Riskilaste konverents 2012: Arne Holte: The burden of mental disorder

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Riskilaste konverents 2012: Arne Holte: The burden of mental disorder

  1. 1. The burden of mental disorder:Integration challenges in child mental health care Arne Holte Deputy Director General, Norwegian Institute of Public Health/ Professor of Health Psychology, University of OsloEvidenced Practice with Children and Youth at Risk: The Norwegian Experience Estonian Ministry of Social Affairs in collaboration with the Ministry of Education Research and the Ministry of Justice 1 EEA/Norway Grant, Tallinn, October 3.-4., 2012
  2. 2. Health promotion and illness prevention: a success story 2
  3. 3. Antall døde 1. leveår per 1000 levende fødte 10 12 14 16 18 0 2 4 6 8 19 67 19 69 19 71 19 73 19 75 19 77 19Source: Norgeshelsa/MFR 79 19 81 19 83 19 85 19 87 År 19 89 19 91 19 93 19 95 19 97 Infant mortality in Norway Boys and girls, 1967-2008 19 99 20 01 20 03 20 05 20 3 07
  4. 4. No of deaths pr 1000 born Average life expectancy (years) 120 Women 90 80 100 70 Men 80 60 50 60 40 40 30 Children 20 20 10 0 0 1876- 1891- 1906- 1921- 1936- 1951- 1966- 1981- 1996- 1880 1895 1910 1925 1940 1955 1970 1985 2000 4
  5. 5. Coronary heart disease and stroke mortality in Norway Men, 45-64, 65-79 and 80+ years, 1990-2009 4000 3500 3000Døde per 100 000 personer Iskemisk hjertesykdom (I20-I25) 45-64 år 2500 Iskemisk hjertesykdom (I20-I25) 65-79 år Iskemisk hjertesykdom (I20-I25) 80+ år 2000 Hjerneslag (I60-I69) 45-64 år Hjerneslag (I60-I69) 65-79 år 1500 Hjerneslag (I60-I69) 80+ år 1000 500 0 1990 1992 1994 1996 1998 2000 2002 2004 2006 2008 ÅrSource: Norgeshelsa/DÅR 5
  6. 6. Road traffic deaths in Norway Men, all age groups and by age, 1970-2009 6Source: Norgeshelsa/DÅR
  7. 7. 3-årig gjennomsnitt (prosent) 19 72 - 0 10 20 30 40 50 60 19 197 74 4 -1 19 97 76 6 -1 19 97 78 8 -1 19 98 80 0 -1 19 98 82 2 -1 19 98 84 4 -1 19 98 86 6Source: Norgeshelsa/SSB -1 19 98 88 8 -1 19 99 90 0 -1 19 99 92 2 -1 19 99 94 4 -1 19 99 96 6 -1 19 99 98 8 -2 20 00 00 0 -2 20 00 02 2 -2 20 00 04 4 -2 20 00 06 6 Tobacco smoking in Norway -2 20 00 08 8 Adults, 16 - 74 years, 1972-2009 -2 00 9 7 menn dagligrøykere kvinner dagligrøykere menn av og til-røykere kvinner av og til-røykere
  8. 8. Suicides in Norway Men and women, 1970-2009 N per 100 000 inhabitants 30 25 20Døde per 100 000 menn 15 kvinner 10 5 0 70 72 74 76 78 80 82 84 86 88 90 92 94 96 98 00 02 04 06 08 19 19 19 19 19 19 19 19 19 19 19 19 19 19 19 20 20 20 20 20 År 8 Source: Norgeshelsa/DÅR
  9. 9. Caries free teeth in Norway 5 and 12 olds 90 80 70 60 50Prosent 5 år 12 år 40 30 20 10 0 1992 1993 1994 1995 1996 1997 1998 1999 2000 2001 2002 2003 2004 2005 2006 2007 2008 2009 Source: Norgeshelsa/SSB 9
  10. 10. No change in incidence of mental disorder• In Estonia and in Norway – Psykiske lidelser i Norge, FHI-rapport, 2009• In Europe – Wittchen et al., 2011• In USA – Kessler et al., 2005• Elsewhere in the world – Kessler & Ustun, 2008• No major evidence based attempt to do it 10
  11. 11. White Paper (1996-1997) Inadequate preventive measures Inadequate municipal services Poor access to specialized care Hospital stays without continuity and follow-up Hospital discharges not being sufficiently planned Poor follow-up systems and routines after discharge 11
  12. 12. Help to people with Help to did for people mental disorders has with mental disorders has failed at all levels! failed at all levels! 12Unanimous Norwegian Parliament, 1998
  13. 13. National programme for mental health 1999 – 2008 8 000 000 000 Euro 13
  14. 14. Main goal: Reorganise mental health services Establish/strengthen local community services Replace traditional psychiatric services and mental institutions with community mental health centers and outreach teams Change attitudes and stigma attached to mental disorders 14
  15. 15. Gaustad asylum in Oslo, build in 1855.From living your life in an institution to…. 15
  16. 16. …to living your life at home and receive local community based services “Josefinegaten” community mental health center, Oslo 16
  17. 17. Services provided in the local environment: 1999-2008 + 3400 assisted homes + 4780 man years in municipalities + 650 more man years dedicated to  Local user organizations  Activity centers  Occupational activities 17
