Assessing Childhood Maltreatment Exposure in Patients Without and With a Diagnosis of Substance Use Disorder.

OBJECTIVES: Childhood maltreatment (CM), widely held as a risk factor for substance use disorders (SUDs), is commonly assessed using the Childhood Trauma Questionnaire (CTQ). Retrospective self-reports are, however, potentially subject to bias. We used a unique patient sample with prospectively documented CM to examine the performance of the CTQ and how this is affected by the presence of SUD. METHODS: Analysis was based on a total of 104 individuals. Subjects with prospectively recorded CM were identified from a specialized childhood trauma unit in Linköping, Sweden (n = 55; 31 with SUD, 61% females; 24 without SUD, 71% females). Clinical controls had SUD but no CM (n = 25, 48% females). Healthy controls had neither SUD nor CM (n = 24, 54% females). We analyzed the agreement between retrospective CTQ scores and prospectively documented CM by κ analysis and assessed the performance of the CTQ to identify CM exposure using receiver operating characteristic (ROC) analysis. RESULTS: Agreement between prospectively and retrospectively recorded CM exposure was poor for sexual abuse (36.6%, Cohen κ = 0.32, P = 0.008) and physical abuse (67.3%, κ = 0.35, P = 0.007). Overall CTQ performance was fair (ROC: area under the ROC curve = 0.78, optimal cutoff = 36.5, sensitivity = 0.65, specificity = 0.75). However, performance was excellent in the absence of SUD (area under the ROC curve = 0.93, cutoff = 32.0, sensitivity = 0.88, specificity = 0.88), but poor in participants with lifetime SUD (area under the ROC curve = 0.62, cutoff = 42.0, sensitivity = 0.60, specificity = 0.36). CONCLUSIONS: These data support the CTQ as a tool to assess CM exposure but suggest that it may be less useful in patients with SUD.

Resilience to substance use disorder following childhood maltreatment: association with peripheral biomarkers of endocannabinoid function and neural indices of emotion regulation.

Childhood maltreatment (CM) is a risk factor for substance use disorders (SUD) in adulthood. Understanding the mechanisms by which people are susceptible or resilient to developing SUD after exposure to CM is important for improving intervention. This case-control study investigated the impact of prospectively assessed CM on biomarkers of endocannabinoid function and emotion regulation in relation to the susceptibility or resilience to developing SUD. Four groups were defined across the dimensions of CM and lifetime SUD (N = 101 in total). After screening, participants completed two experimental sessions on separate days, aimed at assessing the behavioral, physiological, and neural mechanisms involved in emotion regulation. In the first session, participants engaged in tasks assessing biochemical (i.e., cortisol, endocannabinoids), behavioral, and psychophysiological indices of stress and affective reactivity. During the second session, the behavioral and brain mechanisms associated with emotion regulation and negative affect were investigated using magnetic resonance imaging. CM-exposed adults who did not develop SUD, operationally defined as resilient to developing SUD, had higher peripheral levels of the endocannabinoid anandamide at baseline and during stress exposure, compared to controls. Similarly, this group had increased activity in salience and emotion regulation regions in task-based measures of emotion regulation compared to controls, and CM-exposed adults with lifetime SUD. At rest, the resilient group also showed significantly greater negative connectivity between ventromedial prefrontal cortex and anterior insula compared to controls and CM-exposed adults with lifetime SUD. Collectively, these peripheral and central findings point to mechanisms of potential resilience to developing SUD after documented CM exposure.

The effectiveness of weighted blankets on sleep and everyday activities - A retrospective follow-up study of children and adults with attention deficit hyperactivity disorder and/or autism spectrum disorder.

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

Neural processing of self-touch and other-touch in anorexia nervosa and autism spectrum condition.

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

Altered relationship between subjective perception and central representation of touch hedonics in adolescents with autism-spectrum disorder.

