Don’t forget the basics: School Malmö, September 26, 2013 Bo Vinnerljung, professor Social Work, Stockholm University [email protected] Interdisciplinary research, eg. • • • • • • • Anders Hjern, pediatrics/epidemiology Marie Berlin, sociology Karl Gauffin, public health Emma Björkenstam, epidemiology Eva Tideman, psychology Marie Sallnäs, social work Bo Vinnerljung, social work Anders Hjern Menue • Crash course in epidemiological analysis • Results from national cohort studies based on register data • Results from intervention studies • Relevance for work with anti-social adolescents What is risk? • Increased/reduced probability – for something specific – a relative concept – a quantitative concept For what? Compared to whom/what? How much? • The comparison group has always Relative Risk (RR) = 1 • RR = 2 is 100% more • RR >2-3 are high excess risks (“over-risks”) • Risk does not say anything about “how many” • 3% of all girls in Sweden become mothers before age 20 • 0,75% of all boys become fathers before age 20 • The risk of teenage parenthood is 4 times higher for girls compared to boys (RR = 4) To adjust for background factors (confounders) • “If the distribution of these background factors were the same in the groups that we compare – are there still any excess risks?” • Examples: sex, parental education • Adjustments are done in multivariate analyses: each background factor’s unique association with the outcome (”all other variables being equal”) Nordic National registers • Data bases covering the entire population. Purpose: statistics and research. • Individual data, based on a personal ID-number that follows every resident from birth/immigration to death • Each national register is regulated by law, Strict secrecy rules. • All residents have a right to know the information about them in the national registers but they do have the right to erase information about themselves in the registers. • Registers may be used/linked for research after approval from an ethical board. Data are anonymized - individuals cannot be identified. • No cases of abuse or leaks. Some medical national registers in the Nordic countries Register Denmark Finland Norway Sweden Cause of death 1943 1969 1951 1952 Medical Birth 1973 1987 1967 1973 Hospital discharge 1977 1987 2008 1987 Cancer 1943 1952 1952 1958 Prescribed Drugs 1995 1995 2004 2005 Epidemiology, exploratory research How many? Changes over time? Who? Patterns of care? Care leavers experiences. Prevalence of eg, mental and somatic health problems Longitudinal studies Risk factors, protective factors? Risk mechanisms, mediators, moderators? Clinical trials Does school matter for all children • .. in a longitudinal perspective? • Yes, school performance is a powerful predictor of future psychosocial problems • …regardless of SES (socioeconomic background, class), at least in Sweden Grades: final year of primary school (age 16) • Low/incomplete grades= lowest 1/6 in the country < (M-1 SD) • Compared to all the rest (5/6) Suicide attempts Per cent 16 14 Women 12 10 8 6 4 2 0 Manual workers, unskilled Men Per 16 14 12 10 8 6 4 2 0 Manuel NonNonworkers, manual manuel skilled employees, employees, low/middle high Other Low Low/middle Middle/high High Manual workers, unskilled Manuel NonNonworkers, manual manuel skilled employees, employees, low/middle high Other SES for parents at age 10 Vinnerljung et al, 2010 Links between childhood factors and drug abuse after age 20 • All born in Sweden 1973-88, alive at age 16 • N=1,4 million. Follow-up to 2008 (age 20-35). • Indication of drug abuse – – – – Drug related death or Hospitalization with drug abuse diagnosis (not intox) or Convicted for drug related crime 3% (42.000) Gauffin et al, 2012 Background factor RR (all else being equal) Mother’s SES -- Mother born outside Europa 1,7 Mother single 1,5 Mother a teenage mother -- Mother did not work -- Mother disability pension -- Mother lived on welfare 1,4 Mother serious mental health problems 1,3 Father serious mental health problems -- Mother substance abuse 1,4 Father substance abuse 1,6 Mother substantial criminality 1,3 Father substantial criminality 1,5 Grew up in a city vs in a rural community 1,7 Man (sex) 2,4 No/incomplete/very low school grades at age 16 4,1 Poor grades/school performance have links to eg. • Low