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  • 1.
    Agnafors, Sara
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Comasco, Erika
    Division of Pharmacology, Department of Neuroscience, Uppsala University, Uppsala, Sweden.
    Bladh, Marie
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Sydsjö, Gunilla
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Dekeyser, Linda
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences.
    Oreland, Lars
    Division of Pharmacology, Department of Neuroscience, Uppsala University, Uppsala, Sweden.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences.
    Effect of gene, environment and maternal depressive symptoms on pre-adolescence behavior problems - a longitudinal study.2013In: Child and Adolescent Psychiatry and Mental Health, ISSN 1753-2000, E-ISSN 1753-2000, Vol. 7, no 1, p. 10-Article in journal (Refereed)
    Abstract [en]

    BACKGROUND: Depression is a common and disabling condition with a high relapse frequency. Maternal mental health problems and experience of traumatic life events are known to increase the risk of behavior problems in children. Recently, genetic factors, in particular gene-by-environment interaction models, have been implicated to explain depressive etiology. However, results are inconclusive.

    METHODS: Study participants were members of the SESBiC-study. A total of 889 mothers and their children were followed during the child's age of 3 months to 12 years. Information on maternal depressive symptoms was gathered postpartum and at a 12 year follow-up. Mothers reported on child behavior and traumatic life events experienced by the child at age 12. Saliva samples were obtained from children for analysis of 5-HTTLPR and BDNF Val66Met polymorphisms.

    RESULTS: Multivariate analysis showed a significant association between maternal symptoms of depression and anxiety, and internalizing problems in 12-year-old children (OR 5.72, 95% CI 3.30-9.91). Furthermore, carriers of two short alleles (s/s) of the 5-HTTLPR showed a more than 4-fold increased risk of internalizing problems at age 12 compared to l/l carriers (OR 4.73, 95% CI 2.14-10.48). No gene-by-environment interaction was found and neither depressive symptoms postpartum or traumatic experiences during childhood stayed significant in the final model.

    CONCLUSIONS: Concurrent maternal symptoms of depression and anxiety are significant risk factors for behavior problems in children, which need to be taken into account in clinical practice. Furthermore, we found a main effect of 5-HTTLPR on internalizing symptoms in 12-year-old children, a finding that needs to be confirmed in future studies.

  • 2.
    Agnafors, Sara
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Sydsjö, Gunilla
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    deKeyser, Linda
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Göran Svedin, Carl
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Symptoms of Depression Postpartum and 12 years Later-Associations to Child Mental Health at 12 years of Age2013In: Maternal and Child Health Journal, ISSN 1092-7875, E-ISSN 1573-6628, Vol. 17, no 3, p. 405-414Article in journal (Refereed)
    Abstract [en]

    Children of depressed mothers have been shown to express behaviour problems to a greater extent than children of non-depressed mothers. The purpose of this study was to examine the persistence of depressive symptoms in mothers and to evaluate the relative importance of symptoms of postpartum depression (PPD) and concurrent maternal symptoms of depression, on child behaviour at age 12. A birth cohort of 1,707 children and their mothers was followed from 3 months after birth to 12 years after birth. Self-reported symptoms of depression in mothers were assessed at baseline and 12-year follow-up where 893 mothers (52.3 %) and their children participated. The mothers reports on the behaviour of their children at age 12 were used. Multivariate analysis was used to assess factors that increased the risk of child behaviour problems. At baseline, 10.4 % scored above the cutoff for symptoms of postpartum depression. At follow up, 18.2 % scored above the cutoff for depressive symptoms. Multivariate analysis showed that ongoing maternal symptoms of depression, as distinct from PPD-symptoms, was the strongest predictor of child behaviour problems at age 12. The gender of the child and socio-demographic factors at baseline were additional factors that affected the risk of behaviour problems in the 12 year old children. Children of mothers who reported symptoms of depression, both postpartum and at follow-up, were at a greater risk of behaviour problems compared to children of women with no depressive symptoms on either occasion. Our findings indicate that recurrent and ongoing maternal depressive symptoms significantly increase the risk of child behaviour problems as reported by mothers, while symptoms of PPD do not seem to result in an increased risk of behaviour problems in 12 year olds. High maternal socio-demographic life stress at childbirth constitutes an important risk factor for later child behaviour problems.

  • 3.
    Allansson, Elin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per E
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry in Linköping.
    Nelson, Nina
    Linköping University, Department of Clinical and Experimental Medicine, Division of Clinical Sciences. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Paediatrics in Linköping.
    Overweight and obese children have lower cortisol levels than normal weight children2014In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 103, no 3, p. 295-299Article in journal (Refereed)
    Abstract [en]

    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.

  • 4.
    Andersson, Gerhard
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Arts and Sciences.
    Chronic pain and praying to a higher power: useful or useless?2008In: Journal of religion and health, ISSN 1573-6571, Vol. 47, no 2, p. 176-87Article in journal (Refereed)
    Abstract [en]

    In the present study a Swedish sample of 118 persons with chronic pain completed online tests on two occasions in association with treatment trials. A three item subscale measuring praying as a coping strategy was derived from the Coping Strategies Questionnaire (CSQ), but adapted to refer to "a higher power" instead of "God". Measures of pain and anxiety/depression were also included. Results revealed significant associations between praying and pain interference and impairment. Praying was also associated with anxiety and depression scores. Results also showed that prayer predicted depression scores at follow-up, and that follow-up prayer was predicted by pain interference at first measurement occasion. Overall, if prayer had any relation with the other variables it was in the negative direction of more distress being associated with more praying both concurrently and prospectively.

  • 5.
    Andersson, Torbjörn
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    "Om vikten av att bli berörd som behandlare": Metodforum - En arena för reflekterande över den vardagliga praktiken2012Independent thesis Advanced level (professional degree), 10 credits / 15 HE creditsStudent thesis
    Abstract [sv]

    Föreliggande uppsats är en praxisnära fenomenologisk studie genomförd på en mindre skol- och behandlingsverksamhet i Täby, som heter Svalnäs. På Svalnäs samlas personalen en gång per vecka i något de kallar metodforum. I detta forum delas och reflekteras det kring erfarenheter från den dagliga praktiken som på olika sätt berört personalen. Metodforum är ett svårfångat och komplext fenomen och därmed också svårt att beskriva. Denna uppsats är ett försök att beskriva metoden från insidan, via deltagarnas upplevelser av metoden.I uppsatsen presenteras Svalnäs och den värdegrund och kultur ur vilken metodforum uppkommit. Studien bygger i huvudsak på intervjuer med samtliga (9) behandlare i verksamheten. Frågeställningarna i uppsatsen rör deltagarnas beskrivning av metoden, deras upplevelser kring vad i metoden som är verksamt samt metodens eventuella nytta eller användbarhet. En deskriptiv fenomenologisk metod har använts och resultatet redovisas i en illustrativ beskrivning av fenomenets meningsbärande innebörder samt i en sammanfattande generell struktur. I diskussionen reflekteras det över metodforum i relation till presenterad teori och metodens generella användbarhet.

  • 6.
    Annerbäck, Eva-Maria
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Child Physical Abuse: Characteristics, Prevalence, Health and Risk‐taking2011Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    The home is supposed to provide support and safety for children but can also be the place where children suffer abuse and other adverse treatment by their parents. Violence against children in homes has been banned in Sweden for more than 30 years but it is still a considerable problem in the society and a threat to public health. The overall aim of this thesis was to create comprehensive knowledge of the phenomenon Child Physical Abuse (CPA) in Sweden after the ban on corporal punishment. The focus has been on examining the characteristics of cases reported to the police as well as self-reported CPA, prevalence of CPA and finally associations between CPA and health-problems/risk-taking behaviors among adolescents.

    Two samples are used in this thesis. The first comprises cases reported to the police during 11 years (n=142) in a Swedish police-district and the second is a population-based youth survey of the total number of pupils in three different school grades (13, 15 and 17 years old) in Södermanland County, Sweden.

    Cases of severe abuse constituted 14 % of the total number of cases reported to the police. The main difference between the group of severe cases and the remaining was the higher occurrence of convictions in court in the severe cases and the pattern of reporting to the police. The severe cases were reported by agencies to a greater degree than minor cases. Cases of severe abuse were characterized by an accumulation of risk factors in different areas as perpetrator factors, stress- and strain factors, factors of insufficient social network and finally child-related factors.

    In the cross-sectional study a prevalence of 15 % was found for self-reported CPA (n=8 494). There were associations between risk factors in different areas and abuse and there was a dos-response relationship between risks and reported abuse. It was shown that children who reported parental intimate-partner violence were at considerably higher risk for CPA than other children and that only 7 % of the children exposed to violence had disclosed this to authorities.

    The study of associations between health and risk-taking behaviors, were performed among the 15 and 17 years old pupils (n=5 933). Associations with health-problems and risk-taking behaviors were shown and the associations became stronger when the pupils reported 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 (parental intimate partner violence, bullying and being forced to engage in sexual acts) and the associations increased with the number of concurrent abuse.

