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

bo.vinnerljung@socarb.su.se

Nordic values about children and parenting

Every child should have ’a fair go’

Good parents help their children with school/education

Good parents take care of their children’s health

Out of home care: In loco parentis

• When the state assumes parental responsibilities, the state should act as a reasonably good parent

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

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

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

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

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

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

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

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)

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)

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

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

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

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

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

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.

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

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….

Results from cognitive tests (IQ) of children in out-of-home care are often instable

Tend to change over time after interventions

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

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

• 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

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

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

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)

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%

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….

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.

bo.vinnerljung@socarb.su.se

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.

• 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.