Introduction

The mental health and well-being of young people with out-of-home care (OOHC) experience is a growing public health and social care concern [1, 2]. Throughout this review, the term “young people” is used to refer to children and youth up to the age of 21, consistent with common usage in the international OOHC and suicide prevention literature. Compared with their non-care peers, young people in OOHC are more than three times as likely to attempt suicide [3]. 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 [4, 5]. 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 [6, 7]. 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 [8]. Rates of suicidal ideation and attempts are particularly high for young people who are transitioning out of OOHC, as they experience complex and stressful life events with limited social support [9]. 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 [10]. 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 [11]. Framing suicide solely as a mental health issue risks underestimating the broader structural and relational contexts that contribute to despair and disconnection.

Australia’s statutory child protection system is responsible for protecting and supporting young people who are experiencing or at risk of harm from their parents [12], which may include placement in OOHC. These services may be referred to as “social care” or “child welfare” in other countries [13]. 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 [14, 15].Young people with experiences in OOHC are particularly vulnerable and face an elevated risk of poor mental health outcomes, including suicide [3, 16,17,18,19,20].

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 [7, 21]. 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 [22].

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 [23]. 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 [23, 24]. The Lost, Not Forgotten report [23] 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.

Recent literature on this topic has suggested that prevention initiatives should target risk factors and strengthen protective factors for suicide risk [8]. As such, an updated synthesis of risk and protective factors for suicide in the OOHC context is needed to inform future prevention efforts. Furthermore, earlier research into health system integration for young people in OOHC identified serious shortcomings in access to and coordination of health care [16,17,18]. Notably, while general health needs were already poorly met, mental health needs such as addressing suicidal ideation, emerged as even more profoundly neglected, often rendered invisible within service planning and delivery in child protection and health systems [16, 17]. Thus, suicide prevention that is informed by risk and protective factors and well-integrated within the service systems is crucial. The present review aims to provide an overview of risk and protective factors, as well as examine existing interventions, through a system-based lens.

In addition to international peer-reviewed literature, we also examined relevant gray literature relevant to the Australian landscape to contextualise our findings. 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 [25, 26]. “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 [27, 28]. “Interventions” are described as therapeutic approaches and carer-focused training designed to foster responsive, supportive environments for vulnerable young people. 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 and Davis et al. 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 [29,30,31]. The PRISMA-ScR (Preferred Reporting Items for Systematic reviews and Meta-Analyses extension for Scoping Reviews) [32] 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 young people in OOHC?

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
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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 young people 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 [29] 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. The quality of included articles was assessed using the Quality Assessment with Diverse Studies (QuADS) tool [33]. This tool was selected because it is specifically designed to appraise studies employing diverse methodological approaches. The maximum possible score is 39.

Fig. 1
Fig. 1
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PRISMA flowchart

Results

Fourteen peer-reviewed articles published between 2014 and February 2025 met the inclusion criteria. Gray literature informed contextual understanding but did not meet inclusion criteria for formal synthesis. Handsearching the reference lists of two Australian research briefs [22, 24] yielded three additional studies relevant to the current review, and all included articles are presented in Table 2 in alphabetical order.

Table 2 Included studies
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Quality assessment

Overall, the included studies were of medium–high quality, with scores ranging from 20 to 33 out of a possible 39 using the QuADS tool. Scores in the lower range (around 20) generally reflected studies that met core criteria (for example, appropriate design and analytic approach) but provided limited detail regarding stakeholder involvement, reflexivity, or justification of methodological choices. Higher-scoring studies (above 30) demonstrated greater transparency and stronger methodological justification across domains. Although variation in reporting and methodological detail was evident, all studies met key indicators of methodological rigor. The lowest-scoring parameter was the involvement of a stakeholder or advisory group in research design or conduct; only 6 of 17 studies reported this.

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 [34]. 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 [35,36,37,38,39], three were from Spain [40,41,42], one was from Germany [43], two were from Australia [44, 45], and six were from North America [46,47,48,49,50,51]. The studies span from 2014 to 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 [37, 39, 41, 50, 51]. Two studies used a pre–post intervention design to assess outcomes before and after service delivery [44, 49]. One study was a randomised controlled trial [46], whereas two studies used nonrandomised experimental designs [40, 43]. Seven studies employed qualitative methods, including two that used interpretative phenomenological analysis to explore lived experience and meaning-making [35, 36] and two that undertook interviews and focus groups [3, 45]. An additional three studies adopted a mixed-methods approach, combining qualitative and quantitative data [42, 47, 48].

Type of OOHC

The most common setting was residential care, with a number of studies focusing solely on this population [35, 40,41,42, 47], whereas others combined cohorts in residential care with foster and kinship care [36, 38, 43,44,45, 52]. Foster care has also been widely represented, with studies examining both general foster care populations [46, 49, 51] and specific subgroups such as sexual and gender minority foster youth [48]. Two studies did not specify the type of OOHC [37, 39].

Participants

Most study focused on young people in care over the age of 11 [35,36,37, 39,40,41,42,43, 45, 47, 48, 50], one study included 4 to 17 years old [44], two under 11 years old [49, 51], and two were carer-focused [38, 46]. 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 young people’s perspectives [35, 39, 45]. Three studies included some input through open-ended questions or interviews [36, 42, 48].

