[Sweden] Vinnerljung, B. (2014). Making a difference? Education and health of children in...
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Making a difference? Education and health
of children in out-of-home care
EUSARF/Copenhagen, Sept 4, 2014
Bo Vinnerljung, professor Dept of Social Work, Stockholm University
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Nordic values about children and parenting
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Every child should have ’a fair go’
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Good parents help their children with school/education
Good parents take care of their children’s health
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Out of home care: In loco parentis
• When the state assumes parental responsibilities, the state should act as a reasonably good parent
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Does school matter for all children
• .. in a longitudinal perspective?
• Yes, school performance is a powerful predictor of future psychosocial problems
• …regardless of socioeconomic background/ class, at least in Sweden
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Suicide attempts after age 16 (n=930.000, born 1973-1982)
02468
10121416
Manualworkers,unskilled
Manuelworkers,skilled
Non-manual
employees,low/middle
Non-manuel
employees,high
Other
Per cent Women
02468
10121416
Manualworkers,unskilled
Manuelworkers,skilled
Non-manual
employees,low/middle
Non-manuel
employees,high
Other
LowLow/middleMiddle/highHigh
Per Men
SES (socio-economic status) for parents at age 10 Vinnerljung et al, 2010
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Drug abuse after age 20
0
2
4
6
8
10
12
14
Low Low/middle
Per cent Women
Others Unskilled Skilled, Low High Manual Non-manual
0
2
4
6
8
10
12
14
Middle/high High
Per cent Men
Others Unskilled Skilled, Low High Manual Non-manual
SES for parents at age 10
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Poor school performance has links to…
• Low cognitive capacity (0.65 with IQ at conscription)
• Other individual traits, eg. working memory
• Behavioral problems • Mental health problems
• Poor support from home, adverse childhood etc • School related factors, poor peer status in school
Gustafsson et al 2010
Not a one-way street
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This is bad news for
children in out-of-home care?
They do poorly in school
Social services do a poor job with their school/education
School failure is added to other risk factors
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No/incomplete/low grades Above average
Boys Normal group 22% 41% In home care before teens 55% 15% Children from welfare families 57% 13% Grown up in foster care 60% 11%
Girls Normal group 11% 60% In home care before teens 37% 27% Children from welfare families 40% 25% Grown up in foster care 43% 23% Grown up in foster care: > 5 years in care (M= 11), left care after age 17. n=7.000 All persons with disability pension at age 23 excluded from the analyses.
Berlin et al, 2011
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Why poor school performance?
• Low cognitive ability is not the explanation.
• Over-representation of other problems, eg. poor working memory
• Instability during childhood/school years
• Pessimistic expectations from social workers, teachers and foster parents (Sweden, Denmark, UK).
• No statistical links to parental psychopathology
• For children in long term care – no links with age at entry into care or length of care
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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)
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Children growing up in foster care have high risks
(in comparisons with other children) for future… • Suicide RR = 6.4 • Suicide attempts RR = 6.2 • Serious mental health problems RR = 5.0 • Drug abuse RR = 6.8 • Alcohol abuse RR = 4.9 • Serious criminality RR = 7.5 • Teenage parenthood RR = 3.8 • Welfare dependency RR = 9.8
(adjusted for sex and birth year)
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1
2
3
4
5
6
7
Normal Adj for sexand birth
year
Also forschool failure
RR
Long term foster care: Drug abuse after age 20
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Analyses of foster children only • School failure: the only substantial risk factor for all
negative outcomes • Abscence of school failure: the only strong factor that
predicted good outcomes – regardless of how ”good outcome” was defined
• Parental pathology no/weak association with outcomes • No associations between age at placement or time in care
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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.
• The good news: school performance is a variable risk factor. (in contrast to sex, genes, experiences from early childhood etc)
• If we want to improve foster children’s life chances, then we have to help them do better in school
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International scoping review: What works?
• 11 studies during 35 years…… • Positive results : 9 of 11
– tutoring projects – Literacy training, eg. Paired Reading – Letterbox Club in UK – SkolFam in Sweden
• Alla 9 successful projects improved literacy • 7 tried to improve numeracy skills - 3 did, 2 mixed results, 2 failed
Forsman & Vinnerljung, 2012
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Two Swedish trials • Around 50 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
• Done by a psychologist and a special education teacher.
