The long-term cost of childhood conduct problems

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In this podcast, we talk to Dr. Eila Kankaanpää, senior lecturer in health economics at the University of Eastern Finland.

The focus of this podcast is on the JCPP paper, ‘The long-term cost of childhood conduct problems: Finnish Nationwide 1981 Birth Cohort Study’ (

Eila is a co-author of the paper and sets the scene by providing insight into her current role and what prompted her research in child and adolescent mental health.

Eila talks us through what her paper looks at, what the costs associated with conduct problems in childhood include, highlights the methodology used, and shares some of the key findings.

Eila provides further insight into her conclusion that the high costs justify the development and evaluation of interventions for childhood conduct problems. Eila then discusses what she would like to see done about this, as well as what area of research she would like to see being focused on.

Furthermore Eila mentions what message policymakers should take from her findings, what the implications are for practitioners, and what professionals working with young people and their families should also take from her findings.

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Eila Kankaanpää
Dr. Eila Kankaanpää

Dr. Eila Kankaanpää currently works at the Department of Health and Social Management, University of Eastern Finland. Eila’s research interest is in developing economic evaluation to better serve practice and, on the other hand, studying the theoretical framework behind it. Eila’s research projects include: the process and practice of shared decision making (PROSHADE) project which promotes cost-effective and high-quality health care based on reliable information and shared decision-making; and the Awareness, prevention and early intervention (APEX) project 2016-19 which aims to develop and study low-threshold, digitally delivered preventive intervention programs regarding maternal postpartum depression, conduct problems of pre-school children and anxiety problems among school-aged children. (Bio from UEFCONNECT)


Jo Carlow: Hello. Welcome to a different type of In Conversation podcast from the Association for Child and Adolescent Mental Health, ACAMH, where we will look at the paper “The long-term cost of childhood conduct problems: Finnish Nationwide, 1981 Birth Cohort Study,” recently published in the Journal of Child Psychology and Psychiatry, the JCPP.

I’m Jo Carlow, a freelance journalist with a specialism in psychology. And I have with me Eila Kankaanpää, senior lecturer in health economics at the University of Eastern Finland. Eila is a co-author of the paper that we’ll be discussing today.

The JCPP is one of the three journals produced by the Association for Child and Adolescent Mental Health. ACAMH also produces JCPP Advances and the CAMH.

If you’re a fan of our In Conversation series, please subscribe on your preferred streaming platform. Let us know how we did, with a rating or review. And do share with friends and colleagues.

Eila, welcome. Can you start with a brief introduction about yourself and what you do?

Eila Kankaanpää: OK, first, thank you for the opportunity to participate in this In Conversation series. For the audience, the most important thing about my background is that I’m an economist. All my career, my work has been connected to health services and health. And for the last 10 years, I’ve been working at the University of Eastern Finland, balancing between teaching, research, and administration.

Jo Carlow: Eila, what prompted your interest in child and adolescent mental health?

Dr. Eila Kankaanpää: I think it was a stepwise growing interest. About 10 years ago, I was involved in a project initiated by the Save the Children Finland. Then we conducted a systematic review on economic evaluation of parent training programmes. And this publication led to collaboration with Professor Sourander, and he’s leading the Research Centre for Child Psychiatry at the University of Turku. And actually, this paper we are discussing today is one product of that collaboration. Actually, already, at my previous job at the Finnish Institute of Occupational Health, the importance of child and adolescent mental health was noticed. Mental health problems are the most serious health problem in working life. And often, these mental health problems have their origin already in childhood.

Jo Carlow: Let’s turn to the paper. So this is “The long-term cost of childhood conduct problems: Finnish Nationwide 1981 Birth Cohort Study” published in the JCPP. Eila, can you give us a summary of the paper? What did you look at?

Dr. Eila Kankaanpää: Our aim was to evaluate the long-term, cumulative cost of childhood conduct problems. When their almost 6,000 children in their 1981 birth cohort were eight years, both parents and teachers assessed the conduct problem symptoms. And we had registered the data and could follow these kids from the 8-year-old ones until they were 13 and registered data on publicly provided services. Thus, our point of view was to estimate the costs from the public service perspective.

Jo Carlow: In the paper, the costs associated with conduct problems in childhood are described as substantial. Can you set the scene for us? What do these costs include?

Dr. Eila Kankaanpää: With this basic cohort [INAUDIBLE] data from 1988, we combined three different registers. We had register data on all inpatient care and public health services. Another registry contained information about purchased prescribed medicine. And the third register was Finnish police register, which contains all criminal offences. Because its offences and the police has the obligation to register all suspicions, so the threshold is really low. And for the audience, it might be important to know that, in Finland, the age of criminal liability starts at the age of 15. Is this the point to tell that we do not have everything that would be important? Because with this criminal offence cost, all these costs to file prosecutors in courts and punishments are excluded. And we do not have outpatient health services, not social services. And services at school are missing.

Jo Carlow: Can you tell us a little bit about the methodology that you used for the research?

Dr. Eila Kankaanpää: OK. In 1988, when the children were eight, both parents and teachers assessed the psychiatric symptoms on Rutter questionnaires. We summed up the ratings of both parents and teachers and then we, in a way, we put all the participants in a row. And the lowest 50% of the [INAUDIBLE] we named it “low level of conduct problems symptoms group. In the high-level group belongs all those, the 10% having the most conduct problem symptoms. Intermediate-level group, belong those in between. And about the costs, the cost data was right-skewed, as usual. And about 17% of the subjects had zero total costs. And the skewness is also the reason why we present both medians and means for the costs. And in addition, we calculated confidence intervals for the average costs from our bootstrapped Iteration. And to find out if the differences between the groups by gender or the difference between genders were statistically significant, we used the Wilcoxon and rank sum tests.