An impairment of social communication is a core symptom of autism-spectrum disorder (ASD). Affective touch is an important means of social interaction, and C-Tactile (CT) afferents are thought to play a key role in the peripheral detection and encoding of these stimuli. Exploring the neural and behavioral mechanisms for processing CT-optimal touch (~3 cm/s) may therefore provide useful insights into the pathophysiology of ASD. We examined the relationship between touch hedonics (i.e. the subjective pleasantness with which affective touch stimuli are perceived) and neural processing in the posterior superior temporal sulcus (pSTS). This region is less activated to affective touch in individuals with ASD, and, in typically developing individuals (TD), is correlated positively with touch pleasantness. TD and ASD participants received brushing stimuli at CT-optimal, and CT-non-optimal speeds during fMRI. Touch pleasantness and intensity ratings were collected, and affective touch awareness, a measure of general touch hedonics was calculated. As expected, slow touch was perceived as more pleasant and less intense than fast touch in both groups, whereas affective touch awareness was moderately higher in TD compared to ASD. There was a strong, positive correlation between right pSTS activation and affective touch awareness in TD, but not in ASD. Our findings suggest that altered neural coupling between right pSTS and touch hedonics in ASD may be associated with social touch avoidance in ASD.

Re-examining the link between childhood maltreatment and substance use disorder: a prospective, genetically informative study.

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

Psychophysiological and Neural Support for Enhanced Emotional Reactivity in Female Adolescents With Nonsuicidal Self-injury.

BACKGROUND: Nonsuicidal self-injury (NSSI) is prevalent in adolescent populations worldwide. Emotion dysregulation is believed to contribute to NSSI, but underlying mechanisms are less known. We combined psychophysiological and neural data with subjective self-report in close temporal proximity to examine the mechanisms underlying emotion processing in adolescents with NSSI relative to control adolescents without a psychiatric diagnosis. METHODS: Thirty female adolescents with NSSI and 30 age-matched female control subjects were included in this case-control study. Participants were presented with negative affective pictures during a functional magnetic resonance imaging scan. In a separate facial electromyography session, the same participants were shown positive and negative affective images and also provided ratings of valence and arousal. RESULTS: Participants with NSSI responded to affective images with greater positive (e.g., zygomatic) and greater negative (e.g., corrugator) reactivity. We found no differences in self-reported affect in response to the images. Analyses of the negative picture-viewing functional magnetic resonance imaging data showed a significant positive correlation between anterior insula response and the averaged electromyography magnitude in NSSI, but not in control subjects. CONCLUSIONS: Adolescents with NSSI show enhanced emotional reactivity that is associated with anterior insula responding, but no abnormalities in self-reported affect. This discrepancy between self-report and objective measures of emotional reactivity potentially indicates a suppression of the emotional reaction in adolescents with NSSI. Moreover, the current data suggest potential targets for novel therapeutic approaches that can be combined with existing clinical treatment, such as real-time electromyography-based biofeedback focusing on emotional awareness, labeling, and expressing emotional experiences.

Longitudinal pathways of engagement, social interaction skills, hyperactivity and conduct problems in preschool children.

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

Occupational performance goals and outcomes of time-related interventions for children with ADHD.

BACKGROUND: Children with attention deficit hyperactivity disorder (ADHD) have difficulties with occupational performance, related to difficulties with time-processing ability. AIMS: To examine the outcome of a multimodal time-related intervention designed to support children aged 9-15 years with ADHD, to achieve their occupational performance goals and improve satisfaction with occupational performance. A further aim was to compare the children's ratings of outcome with their parents' ratings and to analyse the occupational performance goals. MATERIAL AND METHODS: A pre-post design was used. Participants were 27 children, aged 9-15 years. Children and parents rated occupational performance and satisfaction at baseline and follow-up, after 24 weeks, using the Canadian Occupational Performance Measure (COPM). The intervention consisted of time-skills training and time-assistive devices (TADs). Descriptive and non-parametric statistics were used. RESULTS: Significant improvements were found in reported performance and satisfaction. Children's were higher than those of their parents. Most goals were about carrying out daily routines, knowing the duration of an activity and knowing what will happen in the near future. CONCLUSION AND SIGNIFICANCE: The study contributes to knowledge about suitable interventions for children with ADHD who have time-related difficulties. Occupational therapy interventions, including TADs and time-skills training, resulted in significantly improved occupational performance.

