1
Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353
Open access
Can adop ion a an ea ly age p o ec
child en a isk om dep ession in
adul hood? A Swedish na ional
coho s udy
Ande s Hje n,1,2 Jesus Palacios,3 Bo Vinne ljung2,4
To ci e: Hje nA, PalaciosJ,
Vinne ljungB. Can adop ion
a an ea ly age p o ec
child en a isk om
dep ession in adul hood?
A Swedish na ional coho
s udy. BMJ Paedia ics Open
2018;2:e000353. doi:10.1136/
bmjpo-2018-000353
Recei ed 1 Augus 2018
Re ised 2 No embe 2018
Accep ed 12 No embe 2018
1Cen e o Heal h Equi y
S udies (CHESS), Ka olinska
Ins i u e , S ockholm Uni e si y,
S ockholm, Sweden
2Clinical Epidemiology/
Depa men o Medicine,
Ka olinska Ins i u e , S ockholm,
Sweden
3Depa men o De elopmen al
Psychology, Uni e si y o Se ille,
Se illa, Spain
4Depa men o Social
Wo k, S ockholm Uni e si y,
S ockholm, Sweden
Co espondence o
D Ande s Hje n; ande s. hje n@
chess. su. se
O iginal a icle
© Au ho (s) (o hei
employe (s)) 2018. Re-use
pe mi ed unde CC BY.
Published by BMJ.
Abs AC
Objec i e Ou aim was o in es iga e whe he he isk
o dep ession in adul hood in child en aised by subs i u e
pa en s om an ea ly age di e by ca e a angemen s.
Me hods Regis e s udy in Swedish na ional coho s
bo n 1972–1981, wi h h ee s udy g oups o child en
aised in adop i e o os e homes wi h ca e s a ing be o e
he age o 2 yea s and a compa ison majo i y popula ion
g oup. Cox eg ession es ima ed HRs o p esc ibed
an idep essi e medica ion and specialised psychia ic
ca e wi h a diagnosis o dep ession in adul hood du ing
2006–2012.
esul s Compa ed wi h he gene al popula ion, long-
e m os e ca e ca ied he highes age-adjus ed and
sex-adjus ed HR o bo h an idep essi e medica ion, 2.07
(95% CI 1.87 o 2.28), and psychia ic ca e o dep ession,
2.85 (95% CI 2.42 o 3.35), in adul hood. Adul s aised
by adop i e pa en s we e a mo e simila o he gene al
popula ion wi h HR o 1.19 (95% CI 1.00 o 1.43) o
domes ic and 1.13 (95% CI 1.08 o 1.18) o in e na ional
adop ion o an idep essi e medica ion. Adjus ing he
analysis o school ma ks and income a enua ed hese
isks mo e in he long- e m os e ca e g oup.
Conclusion The s udy demons a es he bene i s o
ea ly adop ion when subs i u e pa en s a e p o ided o
young child en, and unde lines he impo ance o imp o ed
educa ional suppo o child en in os e ca e.
In OduC IOn
Ea ly ad e se expe iences, pa icula ly child
abuse and neglec , ha e been linked o a
numbe o nega i e ou comes, wi h longi u-
dinal e idence showing he impac on phys-
ical1 as well as on men al heal h.2 Resea ch on
s ess neu obiology is helping o gain a be e
unde s anding o he connec ions be ween
ea ly ad e si y (in he o m o abuse and
neglec , auma ic expe iences and ch onic
exposu e o oxic s ess), i s ‘deep-sea ed’
neu obiological al e a ions3 and la e men al
heal h dis u bances.
Li e a u e e iews and me a-analy ic
e idence highligh he connec ion be ween
ea ly ad e si y and poo psychia ic ou comes,
including dep ession. Be ween a qua e and
a hi d o mal ea ed child en mee c i e ia
o majo dep ession by hei la e 20s.4
Compa ed wi h non-mal ea ed indi iduals,
hose wi h a his o y o abuse and neglec a e
wice as likely o de elop bo h ecu en and
pe sis en dep essi e episodes.5
In wel a e socie ies, one common conse-
quence o mal ea men in ea ly childhood
is placemen in o subs i u e amilies. Main-
aining hese child en wi h hei pa en s, o
placing hem in esiden ial ca e, has been
associa ed wi h a highe incidence o men al
heal h p oblems, including anxie y, dep es-
sion and conduc diso de s.6 A he same ime,
s udies om many coun ies ha e consis en ly
shown ha g owing up in subs i u e amilies
does no elimina e he ill consequences o
ea ly ad e si y. Bo h adop ed and os e ed
child en exhibi mo e men al heal h p ob-
lems—including dep ession— han hose in
he gene al popula ion.7 Swedish popula ion
Wha is al eady known on his opic?
