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Troubled childhoods cast long shadows: Studies of childhood adversity and premature mortality in a Swedish post-war birth cohort
Stockholm University, Faculty of Social Sciences, Department of Public Health Sciences.ORCID iD: 0000-0002-5958-2303
2022 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Taking a life course approach can help us to understand health inequalities. This thesis illustrates that socially-patterned childhood experiences might play a critical role for inequalities in mortality. The association between childhood adversity and premature mortality is investigated in the context of a 1953 Stockholm birth cohort. Over a series of four empirical studies, it is shown that childhood adversity is a major risk factor for premature mortality, and is a significant contributor to socioeconomic inequalities in mortality.

More specifically, Study I found that indicators of early life socioeconomic disadvantage and childhood adversity were individually associated with adult mortality. When all of these co-occurring indicators were studied simultaneously, involvement with child welfare services – specifically involvement resulting in placement in out-of-home care – was the indicator most robustly associated with premature mortality in adulthood. Based on the results Study I, involvement with child welfare services was used as a proxy for childhood adversity the following three studies.

Study II showed that involvement with child welfare services could explain almost half of the education and income gradients in life-expectancy between ages 29–67.

Study III demonstrated that the increased mortality risk among adults who were placed in out-of-home care as children persisted to midlife. Moreover, increased mortality risks after out-of-home care were not unique to the Swedish welfare context but could be verified in a cohort from Great Britain.

Finally, Study IV found that adults who experienced involvement with child welfare services not only had increased risks of major diseases in adulthood, but also had worse survival prospects after a first hospitalisation.

Involvement with child welfare services, specifically placement in out-of-home care, can have consequences for socioeconomic attainment, and physical and mental health. Even in this cohort that entered adulthood during some of the most generous years of the Swedish welfare state, the unequal distribution of life chances following experiences of childhood adversity was not eliminated. These empirical studies extend our understanding of how childhood adversity contributes to the complex processes that generate inequalities in mortality. The results further indicate that it is never too early nor too late to prevent inequalities in health.

Place, publisher, year, edition, pages
Stockholm: Department of Public Health Sciences, Stockholm University , 2022. , p. 95
Series
Health Equity Studies, ISSN 1651-5390 ; 24
Keywords [en]
Mortality, Health Equity, Adverse Childhood Experiences, Child Welfare, Adult Survivors of Child Adverse Events, Life Course Perspective, Birth cohort, Longitudinal Studies
National Category
Public Health, Global Health, Social Medicine and Epidemiology Social Sciences Interdisciplinary
Research subject
Public Health Sciences
Identifiers
URN: urn:nbn:se:su:diva-209892ISBN: 978-91-8014-028-7 (print)ISBN: 978-91-8014-029-4 (electronic)OAI: oai:DiVA.org:su-209892DiVA, id: diva2:1699262
Public defence
2022-11-10, Hörsal 4, Albano, Albanovägen 18 and online via Zoom, public link is available at the department website, Stockholm, 10:00 (English)
Opponent
Supervisors
Available from: 2022-10-18 Created: 2022-09-27 Last updated: 2022-10-10Bibliographically approved
List of papers
1. Troubled childhoods cast long shadows: Childhood adversity and premature all-cause mortality in a Swedish cohort
Open this publication in new window or tab >>Troubled childhoods cast long shadows: Childhood adversity and premature all-cause mortality in a Swedish cohort
2019 (English)In: SSM - Population Health, ISSN 2352-8273, Vol. 9, article id 100506Article in journal (Refereed) Published
Abstract [en]

Experiences of childhood adversity are common and have profound health impacts over the life course. Yet, studying health outcomes associated with childhood adversity is challenging due to a lack of conceptual clarity of childhood adversity, scarce prospective data, and selection bias. Using a 65-year follow-up of a Swedish cohort born in 1953 (n = 14,004), this study examined the relationship between childhood adversity (ages 0-18) and premature all-cause mortality (ages 19-65). Childhood adversity was operationalized as involvement with child welfare services, household dysfunction, and disadvantageous family socioeconomic conditions. Survival models were used to estimate how much of the association between child welfare service involvement and mortality could be explained by household dysfunction and socioeconomic conditions. Results show that individuals who were involved with child welfare services had higher hazards of dying prematurely than their majority population peers. These risks followed a gradient, ranging from a hazard ratio of 3.08 (95% CI: 2.68-3.53) among those placed in out-of-home care, followed by individuals subjected to in-home services who demonstrated a hazard ratio of 2.53 (95% CI: 1.93-3.32), to a hazard ratio of 1.81 among those investigated and not substantiated (95% CI: 1.55-2.12). Associations between involvement with child welfare services and premature all-cause mortality were robust to adjustment for household dysfunction and disadvantageous family socioeconomic conditions. Neither household dysfunction nor socioeconomic conditions were related with mortality independent of child welfare services involvement. This study suggests that involvement with child welfare services is a viable proxy for exposure to childhood adversity and avoids pitfalls of self-reported or retrospective measures.

