High maternal cortisol levels during pregnancy are associated with more psychiatric symptoms in offspring at age of nine - A prospective study from Nicaragua.

Maternal exposure to stress or adversity during pregnancy has been associated with negative health effects for the offspring including psychiatric symptoms. Programming of the hypothalamic-pituitary-adrenal (HPA) axis has been suggested as one mediating process. In order to investigate possible long term effects of stressors during pregnancy, we followed 70 children and their mothers from pregnancy up to nine years aiming to investigate if maternal cortisol levels and distress/exposure to partner violence were associated with child psychiatric symptoms and child cortisol levels at follow-up. Maternal distress was evaluated using The Self Reporting Questionnaire, exposure to partner violence by an instrument from WHO and child psychiatric symptoms with Child Behavior Checklist (CBCL). We adjusted the analyses for gestational week, gender, SES, perinatal data and maternal distress/exposure to partner violence at child age of nine years. Elevated maternal cortisol levels during pregnancy, as a possible marker of maternal stress load, were correlated with higher CBCL-ratings, especially concerning externalizing symptoms. Maternal cortisol levels during pregnancy were not associated with child cortisol levels at child age of nine years. Maternal distress and exposure to partner violence during pregnancy were neither associated with child psychiatric symptoms nor child cortisol levels. To conclude, intrauterine exposure to elevated cortisol levels was associated with higher ratings on offspring psychopathology at nine years of age. The lack of association between maternal cortisol levels during pregnancy and child cortisol levels does not support the hypothesis of fetal programming of the HPA-axis, but reliability problems may have contributed to this negative finding.

The Pressure-Activation-Stress scale in relation to ADHD and cortisol.

The Pressure-Activation-Stress (PAS) scale is a self-report questionnaire for children concerning perceived stress. To explore behavioral and physiological correlates, we investigated if scores discriminate between a group prone to perceive high levels of stress [children with attention-deficit/hyperactivity disorder (ADHD)] and a healthy school sample, and if they are associated with diurnal cortisol levels. The PAS scale was filled in at home by children (11-17 years) with clinically confirmed ADHD (n = 102) and non-affected comparisons (n = 146). Saliva samples were collected four times during a regular school day for radioimmunoassay analysis of cortisol. Subtypes and severity of ADHD symptoms were determined using parental rating scales. Children with ADHD scored higher on the PAS scale than a school sample. The PAS scores were similar over ages in the ADHD group while they increased with age in the healthy group. Female sex was associated with higher stress in both groups but no gender interaction was found. No association was found between PAS scores and cortisol levels in neither group. Children in the ADHD group had a lower ratio of cortisol levels/perceived stress on all sampling occasions, built up both by the higher PAS scores and the lower cortisol levels in children with ADHD. The higher PAS scores in children with ADHD support the validity of the scale. The lack of association between PAS scores and diurnal cortisol levels is intriguing and illustrates the complexity of the stress concept. Stress-related fragility seems to accompany ADHD during childhood.

Maternal and paternal psychopathology increases risk of offspring ADHD equally.

BACKGROUND: Parental psychopathology may increase the risk of attention-deficit hyperactivity disorder (ADHD) in the offspring. The aim of this study was to analyze if/how gender influences the association between parental psychiatric/addictive disorders and ADHD medication in the offspring. METHODS: Register study in national birth cohorts of 1.1 million 6-19-year-olds. In this population, 7960 individuals with ADHD medication were identified in the Swedish Prescribed Drug Register during 2006. Data on parental psychiatric/addictive disorders and suicide death were obtained through linkages to national registers. Logistic regression was used for analyses with multiple adjustments for socio-economic, regional and demographic confounders. RESULTS: Parental diagnosis related to illicit drugs was associated with the highest odds ratios (ORs) of ADHD medication (OR: -3.5-4), followed by suicide attempt/death (OR: -3-3.5), alcohol (OR: -2.5-3), affective disorder (OR: -2.5) and psychosis (OR: -2-2.5). The ORs were of similar magnitudes for maternal and paternal psychopathology and did not vary by the gender of the offspring. Adjusting for social characteristics decreased the ORs substantially and in the same way regarding fathers' and mothers' possible influence on the risk of ADHD in children. CONCLUSIONS: Neither parental nor offspring gender seems to influence the link between parental addictive/psychiatric disorder and offspring ADHD.