• Re-tests after 24 months to evaluate the program
Tideman et al, 2011, Tordön et al, 2014
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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.
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Results after two years
• Substantially improved scores on WISC-tests • Substantially improved literacy skills
• Substantial improvements of numeracy skills in
the second trial. ”Re-start” in math with better testing methods + working memory training
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What to do? • A minimum standard for school/education
– Assessment of literacy/numeracy skills for all children – Identify knowledge gaps – Provide literacy and numeracy training
• Also important and effective – Pre-school literacy/numeracy training – Selection/training of foster parents – Cognitive tests for assessing potential - but….
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Results from cognitive tests (IQ) of children in out-of-home care are often instable
Tend to change over time after interventions
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Health
• Children in out-of-home care are a high-risk group for somatic health problems – Before entering care – In care – After exit from care
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Health control for 120 children at care entry (regional study)
Number of referrals
• General practioners 30 • Eyes 8 • Ears/nose/throat 11 • Speech theraphy 1 • Surgery 1 • Orthopaedist 3 • Pediatrician 19 • Child psychiatry 12 • Dermatologist 7 • Dental surgery 6 • Gynaecologist 1
• total 99 Kling & Nilsson, in print
Every second child - at least one referral
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• 75% had a history of severe health problems
• Low rates of immunisation
• Many had untreated and/or undetected health problems - hearing, vision, allergy problems, cronic pain etc
• Every second child age 7-17 had dental decay that
required immediate treatment
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Health: Is it possible to make a difference? (Kessler, Pecora et al, 2008)
• Two groups of matched foster children 1. Casey Family Program (n=111) 2. Ordinary state out-of-home care (n=368)
• Follow-up in young adult age • Casey-alumni lower prevalence of serious somatic
and mental health problems
• NNT for somatic health problems =5
• NNT for mental health problems = 3
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Somatic health – what works?
• Health assessment for all children at care entry • Systematic monitoring of health while in care
• Strict coordination routines
child welfare/health care providers
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Somatic health assessment
• Retrieve files with medical history (anamnesis) • Std test for well-being (Kidscreen) before doctor´s visit • Check vision, hearing, length/weight (BMI) • Medical examination, including check for dental decay • Health talk with a doctor (30-60 minutes)
Plan of action (specialist referrals, immunizations etc)
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Cheap insurance against societal neglect
• Health check takes 3-4 hours/child
• One year in out-of-home care = 8 760 hours
• Health check = 0.04%
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A good parent does not say…
• - Health problems? That’s not my responsibility, We have health care and doctors for that….
• - School/learning problems? That’s not my job.
We have schools and teachers for that….
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Want to make a difference for children in out-of-home care?
• Start with their school/education & health
Give them a fair go. It can be done.
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Selected references
• 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.
• 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.
• Gustafsson et al (2010): School, learning and mental health. Stockholm: Kungl Vetenskapsakademin.
• 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.
• Kessler R, Pecora P et al (2008). Effects of enhanced foster care on long-term physical and mental health of foster care alumni. Archives of General Psychiatry, 65, 625-633.
• Pears K, Fisher P, Kim H, Bruce J, Healy C & Yoerger K (2013). Immediate effects of school readiness intervention for children in foster care. Early Education and Development, 24, 771-791.
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• 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.
• Tordön R, Vinnerljung B & Axelsson U (2014). Improving foster children’s school performance. A replication of the Helsingborg study. Adoption & Fostering, 38, 37-48.
• Vinnerljung B, Berlin M & Hjern A (2010) . Skolbetyg, utbildning och risker för ogynnsam utveckling hos barn. In Socialstyrelsen: Social Rapport 2010, kap 7, pp 227-266. Stockholm: Socialstyrelsen.
• 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.
• Vinnerljung B, Tideman E, Sallnäs M & Forsman H (in print). Paired Reading for foster children. Results from a Swedish replication of an English literacy intervention. Adoption & Fostering.
• Zewdu AM (2010). Health related benefits among children in the child welfare system. Norsk Epidemiologi, 20, 77-84.