Keywords
Sweden, Premature mortality, Cohort study, Adverse childhood experiences, Childhood social conditions, Longitudinal, Child welfare
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public Health Sciences
Identifiers
urn:nbn:se:su:diva-178149 (URN)10.1016/j.ssmph.2019.100506 (DOI)000498893900014 ()31720363 (PubMedID)
Funder
Forte, Swedish Research Council for Health, Working Life and Welfare, 2016-07148
Available from: 2020-01-20 Created: 2020-01-20 Last updated: 2022-09-27Bibliographically approved
2. The Contribution of Childhood Adversity to the Socioeconomic Gradient in Mortality: a Swedish Birth Cohort analysis
Open this publication in new window or tab >>The Contribution of Childhood Adversity to the Socioeconomic Gradient in Mortality: a Swedish Birth Cohort analysis
(English)Manuscript (preprint) (Other academic)
Keywords
Health inequality; Adverse childhood experiences; Mortality; Child welfare services
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Research subject
Public Health Sciences; Demography
Identifiers
urn:nbn:se:su:diva-209887 (URN)
Projects
Risk and resilience: Pathways to (ill)health among men and women with experiences of childhood adversity (RISE)Reproduction of inequality through linked lives (RELINK)
Available from: 2022-09-27 Created: 2022-09-27 Last updated: 2022-09-27
3. Does time heal all wounds? Life course associations between child welfare involvement and mortality in prospective cohorts from Sweden and Britain
Open this publication in new window or tab >>Does time heal all wounds? Life course associations between child welfare involvement and mortality in prospective cohorts from Sweden and Britain
2021 (English)In: SSM - Population Health, ISSN 2352-8273, Vol. 14, article id 100772Article in journal (Refereed) Published
Abstract [en]

Child welfare involvement reflects childhood adversity and is associated with increased adult mortality, but it remains unclear how this association changes over the life course. Drawing on the Stockholm Birth Cohort Multigenerational Study (Sweden) and the National Childhood Development Study (Great Britain) this study examines whether inequalities within these cohorts diverge or converge. Involvement with child welfare services (ICWS) is divided into two levels ('child welfare contact' and 'out-of-home care'). For each cohort, we quantify absolute health inequalities as differences in cumulative probabilities of death (18-58 years) and temporary life expectancy; and relative inequalities as hazard ratios in ten-year intervals and ratios of lifetime lost. Persistently, ICWS was associated with premature mortality. The strength of the association varied by age, sex and level of ICWS. Consistently across both countries, the most robust relationship was between out-of-home care and mortality, with statistically significant age-specific hazard ratios ranging between 1.8 and 3.4 for males and 1.8-2.1 for females. Child welfare contact that did not result in out-of-home placement showed less consistent results. Among females the mortality gap developed later compared to males. Estimates attenuate after controlling for family socioeconomic and other background variables but patterns remain intact. Our results show that absolute inequalities widen with increasing age, while relative inequalities might peak in early adulthood and then stabilize in midlife. The relative disadvantage among looked-after children in early adulthood is heightened by overall low rates of mortality at this age. Absolute inequality increases with age, highlighting the weight of the accumulation of disadvantage in mortality over time. The bulk of excess deaths that could be attributed to ICWS occurs from midlife onwards. Mechanisms that uphold the disadvantage after childhood experiences require further exploration. This study highlights that the association between out-of-home care and premature mortality seems to transcend welfare systems.

National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:su:diva-196274 (URN)10.1016/j.ssmph.2021.100772 (DOI)000661125200011 ()33816748 (PubMedID)
Available from: 2021-09-06 Created: 2021-09-06 Last updated: 2022-09-27Bibliographically approved
4. Risks of hospitalisation and survival prospects following disease among adults with a history of childhood adversity: A 46-year follow-up of a Stockholm birth cohort
Open this publication in new window or tab >>Risks of hospitalisation and survival prospects following disease among adults with a history of childhood adversity: A 46-year follow-up of a Stockholm birth cohort
(English)Manuscript (preprint) (Other academic)
Keywords
Child protective services, Healthcare Disparities, Non-communicable diseases, Mental health, Selfinjurious behavior, Substance-related disorders
National Category
Public Health, Global Health, Social Medicine and Epidemiology
Identifiers
urn:nbn:se:su:diva-209889 (URN)
Projects
Reproduction of inequality through linked lives (RELINK)Risk and resilience: Pathways to (ill)health among men and women with experiences of childhood adversity (RISE)
Available from: 2022-09-27 Created: 2022-09-27 Last updated: 2022-09-27

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