    List of papers
    1. Severe child abuse: A study of cases reported to the police
    Open this publication in new window or tab >>Severe child abuse: A study of cases reported to the police
    2007 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 96, no 12, p. 1760-1764Article in journal (Refereed) Published
    Abstract [en]

    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).

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-39543 (URN)10.1111/j.1651-2227.2007.00519.x (DOI)49586 (Local ID)49586 (Archive number)49586 (OAI)
    Available from: 2009-10-10 Created: 2009-10-10 Last updated: 2017-12-13Bibliographically approved
    2. Characteristic Features of Severe Child Physical Abuse-A Multi-informant Approach
    Open this publication in new window or tab >>Characteristic Features of Severe Child Physical Abuse-A Multi-informant Approach
    2010 (English)In: Journal of family Violence, ISSN 0885-7482, E-ISSN 1573-2851, Vol. 25, no 2, p. 165-172Article in journal (Refereed) Published
    Abstract [en]

    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.

    Place, publisher, year, edition, pages
    Springer, 2010
    Keywords
    Child physical abuse, Severe, Social services, Reports, Sweden
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-53053 (URN)10.1007/s10896-009-9280-1 (DOI)
    Note
    The original publication is available at www.springerlink.com: Eva-Maria Annerbäck, Carl Göran Svedin and Per Gustafsson, Characteristic Features of Severe Child Physical Abuse-A Multi-informant Approach, 2010, JOURNAL OF FAMILY VIOLENCE, (25), 2, 165-172. http://dx.doi.org/10.1007/s10896-009-9280-1 Copyright: Springer Science Business Media http://www.springerlink.com/ Available from: 2010-01-15 Created: 2010-01-15 Last updated: 2017-12-12Bibliographically approved
    3. Prevalence and characteristics of child physical abuse in Sweden - findings from a population-based youth survey
    Open this publication in new window or tab >>Prevalence and characteristics of child physical abuse in Sweden - findings from a population-based youth survey
    2010 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 99, no 8, p. 1229-1236Article in journal (Refereed) Published
    Abstract [en]

    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.

    Place, publisher, year, edition, pages
    Blackwell Publishing Ltd, 2010
    Keywords
    Child physical abuse; Prevalence; Risk factors; Parental intimate-partner violence; Sweden
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-58283 (URN)10.1111/j.1651-2227.2010.01792.x (DOI)000279438000024 ()
    Available from: 2010-08-10 Created: 2010-08-09 Last updated: 2017-12-12
    4. Child Physical Abuse and concurrence of other types of Child Abuse: associations with health and risk behaviors
    Open this publication in new window or tab >>Child Physical Abuse and concurrence of other types of Child Abuse: associations with health and risk behaviors
    Show others...
    2012 (English)In: International Journal of Child Abuse & Neglect, ISSN 0145-2134, E-ISSN 1873-7757, Vol. 36, no 7-8, p. 585-595Article in journal (Refereed) Published
    Abstract [en]

    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.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-67219 (URN)10.1016/j.chiabu.2012.05.006 (DOI)000307913700004 ()
    Available from: 2011-04-04 Created: 2011-04-04 Last updated: 2017-12-11Bibliographically approved
  • 7.
    Annerbäck, Eva-Maria
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Sahlqvist, L.
    Research and Development Centre, Sörmlands County Council, S-631 88 Eskilstuna, Sweden.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Wingren, Gun
    Linköping University, Department of Clinical and Experimental Medicine, Work and Environmental Science. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Child Physical Abuse and concurrence of other types of Child Abuse: associations with health and risk behaviors2012In: International Journal of Child Abuse & Neglect, ISSN 0145-2134, E-ISSN 1873-7757, Vol. 36, no 7-8, p. 585-595Article in journal (Refereed)
    Abstract [en]

    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.

  • 8.
    Annerbäck, Eva-Maria
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Characteristic Features of Severe Child Physical Abuse-A Multi-informant Approach2010In: Journal of family Violence, ISSN 0885-7482, E-ISSN 1573-2851, Vol. 25, no 2, p. 165-172Article in journal (Refereed)
    Abstract [en]

    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.

  • 9.
    Annerbäck, Eva-Maria
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Wingren, Gun
    Linköping University, Department of Clinical and Experimental Medicine, Occupational and Environmental Medicine . Linköping University, Faculty of Health Sciences.
    Göran Svedin, Carl
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Prevalence and characteristics of child physical abuse in Sweden - findings from a population-based youth survey2010In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 99, no 8, p. 1229-1236Article in journal (Refereed)
    Abstract [en]

    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.

  • 10.
    Back, Christina
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per A.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Berterö, Carina
    Linköping University, Department of Medical and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
    How do children overcome difficulties talking about sexual abuseManuscript (preprint) (Other academic)
    Abstract [en]

    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.

  • 11.
    Back, Christina
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per A.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry in Linköping.
    Berterö, Carina
    Linköping University, Department of Medical and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
    Parents’ opinions – view of their child´s experiences in the legal process: An interpretative analysis of parents’ opinionsManuscript (preprint) (Other academic)
    Abstract [en]

    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.

  • 12.
    Back, Christina
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per A.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Berterö, Carina
    Linköping University, Department of Medical and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
    Sexually Abused Children – Prosecutors' Experiences of their Participation in the Legal Process in Sweden2013In: Psychiatry, Psychology and Law, ISSN 1321-8719, E-ISSN 1934-1687, Vol. 20, no 2, p. 273-283Article in journal (Refereed)
    Abstract [en]

    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.

  • 13.
    Back, Kristina
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per A
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Larsson, IngBeth
    Linköping University, The Tema Institute, The Department of Gender Studies. Linköping University, Faculty of Arts and Sciences.
    Berterö, Carina
    Linköping University, Department of Medical and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences.
    Managing the legal proceedings: An interpretative phenomenological analysis of sexually abused children's experience with the legal process2011In: International Journal of Child Abuse & Neglect, ISSN 0145-2134, E-ISSN 1873-7757, Vol. 35, no 1, p. 50-57Article in journal (Refereed)
    Abstract [en]

    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.

  • 14.
    Bergström, Malin
    et al.
    Stockholm University, Sweden.
    Modin, Bitte
    Stockholm University, Sweden.
    Fransson, Emma
    Stockholm University, Sweden.
    Rajmil, Luis
    Catalan Agency Health Informat Assessment and Qual, Spain.
    Berlin, Marie
    National Board Health and Welf, Sweden.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Region Östergötland, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry in Linköping.
    Hjern, Anders
    Stockholm University, Sweden.
    Living in two homes-a Swedish national survey of wellbeing in 12 and 15 year olds with joint physical custody2013In: BMC Public Health, ISSN 1471-2458, E-ISSN 1471-2458, Vol. 13Article in journal (Refereed)
    Abstract [en]

    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.

  • 15.
    Bernfort, Lars
    et al.
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    Nordfeldt, Sam
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry. Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics.
    Persson, Jan
    Linköping University, Department of Medical and Health Sciences, Health Technology Assessment and Health Economics. Linköping University, Faculty of Health Sciences.
    ADHD from a socio-economic perspective2008In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 97, no 2, p. 239-245Article, review/survey (Refereed)
    Abstract [en]

    Aim: Attention deficit hyperactivity disorder (ADHD) and related disorders affect children's ability to function in school and other environments. Awareness has increased in recent years that the same problems often persist in adulthood. Based on previous studies, we aimed to outline and discuss a descriptive model for calculation of the societal costs associated with ADHD and related disorders. Methods: Following a literature review including childhood and adult studies, long-term outcomes of ADHD and associated societal costs were outlined in a simple model. Results: The literature concerning long-term consequences of ADHD and related disorders is scarce. There is some evidence regarding educational level, psychosocial problems, substance abuse, psychiatric problems and risky behaviour. The problems are likely to affect employment status, healthcare consumption, traffic and other accidents and criminality. A proposed model structure includes persisting problems in adulthood, possible undesirable outcomes (and their probabilities) and (lifetime) costs associated with these outcomes. Conclusions: Existing literature supports the conclusion that ADHD and related disorders are associated with a considerable societal burden. To estimate that burden with any accuracy, more detailed long-term data are needed. © 2007 The Author(s).

  • 16.
    Birberg Thornberg, Ulrika
    et al.
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Gustafsson, Per A.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Silfverdal, Sven-Arne
    Division of Paediatrics, Department of Clinical Sciences, Umeå University.
    Duchén, Karel
    Linköping University, Department of Clinical and Experimental Medicine, Pediatrics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Paediatrics in Linköping.
    A Placebo controlled, randomized study of PUFA (Poly Unsaturated Fatty Acids) as treatment for neurodevelopmental problems in 7-year-old children and cognitive performance in relation to an age-matched control groupManuscript (preprint) (Other academic)
    Abstract [en]

    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.

