AimThe stress hormone cortisol is vital to survival, and a disturbed circadian rhythm can be deleterious to health. However, little is known about cortisol levels in healthy children. The aim of this study was to examine cortisol levels in relation to body mass index (BMI), age and sex. MethodsSalivary samples were collected in early morning, late morning and evening, on four consecutive days, from 342 children aged 6-12years using Salivette((R)) tubes. Samples were analysed using a commercial enzyme immunoassay (EIA). School nurses measured the childrens height and weight, and these measurements were used to calculate their BMI. ResultsThe children displayed a circadian rhythm in cortisol secretion, with morning zeniths and evening nadirs. Average cortisol levels in early morning, late morning and evening were significantly lower in overweight and obese children than in their normal weight counterparts. Cortisol levels did not vary significantly with age or sex. ConclusionOur findings may suggest cortisol suppression in overweight and obese children. We found no evidence that sex or age influences cortisol levels. These findings highlight the need for further research on the relationship between stress and obesity in children.

Aim: To investigate the characteristics of severe abuse of children and possible differences in comparison with less severe abuse. Method: Cases of abuse reported to the police within a single police district (n = 142) in Sweden were studied. The severe cases were compared to all the remaining cases. Results: Severe abuse constituted 14% of the total cases and was reported by agencies to a greater degree than minor cases. The suspected perpetrators were socially disadvantaged people in both groups. Half of the most serious cases led to conviction in the courts, compared to 8% in the reference group. The children who had been subjected to abuse were often already known to social services and reports of child abuse had frequently been made. Conclusion: In comparison between cases of severe and minor child abuse reported to the police, the results did not show any crucial differences except the pattern of reporting and a higher occurrence of prosecution/conviction in the severe cases. This finding places a responsibility on agencies outside of the justice system to consider all cases of reported abuse as serious warning signals and to make independent evaluations to identify risks and the possible need for child protection. © 2007 The Author(s).

Objective: To examine the associations between child physical abuse and health problems/risk-taking behaviors among teen-agers. Further to evaluate concurrence of other types of abuse and how these alone and in addition to child physical abuse were associated with bad health status and risk-taking behaviors.

Methods: A population-based survey was carried out in 2008 among all the pupils in two different grades (15 respectively 17 years old) in Södermanland County, Sweden (N=7 262). The response rate was 81.8 %. The pupils were asked among other things about their exposure to child physical abuse, exposure to parental intimate violence, bullying and exposure to being forced to engage in sexual acts. Adjusted analyses were conducted to estimate associations between exposure and illhealth/risk-taking behaviors.

Results: Child physical abuse was associated with poor health and risk-taking behaviors with adjusted Odds Ratios (OR) ranging from 1.6 to 6.2. The associations were stronger when the pupils reported repeated abuse with OR ranging from 2.0 to 13.2. Also experiencing parental intimate partner violence, bullying and being forced to engage in sexual acts was associated with poor health and risk-taking behaviors with the same graded relationship to repeated abuse. Finally there was a cumulative effect of multiple abuse in the form of being exposed to child physical abuse plus other types of abuse and the associations increase with the number of concurrent abuse.

Conclusions: This study provides strong indications that child abuse is a serious public health problem based on the clear links seen between abuse and poor health and behavioral problems. Consistent with other studies showing a graded relationship between experiences of abuse and poor health/risk-taking behaviors our study shows poorer outcomes for repeated and multiple abuse. Thus, our study calls for improvement of methods of comprehensive assessments, interventions and treatment in all settings where professionals meet young people.

Minor child physical abuse has decreased in Sweden since 1979, when a law banning corporal punishment of children was passed, but more serious forms have not decreased. The aim of this study was to examine risk and background factors in cases of severe child abuse reported to the police. Files from different agencies (e.g., Social services, Adult and Child psychiatry and Pediatric clinic) for 20 children and 34 caretakers were studied. An accumulation of risk factors was found. It is concluded that when the following four factors are present, there is a risk for severe child abuse: 1) a person with a tendency to use violence in conflict situations; 2) a strong level of stress on the perpetrator and the family; 3) an insufficient social network that does not manage to protect the child; 4) a child that does not manage to protect him or herself. Thus, multiple sources of information must be used when investigating child abuse.

Aim: To examine prevalence rates of child physical abuse perpetrated by a parent/caretaker, abuse characteristics and the extent of disclosures. Methods: A population-based survey was carried out in 2008 amongst all the pupils in three different grades (n = 8494) in schools in Sodermanland County, Sweden. The pupils were asked about their exposure to violence and their experiences of parental intimate-partner violence. Data were analysed with bi- and multivariate models and a comparison between means of accumulating risk factors between three groups were performed. Results: A total of 15.2% of the children reported that they had been hit. There were strong associations between abuse and risk factors and there was a dose-response relationship between risks and reported abuse. It was shown that children who reported parental intimate-partner violence were at a considerably higher risk for abuse than other children and that only 7% of the children exposed to violence had disclosed this to authorities. Conclusion: Even though child abuse in Sweden has decreased markedly during the last 40 years, violence against children is still a considerable problem. It is a challenge to develop methods of assessment and interventions that will ensure that the violence and its underlying causes are directly addressed.

Aim of this study was to identify and describe the obstacles that can prevent children from talking about sexual abuse in a police interview. Data consisted of 28 investigative interviews with children and 12 police interrogations with non-offending parents. The children in these situations were between 8 and 15 years of age when they were interviewed. Data interpretation and analysis were based on content analysis. The following categories were identified: not being believed/telling the truth, need of support and dependence on adults, guilt and shame, fear, and spatial- and time-oriented.

The aim of this study is to demonstrate how parents of children who are victims of sexual assault experience the legal process from the children’s and parents’ perspective. Nine parents, identified in the records of three public prosecution offices in three cities in Sweden, were interviewed. The parents described feelings of shame and guilt over what their children had experienced. They felt stigmatized and had difficulty fulfilling their parental role, perceived a lack of information and support from the professionals involved, and experienced a sense of withdrawal from their role as parents, though they felt the professionals who worked with their children were helpful and influential.

The aim of this study was to demonstrate how parents of children, who are victims of sexual assault, experience the legal process, seen from the child’s, as well as the parents’ perspective. Nine parents identified in the records of three public prosecution offices in three cities in Sweden, were interviewed. The parents described feelings of shame and guilt over what their children had experienced. They felt stigmatized and had difficulty fulfilling their parental role; perceived a lack of information and support from the professionals involved; experienced a sense of withdrawal from their role as parents, even though they felt the professionals who worked with their children were helpful and influential.

