A population-based case control study of suicide among youth reported for abuse and neglect

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Abstract

Background

Research has indicated an association between child abuse and adolescent suicide. Little population-based information exists, however, about the nature of maltreatment experiences or interactions with the child protection system (CPS).

Objective

To examine child maltreatment characteristics and system-level responses associated with risk of adolescent suicide.

Participants and setting

Linked vital death records and CPS records were used to identify the population of adolescents who died by suicide in California between 2010 and 2017 and who had a history of at least one report to CPS prior to death.

Method

A case control design was used, with cases defined as a suicide of an adolescent with a history of CPS involvement. Using CPS records, living controls were then matched to cases based on year of birth, sex, race and ethnicity, and age of first child maltreatment allegation. A conditional logistic regression model was used to estimate the adjusted odds of adolescent suicide across various CPS and maltreatment characteristics.

Results

Recent CPS involvement, allegations of physical abuse, and allegations of sexual abuse emerged as significant risk factors for death by suicide. No differences in suicide risk were observed between youth with unsubstantiated or substantiated allegations.

Conclusions

Suicide risk appears to be more closely tied to specific maltreatment experiences than to substantiation or placement into foster care. As adolescent suicide rates rise, better a understanding of risk factors among already vulnerable populations of youth is critical.

Introduction

Suicide remains a major public health concern nationwide, with 1 in every 10,000 adolescents dying by suicide (Centers for Disease Control & Prevention, 2020). The adolescent suicide rate increased 57 % from 2008 to 2018, and suicide is currently the second leading cause of death among 15- to 19-year-olds. Previous research has identified several risk factors associated with adolescent suicide, including child maltreatment (Brent, Baugher, Bridge, Chen, & Chiappetta, 1999; Shafii, Carrigan, Whittinghill, & Derrick, 1985). Few population-based studies exist on the relationship between child maltreatment and completed suicide, and those that have been conducted have focused on suicide rates among children and the specific subset of adolescents currently placed or with a history of placement in foster care. These studies suggest that foster youth have suicide rates two to three times that of youth with no foster care history (Kalland, Pensola, Meriläinen, & Sinkkonen, 2001; Katz et al., 2011). A recent study of California youth extended this earlier research by including children with any history of child protection system (CPS) contact and found that youth who had been reported to CPS for alleged abuse or neglect had a significantly higher risk of suicide compared to youth with no such allegations (Palmer, Prindle, & Putnam-Hornstein, 2021). Findings from this population-based study suggest that a heightened risk of suicide may not be unique to foster youth but is a risk for the much larger universe of children who have had any previous allegations of maltreatment leading to involvement with CPS.

Recent estimates document that between 27 % and 37 % of U.S. children will be investigated by CPS for alleged child maltreatment (Kim, Wildeman, Jonson-Reid, & Drake, 2017; Putnam-Hornstein et al., 2021); approximately 12 % will be confirmed as victims and 5.3 % will spend time in foster care (Yi, Edwards, & Wildeman, 2020). Given these high rates, understanding potentially differential suicide risk among children with various levels of CPS contact is important to understanding service needs broadly. Although scarce, studies that have examined differential outcomes among youth with any history of CPS contact have found differences in risk by system response. Kugler et al. (2019) examined differential behavioral and mental health outcomes associated with levels of CPS contact (reported but not investigated, investigated but unsubstantiated, investigated and substantiated) among adolescent girls. Findings indicated differences in drug use, early childbearing, and HIV risk behaviors between those investigated versus not investigated, and differences in depression between those substantiated versus those not investigated. The Kugler study found no differences between those investigated but unsubstantiated and those substantiated. Similarly, Hussey et al. (2005) found no differences in behavioral and developmental outcomes of 8-year-olds between those with a substantiated or unsubstantiated CPS report, and Leiter, Myers, and Zingraff (1994) did not detect any differences in academic and delinquency outcomes between those with a substantiated or unsubstantiated CPS report.

Most studies examining the relationship between maltreatment and completed adolescent suicide have not differentiated between or examined individual types of abuse and neglect (Brent et al., 1999; Shafii et al., 1985), with the exception of Plunkett et al. (2001), who found that Australian youth who self-reported sexual abuse had suicide rates 10–13 times higher than the national Australian rates. Although the literature examining completed adolescent suicide and individual types of maltreatment is sparse, a wealth of research suggests a direct association between both sexual and physical abuse and risk of suicidal behaviors (suicidal thoughts, attempts) in adolescence (Miller, Esposito-Smythers, Weismoore, & Renshaw, 2013). Some evidence also suggests a differential importance, with sexual abuse having the most profound effect on adolescent suicidality (Miller et al., 2013). Less is understood about the relationship between emotional abuse or neglect and adolescent suicidal behaviors, with studies showing mixed results (Arata, Langhinrichsen-Rohling, Bowers, & O’Brien, 2007; Dube et al., 2001; Miller et al., 2017). Other than Palmer et al. (2021), we could not identify any population-based studies of suicide risk among adolescents referred to CPS as alleged victims of child maltreatment, nor could we identify any studies that used CPS records to explore maltreatment types and completed adolescent suicide.

In the current retrospective population-based case control study, we examined whether the nature of the alleged maltreatment (i.e., maltreatment type and recency of allegation) and the accompanying system responses (i.e., substantiation, placement) were associated with increased risk of adolescent suicide. Unlike studies that compared children in foster care to children who never experienced maltreatment or CPS contact, we used a “within-group” framework. Specifically, using linked death and CPS records, we defined cases as any adolescent who died by suicide and had a history of at least one allegation of maltreatment and then matched each case to living controls with a history of at least one allegation. We then examined the nature and extent of CPS contact as risk factors for suicide during adolescence.

Section snippets

Method

An analytic dataset was constructed by linking vital death records maintained by the California Department of Public Health to CPS records under the authority of the California Department of Social Services. Records were accessed for approved research purposes through active data-sharing agreements. Records were probabilistically linked using an open-source software linkage program and an algorithm trained on California data using machine learning methods (ChoiceMaker Technologies, n.d.).

Results

Between January 1, 2010, and December 31, 2017, in California, 515 suicide deaths were recorded among adolescents aged 15–19 years who had a history of one or more CPS allegations during childhood. The mean age of death among these youth was 17 years. Similar to the statewide breakdown for the general population of youth aged 15–19 years, the most common mechanism of death was suffocation (52.0 %), followed by firearms (23.7 %), jumping (10.7 %), and poison (9.3 %; CDC, 2020). Nearly 9% (n =

Discussion

As of 2019, the national adolescent suicide rate was 10.5 per 100,000 (CDC, 2020). For youth with a history of CPS contact, the rate was 27.8 per 100,000 (Palmer et al., 2021). Given the disproportionate rates of suicide among these CPS-involved youth, attention is needed on the specific maltreatment experiences or CPS interactions that elevate or reduce risk in this population. In the current study, we used vital death records linked to administrative CPS records to examine suicide risk among

Declaration of Competing Interest

The authors have no conflicts of interest regarding this work.

Acknowledgements

This work was supported by the Conrad N. Hilton Foundation, with infrastructure support provided by First 5 LA and the Heising-Simons Foundation. The authors would like to acknowledge and thank collaborators from the USC Children’s Data Network and UC Berkeley’s California Child Welfare Indicators Project, as well as the California Department of Social Services and county child welfare departments without whom this work would not be possible. However, the results and conclusions of this study

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