►The isk o dep ession in adul hood is much in-
c eased in mal ea ed child en.
►Fos e ca e and adop ion a e he main ypes o ca e
p o ided o child en mal ea ed a an ea ly age.
►Compa ed wi h hose placed in os e ca e, adop ed
child en ha e been shown o ha e be e educa ion-
al and employmen ou comes in he adul Swedish
popula ion.
Wha his s udy hopes o add?
►Adul s wi h a his o y o long- e m os e ca e had
wo old a es o dep ession indica o s compa ed
wi h he gene al popula ion.
►Adop ion du ing in ancy is associa ed wi h a isk o
adul dep ession lowe han long- e m os e ca e.
►Poo e educa ional and employmen ou comes may
con ibu e o he highe isk o dep ession in o me
os e child en.
BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by
copy igh .
2Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353
Open access
s udies ha e shown ha , compa ed wi h majo i y popula-
ion pee s, young adul s wi h a his o y o long- e m os e
ca e, as well as o domes ic and in e coun y adop ion,
p esen highe isk o a ious psychological and psychi-
a ic diso de s.8–10 Conside able di e ences in educa-
ional achie emen and labou ma ke pa icipa ion ha e
also been epo ed.11
The highe le els o psychological and psychia ic
mo bidi y in adul hood, as well as o poo educa ional
pe o mance indica o s, ha e ypically been assumed o
be ela ed p ima ily o exposu e o amilial isk ac o s
be o e placemen .12 Fo he in e na ional adop ees,
speci ic ad e se consequences ela ed o ea ly neglec ul
ins i u ional ca e ha e been epo ed.13
Age a placemen has been demons a ed o be an
impo an isk ac o o nega i e ou comes la e in li e
such as lowe IQ, p oblem beha iou and emo ional
dis u bances.14 15 Type and quali y o ca e also seem o
play a ole. Adop ion p o ides mo e s abili y han os e
ca e, wi h equen changes o os e amilies and o he
ou -o -home ca e a angemen s being inhe en o long-
e m os e ca e.16 17 This ins abili y causes os e ed
child en o de elop beha iou al and men al heal h p ob-
lems. Fos e ca e ins abili y is also p esen in Sweden, he
se ing o his s udy. E en o long- e m placemen s ha
las om ea ly yea s un il he beginning o adolescence,
e e y ou h b eaks down du ing he i s eenage yea s.18
Adop ed child en in Sweden may also expe ience place-
men ins abili y a some ime be o e age o majo i y, bu
he p e alence (3%) is minuscule compa ed wi h long-
e m os e ca e.19 In hei analysis o he impac o place-
men s abili y on he well-being o os e child en, Rubin
e al20 concluded ha os e child en expe ience place-
men ins abili y un ela ed o hei baseline p oblems,
and ha his ins abili y has pe se a signi ican impac on
hei beha iou and well-being.
In Sweden, domes ic adop ion was common in he
mid-1900s, including a ound 1% o bi h coho s, o en
child en bo n ou o wedlock by young mo he s. Du ing
he 1960s, new wel a e policies ha p o ided economic
suppo o single mo he s and a mo e libe al abo -
ion policy g adually dec eased he numbe o child en
a ailable o adop ion. Since he mid-1970s, domes ic
adop ions ha e been a e in Sweden and os e ca e has
become he main o m o long- e m subs i u e ca e o
young child en who canno be euni ed wi h hei bi h
pa en s.21 22 In e na ional adop ion in Sweden was ini i-
a ed in he 1960s and peaked in he 1970s when bi h
coho s in Sweden included 1.5%–2.0% in e na ionally
adop ed child en, a ha ime he highes pe capi a
p opo ion in he wo ld.8
The aim o his s udy was o exploi his pe iod o
d as ic changes in Swedish adop ion p ac ices o in es i-
ga e whe he he isk o dep ession in adul hood di e s
be ween di e en o ms o subs i u e ca e o child en
placed in ca e in in ancy, and whe he isk pa e ns di e
be ween he ligh e o ms o dep ession, ea ed ou side
o hospi als (ie, an idep essi e medica ion) and mo e
se e e o ms, ea ed in hospi al ca e (ie, specialised
psychia ic ca e wi h a diagnosis o dep ession). Taking
in o accoun he well documen ed di e ences in school
pe o mance and labou ma ke pa icipa ion be ween
adop ed and long- e m os e child en in Sweden,11 we
also wan ed o explo e i hese ac o s in luence hei isk
o dep ession.
Me hOds
This s udy is based on in o ma ion om Swedish na ional
egis e s, con aining da a wi h high alidi y and low a i-
ion a es.23 24 These egis e s a e based on he unique
pe sonal iden i y numbe assigned a bi h (o ime o
immig a ion) o all Swedish esiden s. Da a om di e en
egis e s can be linked using hese iden i y numbe s.