cognitive capacity (0.65 with IQ at conscription) • Other individual traits, eg. working memory • Behavioral problems – but this is not a one-way street • Mental health problems • Poor support from home, adverse childhood etc • School related factors, poor peer status in school What does this mean for children in societal care? They do poorly in school Social services do a poor job with their school/education (but not SiS) School failure is added to other risk factors National cohort study/register data • Analyses of datasets with all born 1972-1981. Linking 10 national registers. • Follow-up from age 16 to 2005 (age 24-33) – 930.000 persons, including – 7.000 children that grew up in foster care, average time in care 12 years Vinnerljung et al, 2010; Berlin et al, 2011 No/incomplete/low grades Above average Boys Normal group In home care before teens Children from welfare families Grown up in foster care 22% 55% 57% 60% 41% 15% 13% 11% 11% 37% 40% 43% 60% 27% 25% 23% Girls Normal group In home care before teens Children from welfare families Grown up in foster care Grown up in foster care: > 5 years in care (M= 11 years in care), left care after age 17. All persons with disability pension at age 23 were excluded from the analysis What factors increase the risk for poor grades among foster children? • • • • • • • • Sex/gender Birth year Age at placement Time in care Mother mental health problems Mother substance abuse Father mental health problems Far substance abuse *** -------- Negative expectations... • Results from trials suggest that social workers, teachers and foster parents commonly – underestimate the cognitive capacity of foster children – have pessimistic expectations of school performance • Same results in Danish and British studies Foster children: Five-fold disadvantaged by the care and education system • • • • High risks of school failure Lower grades than peers with same IQ Lower education than peers with same IQ Lower education than peers with same grades • Lower chances of secondary education if they had poor grades (eg. fewer use adult education) Children growing up in foster care have high risks for future… • • • • • • • • Suicide Suicide attempts Serious mental health problems Drug abuse Alcohol abuse Serious criminality Teenage parenthood Welfare dependency RR = 6.4 RR = 6.2 RR = 5.0 RR = 6.8 RR = 4.9 RR = 7.5 RR = 3.8 RR = 9.8 (adjusted for sex and birth year) Long term foster care: Drug abuse after age 20 7 6 RR 5 4 3 2 1 Normal Adj for sex Also for and birth school failure year Long term foster care: serious criminality after age 20 8 7 6 RR 5 4 3 2 1 Normal Adj for sex & Also for birth year school failure Analyses of foster children only • No/low grades the only substantial risk factor for all negative outcomes (except sex) • Parental pathology no/weak association with outcomes • No associations between age at placement or time in care • Abscence of school failure the only strong factor that predicted good outcomes (except gender) – regardless of how ”good outcome” was defined Conclusions • Children who fail at school are a high risk group for future psychosocial problems – regardless of socioeconomic background • School failure seems to be the strongest risk mechanism for foster children’s long term development (same for other children from the social marginal) • A determinant for foster children’s future • The good news: school performance is a variable risk factor . (in contrast to sex, age, genes, experiences from early childhood etc) The Helsingborg trial - SkolFam • 25 foster children age 7-12 were tested with standardized psychological and educational instruments • Results were used to – access available support from school – tailor individual educational support and interventions – advice teachers/schools, foster parents - and the children • This was done by an educational psychologist and a special education teacher. • Re-tests after 24 months to evaluate the program Results after first measurements • Normal cognitive capacity (average lower than peers, same as international adoptees). • 75% were substantially underachieving in school • Large knowledge gaps were common • Most foster parents, social workers and teachers had low/pessimistic expectations on the children’s school performance. • Lots of pseudo-psychological