  • 17.
    Birberg Thornberg, Ulrika
    et al.
    Linköping University, Department of Behavioural Sciences. Linköping University, Faculty of Arts and Sciences.
    Karlsson, Thomas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Gustafsson, Per
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Duchén, Karel
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Pediatrics. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Paediatrics in Linköping.
    Nutrition and theory of mind: The role of polyunsaturated fatty acids (PUFA) in the development of theory of mind2006In: Prostaglandins, Leukotrienes and Essential Fatty Acids, ISSN 0952-3278, E-ISSN 1532-2823, Vol. 75, no 1, p. 33-41Article in journal (Refereed)
    Abstract [en]

    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.

  • 18.
    Chermá Yeste, Maria Dolores
    et al.
    Linköping University, Department of Medicine and Health Sciences, Clinical Pharmacology . Linköping University, Faculty of Health Sciences.
    Ahlner, Johan
    Linköping University, Department of Medicine and Health Sciences. Linköping University, Faculty of Health Sciences.
    Bengtsson, Finn
    Linköping University, Department of Medicine and Health Sciences, Clinical Pharmacology . Linköping University, Faculty of Health Sciences.
    Gustafsson, Per A.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Concentration of Antidepressant Drugs in Children and Adolescents: a naturalistic clinical studyManuscript (preprint) (Other academic)
    Abstract [en]

    Objective: The aims of this study were to evaluate the pharmacokinetics (PKs) of antidepressant agents, in terms of steady-state and trough values, in a heterogeneous cohort of patients and to describe the utilisation of antidepressant drugs (ATDs) in Child and Adolescent Psychiatry in the south- east of Sweden.

    Method: Patients from Child and Adolescent Psychiatry centres in the counties of Östergötland, Jönköping and Kalmar (Sweden) to be prescribed an antidepressant drug, were studied between 2002 and 2004. The blood concentration of ATDs and, in some cases, also CYP2D6 were determined and relevant clinical information provided.

    Results: Two hundred and eleven children: 64 % girls and 36 % boys, between the ages of 8 and 20 were evaluated. The concentrations of drugs in the patient evaluated (PE) population were as expected from the dose administered in 63 % of this population, higher than expected in 26 % and lower than expected in 11 %.

    Dose-concentration relationships for sertraline (rs=0.48, p<0.001) and metabolite desmethylsertraline (rs=0.5, p<0.001) were seen. No relationship was found between dose and ratio desmethylsertraline-to-sertraline. CYP2D6*4 was the most common poor metabolizer (PM) allele. The primary indication for the antidepressant treatment was depression in 69 % of subjects. Suspected adverse drug reactions were spontaneously reported in 31 %. Monotherapy was indicated in 49 % of request forms. The most common drug combinations with the antidepressant drug were oral anticontraceptives and anxiolytics/sedatives/hypnotic drugs.

    Conclusion: the most prescribed antidepressant drug in children and adolescents in the present study was sertraline. The pharmacokinetic outcomes of serum concentration of sertraline, as well as daily doses administered were similar to the referenced data for adults. Antidepressant drug monotherapy was most common. No serious adverse side effects were spontaneously reported. TDM may provide support to the prescribing physicians to individual dose optimising and to assess drug compliance, above all when the antidepressant drugs are not well studied in pediatric patients before approval for general prescription. Further clinical trials, as well as naturalistic studies are necessary to ensure that children are not exposed to unnecessary risk and to determine the most appropriate dose in children of different ages.

  • 19.
    Cocozza, Madeleine
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    The Parenting of Society: From Report to Support2007Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Child protection is the process that aims to find, investigate and help maltreated children. In many countries this process is initiated by professionals who compile mandated reports that are then submitted to a designated agency that in many cases is part of a separate child protection system. In Sweden there is no separate child protection system. In Sweden, the child protection process is part of the family-service organization system. The system has two main objectives, one is voluntary (provide family service), the other coercive (provide child protection). This system is administered by the municipal social services agencies (referred to throughout as Social Services).

    Aim: The overall purpose of this study was to gain knowledge of the child protection process in Sweden. The aim was two fold, one to carry out an in-depth study of a population of reports, the other to analyse the results of the findings in relation to the child protection system. The child protection system consists of elements outlined in the macro system: the underlying ideology and the framing of the problem, and the legislation, administration and the demands placed on professionals.

    Method: A total population of reports made to one municipality during 1998 was followed to a final decision. The reports were collected in 2000.´There were 1 570 reports made regarding 1 051 children, which composed 4 % of children age 0-18. This initial study was used in four papers where data were analysed covering four different issues. In 2003 a follow-up study was conducted in order to determine the extent to which the child appeared in the database of Social Services. In the first paper the children’s age, gender and contacts with Social Services were described as were the content of the reports and the outcome of reporting. The objective of the second paper was a description of the reporter, and the measurement of the extent to which the reports indicated child maltreatment. The third paper aimed at analysing how the first decision, the decision not to investigate reports, was made in the child protection process. Then a re-evaluation of these decisions was made to see how well the decision was justified. The contacts taken were described. In the fourth paper the influence of the socio-economic load on the child protection process was measured.

    Findings: Few reports (16 %) led to an intervention being provided, and 41% of the reports were not investigated further. In the follow-up study 61% of all 1 051 children appeared in the files of Social Services. As Sweden lacks a juvenile delinquency system these cases are automatically passed from the police to Social Services and are there registered as mandated reports.

    Hence the police became the largest report group of reporters, followed by professionals. Of the professionals’ reports 22 % were not investigated. In the follow-up study 53 % of these re-occurred at the Social Service and were then investigated. Seventy six percent of the reports not investigated were when re-evaluated found to indicate child maltreatment.

    The social worker used the parents as the main source for information in 74 % of the cases. The social worker did not contact the child at all in 53 % of the cases and only nine of the reporters were contacted. In the follow-up study 45 % of the children investigation re-appeared in the files of Social Services. Children from high socio-economic load districts were more often reported than those from middle or low (4.3%, 3.1% 2.3%). The socio economic load when measured in logistic regression was not found to correlate with the decision to investigate.

    A main finding in this study was that the child protection process was difficult to separate from other systems within the family service. This makes it much more difficult to evaluate the child protection process.

    The reports filed by professionals were not investigated adequately, and the lack of criteria of specifying how reports are to be evaluated creates a risk that maltreated children will not be found. The professional reports were handled in a way that increased the risk that professionals will have negative experiences with Social Services that consequently can lead them to refrain from filing eports.

    Conclusion: These findings suggest the following: Pass new legislation that makes it easier to separate each of the three systems from the other. Create a national database in which data on the handling of child-protection cases is systematically recorded. Develop a national reporting form that is to be used by all who file mandated reports of suspected maltreatment. Create clear criteria that specify how a report is to be handled to ensure that the reporting professionals are met with appropriate respect and that the quality of the decisions is guaranteed all over the country.

    List of papers
    1. Child Protection in a Family Service Organisation in Sweden- What is the outcome for maltreated children?
    Open this publication in new window or tab >>Child Protection in a Family Service Organisation in Sweden- What is the outcome for maltreated children?
    2010 (English)In: Children and youth services review, ISSN 0190-7409, E-ISSN 1873-7765, Vol. 32, no 7, p. 922-928Article in journal (Refereed) Published
    Abstract [en]

    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.

    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-12931 (URN)10.1016/j.childyouth.2010.03.003 (DOI)
    Available from: 2008-02-13 Created: 2008-02-13 Last updated: 2017-12-13
    2. Who suspects and report child maltreatment to Social Services in Sweden?: Is there a reliable mandatory reporting process?
    Open this publication in new window or tab >>Who suspects and report child maltreatment to Social Services in Sweden?: Is there a reliable mandatory reporting process?
    2007 (English)In: European Journal of Social Work, ISSN 1369-1457, E-ISSN 1468-2664, Vol. 10, no 2, p. 209-223Article in journal (Refereed) Published
    Abstract [en]

    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.

    Keywords
    Mandatory Reporting, Child Protection, Reporter, Child Welfare, Child Neglect, Child Abuse, Social Services, Anmälningsplikt, Anmälare, Barn Som Far Illa, Social Förvaltning, Barnmisshandel
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-12932 (URN)10.1080/13691450701317996 (DOI)
    Available from: 2008-02-13 Created: 2008-02-13 Last updated: 2017-12-13
    3. Child Protection in Sweden: Are routine assesments reliable?
    Open this publication in new window or tab >>Child Protection in Sweden: Are routine assesments reliable?
    2006 (English)In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 95, no 11, p. 1474-1480Article in journal (Refereed) Published
    Abstract [en]

    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.

    Keywords
    Child abuse, child protection, decision making, mandatory reporting, social service
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-12933 (URN)10.1080/08035250600784352 (DOI)
    Available from: 2008-02-13 Created: 2008-02-13 Last updated: 2017-12-13
    4. The Impact of Socio-economic load in Family Service organized child protection
    Open this publication in new window or tab >>The Impact of Socio-economic load in Family Service organized child protection
    2007 (English)Article in journal (Refereed) Submitted
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-12934 (URN)
    Available from: 2008-02-13 Created: 2008-02-13
  • 20.
    Cocozza, Madeleine
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Sydsjö, Gunilla
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Child Protection in a Family Service Organisation in Sweden- What is the outcome for maltreated children?2010In: Children and youth services review, ISSN 0190-7409, E-ISSN 1873-7765, Vol. 32, no 7, p. 922-928Article in journal (Refereed)
    Abstract [en]

    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.

