Heterogeneous effects of increased availability of alcohol on hospitalisation due to external causes. Quasi-experimental evidence from the introduction of Saturday opening at Swedish alcohol retail stores.

Responses to increased alcohol availability may vary across the population as a function of differential vulnerability. This study therefore aimed to examine the effects of the implementation of Saturday opening at the Swedish alcohol retail monopoly in 2000 on risks of hospitalisation due to external causes (HEC) among different population subgroups. Leveraging the experimental design of the reform, longitudinal difference-in-differences analyses were applied to a register-based cohort of individuals aged 20-40 at the time of implementation. The population was stratified into groups of Swedish, Finnish, and Middle Eastern origin, known to represent different levels of alcohol consumption and rates of alcohol-related morbidity. Results showed a 17.7% increase (p<0.029) in the risk of HEC among individuals of Finnish origin, as jointly caused by both increased prevalence in the experiment area and decreased prevalence in the control area. The increase was primarily driven by younger men with lower levels of education. Those of Swedish origin exhibited largely similar patterns (9.7% increase; p<0.001) while no measurable impact was observed among individuals of Middle Eastern origin (-21.4% decrease; p<0.076). The findings confirm that increasing alcohol availability contributes to the disease burden related to alcohol among population subgroups already susceptible to its effects.

Criminal outcomes among infants placed in out-of-home care: A longitudinal nationwide cohort study.

BACKGROUND: Infant placements into out-of-home care have garnered increased research and societal attention, yet the long-term outcomes of this vulnerable group are virtually unknown. OBJECTIVE: This study aims to examine the association between infant placement and criminal offences across the life course, contrasting with general population peers and children placed at later developmental periods. PARTICIPANTS AND SETTING: The study includes 622,940 individuals born in Sweden between 1975 and 1981, among whom around 0.2 % (n = 1524) were taken into care during infancy (<12 months). METHODS: Utilizing Swedish longitudinal population-based register data, sex-stratified hurdle regression analyses, adjusted for individual and family background characteristics, were conducted to investigate the risk and rates of criminal offences ages 15-38. RESULTS: Infants placed in care exhibited higher risks of any criminal offence compared to the general population (men: RR = 1.32, p < 0.001, women RR = 1.47, p < 0.001), but lower risks compared to children placed at later ages. Incidence-adjusted rates of offences were also higher among infants compared to their general population peers (men: IRR = 2.54, p < 0.001, women: IRR = 2.77, p < 0.001), with differences to other care groups being less pronounced. CONCLUSIONS: Infant placement in care is associated with an increased risk of criminal activity over the life course.

Cardiovascular Disease and Risk Factors in Individuals With a History of Out-of-home Care.

BACKGROUND: Exposure to childhood out-of-home care (foster family and residential care) is associated with an increased risk of ill-health and disability in adulthood, but the risk for cardiovascular disease has not previously been studied longitudinally. METHODS: This was a national cohort study generated from linkage of a range of population-based registers, resulting in a national cohort of 881 731 of whom 26 310 (3.0%) had a history of out-of-home care. The study population, born 1972 to 1981, was followed from age 18 to age 39 to 48 years for hospitalizations and death. RESULTS: After adjusting for year of birth and maternal education, individuals with a history of childhood out-of-home-care experienced a doubling of the risk for coronary disease (hazard ratio; 95% confidence interval: 2.05; 1.74-2.41) and stroke (hazard ratio 1.85; 1.59-2.15), compared with the general population, with similar estimates for men and women. Women with a history of out-of-home care had a more than doubled risk for cigarette smoking in early pregnancy, with a relative risk of 2.26; (2.18-2.34) and a moderately increased risk for gestational diabetes relative risk 1.49 (1.19-1.86). There was marked attenuation (40% to 90%) in effect estimates for disease and risk factors after further control for cohort members educational achievement at age 15-16 years. CONCLUSIONS: A history of childhood out-of-home care was associated with a doubled risk of early cardiovascular disease events. Cigarette smoking and educational underachievement were the main identified risk factors.

WITHDRAWN: Cardiovascular disease in individuals with a history of out-of-home care: a Swedish national cohort study.

