Adoptees 4 Times More Likely to Attempt Suicide

Jenni Laidman

September 09, 2013

Adopted offspring were nearly 4 times more likely to attempt suicide than nonadopted offspring, according to a study published online September 9 in the Pediatrics.

The study included 692 adopted children and 540 nonadopted children, all residing in Minnesota. Fifty-six offspring in the study attempted suicide; 47 of those were adoptees.

The study's lead author cautioned, however, that the increased risk did not characterize adopted children as a whole. "The majority of adoptees are psychologically healthy," Margaret A. Keyes, PhD, told Medscape Medical News. Dr. Keyes is a research associate at the Department of Psychology, University of Minnesota, Minneapolis. "With elevated risk, we are talking about a very small number of people."

Dr. Keyes and colleagues conducted an initial interview of children and parents and then completed a second assessment roughly 3 years later (mean interval, 3.36 years; standard deviation [SD], 0.45 years) between 1998 and 2008. The appraisal included a comprehensive mental health assessment, a personality assessment, an assessment for the presence of childhood disruptive disorders such as oppositional defiant disorder, attention-deficit/hyperactivity disorder, major depressive disorder, and substance abuse disorders. Parents and children were asked separately whether the child had attempted suicide.

Among the 47 adoptees who attempted suicide between the first and second assessment, 16 were boys and 31 were girls; of the 9 nonadoptees who attempted suicide, 4 were boys and 5 were girls.

The odds ratio (OR) for reported suicides among adoptees compared with nonadoptees was 4.23, after adjusting for age and sex. When the odds were adjusted for factors associated with suicidal behavior, such as substance abuse, depression, disruptive behavior disorders, and disruption in family and school life, the OR remained significantly elevated, at 3.70.

Dr. Keyes said this research is in line with findings in earlier studies, including research in Sweden showing increased numbers of suicide attempts among adoptees. A 2002 Lancet study also found that intercountry adoptees were more likely than other Swedish-born children both to die from suicide (OR, 3.6) and to attempt suicide (OR, 3.6).

"They have documented this [increased risk] in very large national cohort studies," Dr. Keyes said. A US study published in Pediatrics in 2001 also found an increased suicide risk among adoptees. In that study, the researchers assessed 6577 adolescents, including 214 adoptees. Of those, 7.6% of adoptees attempted suicide compared with 3.1% of children living with their biological families.

The current study should stand as a warning to clinicians to take the concerns of adoptive parents seriously, Dr. Keyes said. "Adoptive parents are sometimes viewed as overreporters and quick to refer to helping agencies, social service agencies, or their family doctor. I think their concerns should be taken seriously and not necessarily viewed as overreporting or overanxiousness. They may be looking at a real phenomenon in their family."

The authors did not find that specific adoption factors, including age of adoption placement, ethnic minority status, intercountry adoption, and domestic placement, predicted suicide attempts. However, a variety of behavioral issues were more common among suicide attempters than nonattempters (aggregate risk, 1.9 SD), and those same behaviors were more common among adoptees than nonadoptees (aggregate risk, 0.31 SD).

Among the risks associated more consistently with adoptees were childhood disruptive disorders (mean difference [d], 0.40; 95% confidence interval [CI], 0.27 - 0.53; P < .001), reports of family discord (d, 0.40 [95% CI, 0.22 - 0.58; P < .001] when reported by parents and d, 0.26 [95% CI, 0.12 - 0.39; P < .001] when reported by children), academic disengagement (d, 0.21; 95% CI, 0.08 - 0.27; P < .001). Adoptees also had greater levels of teacher-reported externalizing behavior (d, 0.28; 95% CI, 0.12 - 0.43; P < .001) and teacher-reported negative mood (d, 0.34; 95% CI, 0.20 - 0.48; P < .001).

The researchers note, however, that these differences were more pronounced when they compared those who attempted suicide and those who did not, regardless of adoptive/nonadoptive status. The authors reported a d of 1.05 (95% CI, 0.76 - 1.33) for childhood disruptive disorders between attempters and nonattempters and 1.05 (95% CI, 0.76 -1.34) for major depressive disorder (P < .001 for both), a d of 0.64 (95% CI, 0.36 - 0.91) for substance disorders (P < .001), a mean difference of 0.71 (95% CI, 0.43 - 0.99) for low control (P < .001), a d of 0.69 (95% CI, 0.41 - 0.97) for alienation (P < .001), and a d of 0.52 (95% CI, 0.23 - 0.81; P < .001) for low well being.

Parent-reported family discord was also greater for attempters than nonattempters (d, 1.01; 95% CI, 0.67 - 1.34; P < .001), as was child-reported family discord (d, 0.92; 95% CI, 0.61- 1.23; P < .001). Teacher ratings for externalizing behavior and negative mood were also higher for those who attempted suicide (d, 0.92 [95% CI, 0.57 - 1.27] for externalizing behavior; d, 0.71 [95% CI, 0.37 - 1.05] for negative mood; P < .001 for both).

The mean age for adopted children in the Minnesota study was 14.95 years (SD, 1.9 years); nonadoptees had a mean age of 14.89 years (SD, 1.9 years). All the adopted children had been placed in permanent homes before the age of 2 years (mean, 4.7 months; SD, 3.4 months), and 96% were placed before 1 year. Seventy-four percent of the adoptees were born outside the United States; 90% of the international adoptees were born in South Korea, and 60% of the international adoptees were girls.

Chuck Johnson, president of the National Council for Adoption, an Alexandria, Virginia–based advocacy organization, emphasized the good news from the study, saying that most adoptees are not at risk for suicide.

"It doesn't surprise me that children who've been adopted in great numbers have struggles, which, I guess, if you took to its natural consequences, would increase the suicide rate," he told Medscape Medical News. "But the thing that really comes out at me is it appears a vast majority of children are doing really well."

The authors and the commenter have disclosed no relevant financial relationships.

Pediatrics. Published online September 9, 2013. Abstract


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