  • 21.
    Cocozza, Madeleine
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Sydsjö, Gunilla
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology . Linköping University, Faculty of Health Sciences.
    Child Protection in Sweden: Are routine assesments reliable?2006In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 95, no 11, p. 1474-1480Article in journal (Refereed)
    Abstract [en]

    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.

  • 22.
    Cocozza, Madeleine
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Sydsjö, Gunilla
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology . Linköping University, Faculty of Health Sciences.
    The Impact of Socio-economic load in Family Service organized child protection2007Article in journal (Refereed)
  • 23.
    Cocozza, Madeleine
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Sydsjö, Gunilla
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Gynecology and Obstetrics in Linköping.
    Who suspects and report child maltreatment to Social Services in Sweden?: Is there a reliable mandatory reporting process?2007In: European Journal of Social Work, ISSN 1369-1457, E-ISSN 1468-2664, Vol. 10, no 2, p. 209-223Article in journal (Refereed)
    Abstract [en]

    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.

  • 24.
    D Cherma, Maria
    et al.
    Linköping University, Department of Medicine and Health Sciences, Clinical Pharmacology. Linköping University, Faculty of Health Sciences.
    Ahlner, Johan
    Linköping University, Department of Medicine and Health Sciences, Clinical Pharmacology. Linköping University, Faculty of Health Sciences.
    Bengtsson, Finn
    Linköping University, Department of Medicine and Health Sciences, Clinical Pharmacology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre for Laboratory Medicine, Department of Clinical Pharmacology.
    Gustafsson, Per
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Antidepressant Drugs in Children and Adolescents Analytical and Demographic Data in a Naturalistic, Clinical Study2011In: JOURNAL OF CLINICAL PSYCHOPHARMACOLOGY, ISSN 0271-0749, Vol. 31, no 1, p. 98-102Article in journal (Refereed)
    Abstract [en]

    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.

  • 25.
    Dekeyser, Linda
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Agnaförs, Sara
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Sydsjö, Gunilla
    Linköping University, Department of Clinical and Experimental Medicine, Obstetrics and gynecology. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Self-reported mental health in 12-year-old second-generation immigrant children in Sweden2011In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 65, no 6, p. 389-395Article in journal (Refereed)
    Abstract [en]

     Today 29.3% of all newborns in Sweden are second-generation immigrants. Studies on mental health among these children are few, inconclusive and vary widely with regard to the informant used and the age of the immigrant. The majority of previous studies focus on study groups that cover a wide age span but since mental health varies considerably during the pre-adolescent and adolescent years, more age-specific studies are needed. Additional focus on the health and well-being of these children is necessary if a well-functioning society is to develop. Aim: To investigate whether and how second-generation immigrant children in Sweden differ from non-immigrant children in their presentation of self-reported mental health at the age of 12. Methods: Second-generation immigrant children (n = 142) from a birth cohort in southern Sweden, subjects of the SESBiC-study (the South East Sweden Birth Cohort-study) were compared with non-immigrant children (n = 1036) from the same cohort in their presentation of self-reported mental health at the age of 12 using the Strengths and Difficulties Questionnaire. Gender, family structure and parents educational level were controlled for. Results: Second-generation immigrant children did not differ from the non-immigrant children in their own presentation of mental health at the age of 12 in any of the categories of immigrant groups. Conclusion: It is a promising sign for future integration that second-generation immigrant childrens self-reported mental health at the age of 12 was quite similar to that of non-immigrant children.

  • 26.
    Engman, Maria
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Gender and medicine. Linköping University, Faculty of Health Sciences.
    Wijma, Klaas
    Linköping University, Department of Clinical and Experimental Medicine, Medical Psychology. Linköping University, Faculty of Health Sciences.
    Wijma, Barbro
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Gynaecology and Obstetrics in Linköping.
    Long-term coital behaviour in women treated with cognitive behaviour therapy for superficial coital pain and vaginismus2010In: Cognitive Behaviour Therapy, ISSN 1650-6073, E-ISSN 1651-2316, Vol. 39, no 3, p. 193-202Article in journal (Refereed)
    Abstract [en]

    The purpose of the present study was to investigate long-term coital behaviour in women treated with cognitive behaviour therapy (CBT) for superficial coital pain and vaginismus. Data were taken from a questionnaire concerning long-term coital behaviour sent to 59 women who presented to Linköping University Hospital because of superficial coital pain, had been diagnosed with vaginismus, and had been treated with CBT. Data were also traced from therapy records: mean follow-up time was 39 months, the women had suffered for an average of almost 4 years, and required a mean of 14 treatment sessions. Forty-four of the 59 women returned the questionnaire, for a response rate of 74.6%. At follow-up, 81% of the treated women had had intercourse. A majority (61%) rated their ability to have intercourse without pain as 6 or higher (on a scale from 0-10), and 61% rated their ability to enjoy intercourse as 6 or higher (on a scale from 0-10). The proportion of women with positive treatment outcome at follow-up ranged from 81% (able to have intercourse) to 6% (able to have pain-free intercourse). An ability to have intercourse at end of therapy was maintained at follow-up. Two-thirds of the women reported high fulfillment of individual treatment goals. At follow-up, the women estimated a significantly higher self-worth as sex partners, and as women and human beings, than before treatment. Twelve per cent of the original sample had healed after a few assessment sessions and without treatment.

  • 27.
    Ericsson, Elisabeth
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Oto-Rhiono-Laryngology and Head & Neck Surgery . Linköping University, Faculty of Health Sciences.
    Wadsby, Marie
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Hultcrantz, Elisabeth
    Linköping University, Department of Clinical and Experimental Medicine, Oto-Rhiono-Laryngology and Head & Neck Surgery . Linköping University, Faculty of Health Sciences.
    Pre-surgical Child Behavior Ratings and Pain Management after Two Different Techniques of Tonsil Surger2006In: International Journal of Pediatric Otorhinolaryngology, ISSN 0165-5876, E-ISSN 1872-8464, Vol. 70, no 10, p. 1749-1758Article in journal (Refereed)
    Abstract [en]

    Objective

    The purpose of this investigation was to compare child behavior before surgery with experience of pain and anxiety in relation to two techniques of tonsil surgery, to relate previous experiences of surgery/tonsillitis with anxiety and pain, and to compare the children's, parent's and nurse's rating of pain.

    Method

    Ninety-two children (5–15 years) with sleep-disordered breathing (SDB) and with or without recurrent tonsillitis were randomized to partial tonsil resection/tonsillotomy (TT) or full tonsillectomy (TE). Measures: Parents: Child Behavior Checklist (CBCL). Children: State-Trait-Anxiety Inventory for Children (STAIC) and seven-point Faces Pain Scale (FPS). Parents/staff: seven-point Verbal Pain Rating Scale (VPRS). Pain relievers were opoids, paracetamol and diclophenac.

    Results

    These children with SDB scored significantly higher on CBCL than did normative groups, but no connection was observed between CBCL rating and experience of pain. There was no relation between pre-operative anxiety and pain. The post-operative anxiety level (STAIC) correlated with pain. The TE-group scored higher on STAIC after surgery. Previous experience of surgery or tonsillitis did not influence post-operative pain. The TE-group rated higher experience of pain despite more medication. The nurses scored pain lower than the parents/children and under-medicated.

    Conclusion

    SDB may influence children's behavior, but with no relation to post-operative pain. The surgical method predicts pain better than does the child's behavior rating. The nurses underestimated the pain experienced by the child.

  • 28.
    Fredlund, Cecilia
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Svensson, Frida
    Linköping University, The Institute of Technology.
    Göran Svedin, Carl
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Priebe, Gisela
    Lund University, Sweden .
    Wadsby, Marie
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Adolescents Lifetime Experience of Selling Sex: Development Over Five Years2013In: Journal of Child Sexual Abuse, ISSN 1053-8712, E-ISSN 1547-0679, Vol. 22, no 3, p. 312-325Article in journal (Refereed)
    Abstract [en]

    Lifetime experience of selling sex among adolescents was investigated together with sociodemographic correlates, parentchild relationship, and the existence of people to confide in. Changes over time regarding the selling of sex were investigated through a comparison of data from 2004 and 2009. This study was carried out using 3,498 adolescents from a representative sample of Swedish high school students with a mean age 18.3 years. Of these adolescents, 1.5% stated that they had given sexual services for reimbursement and both male and female buyers existed. The adolescents who had sold sex had a poorer parentchild relationship during childhood and had fewer people to confide in about problems and worries. Changes over time were found especially regarding the Internet as a contact source and also immigrant background.

