The Finnish psychiatric birth cohort consortium (PSYCOHORTS) - content, plans and perspectives.

Background: Psychiatric disorders tend to be developmental, and longitudinal settings are required to examine predictors of psychiatric phenomena. Replicating and combining data and results from different birth cohorts, which are a source of reliable data, can make research even more valuable. The Finnish Psychiatric Birth Cohort Consortium (PSYCOHORTS) project combines birth cohorts in Finland. Aim: The aim of this paper is to introduce content, plans and perspectives of the PSYCOHORTS project that brings together researchers from Finland. In addition, we illustrate an example of data harmonization using available data on causes of death. Content: PSYCOHORTS includes eight Finnish birth cohorts. The project has several plans: to harmonize different data from birth cohorts, to incorporate biobanks into psychiatric birth cohort research, to apply multigenerational perspectives, to integrate longitudinal patterns of marginalization and inequality in mental health, and to utilize data in health economics research. Data on causes of death, originally obtained from Finnish Cause of Death register, were harmonized across the six birth cohorts using SAS macro facility. Results: Harmonization of the cause of death data resulted in a total of 21,993 observations from 1965 to 2015. For example, the percentage of deaths due to suicide and the sequelae of intentional self-harm was 14% and alcohol-related diseases, including accidental poisoning by alcohol, was 13%. Conclusions: PSYCOHORTS lays the foundation for complex examinations of psychiatric disorders that is based on compatible datasets, use of biobanks and multigenerational approach to risk factors, and extensive data on marginalization and inequality.

Autism risk associated with parental age and with increasing difference in age between the parents.

Advancing paternal and maternal age have both been associated with risk for autism spectrum disorders (ASD). However, the shape of the association remains unclear, and results on the joint associations is lacking. This study tests if advancing paternal and maternal ages are independently associated with ASD risk and estimates the functional form of the associations. In a population-based cohort study from five countries (Denmark, Israel, Norway, Sweden and Western Australia) comprising 5 766 794 children born 1985-2004 and followed up to the end of 2004-2009, the relative risk (RR) of ASD was estimated by using logistic regression and splines. Our analyses included 30 902 cases of ASD. Advancing paternal and maternal age were each associated with increased RR of ASD after adjusting for confounding and the other parent's age (mothers 40-49 years vs 20-29 years, RR=1.15 (95% confidence interval (CI): 1.06-1.24), P-value<0.001; fathers⩾50 years vs 20-29 years, RR=1.66 (95% CI: 1.49-1.85), P-value<0.001). Younger maternal age was also associated with increased risk for ASD (mothers <20 years vs 20-29 years, RR=1.18 (95% CI: 1.08-1.29), P-value<0.001). There was a joint effect of maternal and paternal age with increasing risk of ASD for couples with increasing differences in parental ages. We did not find any support for a modifying effect by the sex of the offspring. In conclusion, as shown in multiple geographic regions, increases in ASD was not only limited to advancing paternal or maternal age alone but also to differences parental age including younger or older similarly aged parents as well as disparately aged parents.

Elevated maternal C-reactive protein and autism in a national birth cohort.

Autism is a complex neuropsychiatric syndrome with a largely unknown etiology. Inflammation during pregnancy may represent a common pathway by which infections and other insults increase risk for the disorder. Hence, we investigated the association between early gestational C-reactive protein (CRP), an established inflammatory biomarker, prospectively assayed in maternal sera, and childhood autism in a large national birth cohort with an extensive serum biobank. Other strengths of the cohort included nearly complete ascertainment of pregnancies in Finland (N=1.2 million) over the study period and national psychiatric registries consisting of virtually all treated autism cases in the population. Increasing maternal CRP levels, classified as a continuous variable, were significantly associated with autism in offspring. For maternal CRP levels in the highest quintile, compared with the lowest quintile, there was a significant, 43% elevated risk. This finding suggests that maternal inflammation may have a significant role in autism, with possible implications for identifying preventive strategies and pathogenic mechanisms in autism and other neurodevelopmental disorders.

Autism spectrum disorders in IVF children: a national case-control study in Finland.

