All-Cause Mortality Among Children in the US Foster Care System, 2003-2016 | Child Development | JAMA Pediatrics | JAMA Network
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Research Letter
April 20, 2020

All-Cause Mortality Among Children in the US Foster Care System, 2003-2016

Author Affiliations
  • 1SafePlace: The Center for Child Protection and Health, Division of General Pediatrics, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 2Center for Pediatric Clinical Effectiveness, The Children's Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 3Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia
  • 4Department of Pediatrics, Perelman School of Medicine, University of Pennsylvania, Philadelphia
  • 5PolicyLab, The Children’s Hospital of Philadelphia, Philadelphia, Pennsylvania
  • 6Department of Biostatistics, Epidemiology, and Informatics, University of Pennsylvania, Philadelphia
  • 7Division of General Internal Medicine, Perelman School of Medicine, University of Pennsylvania, Philadelphia
JAMA Pediatr. 2020;174(9):896-898. doi:10.1001/jamapediatrics.2020.0715

Children in foster care have worse medical and behavioral health than children in the general population. This is influenced by multiple factors, including a high incidence of poverty, exposure to trauma, and chronic medical conditions.1,2 Despite known differences in health, less is known regarding differences in mortality. In this cross-sectional study, we compared mortality rates and trends for children in the US foster care system with those in the general population for the 2003-2016 time period.

Methods

Data for children in foster care were obtained from the Adoption and Foster Care Analysis and Reporting System. This study was determined to not represent human subjects research by the institutional review board of the Children’s Hospital of Philadelphia. Mortality per person-years was calculated using the number of deaths (identified when death was the listed reason for foster care exit) and the total annual foster care population (the number of children in foster care at any time during a calendar year). Mortality per person-years for children within the general population was extracted from the Centers for Disease Control and Prevention online database WONDER (Wide-Ranging Online Data for Epidemiologic Research).3 Analyses were limited to children 1 to 18 years of age. Infants younger than 1 year were excluded given that 40% of infant deaths occur on day 1 of life,4 and infants never discharged from the hospital are unlikely to enter foster care. Multiracial categorizations within the Adoption and Foster Care Analysis and Reporting System were reassigned to match the Centers for Disease Control and Prevention’s 4 racial categories: American Indian or Alaska Native, Asian or Pacific Islander, black or African American, or white.5 Data were not imputed. Negative binomial regressions were used to calculate mortality rates (for 2003-2016) and trends as an annualized percent change, each adjusted for age, race, sex, ethnicity, and calendar year. Separate race- and age-stratified analyses were conducted. Analyses were performed using Stata, version 14.2 (StataCorp LLC).

Results

Among 8 348 656 person-years for children in foster care from 2003 to 2016, there were 3485 deaths or 35.4 deaths per 100 000 person-years vs 25.0 for the general population (1 036 855 826 person-years), with an incident rate ratio of 1.42 (95% CI, 1.37-1.47 (Figure and Table). There was higher mortality among children in foster care within each race category (eg, among black or African American children, the adjusted mortality rate per 100 000 person-years was 43.8 [95% CI, 41.4- 46.2) vs 34.1 (95% CI, 33.9-34.4]) and also within each age category (except for ages 15-18 years) (eg, for children aged 1-4 years, the adjusted mortality rate per 100 000 person-years was 50.7 [95% CI, 47.8-53.6] vs 27.5 [95% CI, 27.3-27.7]) compared with the general population. Between 2003 and 2016, mortality rates for children in foster care remained steady (−0.5 annual percent change; 95% CI, −1.3% to 0.4%) while mortality in the general population decreased by 2.5% per year (95% CI, −2.6% to −2.5%) for an annualized incident rate ratio of 1.02 (95% CI, 1.01-1.03).

