TRANSFERABILITY OF TRANSFERABILITY OF INTERVENTIONS ACROSS BORDERSINTERVENTIONS ACROSS BORDERS

Family Group Conferencing Family Group Conferencing and other examplesand other examples

Knut SundellNational Board of Health and Welfare

Sweden

Family Group Conference Family Group Conference (Family group decision making)(Family group decision making)

First used in New Zealand with indigenous Maori families

Later in Australia, UK, USA, Canada, Norway, Sweden, Israel...

Basic premises of the FGC modelBasic premises of the FGC model

Families have the right to be involved in decisions about their child

Solutions found within the family are better than those imposed by professionals

Families are more motivated to seek lasting solutions than professionals

Sensitive information is included into the decision making

FGC´s initiate better family functioning by bringing family members together who have lost touch and restoring legitimate parental authority

Basic Basic principlesprinciples

CPA assess risk, extended family suggests support

Extended family = kin, friends, neighbors

Extended family meet in private to develop a protection plan

CPA should accept the plan unless it place the child at risk of significant harm

Research is Research is limitedlimited

Mainly process studies

Few follow-up studies

Weak designs (no direct comparisons)

Unrepresentative samples

The Swedish FGC outcome studyThe Swedish FGC outcome study

1996 – 1999

Involved 10 Swedish local authorities

All FGCs during one year (97 children)

Compared to a random sample of traditional investigations (142 children)

Several qualitative / quantitative measures

36 months follow-up

Immediate outcomesImmediate outcomes

Family members attended the meetings

Professionals did not interfere

Families spent an average of 160 minutes in ”private family time”

All families agreed on a plan

Family plans indicate the inclusion of sensitive information

All plans were accepted by the CPS

Family members felt empowered

So far a success

HypothesesHypotheses

Decrease the risk for referrals

Reduce the risk of repeated neglect/abuse

More reports by the extended family

Out-of-home placement with kin

Increase the possibility of closing a case

Substantiated reports after index Substantiated reports after index investigation investigation (cumulative %)(cumulative %)

0

20

40

60

80

100

6 12 18 24 30 36

Months after closure of index investigation

%

FGCTAU

Service provisionService provision

0

20

40

60

80

100

6 12 18 24 30 36Months after closure of index investigation

%

TAU

FGC

Children in Foster CareChildren in Foster Care

0

10

20

30

40

50

6 12 18 24 30Months after closure of index investigation

%

TAUFGC

Reports of Abuse and Neglect Reports of Abuse and Neglect during follow-upduring follow-up

0

20

40

60

80

100

Neglect Abuse

TAU FGC

Reports by the extended family Reports by the extended family Placement with kinPlacement with kin

0

20

40

60

80

100

Reports by ext.family

Placement with kin

TAU FGC

The differences diminished – FGC accounted for 0–7 %

In the worst case it might be harmful

Similar to other outcome studies (e.g., Weigensberg et. al., 2009)

Controlling for initial Controlling for initial differencesdifferences

The FGC children had more The FGC children had more serious problems at the startserious problems at the start

WHY?WHY?

The FGC model is a primarily a model for selecting appropriate services– not effective treatments. Without the latter it does not make a difference

FGC does not empower families in the long run

FGC is only appropriate in specific cultures (e.g., indigenous families)

WHAT MAKES TREATMENTS

TRANSFERABLE FROM ONE

CONTEXT TO ANOTHER?

PREVENTING HEAVY ALCOHOL USE IN ADOLESCENTS (Koutakis et al, 2008; Koning et al, 2009)

Swedish intervention: during parent meetings in schools, parents are urged to maintain strict attitudes against youth alcohol use.

2,5 years follow up = decrease drunkenness (.35) and delinquency (.38).

Implemented in the Netherlands without effects.

Parents may be less effective in deferring the onset of alcohol use in countries with a lower legal drinking age and more lenient alcohol policies (NL “especially poor on restricting alcohol availability”).