  18. 18. Accessibility: Community mental health centers (CMHC); 1996 2008CommunityMental HealthCentres 48 75Man years in CMHC 1763 6286Beds 978 1865 18
  19. 19. Specialized mental health services 1996 1998 2006 2008Outpatientconsultations 438 000 476 000 931 000 1099 000 19
  20. 20. Earmarked resources to community mental healthservices during the program period (million NOK) 20
  21. 21. Evaluation Research Council of Norway The main goals were met  The number of houses, number of community mental health centers, number of consultations, number of educated mental health personal, etc. Too little focus upon  Quality of the services  Did the patients get better?  Services to the elderly  Services vulnerable to budget cuts 21
  22. 22. Success criteria… Political will across parties/governments/time Detailed plans required to receive financial support Quality standards (psychiatrist and clinical psychologist) Strong emphasis on education Quantified goals, e.g. 75 CMHC, 3400 ass. homes Earmarked financial resources Close political monitoring Systematic use of mass media Strengthened role of user organisations Evaluation by Norwegian Research Council 22
  23. 23. Sick leave openly because of ”depressive reaction” 23Kjell Magne Bondevik, former Prime Minister of Norway
  24. 24. National Programme for Mental Health • Prioritised the most severe cases – children/youth • Human rights, human dignity • Could not accept people freezing to death in a container because of schizophrenia/drug abuse • Comprehensive reform of mental health care - for those who were already ill 24
  25. 25. National Programme for Mental Health • No goals for: – Prevention – Public health – Cost-effectiveness – Society economy • No reduction in mental disorder in the population • Large increase in disability award cost • Particularly amongØyane DPS, Fjell municipality young adults 25
  26. 26. Svein (56), on disability award since 42 Depresjon 26
  27. 27. Hedda-Pernille Sørensen8 years of age - ADHD 27
  28. 28. ADHDHelped at 4 years of ageHedda-Pernille Sørensen (8) 28fikk hjelp som fireåring
  29. 29. Hedda-Pernille Sørensen Svein FarsethNot prioritised in Escalation planfor mental health 29
  30. 30. The Mental Health Challenge 30
  31. 31. Mental disorders is the biggest healthchallenge to Estonia! In terms of: – Prevalence – Children’s burden – Sick leave costs – Disability costs – Lost years of work Estonian Minister of Finance Jurgen Ligi – Mortality – Burden of disease – Cost of illness 31
  32. 32. Prevalence• Every third/second during life time • Kringlen E. et al. 2001• Every third of us in one year • Kessler & Ustun (Eds.), 2008 • Wittchen et al., 2011• As usual as influenza – Some get healthy by themselves – Some experience life long illness – Some die 32
  33. 33. Work related illness by industry 33Figures from Dame Carol Blacks Review of the health of Britains working age population (2008)
  34. 34. Work absence: Main causes of paid sick leave 34
  35. 35. Disability awards: Change in main causes 35
  36. 36. Disability award:Muscle/skelleton diseases most frequent reason 36
  37. 37. Disability awards for muscle/skeleton start at old age Disability awards for mental disorder start at Mental disorder young age Muscle/Skeleton Other diagnoses 37Age at disability award in Norway (2000-2003)
  38. 38. Lost work years because of mental illness: Average: 21 years per disability award Mental disorder Neurological Injury/Poisoning OthertCancer Muscle/skelleton Lung Coronary 38Mykletun A. & Knudsen AK., NIPH, 2004
  39. 39. Lost work years due: EU-27 MentalCardiovascular Diabetes/endocrine Injuries Cancers Muscle/skelet/skin Senses 39
  40. 40. Burden of disease, EU-25• ¼ of all burden of disease in EU 25 – Disability Adjusted Life Years – DALY• 50% more than burden from all cancer illness• 50 % more than burden from all coronary heart disease• 4 x burden from all lung diseases• 4 x burden of all road traffic accidents • Andlin –Sobocki, Jönsson, Wittchen, Olesen, 2005 40
  41. 41. Half of cost of illness due to depression, Sweden€ PPP mill Health Direct non- Indirect Total costs services medical costsAffective 331 mangler 1096 1427Dependency 206 40 519 765Anxiety 294 n.a. 265 559Psychoses 317 17 n.a. 334Total mental 1148 57 1880 3085Dementia 198 554 n.a. 752 Olesen et al. (2007). Cost of mental illness by type of mental illness 41