The s udy popula ion comp ises indi iduals bo n
1972–1981 who, acco ding o he Regis e o he To al
Popula ion (RTP), we e ali e and esiden in Sweden
on 31 Decembe 2005. This popula ion was ollowed up
om 1 Janua y 2006 o 31 Decembe 2012, a age 25–41
yea s. Biological and/o adop i e pa en s o hese indi-
iduals we e iden i ied in he mul igene a ion egis e .
In o ma ion abou egion o bi h, yea o adop ion, sex
and yea o bi h in RTP was linked o he s udy subjec s
and hei pa en s. Da a on age a i s placemen in
ou -o -home ca e (OHC) and ime spen in OHC be o e
age 18 yea s was e ie ed om he Na ional Child
Wel a e Regis e .
Based on his in o ma ion, we c ea ed h ee s udy
g oups o child en who had en e ed OHC o been
adop ed be o e he age o 2 yea s: domes ic adop ees (n=618)
we e Swedish-bo n and had wo egis e ed Swedish-bo n
adop i e pa en s. In e na ional adop ees (n=8878) ul illed
he c i e ia o being bo n ou side o wes e n Eu ope,
ha ing a leas one Swedish-bo n adop i e pa en bu no
bi h pa en in he mul igene a ion egis e , and ha ing
en e ed Sweden be o e hei second bi hday; long- e m
os e ca e subjec s (n=1 115) had no eco d o adop ion
and a o al ime in OHC o a leas 10 yea s (median o
15.2 yea s) in ca e be o e age 18 yea s. A compa ison
popula ion labelled majo i y popula ion (n=930 944), all
Swedish-bo n indi iduals wi h a leas one Swedish-bo n
bi h pa en and no adop i e pa en s in he mul igene -
a ion egis e , and wi h no eco d o placemen in OHC
be o e he age o 18 yea s.
dep ession
Two indica o s o dep ession we e c ea ed o he
ollow-up 2006–20121: i s indica ion o dispensed an i-
dep essi e medica ion (AC-code N06A) was ob ained
om he Swedish P esc ibed D ug Regis e ,2 i s en y
in ou pa ien specialised ca e o a hospi al discha ge wi h
a diagnosis o dep essi e diso de (F32-F39 in 10 h e i-
sion o he In e na ional Classi ica ion o Disease) in o
he Na ional Pa ien Discha ge Regis e .
BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by
copy igh .
3
Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353
Open access
sociodemog aphic end educa ional co a ia es
Da a on age, gende , disposable income, domicile
and indica o s o labou ma ke pa icipa ion we e
e ie ed om he 2005 Longi udinal In eg a ion
Da abase o Heal h Insu ance and Labou Ma ke
S udies. Disposable income was di ided in o quin-
iles, and included all egis e ed sou ces o income
deduc ed by axes, and he ea e di ided by consume
uni s in he household acco ding o a o mula de el-
oped by S a is ics Sweden. Domicile was spli in o h ee
ca ego ies and de ined by he place o esidence in
2008: ‘ci y’ e e ed o he me opoli an a eas o
Sweden’s h ee la ges ci ies, S ockholm, Go hen-
bu g and Malmo, ‘ own’ co e ed o he p edomi-
na ely u ban communi ies, and ‘ u al’ co e ed he
emainde . Labou ma ke pa icipa ion was de ined
as ha ing an income om employmen /sel -employ-
men in No embe 2005 o ha ing ecei ed socie al
bene i s as an ac i e s uden ha yea . School ma ks in
g ade 9 ( inal yea o compulso y school, 15–16 yea s)
we e e ie ed om he Na ional School Regis e ,
which is adminis e ed join ly by he Swedish School
Au ho i y and S a is ics Sweden. The g ading sys em
du ing 1987–1996 na ionally ollowed a Gaussian
dis ibu ion and consis ed o a scale om 1 (poo ) o
5 (excellen ).
s a is ical analyses
Cox p opo ional haza ds models we e used o es ima e
HRs and co esponding 95% CI o dispense o an ide-
p essi e medica ion and hospi al specialised ca e wi h a
diagnosis o dep ession as de ined abo e. Pe son ime o
ollow-up was accumula ed om Janua y 2006 un il he
da e o he i s dispense/da e o i s admission/ isi ,
da e o dea h om he Na ional Cause o Dea h Regis e
o end o ollow-up in Decembe 2013.