The purpose of the present study was to interview prosecutors, based on their experiences working with children who have been sexually abused. The informants were seven prosecutors identified from the records of three public prosecution offices in three cities in Sweden. The informants' experiences were elicited via individual in-depth semi-structured interviews. The interviews were carried out and analysed using interpretative phenomenological analysis (IPA). Three themes emerged: (1) difficulties with evidence of criminal conduct, (2) children's special needs, and (3) children's dependence on adults. Informants' descriptions of how they perceived the children in the legal process were associated with their experience of the difficulty of finding proof of the crime. Informants were found to experience difficulties when they encounter children in the legal process. As prosecutors they often face difficulties proving that the child has been exposed to crime.

OBJECTIVE: The aim of this study was to describe how sexually abused children experience the legal process, a process that includes being questioned by the police during the preliminary investigation and by lawyers and the prosecutor in the courtroom, and meeting other professionals from various agencies.

METHOD: Face-to-face in-depth interviews were conducted with 10 children-9 girls and 1 boy between 9 and 15 years old-who had experienced child sexual abuse (CSA). The interviews were semi structured and carried out and analyzed by interpretative phenomenological analysis (IPA). The aim of IPA is to explore the participants' views of the world and to adopt as far as possible an "insider perspective." IPA draws on a tradition of phenomenology and symbolic interactionism in attempting to understand how people make sense of their experiences.

RESULTS: Five major themes emerged through the analysis: not being believed, making CSA visible, need for support, sanctions for offenders, and lack of respect for the child's integrity. Almost all the children had a feeling of not being believed. They described feelings ranging from anxiety to dread and even terror when they had to describe the CSA they had experienced. Even though the importance of support for such children is already well understood, the children stated that the support they were given was not sufficient. The children said that they wanted support from a single professional who was well informed about both the legal process and CSA. When the children were asked to reflect on sanctions against the abusers, they said that it was important that the perpetrator got treatment/therapy but they also said that imprisonment was desirable. Financial compensation was not as important to them; the damage had been done and money could not compensate for that damage. The children also said that both the lawyers and the media had treated them with disrespect.

CONCLUSIONS: It is valuable for children who have been exposed to CSA to learn that they can take part in the legal process as equal partners with the other participants, and it is evident that the quality of psychological care and support needs to be improved. The children want to be participants in the legal process rather than passive objects of that process.

Background In many Western countries, an increasing number of children with separated parents have joint physical custody, that is, live equally much in their parents respective homes. In Sweden, joint physical custody is particularly common and concerns between 30% and 40% of the children with separated parents. It has been hypothesised that the frequent moves and lack of stability in parenting may be stressful for these children. Methods We used data from a national classroom survey of all sixth and ninth grade students in Sweden (N=147839) to investigate the association between childrens psychosomatic problems and living arrangements. Children in joint physical custody were compared with those living only or mostly with one parent and in nuclear families. We conducted sex-specific linear regression analyses for z-transformed sum scores of psychosomatic problems and adjusted for age, country of origin as well as childrens satisfaction with material resources and relationships to parents. Clustering by school was accounted for by using a two-level random intercept model. Results Children in joint physical custody suffered from less psychosomatic problems than those living mostly or only with one parent but reported more symptoms than those in nuclear families. Satisfaction with their material resources and parent-child relationships was associated with childrens psychosomatic health but could not explain the differences between children in the different living arrangements. Conclusions Children with non-cohabitant parents experience more psychosomatic problems than those in nuclear families. Those in joint physical custody do however report better psychosomatic health than children living mostly or only with one parent. Longitudinal studies with information on family factors before and after the separation are needed to inform policy of childrens postseparation living arrangements.

Background

The practice of joint physical custody, where children spend equal time in each parent’s home after they separate, is increasing in many countries. It is particularly common in Sweden, where this custody arrangement applies to 30 per cent of children with separated parents. The aim of this study was to examine children’s health-related quality of life after parental separation, by comparing children living with both parents in nuclear families to those living in joint physical custody and other forms of domestic arrangements.

Methods

Data from a national Swedish classroom study of 164,580 children aged 12 and 15-years-old were analysed by two-level linear regression modelling. Z-scores were used to equalise scales for ten dimensions of wellbeing from the KIDSCREEN-52 and the KIDSCREEN-10 Index and analysed for children in joint physical custody in comparison with children living in nuclear families and mostly or only with one parent.

Results

Living in a nuclear family was positively associated with almost all aspects of wellbeing in comparison to children with separated parents. Children in joint physical custody experienced more positive outcomes, in terms of subjective wellbeing, family life and peer relations, than children living mostly or only with one parent. For the 12-year-olds, beta coefficients for moods and emotions ranged from −0.20 to −0.33 and peer relations from −0.11 to −0.20 for children in joint physical custody and living mostly or only with one parent. The corresponding estimates for the 15-year-olds varied from −0.08 to −0.28 and from −0.03 to −0.13 on these subscales. The 15-year-olds in joint physical custody were more likely than the 12-year-olds to report similar wellbeing levels on most outcomes to the children in nuclear families.

Conclusions

Children who spent equal time living with both parents after a separation reported better wellbeing than children in predominantly single parent care. This was particularly true for the 15-year-olds, while the reported wellbeing of 12-years-olds was less satisfactory. There is a need for further studies that can account for the pre and post separation context of individual families and the wellbeing of younger age groups in joint physical custody.

OBJECTIVE: The goal of the present randomized placebo controlled double-blind study was to investigate the potential effect of PUFA supplementation on cognitive and behavioural performance in children with neurodevelopmental problems at 7 years of age (n = 28) and to compare findings with an age matched healthy control group (n = 20).

METHODS: Children were screened with parent and teacher rating scales (Conner’s and SNAP-IV), and were included if they showed a range of neurodevelopmental problems that reached ADHD criteria. The group with neurodevelopmental difficulties was randomized to treatment with an EPA rich formula (n = 13) or to placebo (n = 15). Cognitive performance was determined at baseline and after 15 weeks of supplementation with a cognitive test battery including executive function and theory of mind tasks.

RESULTS: Children with neurodevelopmental problems differed from the control group regarding working memory, inhibition and language ability, but not on an advanced theory of mind task. Regarding the treatment with EPA supplement there were no significant advantages in the active treatment group compared to placebo in any of the cognitive measures or in parents or teacher rating scales.

CONCLUSION: The significant differences in cognitive performance and rating scales between the group with neurodevelopmental problems and the healthy control group at baseline indicate problems at a clinical level and suitability for treatment. However we found no significant effects of PUFA supplementation. The study is small and limited by a number of drop-outs.

