The increasing knowledge base on ACEs has led to recommendations of routine screening of ACE in healthcare, however, evidence on the
effectiveness of these processes on mental health outcomes, as well as on the feasibility and acceptability of the screening, remains inconclusive (Ford et al., 2019; Loveday et al., 2022). Since this study used administrative data, the results are reminiscent of a screening process: all the ACEs measured are known to officials, mostly in health and social care settings, but also in the police records. These adverse experiences were associated with an increased risk of self-harm, which implies that there is an opportunity to reach children at elevated risk of self-harm when their parents contact healthcare
professionals due to substance misuse or psychiatric disorders, for instance.
Taking these children and their mental health needs into account and providing them support in the course of parental treatment might be beneficial for mental health promotion of the children (Arango et al., 2018;
Ranning et al., 2020). In addition, as shown in sub-study IV, parents may also need additional support when their child self-harms, which also calls for integrating family members to treatment processes (Arbuthnott & Lewis, 2015).
Furthermore, the findings from this thesis suggest that, when compared to their peers, individuals who self-harm have lower GPAs, are more often in out-of-home care and have more police contacts due to violent offending.
Therefore, incorporating a mental health perspective in these institutional settings outside of healthcare, and establishing multidisciplinary
collaboration between different adults working with the adolescents in different contexts might also be quite beneficial for self-harm prevention (Arango et al., 2018). Finally, besides curative social and healthcare services, population-level prevention of ACEs through increased parental support throughout a child’s early life-course might also be effective (Arango et al., 2018). Possible support might include, for instance, continued healthcare visits with parents and children after the maternity clinic period, greater involvement of parents in day care and compulsory school, as well as more flexibility to combine family and work.
In addition to ACE prevention, income support for low-income families could be beneficial in terms of preventing self-harm and other negative mental health outcomes (Arango et al., 2018). This is supported by the findings from sub-study II of this thesis, which showed that a hypothetical intervention on childhood income decreased the probability of self-harm in young adulthood, as well as the probability of different adolescent outcomes, such as out-of- home placements and violent crime. In the context of a universal welfare state with a considerable level of existing economic redistribution, including both universal and targeted social benefits, income support programmes could be easily implemented. However, the actual effects and costs of such interventions are hard to predict based on results from observational research. The g-formula used in in sub-study II is a step forward since it can be used to simulate effects of a hypothetical income intervention, and to
Discussion
calculate costs of such intervention (Keil et al., 2014). However,
interpretation of estimates derived from g-formula still requires caution, as it is likely that there is at least some unobserved confounding present
(Sariaslan et al., 2021). Real-life applications of income support might also have unintended consequences (Bitler & Karoly, 2015), although these side effects are not always negative (Berkman, 2011). An important practical challenge for income support programmes targeted to low-income households is that public attitudes towards such measures are often unsupportive (Berens & Gelepithis, 2019).
Other policy implications emerging from this thesis relate to inequalities in psychiatric treatment use. Besides this study, many previous papers have documented that individuals in lower SEP tend to use less healthcare, especially specialised care (see e.g., Blomgren & Virta, 2020; Doorslaer et al., 2006). Although lower SEP is associated with higher risk of psychiatric inpatient admissions (Suokas et al., 2020), outpatient visits (Paananen, Santalahti, et al., 2013) and medication use (Junna et al., 2019), results from this thesis indicate that when focusing on populations with a high need of treatment, the direction of the association is reversed. Similar findings have been shown in the previous literature (Moustgaard et al., 2016; Paananen, Ristikari, et al., 2013). To some extent, these findings are likely to be explained by long waiting times in public healthcare, availability of specialised services by region of residence, as well as different services available by SEP due to supplemental use of private healthcare and the occupational healthcare system (Blomgren & Virta, 2020; OECD, 2019;
Paananen, Santalahti, et al., 2013). A reform of the Finnish health and social care system is currently being implemented, and the considerably large inequalities in access to treatment were a major motivating driver behind the restructuring (Finnish Government, 2019). Whether the reform will level off some of the current inequalities is an important future topic in Finnish social and health policy research.
The task of alleviating differences in treatment use spawning from factors not directly related to purchasing power, such as knowledge of the healthcare system and available treatment types (Halonen et al., 2018), stigma related to psychiatric disorders (Radez et al., 2020), or differences in doctor–patient communication by a patient’s socioeconomic status (Verlinde et al., 2012) is more difficult. One possibility might be to introduce programmes aimed at improving mental health literacy and information on the healthcare system at compulsory and secondary schools (Arango et al., 2018; Hawton,
Saunders, et al., 2012). Moreover, additional training in medical schools related to encountering individuals with different sociodemographic backgrounds could also be useful (Verlinde et al., 2012).