Table 1 Cha ac e is ics o he s udy popula ion
Domes ic adop ees In e na ional adop ees Fos e ca e Gene al popula ion
n=618 n=8778 n=1115 930 944
Sex
Men 56.1 38.5 49.4 51.4
Women 43.9 61.5 50.6 48.6
Age a adop ion/en y in o os e ca e
0–12 mon hs 90.3 42.5 45.5 –
13–24 mon hs 9.7 57.5 54.5 –
Yea o bi h
1972–1974 50.3 23.1 30.2 32.6
1975–1977 27.7 32.8 26.0 29.4
1978–1981 22.0 44.1 43.8 38.0
Ma ks in nin h g ade
Mean a e age 2.99 3.08 2.55 3.21
Educa ion in 2005
≤9 yea s 10.0 10.2 35.2 9.3
10–12 yea s 55.2 50.6 54.9 49.1
13+ yea s 34.8 39.2 9.9 41.5
Income in quin iles in 2005
Fi s 11.8 14.6 26.1 13.2
Second 17.3 17.8 24.2 18.3
Thi d 19.4 20.5 23.1 20.2
Fou h 23.6 24.4 16.2 22.7
Fi h 27.8 22.6 10.5 25.6
Employed No embe 2005 79.0 69.7 53.3 73.4
S uden in 2005 13.0 24.8 12.3 20.1
Geog aphic esidency
Ci y 42.9 52.8 37.7 42.9
Town 43.9 39.1 44.6 43.9
Ru al 13.3 8.1 8.5 13.3
BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by
copy igh .
4Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353
Open access
The modelling o ea ly childhood de e minan s
o adul men al heal h is complex, since ajec o ies
po en ially in ol e in e media e ac o s ha a e p od-
uc s o he ea ly childhood en i onmen and de e -
minan s o adul men al heal h. In a p e ious s udy,11
we ha e shown ha he educa ional achie emen and
income o young adul men aised in os e ca e in
Sweden is conside ably lowe han ha o men in he
gene al popula ion wi h he same es sco es on IQ
es s, sugges ing ha educa ional achie emen and
income a e impo an componen s in ajec o ies
om os e ca e o adul hood. In his s udy, we he e-
o e conside ed model 1, adjus ed only o gende ,
and u ban/ u al esidency as ca ego y a iables and
yea o bi h as a con inuous a iable, as he main
analysis o he e ec s o ca e in ea ly childhood. To
s udy he e ec o ca e, a e adjus men o po en ial
consequences o ype o ca e, we also c ea ed a model
2 adjus ed o g ade poin a e ages a age 15–16 yea s
and a model 3 u he adjus ed o employmen /
income in adul age. All analyses we e conduc ed
using SPSS V.24.0.
esul s
Table 1 shows he cha ac e is ics o he s udy g oups.
In e na ional adop ees we e mo e o en emales in
compa ison wi h he o he s udy g oups. The domes ic
adop ees we e he younges when en e ing ca e (90%
du ing hei i s yea o li e), wi h in e na ional adop ees
mo e o en being adop ed be ween hei i s and second
bi hday (46%). As expec ed om he policy change
desc ibed abo e, he domes ic adop ees we e mo e o en
han he o he s udy g oups bo n in 1972–1974 and
he os e child en mo e o en du ing 1975–1981. The
domes ic adop ees had he highes income and employ-
men a es o he s udy g oups. Fos e child en had he
lowes school ma ks in g ade 9, he lowes educa ional
achie emen and he lowes income. Domes ic and in e -
na ional adop ees had mean g ade poin a e ages and
Table 2 Dep ession indica o s by sociodemog aphic a iables (pe cen ages)
Medica ion Hospi al ca e
Men Women Men Women
S udy g oups
Gene al popula ion 12.3 21.6 3.4 5.8
Domes ic adop ees 12.1 29.2 3.2 5.2
In e na ional adop ees 14.1 24.0 5.5 8.1
Fos e ca e 26.8 39.1 11.8 13.5
Yea o bi h
1972–1974 12.2 22.5 3.1 5.3
1975–1977 12.4 21.7 3.4 5.7
1978–1981 12.4 21.0 3.7 6.3
Highes educa ion in 2005
≤9 yea s 19.0 29.4 7.6 12.8
10–12 yea s 12.2 23.1 3.4 6.2
13+ yea s 9.1 16.8 2.1 4.3
S uden and/o employed in 2005
No 24.7 35.2 9.3 12.7
Income in quin iles in 2005
Fi s 17.1 22.5 5.9 8.7
Second 15.1 25.1 4.5 7.2
Thi d 13.9 22.3 4.0 5.9
Fou h 11.7 18.5 3.1 4.6
Fi h 8.8 14.7 1.9 3.5
Geog aphic esidency
Ci y 12.2 21.1 3.4 5.8
Town 12.4 22.2 3.4 5.9
Ru al 12.3 22.4 3.4 5.7
To al 12.3 21.7 3.4 5.8
BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by
copy igh .
