Investigating youth suicides among children involved with the welfare system

Suicide is the second leading cause of death among youth aged 5 to 21 years in the United States. Between 2010 and 2019, suicide rates among this group increased 40%.

Youth involved in the child welfare system experience an even greater risk of suicidal behavior, yet research on this vulnerable population is minimal.

To better understand and prevent suicide in this at-risk group, researchers at Nationwide Children’s Hospital conducted the first study to compare characteristics and health service utilization patterns of youth suicide decedents (those who died by suicide) and non-decedents who were involved with the child welfare system.

The study, published in Pediatrics and supported by a grant from the National Institute of Mental Health (NIMH), found that youth with child welfare system involvement who died by suicide were significantly more likely to experience out-of-home placements (with the frequency and length of those placements strongly predicting suicidal behavior), more likely to have been diagnosed with mental health and chronic medical conditions or substance use disorders and more likely to have visited physical and mental health care settings in the months before their deaths than matched controls.

Researchers studied 1,320 young people aged 5 to 21 who had at least one open case in Ohio’s Statewide Automated Child Welfare Information System (SACWIS) between 2010 and 2017, matching 120 cases of youth who died by suicide to 10 non-decedent controls each based on sex, race, ethnicity, age and year of open case. The study sample was 66% male, 63% non-Hispanic White, 25% non-Hispanic Black and 4% Hispanic. Nearly half of those studied were 15-19 years old when their SACWIS case was opened (44%), with an average age of 15 years.

Youth who died by suicide were twice as likely to have accessed mental health services in the one month and six months prior to their deaths than controls, regardless of the health care setting. Nearly half of suicide decedents with child welfare system involvement used some type of health care services in the one month prior to their death, and almost 90% did so in the preceding six months, compared to 69% of controls. In fact, the odds of a mental health visit in any period or setting were significantly greater for the youth in the child welfare system who died by suicide. A higher incidence of mental health diagnoses among all youth who died by suicide may account for these findings.

Previous research has found that over 90% of all youth who died by suicide had a mental health condition. In this study, however, 59% of suicide decedents had a diagnosed mental health condition compared to less than a third of the control group (31%).

“These findings raise potential concerns about the quality and consistency of mental health screening and care for youth in the welfare system,” said Donna Ruch, Ph.D., a research scientist in the Center for Suicide Prevention and Research at Nationwide Children’s and the study’s lead author. “They also validate growing recommendations to screen for suicide risk in health care settings. Given the nature of child welfare system involvement, where children are in contact with varied service providers, integrating suicide prevention strategies as a core component of health care delivery in these settings is important.”

Additionally, although the number of open SACWIS cases did not significantly differ between suicide decedents and non-decedent controls, those who died by suicide were significantly more likely to have been removed from their homes and placed in foster care, kinship care or another alternative setting.

“Our research suggests youth with child welfare involvement may benefit from both suicide prevention strategies targeting health care settings, such as the Zero Suicide approach, and those that align with family preservation programs,” said Dr. Ruch.

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