Familial factors and suicide: an adoption study in a Swedish National Cohort.

BACKGROUND: Parental characteristics influence the risk of offspring suicide. In this study we wanted to separate the hereditary from the environmental influence of such factors by comparing their effects in the adopted versus non-adopted. METHOD: A register study was conducted in a national cohort of 2,471,496 individuals born between 1946 and 1968, including 27,600 national adoptees, followed-up for suicide during 1987-2001. Cox regression was used to calculate hazard ratios (HR) for suicide of socio-economic indicators of the childhood household and biological parents' suicide, alcohol abuse and psychiatric morbidity separately in the adopted and non-adopted. Differences in effects were tested in interaction analyses. RESULTS: Suicide and indicators of severe psychiatric disorder in the biological parents had similar effects on offspring suicide in the non-adopted and adopted (HR 1.5-2.3). Biological parents' alcohol abuse was a risk factor for suicide in the non-adopted group only (HR 1.8 v. 0.8, interaction effect: p=0.03). The effects of childhood household socio-economic factors on suicide were similar in adopted and non-adopted individuals, with growing up in a single parent household [HR 1.5 (95% confidence interval 1.4-1.5)] as the most important socio-economic risk factor for the non-adopted. CONCLUSIONS: The main familial effects of parental suicide and psychiatric morbidity on offspring suicide are not mediated by the post-natal environment or imitation, in contrast to effects of parental alcohol abuse that are primarily mediated by the post-natal environment. Social drift over generations because of psychiatric disorders does not seem likely to explain the association of socio-economic living conditions in childhood to suicide.

The enigma of the welfare state: excellent child health prerequisites--poor subjective health.

UNLABELLED: The rate of subjective health complaints among Swedish children is increasing by age and over time, and more so than among children in other Scandinavian countries. In contrast, the somatic health and prerequisites for wellbeing are excellent. This paradoxical situation, The Enigma of the Welfare State, is the focus of this viewpoint. We argue that one important background factor may be late adverse effects of the welfare society itself and some of its inherent values. We have identified several possible pathways. We have given them names of diseases--on the society level--like health obsession, stress panic, welfare apathy and hyper-individualism. Together with other factors such as a dysfunctional school and an unsatisfactory labour market for youth, these diseases are involved in an interplay that is constantly inducing anxiety and low self-esteem. CONCLUSION: The gradually deteriorating self-reported health among Swedish youth may, to some degree, be explained as a late adverse effect of the welfare society itself and its inherent values.

Social adversity predicts ADHD-medication in school children--a national cohort study.

AIMS: To test the hypothesis that psychosocial adversity in the family predicts medicated ADHD in school children. METHOD: ADHD-medication during 2006 was identified in the Swedish Prescribed Drug Register in national birth cohorts of 1.1 million 6-19 year olds. Logistic regression models adjusted for parental psychiatric disorders were used to test our hypothesis. RESULTS: There was a clear gradient for ADHD medication with level of maternal education, with an adjusted odds ratio of 2.20 (2.04-2.38) for the lowest compared with the highest level. Lone parenthood and reception of social welfare also implied higher risks of ADHD-medication with adjusted ORs of 1.45 (1.38-1.52) and 2.06 (1.92-2.21) respectively. Low maternal education predicted 33% of cases with medicated ADHD and single parenthood 14%. CONCLUSIONS: Social adversity in the family predicts a considerable proportion of ADHD-medication in school children in Sweden.

Ethnicity, socio-economic status and self-harm in Swedish youth: a national cohort study.

BACKGROUND: Previous studies have shown an elevated risk for self-harm in adolescents from ethnic minorities. However, potential contributions to this risk from socio-economic factors have rarely been addressed. The main aim of this article was to investigate any such effects. METHOD: A national cohort of 1009 157 children born during 1973-1982 was followed prospectively from 1991 to 2002 in Swedish national registers. Multivariate Cox analyses of proportional hazards were used to estimate the relative risk of hospital admission for self-harm. Parental country/region of birth was used as proxy for ethnicity. RESULTS: Youth with two parents born outside Sweden (except those from Southern Europe) had higher age- and gender-adjusted hazard ratios (HRs) of self-harm than the majority population (HR 1.6-2.3). The HRs decreased for all immigrant groups when socio-economic factors were accounted for but remained significantly higher for immigrants from Finland and Western countries and for youth with one Swedish-born and one foreign-born parent. CONCLUSIONS: Socio-economic factors explain much of the variation by parental country of birth of hospital admissions for self-harm in youth in Sweden.