  42. 42. Depression: 86 % indirect costs Indirect costs more than doubled in 7 years, Sweden€ mill 1997 1998 1999 2000 2001 2002 2003 2004 20052005Direct 420 406 419 488 497 498 494 494 502 (14%)Hospital 214 227 211 212 202 189 186 187 187 (37%)Outpatient 132 91 110 163 168 179 194 203* 219 (44%)*Medicines 74 88 99 113 127 130 114 105 96 (19%) (3% of total)Indirect 1319 1505 1749 2044 2484 2668 3034 3037 3040 (86%)Sickleave 286 330 450 558 758 905 1145 1146* 1146*Disability 826 949 1066 1260 1481 1519 1657 1658* 1659*Death 208 225 233 226 245 245 232 233* 234*Total 1739 1911 2168 2532 2981 3166 3528 3532 3542 42Sobocki et al, 2007. Cost of depression in Sweden
  43. 43. Productivity loss from depression far higherthan from diabetes and coronary diseases Hans-Ulrich Wittchen, EU Mental Health Pact Thematic Conference, 43 "Prevention of Depression and Suicide", Budapest, 9-10 Desember 2009
  44. 44. Mortality: Premature death followingdepression as likely as for sigarette smokingDepression Tobacco smokingAdjusted for age, gener, Justert for alder, kjønn:somatic symptoms/diagnoses:+ 52% + 59%HR=1.52 (95% CI 1.35-1.72) HR=1.59 (95% CI 1.44-1.75) Mykletun et al. Brit J Psychiatry 2009 44
  45. 45. Norwegian Minister of Finance Sigbjørn Johnsen Suggested total cost of mental illness in Norway: 9 billion Euro/year Norway • 1800 Euro x NOK x 5 mill • 9 billon Euro/year *2004 NOK, todays change rate, adjusted for cost level difference Norway - UK UK • Total cost: 77 bill GBP/year • Lost work • Social services • Treatment • Mental Health and Social Exclusion. 45 Report from Office of the Deputy Prime Minister, London, 2004.
  46. 46. High cost because of: :• High prevalence, many affected• Low and decrasing age of debut• Interferes with education• Interferes with entry to work market• Promotes expulsion from work market Finance Minister Jurgen Ligi• Leads to repeated longterm work absence• High disability insurance, particularly young adults• High mortality 46 • Judd et al., 1998; Ustun et al., 2004; Smit et al., 2006
  47. 47. The mental health challenge - summarised1. Every second/third of us get it at least once in our life time2. Every third of us in a year3. ¼ of all burden of disease in Europe4. More expensive than any other illness: 9 bill Euro/year5. Burden 50% more than all cancers and heart diseases6. 40 % of registered sickness leave7. 40 % of disability award costs8. Costs increase – particularly among young adults9. 21 lost work years per disability award10. Deadly as tobacco smoking (depression) 47
  48. 48. The mental health challenge – summarised Continued12. Depression alone represents half of the costs13. Direct treatment cost for depression: 10-20%14. Costs due The consequences of depression: 80-90% to mental health challenge - summarised15. Sick leave costs depression doubled in 7 years (Sweden)16. More skewed cost distribution than any other illness17. Easier to prevent and treat than most other mental disorders • Cuijpers et al. 2009 48
  49. 49. Threats to society: ConclusionThe by far largest threat to the society comes from the common mental disorders: • Depression • Anxitey • Alcohol abuse 49
  50. 50. We cannot combat common mental disorders bycontinuing to build out specialised 50 health services!
  51. 51. We must prioritise according to publichealth, cost-effectiveness, and society economy and we must prevent! In terms of:– Prevalence– Children’s burden– Sick leave costs– Disability costs– Lost years of work– Mortality– Burden of disease Hannu Pevkur, Minister of Social Affairs,– Cost of illness Estonia 51
  52. 52. Prevention 52
  53. 53. Concept of prevention• Intervention before disease occur• Reduces number of new cases (incidence)• Effective only in incidence is lower after intervention than if not intervened 53
  54. 54. Prevention and treatment Behandling av beha ardisert sykd g av fisering sykdom Tilb ing om ndlin ake gg v d Innd g a ing by fal Identi Stan I dikk rin lre lsb fø and av efall i aaFo om h on k e titviv nn dsbe uksj tilba han e Se lek Gj ngti red de d tiv la ål: gen ling (M enta gj an dling rbeh ert Ette klud Univ (In g) ersel iliterin l r ehab Reproduced with permission from National Academies Press © (2010) by the National Academy of Sciences, Courtesy of the National 54 Academies Press, Washington, D.C.
