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 Oslo
Evidenced 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. Health promotion and illness prevention:
a success story
2

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
19
Source: 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. 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. Coronary heart disease and stroke mortality in Norway
Men, 45-64, 65-79 and 80+ years, 1990-2009
4000
3500
3000
Døde 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
År
Source: Norgeshelsa/DÅR 5

6. Road traffic deaths in Norway
Men, all age groups and by age, 1970-2009
6
Source: Norgeshelsa/DÅR

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 6
Source: 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. Suicides in Norway
Men and women, 1970-2009
N per 100 000 inhabitants
30
25
20
Døde 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. Caries free teeth in Norway
5 and 12 olds
90
80
70
60
50
Prosent
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. 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. 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. Help to people with Help to did for people
mental disorders has with mental disorders has
failed at all levels! failed at all levels!
12
Unanimous Norwegian Parliament, 1998

13. National programme for mental health
1999 – 2008
8 000 000 000 Euro
13

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. Gaustad asylum in Oslo, build in 1855.
From living your life in an institution to….
15

16. …to living your life at home and receive
local community based services
“Josefinegaten”
community mental
health center, Oslo
16

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. Accessibility: Community mental health
centers (CMHC);
1996 2008
Community
Mental Health
Centres 48 75
Man years in CMHC 1763 6286
Beds 978 1865
18

19. Specialized mental health services
1996 1998 2006 2008
Outpatient
consultations 438 000 476 000 931 000 1099 000
19

20. Earmarked resources to community mental health
services during the program period (million NOK)
20

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. 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. Sick leave openly because of ”depressive reaction”
23
Kjell Magne Bondevik, former Prime Minister of Norway

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. 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 among
Øyane DPS, Fjell municipality young adults
25

26. Svein (56), on disability award since 42
Depresjon 26

27. Hedda-Pernille
Sørensen
8 years of age - ADHD
27

28. ADHD
Helped at 4 years of age
Hedda-Pernille Sørensen (8)
28
fikk hjelp som fireåring

29. Hedda-Pernille
Sørensen
Svein Farseth
Not prioritised in
Escalation plan
for mental health 29

30. The Mental Health Challenge
30

31. Mental disorders is the
biggest health
challenge 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. 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. Work related illness by industry
33
Figures from Dame Carol Black's Review of the health of Britain's working age population (2008)

34. Work absence: Main causes of paid sick leave
34

35. Disability awards: Change in main causes
35

36. Disability award:
Muscle/skelleton diseases most frequent reason
36

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
37
Age at disability award in Norway (2000-2003)

38. Lost work years because of mental illness:
Average: 21 years per disability award
Mental disorder
Neurological
Injury/Poisoning
Othert
Cancer Muscle/skelleton
Lung
Coronary
38
Mykletun A. & Knudsen AK., NIPH, 2004

39. Lost work years due: EU-27
Mental
Cardiovascular
Diabetes/endocrine
Injuries Cancers
Muscle/skelet/skin
Senses
39

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. Half of cost of illness due to depression, Sweden
€ PPP mill Health Direct non- Indirect Total costs
services medical costs
Affective 331 mangler 1096 1427
Dependency 206 40 519 765
Anxiety 294 n.a. 265 559
Psychoses 317 17 n.a. 334
Total mental 1148 57 1880 3085
Dementia 198 554 n.a. 752
Olesen et al. (2007). Cost of mental illness by type of mental illness
41

42. Depression: 86 % indirect costs
Indirect costs more than doubled in 7 years, Sweden
€ mill 1997 1998 1999 2000 2001 2002 2003 2004 2005
2005
Direct 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
42
Sobocki et al, 2007. Cost of depression in Sweden

43. Productivity loss from depression far higher
than 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. Mortality: Premature death following
depression as likely as for sigarette smoking
Depression Tobacco smoking
Adjusted 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. 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. 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. The mental health challenge - summarised
1. Every second/third of us get it at least once in our life time
2. Every third of us in a year
3. ¼ of all burden of disease in Europe
4. More expensive than any other illness: 9 bill Euro/year
5. Burden 50% more than all cancers and heart diseases
6. 40 % of registered sickness leave
7. 40 % of disability award costs
8. Costs increase – particularly among young adults
9. 21 lost work years per disability award
10. Deadly as tobacco smoking (depression) 47

48. The mental health challenge – summarised
Continued
12. Depression alone represents half of the costs
13. Direct treatment cost for depression: 10-20%
14. Costs due The consequences of depression: 80-90%
to mental health challenge - summarised
15. Sick leave costs depression doubled in 7 years
(Sweden)
16. More skewed cost distribution than any other illness
17. Easier to prevent and treat than most other mental
disorders
• Cuijpers et al. 2009 48

49. Threats to society: Conclusion
The by far largest threat to the society
comes from the common mental
disorders:
• Depression
• Anxitey
• Alcohol abuse
49