5
Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353
Open access
educa ional achie emen in be ween he compa ison
popula ion and he os e child en.
As able 2 demons a es, he accumula ed incidence o
an idep essi e medica ion was 12% in men and 21% in
women in he gene al popula ion. The highes incidences
we e ound among he o me os e child en, wi h 27% o
men and 39% o women. Fo hospi al psychia ic ca e wi h
a diagnosis o dep ession, he accumula ed incidence was
3% in men and 6% in women in he gene al popula ion.
Fo me os e child en had he highes incidences also o
his ou come; 13% o women and 12% o men.
Cox eg ession models o he e ec s o ype o ca e on
dep ession ou comes a e p esen ed in able 3. In he main
analysis, p esen ed in model 1, we adjus ed o yea o
bi h, gende and u al/u ban esidency only. Compa ed
wi h he gene al popula ion, indi iduals in he os e ca e
g oup had he highes HRs o bo h ou comes, 2.07 (95%
CI 1.87 o 2.28) o an idep essi e medica ion, and 2.85
(95% CI 2.42 o 3.35) o hospi al psychia ic ca e wi h
a diagnosis o dep ession. In e na ional and domes ic
adop ees had simila isks o an idep essi e medica ion,
HRs 1.13 (95% CI 1.08 o 1.18) and 1.19 (955 CI 1.00
o 1.43), espec i ely, while he HR o psychia ic ca e
o dep ession was highe in in e na ional adop ees, 1.45
(95% CI 1.34 o 1.57) compa ed wi h 0.93 (95% CI 0.63
o 1.38) in he domes ic adop ees. In e ac ion analyses
could no de ec any signi ican gende di e ences o
any o hese wo ou comes.
Adjus ing he analysis o ac o s on he ajec o y om
childhood o adul hood, school ma ks in model 2 and
income and employmen in model 3, a enua ed hese
isks mo e in he os e ca e g oup, sugges ing ha some
o he excess isks o dep ession in he o me os e
child en was indeed associa ed wi h hese in e media e
ac o s. HRs, howe e , emained mo e ele a ed o
o me os e child en han o he adop ion g oups and
he gene al popula ion.
dIsCussIOn
This na ional coho s udy o adul s aised by adop i e o
os e pa en s demons a es ha , compa ed wi h os e
ca e, adop ion du ing he in ancy yea s is associa ed wi h
a lowe isk o an idep essi e medica ion and psychia ic
ca e wi h a diagnosis o dep ession in adul hood. Educa-
ion, employmen and income, as possible consequences
o ype o ca e, a enua ed hese isks mo e in he os e
ca e g oup.
P e ious esea ch on Swedish adul s aised in subs i u e
amilies ha e shown ha os e child en consis en ly ha e
a highe consump ion o psychia ic ca e and psycho-
opic d ugs, and a highe isk o suicidali y han adop-
ees.25–27 The pa e n demons a ed in his s udy sugges s
ha a highe incidence o dep essi e diso de s may be an
impo an ac o behind he excess isk o suicide p e i-
ously ound in o me os e child en compa ed wi h
in e na ional adop ees in Sweden.25
In he os e ca e g oup, he HRs we e s ongly a en-
ua ed by school ma ks and income le els, al hough he
pe cen age o hose wi h highe academic quali ica ions
and be e income is signi ican ly lowe o he os e ca e
g oup. P e ious Swedish s udies ha e shown ha , despi e
a simila cogni i e compe ence,9 adop ees pe o m be e
in school, each highe educa ional le els and ha e highe
labou ma ke pa icipa ion han adul s aised in os e
ca e, wi h he in e na ional adop ees doing pa icula ly
well.11 Thus, amily ela ed en i onmen al di e ences in
cogni i e and educa ional suppo be o e and du ing he
school yea s, and he consequences on labou ma ke
pa icipa ion o his ‘s un ed’ educa ional achie emen
o he o me os e child en may be one mechanism
ha can explain hei highe a e o dep ession.28
The isk es ima es o he os e child en and he in e -
na ional adop ees we e pa icula ly high o he mo e
se e e ou come o hospi al psychia ic ca e, compa ed
wi h an idep essi e medica ion. This is in line wi h
Table 3 Cox eg ession models o indica o s o dep ession and di e en o ms o subs i u e ca e
Model 1 Model 2 Model 3
HR (95% CI) HR (95% CI) HR (95% CI)
An idep essi e medica ion
Gene al popula ion 111
Domes ic adop ees 1.19 (1.00 o 1.43) 1.12 (0.93 o 1.34) 1.13 (0.94 o 1.35)
In e na ional adop ees 1.13 (1.08 o 1.18) 1.06 (1.01 o 1.11) 1.05 (1.00 o 1.10)
Fos e child en 2.07 (1.87 o 2.28) 1.64 (1.47 o 1.83) 1.44 (1.29 o 1.61)
Hospi al ca e
Gene al popula ion 111
Domes ic adop ees 0.93 (0.63 o 1.38) 0.85 (0.57 o 1.27) 0.86 (0.58 o 1.29)
In e na ional adop ees 1.45 (1.34 o 1.57) 1.32 (1.22 o 1.44) 1.30 (1.19 o 1.41)
Fo me os e child en 2.85 (2.42 o 3.35) 2.01 (1.68 o 2.41) 1.62 (1.35 o 1.94)
Model 1 is adjus ed o gende , yea o bi h and u ban/ u al esidency.