Immigrant girls perceive less stress.

AIM: To develop a new stress scale and use it for investigating impact of ethnicity on perception of stress. SUBJECTS AND METHODS: One thousand one hundred and twenty-four students (grades 6-9) from 14 schools filled in a questionnaire at school with questions about age, sex, use of language at home (proxy for cultural background), stress and stressors. Factor analysis and analysis of variance were used to analyze the data. RESULTS: Two-stress dimensions were identified, 'pressure'(7 items, Cronbach's alpha 0.862) and 'activation'(4 items, Cronbach's alpha 0.767). Scores on the two scales and a separate 'stress' item were higher in girls and increased with grade. Use of another language than Swedish at home showed a significant effect only for activation, with lower scores in girls. The interaction effect between sex and language was significant for all variables and was due mainly to lower stress in girls using another language than Swedish at home. CONCLUSION: This new stress scale has some promising qualities like a condensed format, basis in a specific stress concept and formulated to be as age and culture independent as possible. Immigrant girls seem to perceive less stress than Swedish born girls, which opens up for questions about protective mechanisms.

Does age at adoption and geographic origin matter? A national cohort study of cognitive test performance in adult inter-country adoptees.

BACKGROUND: Inter-country adoptees run risks of developmental and health-related problems. Cognitive ability is one important indicator of adoptees' development, both as an outcome measure itself and as a potential mediator between early adversities and ill-health. The aim of this study was to analyse relations between proxies for adoption-related circumstances and cognitive development. METHOD: Results from global and verbal scores of cognitive tests at military conscription (mandatory for all Swedish men during these years) were compared between three groups (born 1968-1976): 746 adoptees born in South Korea, 1548 adoptees born in other non-Western countries and 330 986 non-adopted comparisons in the same birth cohort. Information about age at adoption and parental education was collected from Swedish national registers. RESULTS: South Korean adoptees had higher global and verbal test scores compared to adoptees from other non-European donor countries. Adoptees adopted after age 4 years had lower test scores if they were not of Korean ethnicity, while age did not influence test scores in South Koreans or those adopted from other non-European countries before the age of 4 years. Parental education had minor effects on the test performance of the adoptees - statistically significant only for non-Korean adoptees' verbal test scores - but was prominently influential for non-adoptees. CONCLUSIONS: Negative pre-adoption circumstances may have persistent influences on cognitive development. The prognosis from a cognitive perspective may still be good regardless of age at adoption if the quality of care before adoption has been 'good enough' and the adoption selection mechanisms do not reflect an overrepresentation of risk factors - both requirements probably fulfilled in South Korea.

Birth outcomes and pregnancy complications in women with a history of anorexia nervosa.

OBJECTIVE: To examine birth outcomes and pregnancy complications in women with a history of anorexia nervosa. DESIGN: Prospective cohort study. SETTING: Nationwide study in Sweden. POPULATION: All primiparous women--discharged from hospital with a diagnosis of anorexia nervosa during 1973 to 1996--who gave birth during 1983 to 2002 (n = 1000) were compared with all non-anorexia nervosa primiparous women who gave birth during the same years (n = 827,582). METHOD: Register study with data from Medical Birth Registry and National Patient Discharge Register. MAIN OUTCOME MEASURES: Pre-eclampsia, instrumental delivery, prematurity, small for gestational age, birthweight, Apgar score and perinatal mortality. RESULTS: Main birth outcome measures in women with a history of anorexia nervosa were very similar to the main population. The only observed differences were a slightly lower mean birthweight and lower adjusted odds ratios for instrumental delivery in the anorexia nervosa group compared with the main population. Neither severity of the disease nor a shorter recovery phase after first hospitalisation was related to pregnancy complications or birth outcomes. CONCLUSION: A history of anorexia nervosa was not associated with negative birth outcomes. Thus, special obstetric monitoring of pregnant women with history of anorexia nervosa does not seem to be warranted in a country with a satisfactory maternity surveillance.

Avoidable mortality among child welfare recipients and intercountry adoptees: a national cohort study.

