Health and social problems among young adults who received child welfare interventions during childhood.

Project aims and changes of aims over time
We aimed to use Swedish national registry data to address several distinct knowledge gaps:
1. To expand knowledge about future health and psycho-social problems in young adult age among former child welfare clients (study population).
2. To examine the influence of school achivements/educational attainments on future health and psycho-social problems.
3. To examine links between teenage parenthood and future outcomes in the study population
4. To examine links between parent deaths and future outcomes in the study population.
There are ample results from the project related to the aims of 1, 2 and 4 above. Aim #3 has been less scrutinized than we envisioned from the start. Instead we have focused on using more advanced statistical model to estimate the links between school performance and teenage parenthood, in order to better understand the high overrisks in the study population for this outcome, when compared to majority population peers (Brännström et al, 2015, subm).

The three most important results from the project
1. School performance is a strong predictor for future health and psychosocial problems in the general population, independent from childhood socio-economic background and parental psychopathology (Gauffin et al, 2013; Hjern et al, 2015). In our study population, school performance has such strong statistical links to future outcomes that it seems reasonable to view it (a hypothesis) as a determinant factor for most outcomes, more or less regardless of type of outcome and how the outcome measure is constructed. A yet unpublished study from the project - using propensity score matching models - suggests that this association is causal (Forsman et al, in prep). Furthermore, child welfare children are typically performing below their cognitive potential, in comparison with other peers. Theoretically, this opens a window of opportunity for interventions. Several interventions trials/pilots aiming to improve literacy for child welfare children have been initiated (two are on-going) based on the results from the RJ-project. All have shown promising results, albeit with 'weak' evaluation design (pre/post measurements with age standardized instruments). In sum, it seems reasonable to expect positive results from such interventions, which also was concluded in a scoping review from the project (Forsman & Vinnerljung, 2012; Tideman et al, 2011; Tordön et al, 2014; Vinnerljung et al, 2014).
2. The prevalence of health problems, often cronic mental health problems (indicated by disability pension; Vinnerljung et al, 2015), is very high in comparison with majority population peers. The over-risks are especially high for more severe mental health outcomes (Berlin et al, 2011; Vinnerljung & Hjern, 2014; Vinnerljung et al, 2015) and slightly less pronounced for less serious outcomes (indicated by use of prescription drugs for depression and anxiety problems; Vinnerljung & Hjern, 2014). With high certainty, most of the more serious mental health problems had antecedents in childhood and adolescence, for many in the study population during their time in societal care. Other studies/publications, partly financed by the RJ-project suggest a high prevalence of somatic health and dental health problems at time entry into the child welfare (Kling et al, subm), but also a high prevalence of dental health problems in adulthood, when compared to majority population peers (Cederlund et al, in prep). We therefore conclude that systematic health assessments and health monitoring (somatic/dental/mental health), preferably mandated in legislation (like eg. in the UK) have a great potential to reduce health problems and improve both short and long term health outcomes. It seems reasonable to assume that such measures would produce gains in life quality for individuals in the study population, and may also reduce long term costs (eg. through a reduction in the prevalence of child welfare clients on disability pension in adult age; Vinnerljung et al, 2015).
3. Accumulations of risk markers/factors, often referred to as 'adverse childhood experiences' (ACE's), have a far more profound impact on long term health and social outcomes than singular 'traditional' risk factors, like parental psychopathology. This is also pertinent within populations from adverse childhood backgrounds (eg. child welfare children). Very few ACE studies without connection to the RJ-project have so far been done in Sweden. In international literature, only singular studies have reported on the influence of accumulation of SCE's on the development of children from adverse childhood backgrounds. The RJ-project has contributed to several studies in this domain (Björkenstam et al, 2013, 2015 + 2 submitted manuscripts; Brännström & Vinnerljung, 2015; Lif et al, in prep).

New research questions generated in the project.
The list is long. Firstly, a host of such questions relate to intervention and intervention research. The project has produced an empirical base for several reported and on-going interventions aiming to improve literacy/school performance of child welfare children (weg. Tordön et al, 2014; Vinnerljung et al, 2014). In on-going pilot projects, we are replicating a model tried in the UK and Denmark where children receive monthly book packages for half a year (preliminary results show 1 year gains in reading age). In practice, results from the RJ-project led to Vinnerljung being granted funding for a phd project focusing on educational interventions for children in societal care, financed from within Stockholm University. The project has also spawned new studies, addressing somatic health issues among child welfare children (Kling et al, subm). Vinnerljung and Hjern used results from the RJ-project to apply for funding to investigate somatic and dental health care needs among adolescents in juvenile detention centers. The RJ-project has also raised methodological questions eg. how to address issues of long term causality in a population where randomized trials are difficult or impossible to stage (for legal, ethical or practical reasons). Trying to construct contra-factual models we have used propensity score matching models and siblings designs with differential exposure (Brännström et al, 2013, 2015; Brännström & Vinnerljung, 2015; sibling studies in prep, see list of publications). We have also done several studies comparing long-term outcomes among vulnerable children growing up without being clients of child welfare services with peers who became child welfare clients (Hjern et al, 2013, 2015a, -b).