  55. 55. Ten principlesfor a mentally healthier population 55
  56. 56. 1. Maksimise mental capital rather than prevent mental disorder• Mental capital is the country’s most important resource – and the least deveoped one as compared to its potential• Mental capital: A population’s total potential to develop security, autonomy, creativity, use emotions, think smart, control behaviour, create social networks, and master challenges• Systematic development of a population’s mental capital is likely to prevent more mental disability than interventions designed directly to prevent specific mental illness 56
  57. 57. Mental capital• A society’s potential to develop – Security – Autonomy – Creativity – Emotions – Thinking – Behaviour coordination behaviour – Social networks – Cope with challenges 57
  58. 58. 2. Prioritise conditions according to burden of disease rather than to degree of severity• The common disrders: depression, anxiety disorders and alchol abuse• Burden of disease from depression (EU-25): – 3-4 x schizophrenia – 3-4 x bipolar disorder – 3 x suicide – 3 x personality disorders• No single illness costs more to society• 85-90 % of the costs of depression are indirect costs 58
  59. 59. Sykdomsbelastning i EU 25 (DALY): Psykiske lidelser Total mill. DALY % av total Alle årsaker 98,71. Unipolar Major Depression 6,7 6,82. Schizofreni 2,3 2,33. Bipolar forstyrrelse 1,7 1,74. Obsessiv-kompulsiv forst. 1,5 1,55. Panikklidelse 0,7 0,76. PTSD 0,3 0,37. Villet egenskade (selvmord) 2,2 2,28. Alle mentale forstyrrelser 15,3 15,4 National Institute of Mental Health Publication No. 01-4586 59
  60. 60. 3. Prioritise conditions that we can prevent rather than conditons we wish to prevent• We must prevent unnecessary negative effects of having to live with bipolar disorder, schizophrenia, anorexia nervosa, autism and ADHD• But we do not yet know how to prevent these disorders• Fortunately, we can to a certain degree prevent the most costly mental disorders to society: depression, anxiety disorders and alcohol abuse 60
  61. 61. 4. Prioritise health promotion rather than illness prevention• Learn from the big success in preventing illness and death from physical conditions: – Reduced infant mortality – Reduced mortality from: • Coronary heart disease • Stroke • Several cancer illnesses • Suicide • Tobacco smoking • Road traffic accidents – Less caries in children’s teath – Life expectancy increased significantly 61
  62. 62. What can we learn from the success with physical illness?• Allthough the success was due not only to health interventions, we did something right: – Long term investments – Multi-method approach – Act on indicative evidence – Address exposure factors: Diet, smoking, excercise – Knowledge: Kindergarten, school, mass media – Competence: Show how you do it – Self-efficacy: Every one can achieve something – Laws, regulations and tax-policy• Mental health: family, kindergarten, school, friends, work, parent competence, coping with strain/depression, mental health literacy 62
  63. 63. 5. Prioritise cost-effective solutions, not only degree of severity and human suffering• Politicians tend to prioritise the most severe conditons rather than cost-effectiveness and cost-benefit• Find the most cost-effective interventions• E.g. Impact of long term kindergarten on later mental health: – Only dependent upon kindergarten quality – Low quality: no effect and negative cost-benefit – High quality: Very good cost-benefit for children’s mental health and for society economy 63
  64. 64. Depression: Better cost-benefit of prevention than for any other single disorder • 85-90 % of total costs are indirect costs • Sobocki et al, 2007 – Reduced effectiveness at work (Work presenteism) – Lost work hours – Illness leave costs – Disability award costs • Higher than for any other disorder (also physical) • Berndt et al, 2000; Broadhead et al, 1990 • Indirect costs more than doubled in 7 years (Sweden) • Sobocki et al, 2007. 64
  65. 65. 6. Prioritise interventions towards the general population rather than internventionstargeting high risk groups or individuals at risk • Internvention targeting high risk groups and individuals can be very effective for those they reach • But, most people are not reached by such interventions because people do not seek help for mental difficulties before they become ill • Although the mean impact may be small for the individual, health promoters regard universal interventions targeting the whole population as most cost-effective to the society • As for physical health, we believe that this is true also for mental health 65
  66. 66. We spend too much moneyon mental illness in all the wrong places Michael F. Hogan, char of President George W. Bushs New Freedom Commission on Mental Health. Hogan MF: Spending too much on mental illness in all the wrong places. Psychiatr Serv 2002; 53:1251–1252. 66
  67. 67. 7. Prioritise arenas outside rather than inside the health care services• Health is produced where people live their lives – In the family, kindergarten, school, work place, municipality• The health care services do not produce health, they repear it• Most important arenas are family, kindergarten, school• Better health care services have hardly any impact on public mental health in high income coutries 67
  68. 68. 8. Prioritise the first years of life• Strong evidence that most mental disorders start in childhood and adolescence, rarely disapear by by themselves, and signifcantly increase risk of co- and multimorbidity later in life – de Graf et al., 2011; Kessler et al., 2011, Beesdo et al., 2010, 2009• Such patterns increase the psychosocial disability and contribute strongly to the society’s burden of disease from mental disorder – Wittchen et al., 2011 68
  69. 69. Barn er bedre enn bank og børs! Nobel laureate in economy, James J. Heckman ,Children better than bank and stocks! 69
  70. 70. Heckman, James J. (2006). " Skill Formation and the Economics of70Investing in Disadvantaged Children, Science, 312(5782): 1900-1902.