TREATMENT OF ANTI-SOCIAL BEHAVIOR IN ADOLESCENTS (Sundell et al, 2008)

Multisystemic therapy (MST) – effective in USA

Transported to Sweden in 2004

Compared to Treatment-As-Usual in 27 local authorities

Youth decreased their problem behavior and improved social skills and family relations

None of the improvements were statistically different between the groups

Arguments against transportability

1 Different population-Youth symptomatology is higher or lower

2 The treatment is less potent than in the original context-Program standards are compromised (e.g., lower / higher caseloads)

-Poor fidelity

3 TAU is more potent then in the original context-Fewer iatrogenic interventions-Proactive family service orientation

4 Sociodemografic context is a moderatorLow prevalence of illicit drug consumptionLow prevalence of delinquencyLow rate of poverty, teenage pregnancy et cetera

Mental health (CBCL) change T-scores in evaluations of MST (6-12 month follow-

up)

0

4

8

12

Sundell et al(2008)

Ogden &Halliday-Boykins(2004)

Henggeler etal (2006)

Henggeler etal (2006) -cont man

Rowland et al(2005) -external

Rowland et al(2005) -internal

MST TAU

Arguments against transportability

1 Different population- Youth symptomatology is higher or lower

2 The treatment is less potent than in the original context- Program standards are compromised (e.g., low / high caseloads) - Poor fidelity

3 TAU is more potent than in the original context- Fewer iatrogenic interventions- Proactive family service orientation

4 Sociodemografic context is a moderator- Low prevalence of illicit drug consumption, delinquency et cetera- Low rate of poverty- Culture dimensions unsupportive

Cannabis use (life-time) girls aged 15 (ter Bogt et al, 2006)

0

10

20

30

40

50

60

70

80

90

100

Gree

nlan

d

Cana

da

Schw

itzer

land UK

Spai

n

USA

Tjec

kia

Fran

ce

Slov

enia

Holla

nd

Belg

ium

Danm

ark

Germ

any

Italy

Ukra

ine

Irlan

d

Portu

gal

Croa

tia

Aust

ria

Polen

Estlo

nia

Hung

ary

Finlan

d

Russ

ia

Leth

uania

Swed

en

Lita

uen

Isra

el

Malta

Gree

ce

Mak

edon

ia

%

Cannabis use (life-time) boys aged 15 (ter Bogt et al, 2006)

0

10

20

30

40

50

60

70

80

90

100

Gree

nlan

d

Cana

da

Schw

itzer

land UK

Spai

n

USA

Tjec

kia

Fran

ce

Slov

enia

Holla

nd

Belg

ium

Danm

ark

Germ

any

Italy

Ukra

ine

Irlan

d

Portu

gal

Croa

tia

Aust

ria

Polen

Estlo

nia

Hung

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Finlan

d

Russ

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Leth

uania

Swed

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Lita

uen

Isra

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Malta

Gree

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Mak

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%

Hofstede’s Cultural Dimensions Power distance between members Power distance between members is the extent to which the less powerful members of organizations and institutions (like the family) accept and expect that power is distributed unequally.

Individualism – collectivism. Individualism – collectivism. In individualist societies everyone is expected to look after him/herself and the immediate family. In collectivist societies people are integrated into strong, cohesive in-groups, often extended families which continue protecting them.

Differentiation of gender roles Differentiation of gender roles refers to the distribution of roles between the genders.

Degree of uncertainty avoidance Degree of uncertainty avoidance deals with a society's tolerance for uncertainty and ambiguity. It indicates to what extent individuals feel uncomfortable or comfortable in novel situations.

Hofstede’s Cultural Dimensions (Israel)

0

10

20

30

40

50

60

70

80

90

100

Powerdistance

Individualism Masculinity Uncertaintyavoidance

%

JapanJapan

SwedenSweden

USUSUKUK

CONCLUSIONSCONCLUSIONS

1. Do controlled outcome studies

2. If you have not got any outcome studies, use international evidence (be aware of the risk…)

3. If there is no international evidence, use theoretically sound treatments (be even more aware of the risk…)

Todays situation

Our services arenot tested scientifically.

But think positive – you will get a brand new and untested treatment

Must also

be avoided