STUDY QUESTION: Does IVF increase the risk of autism spectrum disorders (ASDs)? SUMMARY ANSWER: No association between IVF and ASDs or any of its subtypes was found in this sample. WHAT IS KNOWN ALREADY: Certain prenatal factors may increase the risk of ASDs. Studies on the association between IVF and ASDs have shown inconsistent results. IVF is known to increase the risk of perinatal problems but many of them are related to multiple pregnancies. STUDY DESIGN, SIZE, DURATION: This case-control study included 4164 autistic cases and 16 582 matched controls born in Finland in 1991-2005. The cases were diagnosed with ASDs by the year 2007. The maximum age at diagnosis was 16 years. PARTICIPANTS/MATERIALS, SETTING, METHODS: Four controls were matched to each case. For singletons the matching criteria were date of birth, place of birth, sex and residency in Finland. For twins the birth order within a twin pair was included as well. In the whole sample, there were 63 cases (1.51%) and 229 controls (1.38%) born after IVF. MAIN RESULTS AND THE ROLE OF CHANCE: No significant association was found between IVF and ASDs (adjusted odds ratio (OR): 0.9, 95% confidence interval (CI): 0.7-1.3) or its subtypes childhood autism (OR: 0.8, 95% CI: 0.4-1.5), Asperger's syndrome (OR: 0.9, 95% CI: 0.5-1.6) or other pervasive developmental disorder (OR: 1.0, 95% CI: 0.6-1.6). When only singletons were included, there was an association between IVF and Asperger's syndrome in an unadjusted analysis (OR: 2.0, 95% CI: 1.1-3.5) but this was not significant when adjusted for mother's socioeconomic status or parity. When the analyses were conducted separately for boys and girls, there was a significant association between IVF and Asperger's syndrome for boys in an unadjusted analysis (OR: 2.1, 95% CI: 1.2-3.7) but this was not significant in the final adjusted model. LIMITATIONS, REASONS FOR CAUTION: Information both on IVF and on ASDs was based on registers and it is possible that there is some misclassification. No information on different subtypes of IVF or other assisted reproduction techniques was available. Statistical power may have been insufficient. WIDER IMPLICATIONS OF THE FINDINGS: This study showed no increased risk of ASDs in children born after IVF but studies with larger sample sizes and information on different subtypes of IVF are needed to confirm the finding. STUDY FUNDING/COMPETING INTEREST(S): The study was supported by Autism Speaks, NIMH 1K02-MH65422 and NIEHS 1R01ES019004. There are no competing interests.

Cultural adaptation, content, and protocol of a feasibility study of school-based "Let's learn about emotions" intervention for Finnish primary school children.

Introduction: Emotional awareness and emotion regulation are crucial for cognitive and socio-emotional development in children. School-based interventions on socio-emotional skills have the potential to prevent these problems and promote well-being of children. The Japanese school-based program, Universal Unified Prevention Program for Diverse Disorders (Up2-D2), has shown preventive effects on mental health of children in Japan. The aims of this protocol paper are to describe the unique process of adapting the Up2-D2 from Eastern to Western context, and to present a feasibility study of the intervention, conducted in Finland. Methods: The cultural adaptation process started with the linguistic translation of materials, followed by the modification of language to fit the Finnish context. While the Japanese ideology was saved, some content was adapted to fit Finnish school children. Further modifications were made based on feedback from pupils and teachers. The Finnish version of the program was named "Let's learn about emotions" and consisted of 12 sessions and targeted 8- to 12-year-old pupils. A teacher education plan was established to assist Finnish teachers with the intervention, including a workshop, teachers' manual, brief introductory videos, and online support sessions. A feasibility study involving 512 4th graders in the City of Hyvinkää, South of Finland, was conducted. It assessed emotional and behavioral problems, classroom climate, bullying, loneliness, perception of school environment, knowledge of emotional awareness, and program acceptability. Discussion: The originality of this study underlies in the East-West adaptation of a cognitive behavioral therapy-based program. If promising feasibility findings are replicated in Finland, it could pave the way for further research on implementing such programs in diverse contexts and cultures, promoting coping skills, awareness, social skills and early prevention of child mental health problems. Ethics: The ethical board of the University of Turku gave ethics approval for this research. The educational board of the City of Hyvinkää accepted this study.

Use of ADHD drugs in the Nordic countries: a population-based comparison study.

