Avoidable mortality among child welfare recipients and intercountry adoptees: a national cohort study

A Hjern, B Vinnerljung, F Lindblad

The need for substitute care for abandoned and orphaned children is as old as mankind.1 In modern welfare societies the responsibility of substitute care has been extended to children from troubled homes. In Sweden about 1% of recent birth cohorts have experienced more than five years of foster or residential care during childhood.2 Through government sponsored international adoptions the Swedish society has also taken on the ambition of providing substitute care for children from the developing world. Sweden is the country with the largest population of intercountry adoptees in Europe, 43 000, and per capita (1%–1.5% of the cohorts born after 1965) in the whole world.3 In Sweden foster children and intercountry adoptees are raised in quite different kinds of substitute care. Foster children are placed in families who are given financial compensation for doing a job while adoption carries considerable costs for adoptive parents. Foster children are cared for until their 18th birthday under the condition that they may be returned to the original home on short notice, while adoptees become permanent members of their family. A third category of children at risk is supported by child welfare agencies within the framework of the biological family.

The reason for substitute care and other child welfare interventions in early childhood is usually a home environment that is judged to be unsatisfactory to meet the needs of the child, often because of addictive or other deviant parent behaviour. As children raised in such homes have been shown to have an excess death rate during adolescence and young adult years,4 5 one important goal of child welfare interventions is to improve the chance of survival into adulthood. Previous studies of mortality of child welfare populations in Europe have questioned whether this goal is adequately met, demonstrating comparatively high mortality rates.6–9 In this study we used the Swedish national registers to evaluate outcomes in avoidable mortality between 13 and 27 years of age in intercountry adoptees, foster children and children that had received other child welfare interventions started before age 13 in a comparison with the general population in an entire national cohort. Do child welfare interventions during early childhood in Sweden improve survival during adolescence? Are there differences in death rates between the two categories of children in substitute care in early childhood; foster children and intercountry adoptees?