explanations to why the children did poorly in school • Pathologizing of children was common, “amateur diagnoses” Results after 2 years “Clinical knowledge” says that the foster children’s school performance should have deteriorated (larger gaps over time between them and normal population peers) • Wisc IQ Total • Wisc IQ Performance • Wisc IQ Verbal *** ** * • Spelling (DLS) • Reading speed • Word Chains * * * • Magne’s Math diagnosis n.s. (p<0,001) (p<0,01) (p< 0,05) Tideman et al, 2011 Replication in Norrköping 2008-11 • 21 children, two years between tests • Working memory training was added for children with poor numeracy skills • WISC – same results as in Helsingborg • Literacy – similar results to Helsingborg • But Maths…. Tordön et al, submitted Math scores related to working memory training Without WM training With WM training Total Case study – Jens, age 11 At start of intervention: • Personal assistent in school, concentration problems, suspected ADHD, suspected learning disability • IK 70, working memory 62 (WISC) • Maths, stanine 1 • Working memory training • Re-start in math After two years: • IK 86 (+23%) , working memory 99 (+60 %) • Math stanine 5 • No concentration problems • Likes school Paired Reading trial • We trained foster parents to use a special reading tecnique for 80 children age 8-12 • Reading 20 min/day, 3 days/week • 16 weeks (pre-post evaluation, std instruments) • Replication of a English trial Results • The average child increased her/his reading age with almost a year (11 months), after 4 months of Paired Reading ( in England 12 months) • Improved scores on the WISC vocabulary scale Improved Total IQ Interventions younger children + School perform ‒ Anti-soc behavior ‒ Anti-soc behavior + School perform ----------------------------------------------------------------Interventions anti-social adolescents ‒ Anti-soc behavior + School perform + School perform ? Anti-soc behavior Does improved literacy/numeracy skills have a value, even if this is not related to reduced anti-social behavior in the short run? Yes – it increases the chance that youth can benefit from turning points later in life (hypothesis). Turning points • Far more decisive than treatment • Examples: partner, parenthood, getting tired of crime/substance abuse, health concerns, getting a job, religon • Today, inclusion in the labor market usually requires school/education (learning a trade) • The way out,”the escape from disadvantage”. What to do? • A minimum standard for school/education in residential care for anti-social adolsecents • At least… – Assessment of literacy and numeracy skills – Identify knowledge gaps in maths, re-start – Start literacy and numeracy training, high quality programs (evidence based methods). – Cognitive tests for assessing potential - but…. Results from cognitive tests (IQ) of children from the social marginal are often instable, and may change over time References • • • • • • • Jablonska B, Lindberg L, Lindblad F, Rasmussen F, Östberg V & Hjern A (2009) School performance and hospital admissions due to self-inflicted injuries. Int Journal of Epidemiology, 38, 1334-1341. Björkenstam C, Björkenstam E, Ljung R, Vinnerljung B & Tuvblad C (2013). Suicidal behavior among delinquent former child welfare clients. European Child & Adolescent Psychiatry, 22, 349-355. Tideman E, Vinnerljung B, Hintze K & Isaksson AA (2011). Improving foster children’s school achievements: Promising results from a Swedish intensive study. Adoption & Fostering, 35, 44-56. Berlin M, Vinnerljung B & Hjern A (2011). School performance in primary school and psychosocial problems in young adulthood among care leavers from long term foster care. Children and Youth Services Review, 33, 2489-2487. Vinnerljung B & Hjern A (2011). Cognitive, educational and self-support outcomes of long-term foster care versus adoption. A Swedish national cohort study. Children and Youth Services Review, 33, 1902-1910. Forsman H & Vinnerljung B (2012) Interventions aiming to improve school achievements of children in out-of-home care: a scoping review. Children and Youth Services Review. 34, 1084-1091. Gauffin K, Vinnerljung B, Fridell M, Hesse M & Hjern A (2013). Childhood socioeconomic status, school failure, and drug abuse – a Swedish national cohort study. Addiction, 108, 1441-1449.