OBJECTIVE: To compare national use of attention-deficit/hyperactivity disorder (ADHD) drugs between five Nordic countries. METHOD: A population-based drug utilisation study based on nationwide prescription databases, covering in total 24 919 145 individuals in 2007. ADHD drugs defined according to the World Health Organization Anatomic Therapeutic Chemical classification system as centrally acting sympathomimetics (N06BA). RESULTS: The 2007 prevalence of ADHD drug use among the total Nordic population was 2.76 per 1000 inhabitants, varying from 1.23 per 1000 in Finland to 12.46 per 1000 in Iceland. Adjusting for age, Icelanders were nearly five times more likely than Swedes to have used ADHD drugs (Prev.Ratio = 4.53, 95% CI: 4.38-4.69). Prevalence among boys (age 7-15) was fourfold the prevalence among girls (Prev.Ratio = 4.28, 95% CI: 3.70-4.96). The gender ratio was diminished among adults (age 21 +) (Prev.Ratio = 1.24, CI: 1.21-1.27). CONCLUSION: A considerable national variation in use of ADHD drugs exists between the Nordic countries.

Internet-assisted cognitive behavioural therapy with telephone coaching for anxious Finnish children aged 10-13 years: study protocol for a randomised controlled trial.

INTRODUCTION: Childhood anxiety is common, causes significant functional impairment and may lead to psychosocial problems by adulthood. Although cognitive behavioural therapy (CBT) is effective for treating anxiety, its availability is limited by the lack of trained CBT therapists and easily accessible local services. To address the challenges in both recognition and treatment, this study combines systematic anxiety screening in the general population with a randomised controlled trial (RCT) on internet-assisted CBT (ICBT) with telephone coaching. Child, family and intervention-related factors are studied as possible predictors or moderators, together with the COVID-19 pandemic. METHODS AND ANALYSIS: The study is an open two-parallel group RCT, stratified by sex, that compares ICBT with telephone coaching to an education control. Children aged 10-13 are screened at yearly school healthcare check-ups using five items from the Screen for Child Anxiety Related Disorders (SCARED) Questionnaire. The families of children who screen positive for anxiety are contacted to assess the family's eligibility for the RCT. The inclusion criteria include scoring at least 22 points in the 41-item SCARED Questionnaire. The primary outcome is the SCARED child and parent reports. The secondary outcomes include the impact of anxiety, quality of life, comorbidity, peer relationships, perceptions of school, parental well-being and service use. Additional measures include demographics and life events, anxiety disorder diagnoses, as well as therapeutic partnerships, the use of the programme and general satisfaction among the intervention group. ETHICS AND DISSEMINATION: The study has been approved by the research ethics board of the Hospital District of South West Finland and local authorities. Participation is voluntary and based on informed consent. The anonymity of the participants will be protected and the results will be published in a scientific journal and disseminated to healthcare professionals and the general public. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov NCT03310489, pre-results, initially released on 30 September 2017.

Brief report: validity of Finnish registry-based diagnoses of autism with the ADI-R.

AIMS: The aim of the study was to explore the validity of registry-based diagnoses of autism in Finland using the Autism Diagnostic Interview - Revised (ADI-R). This study was designed for the Finnish Prenatal Study of Autism and Autism Spectrum Disorders (FIPS-A), an ongoing research project where registry-based diagnoses will be used for epidemiological studies. METHODS: In this small pilot study, a clinical sample of 95 subjects diagnosed with childhood autism or pervasive developmental disorder/pervasive developmental disorder - not otherwise specified (PDD/PDD-NOS) or Asperger's syndrome according to the Finnish Hospital Discharge Register (FHDR) was gathered nationwide. A small control group consisting of siblings without any registered diagnoses of those being examined was also included in the study. Diagnoses were further re-evaluated by interviewing parents with the ADI-R. RESULTS: The mean scores of autistic subjects clearly exceeded cut-off limits for autism on all three ADI-R domains and 96% of the subjects with registered diagnosis of childhood autism fulfilled the criteria based on the instrument as well. CONCLUSION: These results suggest that the validity of Finnish registry-based diagnoses of childhood autism can be considered good. Our findings lay important groundwork for further population- based studies of the aetiology of autism.

Validation of the Youth Efficacy/Empowerment Scale - Mental Health Finnish version.