Figure.  National Trends in Mortality in US Foster Care and the General Population, 2003-2016
National Trends in Mortality in US Foster Care and the General Population, 2003-2016

Annual adjusted death rate per 100 000 person-years for children in foster care and the general population. Point estimates for annual adjusted mortality were made using the margins estimation command in Stata, version 14.2 (StataCorp LLC) from a negative binomial regression after controlling for age (age bins: 1-4, 5-9, 10-14, or 15-18 years), sex (male or female), race (American Indian or Alaska Native, Asian or Pacific Islander, black or African American, or white), and ethnicity (Hispanic or non-Hispanic). Linear mortality trends were estimated using a negative binomial regression containing an interaction term between foster care status (yes or no) and year (P = .004) after controlling for age, sex, race, and ethnicity.

Table.  Adjusted Mortality Rates for Children in US Foster Care and the General Population, 2003-2016
Adjusted Mortality Rates for Children in US Foster Care and the General Population, 2003-2016

Discussion

Our study findings suggest that children in foster care represent a critically vulnerable population. Children in foster care were 42% more likely to die than children in the general population, and the disparity was largely irrespective of race or age. In addition, the mortality gap widened over time.

This study has at least 2 significant limitations. First, differences in mortality may be underestimated because children in foster care are unable to be excluded from the Centers for Disease Control and Prevention data file, and more deaths in foster care were excluded relative to person-years in foster care because of incomplete demographic data. Second, differences in mortality may be related to known baseline health differences between children in foster care and the general population.2 Although the Adoption and Foster Care Analysis and Reporting System data file indicated that less than half of the children who died in foster care had some medical condition (consistent with prior literature6), condition specifics were not available in foster care records nor were comparable data available for the general population. Therefore, we cannot conclude that foster care is contributing to this observed difference in mortality; rather, it may be reflective of broader, underlying health and social disparities.

These statistics should motivate policy makers, health care professionals, and researchers to work together to better understand these results and to identify potential interventions to reduce mortality for children in foster care.

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Article Information

Corresponding Author: Barbara H. Chaiyachati, MD, PhD, Division of General Pediatrics, Children’s Hospital of Philadelphia, 3500 Civic Center Blvd, Bldg 12, Philadelphia, PA 19146 (chaiyachab@email.chop.edu).

Accepted for Publication: December 16, 2019.

Published Online: April 20, 2020. doi:10.1001/jamapediatrics.2020.0715

Author Contributions: Dr B. H. Chaiyachati had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.

Concept and design: B. H. Chaiyachati, Wood, K. H. Chaiyachati.

Acquisition, analysis, or interpretation of data: All authors.

Drafting of the manuscript: B. H. Chaiyachati, K. H. Chaiyachati.

Critical revision of the manuscript for important intellectual content: All authors.

Statistical analysis: All authors.

Supervision: Wood, K. H. Chaiyachati.

Conflict of Interest Disclosures: Dr B. H. Chaiyachati reported that her employer receives compensation for her expert witness court testimony. Dr Wood reported that her employer receives compensation for her expert witness court testimony. No other disclosures were reported.

Funding/Support: This study was supported in part by grant K12-HS026372-01 from the Agency for Healthcare Research and Quality (Dr K. H. Chaiyachati). The data used in this article were made available in part by the National Data Archive on Child Abuse and Neglect, Cornell University, Ithaca, New York. The data from the Substantiation of Child Abuse and Neglect Reports Project were originally collected by John Doris and John Eckenrode. Funding support for preparing the data for public distribution was provided by contract 90-CA-1370 between the National Center on Child Abuse and Neglect and Cornell University.

Role of the Funder/Sponsor: The funders had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

Disclaimer: The collector of the original data, funding agency, and National Data Archive on Child Abuse and Neglect bear no responsibility for the analyses or interpretations presented here.

Additional Contributions: Brett Drake, PhD, Washington University, provided critical discussion at the outset of this project and did not receive financial compensation.

References
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Lindley  LC, Slayter  EM.  End-of-life trends and patterns among children in the US foster care system: 2005-2015.   Death Stud. 2019;43(4):248-259. doi:10.1080/07481187.2018.1455765 PubMedGoogle ScholarCrossref
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