International links
We have established on-going collaboration with Ottawa University (Vinnerljung spent a month there as a visiting professor). Among other things, this has led to a formalized international network of scholars working with educational research targeting vulnerable children. Vinnerljung is at present participating in several Nordic research ventures, eg. at Aarhus University in Denmark, at Oslo and at Trondheim University in Norway. He has also formed a Nordic network of researchers who use registry data in child welfare research. In addition, Vinnerljung has an intensive collaboration with epidemiologists at Karolinska and UCLA (USA) who are doing ACE-studies (see lsit of publications). For several years, Hjern has an on-going collaboration with a network of European scholars in the field of social pediatrics. Members of this group have recently been awarded substantial funding for research targeting health of vulnerable children. Within this project will be staged a comparative study on health issues for children in societal care (legislation, organization, practice etc). Vinnerljung will join this project in the fall of 2016. This successful application for EU-funding was in part based on findings from the RJ-project.

Information to stakeholders outside the research/university sector
During 2011-2015, Vinnerljung has performed 30-40 lectures/seminars/workshops each year, targeting professionals, politicians/policy makers on local, regional and national levels, consumer groups and parliamentary inquiries. Hjern has had 15-20 such engagements annually. The results from the project have - as far as we can judge - had a significant influence on a national public inquiry into child welfare (SOU 2015:71).

The two most important publications from the project?
This is difficult to answer. Looking at statistics from Harzing's Publish or Perish, the most cited publications (in Nov 2015) are a) an article where we reported on the links between school performance and a host of long term outcomes (Berlin et al, 2011) and b a scoping review about the outcomes of interventions targeting school performance of children in societal care (Forsman & Vinnerljung, 2012). From looking at where these works have been cited and from contacts with international colleagues, it seems that these publications have made pronounced tracks in the international child welfare research.

Publication strategies
Until a couple of years ago, very few child welfare scientific journals offered the alternative of open access publishing. Therefore only four of our publications so far have been published as open access works. In order to at least partly compensate this shortcoming, we have so far published three research reviews in Swedish, based on the results from the project, all available for free through the web (Vinnerljung & Hjern, 2013; Vinnerljung et al, 2015a -b). In addition we have published several reports in Swedish (that can be downloaded for free through the web) from a project where Vinnerljung's participation was financed by the RJ-project (Hjern et al, 2013; 2015a, -b).

Publications

Publikationer helt eller huvudsakligen finansierade av RJ-projektet

1. Vinnerljung B, Brännström L & Hjern A (2015). Disability pension among adult former child welfare clients: A Swedish national cohort study. Children and Youth Services Review, 56, 169-176. (Open access)

2. Brännström L, Vinnerljung B & Hjern A (2015). Risk factors for teenage childbirths among child welfare clients: Findings from Sweden. Children and Youth Services Review, 53, 44-51. (Open access)

3. Vinnerljung B & Hjern A (2014). Consumption of psychotropic drugs among adults who were in societal care during their childhood. Nordic Journal of Psychiatry, 68, 611-619.

4. von Borczykowski A, Vinnerljung B & Hjern A (2013). Alcohol and drug abuse among young adults who grew up in substitute care – findings from a Swedish national cohort study. Children and Youth Services Review, 35, 1954-1961. (Open access)

5. Vinnerljung B & Hjern A (2013). Barn i social dygnsvård – summering av tio års registerstudier. Socionomen #8/2013, s 34-39.

6. 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.

7. Vinnerljung, B (2012) Registerforskning och socialt arbete. I E Backe-Hansen & I Frönes (red) Å forske på og med barn og unge – perspektiver og metodologi, s 242-362. Oslo: Gyldendal Akademisk Forlag.

8. 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.

9. 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, 2489-2494.

10. Vinnerljung, B (2011) Hjälp fosterbarn att klara sig bättre i skolan. I A Fredriksson och A Kakuli (red) Ett annat hemma. Om samhällets ansvar för placerade barn, s 51-68. Stockholm: Gothia förlag.