Breast-milk provides nutrients required for the development of the brain. n-6 and n-3 long-chain polyunsaturated fatty acids (LCPUFAs) have been suggested to be particularly involved. In this study levels of fatty acids in breast-milk were examined in relation to theory of mind (ToM) (n=13) and WISC-III (n=22) in six-year-old children. ToM tasks comprised four illustrated stories with questions about emotional (sad) events. Single polyunsaturated fatty acids (PUFA) were estimated as well as ratios between different fatty acids in order to describe putative associations between PUFA and psychological measures. Results show correlations between both ToM and WISC-III with single n-6 PUFA and the ratios DHA/AA and DHA/DPA. The correlations remained when socio-demographic factors were statistically controlled for. The positive findings related to the n-6 and n-3 LCPUFAs corroborate previous findings related to child cognitive development. © 2006 Elsevier Ltd. All rights reserved.

Background Attention deficit hyperactivity disorder (ADHD) and Autism Spectrum Disorder (ASD) are often accompanied by sleep problems influencing social, emotional and cognitive functioning in everyday activities. Aim The aim of this study was to investigate whether the use of a weighted blanket has a positive impact on sleep and everyday activities in individuals with ADHD and/or ASD. Material and methods The study included 85 individuals diagnosed with ADHD and/or ASD, 48 children aged <= 17 (57%) and 37 adults >= 18 years (44%), who were prescribed with a weighted blanket. The participants responded via a telephone interview. Results Findings demonstrated that a weighted blanket improved abilities related to falling asleep, sleeping the whole night, and relaxing during the day. Using a weighted blanket improved morning/evening daily routine, including preparing/going to sleep and waking up in the morning. Conclusions Weighted blankets showed positive impact on falling asleep, sleeping the whole night, and relaxing during the day, and they were used frequently by children and adults with ADHD and/or ASD. Findings indicate that a weighted blanket improved morning/evening routine, however this research area needs further investigation using both subjective and objective parameters.

The aim of the study was to provide a standardisation of self-reported competencies and emotional/behavioural problems among Swedish adolescents, using the Youth Self-Report (YSR). The YSR was completed by 2522 adolescents aged 13-18 years, recruited from secondary and upper secondary schools in different regions in Sweden. The results showed that effects of gender and age were small but significant with girls scoring higher than boys on most problem scales, and 15- to 16-year-olds scoring higher than younger and older adolescents on the problem scales. Small effects were also found for residence as well as for parental SES. The correlations between internalising and externalising problems were 0.51 for boys and 0.49 for girls, whereas the correlation between competence and problem scores was low. We conclude that the individual variation in YSR-scores is much greater than can be attributed to factors such as gender, age, SES, or residential area. Consequently, the YSR has the potential to serve as an instrument for assessing individual adolescents' self-reported competencies and problems in Sweden. Given the almost orthogonal relation between self-reported competencies and problems, the competence scale is surprisingly little used in psychopathology research.

BACKGROUND: Methylphenidate (MPH), along with behavioral and psychosocial interventions, is the first-line medication to treat attention-deficit hyperactivity disorder (ADHD) in Sweden. The dose of MPH for good symptom control differs between patients. However, studies of MPH concentration measurement in ADHD treatment are limited.

OBJECTIVE: To describe blood and oral fluid (OF) concentrations of MPH after administration of medication in patients with well-adjusted MPH treatment for ADHD, and to identify the most suitable matrix for accurate MPH concentration during treatment.

METHODS: Patients were recruited from Child and Adolescent Psychiatry (CAP), General Psychiatry (GP), and the Department of Dependency (DD). Blood and OF samples were collected in the morning before MPH administration as well as 1 and 6 h after administration of the prescribed morning dose of MPH.

RESULTS: Fifty-nine patients aged between 9 and 69 years, 76 % males. The daily dose of MPH varied from 18 to 180 mg, but the median daily dose per body weight was similar, approximately 1.0 mg/kg body weight. The median MPH concentration in blood 1 and 6 h after the morning dose was 5.4 and 9.3 ng/mL, respectively. Highly variable OF-to-blood ratios for MPH were found at all time points for all three groups.

CONCLUSIONS: Weight is a reliable clinical parameter for optimal dose titration. Otherwise, MPH blood concentration might be used for individual dose optimization and for monitoring of the prescribed dose. Relying only on the outcome in OF cannot be recommended for evaluation of accurate MPH concentrations for treatment monitoring.

This study was conducted to increase the knowledge of what characterises the child-protection process in family-service organisations. A total of 1570 (regarding 1051 children) reports made to Social Services in one municipality during 1 year were followed to a final decision. A five-year follow-up study was conducted. There were 651 (41%) of the reports that were not investigated, 84% of the reports filed were judged not to demonstrate child maltreatment. The most usual cluster consisted of children that had committed a crime/offence when they were between 13 and 18 years old (314/1051–30%). The social worker reported 38% of the reports that regarded sexual or physical abuse to the police. Comparing the filtering pattern with the results from a study conducted in England, the family-service organisation does not seem to lead to the provision of services for a greater percentage of children than does a distinctive child-protection system. In the five-year follow-up period there were 61% of the children that were or had been targeted for an intervention or an investigation. This study raises questions about child protection in Sweden and emphasises the need for the system to be studied further.

Aim: To study the validity of the decision not to investigate mandatory reports of suspected child maltreatment.

Methods: Written files of 220 reports indicating possible child maltreatment were analysed and re-evaluated. As a measure of the justification for the decisions, a 5-y follow-up study was done.

Results: We determined that 76% of the reports still indicated child maltreatment after the initial assessment was done. In the follow-up study, 45% of the children had been investigated. The social worker used the family as the only source of information in 74% of the cases, in 6% someone outside the family was contacted, and in 11% no further information in addition to the report was collected. In 9%, data on information sources were missing.

Conclusion: The findings are rather discouraging, as they challenge the belief that a report is a means of ensuring that maltreatment does not continue. The study shows that, depending upon the way in which the initial assessments are made, maltreated children may run a risk of not being identified, even though the maltreatment has been reported. This suggests that there may be a need for national guidelines concerning the reporting of maltreatment.

This article deals with the mandatory report process in Sweden. The components that are analysed are who makes the reports, what is reported and the outcome for the reports. Data were collected in a Swedish county in the year 2000 by means of locating every report made to the Social Services during one year (1998). The net sample consisted of 1,570 reports regarding 1,051 children. A follow-up study was carried out in 2003 of all the children for whom a report in 1998 did not lead to an investigation being initiated. We found in these study indicators that the process might not be secure. The professionals reported 1% of the children in the municipality; 22% of the reports from professionals were not investigated. The five-year follow-up study shows that 53% of the children that these reports concerned had been the subject of an investigation. This could be an indicator that children continue to be maltreated after being reported since the assessments are not accurate. In this study, 67% of 'crime reports' were 'not indicating' child maltreatment. There should be a questioning of 'crime reports' automatically entering the mandated report process as, if registered nationally, this could lead to a deflation of mandatory reports. Administration needs to change introducing a national form for filing reports.