  71. 71. 9. Aim to reduce the level of mental distress in the community rather than the number of clinical cases• Like the number of alcohol related illnesses in a community follows from the total intake of alcohol, the number of mental disorders follows from the level of mental distress• Alcohol related illnesses in a community is most effectively reduced by reducing the total intake of alcohol in the community (availability and price)• Probably we can reduce the number of depressions in a community most effectively by reducing the level of mental distress• Proof is still lacking, but the hypothesis can be tested. You can do it! 71
  72. 72. 10. Prioritise interventions with a plan and abudget for independent scientific effect evaluation.Avoid interventions with no such plan and budget• Like medical treatment, prevention should be evidence based• Forbid use of large amount of money on health promotion and illness prevention with no plan and budget for independent, scientific assessment of: – Implementation (Is it feasible?) – Effect (Does it work?) – Cost-benefit (Does it pay off?) – User satifaction (Do people want it?)• Otherwise, we do not learn from our experience and waist money 72
  73. 73. Principles of promotion - summarised1. Mental capital before mental disease2. Burden of disease rather than humanism3. Possibilities before wishes4. Health promotion before illness prevention5. Cost-benefit before political correctness6. Universal before targeted7. Outside before inside health services8. First years of life before later years9. Level of distress before number of cases10.Evidence before good intentions 73 Holte, 2012
  74. 74. Clinical treatment• Of course, clinical treatment for mental disorders should be as available, affordable, and effective as for physical illness• Of course, we shall take care of those who suffer the most• But, if we wish to reduce the number of new cases of mental illness in the community – i.e. prevention – such internventions hardly have any effect 74
  75. 75. One institution that scores higher than any other on the ten priority list • Strengthens mental capital in the municipality • Positive cost-benefit ballance • Promotes mental health • Eksposure factors • Buildig competence • Universal • Outside health services • Affects level of distress/well-being • Early preschool year (James Heckman!) • Evidence based 75
  76. 76. Child care center revolution! Child care center revolution• Radically new situation in Norway:• More children in child care centers than at health care station (98% of 4-year olds)• From early age (80% of 1-2 years)• Every body is there!• Every day• Continuously for several years• Natural interplay with other children• Observed by trained professionals• Who meet the parents twice a day 76• Unique arena for health promotion
  77. 77. Children attending a child care center (n) 77Source: Child statistics, Statistics Norway
  78. 78. The Sector Challenge Feelings/anxiety/depression=health=Ministry of Health Tinkning/langage/learning=education= Ministry of Education Behaviour/drugs/parents=family/eviroment=Ministry of Family etc Bullied Child Behavior Kindergarten?Tinking? ? care problems? Education dir Ped Ministry service? Child&familyservice! of Edu! Ministry directorate! of child! 78
  79. 79. In Norway, In Estonia, kindergartens are kindergartens areeducation institutions education institutions– not health services – not health services Kristin Halvorsen, Hannu Pevkur, 79Minister of education, Norway Minister of Social Affairs, Estonia
  80. 80. And does it pay off?But is it healthy? Mental health • The most comprehensive mental health initiative for small children since World War II? 80
  81. 81. Centred child care = Universal mental health promotion• Strengthens cognitive, emotional and social development• Enhances school achievments• Best effect on disadvantaged children• Good effect also on advantaged children• Compensates difficult periods in life• Reduces social inequality in health• Solid documented long term effects (11-13 år alder)• May be into adult life (education, employment)• Very profitable to society economy• Age at start up (1,2,3 years) not significant• Quality is all that counts to achieve positive effects – Jaffe et al., 2011; Sylva et al., 2011; FHI, 2011; Havnes & Mogstad, 81 2010; Pianta, 2009
  82. 82. Is it dangerous?• De minste – under 1 – 1 ½ år ?• Sikker tilknytning ?• God nok kognitiv stimulering ?• Uheldig langtidsvirkning på: – Adferd ? – Følelsesregulering ? – Kognisjon ?• En rekke tidligere undersøkelser fra USA: – ”Barnehager gjør de aller minste rastløse, urolige, aggressive” – Generaliserbart? – Seleksjonseffekter? Jaffe, van Hulle, Rodgers: Effects of Nonmaternal Care in the First 3 Years on Children’s 82 Academic Skills and Behavioral Functioning in Childhood and Early Adolescence: A Sibling Comparison Study. Child Development, 2011.
