Suicide risk, protective factors, and interventions for young people in out-of-home care: A scoping review

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This scoping review synthesises international peer-reviewed literature and relevant Australian gray literature from the past decade to identify risk factors, protective factors, and interventions associated with suicidality among care-experienced young people. Methods This review was guided by the PRISMA-ScR guidelines and followed Arksey and O’Malley’s five-step framework. With the support of a research librarian, a search strategy was developed to capture both peer-reviewed and gray literature. Four electronic databases (Medline, CINAHL, PsycINFO, and ProQuest) were searched via carefully selected keywords, covering publications from 2014 to February 2025. Results Seventeen studies met the inclusion criteria and spanned diverse methodologies and geographic contexts. The key risk factors included a history of trauma, placement instability, mental health comorbidities, and systemic failure in OOHC. Protective factors centred on relational safety, emotional regulation, and culturally affirming support. Interventions ranged from high-intensity therapeutic models to low-intensity relational programs, with promising outcomes linked to caregiver connection and trauma-informed practice. Conclusion The findings demonstrate the need for gender-sensitive, relationally driven approaches and more robust multi-item assessment tools. This review highlights critical gaps in youth voice inclusion and calls for codesigned interventions with care-experienced young people. The implications for policy and practice include strengthening professional development for carers and adapting existing suicide prevention frameworks to the OOHC context. Figures Figure 1 Introduction The mental health and well-being of children and young people with out-of-home care (OOHC) experience is a growing public health and social care concern ( 1 , 2 ). Compared with their non-care peers, youth in OOHC are more than three times as likely to attempt suicide ( 3 ). Throughout this review, the term young people is used to refer to both children and youth up to the age of 21, consistent with common usage in the international OOHC and suicide prevention literature. The elevated rates of suicidality in this group highlight the urgent need to frame suicide prevention as a critical component of child protection policy and practice ( 4 ). Rates of suicidal ideation and attempts are particularly high for youth who are transitioning out of OOHC, as these young people experience complex and stressful life events with limited social support ( 5 ). While mental illness is a significant risk factor, suicide is not solely a mental health problem. It is also deeply shaped by social determinants such as trauma, poverty, discrimination, racism, and systemic failures in care and support ( 6 ). For many young people, particularly those in OOHC, suicide risk is often compounded by disrupted attachments, instability, and a lack of culturally safe services where young people are challenged to have their views heard and taken seriously ( 7 ). Framing suicide solely as a mental health issue risks underestimating the broader structural and relational contexts that contribute to despair and disconnection. In Australia, individual state and territory governments are responsible for protecting and supporting young people aged 0–18, who are experiencing or at risk of harm from their parents ( 8 ). When young people cannot safely live with their families, often due to abuse or neglect, they may be placed in OOHC, which may involve kinship care, foster care, or residential care ( 9 ). These services are part of the statutory child protection system in Australia, although they may be referred to as “social care” or “child welfare” in other countries ( 10 ). It is well documented that suicide prevention capacity among staff within the child welfare system requires further development to ensure they feel confident in identifying and engaging with young people at risk of suicide ( 11 , 12 ). Like colonised First Nations people worldwide, Aboriginal children are significantly overrepresented in Australia’s child protection system and are ten times more likely than non-Aboriginal children to be removed from their parents, kinship networks, and cultural contexts ( 13 – 16 ). Young people with experiences in OOHC are particularly vulnerable and face an elevated risk of poor mental health outcomes including suicide ( 3 , 17 – 21 ). In this paper, we define “suicide” as the intentional act of ending one’s own life, whereas “suicidality” encompasses a broader range of thoughts and behaviours associated with suicide, including thoughts of suicide, planning, and attempts ( 22 , 23 ). We include “self-harm” as a wide range of behaviours where the individual intentionally causes pain or injury to themselves with or without the wish to die ( 24 , 25 ). In Australia, suicide has remained the leading cause of death among young people aged 15–24 years for more than a decade. Recent data show that in 2023, suicide accounted for 31.8% of all deaths among 15–17-year-olds and 33.1% among those aged 18–24 ( 25 , 26 ). Compared with their peers in the general population, young people in OOHC are at significantly greater risk of suicide and self-harm ( 3 ). Many of these young people have histories of trauma, family violence, mental health challenges, and disrupted support networks ( 27 ). Systemic failures, such as inadequate recognition of escalating risk, a lack of sustained trauma-informed care, and poor continuity due to frequent changes in placements and caseworkers, contribute significantly to their vulnerability ( 28 ). Aboriginal children are disproportionately affected, with previous research demonstrating the role of systemic racism, the absence of culturally safe services, and the urgent need for self-determination in care provision ( 28 , 29 ). The Lost, Not Forgotten report (2019) was commissioned by the State of Victoria to better understand and respond to the elevated risk of suicide and self-harm among young people with care experience. The findings highlight that the deaths of these young people by suicide were not inevitable; rather, they were the result of systemic failure. This paper builds on earlier research into health system integration for young people in the OOHC ( 17 – 19 ), where we identified serious shortcomings in access to and coordination of health care. Notably, while general health needs were already poorly met for those in OOHC, oral and mental health needs, including suicidal ideation, merged as even more profoundly neglected, often rendered invisible within service planning and delivery in child protection and health systems ( 17 , 18 ). This review continues that critical examination. The aim of this paper is to undertake a scoping review of the international peer-reviewed literature to identify the risk factors, protective factors, and interventions associated with suicide among care-experienced young people. To contextualise our findings, we also examined relevant gray literature relevant to the Australian landscape. We define “ risk factors” as individual characteristics or lived experiences, such as trauma, instability, or service disengagement, that increase the likelihood of suicidal thoughts or behaviours ( 30 , 31 ). “Protective factors” refer to strengths, mental health support, culturally safe services, positive diversion activities such as reading books, watching films, or using smartphones for social networking, or stable relationships that mitigate this risk ( 32 , 33 ). “Interventions” are described as therapeutic approaches and carer-focused training designed to foster responsive, supportive environments for vulnerable youth. The critical elements, both practical and theoretically, necessary to inform the development of suicide prevention for young people in OOHC are explored in this paper. By identifying and integrating risk, protective factors and interventions, a better understanding of what contributes to suicide prevention in OOHC is presented. Methods Frameworks established by Arksey and O’Malley (2005) and Davis et al. (2009) were used in this scoping review. The study followed a five-stage sequential process: ( 1 ) defining the research question, ( 2 ) identifying relevant studies, ( 3 ) selecting studies, ( 4 ) charting the data, and ( 5 ) collating, summarising, and reporting the results. A narrative synthesis approach was employed, which is well suited to the appraisal of diverse studies and enables an iterative, conceptual analysis that prioritises the credibility and contribution of selected research ( 34 – 36 ). The PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) ( 37 ) checklist was used to guide the reporting. Step 1: Identifying the research question The research question that guided the review process was as follows: what are the risk factors, protective factors and interventions for suicide in youth in out-of-home care? Step 2: Identifying relevant studies The search strategy was designed to identify peer-reviewed and gray literature with the assistance of a research librarian. Four electronic databases (Medline, CINAHL, PsycINFO, and ProQuest Social Science Premium Collection) were searched via a combination of carefully selected keywords (Table 1 ). Searches were conducted from 2014 to February 2025. This 10-year timeframe was chosen to capture the most relevant research, reflecting recent shifts such as digital technology, social media, COVID-19, and evolving mental health and child protection practices. Focusing on the past decade ensures that findings align with current systems, risks, and protective factors for suicide among young people in OOHC. Table 1 Search strategy Concept 1 Concept 2 • Suicide (MeSH) • Suicidal ideation (MeSH) • Suicide prevention (MeSH) • Suicide, attempted (MeSH) • Suicide, completed (MeSH) • Suicid* • Parasuicid* • Self-injurious behaviour (MeSH) • Self mutilation (MeSH) • “self harm*” • “self injur*” • “self mutilat*” • “self destruct*” • “self inflict*” • “self poison*” • “self immolate*” • Automutilat* • “auto mutilat*” • “self cut*” • “auto destruct*” • Child, Foster/(MeSH) • (foster* adj2 (care* or home* or child* or parent* or guardian* or placement* or family or kid or teen* or "young person" or "young people" or youth or adolescen*)) • Foster Home Care/(MeSH) • "out of home care" • "kinship care" • "alternative care" • ("looked after child*" or "looked after young person" or "looked after young people" or "looked after teen*" or "looked after youth") • ((child* or youth or adolescen* or teen* or "young people" or "young person") adj2 "residential care") A structured gray literature search was conducted via Google Advanced Search to identify publicly available Australian reports, discussion