Psychiatric disorders are multi-factorial and their symptoms overlap. Constitutional and environmental factors influence each other, and this contributes to risk and resilience in mental ill-health. We investigated functional genetic variation of stress responsiveness, assessed as FKBP5 genotype, in relation to early life adversity and mental health in two samples of adolescents. One population-based sample of 909 12-year-old adolescents was assessed using the Life Incidence of Traumatic Events scale and the Strengths and Difficulties Questionnaire. One sample of 398 17-year-old adolescents, enriched for poly-victimized individuals (USSS), was assessed using the Juvenile Victimization Questionnaire and the Trauma Symptom Checklist for Children (TSCC). The FKBP5 rs1360780 and rs3800373 polymorphisms were genotyped using a fluorescence-based competitive allele-specific PCR. Most prominently among poly-victimized older male adolescents, the least common alleles of the polymorphisms, in interaction with adverse life events, were associated with psychiatric symptoms, after controlling for ethno-socio-economic factors. The interaction effect between rs3800373 and adverse life events on the TSCC sub-scales-anxiety, depression, anger, and dissociation-and with the rs1360780 on dissociation in the USSS cohort remained significant after Bonferroni correction. This pattern of association is in line with the findings of clinical and neuroimaging studies, and implies interactive effects of FKBP5 polymorphisms and early life environment on several psychiatric symptoms. These correlates add up to provide constructs that are relevant to several psychiatric symptoms, and to identify early predictors of mental ill-health.

Pharmacokinetics of antidepressant drugs (ATDs), in terms of steady-state and trough values, in patients from Child and Adolescent Psychiatry centers in the midsouth-eastern part of Sweden, were evaluated, and the use of ATDs in this population were described. Patients to be prescribed an ATD were studied between 2002 and 2004. Two hundred eleven children, 64% girls and 36% boys (ages 8-20 years) were evaluated. The primary indication for the antidepressant treatment was depression in 69% of subjects. The median body mass index was 20.2 kg/m(2) (range, 12.4-38.6 kg/m(2)). Suspected adverse drug reactions were spontaneously reported in 31% (no serious). Monotherapy was indicated in 49% of request forms. The most common drug combination with the ATD was oral contraceptives. The concentrations of drugs in the patient evaluated population to referenced data for adults from the dose administered were as expected in 63%, higher than expected in 26% and lower than expected in 11%. The most prescribed ATD was sertraline (SERT). Dose-concentration relationships for SERT and metabolite desmethylsertraline (DSERT) were seen, r(s) = 0.48 and r(s) = 0.5, respectively. No relationship was found between dose and ratio DSERT/SERT. The median daily dose was 50 mg (range, 12.5-150 mg), SERT concentration 16 ng/mL (range, 3-88 ng/mL), and DSERT 33 ng/mL (range, 0-253 ng/mL). CYP2D6*4 was the most common poor metabolizer allele. Therapeutic drug monitoring may provide support to prescribing physicians to individual dose optimizing and to assess drug compliance, above all when ATDs are not well studied in pediatric patients before approval for general prescription.

Objectives: The purpose of this study was to assess the reliability and validity of Swedish translations of the Beliefs about Medicines Questionnaire-Specific (BMQ-Specific) and Brief Illness Perception Questionnaire (B-IPQ) for use in adolescents with ADHD. Methods: Forward and backward translations of the BMQ-Specific and B-IPQ scales to Swedish were conducted and reviewed by adolescents with ADHD and professionals. The validity and reliability of both questionnaires were investigated in a cross-sectional study of 101 adolescents (13?17?years) on a long-term prescription of ADHD medication recruited from two child and adolescent psychiatric outpatient clinics in Sweden. Results: Regarding the BMQ-Specific, principal component analysis (PCA) loadings confirmed the previously defined components of Specific-Necessity and Specific-Concern. The PCA for B-IPQ revealed two components, the first one, B-IPQ Consequences, captured questions regarding perceptions of the implication of having ADHD (items 1, 2, 5, 6 and 8) and the second one, B-IPQ-Control, the perceptions of the capability to manage the ADHD disorder (items 3, 4 and 7). The Cronbach alpha coefficients for BMQ-Specific-Necessity scale was ??=?0.80, for BMQ-Specific-Concern scale ??=?0.75, B-IPQ Consequences ??=?0.74 and for B-IPQ-Control ??=?0.44. Conclusions: The present results prove the Swedish translation of BMQ-Specific and B-IPQ to be valid and reliable for utilization in adolescents with ADHD. The PCA confirmed the original components for BMQ-Specific and the recent findings of two main B-IPQ components describing emotional and cognitive implications versus the capability for self-care maintenance of ADHD.

Adherence to attention deficit hyperactivity disorder (ADHD) treatment is important because, when untreated, it may have serious consequences with lifelong effects. In the case of adolescents on long-term medicine prescription, more knowledge is needed regarding adherence and factors influencing adherence, which was the purpose of this study. Adolescents (n = 101) on ADHD medication ≥6 months were administrated questionnaires at a monitoring appointment: Medication Adherence Report Scale (MARS), beliefs about medicines (BMQ) and the Brief Illness Perception Questionnaire (B-IPQ). Adherence was high, the mean value was 88% of the maximum MARS score, and correlated positively with the “BMQ-necessity-concerns differential” but negatively with “BMQ-concerns” and “BMQ-side effects”. Adolescents with more belief in the necessity of the medication, less concerns and less experience of side effects tended to be more adherent to medication prescription (“intentional non-adherence”), while “unintentional non-adherence” (forgetfulness) was associated with how much they perceived that their ADHD affected their lives. In a multiple regression model, the variance of MARS total (R² = 0.21) and “intentional non-adherence” (R² = 0.24) was explained by the “BMQ-necessity–concern differential” and “BMQ-experienced side effects”. The variance of “unintentional non-adherence” (R² = 0.12) was explained by the “BMQ-necessity–concern differential” and “B-IPQ-consequences of ADHD”. In conclusion, adolescents on long-term medication reported good adherence, mainly influenced by more beliefs in the necessity versus concerns of the medications, less experienced side effects and more perceived consequences of ADHD. BMQ could be useful to identify risks of low adherence, which should be counteracted by partially gender-specific interventions.