50. We cannot combat
common mental
disorders by
continuing to build
out specialised
50
health services!

51. We must prioritise according to public
health, 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. Prevention
52

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. 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 l
re
lsb
fø and av efall
i aa
Fo
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. Ten principles
for a mentally healthier population
55

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. Mental capital
• A society’s potential to
develop
– Security
– Autonomy
– Creativity
– Emotions
– Thinking
– Behaviour coordination
behaviour
– Social networks
– Cope with challenges 57

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. Sykdomsbelastning i EU 25 (DALY): Psykiske lidelser
Total mill. DALY % av total
Alle årsaker 98,7
1. Unipolar Major Depression 6,7 6,8
2. Schizofreni 2,3 2,3
3. Bipolar forstyrrelse 1,7 1,7
4. Obsessiv-kompulsiv forst. 1,5 1,5
5. Panikklidelse 0,7 0,7
6. PTSD 0,3 0,3
7. Villet egenskade (selvmord) 2,2 2,2
8. Alle mentale forstyrrelser 15,3 15,4
National Institute of Mental Health Publication No. 01-4586
59

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. 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. 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. 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. 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. 6. Prioritise interventions towards the general
population rather than internventions
targeting 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. We spend too much money
on mental illness in all the
wrong places
Michael F. Hogan, char of President
George W. Bush's 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. 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. 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. Barn er bedre enn
bank og børs!
Nobel laureate
in economy,
James J. Heckman
,
Children better than
bank and stocks! 69

70. Heckman, James J. (2006). " Skill Formation and the Economics of70
Investing in Disadvantaged Children, Science, 312(5782): 1900-1902.

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. 10. Prioritise interventions with a plan and a
budget 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. Principles of promotion - summarised
1. Mental capital before mental disease
2. Burden of disease rather than humanism
3. Possibilities before wishes
4. Health promotion before illness prevention
5. Cost-benefit before political correctness
6. Universal before targeted
7. Outside before inside health services
8. First years of life before later years
9. Level of distress before number of cases
10.Evidence before good intentions 73
Holte, 2012

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. 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. 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. Children attending a child care center (n)
77
Source: Child statistics, Statistics Norway

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&family
service!
of Edu! Ministry directorate!
of child!
78

79. In Norway, In Estonia,
kindergartens are kindergartens are
education institutions education institutions
– not health services – not health services
Kristin Halvorsen, Hannu Pevkur, 79
Minister of education, Norway Minister of Social Affairs, Estonia

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. 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. 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. 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. 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. Konklusjon, Jaffe et al., 2011
”Basert på sammenligning av barn som begynte i
omsorg utenfor hjemmet på ulike tidspunkter i de tre
første leveår, med deres søsken som ikke gjorde det,
konkluderer vi at tidspunkt for oppstart i omsorg
utenfor hjemmet har verken positive eller negative
virkninger på barns utvikling. Kjennetegn ved familier
som velger å benytte omsorg spiller en større rolle i å
påvirke barns utvikling enn tidspunktet for når barna
begynner i omsorg utenfor hjemmet i de tre første
leveårene”
Jaffe, van Hulle, Rodgers: Effects of Nonmaternal Care in the First 3 Years on
Children’s Academic Skills and Behavioral Functioning in Childhood and Early
Adolescence: A Sibling Comparison Study. Child Development, 2011.
85

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. The only thing that counts is quality
Sylva 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. Assessment at 3 and 11 years of age
Sylva 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. 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. Do child care centers prevent anxiety,
depression and behavior problems?
We do not know yet. But we did not know when
when we invested in employment for all, healthy
dieting, exercise, high tax on tobacco and alcohol,
round abouts in road crosses, concrete road
division, fluor tooth paste, and laying infants on
their back, that it would result in reduced: infant
mortality, cornary heart mortality, stroke mortality,
cancers mortality, traffic deaths, healthier teeth,
increased longevity of life
99

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. 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. ”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. ”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. 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. 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. 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. 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. 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. 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. 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. 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. 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. We spend too much money
on mental illness in all the
wrong places
Hannu Pevkur,
Minister of Social Affairs,
113
Estonia

114. I go for high quality child
centers for all preschool
children in Estonia – by
2017. And, I will set up a
research group to monitor
the long term mental
health effects to Estonia.
Hannu Pevkur,
Minister of Social Affairs,
Estonia 114

115. Concrete grips
115

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. Svein (56), on disability award since 42
Depresjon 117

118. Hedda-Pernille
Sørensen
8 years of age - ADHD
118

119. Just like
Christmas Eve!
Yeeeeeah!
119

120. And it pays off!
It’ soooo
healthy! Child care centers!
120

121. They could have Do you really
helped us at the believe that?
child care center!
121

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 Oslo
Evidenced 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