  83. 83. Søskendesign: Jaffe et al., 2011• USA, 9000 barn, representativ• Oppstart barnepassordning i 1., 2., 3. leveår• Fulgt opp ved 4 -13 års alder• Utfallsmål 1: Adferdsproblemer, ADHD-symptomer, trass – 5-7 år – 11-13 år• Utfallsmål 2: Akademisk kompetanse: Matte og lese – 5-7 år – 11-13 år• Kontrollert for i tillegg til felles søskenbakgrunn – Barnets temperament før 12 mnd – Fødselsvekt – Rekkefølge i søskenrekken – Mors intelligens – Mors alder ved første fødsel – Mors ekteskapelige status – Familiens inntekt 83
  84. 84. Resultat• Ulikt tidspunkt mellom søsken for oppstart av barnepassordning hjemmet gir ingen forskjell i senere akademiske ferdigheter eller adferd• God kontroll for seleksjonseffekter visker bort alle effekter av tidspunkt for barnepass utenfor hjemmet• Hvis det er effekter av tidspunkt før treårs alder for omsorg utenfor hjemmet iverksettes, er de eventuelt svært små og ikke konsistente over tid• Tilsvarende funn i FHIs undersøkelse fra Norge • Jaffe, van Hulle & Rodgers, 2011 84
  85. 85. Konklusjon, Jaffe et al., 2011”Basert på sammenligning av barn som begynte iomsorg utenfor hjemmet på ulike tidspunkter i de treførste leveår, med deres søsken som ikke gjorde det,konkluderer vi at tidspunkt for oppstart i omsorgutenfor hjemmet har verken positive eller negativevirkninger på barns utvikling. Kjennetegn ved familiersom velger å benytte omsorg spiller en større rolle i åpåvirke barns utvikling enn tidspunktet for når barnabegynner i omsorg utenfor hjemmet i de tre førsteleveårene”Jaffe, van Hulle, Rodgers: Effects of Nonmaternal Care in the First 3 Years onChildren’s Academic Skills and Behavioral Functioning in Childhood and EarlyAdolescence: A Sibling Comparison Study. Child Development, 2011. 85
  86. 86. Er tidlig start skadelig ?• Nei, tidspunkt for oppstart i barnepassordning utenfor hjemmet har ingen betydning verken for senere skolepresasjoner eller adferdsutvikling, verken i USA eller i Norge 86
  87. 87. The only thing that counts is qualitySylva et al. Journal of Early Childhood Research, 2011 • UK, 3000+ kids, representative • 141 kindergartens • 6 types + home care • Out come at 11 years of age • Start at 3 years • Center quality, 1-7 on sub scales: – Localities/equipment, Care routines, Language/thinking, Social interaction, Programme structure, Parents and personnel • Center quality, 1-7 cognitive curriculum: – Reading, Math, Science, Environment, Diversity 87
  88. 88. Assessment at 3 and 11 years of ageSylva et al., Journal of Early Childhood Research, 2011 • Cognition: English and math – National Assessment Test (BAS 3 år) • Social competence and behaviour (SDQ) (ASBI 3 år) – Self regulation – Positive social behaviour – Hyperactivity – Anti-social behaviour • Home Learning Environment (HLE), intervju 3-4+ år – Reading – Painting/drawing – Library visits – Play/numbers/form – Alphabet/letters 88 – Songs/children’s rime
  89. 89. Sylva et al., 2011• Første som ser på kombinasjonen av læringsmiljø hjemme og barnehagekvalitet• Kan virke hver for seg og sammen• Høy hjemmekvalitet for barn som ikke er i barnehage fremmer selvregulering (SDQ)• Høy kvalitet på barnehage hos barn dårlig læringsmiljø hjemme fremmer selvregulering (SDQ)• Begge kan kompensere for den andre• Begge har langtidseffekter opp til 11 år 89
  90. 90. Sylva et al., 2011• Kvalitet på barnehagen påvirker både kognitiv og sosial utvikling ved 11 år• Lav barnehagekvalitet gir færre langtidseffekter på kognitiv og sosial utvikling ved 11 år• Middels og god barnehagekvalitet gir langt større gevinst enn svak barnehage kvalitet• Take home: Betydelig forebedring av læringsmiljøet til førskolebarn, særlig for dem som kommer fra vanskelige levekår gir dem sterk posisjon ved skolestart og ha langtids effekt. 90
  91. 91. Kostnad-nytte Pianta et al., Psychological Science, 2009• Perry preschool, Chicago CPC – Deltids og kun 2 år før skolestart• Abecederian program – Full tid, helårs, fra første leveår – Jobb for foreldrene mulig• Alle: Nytte overgår kostnad med betydelig margin• Førskoleprogammer er fornuftig offentlig investering: – Mindre fremtidige skolekostnader • Mindre spesialundervisning og mindre om igjen – Økte foreldreinntekter – Mindre kriminalitet/delinquency – Mindre risikoadferd (Abecedarian) • Ubeskyttet sex, tobakksrøyking: (lavere fremtidige helsekostnader) – Økte langtidsinntekter for mødre (Abecedarian)• Abecedarian betaler seg selv via mors økte inntekt 91
  92. 92. Oppsummert velkontrollerte u.s. Pianta et al., Psychological Science, 2009• Ingen effekt av tidspunkt for barnehagestart• Varig positive virkninger på kognitiv, adferdsmessig og sosial utvikling• Replisert i en rekke land• Økonomisk lønnsomt: – Skoleprestasjoner – Mindre om igjen – Mindre spesialundervisning – Høyere utdanning – Høyere familieinntekt – Bedre sosial/emosjonell/adferdsutvikling – Lavere kriminalitet/deliquency• Mulige negative effekter ikke latt seg replisere i eksperimentelle studier 92