Jo Carlow: And what did you find? Can you share some of the key findings?

Dr. Eila Kankaanpää: OK, I think the rule of thumb is actually the magnitude differences. So they could give a concrete picture. So those individuals with high level of symptoms, they had fourfold and within the medial level symptoms they had twofold higher costs compared to children with a low level of conduct problem symptoms. OK, first I take this difference between high level and low-level conduct problem groups for both boys and girls.

For girls, the high-level groups had 2.5 times the costs in the low level group. But for the boys, the difference was almost six-fold. So it means that the seriousness in a way, the differences in conduct problems seem to be more serious for boys than for girls. And if you want to have this difference in monetary terms, so the difference between the high and low groups was about 15,000 euros for girls and almost 56,000 euros for boys.

Jo Carlow: It’s such a substantial difference. Can you elaborate on this? Why is this?

Dr. Eila Kankaanpää: Main cost difference driver is criminal offences. In general, about 80% of all offences are registered for men in Finland.

But also, the psychiatric inpatient care during the years from eight year to 30 has an important role in the cost difference between genders. And I think there is a problem because the previous research has mainly concerned boys. And with my background, I cannot really tell if the conduct problems is a different problem for girls and boys. So this is for someone else to tell. But it differs according to gender.

Jo Carlow: Right, well, it touches a bit on my next question because you conclude that the high costs justify development and evaluation of interventions for childhood conduct problems. Can you say more about this?

What would you like to see done? And I suppose an extra question is, what area of research would you like to see focused on?

Dr. Eila Kankaanpää: First I would like to remind that this kind of costing studies can only raise up the importance of the problem. We don’t provide any solutions. But it clearly shows that there is a need to develop interventions for screening, prevention, and treatment for conduct problems in childhood. And both the effectiveness and cost effectiveness of interventions should be evaluated. And actually, what is most needed is long term evaluations.

Therefore, it would be really good if more effectiveness studies could use register data to have a longer follow up. And for practise and politicians, studies that compare several alternative interventions would be the best.

Jo Carlow: Eila, you mentioned policy makers there. What message should they take from your findings?

Dr. Eila Kankaanpää: The consequences and costs associated with problems in childhood are substantial also especially to the society. I don’t take this individual suffering into account. So already these high costs would justify development and evaluation of interventions. So the clear message is give funding for research.

Jo Carlow: Right.

Dr. Eila Kankaanpää: But also while steering the service system, they should find means to support practitioners to implement cost effective services in prevention and treatment. So actually, they have both tasks-to support researchers and to support practitioners.

Jo Carlow: Yeah, absolutely. What are the implications for practitioners? So for professionals working with young people and their families, what should they take from your findings?

Eila Kankaanpää: I think they should take care that they first find those children and families that need help and that they should use effective services. And I doubt that one intervention could solve the whole problem. So in a way, they need a bundle of services so that they fit the age of the child and support families in different ways. And another thing that doesn’t usually come up with intervention effectiveness studies is equity. So they should also take care that those who need have access to services.

Jo Carlow: Is there anything else in the paper that you would like to highlight?

Dr. Eila Kankaanpää: Also, I say that this paper doesn’t solve the problem. So I would still emphasise that this is still needed. Because if we want to study this long run effectiveness and cost effectiveness, we need economic models. Models can benefit from this kind of studies. Actually, they need it. So first, you have to give up the scenario that what happens in the long run. And then you can evaluate what happens if something is effective in youth or childhood.

Jo Carlow: And are you planning some follow up research that you can share with us?

Dr. Eila Kankaanpää: We have a group of young researchers. So some of them are working on issues like this. So Elisa Rissanen, the first author, she works on a project to evaluate cost effectiveness of incredible years programme but this time for families who already receive family support services from social services or child protection. And listeners might also be interested in our systematic review and economic evaluation studies of preventive interventions for anxiety disorders in children and adolescents.

Jo Carlow: Is there anything else in the pipeline for you that you’d like to mention?

Dr. Eila Kankaanpää: Personally, I’m a little bit leaving this field because during the next five years, I’m leading a project where we develop and evaluate means to integrate economic information in clinical practise guidelines. So my research is taking a step towards implementation and practise.

Jo Carlow: Still within child and adolescent research?

Dr. Eila Kankaanpää: It depends what kind of practise guidelines will be in the pipeline, but I think mental health will be there for sure.

Jo Carlow: Fantastic. And finally, what is your take-home message for those listening to our conversation?

Dr. Eila Kankaanpää: I would emphasise that it is very important to develop cost effective interventions. And even more important is to integrate these into the service system,
and not only in health care, but also in early childhood education and at schools. And I think that to gain success, we need researchers’, politicians’, and practitioners’ collaboration and families.

Jo Carlow: Eila, thank you so much. For more details of Eila Kankaanpää, please visit the ACAMH website, and Twitter @acamh. ACAMH is spelt A-C-A-M-H. And don’t forget to follow us on your preferred streaming platform. Let us know if you enjoyed the podcast with a rating or review, and do share with friends and colleagues.

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