Estimating the impact of out-of-home placement on health risk behavior in adolescents exposed to maltreatment: An advanced causal inference approach.

BACKGROUND

Youth who experience out-of-home placement (OOHP) engage in elevated health risk behaviors (e.g., substance use, unprotected sex), with risk potentially heightened for those placed during adolescence. Estimating causal effects is challenging because maltreated youth who are placed differ systematically from those who remain in-home.

OBJECTIVE

This study examined the effects of adolescent OOHP on health risk behaviors, applying causal inference methods (g-estimation and inverse probability of treatment weighting; IPTW) to address selection bias and time-varying confounders.

PARTICIPANTS AND

SETTING

Data were drawn from 734 maltreated adolescents in the U.S. National Survey on Child and Adolescent Wellbeing.

METHODS

IPTW and g-estimation were used to estimate effects of adolescent OOHP on substance use and sexual risk behavior during adolescence and into young adulthood, adjusting for numerous confounders. Results were compared with regression analyses using traditional covariate adjustment.

RESULTS

In traditional regression models, OOHP was not significantly associated with health risk behaviors. However, both causal inference approaches revealed that OOHP predicted increased substance use later in adolescence. IPTW analyses also indicated greater sexual risk behavior in adolescence and increased substance use in adulthood among placed youth.

CONCLUSIONS

Although OOHP is intended to enhance safety, adolescent OOHP may heighten risk for harmful health behaviors. Given the severe consequences of such behaviors and the risk of losing service access in adulthood, the period following OOHP is a critical window for intervention. The results demonstrate how robust causal inference techniques may lead to more accurate assessment of OOHP than traditional regression methods.