Model 2 is also adjus ed o mean g ade poin a e ages in nin h g ade.
Model 3 is also adjus ed o income in quin iles and employmen /being a s uden in young adul hood.
BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by
copy igh .

6Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353
Open access
p e ious s udies, whe e dep ession associa ed wi h child-
hood ad e si y has been linked o a g ea e isk o ecu -
en and pe sis en dep essi e episodes, and also o less
bene i s om ea men .5
The esul s o his s udy sugges s ha ea ly adop ion
can limi he isk o dep ession associa ed wi h ea ly
childhood ad e si y. Lacking de ailed indi idual da a, we
hypo hesise ha an impo an mechanism is ha adop-
ion p o ides be e s abili y and a mo e p edic able
childhood home base—bo h o child en and subs i u e
pa en s.29 F om a de elopmen al pe spec i e, sa e y, secu-
i y, s abili y and nu u ance in ou -o -home placemen s
a e key equisi es o he eco e y om pas ad e si ies
and he well-being o looked a e child en.30 The impo -
ance o s abili y is highligh ed by s udies showing ha an
inc ease in he numbe o OHC placemen expe iences
p edic s a g ea e a e o men al heal h di icul ies.31 32
The well-known di icul ies o you h ansi ioning om
OHC o independen li ing also seem o include subs an-
ial p oblems wi h access o adul men al heal h se ices.33
Ou indings can be pu a i ely linked o neu obio-
logical s udies showing he connec ion be ween ea ly
ad e si y and he HPA sys em, wi h pe sis en high le els
o co isol ha ing been linked o adul dep ession in
animal models.34 Lau en e al35 ha e demons a ed ha
a high-quali y ca ing en i onmen has he po en ial o
no malise and s abilise he daily pa e n o co isol le els
in ea ly childhood.
s eng hs and limi a ions
The main s eng h o his s udy is he use o he Swedish
na ional egis e s ha allows o long- e m ollow-up
wi h minimal a i ion and high-quali y da a. The main
limi a ion is he lack o in o ma ion abou amilial isk
ac o s, ha is, he edi a y, e al and ea ly childhood
exposu es in he s udy g oups and he eason o why he
child en we e aken in o os e ca e o we e adop ed. In
a p e ious s udy, whe e we had access o mo e in o ma-
ion abou he bi h pa en s, we showed ha he bi h
pa en s o na ional adop ees as well as child en in long-
e m os e ca e ha e much highe cumula ed incidences
o psychia ic diso de s and subs ance abuse han he
gene al popula ion, wi h he long- e m os e child en
ha ing he highes incidences. Thus, i seems p ob-
able ha e al exposu es o subs ances and gene ic isk
ac o s o dep ession explain some o he di e ences
be ween he s udy g oups.11 The use o a unique window
in Swedish child wel a e his o y, howe e , when domes ic
adop ions we e eplaced wi h os e ca e as he de aul
choice o placemen s in mal ea ed young child en can
be expec ed o limi he in luence o such con ounding.
Ano he ype o po en ial con ounding would ha e o
ha e been conside ed i adop ed child en and/o os e
child en we e o e ed a ge ed psychia ic se ices ha
would inc ease he chance o ecei ing psychia ic ca e
and ha ing been being p esc ibed an idep essi e medi-
ca ion in adul hood. Such a ge ed se ices, howe e , a e
no in place in Sweden oday and we e no in place when
he s udied popula ions we e child en. This and o he
s udies indica e ha such se ices should be conside ed.36
COnClusIOns
This s udy sugges s ha ea ly adop ion can p o ec chil-
d en om some o e en all o he isk o dep ession
associa ed wi h ea ly childhood ad e si y. Fu he s udies
wi hin he os e ca e g oup a e needed o elucida e he
p o ec i e e ec o placemen s abili y.
