide adequate resources and supports to mitigate the effects of abuse and neglect.¹⁴ Although the health outcomes of this population are a frequent topic of concern in the media, population-based research describing these outcomes is limited.To our knowledge, only two studies of a population cohort of children and adolescents in care have been published to date, both describing the psychiatric morbidity and mortality of children and adolescents in care in Sweden.^4,6 These studies found greater rates of suicide, suicide attempts and psychiatric hospital admissions among children in care than in the general population. However, these studies had substantial limitations. Although they used the general population as a comparison group, they did not analyze for the presence of psychiatric morbidity in the period before entry into care. This omission limits the ability to draw conclusions about whether the poor outcomes of these children were associated with disruptions in their lives and families related to involvement in the child welfare system or whether they were a consequence of their life, health and psychological characteristics before they entered the care system.The first objective of the current study was to assess the relative rates (RRs) of suicide and attempted suicide and the number of hospital admissions and visits to physicians’ offices among children and adolescents with a history of being in the care of child and family services in Manitoba, relative to the general population of children and adolescents not in care. The second objective was to assess the RR of attempting suicide and the number of hospital admissions and physician visits in the child welfare population before and after entry into care.