No widening socioeconomic gap within a general decline in Swedish breastfeeding.

AIM: To study potential socioeconomic differences within the general decline in breastfeeding over time. METHODS: Data was collected for 51 415 infants born 2004-2010 from the databases of statistics of the Preventive Child Health Care Services in Uppsala and Orebro counties in Sweden and socioeconomic indicators from Swedish national registers. Breastfeeding data (breastfed/not breastfed) from 1 week, 4 months and 6 months of age were used as the main outcome variables. Educational level of the mother was defined as the highest level on a three-grade scale, low, medium and high. Family type was defined as whether the mother was single or married/cohabiting. Family disposable income was divided into quartiles where quartile 1 included the 25% children in families with the lowest incomes. Analyses were conducted by logistic regression models using the methodology of generalized estimating equations (GEE). An exchangeable correlation structure was used to control for the dependence among infants with the same mother. RESULTS: Breastfeeding rate in Sweden has declined gradually since the late 1990s. The results indicated that overall breastfeeding rates over the study period were influenced by socioeconomic status in a gradient manner but no widening socioeconomic gap was detected. Rather the interaction analyses showed a narrowing socioeconomic gap over the study period between high and low educational level and single versus cohabiting mothers at 4 months. The narrowing socioeconomic gap between the educational level categories was also detectable at 6 months. CONCLUSION: No increase in socioeconomic gap was detected within the general decline in Swedish breastfeeding. However, there are reasons to maintain and strengthen the overall breastfeeding supportive measures including extended support for vulnerable groups.

Expressive vocabulary in 18-month-old children in relation to demographic factors, mother and child characteristics, communication style and shared reading.

BACKGROUND: Previous research has elucidated the associations between children's language development and reading habits, and maternal education, communication style, gender and birth order. Research including maternal age and child temperament is more scarce. We studied the associations of all these factors with children's expressive vocabulary and reading habits. We also analysed the relationships of reading with expressive vocabulary, and effect sizes associated with frequent reading. METHODS: Questionnaires were completed by mothers of 1091 children aged 17-19 months visiting the Swedish Child Health Services. Expressive vocabulary was assessed by the Swedish Communication Screening at 18 months, a screening version of McArthur-Bates Communicative Development Inventories. Mother's perception of ability to communicate was measured by a scale constructed ad hoc from the International Child Development Programmes, a parent education curriculum. Bates' 'difficultness' scale was used to assess temperament. RESULTS: Good communication, low maternal age, female gender and frequent reading were significantly associated with expressive vocabulary. High maternal education, good communication, higher maternal age, female gender and being a first-born child were significantly associated with frequent reading. Reading at least 6 times/week added more than 0.3 SD in vocabulary regardless of gender and communication. CONCLUSIONS: The findings support the importance of reading and communication quality to early language development. Knowledge of the relationship between children's vocabulary and book reading in a context of joint attention is both theoretically and practically valuable to speech and language pathologists, pre-school teachers, child health workers and other professionals.

Child health services in transition: I. Theories, methods and launching.

AIM: To describe an evidence-based model for preventive child health care and present some findings from baseline measurements. METHODS: The model includes: parent education; methods for interaction and language training; follow-up of low birthweight children; identification and treatment of postnatal depression, interaction difficulties, motor problems, parenthood stress, and psychosocial problems. After baseline measurements at 18 mo (cohort I), the intervention was tested on children from 0 to 18 mo at 18 child health centres in Uppsala County (cohort II). Eighteen centres in other counties served as controls. Two centres from a privileged area were included in the baseline measurements as a "contrasting" sample. Data are derived from health records and questionnaires to nurses and mothers. RESULTS: Baseline experiment (n = 457) and control mothers (n = 510) were largely comparable in a number of respects. Experiment parents were of higher educational and occupational status, and were more frequently of non-Nordic ethnicity. Mothers in the privileged area (n = 72) differed from other mothers in several respects. Experiment nurses devoted considerably fewer hours per week to child health services and to child patients than did control nurses. CONCLUSIONS: Despite certain differences, experiment and control samples appeared comparable enough to permit, in a second step, conclusions about the effectiveness of the intervention.

Child health services in transition: II. Mothers' perceptions of 18-month-old children in the light of socio-economic status and some subjective factors.

AIMS: To analyse mothers' self-assessed quality of interaction with their children and their opinions about child difficulty with respect to socio-economic status and subjective factors: postnatal depression, social isolation, sense of coherence and locus of control. METHODS AND MATERIAL: A comprehensive questionnaire was completed by 1039 mothers of 18-mo-old children participating in the baseline measurements of a Swedish multicentre study developing and testing a new psychosocial model for the child health services. RESULTS: All subjective factors, including the number of factors, showed significant associations with perceived interaction and difficultness. Effect sizes of subjective factors ranged from about 0.3 to 1 SD for interaction, and from about 0.2 to 0.8 SD for difficultness. As for difficultness, effect sizes were larger for boys. There were no associations between high socio-economic status and high-quality interaction or low child difficultness: the few significant differences in fact favoured low-status children. CONCLUSION: The results provided some contradictory findings to the well-known association between high socio-economic status and favourable outcome. This result is of practical relevance for interventions: supportive programmes cannot be limited to areas and families of low socio-economic status. Positive effects may ensue if subjective factors like those studied here can be promoted among parents and children through the child health services.