  • 29.
    Gimbler Berglund, Ingalill
    et al.
    Omvårdnad, Hälsohögskolan i Jönköping.
    Ericsson, Elisabeth
    Linköping University, Department of Medical and Health Sciences, Nursing Science. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Anaesthetics, Operations and Specialty Surgery Center, Department of Otorhinolaryngology in Linköping.
    Proczkowska-Björklund, Marie
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Fridlund, Bengt
    Omvårdnad, Hälsohögskolan i Jönköping.
    Nurse anaesthetists' experiences with pre-operative anxiety2013In: Nursing Children and Young People, ISSN 2046-2336, Vol. 25, no 1, p. 28-34Article in journal (Refereed)
    Abstract [en]

    AIMS:

    To explore nurse anaesthetists' experiences and actions when administering and caring for children requiring anaesthesia.

    METHOD:

    A qualitative design employing critical incident technique was used. Interviews were carried out with a purposeful sample of nurse anaesthetists (n=32). The nurse anaesthetists' experiences were grouped into two main areas: organisation focused and interrelational focused. Actions were grouped into two main areas: optimising the situation and creating interpersonal interaction.

    FINDINGS:

    The categories and subcategories of the nurses' experiences appeared to influence the outcome for the child. The nurse anaesthetists' first priority was to create an optimal environment and increase sensitivity in their interactions with the child.

    CONCLUSION:

    Sensitivity to the child and flexibility in altering actions are key strategies to avoid physical restraint.

  • 30.
    Green Landell, Malin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Oncology . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Surgery and Oncology, Department of Oncology UHL.
    Tillfors, Maria
    Dept. of Behavioural, Social and Legal Sciences Örebro University.
    Furmark, Tomas
    Dept. of Psychology Uppsala University.
    Bohlin, Gunilla
    Dept. of Psychology Uppsala University.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Göran Svedin, Carl
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Social phobia in Swedish adolescents: Prevalence and gender differences2009In: Social Psychiatry and Psychiatric Epidemiology, ISSN 0933-7954, E-ISSN 1433-9285, Vol. 44, no 1, p. 1-7Article in journal (Refereed)
    Abstract [en]

    Background The aim of this study was to investigate the prevalence of self-reported social phobia in a community sample of Swedish adolescents in junior high school, at the risk-period for developing social phobia. Of particular interest was to investigate gender differences in prevalence across ages. Prevalence of sub-threshold social phobia was also studied. Methods Students in grades 6-8 (aged 12-14) from seventeen schools in five Swedish municipalities were screened by means of a self-report questionnaire, the social phobia screening questionnaire-for children (SPSQ-C). Results Data from a sample of 2,128 students were analysed and showed a point-prevalence rate of 4.4% (95% CI 3.5-5.2) and a significant gender difference (6.6% girls vs. 1.8% boys, P < 0.001). No significant differences in prevalence of probable cases emerged across the ages. At sub-threshold level, marked social fear of at least one social situation was reported by 13.8% of the total group. "Speaking in front of class and "calling someone unfamiliar on the phone were the most feared social situations. In the social phobia group, 91.4% reported impairment in the school-domain due to their social fear. Conclusion Social phobia is a common psychiatric condition in Swedish adolescents, especially in girls. As impairment in the school-domain is reported to a high degree, professionals and teachers need to recognize social phobia in adolescents so that help in overcoming the difficulties can be offered.

  • 31.
    Green-Landell, Malin
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Social Anxiety Disorder in Swedish Adolescents: Prevalence, Victimization & Development2010Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Human beings are social creatures. Accordingly, fear of social situations can be severely disabling. Social anxiety disorder (SAD) is characterized by excessive fear of negative evaluation in social or performance situations. SAD has an early onset and often goes undetected an untreated. Descriptive studies on non‐clinical samples are required in order to find ways to prevent SAD and associated consequences. This thesis aimed at examining epidemiological variables of SAD in adolescence which is the critical period for onset of SAD. More exactly, issues of detection and prevalence, victimization and developmental course were addressed.

    Data was collected in four different community samples, using cross‐sectional and longitudinal designs. In the first study (n=169), psychometric evaluation of a screening questionnaire for use with adolescents was conducted. The second study (n=2128) investigated prevalence of SAD in students in grade 6‐8 (age 12‐14 years). In the third study (n=3211), the association between SAD and victimization in high‐school students (aged 17) was investigated. Finally, in the fourth study (n=350), longitudinal associations between social anxiety and depressive symptoms were investigated, with 4 waves of data from grade 7 to grade 11.

    Self‐reported SAD was found among 4.4% of students in grade 6‐8 and among 10.6% of high‐school students. Females reported SAD to a significantly higher degree than males in all age groups. Experiences of peer victimization, maltreatment and sexual victimization were significantly more common in those reporting SAD than in non‐cases. Social anxiety was stable over adolescence. Further, peer victimization in grade 7 predicted social anxiety that mediated subsequent depressive symptoms. In conclusion, self‐reported SAD is common in Swedish adolescents and especially in girls and older adolescents. Social anxiety is stable over adolescence and correlated with depressive symptoms over course. The high prevalence rates, stable course and mediation of depressive symptoms call for early detection and prevention of social anxiety. The relationship between victimization and SAD needs to be investigated further in controlled prospective studies on children and adolescents.

    List of papers
    1. Evaluation of the psychometric properties of a modified version of the Social Phobia Screening Questionnaire for use in adolescents.
    Open this publication in new window or tab >>Evaluation of the psychometric properties of a modified version of the Social Phobia Screening Questionnaire for use in adolescents.
    Show others...
    2009 (English)In: Child and Adolescent Psychiatry and Mental Health, ISSN 1753-2000, E-ISSN 1753-2000, Vol. 3, no 1, p. 36-Article in journal (Refereed) Published
    Abstract [en]

    ABSTRACT: BACKGROUND: Social phobia (social anxiety disorder - SAD) is a rather common but often undetected and undertreated psychiatric condition in youths. Screening of SAD in young individuals in community samples is thus important in preventing negative outcomes. The present study is the first report on the psychometric properties of the Social Phobia Screening Questionnaire for Children and adolescents (SPSQ-C). METHODS: The SPSQ-C was administered to a community sample of high-school students. Test-retest reliability over three weeks was evaluated (n = 127) and internal consistency was calculated for items measuring level of fear in eight social situations. To measure concurrent validity, subjects who reported SAD on at least one occasion and randomly selected non-cases were blindly interviewed with the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I), as gold standard (n = 51). RESULTS: A moderate test-retest reliability, r = .60 (P < .01), and a satisfactory alpha coefficient of .78 was found. Values of sensitivity and specificity were 71% and 86% respectively, and area under the curve (AUC) was .79. Positive likelihood ratio (LR+) showed that a positive screening result was five times more likely to be correct than to reflect a non-case. Negative likelihood ratio (LR -) was .34. In addition, positive predictive value was 45% and negative predictive value was 95%. The prevalence of self-reported SAD was found to be 7.2% at the first assessment. CONCLUSION: The SPSQ-C is a short and psychometrically sound questionnaire for screening of SAD in adolescents, with the advantage of being based on the DSM-IV criteria.

    Place, publisher, year, edition, pages
    BioMed Central, 2009
    National Category
    Psychiatry
    Identifiers
    urn:nbn:se:liu:diva-53087 (URN)10.1186/1753-2000-3-36 (DOI)19906313 (PubMedID)
    Note

    Original Publication: Malin Green-Landell, Andreas Björklind, Maria Tillfors, Tomas Furmark, Carl Göran Svedin and Gerhard Andersson, Evaluation of the psychometric properties of a modified version of the Social Phobia Screening Questionnaire for use in adolescents., 2009, Child and adolescent psychiatry and mental health, (3), 1, 36. http://dx.doi.org/10.1186/1753-2000-3-36 Licensee: BioMed Central http://www.biomedcentral.com/ Postprint available at: Linköping University Electronic Press http://urn.kb.se/resolve?urn=urn:nbn:se:liu:diva-53087

    Available from: 2010-01-15 Created: 2010-01-15 Last updated: 2017-12-12Bibliographically approved
    2. Social phobia in Swedish adolescents: Prevalence and gender differences
    Open this publication in new window or tab >>Social phobia in Swedish adolescents: Prevalence and gender differences
    Show others...
    2009 (English)In: Social Psychiatry and Psychiatric Epidemiology, ISSN 0933-7954, E-ISSN 1433-9285, Vol. 44, no 1, p. 1-7Article in journal (Refereed) Published
    Abstract [en]

    Background The aim of this study was to investigate the prevalence of self-reported social phobia in a community sample of Swedish adolescents in junior high school, at the risk-period for developing social phobia. Of particular interest was to investigate gender differences in prevalence across ages. Prevalence of sub-threshold social phobia was also studied. Methods Students in grades 6-8 (aged 12-14) from seventeen schools in five Swedish municipalities were screened by means of a self-report questionnaire, the social phobia screening questionnaire-for children (SPSQ-C). Results Data from a sample of 2,128 students were analysed and showed a point-prevalence rate of 4.4% (95% CI 3.5-5.2) and a significant gender difference (6.6% girls vs. 1.8% boys, P < 0.001). No significant differences in prevalence of probable cases emerged across the ages. At sub-threshold level, marked social fear of at least one social situation was reported by 13.8% of the total group. "Speaking in front of class and "calling someone unfamiliar on the phone were the most feared social situations. In the social phobia group, 91.4% reported impairment in the school-domain due to their social fear. Conclusion Social phobia is a common psychiatric condition in Swedish adolescents, especially in girls. As impairment in the school-domain is reported to a high degree, professionals and teachers need to recognize social phobia in adolescents so that help in overcoming the difficulties can be offered.