papers, and publications relevant to suicide among young people with OOHC experience. Four targeted searches were completed: ( 1 ) suicide young people out of home care , ( 2 ) suicide young people foster care , ( 3 ) suicide young people in kinship care , and ( 4 ) suicide young people in residential care . Filters were applied to limit the results to PDF documents in English and from Australian domains. For each search, URLs were scanned and logged, with duplicate content removed across search iterations. We considered studies employing any design, including qualitative and quantitative methodologies and reports. Studies were excluded if they met the following criteria: (International) adoption Mental health hospitals/inpatient treatment centres Juvenile detention centres and secure children’s homes Homeless children Specific focus on care leavers Intellectual disability/homes Sex trafficking/safe housing for young people Substance abuse recovery care/homes Coroners’ investigation reports Senate submissions Research briefs (not reporting on primary data) Conference abstracts and book reviews Practice manuals Protocols Non-English language Step 3: Study selection The review focused on risk factors, protective factors and interventions for suicide (ideation, attempts, self-harm) in youth aged 0–21 years who are actively in care. The inclusion and exclusion of studies were determined by three researchers with the support of the screening tool Covidence™. CM and MV screened 1107 studies for relevance based on the information provided in the title and abstract. Records that did not match the inclusion criteria were excluded (n = 907), and any citations that CM and MV did not agree upon were reviewed by LH for a final decision. Full articles (n = 200) were retrieved for citations that had been approved. CM and MV examined these articles, continually reflecting on search strategies and methodological choices at each stage of sifting, charting and sorting ( 34 ) to decide if the citations conformed to the inclusion criteria. LH resolved any disagreements, resulting in 17 studies being included in the scoping review (see Fig. 1 ). The gray literature resulted in 28 new, unique sources. These were reviewed by LH and CM, and conflicts were resolved by MV, resulting in none of these conflicts being included based on the exclusion criteria above. The gray literature obtained from these searches provided some context to supplement peer-reviewed evidence, capturing research briefs and practice manuals not always reflected in academic databases that are relevant for the Australian context of OOHC. Results Fourteen peer-reviewed articles published between 2014 and February 2025 met the inclusion criteria. No additional publications were identified through gray literature sources. However, handsearching the reference lists of two Australian research briefs ( 27 , 29 ) yielded three additional studies relevant to the current review, and all included articles are presented in Table 2 in alphabetical order. Table two: Included studies INSERT HERE Step 4: Charting the data A scoping review is a systematic analytical process that organises, synthesises and interprets data around key topics to address the research question ( 38 ). Two researchers (CM and MV) created preselected headings to chart the data according to authors, year, country, title, study design, type of OOHC, participants and the voices of young people, risk factors, protective factors, and interventions and outcomes. Author details/date/location Details about the authors, the year of publication, and the location in which the studies were undertaken are available in Table 2. Among the 17 papers selected, five were from the United Kingdom ( 39 – 43 ), three were from Spain ( 44 – 46 ), one was from Germany ( 47 ), two were from Australia ( 48 , 49 ), and six were from North America ( 50 – 55 ). The studies span from 2014–2024, with most published after 2017, indicating a growing research focus on suicide prevention in the OOHC over the past decade and reflecting a range of child welfare systems and approaches. Design Five studies employed a cross-sectional design, measuring variables at a single point in time ( 41 , 43 , 45 , 54 , 55 ). Two studies used a pre–post intervention design to assess outcomes before and after service delivery ( 48 , 53 ). One study was a randomised controlled trial ( 50 ), whereas two studies used nonrandomised experimental designs ( 44 , 47 ). Seven studies employed qualitative methods, including two that used interpretative phenomenological analysis to explore lived experience and meaning-making ( 39 , 40 ) and two that undertook interviews and focus groups ( 3 , 49 ). An additional three studies adopted a mixed-methods approach, combining qualitative and quantitative data ( 46 , 51 , 52 ). Type of OOHC The most common setting was residential care, with a number of studies focusing solely on this population ( 39 , 44 – 46 , 51 ), whereas others combined cohorts in residential care with foster and kinship care ( 40 , 42 , 47 – 49 , 56 ). Foster care has also been widely represented, with studies examining both general foster care populations ( 50 , 53 , 55 ) and specific subgroups such as sexual and gender minority foster youth ( 52 ). Two studies did not specify the type of OOHC ( 41 , 43 ). Participants Most study focused on young people in care over the age of 11 ( 39 – 41 , 43 – 47 , 49 , 51 , 52 , 54 ), one study included 4 to 17 years old ( 48 ), two under 11 years old ( 53 , 55 ), and two were carer-focused ( 42 , 50 ). Further details, including participant type, age range, and sample size for each study, are provided in Table 2. Voices of young people Given the type of studies and research design, most did not include the voices of young people with lived experience. Only three studies explicitly incorporated youth perspectives ( 39 , 43 , 49 ). Three studies included some input through open-ended questions or interviews ( 40 , 46 , 52 ). Risk/Protective/Intervention Most papers have reported on risk factors ( 39 – 45 , 47 , 50 – 55 ). Nine studies reported on protective factors ( 39 , 40 , 43 , 46 – 49 , 52 – 54 ), and six reported specific interventions ( 44 , 46 , 48 – 50 , 53 ). Please note that some papers reported on both as the number of papers exceeded the number of papers included. Risk factors The risk factors common across studies were a history of childhood trauma, particularly multiple forms of abuse and neglect ( 53 , 55 ), placement instability, and mental health comorbidities such as depression and emotional dysregulation ( 44 , 51 ). Gender plays a significant role, with girls and gender-diverse young people showing disproportionately high rates of suicidality and victimisation ( 45 , 47 , 52 ). Other risk factors include hopelessness, self-hatred, impulsivity ( 41 ), feelings of loneliness, and a lack of emotional connection with caregivers or staff ( 39 , 47 ). These vulnerabilities were compounded by systemic challenges in child protection service delivery, such as frequent placement disruptions and changes, as well as support from services that young people experienced as inadequate or unhelpful ( 40 , 43 ). One study mentioned the limitations of traditional assessment tools, which may fail to capture the complexity of suicidality ( 47 ), especially when only single-item measures are used in the context of OOHC. Carers and practitioners misunderstood or minimised self-harming behaviours, interpreting them as attention-seeking or relational acts rather than indicators of serious distress ( 42 ). Sexual and gender minority youth in the OOHC experienced intersectional discrimination and systemic marginalisation, including racism, homophobia, and transphobia, which emerged as additional risk factors ( 52 ). The included studies emphasised that young people in OOHC face risks that are cumulative, relational, and often compounded by systemic and placement-level challenges with females. and sexual and gender minority youth identified as being at particularly high risk of suicide. Protective factors Fewer studies have reported on protective factors than risk factors, and these factors are more implicit than directly measured. Several studies have emphasised the central role of relationships and the relational environment. Young people in the OOHC reported feeling safer and more supported when they had caregivers who were trustworthy, responsive, and committed, and emotional safety emerged as protective distress and suicidality ( 39 , 40 , 49 ). Young people in OOHC drew the most support for foster carers, friends, and pets, and at times, counsellors were mentioned as key sources of support ( 43 ). Relational and authentic care in residential settings emerged as a buffer against self-harm ( 39 ). Other protective contexts have been identified in system-level studies. Young people living in foster care settings were found to experience lower levels of loneliness than their peers in residential care ( 47 ). Strong peer and teacher connections in a positive school environment are associated with reduced rates of depression and suicidal ideation ( 54 ). For sexual and gender minority young people, access to affirming care and community engagement act as protective buffers against the negative effects of systemic discrimination ( 52 ). A smaller number of intervention studies highlighted protective gains. For example, reductions in self-injury following trauma-integrated therapeutic service ( 48 ) and emotional intelligence therapy reduce hopelessness and suicidal ideation ( 44 ). Animal-assisted interventions enhance coping strategies and help-seeking among residential care youth ( 46 ), whereas long-term accessible and relationship-based therapy functions as a protective factor by reducing barriers to mental health care and support for as long as needed ( 53 ). Interventions Six of the included studies explicitly evaluated or described interventions aimed at reducing suicidality improving mental health outcomes among young people in OOHC ( 44 , 46 , 48 – 50 , 53 ). A consistent feature across these interventions was the emphasis on relational, therapeutic, and skill-building approaches, although the intensity and format varied. The Evolve Therapeutic Services program, which involves trauma-integrated, wrap-around therapeutic support across care types, was associated with a significant reduction in nonaccidental self-injury (from 17.5% to 7.2%) ( 48 ). Similarly, the Ripple Project, which includes the capacity of carers and case managers to create emotionally attuned environments, aims to strengthen relational safety and reduce suicide risk ( 49 ). Emotional intelligence therapy (EIT) was trialled with young people in residential care and demonstrated significant reductions in hopelessness, emotional dysregulation, and suicidal ideation ( 44 ). In addition, a pilot study