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TRANSFERABILITY OF INTERVENTIONS ACROSS BORDERS Family Group Conferencing and other examples Knut Sundell National TRANSFERABILITY OF INTERVENTIONS ACROSS BORDERS Family Group Conferencing and other examples Knut Sundell National Board of Health and Welfare Sweden

Family Group Conference (Family group decision making) First used in New Zealand with indigenous Family Group Conference (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 model Families have the right to be involved in Basic 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 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 principles CPA assess risk, extended family suggests support Extended family = kin, friends, Basic principles 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 limited Mainly process studies Few follow-up studies Weak designs (no direct comparisons) Research is limited Mainly process studies Few follow-up studies Weak designs (no direct comparisons) Unrepresentative samples

The Swedish FGC outcome study 1996 – 1999 Involved 10 Swedish local authorities All The 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 outcomes Family members attended the meetings Professionals did not interfere Families spent an Immediate 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 So far a sensitive information All plans were accepted by the success CPS Family members felt empowered

Hypotheses Decrease the risk for referrals Reduce the risk of repeated neglect/abuse More reports Hypotheses 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 investigation (cumulative %) Substantiated reports after index investigation (cumulative %)

Service provision Service provision

Children in Foster Care Children in Foster Care

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

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

The FGC children had more Controlling for initial differences serious problems at the start The FGC children had more Controlling for initial differences serious problems at the start 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)

WHY? The FGC model is a primarily a model for selecting appropriate services– not 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? WHAT MAKES TREATMENTS TRANSFERABLE FROM ONE CONTEXT TO ANOTHER?

PREVENTING HEAVY ALCOHOL USE IN ADOLESCENTS (Koutakis et al, 2008; Koning et al, 2009) 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) – 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 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 moderator Low prevalence of illicit drug consumption Low prevalence of delinquency Low rate of poverty, teenage pregnancy et cetera

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

Arguments against transportability 1 Different population - Youth symptomatology is higher or lower 2 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) Cannabis use (life-time) girls aged 15 (ter Bogt et al, 2006)

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

Hofstede’s Cultural Dimensions Power distance between members is the extent to which the less Hofstede’s Cultural Dimensions 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. In individualist societies everyone is expected to look after him/herself and the immediate family. In collectivist societies people are integrated into strong, cohesive ingroups, often extended families which continue protecting them. Differentiation of gender roles refers to the distribution of roles between the genders. 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) Japan US UK Sweden Hofstede’s Cultural Dimensions (Israel) Japan US UK Sweden

CONCLUSIONS 1. Do controlled outcome studies 2. If you have not got any outcome CONCLUSIONS 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…)

Our services are not tested scientifically. But think positive – you will get a Our services are not tested scientifically. But think positive – you will get a brand new and untested treatment u ion at od T sit s ay

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