Αdolescents face mental health problems and still their mental health needs are often neglected. Empowerment provides adolescents with the skills to impact their own lives and communities in general. The aim of the study is to examine the validity and reliability of the Finnish version of the Youth Efficacy/Empowerment Scale - Mental Health (YES-MH). Data was collected through an online questionnaire from pupils aged 12-17 years in Western Finland, comprised of the following instruments; the YES-MH, the Goodman's the Strengths and Difficulties Questionnaire (SDQ), and the Warwick-Edinburgh Mental Wellbeing Scale. Exploratory factor analysis was carried out to evaluate construct validity and disclose underlying structures which yielded the following subscales: Self, Services, System. The internal consistency of subscales was analyzed with Cronbach's α. Construct validity was further investigated by computing the Pearson's correlations coefficients between the subscales. Furthermore, correlations with SDQ and mental well-being dimensions were explored as measures of convergent validity. In the final model all items the Youth Efficacy/ Empowerment Scale - Mental Health were entered into the factor analysis. All factor loadings were more than 0.40, ranging from 0.63 to 0.89. All the scales exceeded the minimum reliability standard of 0.70 and all corrected item-total correlations were high. All the YES-MH subscales were significantly and positively correlated each other with correlations coefficients ranging from medium to high. Correlations of Mental Well-being score with Self and Services subscales were significant. Moreover, Self subscale was significantly correlated with all SDQ dimensions. Services subscale was significantly correlated with Emotional symptoms and total SDQ score, while System subscale was significantly correlated with Conduct problems. The exploratory factor analysis showed a clear factor structure and the results suggest that the YES-MH is a reliable scale for assessing empowerment among young people. The YES-MH can be useful for health professionals not only as an assessment tool but also when they need to evaluate mental health interventions and examine empowerment as an outcome. However, further research can provide insights for the use of the scale in specific adolescent target groups and among different ethnic groups as well.

Life events, self-reported psychopathology and sense of coherence among young men--a population-based study.

The aim is to study the associations between sense of coherence (SOC), and psychopathology and major life events among adolescent boys. The study population consisted of 2314 Finnish boys born during 1981 who attended military call-up (79% of the original sample). At military call-up in 1999, the boys filled in the Young Adult Self-Report (YASR) and Antonovsky's Orientation to Life Questionnaire (SOC-13), which measure SOC. In univariate analysis, low parental education level, death and serious illness of parent, parental divorce and high symptom level in all YASR scales were associated with poor SOC. In multivariate analysis, most YASR syndrome scales and father's education level were independently associated with SOC. The study demonstrates the sensitivity of the SOC-13 scale to a wide range of mental health problems. The results offer additional support to the argument that SOC may be an important global measure for use in both clinical and research purposes in adolescent psychiatry.

Violence and child mental health in Brazil: The Itaboraí Youth Study methods and findings.

OBJECTIVES: To demonstrate a study design that could be useful in low-resource and violent urban settings and to estimate the prevalence of child violence exposure (at home, community, and school) and child mental health problems in a low-income medium-size city. METHODS: The Itaboraí Youth Study is a Norway-Brazil collaborative longitudinal study conducted in Itaboraí city (n = 1409, 6-15 year olds). A 3-stage probabilistic sampling plan (random selection of census units, eligible households, and target child) generated sampling weights that were used to obtain estimates of population prevalence rates. RESULTS: Study strengths include previous pilot study and focus groups (testing procedures and comprehension of questionnaire items), longitudinal design (2 assessment periods with a mean interval of 12.9 months), high response rate (>80%), use of standardized instruments, different informants (mother and adolescent), face-to-face interviews to avoid errors due to the high frequency of low-educated respondents, and information gathered on a variety of potential predictors and protective factors. Children and adolescents presented relevant levels of violence exposure and clinical mental health problems. CONCLUSIONS: Prevalence estimates are probably valid to other Brazilian low-income medium-size cities due to similarities in terms of precarious living conditions. Described study methods could be useful in other poor and violent world regions.

ViPAR: a software platform for the Virtual Pooling and Analysis of Research Data.

BACKGROUND: Research studies exploring the determinants of disease require sufficient statistical power to detect meaningful effects. Sample size is often increased through centralized pooling of disparately located datasets, though ethical, privacy and data ownership issues can often hamper this process. Methods that facilitate the sharing of research data that are sympathetic with these issues and which allow flexible and detailed statistical analyses are therefore in critical need. We have created a software platform for the Virtual Pooling and Analysis of Research data (ViPAR), which employs free and open source methods to provide researchers with a web-based platform to analyse datasets housed in disparate locations. METHODS: Database federation permits controlled access to remotely located datasets from a central location. The Secure Shell protocol allows data to be securely exchanged between devices over an insecure network. ViPAR combines these free technologies into a solution that facilitates 'virtual pooling' where data can be temporarily pooled into computer memory and made available for analysis without the need for permanent central storage. RESULTS: Within the ViPAR infrastructure, remote sites manage their own harmonized research dataset in a database hosted at their site, while a central server hosts the data federation component and a secure analysis portal. When an analysis is initiated, requested data are retrieved from each remote site and virtually pooled at the central site. The data are then analysed by statistical software and, on completion, results of the analysis are returned to the user and the virtually pooled data are removed from memory. CONCLUSIONS: ViPAR is a secure, flexible and powerful analysis platform built on open source technology that is currently in use by large international consortia, and is made publicly available at [http://bioinformatics.childhealthresearch.org.au/software/vipar/].