of OverCome-AAI, an animal-assisted intervention, revealed enhanced coping strategies, help-seeking, and reduced self-harm behaviours among residential care youth ( 46 ). Home Within, a volunteer-driven model provides long-term, relationship-based psychotherapy to foster children, resulting in reductions in depression and self-harm ( 53 ). The program connects a low-intensity, self-directed program delivered to foster families through workbooks and video vignettes, which has shown modest but positive effects on mental health and placement outcomes ( 50 ). The importance of relational, trauma-informed, and context-sensitive approaches to addressing suicidality and self-harm among young people in OOHCs has been explored in several studies. The results support a shift towards systems-based, relationally driven models that centre emotional safety and collaboration in mental health interventions. Discussion This review provides a systematic synthesis of risk factors, protective factors, and interventions for suicidality, specifically among young people in the OOHC. The results demonstrate that suicidality in this population cannot be understood solely through an individualised clinical lens. Rather, risks are cumulative, relational, and systemically produced, arising from a history of trauma, compounded by placement instability, and magnified by service responses that are often inconsistent or experienced as unhelpful ( 40 , 43 ). Girls and gender-diverse young people appear particularly vulnerable ( 45 , 47 , 52 ), reflecting how gendered and intersectional inequalities shape mental health outcomes in OOHC contexts. Importantly, these findings highlight that OOHC itself is not a neutral setting but rather a structural determinant of suicidality, shaping both risk and protection in young people’s lives. The imbalance between risk and protective factors across the literature is striking. Much of the research continues to prioritise risk detection, with relatively limited attention given to relational, cultural, and systemic protective processes. When protective factors are described, they consistently emphasise the importance of relational safety: the presence of caregivers, caseworkers, and peers who are trustworthy, emotionally attuned, and committed to sustaining relationships despite challenges ( 39 , 49 ). Relational care not only buffers distress but also provides a foundation for developing coping skills, identity affirmation, and help-seeking behaviours ( 43 , 52 ). While prior reviews have focused largely on prevalence or intervention outcomes rather than determinants specific to OOHC ( 4 , 20 ), the results suggest that suicide prevention in OOHC is as much about fostering safe and authentic relational environments as it is about addressing individual-level symptoms. The interventions identified in this review reinforce this relational emphasis. Trauma-integrated therapeutic models ( 48 ), carer capacity-building initiatives ( 49 ), emotional skills training ( 44 ), animal-assisted interventions ( 46 ), and long-term psychotherapy ( 53 ) all reinforce the principle that emotional connection and consistent support are central to preventing suicide in the context of OOHC. Even low-intensity family-based programs such as Connecting ( 50 ) showed promise when they increased caregiver–youth interaction and strengthened family belonging. However, the evidence base remains thin, with few interventions evaluated at scale and little cross-contextual replication, limiting the generalisability of findings. Young people’s voices remain marginal within this scoping review. Only three studies ( 39 , 43 , 49 ) explicitly included the perspectives of young people in care, despite growing commitments to participation and codesign. These types of silencing risk reproducing the very systemic disempowerment that young people identify as harmful ( 7 ). Measurement practices to assess suicide risk also require strengthening. Reliance on single-item assessments, as noted by Emmerich et al. (2024), oversimplifies the complexity of suicidality, obscuring differences between fleeting ideation, persistent self-harm urges, and suicide attempts. Without more nuanced, multidimensional tools, there is a danger that suicide risk in OOHC remains under- or mischaracterised, particularly for marginalised groups. The results highlight the significance of intersectional risk. Young people who experience racism, homophobia, or transphobia within OOHC systems carry an additional burden of marginalisation that directly heightens suicidality ( 52 ). These findings demonstrate that suicide prevention in OOHC is not only trauma-informed but also culturally safe, identity-affirming, and anti-oppressive ( 4 ). Without such approaches, interventions risk overlooking the cumulative risks faced by minority groups. The results highlight the urgent need to embed systems-based, trauma-informed, and relationally driven models of care across OOHC service delivery. Workforce training in evidence-informed programs such as Suicide Alertness for Everyone (safeTALK) training can strengthen suicide literacy, stigma reduction, and crisis response capacity among carers ( 11 ). However, such training should be adapted through co-design with care-experienced young people to ensure relevance. Co-designing suicide prevention programs with youth, specifically tailored to the OOHC context, can foster inclusivity and support empowered self-determination. This review demonstrates that suicide prevention in OOHC must be understood within the unique ecology of OOHC, where trauma history, placement instability, and systemic challenges intersect with young people’s identities and relationships. The next phase of this research will involve world-café conversations with care-experienced young people to gather their feedback on the results discussed here. Suicide prevention for this group requires authentic youth participation. Only by addressing the specific context of OOHC in partnership with young people can policy, practice, and research meaningfully reduce suicide risk and strengthen protective pathways and interventions. Limitations This scoping review has several limitations. The evidence base is relatively small and methodologically diverse, spanning qualitative, quantitative, and mixed methods designs, which limits comparability and generalisability across studies. Differences between care settings (e.g., foster, kinship, and residential care) further constrain the extent to which findings can be applied uniformly. Consistent with the scoping review methodology, we did not conduct a formal quality appraisal of the included studies, which may have affected the strength of the conclusions. Finally, the voices of young people with lived experience in OOHC remain largely absent, both within the literature and in this review. Conclusion This scoping review synthesised risk and protective factors, as well as interventions, for suicide prevention among young people in out-of-home care. The results highlight the intersecting influence of trauma histories, placement instability, mental health comorbidities, and systemic challenges, while demonstrating the protective value of relational safety, culturally affirming support, and caregiver connection. Despite emerging evidence of promising interventions, substantial gaps remain, particularly in the inclusion of youth voice and the co-design of suicide prevention strategies. Policy and practice must prioritise structural reform, professional development for carers, and the adaptation of existing suicide prevention frameworks to the unique context of OOHC. Future research should partner directly with care-experienced young people to ensure interventions are responsive, effective, and capable of reducing suicide risk while strengthening protective pathways. Declarations Funding The authors received no financial support for the research, authorship, or publication of this article. Author Contribution The conception and design of this work, acquisition of data, analysis and preparation of each draft have been the responsibility of all authors: Corina Modderman (lead), Maria Veresova and Laura Hemming. Acknowledgement This study was developed in partnership with welfare agencies in regional Australia. We thank them for their advice. Data Availability No specific data set is provided. All data relevant to the study are included in the article. Contributors The conception and design of this work, acquisition of data, analysis and preparation of each draft have been the responsibility of all authors: Corina Modderman (lead), Maria Veresova and Laura Hemming. Ethics statements Not applicable. Ethics approval Given the use of published literature for this scoping review, ethics approval or oversight was not required. 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Improving the mental health of Indigenous children and young people in child protection. Canberra 2021. World Health Organization. Preventing suicide: A global imperative. 2014. Nazeer A. Public health aspects of suicide in children and adolescents. Int Public Health J. 2016;8(4):427. Ati NA, Paraswati MD, Windarwati HD. What are the risk factors and protective factors of suicidal behavior in adolescents? A systematic review. J child Adolesc psychiatric Nurs. 2021;34(1):7–18. Kim M-H, Min S, Ahn J-S, An C, Lee J. Association between high adolescent smartphone use and academic impairment, conflicts with family members or friends, and suicide attempts. PLoS ONE. 2019;14(7):e0219831. Arksey H, O'Malley L. Scoping studies: Towards a methodological framework. Int J Soc Res Methodol. 2005;8(1):19–32. Davis K, Drey N, Gould D. What are scoping studies? A review of the nursing literature. Int J Nurs Stud. 2009;46(10):1386–400. Levac D, Colquhoun H, O'Brien KK. Scoping studies: advancing the methodology. Implement Sci. 2010;5(1):69. Tricco AC, Lillie E, Zarin W, O'Brien KK, Colquhoun H, Levac D, et al. PRISMA extension for scoping reviews (PRISMA-ScR): checklist and explanation. Ann Intern Med. 2018;169(7):467–73. McKinstry C, Brown T, Gustafsson L. Scoping reviews in occupational therapy: The what, why, and how to. Aust Occup Ther J. 2014;61(2):58–66. Rouski C, Knowles SF, Sellwood W, Hodge S. The quest for genuine care: a qualitative study of the experiences of young people who self-harm in residential care. Clin Child Psychol Psychiatry. 2021;26(2):418–29. Wadman R, Armstrong M, Clarke D, Harroe C, Majumder P, Sayal K, et al. Experience of self-harm and its treatment in looked-after young people: an interpretative phenomenological analysis. Archives suicide Res. 2018;22(3):365–79. Wadman R, Clarke D, Sayal K, Armstrong M, Harroe C, Majumder P, et al. A sequence analysis of patterns in self-harm in young people with and without experience of being looked after in care. Br J Clin Psychol. 