Early Interventions for Children at Risk, case of Norway

Early Interventions for Children at Risk, case of Norway Nuuk, August 28th 2013 Terje Christiansen Norwegian Center for Child Behavioral Development University of Oslo 08.09.2013 Side 1

Overview Background for the Norwegian initiative Who - children aged 3-12 years who currently have or are at risk to developed behavioral problems. This includes, but is not limited to children who have behavioral diagnosis. Why risk exposed children are short of time! What Evidence based/informed interventions- a program! How Effective implementation! www.pmto.no (if we have time) 08.09.2013 Side 2

Background, context and status of implementation Nation-wide implementation of services for children and families with conduct problems governmental initiative from 1998 Treatment and Prevention What works - Evidence based practices - RCT Same access to services geographically Accessible where children and families are 08.09.2013 Side 3

Why early investment in disadvantaged children Early interventions promote schooling, reduce crime, and foster workforce productivity programs that target the early years seem to have the greatest promise, These interventions are estimated to have high benefit-cost ratios and rates of return, Experimental evidence on the positive effects of early interventions on children in disadvantaged families is consistent with a large body of non-experimental evidence showing that the absence of supportive family environments harms child outcomes, The quality of parenting is the important scarce resource and is not always closely linked to family income or parent education. 08.09.2013 Side 4

Problem development and young children Difficulties in young children is often expressed as problems with the regulation of sleep and eating, but also about the regulation of emotions and attention, and can be expressed as aggressive behavior, agitation and anxiety. The risk of persistent problems increases with age. While 25 percent of children with significant symptoms at 18 months of age also have this when they are 4 years, 40 percent of 4-year-olds with diagnosable mental disorders still fit the criteria as 10-year-olds (FHI, 2009:8), There seems to be a significant shortfall of aid to the youngest age groups, with few references to mental health, child welfare services and for special educational measures. 08.09.2013 Side 5

A child at risk is short of time Help often comes too late to children with disabilities, children with mental and physical disabilities and behavioral problems, children with physical problems and children who have a difficult family situation. The importance of early intervention is emphasized not only in research, but also in several public documents. With the exception of health issues, best practices for identifying young children at risk of developing learning disabilities, behavioral problems, and mental or physical health problems is yet in the beginning of reaching the field. The difficulties comes to surface later, when the children are not able to adapt to the school situation - and it takes time to get help in place. 08.09.2013 Side 6

Early interventions better response There are critical, sensitive or optimal periods in young children's development when they are particularly dependent on environmental influences. Such periods are important for the development of sensory systems, languages and children's social and emotional development. Children seem to be particularly eager to learn and motivated to master the challenges of the current development stage. Research and studies are unanimous in calling for no longer to condone child's risk, and the tendency to "wait and see". 08.09.2013 Side 7

Evidence based, evidence informed practice Research documents the positive effects of early intervention in the form of 1) structured, intensive programs and 2) a competent staff who have received good training in a method. 3) Delivered with program fidelity and 4) Effectively implemented. An important aspect of prevention is about assisting parents, staff in kindergartens and schools with advice and guidance on how best to stimulate and encourage to better master the different challenges.

Early identification better results, earlier easier! With good tolerance for individual variations one can identify children who need assessment and help. Such assessments may help to reduce worry and exclude risk factors, while ensuring that alarming signals taken seriously. Early identification without early intervention is ethically questionable. If one identifies and provides assistance to children who would have made it anyway, the interventions have no radical measures but stimulate and train encouragement and support to master essential parenting skills and development tasks. Thus could do no harm. 08.09.2013 Side 9

Effect To make a difference Effect x Reach = public health! Large With TIBIR we have the chance to make a difference! Smal Reach Stor 08.09.2013 Side 10

The coercion theory CLEAN UPNOW Terje Christiansen

Terje Christiansen

Early Interventions for Children at Risk Side 13

08.09.2013 Side 14

What we hope to achieve! To establish a nation-wide effort to prevent, treat and reduce behavioral problems among children and strengthen their social skills. Implementation of primarily preventative efforts with a low threshold and early intervention in municipalities, Provides employees and managers who work and have responsibility for children a common understanding of how behavior problems occur and can be helped. Creates a common language and understanding! That TIBIR show to have a comprehensive range of measures where interventions are adapted to the individual family and child s needs and conditions. 08.09.2013 Side 15

