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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
ary
Finlan
d
Russ
ia
Leth
uania
Swed
en
Lita
uen
Isra
el
Malta
Gree
ce
Mak
edon
ia
%
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
Recommended