Nonsuicidal Self-Injury Disorder in Adolescents: Clinical Utility of the Diagnosis Using the Clinical Assessment of Nonsuicidal Self-Injury Disorder Index.

Nonsuicidal self-injury disorder (NSSID) is a condition in need of further study, especially in adolescent and clinical populations where it is particularly prevalent and studies are limited. Twenty-nine clinical self-injuring adolescents were included in the study. The Clinical Assessment of Nonsuicidal Self-Injury Disorder Index (CANDI) was used to assess prevalence of NSSID. The NSSID diagnosis criteria were met by 62.1% of adolescents. The impairment or distress criterion was least often met. Criteria B and C (assessing reasons for NSSI and cognitions/emotions prior to NSSI) were confirmed by 96-100% of all participants. Adolescents with NSSI in this clinical sample had several comorbidities and high levels of psychopathology. NSSID occurred both in combination with and independently of borderline personality disorder traits as well as suicide plans and attempts. Those with NSSID had a significantly higher cutting frequency than those not meeting full NSSID criteria. Other NSSI characteristics, comorbidity, psychopathology, and trauma experiences did not differ between groups. CANDI was a feasible tool to assess NSSID in adolescents. It is important to use structured measures to assess the validity of the NSSID diagnosis across development in both community and clinical samples. The clinical utility of the NSSID diagnosis is discussed.

Reliability and validation of Swedish translation of Beliefs about Medication Specific (BMQ-Specific) and Brief Illness Perception Questionnaire (B-IPQ) for use in adolescents with attention-deficit hyperactivity disorder.

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

Brain-based Classification of Negative Social Bias in Adolescents With Nonsuicidal Self-injury: Findings From Simulated Online Social Interaction.

BACKGROUND: Interpersonal stress and perceived rejection have been clinically observed as common triggers of nonsuicidal self-injury (NSSI), with self-injury behavior regulating both affective and social experiences. We investigated whether the subjective interpretation of social interaction in a simulated online environment might be biased in the NSSI group, and the brain mechanisms underlying the experience. METHODS: Thirty female adolescent patients with NSSI and thirty female age-matched controls were investigated in this case-control study. In our novel task that simulates interaction on current social media platforms, participants indicated whether they liked or disliked pictures of other players during a functional magnetic resonance imaging (fMRI) scan. Participants also viewed positive and negative feedback directed toward them by others. The task also assessed the subjective effects of the social interaction. Finally, subjects underwent a separate facial electromyography session, which measured facial expressions processing. OUTCOMES: Behaviorally, the NSSI group showed a negative bias in processing social feedback from others. A multi-voxel pattern analysis (MVPA) identified brain regions that robustly classified NSSI subjects and controls. Regions in which mutual activity contributed to the classification included dorsomedial prefrontal cortex and subgenual anterior cingulate cortex, a region implicated in mood control. In the NSSI group, multi-voxel classification scores correlated with behavioral sensitivity to negative feedback from others. Results remained significant after controlling for medication, symptoms of depression, and symptoms of borderline personality disorder. INTERPRETATION: This study identified behavioral and neural signatures of adolescents with NSSI during social interaction in a simulated social media environment. These findings highlight the importance of understanding social information processing in this clinical population and can potentially advance treatment approaches.

Weight and Height in Children and Adolescents with Attention-Deficit/Hyperactivity Disorder: A Longitudinal Database Study Assessing the Impact of Guanfacine, Stimulants, and No Pharmacotherapy.