    Keywords
    prevalence, social phobia, adolescents, gender
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-18017 (URN)10.1007/s00127-008-0400-7 (DOI)
    Available from: 2009-05-04 Created: 2009-05-04 Last updated: 2017-12-13
    3. Social anxiety disorder and victimization in a community sample of adolescents
    Open this publication in new window or tab >>Social anxiety disorder and victimization in a community sample of adolescents
    2011 (English)In: Journal of Adolescence, ISSN 0140-1971, E-ISSN 1095-9254, Vol. 34, no 3, p. 569-577Article in journal (Refereed) Published
    Abstract [en]

    Despite high prevalence rates of social anxiety disorder (SAD) and high rates of victimization in adolescents, studies on the relationship between these phenomena are missing. In the present study we report associations between SAD and multiple victimization experiences in a community sample of adolescents. A cross-sectional study was conducted on 3211 Swedish high-school students. The prevalence rate of self-reported SAD was 10.6% (n=340). Significantly higher rates of lifetime victimization was found in subjects with self-reported SAD compared to non-cases, on the total score on the Juvenile Victimization Questionnaire, and on the subscales maltreatment, sexual victimization and victimization from peer/siblings. Different results emerged due to gender. In females, maltreatment and sexual victimization was associated with an increased risk of SAD and, in males sexual victimization increased the risk of reporting SAD. Further studies are needed to elaborate developmental models on SAD and to add to modification of prevention- and treatment interventions.

    Place, publisher, year, edition, pages
    Elsevier, 2011
    Keywords
    Social anxiety disorder, Adolescents, Victimization, Gender
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-57936 (URN)10.1016/j.adolescence.2010.03.007 (DOI)20416944 (PubMedID)
    Available from: 2010-07-09 Created: 2010-07-09 Last updated: 2018-02-21
    4. Longitudinal associations between social anxiety, depressive symptoms and peer victimization in adolescence: A prospective community study
    Open this publication in new window or tab >>Longitudinal associations between social anxiety, depressive symptoms and peer victimization in adolescence: A prospective community study
    Show others...
    (English)Manuscript (preprint) (Other academic)
    Abstract [en]

    Self-reported social anxiety, depressive symptoms and peer victimization was investigated in 350 students in grade 7 and then in grade 8, 9 and 11. Using latent growth modeling, social anxiety was found to be stable over time and to have a time-invariant association with depressive symptoms. Further, social anxiety predicted subsequent depressive symptoms but not vice versa. Support was found for a meditational model. That is, peer victimization in grade 7 was related to higher level of social anxiety, which in turn was associated with more depressive symptoms in grade 8, 9 and 11. The development of social anxiety and depression symptomatology among adolescents can thus be described as one sequential longitudinal process initiated by peer victimization.

    Keywords
    Social anxiety, adolescents, developmental course, depressive symptoms, peer victimization, latent growth modeling
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-57937 (URN)
    Available from: 2010-07-09 Created: 2010-07-09 Last updated: 2018-12-12Bibliographically approved
  • 32.
    Green-Landell, Malin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
    Björklind, Andreas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social work, Örebro, Sweden.
    Furmark, Tomas
    Uppsala University, Department of Psychology, Uppsala, Sweden.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences. Karolinska Institutet, Department of Clinical Neuroscience, Stockholm, Sweden.
    Evaluation of the psychometric properties of a modified version of the Social Phobia Screening Questionnaire for use in adolescents.2009In: Child and Adolescent Psychiatry and Mental Health, ISSN 1753-2000, E-ISSN 1753-2000, Vol. 3, no 1, p. 36-Article in journal (Refereed)
    Abstract [en]

    ABSTRACT: BACKGROUND: Social phobia (social anxiety disorder - SAD) is a rather common but often undetected and undertreated psychiatric condition in youths. Screening of SAD in young individuals in community samples is thus important in preventing negative outcomes. The present study is the first report on the psychometric properties of the Social Phobia Screening Questionnaire for Children and adolescents (SPSQ-C). METHODS: The SPSQ-C was administered to a community sample of high-school students. Test-retest reliability over three weeks was evaluated (n = 127) and internal consistency was calculated for items measuring level of fear in eight social situations. To measure concurrent validity, subjects who reported SAD on at least one occasion and randomly selected non-cases were blindly interviewed with the Structured Clinical Interview for DSM-IV Axis-I disorders (SCID-I), as gold standard (n = 51). RESULTS: A moderate test-retest reliability, r = .60 (P < .01), and a satisfactory alpha coefficient of .78 was found. Values of sensitivity and specificity were 71% and 86% respectively, and area under the curve (AUC) was .79. Positive likelihood ratio (LR+) showed that a positive screening result was five times more likely to be correct than to reflect a non-case. Negative likelihood ratio (LR -) was .34. In addition, positive predictive value was 45% and negative predictive value was 95%. The prevalence of self-reported SAD was found to be 7.2% at the first assessment. CONCLUSION: The SPSQ-C is a short and psychometrically sound questionnaire for screening of SAD in adolescents, with the advantage of being based on the DSM-IV criteria.

  • 33.
    Green-Landell, Malin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Hesser, Hugo
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Persson, Stefan
    3Örebro University, School of Law, Psychology and Social work, Örebro, Sweden.
    Furmark, Tomas
    Uppsala University, Department of Psychology, Uppsala, Sweden.
    Bohlin, Gunilla
    Uppsala University, Department of Psychology, Uppsala, Sweden.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Tillfors, Maria
    Örebro University, School of Law, Psychology and Social work, Örebro, Sweden.
    Longitudinal associations between social anxiety, depressive symptoms and peer victimization in adolescence: A prospective community studyManuscript (preprint) (Other academic)
    Abstract [en]

    Self-reported social anxiety, depressive symptoms and peer victimization was investigated in 350 students in grade 7 and then in grade 8, 9 and 11. Using latent growth modeling, social anxiety was found to be stable over time and to have a time-invariant association with depressive symptoms. Further, social anxiety predicted subsequent depressive symptoms but not vice versa. Support was found for a meditational model. That is, peer victimization in grade 7 was related to higher level of social anxiety, which in turn was associated with more depressive symptoms in grade 8, 9 and 11. The development of social anxiety and depression symptomatology among adolescents can thus be described as one sequential longitudinal process initiated by peer victimization.

  • 34.
    Gren Landell, Malin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Aho, Nikolas
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Carlsson, Elisabeth
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Jones, Annica
    Linköping University, The Swedish Institute for Disability Research. Linköping University, Department of Behavioural Sciences and Learning, Disability Research. Linköping University, Faculty of Arts and Sciences.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Posttraumatic stress symptoms and mental health services utilization in adolescents with social anxiety disorder and experiences of victimization2013In: European Child and Adolescent Psychiatry, ISSN 1018-8827, E-ISSN 1435-165X, Vol. 22, no 3, p. 177-184Article in journal (Refereed)
    Abstract [en]

    Recent findings from studies on adults show similarities between social anxiety disorder (SAD) and posttraumatic stress in the form of recurrent memories and intrusive and distressing images of earlier aversive events. Further, treatment models for SAD in adults have been successfully developed by using transdiagnostic knowledge on posttraumatic stress symptoms (PTSS). Studies on adolescents are though missing. The present study aimed at exploring the association between PTSS and SAD in Swedish adolescents. A second aim was to study mental health services utilization in relation to these conditions. A total of 5,960 high-school students participated and reported on SAD, life time victimization, PTSS and mental health service utilization. Socially anxious adolescents reported significantly higher levels of PTSS than adolescents not reporting SAD and this difference was seen in victimized as well as non-victimized subjects. Contact with a school counselor was the most common mental health service utilization in subjects with SAD and those with elevated PTSS. In the prediction of contact with a CAP-clinic, significant odds ratios were found for a condition of SAD and elevated PTSS (OR = 4.88, 95 % CI = 3.53–6.73) but not for SAD only. Screening of PTSS in adolescents with SAD is recommended. The service of school counselors is important in detecting and helping young people with SAD and elevated PTSS. Clinical studies on SAD and PTSS in adolescents could aid in modifying treatment models for SAD.