A descriptive survey of Swedish child health nurses' awareness of abuse and neglect. II. Characteristics of the children.

AIM: To determine whether children considered by child health nurses to be at risk of abuse or neglect differed from the general population in gender, age and health status, and whether such child characteristics were related to nurses' perceptions of case seriousness, or to reporting to the child protection services (CPS). METHODS: Questionnaires were sent to nurses in the preventive Child Health Services, 951 of whom identified a total of 6044 children aged 0 to 6 y as suspected of risk of maltreatment. RESULTS: Boys and older children were over-represented among the identified children, possibly because the attention of the nurses was attracted by salient symptoms in older boys. Children with health problems and boys exposed to disturbed parenting/neglect were perceived as more serious cases than other children. Children aged 4-6 y were more likely to be reported to the CPS than children under 3 y of age. CONCLUSION: The findings raise the question whether possibly maltreated children who are very young, female or in good health run a particularly high risk of non-detection, of being considered non-serious cases and of not being reported to the CPS. The risk of going unnoticed may be higher for some children at risk of maltreatment than for others.

Sexual knowledge and behaviour in South African students: a case for prevention with focus on behaviour.

UNLABELLED: A study by James et al. revealed discrepancies between students' knowledge of sexuality and their behaviour. CONCLUSION: Preventive programmes should be intensive, comprehensive and preferably school based, involving parents and local communities. To make themselves trustworthy, it may be worthwhile for programmes to acknowledge adolescents' life situation as it is.

Comorbidity in children with severe developmental language disability.

UNLABELLED: In a cohort of 2359 children, screened for severe developmental language disability (DLD) at 3 y of age, 45 children were identified as true positives. The development, concerning DLD and comorbidity of 41 of these children still living in the municipality of Uppsala was followed up to school start. Criteria for comorbidity were: (a) suspected or diagnosed neuropsychiatric/neurodevelopmental disability according to information from the Child Habilitation Centre and the Child Psychiatric Centre or (b) low performance IQ, signs of activity/distractibility problems according to a psychologist's examination. By school start, 61% of the children with severe DLD were identified with comorbidity. CONCLUSION: Severe DLD is often combined with other disabilities within the neuropsychiatric/neurodevelopmental spectra. The comorbidity might not be obvious at 3 y of age--the age at which severe DLD is effectively identified by the 3-y screening programme. This in turn stresses the necessity of multidisciplinary teamwork both at the referral level and during the therapy work.

Parents' observations of sexual behaviour in pre-school children.

UNLABELLED: This commentary on the Larsson and Svedin study of sexual behaviour in pre-school children, published in the present issue of Acta Paediatrica, centres around three questions: 1. How can normal sexual behaviour in children be distinguished from problematic behaviour? 2. What characterizes the sexual development of the normal child? 3. Can knowledge about normal and problematic sexual behaviour be used to screen for sexual abuse or to confirm cases of sexual victimization? It is recommended that the inventory used by the authors be standardized on a representative sample of Swedish children, because this would enhance its usefulness in distinguishing normal from problematic behaviour. It is further recommended that research about sexual development in children be based on person-oriented rather than on variable-oriented analyses. It is finally argued that knowledge about normal and problematic sexual behaviour may not contribute to more effective screening or confirmation procedures in suspicions of sexual abuse. However, knowledge about normal sexual behaviour is valuable in studies of sexual behaviour in different categories of children, e.g. in the developmentally delayed or psychosocially deprived. CONCLUSION: By helping to identify problematic sexual behaviour in individual children, a standardized inventory could guide professionals in detecting possible psychological problems accompanying the behaviour.

A descriptive survey of Swedish child health nurses' awareness of abuse and neglect. I. Characteristics of the nurses.