TIBIR in a nutshell Intervention Training program Target group of intervention # of sessions Assessment 3 days of training in assessment tools Brief Parent training 9 days of training during ½ year followed by ½ a year of supervised counseling. Parents 4-6 Social Skill Training Teacher Consultation 6 days of training during ½ year with Supervised Social Skill Training. 4 days training in consultation for PMTO therapists and Parent counselors. Children 8-10 Teachers 6-8 PMTO Groups 2 day training for PMTO therapists Parents 12 PMTO therapy 20 days of training during 1 ½ year Parents 20 30 Side 16

How to bridge the gap? Practices Implementation Research Evidence based practices demands practice based evidence 17 Atferdssenteret

HOW - Implementation Implementation strategy Recruiting professionals for training in clusters Side 18

Status PMTO/TIBIR implementation 2013 290 PMTO therapists 1179 TIBIRpractitioners 81 TIBIRmunicipalities Registered 333 workplaces Registered 636 users 18 / 115 22 / 66 14 / 42 19 / 71 8 / 39 08.09.2013 Side 19

NIT Nord Øst Sør Midt Vest

Implementation Quality An overarching term which refers to how well the correspondence between how a proven ideal model are planned and how the intervention is actually carried out by the practitioner of ordinary care services Implementation quality Program integrity Program fidelity

Thank You Take home message Effective For the child and family; life quality For society; cost effective Evidence based/informed programs Low threshold services Implementation quality Training and fidelity systems Implementation teams 08.09.2013 Side 22

Kjøbli, J., & Ogden, T. (2012). A Randomized Effectiveness Trial of Brief Parent Training in Primary Care Settings. Prevention Science, 13(6), 616-626. doi: DOI 10.1007/s11121-012-0289-y Kjøbli, J., Hukkelberg, S., & Ogden, T. (2013). A randomized trial of group parent training: Reducing child conduct problems in real-world settings. Behaviour Research and Therapy, 51(3), 113-121. doi: DOI 10.1016/j.brat.2012.11.006 Ogden, T., & Hagen, K. A. (2008). Treatment effectiveness of Parent Management Training in Norway: A randomized controlled trial of children with conduct problems. Journal of Consulting and Clinical Psychology, 76(4), 607-621. doi: Doi 10.1037/0022-006x.76.4.607 Ogden, T., Forgatch, M. S., Askeland, E., Patterson, G. R., & Bullock, B. M. (2005). Implementation of parent management training at the national level: The case of Norway. Journal of Social Work Practice, 19(3), 317-329. Ogden, T., Bjørnebekk, G., Kjøbli, J., Patras, J., Christiansen, T., Taraldsen, K., & Tollefsen, N. (2012). Measurement of implementation components ten years after a nationwide introduction of empirically supported programs a pilot study. Implementation Science, vol. 7:49. Solholm, R., Kjobli, J., & Christiansen, T. (2013). Early initiatives for children at risk-development of a program for the prevention and treatment of behavior problems in primary services. First Posting Feb 13, 2013. [Peer Reviewed]. Prevention Science. Feb 2013, pp. No Pagination Specified. Amlund-Hagen, K., Ogden, T., & Bjørnebekk, G. (2011). Treatment outcomes and mediators of Parent Management Training: A one-year follow-up of children with conduct problems. Journal of Clinical Child and Adolescent Psychology, 40(2), 1-14. Kjøbli, J., Nærde, A., Bjørnebekk, G., & Askeland, E. (2013). Maternal mental distress influences child outcomes in brief parent training. Child and Adolescent Mental Health. doi:10.1111/camh.12028 08.09.2013 Side 23

Etablering av evidens for at TIBIR virker

Evaluering av PMTO-foreldregrupper for mødre med etnisk minoritetsbakgrunn I en RCT ble det dokumentert at somaliske og pakistanske mødre og deres barn hadde utbytte av å delta i «kultursensitive» PMTO foreldregrupper over 18 samlinger á to timer (Bjørknes & Manger).