  • 35.
    Gren-Landell, Malin
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Aho, Nikolas
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Andersson, Gerhard
    Linköping University, Department of Behavioural Sciences and Learning, Clinical and Social Psychology. Linköping University, Faculty of Arts and Sciences.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Social anxiety disorder and victimization in a community sample of adolescents2011In: Journal of Adolescence, ISSN 0140-1971, E-ISSN 1095-9254, Vol. 34, no 3, p. 569-577Article in journal (Refereed)
    Abstract [en]

    Despite high prevalence rates of social anxiety disorder (SAD) and high rates of victimization in adolescents, studies on the relationship between these phenomena are missing. In the present study we report associations between SAD and multiple victimization experiences in a community sample of adolescents. A cross-sectional study was conducted on 3211 Swedish high-school students. The prevalence rate of self-reported SAD was 10.6% (n=340). Significantly higher rates of lifetime victimization was found in subjects with self-reported SAD compared to non-cases, on the total score on the Juvenile Victimization Questionnaire, and on the subscales maltreatment, sexual victimization and victimization from peer/siblings. Different results emerged due to gender. In females, maltreatment and sexual victimization was associated with an increased risk of SAD and, in males sexual victimization increased the risk of reporting SAD. Further studies are needed to elaborate developmental models on SAD and to add to modification of prevention- and treatment interventions.

  • 36.
    Gustafsson, P
    et al.
    Dept of Child and Adolescent Psychiatry Lund University.
    Thernlund, G
    Dept of Child and Adolescent Psychiatry Lund University.
    Besjakov, J
    Dept of Radiology Malmö University Hospital.
    Karlsson, MK
    Dept of Orthopaedics Malmö University Hospital.
    Ericsson, I
    School of Education Malmö University.
    Svedin, Carl Göran
    Linköping University, Faculty of Health Sciences. Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry .
    ADHD symptoms and maturity - A study in primary school children2008In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 97, no 2, p. 233-238Article in journal (Refereed)
    Abstract [en]

    Aim: To study if age and non-behavioural measures of biological maturity have any associations with attention deficit hyperactivity disorder (ADHD). Methods: Two hundred fifty-one children 7 to 9 years of age in a Swedish school were screened for ADHD-symptom. ADHD-symptoms were estimated by Conners Abbreviated Questionnaire by both parents and teachers. Motor function, body weight and body height were measured. Skeletal age was estimated through hand radiographs. Results: Height, weight and skeletal bone-age did correlate significantly with age (rs = 0.44-0.69, p < 0.001) but not with ADHD symptom scores. Motor dysfunction had a weak negative correlation with age (rs = -0.21, p < 0.05). Parent and teacher scores of ADHD-symptoms did not correlate with age. Conclusion: This study showed that the variables measuring general biological maturity had a strong association with age, whereas motor dysfunction and ADHD symptoms had no significant association with age. ADHD symptoms did not correlate with the variables measuring general biological maturity. These results do not support the hypothesis that a general biological immaturity is an important etiologic factor for ADHD symptomatology. © 2007 The Author(s).

  • 37.
    Gustafsson, Peik
    et al.
    Lund University.
    Göran Svedin, Carl
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Ericsson, Ingegerd
    Malmö University.
    Linden, Christian
    Lund University.
    Karlsson, Magnus K
    Lund University .
    Thernlund, Gunilla
    Lund University.
    Reliability and validity of the assessment of neurological soft-signs in children with and without attention-deficit-hyperactivity disorder2010In: DEVELOPMENTAL MEDICINE AND CHILD NEUROLOGY, ISSN 0012-1622, Vol. 52, no 4, p. 364-370Article in journal (Refereed)
    Abstract [en]

    AIM To study the value and reliability of an examination of neurological soft-signs, often used in Sweden, in the assessment of children with attention-deficit-hyperactivity disorder (ADHD), by examining children with and without ADHD, as diagnosed by an experienced clinician using the DSM-III-R. METHOD We have examined interrater reliability (26 males, nine females; age range 5y 6mo-11y), internal consistency (94 males, 43 females; age range 5y 6mo-11y), test-retest reliability (12 males, eight females; age range 6-9y), and validity (79 males, 33 females; age range 5y 6mo-9y). RESULTS The sum of the scores for the items on the examination had good interrater reliability (intraclass correlation [ICC] 0.95) and acceptable internal consistency (Cronbachs alpha 0.76). The test-retest study also showed good reliability (ICC 0.91). There were modest associations between the examination and the assessment of motor function made by the physical education teacher (ICC 0.37) as well as from the parents description (ICC 0.39). The examination of neurological soft-signs had a sensitivity of 0.80 and a specificity of 0.76 in predicting motor problems as evaluated by the physical education teacher. INTERPRETATION The reliability and validity of this examination seem to be good and can be recommended for clinical practice and research.

  • 38.
    Gustafsson, Per
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Birberg Thornberg, Ulrika
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    Duchén, Karel
    Linköping University, Department of Clinical and Experimental Medicine, Pediatrics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Paediatrics in Linköping.
    Landgren, Magnus
    Department of Pediatrics, Mariestad, Sweden .
    Malmberg, Kerstin
    Karolinska Institutet, Stockholm.
    Pelling, Henrik
    Uppsala University.
    Strandvik, Birgitta
    Gothenburg University, Sweden.
    Karlsson, Thomas
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Faculty of Arts and Sciences.
    EPA supplementation improves teacher-rated behaviour and oppositional symptoms in children with ADHD2010In: Acta Paediatrica, ISSN 0803-5253, E-ISSN 1651-2227, Vol. 99, no 10, p. 1540-1549Article in journal (Refereed)
    Abstract [en]

    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.

  • 39.
    Gustafsson, Per E
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Psychosocial Stress, Mental Health and Salivary Cortisol in Children and Adolescents2008Doctoral thesis, comprehensive summary (Other academic)
    Abstract [en]

    Stressful experiences and conditions in childhood influence the health and well-being of the growing individual, and can also confer a long-lasting impact into adult life. Delineating the social, mental and biological aspects of stress in children and adolescents is therefore of great concern for human beings. Despite these notions, much knowledge is lacking regarding stress in childhood.

    This thesis aimed at examining diverse aspects of stress in children and adolescents: associations between social conditions, traumatic life events, mental health, and salivary cortisol as a measure of the activity of a major physiological stress system. Cross-sectional samples included two non-clinical samples of school-aged children (N=240-336) and adolescents (N =400), and two clinical samples of children with obsessive-compulsive disorder (OCD) (N =23) and adolescents who had experienced childhood abuse (N =15). Main measures were salivary cortisol sampled three times a day, and questionnaires to teachers, parents and children with questions about each child’s mental health, traumatic life events and about the socioeconomic situation of the parents.

    The main findings include observation of 1) higher cortisol levels in children with a moderate level of psychosocial burden (low socioeconomic status, immigrant family, social impairment of mental health problems), 2) higher cortisol levels in children with OCD who also displayed a tendency to decreasing cortisol in the face of an acute stressor, and 3) cortisol was positively related to mental health problems in abused adolescents. Furthermore, the deleterious effect of 4) traumatic events involving a social dimension, interpersonal traumas, and 5) cumulative traumatic events, polytraumatization, on the mental health of children and adolescents was indicated.

    The findings are discussed with respect to the complex interactions between social, mental and biological aspects of children and adolescents. The consequences of adverse experiences in childhood may represent pathways to future health problems. Consideration of the social circumstances in childhood might in the future guide public health policies and the identification of target groups for preventive interventions as well as leading to improvements in treatment for children exposed to severe stress.

    List of papers
    1. Cortisol levels and psychosocial factors in preadolescent children
    Open this publication in new window or tab >>Cortisol levels and psychosocial factors in preadolescent children
    2006 (English)In: Stress and Health, ISSN 1532-3005, E-ISSN 1532-2998, Vol. 22, no 1, p. 3-9Article in journal (Refereed) Published
    Abstract [en]

    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.

    Keywords
    Psychiatric symptoms, child, cortisol, socio-economic factors, stress
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-15680 (URN)10.1002/smi.1074 (DOI)
    Available from: 2008-11-26 Created: 2008-11-26 Last updated: 2017-12-14
    2. Diurnal Cortisol Levels and Cortisol Response in Youths with Obsessive-Compulsive Disorder
    Open this publication in new window or tab >>Diurnal Cortisol Levels and Cortisol Response in Youths with Obsessive-Compulsive Disorder
    2008 (English)In: Neuropsychobiology, ISSN 0302-282X, E-ISSN 1423-0224, Vol. 57, no 1-2, p. 14-21Article in journal (Refereed) Published
    Abstract [en]

    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.

    Place, publisher, year, edition, pages
    S. Karger, 2008
    Keywords
    Cortisol, Stress response, Obsessive-compulsive disorder, children
    National Category
    Neurosciences
    Identifiers
    urn:nbn:se:liu:diva-15681 (URN)10.1159/000123117 (DOI)000257134900005 ()
    Available from: 2008-11-26 Created: 2008-11-26 Last updated: 2018-01-13Bibliographically approved
    3. Diurnal cortisol levels, psychiatric symptoms and sense of coherence in abused adolescents
    Open this publication in new window or tab >>Diurnal cortisol levels, psychiatric symptoms and sense of coherence in abused adolescents
    2010 (English)In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 64, no 1, p. 27-31Article in journal (Refereed) Published
    Abstract [en]

    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.