Background Adherence to attention deficit hyperactivity disorder (ADHD) medication can prevent serious consequences, possibly with lifelong effects. Numerous factors have been observed that influence adherent behaviour, but the impact of personality traits has been inadequately explored. The purpose of this study was to explore the associations between personality traits and adherence to ADHD medication, beliefs about the medication, and perceptions of ADHD. Method Adolescents (n = 99) on ADHD medication were administered: Health-Relevant Personality Traits Five-Factor Inventory, Medication Adherence Report Scale, Beliefs about Medicines Specific and Brief Illness Perceptions Questionnaires. Results The personality trait Antagonism correlated with adherence behaviour (r = - 0.198, p = 0.005) and perceived personal control of ADHD (r = - 0.269, p = 0.007). Negative Affectivity correlated with beliefs regarding necessity (r = 0.319, p = 0.001), concerns (r = 0.344, p = 0.001), and experienced side effects of medication (r = 0.495, p = 0.001), alongside perceptions regarding duration (r = 0.272, p = 0.007), identity (r = 0.388, p < 0.001), being emotionally affected (r = 0.374, p < 0.01), personal control (r = - 0.287, p = 0.004) and concerns about ADHD (r = 0.465, p < 0.001). Impulsivity correlated with perceived consequences (r = - 0.226, p = 0.0255) and personal control of ADHD (r = - 0.379, p < 0.001). Hedonic Capacity correlated with concerns about medication (r = - 0.218, p = 0.0316) and perceived identification with ADHD (r = - 0.203, p = 0.045). Conclusion Personality traits are related to adherence, beliefs about ADHD medicines and perceptions of ADHD. Antagonism is associated with adherence, especially intentional non-adherence, while Negative Affectivity correlates with numerous perceptions of ADHD and beliefs about medications. Personality assessments could be useful in the care and treatment of adolescents with ADHD.

Introduction: The tactile sense plays a crucial role in the development and maintenance of a functional bodily self. The ability to differentiate between self-and nonself-generated touch contributes to the perception of the bodies boundaries and more generally to self-other-distinction, both of which are thought be altered in anorexia nervosa (AN) and autism spectrum condition (AS). While it has been suggested that AN and AS are characterized by overlapping symptomatology, they might differ regarding body perception and self-other-distinction. Methods: Participants with a diagnosis of AN (n = 25), AS (n = 29), and a comparison group without diagnoses (n = 57) performed a self-other-touch task during functional brain imaging. In the experimental conditions, they stroked their own arm or were stroked on the arm by an experimenter. Results: As shown previously, the CG group showed lower activation or deactivation in response to self-touch compared to social touch from someone else. A main group effect was found in areas including somatosensory cortex, frontal and temporal gyri, insula, and subcortical regions. This was driven by increased activations in participants with AN, while participants in the AS group showed mostly comparable activations to the com-parison group. Conclusions: AN diagnosis was associated with an increased neural activity in response to both self-touch and social touch. Failure to attenuate self-touch might relate to altered predictions regarding the own body and reduced perception of bodily boundaries. Participants with an AS diagnosis were mostly comparable to the comparison group, potentially indicating unaltered tactile self-other-distinction.

Preschool childrens engagement/social interaction skills can be seen as aspects of positive functioning, and also act as protective aspects of functioning. On the other hand, hyperactivity/conduct problems are risk aspects that negatively affect childrens everyday functioning. Few studies have investigated such orchestrated effects on mental health in young children over time. The aims of the study are first, to identify homogeneous groups of children having similar pathways in mental health between three time points. Second, to examine how children move between time points in relation to risk and protective factors. Alongitudinal study over 3 years, including 197 Swedish preschool children was used. Questionnaire data collected from preschool teachers. Statistical analysis using person-oriented methods with repeated cluster analyses. Children high in engagement/social skills and low in conduct problems continue to function well. Children with low engagement/social skills exhibiting both hyperactivity and conduct problems continue to have problems. Children with mixed patterns of protective factors and risk factors showed mixed outcomes. The stability of childrens pathways was quite high if they exhibited many positive protective factors but also if they exhibited many risk factors. Children exhibiting a mixed pattern of protective and risk factors moved between clusters in a less predictable way. That stability in mental health was related to the simultaneous occurrence of either many protective factors or many risk factors supports the notion of orchestrated effects. The results indicate that early interventions need to have a dual focus, including both interventions aimed at enhancing child engagement and interventions focused on decreasing behavior problems.

Background: Externalising problems are among the most common symptoms of mental health problems in preschool children.

Aims: To investigate the development of externalising problems in preschool children over time, and the way in which conduct problems are linked to hyperactivity problems.

Method: In this longitudinal study, 195 preschool children were included. Latent growth modelling of conduct problems was carried out, with gender and hyperactivity at year 1 as time-invariant predictors.

Results: Hyperactivity was a significant predictor for the intercept and slope of conduct problems. Children with more hyperactivity at year 1 had more conduct problems and a slower reduction in conduct problems. Gender was a significant predictor for the slope of conduct problems.

Conclusions: Children with more initial hyperactivity have less of a reduction in conduct problems over time. It is important to consider the role of hyperactivity in studies of the development of conduct problems.

Declaration of interest: None.

Background: In Sweden, 80-90% of children aged 1-5 years attend preschool, and that environment is well suited to identify behaviours that may be signs of mental health problems. The Strengths and Difficulties Questionnaire (SDQ) is a well-known short and structured instrument measuring child behaviours that indicate mental health problems well suited for preschool use.Aim: To investigate whether SDQ is a reliable and valid instrument for identifying behavioural problems in children aged 1-3 years and 4-5 years in a Swedish population, as rated by preschool teachers.Methods: Preschools situated in different sized municipalities in Sweden participated. The preschool teacher rated each individual child. Concurrent validity was tested using the Child-Teacher Report Form (C-TRF) and Child Engagement Questionnaire (CEQ). Exploratory factor analysis was conducted for age groups, 1-3 years and 4-5 years.Results: The preschool teachers considered most of the SDQ items relevant and possible to rate. For the children aged 1-3 years, the subscales Hyperactivity (Cronbach alpha=0.84, split half=0.73) and Conduct (Cronbach alpha=0.76, split half=0.80) were considered to be valid. For the age group 4-5 years, the whole original SDQ scale, 4-factor solution was used and showed reasonable validity (Cronbach alpha=0.83, split half=0.87).Conclusion: SDQ can be used in a preschool setting by preschool teachers as a valid instrument for identifying externalizing behavioural problems (hyperactivity and conduct problems) in young children.Clinical implications: SDQ could be used to identify preschool children at high-risk for mental health problems later in life.

Background: There is a high risk that young children who show early signs of mental health problems develop symptoms in the same or overlapping areas some years later. The Strengths and Difficulties Questionnaire (SDQ) is widely used to screen externalizing and internalizing problems early in life. In Sweden 80-90% of all children aged 1-5 years go to preschool and preschool is thus an appropriate context for finding early signs of mental health problems among children. Methods: This study is part of a longitudinal project too investigate the frequency of emotional and behavioural problems for children between 1 and 5 years of age in Sweden. The SDQ including the impairment supplement questions were rated by preschool teachers too establish Swedish norms for SDQ in preschool children. Results: The sample involved 815 children with a mean age of 42 months (SD = 16, range 13-71 months). 195 children were followed longitudinally for three years. There were significant differences between boys and girls on all subscales except for the Emotional subscale. The prevalence of behavioural problems was similar to other that in European countries, except for Prosocial behaviour, which was rated lower, and Conduct problems, rated higher. Swedish children were estimated to have more problems in the preschool setting, scored by preschool teachers. The development of behaviour over time differed for the different subscales of SDQ. Conclusions: The teacher version of the SDQ, for 2-4 year-olds, can be used as a screening instrument to identify early signs of emotional distress/behavioural problems in young children. Preschool teachers seem to be able to identify children with problematic behaviour with the use of SDQ at an early age. The development of behaviour over time differs for the different subscales of SDQ. The Swedish norms for SDQ are to a large extent, similar to findings from other European countries.