2017;56(4):388–407. Evans RE. Survival, signaling, and security: Foster carers’ and residential carers’ accounts of self-harming practices among children and young people in care. Qual Health Res. 2018;28(6):939–49. Holland J, Sayal K, Berry A, Sawyer C, Majumder P, Vostanis P, et al. What do young people who Self-Harm find helpful? A comparative study of young people with and without experience of being looked after in care. Child Adolesc Mental Health. 2020;25(3):157–64. Bonet C, Palma C, Santos GG. Effectiveness of emotional intelligence therapy on suicide risk among adolescents in residential care. Int J Psychol Psychol therapy. 2020;20(1):61–74. Águila-Otero A, Bravo A, Santos I, Del Valle J. Addressing the most damaged adolescents in the child protection system: An analysis of the profiles of young people in therapeutic residential care. Child Youth Serv Rev. 2020;112:104923. Muela A, Balluerka N, Sansinenea E, Machimbarrena JM, García-Ormaza J, Ibarretxe N, et al. A social-emotional learning program for suicide prevention through animal-assisted intervention. Animals. 2021;11(12):3375. Emmerich OLM, Wagner B, Heinrichs N, van Noort BM. Lifetime victimization experiences, depressiveness, suicidality, and feelings of loneliness in youth in care. Child Abuse Negl. 2024;154:106870. Eadie K. Evolve Therapeutic Services: Outcomes for children and young people in out-of-home care with complex behavioural and mental health problems. Child Australia. 2017;42(4):277–84. Herrman H, Harvey C, Humphreys C, Halperin S, Murray L, Moeller-Saxone K. Supporting carers of vulnerable young people living in out-of-home care: the Ripple project. L'information psychiatrique. 2017;93(1):43–50. Haggerty KP, Barkan SE, Caouette JD, Skinner ML, Hanson KG. Family, mental health, and placement outcomes of a low-cost preventive intervention for youth in foster care. Child Youth Serv Rev. 2023;150:106973. Duppong Hurley K, Wheaton RL, Mason WA, Schnoes CJ, Epstein MH. Exploring suicide risk history among youth in residential care. Residential Treat Child Youth. 2014;31(4):316–27. Prince DM, Ray-Novak M, Tossone K, Peterson E, Gillani B, Mintz L. Psychological comorbidities and suicidality in sexual and gender minority foster youth. Child Youth Serv Rev. 2024;156:107379. Ruff SC, Aguilar RM, Clausen JM. An exploratory study of mental health interventions with infants and young children in foster care. J Family Social Work. 2016;19(3):184–98. Shim-Pelayo H, De Pedro KT. The role of school climate in rates of depression and suicidal ideation among school-attending foster youth in California public schools. Child Youth Serv Rev. 2018;88:149–55. Taussig HN, Harpin SB, Maguire SA. Suicidality among preadolescent maltreated children in foster care. Child Maltreat. 2014;19(1):17–26. Shim M. Do Organisational Culture and Climate Really Matter for Employee Turnover in Child Welfare Agencies? Br J Social Work. 2014;44(3):542–58. Tables Table 2 is available in the Supplementary Files section. Additional Declarations No competing interests reported. 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1","display":"","copyAsset":false,"role":"figure","size":24558,"visible":true,"origin":"","legend":"\u003cp\u003ePRISMA flowchart\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-7531546/v1/8c062c925c89eb70c87c418c.png"},{"id":103766055,"identity":"8c9e2c5a-0e8a-47c7-8a77-a8b91aa26863","added_by":"auto","created_at":"2026-03-02 16:11:55","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":663943,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-7531546/v1/fca41095-12dc-4505-9e29-31ee46b1346a.pdf"},{"id":92584447,"identity":"a4ba85b0-6f4c-41c0-94e0-b13ad5e7fc61","added_by":"auto","created_at":"2025-10-01 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Compared with their non-care peers, youth in OOHC are more than three times as likely to attempt suicide (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Throughout this review, the term young people is used to refer to both children and youth up to the age of 21, consistent with common usage in the international OOHC and suicide prevention literature. The elevated rates of suicidality in this group highlight the urgent need to frame suicide prevention as a critical component of child protection policy and practice (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Rates of suicidal ideation and attempts are particularly high for youth who are transitioning out of OOHC, as these young people experience complex and stressful life events with limited social support (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e). While mental illness is a significant risk factor, suicide is not solely a mental health problem. It is also deeply shaped by social determinants such as trauma, poverty, discrimination, racism, and systemic failures in care and support (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e). For many young people, particularly those in OOHC, suicide risk is often compounded by disrupted attachments, instability, and a lack of culturally safe services where young people are challenged to have their views heard and taken seriously (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Framing suicide solely as a mental health issue risks underestimating the broader structural and relational contexts that contribute to despair and disconnection.\u003c/p\u003e\u003cp\u003eIn Australia, individual state and territory governments are responsible for protecting and supporting young people aged 0\u0026ndash;18, who are experiencing or at risk of harm from their parents (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e). When young people cannot safely live with their families, often due to abuse or neglect, they may be placed in OOHC, which may involve kinship care, foster care, or residential care (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e). These services are part of the statutory child protection system in Australia, although they may be referred to as \u0026ldquo;social care\u0026rdquo; or \u0026ldquo;child welfare\u0026rdquo; in other countries (\u003cspan citationid=\"CR10\" class=\"CitationRef\"\u003e10\u003c/span\u003e). It is well documented that suicide prevention capacity among staff within the child welfare system requires further development to ensure they feel confident in identifying and engaging with young people at risk of suicide (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eLike colonised First Nations people worldwide, Aboriginal children are significantly overrepresented in Australia\u0026rsquo;s child protection system and are ten times more likely than non-Aboriginal children to be removed from their parents, kinship networks, and cultural contexts (\u003cspan additionalcitationids=\"CR14 CR15\" citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR16\" class=\"CitationRef\"\u003e16\u003c/span\u003e). Young people with experiences in OOHC are particularly vulnerable and face an elevated risk of poor mental health outcomes including suicide (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan additionalcitationids=\"CR18 CR19 CR20\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eIn this paper, we define \u0026ldquo;suicide\u0026rdquo; as the intentional act of ending one\u0026rsquo;s own life, whereas \u0026ldquo;suicidality\u0026rdquo; encompasses a broader range of thoughts and behaviours associated with suicide, including thoughts of suicide, planning, and attempts (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e, \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e). We include \u0026ldquo;self-harm\u0026rdquo; as a wide range of behaviours where the individual intentionally causes pain or injury to themselves with or without the wish to die (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). In Australia, suicide has remained the leading cause of death among young people aged 15\u0026ndash;24 years for more than a decade. Recent data show that in 2023, suicide accounted for 31.8% of all deaths among 15\u0026ndash;17-year-olds and 33.1% among those aged 18\u0026ndash;24 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e, \u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e). Compared with their peers in the general population, young people in OOHC are at significantly greater risk of suicide and self-harm (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e). Many of these young people have histories of trauma, family violence, mental health challenges, and disrupted support networks (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eSystemic failures, such as inadequate recognition of escalating risk, a lack of sustained trauma-informed care, and poor continuity due to frequent changes in placements and caseworkers, contribute significantly to their vulnerability (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e). Aboriginal children are disproportionately affected, with previous research demonstrating the role of systemic racism, the absence of culturally safe services, and the urgent need for self-determination in care provision (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e). The Lost, Not Forgotten report (2019) was commissioned by the State of Victoria to better understand and respond to the elevated risk of suicide and self-harm among young people with care experience. The findings highlight that the deaths of these young people by suicide were not inevitable; rather, they were the result of systemic failure.\u003c/p\u003e\u003cp\u003eThis paper builds on earlier research into health system integration for young people in the OOHC (\u003cspan additionalcitationids=\"CR18\" citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e), where we identified serious shortcomings in access to and coordination of health care. Notably, while general health needs were already poorly met for those in OOHC, oral and mental health needs, including suicidal ideation, merged as even more profoundly neglected, often rendered invisible within service planning and delivery in child protection and health systems (\u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e17\u003c/span\u003e, \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e). This review continues that critical examination.