    Keywords
    Adolescents, Childhood Abuse, Cortisol, Psychiatric Symptoms, Sense of Coherence
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-15683 (URN)10.3109/08039480903265314 (DOI)000273780200005 ()
    Available from: 2008-11-26 Created: 2008-11-26 Last updated: 2017-12-14
    4. Sociocultural Disadvantage, Traumatic Life Events, and Psychiatric Symptoms in Preadolescent Children
    Open this publication in new window or tab >>Sociocultural Disadvantage, Traumatic Life Events, and Psychiatric Symptoms in Preadolescent Children
    2009 (English)In: American Journal of Orthopsychiatry, ISSN 0002-9432, E-ISSN 1939-0025, Vol. 79, no 3, p. 387-397Article in journal (Refereed) Published
    Abstract [en]

    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.

     

    Keywords
    stressor-outcome specificity, traumatic life events, sociocultural disadvantage, mental health, children
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-15684 (URN)10.1037/a0016559 (DOI)
    Available from: 2008-11-26 Created: 2008-11-26 Last updated: 2017-12-14
    5. Polytraumatization and Psychological Symptoms in Children and Adolescents
    Open this publication in new window or tab >>Polytraumatization and Psychological Symptoms in Children and Adolescents
    2009 (English)In: European Child and Adolescent Psychiatry, ISSN 1018-8827, E-ISSN 1435-165X, Vol. 18, no 5, p. 274-283Article in journal (Refereed) Published
    Abstract [en]

    Previous research on the impact of traumatic experiences in children and adolescents has focused almost entirely on the effect of single trauma. Research on cumulative traumas been lacking, but Finkelhor (2007) has recently directed the attention to the concept of polyvictimization. As an extension of this concept, this study examined the impact of polytraumatization, operationalized as the number of different potentially traumatic events. The study population comprised two cross-sectional samples of school-aged children (n = 270) and adolescents (n = 400). Information of life-time incidence of traumatic events was collected by the Life Incidence of Traumatic Events (LITE), and psychological symptoms by the parent version of the Strengths and Difficulties Questionnaire (SDQ) for the school children and the self-report Trauma Symptom Checklist for Children (TSCC) for the adolescents. We found that exposure to at least one traumatic event was common in both the samples (63% of the children and 89.5% of the adolescents). The number of different traumatic events, polytraumatization, was highly predictive of symptoms in both samples, and with a few exceptions surpassed the impact of specific events in exploratory analyses. We furthermore replicated previous findings of the important impact of interpersonal over noninterpersonal events on symptoms in both samples, and found an indication that this effect differed by gender in different manners in the two samples. This study emphasizes the significance of both the quantity of traumatic events, polytraumatization, as well as the quality, interpersonal events.

    Keywords
    child traumatization, symptomatology, multiple traumatization, gender differences
    National Category
    Medical and Health Sciences
    Identifiers
    urn:nbn:se:liu:diva-15685 (URN)10.1007/s00787-008-0728-2 (DOI)
    Available from: 2008-11-26 Created: 2008-11-26 Last updated: 2017-12-14
  • 40.
    Gustafsson, Per E
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Gustafsson, Per A
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Nelson, Nina
    Linköping University, Department of Clinical and Experimental Medicine, Pediatrics . Linköping University, Faculty of Health Sciences.
    Cortisol levels and psychosocial factors in preadolescent children2006In: Stress and Health, ISSN 1532-3005, E-ISSN 1532-2998, Vol. 22, no 1, p. 3-9Article in journal (Refereed)
    Abstract [en]

    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.

  • 41.
    Gustafsson, Per E
    et al.
    Dept. of Public Health and Clinical Medicine, Family Medicine, Umeå University.
    Anckarsäter, Henrik
    Dept. of Neuroscience and Physiology, Forensic Psychiatry, Gothenburg University.
    Lichtenstein, Paul
    Dept. of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm.
    Nelson, Nina
    Linköping University, Department of Clinical and Experimental Medicine, Pediatrics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Centre of Paediatrics and Gynecology and Obstetrics, Department of Paediatrics in Linköping.
    Gustafsson, Per A
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Does quantity have a quality all its own?: Cumulative adversity and up- and down-regulation of circadian salivary cortisol levels in healthy children2010In: Psychoneuroendocrinology, ISSN 0306-4530, E-ISSN 1873-3360, Vol. 35, no 9, p. 1410-1415Article in journal (Refereed)
    Abstract [en]

    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.

  • 42.
    Gustafsson, Per E.
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Gustafsson, Per A.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry in Linköping.
    Ivarsson, Tord
    Department of Child and Adolescent Psychiatry, Göteborg University, Göteborg, Sweden; The Regional Center for Child and Adolescent Psychiatry (R. BUP), Oslo, Norway.
    Nelson, Nina
    Linköping University, Department of Clinical and Experimental Medicine, Pediatrics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Paediatrics in Linköping.
    Diurnal Cortisol Levels and Cortisol Response in Youths with Obsessive-Compulsive Disorder2008In: Neuropsychobiology, ISSN 0302-282X, E-ISSN 1423-0224, Vol. 57, no 1-2, p. 14-21Article in journal (Refereed)
    Abstract [en]

    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.

  • 43.
    Gustafsson, Per E.
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Larsson, Ingbeth
    Linköping University, Department of Clinical and Experimental Medicine. Linköping University, Faculty of Health Sciences.
    Nelson, Nina
    Linköping University, Department of Clinical and Experimental Medicine, Pediatrics . Linköping University, Faculty of Health Sciences.
    Gustafsson, Per A
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Sociocultural Disadvantage, Traumatic Life Events, and Psychiatric Symptoms in Preadolescent Children2009In: American Journal of Orthopsychiatry, ISSN 0002-9432, E-ISSN 1939-0025, Vol. 79, no 3, p. 387-397Article in journal (Refereed)
    Abstract [en]

    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.

     

  • 44.
    Gustafsson, Per E.
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences.
    Nelson, Nina
    Linköping University, Department of Clinical and Experimental Medicine, Pediatrics. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Center of Paediatrics and Gynaecology and Obstetrics, Department of Paediatrics in Linköping.
    Gustafsson, Per A
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry. Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry in Linköping.
    Diurnal cortisol levels, psychiatric symptoms and sense of coherence in abused adolescents2010In: Nordic Journal of Psychiatry, ISSN 0803-9488, E-ISSN 1502-4725, Vol. 64, no 1, p. 27-31Article in journal (Refereed)
    Abstract [en]

    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.

  • 45.
    Gustafsson, Per E
    et al.
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Nilsson, Doris
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences. Östergötlands Läns Landsting, Local Health Care Services in Central Östergötland, Department of Child and Adolescent Psychiatry.
    Svedin, Carl Göran
    Linköping University, Department of Clinical and Experimental Medicine, Child and Adolescent Psychiatry . Linköping University, Faculty of Health Sciences.
    Polytraumatization and Psychological Symptoms in Children and Adolescents2009In: European Child and Adolescent Psychiatry, ISSN 1018-8827, E-ISSN 1435-165X, Vol. 18, no 5, p. 274-283Article in journal (Refereed)
    Abstract [en]

    Previous research on the impact of traumatic experiences in children and adolescents has focused almost entirely on the effect of single trauma. Research on cumulative traumas been lacking, but Finkelhor (2007) has recently directed the attention to the concept of polyvictimization. As an extension of this concept, this study examined the impact of polytraumatization, operationalized as the number of different potentially traumatic events. The study population comprised two cross-sectional samples of school-aged children (n = 270) and adolescents (n = 400). Information of life-time incidence of traumatic events was collected by the Life Incidence of Traumatic Events (LITE), and psychological symptoms by the parent version of the Strengths and Difficulties Questionnaire (SDQ) for the school children and the self-report Trauma Symptom Checklist for Children (TSCC) for the adolescents. We found that exposure to at least one traumatic event was common in both the samples (63% of the children and 89.5% of the adolescents). The number of different traumatic events, polytraumatization, was highly predictive of symptoms in both samples, and with a few exceptions surpassed the impact of specific events in exploratory analyses. We furthermore replicated previous findings of the important impact of interpersonal over noninterpersonal events on symptoms in both samples, and found an indication that this effect differed by gender in different manners in the two samples. This study emphasizes the significance of both the quantity of traumatic events, polytraumatization, as well as the quality, interpersonal events.

  • 46.
    Gustafsson, Per E
    et al.
    Folkhälsa och Klinisk Medicin/Socialmedicin, Umeå University.
    Szczepanski, Anders
    Linköping University, Department of Behavioural Sciences and Learning. Linköping University, Department of Culture and Communication, Arts, Crafts and Design. Linköping University, Faculty of Arts and Sciences.