Suicide Prevention for Children in the
Welfare System

Jaleesa Baulkman

April 02, 2021

Children in the welfare system who died by suicide were twice as likely to receive mental health services within six months before their death, according to a recent study published in Pediatrics.

"These findings raise potential concerns about the quality and consistency of services suicide decedents may have received to prevent more critical care associated with these type of service," study author Donna Ruch, PhD, a research scientist at the Nationwide Children's Hospital, told Medscape.

Researchers noted that integrating suicide prevention strategies in primary care and providing access to effective health services for this vulnerable group could be beneficial.

At-risk Kids Are Falling Through the Cracks

Suicide is the second leading cause of death in children, adolescents, and young adults between the ages of 15 and 24 years old. Children in the welfare system are four times more likely to have attempted suicide, however, research on suicide rates in this population is minimal.

"Kids in the child welfare system are so understudied and yet at such a high risk for suicide," said Lisa Horowitz, PhD, clinical psychologist at the National Institutes of Health, who was not involved in the study. "A lot of kids pass through the health care system undetected."

In an attempt to understand and prevent suicide in this group, Ruch and her team examined health service utilization patterns of children in the welfare system who committed suicide compared to those in the system who did not die by suicide.

Researchers collected data on 120 deceased youth between the ages of 5 and 21 years old who had an open case in Ohio's Statewide Automated Child Welfare Information System between 2010 and 2017. For the purpose of the study, open cases were defined as investigated child maltreatment where the family received services or the child was removed from the home.

Researchers matched each child who died by suicide with 10 controls — children in the welfare who did not commit suicide — based on sex, race, and ethnicity.

The findings revealed that 59.2% of suicide decedents had a diagnosed mental health condition compared to 31.3% of the control group. Researchers also found that the suicide decedent group was more likely to have multiple mental health diagnoses, with a quarter of them having at least three diagnosed conditions. 

Children who died by suicide were also more likely to have a history of self-harm and to have been placed in foster or kinship care.

"Existing research also suggests that known risk factors for youth suicide are more common in youth involved with the child welfare system. This includes mental health conditions, developmental delays, problematic family-related issues, and trauma," said Ruch. "All of these factors may be compounded for youth who are removed from their homes."

Ruch said it is likely that children who are removed from their homes and placed in foster care may not have consistent access to necessary health services, such as therapy, which may place them at an increased risk for suicidal behavior.

Robust Prevention Strategies Needed

Researchers also found that 90% of children who died by suicide had a health care visit within six months of their deaths compared to 69.4% of controls, 48% of those visits occurred one month before they died.

The frequency of health care services used by suicide decedents suggests that prevention strategies for children in the welfare system should be embedded in routine medical and mental health care.

"If we as mental health counselors allow these kids to pass through the health care system, it's really further neglect," said Horowitz, who wrote an accompanying commentary. "And these children already deal with abuse and neglect we don't need to further neglect them."

Horowitz said healthcare providers could go over coping strategies and discuss how children deal with hard times and make sure they have access to suicide prevention resources, such as the suicide hotline.

Additionally, better coordination with health care systems and children welfare system to make sure there are follow-ups and screenings for suicide and other mental health conditions.

"It's not one size fits all, there may be tailored suicide prevention strategies that work better," Horowitz explained.

Ruch and her team also believe suicide prevention strategies such as the Zero Suicide approach — an initiative that aims to embed suicide prevention health and behavioral health care systems — as well as interventions focused on family-preservation to reduce the chance of a child being removed from their home could also benefit children in the welfare system.

The authors and Horowitz have disclosed no relevant financial relationships.

Pediatrics. Published online March 2021. Full text, Editorial

Jaleesa Baulkman is a writer/editor of Medscape Pediatrics. She can be reached at

This article originally appeared on, part of the Medscape Professional Network.