Characteristics and staff resources of child and adolescent psychiatric hospital wards in Finland.

The aim of this study is to describe structural characteristics and staff resources of child psychiatric and adolescent psychiatric hospital wards in Finland. The target group of the survey consisted of 69 child and adolescent psychiatric hospital units in Finland. Information was obtained from 64 units (93%). Most of the wards were based on 24-h-a-day provision. There were only 7-day-treatment programmes including two family wards. When compared internationally, the numbers of units, beds and staff levels were high in Finland, with all members of staff qualified. The nurse-patient ratio and psychiatrist resources were rather satisfactory. However, in many units there was a lack of psychologists, social workers and occupational therapists. General recommendations and guidelines for staff resources in child and adolescent hospital treatment wards are warranted.

Psychiatric symptoms in preadolescents with musculoskeletal pain and fibromyalgia.

OBJECTIVES: To study the association of musculoskeletal pain with emotional and behavioral problems, especially depressive symptoms in Finnish preadolescents. STUDY DESIGN: A structured pain questionnaire was completed by 1756 third- and fifth-grade schoolchildren for identifying children with widespread pain (WSP), children with neck pain (NP), and pain-free controls for the comparative study. There were 124 children with WSP (mean age, 10.7 years), 108 children with NP (mean age, 11.1 years), and 131 controls (mean age, 10.7 years) who completed the Children's Depression Inventory (CDI) and a sleep questionnaire. A blinded clinical examination was done to detect fibromyalgia. For parental evaluation, the Child Behavior Checklist and a sociodemographic questionnaire were used. For teacher evaluation the Teacher Report Form was used. RESULTS: Children with WSP had significantly higher total emotional and behavioral scores than controls, according to child and parent evaluation. A significant difference in the mean total CDI scores was also found between the WSP and NP groups. Children with fibromyalgia had significantly higher CDI scores than the other children with WSP. CONCLUSIONS: Musculoskeletal pain, especially fibromyalgia, and depressive symptoms had high comorbidity. Pain and depressive symptoms should be recognized to prevent a chronic pain problem.

Mood, latitude, and seasonality among adolescents.

OBJECTIVE: To examine the effect of sex, latitude, and behavior problems on symptoms related to pediatric seasonal affective disorder among seventh and ninth graders. METHOD: A school survey including a modified version of the Seasonal Pattern Assessment Questionnaire was carried out in 2 Finnish cities located in the 60th and 67th northern latitudes. Altogether 1,458 questionnaires were analyzed, representing 89% of the target population. RESULTS: Seasonal changes in mood and behavior were commonly reported among seventh and ninth graders. A high Global Seasonality score (> 95th percentile) was associated with female gender and emotional and hyperactivity symptoms. During February and March, girls living in the 67th latitude reported more seasonal distress than girls living at the 60th latitude. CONCLUSIONS: It is important to recognize pediatric seasonal affective disorder and related problems among adolescents. Seasonal alterations in child and adolescent behavior are not well understood and need to be investigated more thoroughly.

Suicidal thoughts and attempts among adolescents: a longitudinal 8-year follow-up study.

BACKGROUND: To study the prevalence of and factors associated with suicidal behaviour among 580 adolescents. METHODS: An 8-year longitudinal study included questions about suicidal attempts and thoughts at age 16. Children were evaluated with parent and teacher Rutter scales and self-reported Child Depression Inventory at age 8. At age 16, parents filled in the Child Behaviour Check List and adolescents the Youth Self Report. RESULTS: 14% of girls and 7% of boys reported suicidal thoughts or preoccupations at age 16. Emotional and behavioural problems at age 8, especially antisocial symptoms, reported by parents and teachers and depressive symptoms reported by the child were correlated with suicidal thoughts and behaviour 8 years later. At age 16, internalizing and externalizing problems and low social competence were associated with suicidal features. Only about 20% of those who reported suicidal features had been referred to child mental health services. CONCLUSIONS: Many adolescents with suicidal thoughts and behaviour had a high rate of behavioural and emotional problems already at age 8. CLINICAL IMPLICATIONS: The early school years represent an opportunity for interventions which may prevent self-destructive behaviours in adolescence.