Risk/protective/intervention

Most papers have reported on risk factors [35,36,37,38,39,40,41, 43, 46,47,48,49,50,51]. Nine studies reported on protective factors [35, 36, 39, 42,43,44,45, 48,49,50], and six reported specific interventions [40, 42, 44,45,46, 49]. 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 [49, 51], placement instability, and mental health comorbidities such as depression and emotional dysregulation [40, 47]. Gender plays a significant role, with girls and gender-diverse young people showing disproportionately high rates of suicidality and victimisation [41, 43, 48]. Other risk factors include hopelessness, self-hatred, impulsivity [37], feelings of loneliness, and a lack of emotional connection with caregivers or staff [35, 43]. 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 [36, 39].

One study mentioned the limitations of traditional assessment tools, which may fail to capture the complexity of suicidality [43], 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 [38]. 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 [48].

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 [35, 36, 45]. 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 [39]. Relational and authentic care in residential settings emerged as a buffer against self-harm [35].

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 [43]. Strong peer and teacher connections in a positive school environment are associated with reduced rates of depression and suicidal ideation [50]. 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 [48].

A smaller number of intervention studies highlighted protective gains. For example, reductions in self-injury following trauma-integrated therapeutic service [44] and emotional intelligence therapy reduce hopelessness and suicidal ideation [40]. Animal-assisted interventions enhance coping strategies and help-seeking among young people in residential care [42], 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 [49].

Interventions

Six of the included studies explicitly evaluated or described interventions aimed at reducing suicidality improving mental health outcomes among young people in OOHC [40, 42, 44,45,46, 49]. 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 reduction in nonaccidental self-injury (from 17.5% to 7.2%) [44]. 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 [45]. Emotional intelligence therapy (EIT) was trialled with young people in residential care and demonstrated reductions in hopelessness, emotional dysregulation, and suicidal ideation [40]. In addition, a pilot study of OverCome-AAI, an animal-assisted intervention, revealed enhanced coping strategies, help-seeking, and reduced self-harm behaviours among young people in residential care [42]. Home Within, a volunteer-driven model provides long-term, relationship-based psychotherapy to foster children, resulting in reductions in depression and self-harm [49]. 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 [46].

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 included studies were highly heterogenous, dominated by cross-sectional studies, with only one randomised controlled trial alongside qualitative and mixed-methods studies. Accordingly, this scoping review aimed to map the breadth of available research rather than to aggregate effect sizes, as doing so would risk oversimplifying important contextual and methodological difference.

The results demonstrate that suicidality in the OOHC population cannot be understood solely through an individualised clinical lens. Rather, risks are cumulative and results suggest these arise from a history of trauma, placements not delivering continuity of care, and OOHC systems that are experienced as unhelpful by young people [36, 39]. Girls and gender-diverse young people appear particularly vulnerable [41, 43, 48], 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. Most studies prioritised the identification of risk, with fewer examining protective processes, particularly those operating at relational, cultural, or systemic levels. Where protective factors were described quantitatively, they included school connection and positive school climate [50], reduced loneliness in family-based care settings [43], emotional regulation and emotional intelligence skills [40], affirming care and identity support for sexual and gender minority youth [48], and improved help-seeking following structured interventions [42]. Qualitative studies consistently emphasised the importance of relational safety and care, described as the presence of caregivers, caseworkers, and peers who are trustworthy, emotionally attuned, and willing to sustain relationships despite distress and behavioural challenges [35, 36, 39, 45]. In these studies, protective factors were not measured as discrete variables but were inferred from young people’s accounts of feeling emotionally safe, heard, understood, and able to belong within care environments.

Taken together, these quantitative and qualitative findings suggest that relational safety and care in OOHC operates both as a direct protective factor and as a foundation for other protective processes, including the development of coping skills, identity affirmation, and help-seeking behaviours. This interpretation extends beyond any single study and represents a synthesis of patterns observed across the evidence base, suggesting 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, including trauma-integrated therapeutic models [44], carer capacity-building initiatives [45], emotional skills training [40], animal-assisted interventions [42], and long-term psychotherapy [49] 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 [46], evaluated through a randomised controlled trial, produced generally modest effects on risk and for several mental health outcomes demonstrated positive trends, This suggests that programs offering structured opportunities for caregiver–young person interaction and fostering a sense of family belonging can have meaningful, cost-effective impacts, even when delivered at low intensity. However, the evidence base for interventions included in the review remains limited. Few programs have been rigorously evaluated at scale, and there is little cross-contextual replication, which constrains the generalisability of findings.

Young people’s voices remain marginal within this scoping review. Only three studies [35, 39, 45] explicitly included the perspectives of young people in care, despite growing commitments to participation and codesign. Given the strong emphasis on youth voice and co-design in suicide prevention for young people in OOHC, this represents an important gap in the current evidence base. Greater integration of lived experience perspectives in future research is needed to enhance the relevance and responsiveness of interventions. These types of silencing risk reproducing the very systemic disempowerment that young people identify as harmful [11]. Measurement practices to assess suicide risk also require strengthening. Reliance on single-item assessments, as noted by Emmerich et al. [43] 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 may carry an additional burden of marginalisation that directly heightens suicidality [48]. These findings demonstrate that suicide prevention in OOHC is not only trauma-informed but also culturally safe, identity-affirming, and anti-oppressive [8]. 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 [14]. However, such training should be adapted through co-design with care-experienced young people to ensure relevance. Co-designing suicide prevention programs with young people, 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. 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 OOHC. 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 young people’s 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.