Objectives: To assess the impact of long-term pharmacotherapy with guanfacine immediate- or extended-release (GXR), administered alone or as an adjunctive to a stimulant, on weight and height in children and adolescents with attention-deficit/hyperactivity disorder (ADHD). Methods: Data were extracted from U.S. Department of Defense medical records for patients 4-17 years of age at index date (initiation of any study medication following a year without ADHD medications, or diagnosis if unmedicated) with weight/height measurements for the analysis period (January 2009-June 2013) and the previous year (baseline). Longitudinal weight and height z-scores were analyzed using multivariable regression in three cohorts: guanfacine (initial period of guanfacine exposure), first-line stimulant monotherapy (initial period of exposure), and unmedicated. Guanfacine cohort subgroups were based on previous/concurrent stimulant exposure. Results: The weight analyses included 47,910 patients (66.8% male) and the height analyses 41,248 (67.2% male). Mean initial exposure in the weight analyses was 237 days (standard deviation [SD] = 258, median = 142) for guanfacine and 257 days (SD = 284, median = 151) for first-line stimulant monotherapy, and was similar in the height analyses. Modeling indicated that guanfacine monotherapy was not associated with clinically meaningful deviations from normal z-score trajectories for weight (first-line, n = 943; nonfirst-line, n = 796) or height (first-line, n = 741; nonfirst-line, n = 644). In patients receiving guanfacine adjunctive to a stimulant, modeled weight (n = 1657) and height (n = 1343) z-scores followed declining trajectories. In this subgroup, mean standardized weight/height had decreased during previous stimulant monotherapy. For first-line stimulant monotherapy, modeled weight (n = 32,999) and height (n = 28,470) z-scores followed declining trajectories during year 1. In the unmedicated cohort, modeled weight (n = 11,515) and height (n = 10,050) z-scores were stable. Conclusions: Guanfacine monotherapy (first-line or nonfirst-line) was not associated with marked deviations from normal growth in this modeling study of children and adolescents with ADHD. In contrast, growth trajectories followed an initially declining course with stimulants, whether given alone or with adjunctive guanfacine.

Hyperactivity precedes conduct problems in preschool children: a longitudinal study.

BACKGROUND: Externalising problems are among the most common symptoms of mental health problems in preschool children. AIMS: To investigate the development of externalising problems in preschool children over time, and the way in which conduct problems are linked to hyperactivity problems. METHOD: In this longitudinal study, 195 preschool children were included. Latent growth modelling of conduct problems was carried out, with gender and hyperactivity at year 1 as time-invariant predictors. RESULTS: Hyperactivity was a significant predictor for the intercept and slope of conduct problems. Children with more hyperactivity at year 1 had more conduct problems and a slower reduction in conduct problems. Gender was a significant predictor for the slope of conduct problems. CONCLUSIONS: Children with more initial hyperactivity have less of a reduction in conduct problems over time. It is important to consider the role of hyperactivity in studies of the development of conduct problems. DECLARATION OF INTEREST: None.

The salience of self, not social pain, is encoded by dorsal anterior cingulate and insula.

The human neural correlates of social rejection have attracted significant research interest, but remain subject to vigorous debate. Specifically, it has been proposed that a matrix of brain regions overlapping with the classical pain matrix, and including the dorsal anterior cingulate cortex (dACC) and the anterior insular cortex (AI) is critical for processing of social rejection. The present study expands on this conceptualization, by showing that these areas are involved in processing of self-relevant social evaluation, irrespective of valence. Forty healthy adolescents (N = 20 females) were tested in a magnetic resonance imaging (MRI) scanner. We used a novel paradigm that balanced participants' experience of rejection and acceptance. In addition, the paradigm also controlled for whether the social judgment was towards the participants or towards other fictitious players. By creating a "self" and "other" distinction, we show that right AI and dACC are involved in processing the salience of being judged by others, irrespective of the quality of this judgment. This finding supports the idea that these regions are not specific to social rejection or even to pain or metaphorically painful experiences, but activate to self-relevant, highly salient information.

School Contextual Features of Social Disorder and Mental Health Complaints-A Multilevel Analysis of Swedish Sixth-Grade Students.

This study addressed school-contextual features of social disorder in relation to sixth-grade students' experiences of bullying victimization and mental health complaints. It investigated, firstly, whether the school's concentrations of behavioural problems were associated with individual students' likelihood of being bullied, and secondly, whether the school's concentrations of behavioural problems and bullying victimization predicted students' emotional and psychosomatic health complaints. The data were derived from the Swedish National Survey of Mental Health among Children and Young People, carried out among sixth-grade students (approximately 12-13 years old) in Sweden in 2009. The analyses were based on information from 59,510 students distributed across 1999 schools. The statistical method used was multilevel modelling. While students' own behavioural problems were associated with an elevated risk of being bullied, attending a school with a higher concentration of students with behavioural problems also increased the likelihood of being bullied. Attending a school with higher levels of bullying victimization and behavioural problems predicted more emotional and psychosomatic complaints, even when adjusting for their individual level analogues. The findings indicate that school-level features of social disorder influence bullying victimization and mental health complaints among students.