Con ibu o s AH came up wi h he idea o his manusc ip , made he egis e
linkages, c ea ed he da a se o he analyses, made all s a is ical analyses and
w o e he i s d a o he manusc ip . JP and BV bo h con ibu ed o he heo e ical
amewo k o he s udy, he in e p e a ion o he esul s and he w i ing o he
manusc ip . All h ee au ho s ha e ead and app o ed he inal manusc ip .
Funding This s udy was suppo ed by a g an om he Bank o Sweden
Te cen ena y Founda ion P10-0514:1.
Compe ing in e es s None decla ed.
Pa ien consen o publica ion No equi ed.
e hics app o al This s udy was app o ed by he e hics commi ee in he
S ockholm egion (No. 2014/415-31/5).
P o enance and pee e iew No commissioned; ex e nally pee e iewed.
da a sha ing s a emen The egis e da a used in his s udy is p o ec ed by
Swedish legisla ion and canno be sha ed by esea che s no in ol ed in he s udy.
Open access This is an open access a icle dis ibu ed in acco dance wi h he
C ea i e Commons A ibu ion 4.0 Unpo ed (CC BY 4.0) license, which pe mi s
o he s o copy, edis ibu e, emix, ans o m and build upon his wo k o any
pu pose, p o ided he o iginal wo k is p ope ly ci ed, a link o he licence is gi en,
and indica ion o whe he changes we e made. See: h ps:// c ea i ecommons. o g/
licenses/ by/ 4. 0/.
eFe enCes
1 Flahe y EG, Thompson R, Li ownik AJ, e al. E ec o ea ly
childhood ad e si y on child heal h. A ch Pedia Adolesc Med
2006;160:1232–8.
2 E hie LS, Lemelin JP, Lacha i é C. A longi udinal s udy o he e ec s
o ch onic mal ea men on child en's beha io al and emo ional
p oblems. Child Abuse Negl 2004;28:1265–78.
3 Sonuga-Ba ke EJS, Kennedy M, Kums a R, e al. Child- o-adul
neu ode elopmen al and men al heal h ajec o ies a e ea ly li e
dep i a ion: he young adul ollow-up o he longi udinal English and
Romanian Adop ees s udy. Lance 2017;389:1539–48.
4 Gilbe R, Widom CS, B owne K, e al. Bu den and consequences
o child mal ea men in high-income coun ies. Lance
2009;373:68–81.
5 Nanni V, Uhe R, Danese A. Childhood mal ea men p edic s
un a o able cou se o illness and ea men ou come in dep ession:
a me a-analysis. Am J Psychia y 2012;169:141–51.
6 Mel ze H, Ga wa d R, Co bin T, e al. The men al heal h o young
people looked a e by local au ho i ies in England. UK: The
S a ione y O ice, 2003.
7 B onsa d G, Alessand ini M, Fond G, e al. The p e alence o
men al diso de s among child en and adolescen s in he child
wel a e sys em: a sys ema ic e iew and me a-analysis. Medicine
2016;95:e2622.
8 Hje n A, Lindblad F, Vinne ljung B. Suicide, psychia ic illness, and
social maladjus men in in e coun y adop ees in Sweden: a coho
s udy. Lance 2002;360:443–8.
9 Vinne ljung B, F anzén E, Hje n A, e al. Long e m ou come o os e
ca e: lessons om Swedish na ional coho s udies. In: Fe nandez E,
Ba h R, eds. How does os e ca e wo k? In e na ional e idence o
ou comes. UK: Jessica Kingsley, 2010:206–20.
10 on Bo czyskowski A, Hje n A, Lindblad F, e al. Suicidal beha iou
in na ional and in e na ional adul adop ees: a Swedish coho s udy.
Soc Psychia y Psychia Epidemiol 2006;41:95–102.
11 Vinne ljung B. Cogni i e, educa ional and sel -suppo ou comes
o long- e m os e ca e s adop ion. Child You h Se Re
2011;33:2489–94.
BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by
copy igh .
7
Hje nA, e al. BMJ Paedia ics Open 2018;2:e000353. doi:10.1136/bmjpo-2018-000353
Open access
12 Tu ney K, Wildeman C. Ad e se childhood expe iences among
child en placed in and adop ed om os e ca e: E idence om a
na ionally ep esen a i e su ey. Child Abuse Negl 2017;64:117–29.
13 an IJzendoo n MH, Palacios J, Sonuga-Ba ke EJ, e al. Child en
in Ins i u ional Ca e: Delayed De elopmen and Resilience. Monog
Soc Res Child De 2011;76:8–30.
14 Gunna MR. A commen a y on dep i a ion-speci ic psychological
pa e ns: e ec s o ins i u ional dep i a ion. Monog Soc Res Child
De 2010;75:232–47.