Antenatal depression, substance dependency and social support.

BACKGROUND: The purpose of this study was to explore the prevalence of depression and factors associated with depressive mood among pregnant women. METHOD: 391 women who were 14-37 weeks pregnant were evaluated with the Edinburgh Postnatal Depression Screen (EPDS), which has also been validated for prenatal use. Four questionnaires were used in order to explore associated factors: a questionnaire on background and pregnancy data, the Substance Abuse Subtle Screening Inventory (SASSI) and two Social Support Questionnaires (SSQ1 and 2). RESULTS: 7.7% of the total sample screened positive on the EPDS with a cut-off point of 12/13 recommended. Substance dependency and experienced difficulties in social environment had an independently significant association with maternal depression. LIMITATION: The caseness was defined with a self-report instrument. CONCLUSION: Substance dependency and experienced difficulties, especially in relation to friends, partner and own mother, are associated with antenatal depression. It is important to be aware of this when developing interventions in maternity care primary units.

An early report on the mother-baby interactive capacity of substance-abusing mothers.

OBJECTIVE: Examination of maternal interactive behavior and psychosocial situation of substance-abusing mothers in treatment. METHOD: Twelve mothers with an alcohol or drug abuse problem and 12 control mothers were assessed in random order with the Parent-Child Early Relational Assessment, for the analysis of videotaped mother-infant interactions at 3 and 6 months' postpartum. Depressive symptoms were assessed with Edinburgh Postnatal Depression Scale and aspects of social support with two Social Support Questionnaires. RESULTS: Substance-abusing mothers tended to have more problematic areas in their interactive behavior, a tendency which increased during the study period. As was expected, they were more often depressive, and experienced more social environment difficulties and less social support. CONCLUSIONS: Mothers with alcohol and drug abuse problems need intensive professional support in early motherhood, and are seen to be particularly motivated to strive for abstinence and accept help at this stage of life.

Behavior problems and traumatic events of unaccompanied refugee minors.

OBJECTIVE: The present study examined the traumatic events and behavior symptoms of 46 unaccompanied refugee minors waiting for placement in an asylum center in Finland. METHOD: Using all the clinical information available information about the refugee children's experiences before and during their flight and after their arrival in Finland was gathered. Children were evaluated with the Child Behavior Checklist (CBCL). RESULTS: The refugee children had experienced a number of losses, separations, persecution, and threats. About half of the minors were functioning within clinical or borderline range when evaluated with the CBCL. Young age (< 15 years) was associated with more severe psychiatric problems. There was a lack of rehabilitative services, the staff ratio was very low and the time spent in the asylum center waiting for the placement decision was relatively long for these minors. CONCLUSIONS: Unaccompanied refugee minors are in a highly vulnerable situation. Younger refugee children are more vulnerable to emotional distress than older children. Current procedures for dealing with asylum-seekers may contribute to high level of stress and emotional symptoms in previously traumatized refugee children. A high level of social security and mental health care does not guarantee an appropriate level of care for unaccompanied refugee children.

Persistence of bullying from childhood to adolescence--a longitudinal 8-year follow-up study.

OBJECTIVE: To examine factors associated with bullying and victimization from age 8 to 16. METHOD: An 8-year longitudinal study included questions about bullying and victimization at age 8 and 16. Children were evaluated with Rutter scales by parents and teachers and with the Child Depression Inventory filled in by the children at age 8. When the children were at the age of 16 parents filled in the CBCL and adolescents the YSR. RESULTS: About 15% of boys and 7% of girls were bullied and 12% of girls and 13% of boys were victimized at age 16. Both bullying and victimization at age 16 were associated with a wide range of psychological problems at age 8 and 16, and with referral to child mental health services. Bullying at age 8 was associated with bullying at age 16, while victimization at age 8 was associated with victimization 8 years later. CONCLUSIONS: Bullying and victimization are often persistent and associated with severe emotional and behavior problems. Preventive efforts should be focused, and targeted at those children who are characterized by both psychological disturbance and bullying.