Effectiveness of time-related interventions in children with ADHD aged 9-15 years: a randomized controlled study.

Specific problems with time and timing that affect daily routines, homework, school work, and social relations have been recognized in children with ADHD. The primary treatments for children with ADHD do not specifically focus on time-related difficulties. The aim of this randomized controlled study (RCT) was to investigate how multimodal interventions, consisting of training in time-processing ability (TPA) and compensation with time-assistive devices (TAD), affect TPA and daily time management (DTM) in children with ADHD and time difficulties, compared with only educational intervention. Thirty-eight children on stable medication for ADHD in the 9-15-year age range were randomly allocated to an intervention or a control group. The children's TPA was measured with a structured assessment (KaTid), and the children's DTM was rated by a parent questionnaire (Time-Parent scale) and by children's self-reporting (Time-Self-rating). The intervention consisted of time-skill training and compensation with TAD. Data were analysed for differences in TPA and in DTM between the control and intervention groups in the 24-week follow-up. Children in the intervention group increased their TPA significantly (p = 0.019) more compared to the control group. The largest increase was in orientation to time. In addition, the parents in the intervention group rated their children's DTM as significantly (p = 0.01) improved compared with the parents in the control group. According to the children, their DTM was not significantly changed. In conclusion, a multimodal intervention consisting of time-skill training and TAD improved TPA and DTM in children with ADHD aged 9-15 years.

Emotional and behavioural problems in Swedish preschool children rated by preschool teachers with the Strengths and Difficulties Questionnaire (SDQ).

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

Treatment Patterns among Children and Adolescents with Attention-Deficit/Hyperactivity Disorder with or without Psychiatric or Neurologic Comorbidities in Sweden: A Retrospective Cohort Study.

INTRODUCTION: Attention-deficit/hyperactivity disorder (ADHD) is a common psychiatric disorder in children/adolescents and occurs frequently with psychiatric/neurologic comorbidities. The objective of this study was to assess the impact of psychiatric/neurologic comorbidities on pharmacotherapy patterns among patients with ADHD in Sweden. METHODS: A retrospective cohort analysis was conducted using medical records from a regional database in Sweden. Patients aged 6-17 years, with ≥1 prescription for ADHD medication between July 1, 2007 and June 30, 2009, and continuously active in the database for ≥12 months before and after their prescription index date were selected. Patients were categorized as ADHD alone (ADHD-only) or with comorbidities (ADHD-comorbid). Between-group differences were analyzed before and after adjusting for potentially confounding variables. RESULTS: Data on 1794 patients (1083 ADHD-only; 711 ADHD-comorbid) were analyzed. Among newly treated patients, 21.7% augmented their index therapy (ADHD-only, 20.5%; ADHD-comorbid, 24.4%; p = 0.23). After adjustment, ADHD-only patients were less likely (p = 0.002) to augment versus ADHD-comorbid patients [odds ratio = 0.44, 95% confidence interval (CI) 0.27, 0.73]. ADHD-comorbid patients received more prescriptions versus ADHD-only patients (mean 13.1 vs 10.0; p < 0.001), and had more outpatient visits (mean 11.9 vs. 8.1; p < 0.001) and hospitalizations (10.7% vs. 6.0%; p < 0.001). After adjustment, ADHD-only patients had fewer outpatient visits (p < 0.001) and referrals (p < 0.001) versus ADHD-comorbid patients (visits: ß = -0.21, 95% CI -0.28, -0.13; referrals: ß = -0.25, 95% CI -0.33, -0.18). CONCLUSION: Patients with ADHD with comorbidities had more hospitalizations, physician visits, and medication prescriptions during 12 months' follow-up than did those with ADHD alone. ADHD therapy augmentation was prevalent among children/adolescents with ADHD, even among those without psychiatric/neurologic comorbidities.