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Publikationer där Vinnerljungs och/eller Hjerns arbete har finansierats av RJ-projektet

1. Brännström L & Vinnerljung B (2015). Kontaktfamilj/-person för yngre och äldre barn: Har insatsens varaktighet och ansamlingar av ogynnsamma omständigheter under barnens uppväxt någon betydelse för utfall på lång sikt? Stockholm: Stockholms Universitet, Inst för Socialt Arbete, Arbetsrapport 2015:2.

2. Björkenstam E, Burström B, Brännström L, Vinnerljung B, Björkenstam C & Pebley A (2015). Cumulative exposure to childhood stressors and subsequent psychological distress. An analysis of US panel data. Social Science & Medicine, 142, 109-117.

3. Gauffin K, Vinnerljung B & Hjern A (2015). School performance and alcohol-related disorders in early adulthood: a Swedish national cohort study. International Journal of Epidemiology, E-publ, Advance Access, doi: 10.1093/ije/dyv006.

4. Ragmar J, Hjern A, Vinnerljung B, Strömland K, Aronson M & Fahlke C (2015). Psychosocial outcomes of fetal alcohol syndrome in adulthood. Pediatrics, 135, e52-e58.

5. Hjern A, Arat A, Rostila M, Berg L & Vinnerljung B (2015). Hälsa och sociala livsvillkor hos unga vuxna som förlorat en förälder i barndomen. Nka Rapport 2014:3. Växjö/Stockholm: Nka, Linnéuniversitetet/Stockholms Universitet/KI, CHESS.

6. Hjern A, Arat A & Vinnerljung B (2015). Att växa upp med föräldrar som har missbruksproblem eller psykisk sjukdom – hur ser livet ut i vuxen ålder? Nka-rapport 2013:4. Växjö/Stockholm: Nka, Linnéuniversitetet/Stockholms Universitet/KI, CHESS.

7. Brännström L, Vinnerljung B & Hjern A (2015). Effectiveness of Sweden´s Contact Family/Person program for older children. Research on Social Work Practice, 25, 190-208.

8. Tordön R, Vinnerljung B & Axelsson U (2014). Improving foster children’s school performance. A replication of the Helsingborg study. Adoption & Fostering, 38, 38-49.

9. Hjern A, Berg L, Rostila M & Vinnerljung B (2013). Barn som anhöriga: hur går det i skolan? Nka-rapport 2013:3. Växjö/Stockholm: Nka, Linnéuniversitetet/Stockholms Universitet/KI, CHESS.

10. Gauffin K, Vinnerljung B, Fridell M, Hesse M & Hjern A (2013). Childhood socio-economic status, school failure, and drug abuse – a Swedish national cohort study. Addiction, 108, 1441-1449.

11. Björkenstam E, Hjern A, Mittendorfer-Rutz, Vinnerljung B, Hallqvist J & Ljung R (2013). Multi-exposure and clustering of adverse childhood experiences, socioeconomic differences, and psychotropic medication in young adults. PLOS ONE, 8:1, e53551 (www.plosone.org). (Open acess).

12. Brännström L, Vinnerljung B & Hjern A (2013). Long term outcomes of Sweden’s Contact Family Program for children. Child Abuse & Neglect, 37, 404-414.

13. Vinnerljung B (2013). Uppväxtbakgrund, skolmisslyckande och narkotikamissbruk – en registerstudie av 1.4 miljoner svenskar. I B Johnson och P Lalander (red) Med narkotikan som följeslagare, s 139-146. Malmö Högskola: Fakulteten för hälsa och samhälle, FoU-rapport 2013:3.

14. Björkenstam C, Björkenstam E, Ljung R, Vinnerljung B & Tuvblad C (2013). Suicidal behavior among delinquent former child welfare clients. European Child & Adolescent Psychiatry, 22, 349-355.

15. Tideman E, Vinnerljung B, Hintze K & Isaksson A A (2011). Improving foster children’s school achievements: Promising results from a Swedish intensive study. Adoption & Fostering, 35, 44-56. Reprinted in S Jackson (ed) (2013). Pathways through education for young people in care, pp 87-100. London: BAAF.

16. Björkenstam E, Björkenstam C, Vinnerljung B, Hallqvist J & Ljung R (2011) Juvenile delinquency, socio-economic background and suicide – A Swedish national cohort study of 992 881 adults. International Journal of Epidemiology, 40, 1595-1592.