The authors have withdrawn their manuscript owing to errors apparent in the results. Therefore, the authors do not wish this work to be cited as reference for the project. If you have any questions, please contact the corresponding author.

Associations between out-of-home care and mental health disorders within and across generations in a Swedish birth cohort.

Previous studies have shown that mental health disorders (MHD) among parents might be an important mechanism in the intergenerational transmission of out-of-home care (OHC). The current study aimed to further study this interplay by investigating the associations between OHC and MHD within and across generations. We used prospective data from the Stockholm Birth Cohort Multigenerational Study (SBC Multigen) on 9033 cohort members (Generation 1; G1) and their 15,305 sons and daughters (Generation 2; G2). By odds ratios of generalised structural equation modelling, we investigated the intergenerational transmission of OHC and MHD, respectively, as well as the association between OHC and MHD within each generation. Second, we examined the associations between OHC and MHD across the two generations. In order to explore possible sex differences, we performed the analyses stratified by the sex of G2. The results showed an intergenerational transmission of OHC, irrespective of sex. Regarding the intergenerational transmission of MHD, it was shown for both sexes although only statistically significant among G2 males. OHC was associated with MHD within both generations; in G2, this association was stronger among the males. While we found no direct association between OHC in G1 and MHD in G2, there was a significant association between MHD in G1 and OHC in G2. The latter was more evident among G2 females than G2 males. We conclude that OHC and MHD seem to be processes intertwined both within and across generations, with some variation according to sex. Although there did not seem to be any direct influences of OHC in one generation on MHD in the next generation, there was some indication of indirect paths going via parental MHD and child OHC.

Intergenerational transmission of placement in out-of-home care: Mediation and interaction by educational attainment.

BACKGROUND: Persons with childhood experiences of out-of-home care (OHC) have elevated risks of having their own children taken into societal care. High educational attainment has been linked to favorable long-term outcomes in a host of previous studies on OHC alumni. This could be indicative of resilience, which may also have protective potential against intergenerational continuity of OHC placements. OBJECTIVE: The present study examined the processes of mediation and interaction by educational attainment, here conceptualized as having completed upper secondary school, regarding the intergenerational transmission of placement in OHC. PARTICIPANTS AND SETTING: Longitudinal data came from a Swedish cohort of parents (and their children) born in 1953 (n = 11,338). METHODS: Associations between parental experience of OHC and their children's placement in OHC were analyzed by means of binary logistic regression. Four-way decomposition was used to explore mediation and interaction by parental educational attainment. RESULTS: The odds of having at least one child being placed in OHC was more than six-fold (OR = 6.67, 95% CI = 5.28; 8.06) in the OHC group compared to majority population peers. Mediation and/or interaction by educational attainment accounted for a substantial proportion of the overall association (53%). Interaction effects appeared to be more important for the outcome than mediation. CONCLUSIONS: Having completed upper secondary school seems to reflect processes of resilience with the potential to break the intergenerational transmission of placement in OHC. These findings suggest that the impact of enhanced educational attainment of OHC populations may have potential of extending into the fate of the next generation.

Intergenerational transmission of out-of-home care and the role of mental health problems: Findings from Stockholm birth cohort multigenerational study.

Out-of-home care (OHC) experiences are associated with poor long-term outcomes throughout life. However, the continuity of OHC over generations is not fully explored, and the influence of mental health problems (MHP) and socioeconomic conditions on such transmission is still unclear. We therefore assessed the extent to which MHP affect the intergenerational transmissions of OHC as well as whether there are differential patterns depending on the socioeconomic conditions of the family of origin. We used a prospective data from the Stockholm Birth Cohort Multigenerational Study (SBC Multigen) on 11,333 cohort members (Generation 1; G1), their parents (Generation 0; G0), and 24,905 children (Generation 2; G2). Multivariate regressions and path models were used to examine the associations between OHC and MHP across generations; stratified analysis by occupational class in G0 was performed to explore potentially differential patterns. Our findings support the existence of an intergenerational transmission of OHC, particularly in the working class group (OR 4.70); MHP was only transmitted across generations in this group (OR 1.51). While the results indicated a stronger role of MHP among the middle/upper class (OR 5.59) compared to working class (OR 3.52) in part of the pathway (MHP G1→OHC G2), this patter was not consistent throughout the whole pathway (e.g. OHC G1→MHP G1). We conclude that there is a tendency for OHC and MHP experiences to continue across generations, particularly among families with more disadvantageous socioeconomic conditions. MHP seem to play an important role in the transmission of OHC irrespective of socioeconomic conditions.