\u003c/p\u003e\u003cp\u003eThe aim of this paper is to undertake a scoping review of the international peer-reviewed literature to identify the risk factors, protective factors, and interventions associated with suicide among care-experienced young people. To contextualise our findings, we also examined relevant gray literature relevant to the Australian landscape. We define \u003cb\u003e\u0026ldquo;\u003c/b\u003erisk factors\u0026rdquo; as individual characteristics or lived experiences, such as trauma, instability, or service disengagement, that increase the likelihood of suicidal thoughts or behaviours (\u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e30\u003c/span\u003e, \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e31\u003c/span\u003e). \u0026ldquo;Protective factors\u0026rdquo; refer to strengths, mental health support, culturally safe services, positive diversion activities such as reading books, watching films, or using smartphones for social networking, or stable relationships that mitigate this risk (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e, \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e33\u003c/span\u003e). \u0026ldquo;Interventions\u0026rdquo; are described as therapeutic approaches and carer-focused training designed to foster responsive, supportive environments for vulnerable youth. The critical elements, both practical and theoretically, necessary to inform the development of suicide prevention for young people in OOHC are explored in this paper. By identifying and integrating risk, protective factors and interventions, a better understanding of what contributes to suicide prevention in OOHC is presented.\u003c/p\u003e"},{"header":"Methods","content":"\u003cp\u003eFrameworks established by Arksey and O\u0026rsquo;Malley (2005) and Davis et al. (2009) were used in this scoping review. The study followed a five-stage sequential process: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) defining the research question, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) identifying relevant studies, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) selecting studies, (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) charting the data, and (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e) collating, summarising, and reporting the results. A narrative synthesis approach was employed, which is well suited to the appraisal of diverse studies and enables an iterative, conceptual analysis that prioritises the credibility and contribution of selected research (\u003cspan additionalcitationids=\"CR35\" citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e). The PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) (\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) checklist was used to guide the reporting.\u003c/p\u003e\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStep 1: Identifying the research question\u003c/h2\u003e\u003cp\u003eThe research question that guided the review process was as follows: what are the risk factors, protective factors and interventions for suicide in youth in out-of-home care?\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eStep 2: Identifying relevant studies\u003c/h3\u003e\n\u003cp\u003eThe search strategy was designed to identify peer-reviewed and gray literature with the assistance of a research librarian. Four electronic databases (Medline, CINAHL, PsycINFO, and ProQuest Social Science Premium Collection) were searched via a combination of carefully selected keywords (Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). Searches were conducted from 2014 to February 2025. This 10-year timeframe was chosen to capture the most relevant research, reflecting recent shifts such as digital technology, social media, COVID-19, and evolving mental health and child protection practices. Focusing on the past decade ensures that findings align with current systems, risks, and protective factors for suicide among young people in OOHC.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eSearch strategy\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"2\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eConcept 1\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eConcept 2\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026bull; Suicide (MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; Suicidal ideation (MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; Suicide prevention (MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; Suicide, attempted (MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; Suicide, completed (MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; Suicid*\u003c/p\u003e\u003cp\u003e\u0026bull; Parasuicid*\u003c/p\u003e\u003cp\u003e\u0026bull; Self-injurious behaviour (MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; Self mutilation (MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;self harm*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;self injur*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;self mutilat*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;self destruct*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;self inflict*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;self poison*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;self immolate*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; Automutilat*\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;auto mutilat*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;self cut*\u0026rdquo;\u003c/p\u003e\u003cp\u003e\u0026bull; \u0026ldquo;auto destruct*\u0026rdquo;\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u0026bull; Child, Foster/(MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; (foster* adj2 (care* or home* or child* or parent* or guardian* or placement* or family or kid or teen* or \"young person\" or \"young people\" or youth or adolescen*))\u003c/p\u003e\u003cp\u003e\u0026bull; Foster Home Care/(MeSH)\u003c/p\u003e\u003cp\u003e\u0026bull; \"out of home care\"\u003c/p\u003e\u003cp\u003e\u0026bull; \"kinship care\"\u003c/p\u003e\u003cp\u003e\u0026bull; \"alternative care\"\u003c/p\u003e\u003cp\u003e\u0026bull; (\"looked after child*\" or \"looked after young person\" or \"looked after young people\" or \"looked after teen*\" or \"looked after youth\")\u003c/p\u003e\u003cp\u003e\u0026bull; ((child* or youth or adolescen* or teen* or \"young people\" or \"young person\") adj2 \"residential care\")\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eA structured gray literature search was conducted via Google Advanced Search to identify publicly available Australian reports, discussion papers, and publications relevant to suicide among young people with OOHC experience. Four targeted searches were completed: (\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e) \u003cem\u003esuicide young people out of home care\u003c/em\u003e, (\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e) \u003cem\u003esuicide young people foster care\u003c/em\u003e, (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e) \u003cem\u003esuicide young people in kinship care\u003c/em\u003e, and (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e) \u003cem\u003esuicide young people in residential care\u003c/em\u003e. Filters were applied to limit the results to PDF documents in English and from Australian domains. For each search, URLs were scanned and logged, with duplicate content removed across search iterations.\u003c/p\u003e\u003cp\u003eWe considered studies employing any design, including qualitative and quantitative methodologies and reports. Studies were excluded if they met the following criteria:\u003c/p\u003e\u003cp\u003e\u003cul\u003e\u003cli\u003e\u003cp\u003e(International) adoption\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eMental health hospitals/inpatient treatment centres\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eJuvenile detention centres and secure children\u0026rsquo;s homes\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eHomeless children\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSpecific focus on care leavers\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eIntellectual disability/homes\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSex trafficking/safe housing for young people\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSubstance abuse recovery care/homes\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eCoroners\u0026rsquo; investigation reports\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eSenate submissions\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eResearch briefs (not reporting on primary data)\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eConference abstracts and book reviews\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003ePractice manuals\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eProtocols\u003c/p\u003e\u003c/li\u003e\u003cli\u003e\u003cp\u003eNon-English language\u003c/p\u003e\u003c/li\u003e\u003c/ul\u003e\u003c/p\u003e\n\u003ch3\u003eStep 3: Study selection\u003c/h3\u003e\n\u003cp\u003eThe review focused on risk factors, protective factors and interventions for suicide (ideation, attempts, self-harm) in youth aged 0\u0026ndash;21 years who are actively in care. The inclusion and exclusion of studies were determined by three researchers with the support of the screening tool Covidence\u0026trade;. CM and MV screened 1107 studies for relevance based on the information provided in the title and abstract. Records that did not match the inclusion criteria were excluded (n\u0026thinsp;=\u0026thinsp;907), and any citations that CM and MV did not agree upon were reviewed by LH for a final decision. Full articles (n\u0026thinsp;=\u0026thinsp;200) were retrieved for citations that had been approved. CM and MV examined these articles, continually reflecting on search strategies and methodological choices at each stage of sifting, charting and sorting (\u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e34\u003c/span\u003e) to decide if the citations conformed to the inclusion criteria. LH resolved any disagreements, resulting in 17 studies being included in the scoping review (see Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e). The gray literature resulted in 28 new, unique sources. These were reviewed by LH and CM, and conflicts were resolved by MV, resulting in none of these conflicts being included based on the exclusion criteria above. The gray literature obtained from these searches provided some context to supplement peer-reviewed evidence, capturing research briefs and practice manuals not always reflected in academic databases that are relevant for the Australian context of OOHC.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e"},{"header":"Results","content":"\u003cp\u003eFourteen peer-reviewed articles published between 2014 and February 2025 met the inclusion criteria. No additional publications were identified through gray literature sources. However, handsearching the reference lists of two Australian research briefs (\u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e27\u003c/span\u003e, \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e29\u003c/span\u003e) yielded three additional studies relevant to the current review, and all included articles are presented in Table\u0026nbsp;2 in alphabetical order.