Studies have shown inverse associations between childhood social class and mortality,1 and others have shown higher mortality in children in care.2,3 However, to our knowledge, only one study has investigated mortality in children in care with results specific to sex and cause of death.3 Mortality in that study was higher than expected among boys, although mortality related to age at the time of death was not reported.3
In Finland, children are cared for within the child protection system up to the age of 18. Our specific interest lies in whether mortality before age 18 in children in care is higher than expected on the basis of figures for the general population, reflecting failure in the child protection system, or whether mortality is increased from age 18, reflecting difficulties in adapting to independent living.
Methods and results
The basic data source was the Finnish child welfare registry. The data were completed by individual linkage with the Finnish cause of death registry, using the personal identification number of each child. The study covered all children in Finland who were taken into care between 1 January 1991 and 31 December 1997 (n=13 371). One per cent (133) could not be linked to the cause of death registry owing to errors in the personal identification number. All subjects were born between 1 January 1973 and 31 December 1997 and followed up until 31 December 1999 or, if earlier, their 25th birthday or, if earlier, their death. During the study period 106 individuals (32 females and 74 males) died. Mortality ratios standardised for age were used to compare the mortality of children in the cohort (girls and boys separately) with that of the general population of the same age in Finland.
In this cohort, both sexes had higher mortality than would have been expected on the basis of general population figures (table). We also compared the mortality of the cohort with that of Finnish people aged 5-24 from the manual class.4 The mortality ratio for females was 282 (95% confidence interval 189 to 405), and that for males was 218 (169 to 275), indicating that mortality was higher in comparison with this socially disadvantaged group.
The higher mortality of the cohort is related to deaths caused by substance misuse, accidents, and suicide. Six females and 29 males aged 15-24 years committed suicide, with mortality ratios of 353 (130 to 768) and 242 (162 to 348) respectively. Deaths related to alcohol and drug misuse also occurred at a higher rate than expected; the mortality ratio for females was 841 (385 to 1597), and that for males was 420 (291 to 587).
Fourteen girls and 24 boys died before the age of 18, of whom seven girls and 11 boys died of illness (four girls and seven boys aged <11). This can be attributed to an increase in acute and chronic health conditions and developmental delays among children in foster care.5
Comment
We found that both females and males in the child welfare registry cohort had excess mortality in comparison with the general population or the manual class. Excess mortality of males was not higher than that of females (see table). The belief that girls are more resilient to environmental factors than boys was thus not supported. The child protection system does not cause the deaths—none of the children died as a result of abuse or violence by parents or foster parents. However, the system fails to protect adolescents from self endangering behaviour both within the system and during adaptation to independent living. The results indicate the need for continuing attention to be paid to the transition period from foster care to independence.
Table.
Mortality ratios standardised for age* of Finnish people aged 1-24 in the child protection system in 1991-9, and the number of deaths and person years
| Age group (years) | Females
|
Males
|
|||
|---|---|---|---|---|---|
| Mortality ratio (95% CI) | Deaths/person years | Mortality ratio (95% CI) | Deaths/person years | ||
| 1-10 | 186 (51 to 476) | 4/14 626 | 270 (117 to 532) | 8/15 079 | |
| 11-17 | 351 (137 to 524) | 10/16 961 | 201 (115 to 326) | 16/19 292 | |
| 18-24 | 441 (261 to 693) | 18/11 875 | 318 (236 to 419) | 50/13 534 | |
| 1-24 | 330 (226 to 466) | 32/43 462 | 279 (219 to 350) | 74/47 905 | |
The mortality of Finnish males and females aged 1-24 in 1991-6 is used as a standard.
Acknowledgments
We thank the Ministry of Social Welfare and Health, the National Research and Development Centre for Welfare and Health, Statistics Finland, and the Data Protection Authority for giving permission to link the registers.
Footnotes
Funding: Academy of Finland, Research Council for Culture and Society.
Competing interests: None declared.
References
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