Association of Child Placement in Out-of-Home Care With Trajectories of Hospitalization Because of Suicide Attempts From Early to Late Adulthood.

Importance: Children placed in out-of-home care (OHC) have higher rates of suicidal behaviors, including suicide attempts, compared with those who grow up in their family of origin. Several studies have shown that this elevated risk persists into young adulthood. Yet, our knowledge about any longer-term associations of OHC with suicide attempts is limited. Objective: To examine how childhood experiences of placement in OHC are associated with trajectories of hospitalization because of suicide attempts (HSA) from early into late adulthood. Design, Setting, and Participants: This prospective birth cohort study that was conducted in Stockholm, Sweden, and analyzed in March 2020 included 14 559 individuals born in 1953 who were living in the greater metropolitan of Stockholm in November 1963 and followed through registers up until December 2016. Exposures: Childhood experiences of OHC based on information from the Social Register (age 0-19 years). Main Outcomes and Measures: Hospitalization because of suicide attempts based on in-patient care data from the National Patient Register. Group-based trajectory modeling was used to cluster individuals according to their probabilities of HSA across adulthood (age 20-63 years). Results: In this cohort of 14 559 individuals (7146 women [49.1%]), 1320 individuals (9.1%) had childhood experiences of OHC, whereas 525 individuals ( 3.6%) had HSA. A Cox regression analysis showed a substantially higher risk of HSA among those with childhood experiences of OHC (hazard ratio, 3.58; 95% CI, 2.93-4.36) and after adjusting for a range of adverse childhood living conditions (hazard ratio, 2.51; 95% CI, 2.00-3.15). Those with at least 1 HSA were grouped into 4 trajectories: (1) peak in middle adulthood (66 [12.6%]), (2) stable low across adulthood (167 [31.8%]), (3) peak in early adulthood (210 [40.0%]), and (4) peak in emerging adulthood (82 [15.6%]). A multinomial regression analysis suggested that those with experiences of OHC had higher risks of following any of these trajectories (trajectory 1: relative risk ratio [RRR], 2.91; 95% CI, 1.61-5.26; trajectory 2: RRR, 3.18; 95% CI, 2.21-4.59; trajectory 3: RRR, 4.32; 95% CI, 3.18-5.86; trajectory 4: RRR, 3.26; 95% CI, 1.94-5.46). The estimates were reduced after adjusting for adverse childhood living conditions. Conclusions and Relevance: The findings suggest that the elevated risk of suicide attempts among former child welfare clients does not cease after young adulthood, indicating the necessity for clinical attention to childhood experiences of OHC as a risk marker for suicidal behavior across the life span.

Inequalities in educational outcomes in individuals with childhood experience of out-of-home care: What are driving the differences?

BACKGROUND: Prior research has shown that individuals with experience of out-of-home care (foster family care or residential care) in childhood are educationally disadvantaged compared to their peers. In order to be better equipped to design interventions aimed at improving the educational outcomes of children for whom society has assumed responsibility, this study seeks to further our understanding about which factors that contribute to the educational disparities throughout the life course. METHODS: Using longitudinal data from a cohort of more than 13,000 Swedes, of which around 7% have childhood experience of out-of-home care, Peters-Belson decomposition is utilized to quantify the extent to which the gap in educational achievement in school (age 16) and midlife educational attainment (age 50) captures differences in the prevalence of factors influencing educational outcomes, and differences in the impacts between these factors. RESULTS: We find that the achievement and the attainment gap was around 13% and 9% respectively. These gaps were to a large extent explained by differences in the distribution of predictors. The major explanatory factor for placed children's lower achievement was a lower average cognitive ability. Yet there were some evidence that the rewards of cognitive ability in these children differed across the life course. While the lower returns of cognitive ability suggest that they were underperforming in compulsory school, the higher returns of cognitive ability on midlife attainment indicate that-given previous underperformance-their attainment at age 50 reflects their cognitive capacity more accurately than their achievement at age 16 do. CONCLUSION: The large influence of the unequal distribution of predictors suggests that policy efforts are needed to promote equity in the distribution of factors contributing to educational achievement and attainment. Since cognitive ability was found to be an important contributory factor, such efforts may include promoting cognitive and intellectual development among children in out-of-home care, preferably starting at a young age.