\u003c/p\u003e\u003cp\u003eTable two: Included studies\u003c/p\u003e\n\u003ch3\u003eINSERT HERE\u003c/h3\u003e\n\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eStep 4: Charting the data\u003c/h2\u003e\u003cp\u003eA scoping review is a systematic analytical process that organises, synthesises and interprets data around key topics to address the research question (\u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Two researchers (CM and MV) created preselected headings to chart the data according to authors, year, country, title, study design, type of OOHC, participants and the voices of young people, risk factors, protective factors, and interventions and outcomes.\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eAuthor details/date/location\u003c/strong\u003e\u003cp\u003eDetails about the authors, the year of publication, and the location in which the studies were undertaken are available in Table\u0026nbsp;2. Among the 17 papers selected, five were from the United Kingdom (\u003cspan additionalcitationids=\"CR40 CR41 CR42\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e), three were from Spain (\u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), one was from Germany (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), two were from Australia (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e), and six were from North America (\u003cspan additionalcitationids=\"CR51 CR52 CR53 CR54\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). The studies span from 2014\u0026ndash;2024, with most published after 2017, indicating a growing research focus on suicide prevention in the OOHC over the past decade and reflecting a range of child welfare systems and approaches.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eDesign\u003c/strong\u003e\u003cp\u003eFive studies employed a cross-sectional design, measuring variables at a single point in time (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Two studies used a pre\u0026ndash;post intervention design to assess outcomes before and after service delivery (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). One study was a randomised controlled trial (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e), whereas two studies used nonrandomised experimental designs (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Seven studies employed qualitative methods, including two that used interpretative phenomenological analysis to explore lived experience and meaning-making (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e) and two that undertook interviews and focus groups (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). An additional three studies adopted a mixed-methods approach, combining qualitative and quantitative data (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eType of OOHC\u003c/strong\u003e\u003cp\u003eThe most common setting was residential care, with a number of studies focusing solely on this population (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan additionalcitationids=\"CR45\" citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e), whereas others combined cohorts in residential care with foster and kinship care (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan additionalcitationids=\"CR48\" citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e56\u003c/span\u003e). Foster care has also been widely represented, with studies examining both general foster care populations (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e) and specific subgroups such as sexual and gender minority foster youth (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Two studies did not specify the type of OOHC (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eParticipants\u003c/strong\u003e\u003cp\u003eMost study focused on young people in care over the age of 11 (\u003cspan additionalcitationids=\"CR40\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e, \u003cspan additionalcitationids=\"CR44 CR45 CR46\" citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e, \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), one study included 4 to 17 years old (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e), two under 11 years old (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), and two were carer-focused (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e, \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e). Further details, including participant type, age range, and sample size for each study, are provided in Table\u0026nbsp;2.\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eVoices of young people\u003c/strong\u003e\u003cp\u003eGiven the type of studies and research design, most did not include the voices of young people with lived experience. Only three studies explicitly incorporated youth perspectives (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Three studies included some input through open-ended questions or interviews (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e\u003c/p\u003e\u003cp\u003e\u003cstrong\u003eRisk/Protective/Intervention\u003c/strong\u003e\u003cp\u003eMost papers have reported on risk factors (\u003cspan additionalcitationids=\"CR40 CR41 CR42 CR43 CR44\" citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan additionalcitationids=\"CR51 CR52 CR53 CR54\" citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e). Nine studies reported on protective factors (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan additionalcitationids=\"CR47 CR48\" citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e, \u003cspan additionalcitationids=\"CR53\" citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e), and six reported specific interventions (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). Please note that some papers reported on both as the number of papers exceeded the number of papers included.\u003c/p\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eRisk factors\u003c/h3\u003e\n\u003cp\u003eThe risk factors common across studies were a history of childhood trauma, particularly multiple forms of abuse and neglect (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e, \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e55\u003c/span\u003e), placement instability, and mental health comorbidities such as depression and emotional dysregulation (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR51\" class=\"CitationRef\"\u003e51\u003c/span\u003e). Gender plays a significant role, with girls and gender-diverse young people showing disproportionately high rates of suicidality and victimisation (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). Other risk factors include hopelessness, self-hatred, impulsivity (\u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e41\u003c/span\u003e), feelings of loneliness, and a lack of emotional connection with caregivers or staff (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). These vulnerabilities were compounded by systemic challenges in child protection service delivery, such as frequent placement disruptions and changes, as well as support from services that young people experienced as inadequate or unhelpful (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOne study mentioned the limitations of traditional assessment tools, which may fail to capture the complexity of suicidality (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e), especially when only single-item measures are used in the context of OOHC. Carers and practitioners misunderstood or minimised self-harming behaviours, interpreting them as attention-seeking or relational acts rather than indicators of serious distress (\u003cspan citationid=\"CR42\" class=\"CitationRef\"\u003e42\u003c/span\u003e). Sexual and gender minority youth in the OOHC experienced intersectional discrimination and systemic marginalisation, including racism, homophobia, and transphobia, which emerged as additional risk factors (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe included studies emphasised that young people in OOHC face risks that are cumulative, relational, and often compounded by systemic and placement-level challenges with females. and sexual and gender minority youth identified as being at particularly high risk of suicide.\u003c/p\u003e\n\u003ch3\u003eProtective factors\u003c/h3\u003e\n\u003cp\u003eFewer studies have reported on protective factors than risk factors, and these factors are more implicit than directly measured. Several studies have emphasised the central role of relationships and the relational environment. Young people in the OOHC reported feeling safer and more supported when they had caregivers who were trustworthy, responsive, and committed, and emotional safety emerged as protective distress and suicidality (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Young people in OOHC drew the most support for foster carers, friends, and pets, and at times, counsellors were mentioned as key sources of support (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Relational and authentic care in residential settings emerged as a buffer against self-harm (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eOther protective contexts have been identified in system-level studies. Young people living in foster care settings were found to experience lower levels of loneliness than their peers in residential care (\u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e). Strong peer and teacher connections in a positive school environment are associated with reduced rates of depression and suicidal ideation (\u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e54\u003c/span\u003e). For sexual and gender minority young people, access to affirming care and community engagement act as protective buffers against the negative effects of systemic discrimination (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eA smaller number of intervention studies highlighted protective gains. For example, reductions in self-injury following trauma-integrated therapeutic service (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e) and emotional intelligence therapy reduce hopelessness and suicidal ideation (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). Animal-assisted interventions enhance coping strategies and help-seeking among residential care youth (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), whereas long-term accessible and relationship-based therapy functions as a protective factor by reducing barriers to mental health care and support for as long as needed (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e).\u003c/p\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eInterventions\u003c/h2\u003e\u003cp\u003eSix of the included studies explicitly evaluated or described interventions aimed at reducing suicidality improving mental health outcomes among young people in OOHC (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e, \u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e, \u003cspan additionalcitationids=\"CR49\" citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e, \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). A consistent feature across these interventions was the emphasis on relational, therapeutic, and skill-building approaches, although the intensity and format varied.