  93. 93. Hvor viktige er langtidseffektene Pianta et al., Psychological Science, 2009• Vanlig: 10-20 % av forskjell i skoleprestasjon• Mer intensive og varige programmer: Mye sterkere effekter• Svært kostnadseffektivt: – USA: mest kostnadsintensive programmene av topp kvalitet fra 3 år: + 300 000 USD per barn• Billigere programmer (CPC; pre-K) – + 90 000 USD per barn• Estimert økonomisk verdi av virkingen på barna kan være betydelig sammenlignet med kostnadene, men avhengig av kvaliteten på programmet• Den økonomiske fordelen for foreldrene kommer i tillegg 93
  94. 94. Hvem profitterer på barnehagen Pianta et al., Psychological Science, 2009• Alle barn har godt av høykvalitetsbarnehager• Påstander om at bare gutter/jenter, noen etniske grupper, bare fattige, finner ikke støtte i forskningslitteraturen• Barn fra familier med lav utdanning/inntekt har størst effekt• Men barn fra familier med høy utdanning/inntekt har effekt tilsvarende 75 % av barn fra lavinntektsfamilier• Mindre velstående lærer mer når de går sammen med mer velstående• Og får bedre kamerateffekt når skoles med barn fra høykvalitetsbarnehage• Tradisjonelle barnehager har mye svakere kort- og langtids effekt enn pedagogisk fokuserte programmer og høykvalitets førskoleprogrammer – fra null til 1 sd i forskjell (prestasjonsgap for fattige barn)• Null evidens for at gjennomsnittlige førskoleprogrammer gir effekt på samme nivå som de beste programmene. 94
  95. 95. What is quality?• Process quality: – Samhandling mellom individer • Emosjonelt • Instruksjonsmessig• Structural quality – Sider som ikke direkte angår samhandling med barna • Pedagogiske kvalifikasjoner • Utstyr • Gruppestørrelse/ratio• Prosesskvalitet hviler på strukturell kvalitet 95
  96. 96. Strukturelle (statiske) forhold • Barnegruppen (distrikt etc) • Gruppestørrelser • Voksen-barn ratio • Personellkvalifikasjoner • Tjenester til barn og familie • Dagslengde • Konsept, pedagogikk, program • Lønn • Utviklingsmuligheter for personalet • Ledelse • Menn • Minioritetsansatte • Observasjon og tilbakemelding • Tilbakemelding til personalet 96
  97. 97. Prosessuelle (dynamiske) forhold• Barnas direkte opplevelse med folk, gjenstander• Måten pedagoger gjør ting på• Kvalitet i samhandlingen mellom og med barn og foreldre• Tilgang på ulike aktiviteter• Dynamisk, avhengig av det enkelte barns behov• Det som skjer i de nære relasjoner aller viktigst – Lamb, 1998; NICHD ECCRN, 2002, Vandell, 2004 97
  98. 98. Provided high quality:Indicative knowledg that:• Age at start does not matter (Jaffe et al., 2011)• Promotes mental health in the child (Sylva et al.,2011)• Pays of for society (Pianta et al.)• Strengthens familiy life in modern society• Makes children happy? 98
  99. 99. Do child care centers prevent anxiety, depression and behavior problems?We do not know yet. But we did not know whenwhen we invested in employment for all, healthydieting, exercise, high tax on tobacco and alcohol,round abouts in road crosses, concrete roaddivision, fluor tooth paste, and laying infants ontheir back, that it would result in reduced: infantmortality, cornary heart mortality, stroke mortality,cancers mortality, traffic deaths, healthier teeth,increased longevity of life 99
  100. 100. The kids are there…• …for other reasons than promotion of mental health. You cannot do anything with that - except utilising the situation to promote mental health.• The challenge now is not to find out whether child care centers are healthy or pay off, but to find out which child care centre set up are the most effective in promoting children’s mental health and wellbeing 100
  101. 101. Why is this so important?• Extensive evidence that significant adversity can lead to excessive activation of stress response systems (including persistently elevated stress hormones) that can disrupt development of the brain. – Lupien, S.J., McEven, B.S., Gunnar, M.R., Heim, C. Nat. Rev. Neurosci., 2009 101
  102. 102. ”Fear learning”• When children experience recurrent threat, fear conditioning affects developing circuits in the amygdala and hippocampus, which can lead to anxiety that impairs learning. – Pine, D.S. Biological Psychiatry, 1999 102
  103. 103. ”Fear unlearning”• This ”fear learning” can begin early in infancy, whereas ”fear unlearning” requires further development of the prefrontal cortex (PFC) later in childhood. – Sotres-Byon, F., Bush, D.E., LeDoux, J.E. Learning and Memory, 2004 103
  104. 104. Social class difference in PFC functioning• In contrast to the relatively early maturation of the amygdala and hippocampus, the range of executive function and self- regulation skills mediated by the PFC develops into adulthood. As the foundations of these skills emerge in the infant-toddler period, social class differences in the development and function of the PFC begin to appear. – Best, J.R., Miller, P.H. Child Development, 2010 104