A family/systems approach allows us to see the individual in context. The family and the informal social network constitute the most important environment for a child. A basic assumption is that changes in family interaction patterns will have an impact on somatic as well as psychiatric symptoms in the child. In modern paediatric practice parents are routinely instructed to give their sick child the prescribed treatment and to implement preventive measures, they are recruited as part of the medical team. A family/systems approach helps families to identify their strengths and needs. The approach described here with a session transcript illustrates how understanding the ways in which family relatioinships interact with the course of illness and treatment can influence quality of life.

This thesis comprises a literature review of gastro-ocsophageal reflux (GOR) and six studies which aim to determine the prevalence of oesophageal dysfunction (OD) and pathological GOR and their significance concerning the bronchopulmonary disease in children and adolescents with bronchial asthma or cystic fibrosis (CF). Oesophageal function was assessed by manomctry combined with oesophageal provocation tests. 24-hour two-level oesophageal pH monitoring was used to quantify GOR, to study the temporal relationship between acid reflux and asthma symptoms, and to assess the propensity to aspirate. Symptoms of OD and asthma were evaluated by interview and by the use of questionnaires. Severity of bronchopulmonary disease in the CF patients was assessed by radiography and spirometry. A double-blind placebo-controlled trial of ranitidine 150/300 mg per day over four weeks was performed in the asthma group to see if a reduction in acid reflux improved asthma. The relative significance of reflux symptoms and atopic allergy, regarding lung function and bronchial histamine reactivity in asthma, was evaluated. Pathological GOR and OD were significantly more common in asthma and CF patients than in controls. Episodes of acid reflux seemed to provoke asthma symptoms in a few patients. Ranitidine produced a significant but modest reduction in nocturnal/morning asthma symptoms in patients with pathological GOR, when compared to those with normal GOR. Asthma patients with reflux symptoms more frequently experienced asthma attacks initiated by non-specifictrigger factors than patients without such symptoms. The presence of atopic allergy was related to impaired lung function and increased bronchial hyperreactivity. Severity of OD and bronchopulmonarydisease correlated well in CF patients.

OD or pathological GOR are found in the majority of children and adolescents with asthma or CF. In CF subjects OD and GOR may be parts of a vicious circle including malnutrition and progressive lung damage. In asthma acid reflux is, on the whole, a mild trigger or a modulatory factor, and appears to influence the airways via oesophago-bronchial reflexes rather than by aspiration. Atopic allergy is still more important than GOR in childhood asthma.

Aim: Measure efficacy of eicosapentaenoic acid (EPA) in children with attention deficit hyperactivity disorder (ADHD). Methods: Randomized controlled trial (RCT) of 0.5 g EPA or placebo (15 weeks) in 92 children (7-12 years) with ADHD. Efficacy measure was Conners Parent/Teacher Rating Scales (CPRS/CTRS). Fatty acids were analysed in serum phospholipids and red blood cell membranes (RBC) at baseline and endpoint with gas chromatography. Results: EPA improved CTRS inattention/cognitive subscale (p = 0.04), but not Conners total score. In oppositional children (n = 48), CTRS total score improved andgt;= 25% in 48% of the children receiving EPA vs. 9% for placebo [effect size (ES) 0.63, p = 0.01]. In less hyperactive/impulsive children (n = 44), andgt;= 25% improvement was seen in 36% vs. 18% (ES 0.41, n.s.), and with both these types of symptoms 8/13 with EPA vs. 1/9 for placebo improved andgt;= 25% (p = 0.03). Children responding to treatment had lower EPA concentrations (p = 0.02), higher AA/EPA (p = 0.005) and higher AA/DHA ratios (p = 0.03) in serum at baseline. Similarly, AA/EPA (p = 0.01), AA/DHA (p = 0.038) and total omega-6/omega-3 ratios (p = 0.028) were higher in RBC, probably because of higher AA (p = 0.011). Conclusion: Two ADHD subgroups (oppositional and less hyperactive/impulsive children) improved after 15-week EPA treatment. Increasing EPA and decreasing omega-6 fatty acid concentrations in phospholipids were related to clinical improvement.

Aim: Breastfeeding seems to be favorable for cognitive development. Could levels of polyunsaturated fatty acids (PUFA) explain this? Methods: Pregnant mothers were recruited consecutively at maternity care centres. PUFA were analysed in colostrum and breast milk at 1 and 3 mo. The product-precursor ratios of n-6+n-3 PUFA were examined as measures of activity in respective steps in the fatty acid metabolic chain. Also, the quotient between DHA and AA was analysed. The children were tested with the full WISC-III at 6.5 y. Results: First, the influence of length of breastfeeding was analysed by multiple regression together with relevant cofactors (except for PUFA). In the best models, 46% of the variation in total IQ was explained. Length of breastfeeding contributed significantly to total IQ (beta = 0.228, p = 0.021), verbal IQ (beta = 0.204, p = 0.040) and performance IQ (beta = 0.210, p = 0.056). There were no significant single correlations between PUFA and measures of cognitive development. However, in multiple regression analysis of colostrum, significant beta-coefficients were found for steps 4+5 in the fatty acid metabolic chain (beta = 0.559, p = 0.002). If length of breastfeeding and gestation week were added to steps 4+5, this three-factor model could explain 67% of the variation of total IQ. Introducing length of breastfeeding and gestation week together with the quotient DHA/AA (beta = 0.510, p < 0.001) yielded a three-factor model, which explained 76% of the variation in total IQ. Conclusion: Our findings could be interpreted as supporting the importance of high levels of PUFA for cognitive development. However, the sample is small and the results must be interpreted with caution.