OBJECTIVE: To compare rates of avoidable mortality in adolescence in child welfare recipients and intercountry adoptees with the general population. DESIGN: A register study of the entire national cohort of 989 871 Swedish residents born 1973-82 in the national census of 1990. Multivariate Cox analyses of proportional hazards were used to analyse avoidable deaths between 13 to 27 years of age during 1991-2000. PARTICIPANTS: 12 240 intercountry adoptees, 6437 foster children, 15 868 subjected to other forms of child welfare interventions, and the remaining 955 326 children in the cohort. RESULTS: Intercountry adoptees had a high sex and age adjusted relative risk (RR) for suicide death only (RR 3.5; 95% CI 2.3 to 5.0) in comparison with the general population, while foster children and adolescents who had received other kinds of child welfare interventions had high sex and age adjusted RRs for suicide death; 4.3 (2.8 to 6.6) and 2.7 (1.9 to 3.9) respectively, as well as for other avoidable deaths; RRs 2.5 (1.6 to 3.7) and 2.8 (2.1 to 3.6). The RRs of avoidable deaths for foster children and other child welfare recipients decreased considerably when compared with youth brought up in homes with similar psychosocial characteristics as their original home. CONCLUSION: Children in substitute care in early childhood were at particular risk for suicide death in adolescence and young adulthood. Child welfare interventions were insufficient to prevent excess deaths in children at risk.

Delayed disclosure and disrupted communication during forensic investigation of child sexual abuse: a study of 47 corroborated cases.

AIM: To study factors of relevance for the understanding of disclosure of child sexual abuse. METHODS: Cases from a Swedish district court involving 47 children in which allegations of child sexual abuse had been corroborated by a confession from the defendant were studied. RESULTS: Delayed disclosure was related to a close relationship with the perpetrator and young age at the first experience of abuse. Disrupted communication during the police interview was related to less violent abuse. CONCLUSION: The findings highlight the importance of social factors in children's disclosure of sexual abuse.

Communication between courts and expert witnesses in legal proceedings concerning child sexual abuse in Sweden: a case review.

OBJECTIVE: The objective was to explore the communication between courts and expert witnesses in legal proceedings concerning child sexual abuse in Sweden. METHOD: A cross professional research team performed a qualitative text analysis of files covering 20 court cases (court report and expert witness statement) from 4 different years (1985, 1989, 1992, and 1997). RESULTS: Expert witnesses applied a wide variety of assessment procedures. Several patterns of communicative difficulties were identified, categorized as "mismatch," "misunderstanding," "misuse," and "missing pieces." Experts and courts sometimes used similar words (e.g., "credibility") but seemed to apply different meanings to them, indicating a lack of a mutual conceptual framework. CONCLUSIONS: The combination of brief expert assignments and diverse assessment procedures turned out to be a specific risk factor for communicative impairment. Alternate strategies for improved communication are discussed.

Renal transplantation in children: psychological and donation-related aspects from the parental perspective.

Parent(s) accompanying their 18 children to the annual medical follow-up after renal transplantation were interviewed by a child psychiatric social worker. Thirteen of the children had received their grafts from one of their parents, two from other relatives, and three from cadaveric donors. The aims of this interview were to study the decision-making process regarding donation, and the consequences, reflections, and psychological reactions from the parental perspective. Although most parents reported improved psychosocial functioning of the family, many parents also reported significant psychological distress, in many cases complicated by unemployment related to the care of the child. Most parent donors reported that the relationship with their child had improved. For most parents, the decision about the donation seemed to have been a matter of course. However, the process may have induced suffering in those parents who had felt obliged to donate. Thus, questions regarding donation must be approached in a professional and non-judgmental manner when parents are informed about the preconditions of transplantation. The present results indicate a need of psychosocial support for all families during the transplantation process. Therefore, a psychologist and a social worker have been included in the pediatric nephrology team at our unit. The donors also require further information concerning the operative details as well as in regard to the post-operative pain.

Sexual abuse at a Swedish daycare centre: allegations, confessions and evaluations.