\u003c/p\u003e\u003cp\u003eThe Evolve Therapeutic Services program, which involves trauma-integrated, wrap-around therapeutic support across care types, was associated with a significant reduction in nonaccidental self-injury (from 17.5% to 7.2%) (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e). Similarly, the Ripple Project, which includes the capacity of carers and case managers to create emotionally attuned environments, aims to strengthen relational safety and reduce suicide risk (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Emotional intelligence therapy (EIT) was trialled with young people in residential care and demonstrated significant reductions in hopelessness, emotional dysregulation, and suicidal ideation (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e). In addition, a pilot study of OverCome-AAI, an animal-assisted intervention, revealed enhanced coping strategies, help-seeking, and reduced self-harm behaviours among residential care youth (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e). Home Within, a volunteer-driven model provides long-term, relationship-based psychotherapy to foster children, resulting in reductions in depression and self-harm (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e). The program connects a low-intensity, self-directed program delivered to foster families through workbooks and video vignettes, which has shown modest but positive effects on mental health and placement outcomes (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe importance of relational, trauma-informed, and context-sensitive approaches to addressing suicidality and self-harm among young people in OOHCs has been explored in several studies. The results support a shift towards systems-based, relationally driven models that centre emotional safety and collaboration in mental health interventions.\u003c/p\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis review provides a systematic synthesis of risk factors, protective factors, and interventions for suicidality, specifically among young people in the OOHC. The results demonstrate that suicidality in this population cannot be understood solely through an individualised clinical lens. Rather, risks are cumulative, relational, and systemically produced, arising from a history of trauma, compounded by placement instability, and magnified by service responses that are often inconsistent or experienced as unhelpful (\u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e40\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e). Girls and gender-diverse young people appear particularly vulnerable (\u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e45\u003c/span\u003e, \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e47\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e), reflecting how gendered and intersectional inequalities shape mental health outcomes in OOHC contexts. Importantly, these findings highlight that OOHC itself is not a neutral setting but rather a structural determinant of suicidality, shaping both risk and protection in young people\u0026rsquo;s lives.\u003c/p\u003e\u003cp\u003eThe imbalance between risk and protective factors across the literature is striking. Much of the research continues to prioritise risk detection, with relatively limited attention given to relational, cultural, and systemic protective processes. When protective factors are described, they consistently emphasise the importance of relational safety: the presence of caregivers, caseworkers, and peers who are trustworthy, emotionally attuned, and committed to sustaining relationships despite challenges (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e). Relational care not only buffers distress but also provides a foundation for developing coping skills, identity affirmation, and help-seeking behaviours (\u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). While prior reviews have focused largely on prevalence or intervention outcomes rather than determinants specific to OOHC (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e, \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e), the results suggest that suicide prevention in OOHC is as much about fostering safe and authentic relational environments as it is about addressing individual-level symptoms.\u003c/p\u003e\u003cp\u003eThe interventions identified in this review reinforce this relational emphasis. Trauma-integrated therapeutic models (\u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e48\u003c/span\u003e), carer capacity-building initiatives (\u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e), emotional skills training (\u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e44\u003c/span\u003e), animal-assisted interventions (\u003cspan citationid=\"CR46\" class=\"CitationRef\"\u003e46\u003c/span\u003e), and long-term psychotherapy (\u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e53\u003c/span\u003e) all reinforce the principle that emotional connection and consistent support are central to preventing suicide in the context of OOHC. Even low-intensity family-based programs such as Connecting (\u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e50\u003c/span\u003e) showed promise when they increased caregiver\u0026ndash;youth interaction and strengthened family belonging. However, the evidence base remains thin, with few interventions evaluated at scale and little cross-contextual replication, limiting the generalisability of findings.\u003c/p\u003e\u003cp\u003eYoung people\u0026rsquo;s voices remain marginal within this scoping review. Only three studies (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e43\u003c/span\u003e, \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e49\u003c/span\u003e) explicitly included the perspectives of young people in care, despite growing commitments to participation and codesign. These types of silencing risk reproducing the very systemic disempowerment that young people identify as harmful (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Measurement practices to assess suicide risk also require strengthening. Reliance on single-item assessments, as noted by Emmerich et al. (2024), oversimplifies the complexity of suicidality, obscuring differences between fleeting ideation, persistent self-harm urges, and suicide attempts. Without more nuanced, multidimensional tools, there is a danger that suicide risk in OOHC remains under- or mischaracterised, particularly for marginalised groups.\u003c/p\u003e\u003cp\u003eThe results highlight the significance of intersectional risk. Young people who experience racism, homophobia, or transphobia within OOHC systems carry an additional burden of marginalisation that directly heightens suicidality (\u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e52\u003c/span\u003e). These findings demonstrate that suicide prevention in OOHC is not only trauma-informed but also culturally safe, identity-affirming, and anti-oppressive (\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e). Without such approaches, interventions risk overlooking the cumulative risks faced by minority groups.\u003c/p\u003e\u003cp\u003eThe results highlight the urgent need to embed systems-based, trauma-informed, and relationally driven models of care across OOHC service delivery. Workforce training in evidence-informed programs such as Suicide Alertness for Everyone (safeTALK) training can strengthen suicide literacy, stigma reduction, and crisis response capacity among carers (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e). However, such training should be adapted through co-design with care-experienced young people to ensure relevance. Co-designing suicide prevention programs with youth, specifically tailored to the OOHC context, can foster inclusivity and support empowered self-determination.\u003c/p\u003e\u003cp\u003eThis review demonstrates that suicide prevention in OOHC must be understood within the unique ecology of OOHC, where trauma history, placement instability, and systemic challenges intersect with young people\u0026rsquo;s identities and relationships. The next phase of this research will involve world-caf\u0026eacute; conversations with care-experienced young people to gather their feedback on the results discussed here. Suicide prevention for this group requires authentic youth participation. Only by addressing the specific context of OOHC in partnership with young people can policy, practice, and research meaningfully reduce suicide risk and strengthen protective pathways and interventions.\u003c/p\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003eLimitations\u003c/h2\u003e\u003cp\u003eThis scoping review has several limitations. The evidence base is relatively small and methodologically diverse, spanning qualitative, quantitative, and mixed methods designs, which limits comparability and generalisability across studies. Differences between care settings (e.g., foster, kinship, and residential care) further constrain the extent to which findings can be applied uniformly. Consistent with the scoping review methodology, we did not conduct a formal quality appraisal of the included studies, which may have affected the strength of the conclusions. Finally, the voices of young people with lived experience in OOHC remain largely absent, both within the literature and in this review.\u003c/p\u003e\u003c/div\u003e"},{"header":"Conclusion","content":"\u003cp\u003eThis scoping review synthesised risk and protective factors, as well as interventions, for suicide prevention among young people in out-of-home care. The results highlight the intersecting influence of trauma histories, placement instability, mental health comorbidities, and systemic challenges, while demonstrating the protective value of relational safety, culturally affirming support, and caregiver connection. Despite emerging evidence of promising interventions, substantial gaps remain, particularly in the inclusion of youth voice and the co-design of suicide prevention strategies. Policy and practice must prioritise structural reform, professional development for carers, and the adaptation of existing suicide prevention frameworks to the unique context of OOHC. Future research should partner directly with care-experienced young people to ensure interventions are responsive, effective, and capable of reducing suicide risk while strengthening protective pathways.\u003c/p\u003e"},{"header":"Declarations","content":"\u003ch2\u003eFunding\u003c/h2\u003e\u003cp\u003eThe authors received no financial support for the research, authorship, or publication of this article.