Regarding the relationship between psychosocial factors and health, one model of explanation states that psychosocial stress constitutes a principal mediator connecting psychosocial factors to health outcome, affecting the body through psychobiological mechanisms. This relationship has scarcely been studied in children. In the present study the relation between diurnal cortisol secretion and psychosocial factors [socio-economic status (SES), immigrant status and impact of psychiatric symptoms] was investigated in a normal population of 6-12 year old children (n = 273). Salivary cortisol levels were measured in the early morning, late morning and in the evening during three consecutive days. Parents answered demographic questionnaires and teachers answered psychiatric questionnaires concerning the children. Children exposed to one or more of the factors of psychosocial load (n = 117) had significantly higher morning (p < 0.001) and evening (p = 0.029) cortisol levels as well as total daily cortisol secretion [measured by the area under the curve (AUC), p = 0.003] compared to the group of children with none of the factors (n = 156). Different psychosocial stressors seemed to influence different parts of the diurnal cortisol curve. In conclusion, this study indicates that even children exposed to a moderate degree of psychosocial load differ in their cortisol levels compared to non-exposed children.

Findings have been divergent regarding the direction of basal cortisol dysregulations resulting from stressor exposure, and seem to differ between young people and adults. Accumulated stress exposure has been suggested to be a risk factor for the development of hypocortisolism. This cross-sectional study aims to examine the impact of cumulative adversity, i.e., the number of adversities, on diurnal salivary cortisol levels, including the cortisol awakening response (CAR), in children without psychiatric disorder. The sample consisted of 130 children (mean age 12.8 years), representing one in each twin pair included in the population-based Child and Adolescent Twin Study in Sweden (CATSS). Information about socioeconomic disadvantage, negative life events and potentially traumatic life events were collected by telephone interview and questionnaires, with parents as informants. Salivary cortisol sampling was performed in the home during two school days: at awakening, +30 min post-awakening, and at bedtime. Results showed that the number of adversities was related to the CAR, diurnal decline and +30 min post-awakening cortisol levels. Children with a moderate amount of cumulative adversity displayed high cortisol measures, while those with a high amount (3 or more) of adversities instead showed levels similar to the non-exposed group, yielding an inverse U-pattern of the association between cortisol and adversity. These results indicate that the accumulation of adversity might be an explanation of patterns of basal cortisol up-regulation in children and that those most severely exposed can exhibit an early stage of down-regulation, an issue which should be further examined in longitudinal studies.

Background/Aims: Recent results indicate a role of the hypothalamic-pituitary-adrenal (HPA) axis in the pathophysiology of obsessive-compulsive disorder (OCD). Although childhood onset is common, the HPA axis has scarcely been studied in young OCD subjects. Therefore, the present study aimed at examining basal and response levels of salivary cortisol in a sample of young OCD subjects.

Methods: Twenty-three children and adolescents with DSM-IV OCD were compared to a reference group of school children (n = 240-336). The basal cortisol rhythm was measured through saliva samples 3 times/day. The cortisol response to a psychological stressor (exposure therapy in the OCD group and a fire alarm in the reference group) was also examined.

Results: Compared to the reference group, OCD subjects displayed higher early-morning cortisol values (p = 0.005) with no difference between the late-morning and evening values. The cortisol levels in the OCD group diminished in response to the psychological stressor, compared to a positive response in the reference group (p < 0.001). No relation was found between cortisol and clinical parameters.

Conclusion: These results support the idea that HPA hyperactivity, commonly found in adult OCD patients, is also present at an earlier stage of development, with specificity for the early-morning peak.

Previous research has demonstrated impact of psychosocial adversity on the mental health of children. This cross-sectional study examined the differential relationships between life-time exposure to interpersonal and non-interpersonal traumatic life events as well as sociocultural factors (family social class and immigrant family), and the level of externalizing versus internalizing symptoms. Participants included 258 children aged 6 to 12 years from two Swedish elementary schools. Information was obtained from their parents by means of questionnaires (a demographic form including information about parental occupation and country of origin, the Strengths and Difficulties Questionnaire and the Life Incidence of Traumatic Events checklist). While controlling for gender, age and the other symptom dimension, the sociocultural factors were associated to internalizing but not to externalizing symptoms. In contrast, traumatic life events and especially interpersonal traumas related to externalizing symptoms but not to internalizing symptoms. These findings provide some support for specificity of psychosocial adversities and for the importance of interpersonal traumas, in the impact on child mental health.

Background. The role of the HPA axis in psychiatric disorders following trauma is poorly studied and most studies have been done on adults. Aims. To investigate the association of mental well-being and diurnal cortisol in abused adolescents. Methods. The present crosssectional study examined diurnal salivary cortisol (measured three times a day during three days) in relation to psychiatric symptoms (Trauma Symptoms Checklist for Children) and the salutogenic construct “Sense of coherence”, in fifteen adolescents exposed to childhood abuse. Results. Significant positive correlations were found between symptoms and sense of coherence versus early and late morning cortisol concentrations. The correlations were most consistent for internalizing and externalizing symptoms, and somewhat less for post-traumatic symptoms and sense of coherence. In contrast, evening cortisol did not correlate with any of the psychological measures. Conclusion. These results extend previous research findings by pointing towards a relation between symptoms and higher morning cortisol and accentuated diurnal cortisol variation in abused adolescent as opposed to lower basal cortisol and a flattening of the cortisol rhythm repeatedly observed in traumatized adults.

This study aimed at examining the effects of an outdoor educational intervention on the mental health of schoolchildren. Two elementary schools participated (N = 230); one experimental school where the intervention was implemented, and the other a reference school. Demographic questions and the Strengths and Difficulties Questionnaire were completed by the parents. An outdoor educational intervention was implemented at the experimental school, and the data collection was repeated after one year. The results point towards a small but non-significant improvement in mental health at the experimental school while adjusting for demographics. However, this effect was significantly moderated by gender: boys generally fared better than girls at the intervention school, relative to the reference school. The results indicate that it may be important to address gender issues when educational programmes are implemented in schools.

Background: The normal development of cortisol regulation during childhood is thought to be influenced by a complex interplay between environmental and genetic factors. Method: The aim of this study was to estimate genetic and environmental influences on basal cortisol levels in a sample of 151 twin pairs aged 9-16 years. Salivary cortisol was collected on two consecutive days when the children attended school immediately after awakening, 30 min post-awakening and at bedtime. Results: Heritability was highest (60%) for cortisol levels about 30 min after awakening. For samples taken immediately at awakening heritability was less pronounced (28%) and in the evening low (8%). Conclusion: The limited genetic influence on evening levels, moderate on cortisol at awakening and high on awakening response, might imply two genetic regulation patterns, one specifically for awakening response and one for the circadian rhythm proper. These findings could explain divergent results in previous studies and highlight the importance of taking the circadian rhythm into account in studies of cortisol levels in children.