  105. 105. Emotional problems• Because these higher-level neural circuits have extensive interconnections with deeper structures in the amygdala and hippocampus that control simple memory formation and responses to stress, executive function skills both influence and are affected by a young child’s management of strong emotions. Thus early childhood and repeated exposure to adversity can lead to emotional problems, as well as comprised working memory, cognitive flexibility, and inhibitory control. – Shonkoff, J. Science, 2011 105
  106. 106. Behaviour problems• Young children who experience the burdens of multiple economic and social stressors enter preschool with higher rates of emotional difficulties related to fear and anxiety, disruptive behaviours, impairments in executive function and self-regulation, and a range of difficulties categorised as behaviour problems, learning difficulties, attention deficit hyperactivity disorder (ADHD), or mental health problems. – Shonkoff, J., Phillips, D. (Eds.). From neurons to neighbourhoods. National Academy Press, 2000 106
  107. 107. Vulnerable and well-functioning• Vulnerable children who do well in school often have well-developed capacities in executive function and emotional regulation, which help them manage adversity more effectively and provide a solid foundation for academic achievement and social competence. – Raver, C.C. Child development, 2004 107
  108. 108. Executive function and literacy/numeracy• Evidence that executive function and self- regulation predict literacy and numeracy skills underscores the salience of these capacities for targeted interventions. – Raver, C.C. et al., Child Development, 2011 108
  109. 109. Facilitation during sensitive periods• The same neuroplasticity that leaves these capacities vulnerable to early disruption also enables their facilitation during sensitive development periods. – Loman, M.M. & Gunnar, M.R. Neurosci. Biobehav. Rev., 2010 109
  110. 110. Responsive caregiving• For example, responsive caregiving has been shown to be a potent buffer for primates with ”vulnerability genes” that affect stress hormone regulation, as well as for human toddlers who are biologically predisposed to be more fearful or anxious than typically developing children. – Barr, C.S. et al., Archieves of General Psychiatry, 2004 – Nachimias, M., Gunnar, M.R., Mangelsdorf, S., Parritz, R.H. & Buss, K. Child Development, 1996. 110
  111. 111. Interdisciplinary collaboration• If early childhood policy and practice focused more explicit attention on buffering young children from the neurodevelopmental consequences of toxic stress, then scientists, practitioners, and policy-makers could work together to design and test creative new interventions that combine both cognitive- linguistic stimulation with protective interactions that mitigate the harmful effects of significant adversity, beginning as early as possible and continuing throughout preschool.111 – Shonkoff, J., Science, 2011
  112. 112. Strengthen the capacity of early care providers• For this approach to succeed, new strategies will be needed to strengthen the capacities of parents and providers of early care and education to help young children cope with stress.• Providing the child care centers with personally suitable, pedagogically educated, and stable employees will be a major step in this direction. – Shonkoff, J. Science, 2011. 112
  113. 113. We spend too much moneyon mental illness in all the wrong places Hannu Pevkur, Minister of Social Affairs, 113 Estonia
  114. 114. I go for high quality child centers for all preschool children in Estonia – by 2017. And, I will set up aresearch group to monitor the long term mental health effects to Estonia. Hannu Pevkur, Minister of Social Affairs, Estonia 114
  115. 115. Concrete grips 115
  116. 116. Grips to promote children’s mental health• Regular municipality monitoring of distress/SWB• Child care center as local center for children’s health• Organise children’s health around child care centers• Family centers (Familiens hus)• Mental health aim in child care centers• Health contols moved to child care centers• Cololaps pedagogical service and school health service• Community psychologists in all municipalities• Systematic assessment off all children’s emotional, social and cognitive development in child care center• Continous effect evaluation• Good and independent quality contol porcedures 116
  117. 117. Svein (56), on disability award since 42 Depresjon 117
  118. 118. Hedda-Pernille Sørensen8 years of age - ADHD 118
  119. 119. Just likeChristmas Eve! Yeeeeeah! 119
  120. 120. And it pays off!It’ soooohealthy! Child care centers! 120
  121. 121. They could have Do you really helped us at the believe that?child care center! 121
  122. 122. The burden of mental disorder:Integration challenges in child mental health care Arne Holte Deputy Director General, Norwegian Institute of Public Health/ Professor of Health Psychology, University of OsloEvidenced Practice with Children and Youth at Risk: The Norwegian Experience Estonian Ministry of Social Affairs in collaboration with the Ministry of Education Research and the Ministry of Justice 122 EEA/Norway Grant, Tallinn, October 3.-4., 2012

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