Outcomes in Adulthood After Long-Term Foster Care: A Sibling Approach.

When a child is removed from their home and placed in foster care, society takes over the responsibility for that child's well-being and development. Failure to provide a child with a nurturing upbringing may have negative consequences for the child as well as for society. Using Swedish longitudinal registry data for a national cohort sample of siblings, in which some were placed in foster care and others remained in their birth parents' care, this study asks whether long-term foster care ensures improved life chances. Results from multilevel regression analyses of a wide range of educational, social, and health-related outcomes in mature adult age (16 outcome constructs) support a row of previous studies indicating that traditional long-term foster care does not seem to improve maltreated children's life chances.

Troubled childhoods cast long shadows: Childhood adversity and premature all-cause mortality in a Swedish cohort.

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.

Do trajectories of economic, work- and health-related disadvantages explain child welfare clients' increased mortality risk? A prospective cohort study.

BACKGROUND: Past research has shown that individuals who have had experiences of out-of-home care (OHC) in childhood have increased risks of premature mortality. Prior studies also suggest that these individuals are more likely to follow long-term trajectories that are characterised by economic, work-, and health-related disadvantages, compared to majority population peers. Yet, we do not know the extent to which such trajectories may explain their elevated mortality risks. The aim of this study is therefore to examine whether trajectories of economic, work-, and health-related disadvantages in midlife mediate the association between OHC experience in childhood and subsequent all-cause mortality. METHODS: Utilising longitudinal Swedish data from a 1953 cohort (n = 14,294), followed from birth up until 2008 (age 55), this study applies gender-specific logistic regression analysis to analyse the association between OHC experience in childhood (ages 0-19; 1953-1972) and all-cause mortality (ages 47-55; 2000-2008). A decomposition method developed for non-linear regression models is used to estimate mediation by trajectories of economic, work-, and health-related disadvantages (ages 39-46; 1992-1999), as indicated by social welfare receipt, unemployment, and mental health problems. To account for selection processes underlying placement in OHC, an alternative comparison group of children who were investigated by the child welfare committee but not placed, is included. RESULTS: The results confirm that individuals with experience of OHC have more than a two-fold increased risk of all-cause mortality, for men (OR: 2.10, 95% CI: 1.42-3.11) and women (OR: 2.23, 95% CI: 1.39-3.59) alike. Approximately one-third (31.1%) of the association among men, and one-fourth (27.4%) of the association among women, is mediated by the long-term trajectories of economic, work-, and health-related disadvantages. The group who were investigated but not placed shows similar, yet overall weaker, associations. CONCLUSIONS: Individuals who come to the attention of the child welfare services, regardless of whether they are placed in out-of-home care or not, continue to be at risk of adverse outcomes across the life course. Preventing them from following trajectories of economic, work-, and health-related disadvantages could potentially reduce their risk of premature death.

A decade lost: does educational success mitigate the increased risks of premature death among children with experience of out-of-home care?

BACKGROUND: Past research has consistently identified children with out-of-home care (OHC) experience as a high-risk group for premature mortality. While many have argued that educational success is a key factor in reducing these individuals' excessive death risks, empirical evidence has hitherto been limited. The aim of the current study was therefore to examine the potentially mitigating role of educational success in the association between OHC experience and premature mortality. METHODS: Drawing on a Stockholm cohort born in 1953 (n=15 117), we analysed the associations among placement in OHC (ages 0-12), school performance (ages 13, 16 and 19) and premature all-cause mortality (ages 20-56) by means of Cox and Laplace regression analyses. RESULTS: The Cox regression models confirmed the increased risk of premature mortality among individuals with OHC experience. Unadjusted Laplace regression models showed that, based on median survival time, these children died more than a decade before their majority population peers. However, among individuals who performed well at school, that is, those who scored above-average marks at the age of 16 (grade 9) and at the age of 19 (grade 12), the risks of premature mortality did not significantly differ between the two groups. CONCLUSION: Educational success seems to mitigate the increased risks of premature death among children with OHC experience.

