TRANSFERABILITY OF INTERVENTIONS ACROSS BORDERS

Family Group Conferencing and other examplesKnut SundellNational Board of Health and WelfareSweden

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 modelFamilies have the right to be involved in decisions about their childSolutions 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 FGCs initiate better family functioning by bringing family members together who have lost touch and restoring legitimate parental authority

Basic principlesCPA assess risk, extended family suggests support Extended family = kin, friends, neighborsExtended family meet in private to develop a protection planCPA should accept the plan unless it place the child at risk of significant harm

Research is limitedMainly process studiesFew follow-up studies Weak designs (no direct comparisons) Unrepresentative samples

The Swedish FGC outcome study1996 1999Involved 10 Swedish local authorities All FGCs during one year (97 children) Compared to a random sample of traditional investigations (142 children) Several qualitative / quantitative measures36 months follow-up

Immediate outcomesFamily members attended the meetingsProfessionals did not interfereFamilies spent an average of 160 minutes in private family timeAll families agreed on a plan Family plans indicate the inclusion of sensitive informationAll plans were accepted by the CPSFamily members felt empoweredSo far a success

HypothesesDecrease the risk for referrals Reduce the risk of repeated neglect/abuse More reports by the extended familyOut-of-home placement with kinIncrease the possibility of closing a case

Substantiated reports after index investigation (cumulative %)

Service provision

Children in Foster Care

Reports of Abuse and Neglect during follow-up

Reports by the extended family Placement with kin

The differences diminished FGC accounted for 07 % In the worst case it might be harmfulSimilar to other outcome studies (e.g., Weigensberg et. al., 2009)Controlling for initial differencesThe FGC children had more serious problems at the start

WHY?The FGC model is a primarily a model for selecting appropriate services not effective treatments. Without the latter it does not make a differenceFGC does not empower families in the long runFGC 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 USATransported to Sweden in 2004Compared to Treatment-As-Usual in 27 local authoritiesYouth decreased their problem behavior and improved social skills and family relations None of the improvements were statistically different between the groups

Arguments against transportability Different population-Youth symptomatology is higher or lower 2The treatment is less potent than in the original context-Program standards are compromised (e.g., lower / higher caseloads) -Poor fidelity3TAU is more potent then in the original context-Fewer iatrogenic interventions-Proactive family service orientation4Sociodemografic 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)

Arguments against transportability Different population- Youth symptomatology is higher or lower 2The treatment is less potent than in the original context- Program standards are compromised (e.g., low / high caseloads)- Poor fidelity3TAU is more potent than in the original context- Fewer iatrogenic interventions- Proactive family service orientation4Sociodemografic 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) boys aged 15 (ter Bogt et al, 2006)

Hofstedes 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 in-groups, 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.

Hofstedes Cultural Dimensions (Israel)JapanSwedenUSUK

CONCLUSIONSDo controlled outcome studies If you have not got any outcome studies, use international evidence (be aware of the risk)If there is no international evidence, use theoretically sound treatments (be even more aware of the risk)

Todays situationOur services arenot tested scientifically. But think positive you will get a brand new and untested treatment

Must also be avoided

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