15 She idan M, D u y S, McLaughlin K, e al. Ea ly ins i u ionaliza ion:
neu obiological consequences and gene ic modi ie s. Neu opsychol
Re 2010;20:414–29.
16 Palacios J, Rolock N, Selwyn J, e al. Adop ion b eakdown: concep ,
esea ch and implica ions. Res Social Wo k P ac. In P ess.
17 Oos e man M, Schuengel C, Wim Slo N, e al. Dis up ions in
os e ca e: a e iew and me a-analysis. Child You h Se Re
2007;29:53–76.
18 Vinne ljung B, Sallnäs M, Be lin M. Placemen b eakdowns in long-
e m os e ca e - a egional Swedish s udy. Child Fam Soc Wo k
2017;22:15–25.
19 Elmund A, Lindblad F, Vinne ljung B, e al. In e coun y adop ees
in ou -o -home ca e: a na ional coho s udy. Ac a Paedia
2007;96:437–42.
20 Rubin DM, O'Reilly AL, Luan X, e al. The impac o placemen
s abili y on beha io al well-being o child en in os e ca e.
Pedia ics 2007;119:336–44.
21 Bohman M. Adop ed child en and hei amilies. P op ius, Sweden,
1970.
22 No dlö B. S enska adop ione i S ockholm 1918-1973 [Swedish
adop ions in S ockholm 1918-1973]. Sweden: S ockholms S ad,
2001.
23 Lud igsson JF, Ande sson E, Ekbom A, e al. Ex e nal e iew and
alida ion o he Swedish na ional inpa ien egis e . BMC Public
Heal h 2011;11:450.
24 We e ma k B, Hamma N, Fo ed CM, e al. The new
Swedish P esc ibed D ug Regis e –oppo uni ies o
pha macoepidemiological esea ch and expe ience om he i s six
mon hs. Pha macoepidemiol D ug Sa 2007;16:726–35.
25 Hje n A, Vinne ljung B, Lindblad F. A oidable mo ali y among child
wel a e ecipien s and in e coun y adop ees: a na ional coho
s udy. J Epidemiol Communi y Heal h 2004;58:412–7.
26 Vinne ljung B, Hje n A. Consump ion o psycho opic d ugs among
adul s who we e in socie al ca e du ing hei childhood-A Swedish
na ional coho s udy. No d J Psychia y 2014;68:611–9.
27 Vinne ljung B, Hje n A, Lindblad F. Suicide a emp s and se e e
psychia ic mo bidi y among o me child wel a e clien s–a na ional
coho s udy. J Child Psychol Psychia y 2006;47:723–33.
28 Bjö kens am E, Dalman C, Vinne ljung B, e al. Childhood
household dys unc ion, school pe o mance and psychia ic
ca e u ilisa ion in young adul s: a egis e s udy o 96 399
indi iduals in S ockholm Coun y. J Epidemiol Communi y Heal h
2016;70:473–80.
29 Bohman M, Sig a dsson S. Ou comes in adop ion: lessons om
longi udinal s udies. In: B odzinsky D, Schech e M, eds. The
psychology o adop ion. USA: Ox o d Uni e si y P ess, 1990.
30 Ha den BJ. Sa e y and s abili y o os e child en: a de elopmen al
pe spec i e. Fu u e Child 2004;14:30–47.
31 Webs e D, Ba h RP, Needell B. Placemen s abili y o child en
in ou -o -home ca e: a longi udinal analysis. Child Wel a e
2000;79:614–32.
32 James S, Lands e k J, Slymen DJ, e al. P edic o s o ou pa ien
men al heal h se ice use– he ole o os e ca e placemen change.
Men Heal h Se Res 2004;6:127–41.
33 Akis e J, Owens M, Goodye IM. Lea ing ca e and men al heal h:
ou comes o child en in ou -o -home ca e du ing he ansi ion o
adul hood. Heal h Res Policy Sys 2010;8:10.
34 Kau man J, Cha ney D. E ec s o ea ly s ess on b ain s uc u e
and unc ion: implica ions o unde s anding he ela ionship
be ween child mal ea men and dep ession. De Psychopa hol
2001;13:451–71.
35 Lau en HK, Gilliam KS, B uce J, e al. HPA s abili y o child en
in os e ca e: men al heal h implica ions and mode a ion by ea ly
in e en ion. De Psychobiol 2014;56:1406–15.
36 Vinne ljung B, Hje n A. Heal h and heal h ca e o child en in ou -o -
home ca e. In J Soc Wel 2018;27:321–4.
BMJ Paedia ics Open: i s published as 10.1136/bmjpo-2018-000353 on 7 Decembe 2018. Downloaded om h ps://bmjpaedsopen.bmj.com on 10 Decembe 2024 by gues . P o ec ed by
copy igh .