Evicted children and subsequent placement in out-of-home care: A cohort study.

BACKGROUND: Evictions may have serious consequences for individuals' health and wellbeing. Even though an eviction may be experienced as a significant crisis for the family, there is little previous knowledge on consequences for evicted children. This study represents the first attempt to examine to what extent children from evicted households were separated from their parents and placed in out-of-home care (foster family or residential care) using population-based data, net of observed confounding factors related to the socioeconomic and psychosocial circumstances of their parents. METHODS: This study takes advantage of information from a Swedish national database, consisting of about 8 000 evicted individuals and a random sample of 770 000 individuals from the national population, linked to individual-level, longitudinal data from Swedish national registers. Our analytical sample consists of information for more than 250 000 children born in 1995-2008, including 2 224 children from evicted households. We used binary logistic regression based on the Karlson/Holm/Breen method to account for observed imbalances at baseline between evicted and non-evicted children. RESULTS: Compared to non-evicted children, the crude odds ratio for placement in out-of-home care in evicted children was 12.10 (95% CI 8.54-17.14). Net of observed confounding factors related to the socioeconomic and psychosocial circumstances of the parents, evicted children had a twofold elevated risk of being placed in out-of-home care (odds ratio 2.26, 95% CI 1.55-3.27). Crude OR for evicted children in comparison with children under threat of eviction (eviction not formally executed) was 1.71 (95% CI 1.17-2.49) and adjusted OR 1.58 (95% CI 1.06-2.35). CONCLUSION: Children who experience eviction constitute a disadvantaged group and are at significant risk of being separated from their parents and placed in out-of-home care. These results demonstrate the importance of providing support for these children and their parents. Strategies to prevent households with children from being evicted seem to be an important and viable intervention path.

Childhood Adversity and Trajectories of Disadvantage Through Adulthood: Findings from the Stockholm Birth Cohort Study.

Children whose parents experience adverse social, economic, or health-related living conditions are more likely to face similar types of disadvantage in their adult life. However, a limitation of many earlier studies is that they do not account for the multidimensionality of the concept of living conditions, and that the child generation's life courses are targeted as static and independent from the societal context in which they are imbedded. The current investigation addressed these aspects by focusing on the complexity, duration, and timing of disadvantage with regard to how adverse circumstances in the family of origin are associated with trajectories of social, economic, and health-related living conditions across adulthood. We also examined the role of educational attainment for these associations. Analyses were based a Swedish cohort born in 1953 (n = 14,294). We first conducted sequence analysis, followed by hierarchical cluster analysis, to generate 'outcome profiles', i.e. trajectories of adult disadvantage. Second, several indicators of adverse circumstances in childhood were analysed by means of multinominal regression analysis, showing the odds of ending up in the different trajectories. The results indicated that individuals who grew up under adverse conditions were more likely to experience disadvantaged social, economic, and health-related trajectories. This was particularly the case for trajectories characterised by a high degree of complexity, i.e. coexisting disadvantages, and-among men only-by a longer duration of disadvantage. Educational attainment was identified as a powerful mediator, suggesting that efforts to increase equal educational opportunity may be a way of reducing the intergenerational transmission of disadvantage.

Children Placed In Out-of-Home Care as Midlife Adults: Are They Still Disadvantaged or Have They Caught Up With Their Peers?

International research has consistently reported that children placed in out-of-home care (OHC) have poor outcomes in young adulthood. Yet, little is known about their outcomes in midlife. Using prospective data from a cohort of more than 14,000 Swedes born in 1953, of which nearly 9% have been placed in OHC, this study examines whether there is developmental continuity or discontinuity of disadvantage reaching into middle age in OHC children, compared to same-aged peers. Outcome profiles, here conceptualized as combinations of adverse outcomes related to education, economic hardship, unemployment, and mental health problems, were assessed in 1992-2008 (ages 39-55). Results indicate that having had experience of OHC was associated with 2-fold elevated odds of ending up in the most disadvantaged outcome profile, controlling for observed confounding factors. These findings suggest that experience of OHC is a strong marker for disadvantaged outcomes also in midlife.