UNLABELLED: In September 1997, sexual abuse at a Swedish daycare centre was disclosed. The suspect, a male member of the staff, admitted having abused six children. A total of 30 children were included in the police investigation. In this study, these cases were evaluated individually using a child psychiatric method. Information was collected from the police investigation and from interviews with parents. The conclusions--categorized as "abuse likely", "abuse conceivable" or "abuse uncertain"--were compared with the children's own reports, the legal evaluations and the confessions of the suspects. CONCLUSIONS: The correspondence of child reports with child psychiatric evaluations was fairly high, indicating that child reports may serve as a good screening indicator of abuse. There was little agreement between child psychiatric evaluations and legal decisions, which were based on the reports of suspects. Some differences may be explained by varied methodology, definitions and criteria. Others reflect real differences in opinion. Our study illustrates the need to establish legal criteria for statements from pre-schoolers if such evidence is to constitute the basis of a ruling without a confession. Studies comparing professional psychological assessments of children's statements about sexual abuse with independent data stand out as an important line of research for the future.

Disclosure of donor insemination to the child: the impact of Swedish legislation on couples' attitudes.

The question whether or not parents of children conceived after donor insemination (DI) tell their offspring about its biological background was addressed. Swedish legislation from 1985 gives the child born after DI the right, when grown up, to receive identifying information about the sperm donor. Until now no information about compliance with the law has been available. All parents who gave birth to a child by DI after the new legislation in two major Swedish fertility centres (Stockholm and Umeâ) received a questionnaire containing questions about the issue of informing the child. The response rate was 80%. The majority of parents (89%) had not informed their children, whereas 59% had told someone else. As a response to an open question, 105/132 parents chose to comment on their answer about not having informed their child. Of these families, 61 intended to tell their child later, 16 were not sure and 28 were not going to inform the child. Compliance with the law must be regarded as low since only 52% of the parents had told or intended to tell their child. In addition, concern is raised about the children who run the risk of being informed by someone other than their parents.

A preliminary typology of young sex offenders.

Data concerning all young (15-20 years, n = 56) sex offenders (YSOs) subjected to forensic psychiatric investigation in Sweden during 1988-1995 were used in an attempt to construct and validate an introductory YSO typology based solely on offence characteristics. A 5-cluster solution received optimal support from cluster analysis of 15 offence-related variables. A few historical and clinical characteristics varied across clusters. Survival analyses revealed that the clusters differed with respect to sexual but not to violent or general reconviction rates.

To tell or not to tell--what parents think about telling their children that they were born following donor insemination.

Pioneering legislation regarding donor insemination was introduced in Sweden in 1985. The law gives the child, upon reaching sufficient maturity, the right to obtain information about the donor and his identity. One hundred and forty-eight Swedish couples with children conceived through donor insemination after the law was introduced have answered questions about disclosure and donation in a questionnaire. This article addresses the reasoning employed by individual couples in their decision whether or not to inform the children about their origin. Parental reflections on their decision and the children's reactions to receiving this information are also presented. Five categories of parental arguments are reported. These included 'reasons to tell', 'reasons not to tell', 'reasons why the question about telling or not would not be answered at all', 'inconclusive types of reasoning, that can still influence the fundamental decision' and 'context-dependent reasons associated with actual circumstances'. Through this meta-classification of arguments it was possible to identify clues to how professionals could facilitate parental decision-making and promote disclosure. Parents who had informed their children did not regret their decision. All of the parents who responded to the question of whether it had been beneficial to the child to tell answered 'yes'.

To be or not to be a living donor: questionnaire to parents of children who have undergone renal transplantation.

BACKGROUND: Between 1981 and 1994, 67 transplantations were performed in 59 children below 16 years of age at Huddinge University Hospital. In most of the cases, one of the parents was the donor. The aim of this study was to evaluate how the transplantation influenced the parents. METHODS: One hundred sixteen individual questionnaires were sent out to the donor parents and to the parents who for different reasons had not been donors. Of special interest was to investigate the emotional reactions, the social consequences, the relationship to the child, and the parents' attitudes toward donation. RESULTS: Thirty-five donors and 41 nondonors replied. The majority of both donors and nondonors were satisfied with the medical information. The nondonors expressed more stress and anxiety before the transplantation. More than half of the donors experienced the operation as more painful than they had expected. Despite this fact, the nondonors showed significantly more psychosomatic/psychiatric symptoms than the donors after the operation. The donors reported an improved relation to the recipient child after the transplantation to a greater extent than the nondonors. Half of the donors reported an improved self-esteem after the donation. None of the donors regretted their donation and all of them would do the same again. CONCLUSIONS: This study indicates that ethical and psychological risks in parental kidney donation should not be regarded as a major obstacle. However, irrespective of the parents being a donor or not, they wanted more psychosocial support both before, during, and after the transplantation.