The role of psycho-social factors in the development of allergy was studied prospectively in 82 infants with a family history of atopy. The family participated in a standardized family test when the children were 18 months old. The ability to adjust to demands of the situation ('adaptability'), and the balance between emotional closeness and distance ('cohesion'), were assessed from videotapes by independent raters. Families rated as functional in both of these aspects were classified as 'functional', otherwise as 'dysfunctional'. The social network, life events, atopic symptoms (based on postal inquiries regarding symptoms answered by the parents, and on physical examinations), psychiatric symptoms, and socio-economic circumstances of the families were evaluated when the children were 18 months and 3 years of age. The children were classified as atopic (asthmatic symptoms or eczema) or as non-atopic. All but two children with atopic disease at 3 years of age had atopic disease before 18 months of age, while 32 of 60 children with atopic disease at 18 months of age had no problems by 3 years of age. An unbalanced family interplay at 18 months was associated with a relative risk (RR) of 1.99 for continuing atopic illness at 3 years of age (1.18

Background: The aim of this study was to investigate the impact of migrant density in school on the well-being of pupils with a migrant origin in first as well as second generation. Methods: Cross-sectional analysis of data from a national classroom survey of 15-year-old Swedish schoolchildren. The study population included 76 229 pupils (86.5% participation) with complete data set from 1352 schools. Six dimensions of well-being from the KIDSCREEN were analysed in two-level linear regression models to assess the influence of migrant origin at individual level and percentage of students with a migrant origin at school level, as well as interaction terms between them. Z-scores were used to equalize scales. Results: A high density (andgt; 50%) of pupils with a migrant origin in first or second generation was associated with positive well-being on all six scales for foreign-born pupils originating in Africa or Asia compared with schools with low (andlt; 10%) migrant density. The effect sizes were 0.56 for boys and 0.29 for girls on the comprehensive KIDSCREEN 10-index (P andlt; 0.001) and 0.61 and 0.34, respectively, for psychological well-being (P andlt; 0.001). Of the boys and girls born in Africa or Asia, 31.6% and 34.6%, respectively, reported being bullied during the past week in schools with low (andlt; 10%) migrant density. Conclusions: Pupils born in Africa or Asia are at high risk for being bullied and having impaired well-being in schools with few other migrant children. School interventions to improve peer relations and prevent bullying are needed to promote well-being in non-European migrant children.

The aim of this study was to compare refugee children’s psychological well-being before and after brief family therapy. Families from Bosnia-Herzegovina with one child aged 5–12 years received three family therapy sessions. Psychological assessments using the Erica play-diagnostic method and parental interviews were made before and after the intervention. The main finding was that more children built normal sandboxes (showing no pathological findings)after the intervention than before, indicating that the rather short intervention had a positive effect on the children’s psychological well-being. To conclude, it might be valuable to offer refugee families a few family therapy sessions even if the children do not have psychiatric symptoms with the aim of helping them adapt to a new system of society.

Background

Due to the armed conflicts in the Balkans in the 1990s many families escaped to other countries. The main goal of this study was to explore in more detail the complexity of various family members’ experiences and perceptions from their life before the war, during the war and the escape, and during their new life in Sweden. There is insufficient knowledge of refugee families’ perceptions, experiences and needs, and especially of the complexity of family perspectives and family systems. This study focused on three families from Bosnia and Herzegovina who came to Sweden and were granted permanent residence permits. The families had at least one child between 5 and 12 years old.

Method

Family therapy sessions were videotaped and verbatim transcriptions were made. Nine family therapy sessions were analysed using a qualitative method with directed content analysis.

Results

Three main categories and ten subcategories were found - 1. Everyday life at home, with two subcategories: The family, Work and School/preschool; 2. The influence of war on everyday life, with three subcategories: The war, The escape, Reflections; 3. The new life, with five subcategories: Employment, Health, Relatives and friends, Limited future, Transition to the new life.

Conclusions

Health care and social welfare professionals need to find out what kind of lives refugee families have lived before coming to a new country, in order to determine individual needs of support. In this study the families had lived ordinary lives in their country of origin, and after experiencing a war situation they escaped to a new country and started a new life. They had thoughts of a limited future but also hopes of getting jobs and taking care of themselves and their families. When analysing each person’s point of view one must seek an all-embracing picture of a family and its complexity to tie together the family narrative. To offer refugee families meetings with family-oriented professionals to provide the opportunity to create a family narrative is recommended for the health and social welfare sector. Using this knowledge by emphasizing the salutogenic perspectives facilitates support to refugee families and individuals. This kind of support can help refugee families to adapt to a new system of society and recapture a sense of coherence, including all three components that lead to coherence: comprehensibility, manageability and meaningfulness. More studies are needed to further investigate the thoughts, experiences and needs of various refugee families and how refugee receiving societies can give the most effective support.

Many refugee families from Bosnia and Herzegovina arrived in Sweden during the Balkan conflict in the 1990s. We studied 14 of these families to compare psychological evaluation of the children using two different methods. We first carried out a semi-structured interview of a parent or parents in each family. The symptoms of each of the children, who ranged in age from 5 to 12 years, were evaluated based on these interview results. Then a second method, the Erica play-diagnosis method, was used to study the inner thoughts and feelings of the children. Results from the Erica play-diagnosis method were compared with results from Erica play- diagnosis from a normal group. According to results from the parental interviews all but one child in this study had a low level of psychological symptoms. In contrast, results from Erica play-diagnosis of these children showed that there were higher frequencies of not-normal play in these children compared with those in the normal group, which is an indication of deficiencies in the psychological well-being of these children. The results emphasise the importance of getting diagnostic information from the child in order to understand each child's psychological condition.

Childhood maltreatment is considered a risk factor for substance use disorders (SUD), but this is largely based on retrospective self-reports that are subject to recall bias, designs that do not control for familial confounding, or both. The specific contribution of childhood maltreatment to SUD risk thus remains unclear. Here, we evaluated this contribution in a prospective cohort with objectively recorded childhood maltreatment, using a design that allows controlling for familial confounding. We used medical records and registers to study 525 young adults (20-37 years) with prospectively and objectively documented severe maltreatment exposure, 1979 clinical controls (unexposed former child and adolescent psychiatry patients), 1388 matched healthy controls; and their siblings and cousins. We examined the association between maltreatment and SUD using Cox regression models in the population, as well as stratified within siblings in the same family. SUD risk was significantly increased with childhood maltreatment exposure (crude HR: 6.61, 95% CI: 5.81-7.53; HR adjusted for sex, birthyear, externalizing problems, parents SUD and socioeconomic factors: 3.50, 95% CI 2.95, 4.16). An approximately threefold elevated SUD risk remained when comparing exposed individuals with their unexposed siblings (adjusted HR: 3.12, 95% CI 2.21, 4.42). We provide estimates of the association between childhood maltreatment and SUD accounting for possible confounds of both recall bias and familial factors. When familial confounding is controlled for, SUD risk attributable to severe childhood maltreatment is decreased, but nevertheless considerable. These findings establish a specific contribution of childhood maltreatment to SUD, underscoring the need for SUD prevention in young people exposed to maltreatment.