Exposure to out-of-home care in childhood and adult all-cause mortality: a cohort study.

Background: Children placed in out-of-home care (OHC) have exceedingly high rates of health problems. Their poor health tends to persist across adolescence and into young adulthood, resulting in increased risks of mortality. Yet, very little is known about this group's mortality risks later in life. The aim of this study was to investigate whether OHC was associated with the risk of all-cause mortality across adulthood, and whether these risks varied across different placement characteristics. Moreover, the study addressed potential confounding by including two comparison groups with children who grew up under similarly adverse living conditions but did not experience placement. Methods: Data were derived from a 60-year follow-up of a Stockholm cohort born in 1953 ( n = 15 048), of whom around 9% have had experiences of OHC. The associations between OHC and subsequent all-cause mortality were analysed by means of Cox's proportional hazards regression models. Results: Individuals who were placed in OHC at any point during their formative years had increased mortality risks across ages 20 to 56 years. Elevated risk of mortality was particularly pronounced among those who were placed in adolescence and/or because of their own behaviours. Children who were exposed to OHC had increased risks of mortality also when compared with those who grew up under similar living conditions but did not experience placement. Conclusions: Children in OHC constitute a high-risk group for subsequent mortality. In order to narrow the mortality gap, interventions may need to monitor not only health aspects but also to target the cognitive and social development of these children.

The truly disadvantaged? Midlife outcome dynamics of individuals with experiences of out-of-home care.

Little is known about developmental outcomes in midlife of persons who were placed in out-of-home care (OHC) in childhood. Utilizing longitudinal Swedish data from a cohort of more than 14,000 individuals who we can follow from birth (1953) to the age of 55 (2008), this study examines midlife trajectories of social, economic, and health-related disadvantages with a specific focus on the complexity, timing, and duration of disadvantage in individuals with and without childhood experience of OHC. Roughly half of the OHC alumni did not have disadvantaged outcomes in midlife. However, experience of OHC was associated with a two-fold risk for various forms of permanent disadvantage, net of confounding factors. Implications for research, policy, and practice are discussed.

Does poor school performance cause later psychosocial problems among children in foster care? Evidence from national longitudinal registry data.

Research has shown that children in foster care are a high-risk group for adverse economic, social and health related outcomes in young adulthood. Children's poor school performance has been identified as a major risk factor for these poor later life outcomes. Aiming to support the design of effective intervention strategies, this study examines the hypothesized causal effect of foster children's poor school performance on subsequent psychosocial problems, here conceptualized as economic hardship, illicit drug use, and mental health problems, in young adulthood. Using the potential outcomes approach, longitudinal register data on more than 7500 Swedish foster children born 1973-1978 were analyzed by means of doubly robust treatment-effect estimators. The results show that poor school performance has a negative impact on later psychosocial problems net of observed background attributes and potential selection on unobservables, suggesting that the estimated effects allow for causal interpretations. Promotion of school performance may thus be a viable intervention path for policymakers and practitioners interested in improving foster children's overall life chances.

Child welfare clients have higher risks for teenage childbirths: which are the major confounders?

BACKGROUND: Aiming to support effective social intervention strategies targeting high-risk groups for teenage motherhood, this study examined to what extent the elevated crude risks of teenage childbirth among child welfare groups were attributable to the uneven distribution of adverse individual and family background factors. METHODS: Comprehensive longitudinal register data for more than 700 000 Swedish females born 1973-1989 (including around 29 000 child welfare clients) were analysed by means of binary logistic regression. The Karlson/Holm/Breen-method was used to decompose each confounding factor's relative contribution to the difference between crude and adjusted odds ratios (ORs). RESULTS: Elevated crude risks for teenage childbirth are to a large extent attributable to selection on observables. Girls' school failure was the most potent confounder, accounting for 28-35% of the difference between crude and adjusted ORs. CONCLUSION: As in majority populations, girls' school failure was a strong risk factor for teenage childbirth among former child welfare children. At least among pre-adolescents, promoting school performance among children in the child welfare system seems to be a viable intervention path.