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Publikationer som finansierats av andra men som initierats av resultat från RJ-projektet

1. Vinnerljung B, Forsman H, Jacobsen H, Kling S, Kornor H & Lehman S (2015). Barn kan inte vänta. Översikt av kunskapsläget och exempel på genomförbara förbättringar. Stockholm: Nordens Välfärdscenter, Projekt: Nordens barn – fokus på barn i fosterhem.

2. Vinnerljung B & Andreassen T (2015). Barn och unga i samhällets vård. Forskning om den sociala dygnsvården. Stockholm: FORTE, Forskning i korthet, #4.

3. Vinnerljung B, Tideman E, Sallnäs M & Forsman H (2014). Paired Reading for foster children: results from a Swedish replication of an English literacy intervention. Adoption & Fostering, 38, 361-373.

4. Brännström L & Vinnerljung B (2014). Långsiktiga resultat av kontaktperson/familj för äldre barn: En personorienterad ansats. Stockholm: Stockholms Universitet/Allmänna Barnhuset.

http://www.allmannabarnhuset.se/wp-content/uploads/2014/09/Brännström-Vinnerljung-2014.pdf

5. Vinnerljung B & Sallnäs M (2014). Placement breakdowns in long term foster care - a regional Swedish study. Child and Family Social Work. Epubl DOI:10.1111/cfs.12189

6. Tideman E, Sallnäs M, Vinnerljung B & Forsman H (2013). Paired Reading. Ett försök i sju kommuner med lästräning för familjehemsplacerade barn. Stockholm: Allmänna Barnhuset.

7. Vinnerljung B, Brännström L & Hjern A (2011). Kontaktfamilj/-person för barn. Uppföljning och utvärdering med registerdata. Stockholm: Stockholms Universitet, inst för socialt arbete, Rapport i Socialt Arbete #138. http://su.diva-portal.org/smash/record.jsf?searchId=1&pid=diva2:460207

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Insända manus där Vinnerljungs och/eller Hjerns arbete har finansierats av RJ-projektet

1. Gauffin K, Hjern A, Vinnerljung B & Björkenstam E (rev/resubm). Childhood household dysfunction, social inequality and alcohol related illness in young adulthood. A Swedish national cohort study.

2. Björkenstam E, Dalman C, Vinnerljung B, Weitoft GR, Walder D & Burström B (rev/subm) Childhood household dysfunction, school performance and psychiatric care utilization in young adults: a register study of 96,399 individuals in Stockholm County.

3. Kling S, Vinnerljung B & Hjern A (rev/resubm). Somatic health assessments of 120 children entering the Swedish child welfare system.

4. Björkenstam E, Burström B, Vinnerljung B & Kosidou K (subm). Childhood household dysfunction and adult psychiatric disorder: An analysis of 107 704 Swedes.

5. Berg L, Back K, Vinnerljung B & Hjern A (subm). Parental alcohol-related disorders and school performance in 16 year olds–a national cohort study.

6. Brännström L, Vinnerljung B & Hjern A (subm). Child welfare clients have higher risks for teenage childbirths: Which are the major confounders?

7. Österberg T, Gustavsson B & Vinnerljung B (subm). A big-data study of atypical childhoods and adult labour market status during a severe recession in Sweden.

8. Rostila M, Berg L, Arat A, Vinnerljung B & Hjern A (subm). Parental death in childhood and self-inflicted injuries in young adults-a national cohort study from Sweden.

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Manus under arbete där Vinnerljung och/eller Hjerns arbete har finansierats av RJ-projektet

1. Lif E, Brännström L & Vinnerljung B. Cumulative adverse childhood experiences and later economic hardship. A longitudinal analysis of Swedish former child welfare clients.

2. Hjern A, Vinnerljung B, Brännström L & Berg L. Does long-term foster care improve health outcomes in young adult age? Evidence from a sibling study.

3. Vinnerljung B, Hjern A, Brännström L & Berg L. Does long-term foster care improve social outcomes in young adult age? Evidence from a sibling study.

4. Hjern A, Vinnerljung B, Brännström L & Berg L. Does adoption from foster care improve long-term outcomes? Evidence from a sibling study.

5. Forsman H, Brännström L, Vinnerljung B & Hjern A. Does poor school performance cause later psychosocial problems among children in foster care? Evidence from Swedish longitudinal registry data.

6. Cederlund A, Berlin M, Vinnerljung B & Hjern A. Dental health and dental health care consumption among young adults who were in out-of-home care during their formative years.