OBJECTIVE: The objectives were to assess: (1) child health nurses' identification of abuse/neglect of children of preschool age in their districts; (2) overall prevalence of abuse/neglect according to the nurses; (3) determinants of nurse identification; (4) determinants of nurse-reported district prevalences; and (5) determinants of reporting to the child protection services (CPS). METHOD: Questionnaires were mailed to about 3,000 child health centers. RESULTS: Fifty-five percent responded. Of these, 22% identified no case and 33% at least one (mostly five or fewer). The overall prevalence was 1.4%. Identification correlated with general participation rate in the county. Other determinants of identification were acquaintance with the district, large district populations, and three variables assumed to reflect a personal interest. Determinants of prevalences were small district populations, regular contacts with the social services, and two personal interest variables. With large district populations, identification increased, whereas prevalences decreased. Only 30.3% had made a report to the CPS. Regular contacts with the social services correlated with reporting. Personal interest was a determinant of the decision to report, and acquaintance with the district a determinant of reporting rate. CONCLUSIONS: Abuse and neglect did not appear as priorities for the Child Health Services. The method probably led to an underestimation of the true prevalence. Personal interest and social services contacts emerged as important determinants. However, the assumed criteria of "interest" were not validated. For effective identification, no nurse should be responsible for more than 400 to 500 children. Implications for practice and research are discussed.

Secondary prevention in child health: effects of psychological intervention, particularly home visitation, on children's development and other outcome variables.

This paper reviews interventions targeting socially deprived families, families with low birthweight/premature children, and some other problems (child abuse, sensitivity/attachment, postnatal depression). Conclusions are mainly based on randomized controlled trials. Earlier reviews in the field have emphasized the importance of intensive, enduring home visitation and of early education programmes for young children. Home visitation may positively effect several outcomes, including health behaviour, child safety and stimulation. Rates of child abuse and neglect have proven difficult to influence, but home visitation may result in other gains such as fewer accidents and serious injuries, and greater home safety. The cognitive development of low birthweight and premature children may be positively influenced by home visitation, particularly in combination with an early stimulation programme in the neonatal unit and pre-school placement. Postnatally depressed mothers have been shown to improve substantially from nurse counselling once a week for 6-8 wk. It is suggested that home visitation should be tried on a systematic basis, and that early pre-school experiences should be offered to children in different risk situations. Child Health Centres should introduce a screening programme for postnatal depression. Specialist child health units should be encouraged.

Growing up in Uppsala: the "new morbidity" in the adolescent period. A longitudinal epidemiological study based on school data and some external sources.

The study comprised all 1805 children, most born in 1967, who were in grade 9 of the compulsory school in Uppsala in the spring of 1983 (cross-sectional population) and all 1723 children born in 1967 and resident in Uppsala at ages 10 and 15 years (longitudinal population). The aims were (1) to describe and analyse a normal population of 9th graders in social, medical, educational and psychological respects, (2) to assess relationships between risk level at 10 years, school-identified difficulties at 15 years and psychosocial problems up to age 18, (3) to assess relationships between intervention in school at 15 years and psychosocial problems up to 18 years. Ten-year data had been collected through teacher interviews and analysis of school health records in grade 3. Fifteen-year data were collected through interviews with school health staff and analysis of school health records in grade 9. School marks were gathered at the end of grade 9. Psychosocial problems up to 18 years were assessed on the basis of all registered contacts with official institutions outside school (authorities for care of the handicapped, Department of Child Psychiatry, social agencies, legal authorities). CROSS-SECTIONAL POPULATION. Children older than the grade norm and children of lower social class manifested a more problematic school adjustment and had lower mean marks than younger children and those of higher social classes. Twenty-five per cent of the population had entries in official registers up to age 18, indicating psychosocial problems. Social conditions were related both to the learning process and to psychological health. Educational and psychological problems were mutually correlated. Social problems increased the risk of a number of medical conditions. There were certain relationships between medical and educational problems as well as between medical and psychological problems. LONGITUDINAL POPULATION. Both 10- and 15-year data, particularly the latter, contributed independently to the prediction of psychosocial problems up to age 18. There was a considerably increased risk of psychosocial problems if there had been numerous school difficulties at age 15. Children who had been offered intervention in school at 15 years did not escape psychosocial problems up to 18 years more frequently than children without interventions. In fact, the contrary was the case: with more interventions, the frequencies of psychosocial problems up to age 18 increased.

Child health records as a database for clinical practice, research and community planning.

In considering health information systems, great hope is attached to the use of child health records as a data source for research and community planning. In order to test the completeness of child health records data and their agreement with other sources, information about living conditions, use of medical services and health problems in preschool children were studied in 707 child health centres' records. The results show a considerable number of deficiencies in the system which could, to a certain extent, be remedied by improved instructions to the staff. Health problems in the area of child care also need to be fully defined.

Services to families with children. A study of community work in Uppsala.

This article describes some of the results of a study of services to families and children in a suburban district, Sweden. Services included in the study were: maternal and child health care, child psychiatry, services for handicapped children, school health care, day care services, community social services and family counselling services. The baseline studies comprised analyses of official goals expressed in legislation and recommendations, interviews with local politicians and administrators, record studies, studies of working time distribution and questionnaires to field professionals and families. The results indicate that services with traditional goals and well-defined tasks (e.g. health supervision) were more satisfied with their goal attainment, less inclined to collaborate with other services, and more occupied with direct client work than services with non-traditional goals and vaguely defined tasks (e.g. strengthening democracy).