\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eThe conception and design of this work, acquisition of data, analysis and preparation of each draft have been the responsibility of all authors: Corina Modderman (lead), Maria Veresova and Laura Hemming.\u003c/p\u003e\u003ch2\u003eAcknowledgement\u003c/h2\u003e\u003cp\u003eThis study was developed in partnership with welfare agencies in regional Australia. We thank them for their advice.\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eNo specific data set is provided. All data relevant to the study are included in the article.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec16\" class=\"Section2\"\u003e\u003ch2\u003eContributors\u003c/h2\u003e\u003cp\u003eThe conception and design of this work, acquisition of data, analysis and preparation of each draft have been the responsibility of all authors: Corina Modderman (lead), Maria Veresova and Laura Hemming.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eEthics statements\u003c/h2\u003e\u003cp\u003eNot applicable.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eEthics approval\u003c/h2\u003e\u003cp\u003eGiven the use of published literature for this scoping review, ethics approval or oversight was not required.\u003c/p\u003e\u003c/div\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eEvans R, Boffey M, MacDonald S, Noyes J, Melendez-Torres G, Morgan HE, et al. 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Ann Intern Med. 2018;169(7):467\u0026ndash;73.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMcKinstry C, Brown T, Gustafsson L. Scoping reviews in occupational therapy: The what, why, and how to. Aust Occup Ther J. 2014;61(2):58\u0026ndash;66.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRouski C, Knowles SF, Sellwood W, Hodge S. The quest for genuine care: a qualitative study of the experiences of young people who self-harm in residential care. Clin Child Psychol Psychiatry. 2021;26(2):418\u0026ndash;29.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWadman R, Armstrong M, Clarke D, Harroe C, Majumder P, Sayal K, et al. Experience of self-harm and its treatment in looked-after young people: an interpretative phenomenological analysis. Archives suicide Res. 2018;22(3):365\u0026ndash;79.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eWadman R, Clarke D, Sayal K, Armstrong M, Harroe C, Majumder P, et al. A sequence analysis of patterns in self-harm in young people with and without experience of being looked after in care. Br J Clin Psychol. 2017;56(4):388\u0026ndash;407.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEvans RE. Survival, signaling, and security: Foster carers\u0026rsquo; and residential carers\u0026rsquo; accounts of self-harming practices among children and young people in care. Qual Health Res. 2018;28(6):939\u0026ndash;49.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHolland J, Sayal K, Berry A, Sawyer C, Majumder P, Vostanis P, et al. What do young people who Self-Harm find helpful? A comparative study of young people with and without experience of being looked after in care. Child Adolesc Mental Health. 2020;25(3):157\u0026ndash;64.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eBonet C, Palma C, Santos GG. Effectiveness of emotional intelligence therapy on suicide risk among adolescents in residential care. Int J Psychol Psychol therapy. 2020;20(1):61\u0026ndash;74.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003e\u0026Aacute;guila-Otero A, Bravo A, Santos I, Del Valle J. Addressing the most damaged adolescents in the child protection system: An analysis of the profiles of young people in therapeutic residential care. Child Youth Serv Rev. 2020;112:104923.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eMuela A, Balluerka N, Sansinenea E, Machimbarrena JM, Garc\u0026iacute;a-Ormaza J, Ibarretxe N, et al. A social-emotional learning program for suicide prevention through animal-assisted intervention. Animals. 2021;11(12):3375.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEmmerich OLM, Wagner B, Heinrichs N, van Noort BM. Lifetime victimization experiences, depressiveness, suicidality, and feelings of loneliness in youth in care. Child Abuse Negl. 2024;154:106870.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eEadie K. Evolve Therapeutic Services: Outcomes for children and young people in out-of-home care with complex behavioural and mental health problems. Child Australia. 2017;42(4):277\u0026ndash;84.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHerrman H, Harvey C, Humphreys C, Halperin S, Murray L, Moeller-Saxone K. Supporting carers of vulnerable young people living in out-of-home care: the Ripple project. L'information psychiatrique. 2017;93(1):43\u0026ndash;50.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eHaggerty KP, Barkan SE, Caouette JD, Skinner ML, Hanson KG. Family, mental health, and placement outcomes of a low-cost preventive intervention for youth in foster care. Child Youth Serv Rev. 2023;150:106973.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eDuppong Hurley K, Wheaton RL, Mason WA, Schnoes CJ, Epstein MH. Exploring suicide risk history among youth in residential care. Residential Treat Child Youth. 2014;31(4):316\u0026ndash;27.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003ePrince DM, Ray-Novak M, Tossone K, Peterson E, Gillani B, Mintz L. Psychological comorbidities and suicidality in sexual and gender minority foster youth. Child Youth Serv Rev. 2024;156:107379.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eRuff SC, Aguilar RM, Clausen JM. An exploratory study of mental health interventions with infants and young children in foster care. J Family Social Work. 2016;19(3):184\u0026ndash;98.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShim-Pelayo H, De Pedro KT. The role of school climate in rates of depression and suicidal ideation among school-attending foster youth in California public schools. Child Youth Serv Rev. 2018;88:149\u0026ndash;55.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eTaussig HN, Harpin SB, Maguire SA. Suicidality among preadolescent maltreated children in foster care. Child Maltreat. 2014;19(1):17\u0026ndash;26.\u003c/span\u003e\u003c/li\u003e\u003cli\u003e\u003cspan\u003eShim M. Do Organisational Culture and Climate Really Matter for Employee Turnover in Child Welfare Agencies? Br J Social Work. 2014;44(3):542\u0026ndash;58.\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"},{"header":"Tables","content":"\u003cp\u003eTable 2 is available in the Supplementary Files section.\u003c/p\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"","lastPublishedDoi":"10.21203/rs.3.rs-7531546/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-7531546/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eIntroduction\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eYoung people in out-of-home care (OOHC) experience disproportionately high rates of suicide and self-harm, yet suicide prevention remains underdeveloped within child protection systems. This scoping review synthesises international peer-reviewed literature and relevant Australian gray literature from the past decade to identify risk factors, protective factors, and interventions associated with suicidality among care-experienced young people.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThis review was guided by the PRISMA-ScR guidelines and followed Arksey and O’Malley’s five-step framework. With the support of a research librarian, a search strategy was developed to capture both peer-reviewed and gray literature. Four electronic databases (Medline, CINAHL, PsycINFO, and ProQuest) were searched via carefully selected keywords, covering publications from 2014 to February 2025.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeventeen studies met the inclusion criteria and spanned diverse methodologies and geographic contexts. The key risk factors included a history of trauma, placement instability, mental health comorbidities, and systemic failure in OOHC. Protective factors centred on relational safety, emotional regulation, and culturally affirming support. Interventions ranged from high-intensity therapeutic models to low-intensity relational programs, with promising outcomes linked to caregiver connection and trauma-informed practice.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusion\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe findings demonstrate the need for gender-sensitive, relationally driven approaches and more robust multi-item assessment tools. This review highlights critical gaps in youth voice inclusion and calls for codesigned interventions with care-experienced young people. The implications for policy and practice include strengthening professional development for carers and adapting existing suicide prevention frameworks to the OOHC context.\u003c/p\u003e","manuscriptTitle":"Suicide risk, protective factors, and interventions for young people in out-of-home care: A scoping review","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-01 10:11:37","doi":"10.21203/rs.3.rs-7531546/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"decision","content":"Revision requested","date":"2025-12-29T06:21:40+00:00","index":"","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-12-26T04:43:42+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317265192787825260102332559523762074648","date":"2025-12-14T01:24:32+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-11-02T14:31:53+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"317265192787825260102332559523762074648","date":"2025-10-06T07:09:34+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"178824570854939625313216397927896140021","date":"2025-09-25T06:07:56+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-09-21T03:01:47+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-09-18T08:21:32+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-09-18T08:21:10+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-09-04T03:12:52+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"dbb28e6d-cbcc-461d-8013-64b2cc6213c5","owner":[],"postedDate":"October 1st, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"published-in-journal","subjectAreas":[],"tags":[],"updatedAt":"2026-03-02T16:09:27+00:00","versionOfRecord":{"articleIdentity":"rs-7531546","link":"https://doi.org/10.1186/s12887-026-06675-z","journal":{"identity":"bmc-pediatrics","isVorOnly":false,"title":"BMC Pediatrics"},"publishedOn":"2026-02-28 15:59:14","publishedOnDateReadable":"February 28th, 2026"},"versionCreatedAt":"2025-10-01 10:11:37","video":"","vorDoi":"10.1186/s12887-026-06675-z","vorDoiUrl":"https://doi.org/10.1186/s12887-026-06675-z","workflowStages":[]},"version":"v1","identity":"rs-7531546","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-7531546","identity":"rs-7531546","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}