Comparison of new psychiatric diagnoses among Finnish children and adolescents before and during the COVID-19 pandemic: A nationwide register-based study.

BACKGROUND: Coronavirus Disease 2019 (COVID-19) restrictions decreased the use of specialist psychiatric services for children and adolescents in spring 2020. However, little is known about the pattern once restrictions eased. We compared new psychiatric diagnoses by specialist services during pandemic and pre-pandemic periods. METHODS AND FINDINGS: This national register study focused on all Finnish residents aged 0 to 17 years from January 2017 to September 2021 (approximately 1 million a year). The outcomes were new monthly diagnoses for psychiatric or neurodevelopmental disorders in specialist services. These were analyzed by sex, age, home location, and diagnostic groups. The numbers of new diagnoses from March 2020 were compared to predictive models based on previous years. The predicted and observed levels in March to May 2020 showed no significant differences, but the overall difference was 18.5% (95% confidence interval 12.0 to 25.9) higher than predicted in June 2020 to September 2021, with 3,821 more patients diagnosed than anticipated. During this period, the largest increases were among females (33.4%, 23.4 to 45.2), adolescents (34.4%, 25.0 to 45.3), and those living in areas with the highest COVID-19 morbidity (29.9%, 21.2 to 39.8). The largest increases by diagnostic groups were found for eating disorders (27.4%, 8.0 to 55.3), depression and anxiety (21.0%, 12.1 to 51.9), and neurodevelopmental disorders (9.6%, 3.0 to 17.0), but psychotic and bipolar disorders and conduct and oppositional disorders showed no significant differences and self-harm (-28.6, -41.5 to -8.2) and substance use disorders (-15.5, -26.4 to -0.7) decreased in this period. The main limitation is that data from specialist services do not allow to draw conclusions about those not seeking help. CONCLUSIONS: Following the first pandemic phase, new psychiatric diagnoses in children and adolescents increased by nearly a fifth in Finnish specialist services. Possible explanations to our findings include changes in help-seeking, referrals and psychiatric problems, and delayed service access.

Psychiatric disorders diagnosed in adolescence and subsequent long-term exclusion from education, employment or training: longitudinal national birth cohort study.

BACKGROUND: Long-term 'not in education, employment or training' (NEET) status is an important indicator of youth marginalisation. AIMS: To carry out a comprehensive overview of the associations between different psychiatric illnesses and long-term NEET status. METHOD: We used the register-based 1987 Finnish Birth Cohort study, which includes all live births in Finland during that year. The analyses comprised 55 273 individuals after exclusions for intellectual disability, death or emigration. We predicted that psychiatric disorders, diagnosed by specialist services between 1998 and 2007 when the cohort were 10-20 years of age, would be associated with subsequent long-term NEET (defined as NEET for at least 5 years between 2008 and 2015, when they were 20-28 years of age). RESULTS: In total, 1438 individuals (2.6%) were long-term NEET during follow-up and the associations between long-term NEET and the 11 diagnostic categories we studied were statistically significant (P < 0.001). In multivariate models we included sociodemographic characteristics and upper secondary education as covariates, and the highest effect sizes, measured by odds ratios (OR) with 95% confidence intervals (CI), were found for psychosis (OR = 12.0, 95% CI 9.5-15.2) and autism spectrum disorder (OR = 17.3, 95% CI 11.5-26.0). If individuals had not successfully completed this education, 70.6% of those with autism spectrum disorder and 48.4% of those with psychosis were later long-term NEET. CONCLUSIONS: Adolescents who receive treatment for psychiatric disorders, particularly autism spectrum disorder or psychosis, need support to access education and employment. This could help to prevent marginalisation in early adulthood.

School performance and later diagnoses of nonaffective psychoses, bipolar disorder, and depression.

OBJECTIVE: It is unclear whether there are differences between specific school subject performance and later psychiatric disorders. We examined whether mean grade point average (MGPA) and specific school subjects associated with diagnoses of nonaffective psychoses, bipolar disorder and depression. METHODS: In this register-based study, we studied the Finnish population born in 1987 who had available MGPA and six specific school grades (age = 15.4-16.4 years; n = 50,508). Grades were analyzed with smoothing splines. Covariates included sex, urbanicity, parental education level and parental diagnosed psychiatric disorders. Outcomes were incident nonaffective psychosis, bipolar disorder and depression diagnosed in specialized services until year 2015 (age = 28.0-28.9 years). RESULTS: During the follow-up, 727 individuals were diagnosed with nonaffective psychoses, 489 with bipolar disorder and 3492 with depression. MGPA was inversely associated with all outcomes. In multivariate models including specific school subjects and covariates, the school subject with largest risk ratios (RR) was Physical Education (RR and Bonferroni-corrected confidence interval [CI] at -1.5 SD: nonaffective psychoses 1.63, 1.36-1.95; bipolar disorder 1.64, 1.30-2.05; depression 1.72, 1.53-1.93). Higher grades in Art were associated with nonaffective psychoses and depression (RR and Bonferroni-corrected CI at +1.5 SD: nonaffective psychoses 1.48, 1.11-1.96; depression 1.22, 1.07-1.38). CONCLUSION: There was a robust association between poorer scores on Physical Education and risk for psychosis, bipolar disorder and depression. Higher grades in Art were also associated with risk for later disorders. Subject specific school performance may be more informative about mental disorder risk than overall school performance.

Psychiatric and neurodevelopmental diagnoses in adolescence and adulthood over-indebtedness among Finns born in 1987.

BACKGROUND: Adolescence psychiatric and neurodevelopmental diagnoses are common but their link to adulthood over-indebtedness is unknown. This study aims to determine this relationship and explores the possible mediating role of upper secondary education completion. METHODS: We analyzed the 1987 Finnish Birth Cohort, which consisted of a complete census of children born in Finland in 1987 and registered in the Medical Birth Register (n = 53 743). Records of debt payment defaults, at the age of 33, were used as a measure of over-indebtedness. Adolescent psychiatric and neurodevelopmental diagnoses at ages 13-17 were derived from the national hospital discharge register. Inverse probability treatment weighting was used to investigate the role of pre-exposure variables in this relationship, and the mediating role of upper secondary education completion. RESULTS: Compared to unexposed individuals, those affected by an adolescent psychiatric or neurodevelopmental diagnosis had a 15 percentage points higher prevalence of over-indebtedness in adulthood. This association was more common for males and was additionally notably strong for suicidality and conduct and oppositional disorders. Controlling for measured potential confounding factors, the diagnoses were linked to a 11-percentage point (95% confidence interval 9-12) higher risk of over-indebtedness. Completing at least upper secondary education reduced this effect by some 39%. CONCLUSION: People with psychiatric and neurodevelopmental disorders diagnosed in adolescence are at elevated risk of over-indebtedness in adulthood. Recognizing this high risk may help in efforts to prevent further debt problems. Better education may serve as a protective factor against over-indebtedness and perhaps similar other behavioural consequences.

The association between treated psychiatric and neurodevelopmental disorders and out-of-home care among Finnish children born in 1997.

Comprehensive overviews of the use of psychiatric services among children and adolescents placed in out-of-home care (OHC) by child welfare authorities are scarce. We examine specialized service use for psychiatric and neurodevelopmental disorders among children and adolescents in a total population involving children in OHC. We used the longitudinal administrative data of a complete Finnish birth cohort 1997 (N = 57,174). We estimated risk ratios (RRs) for a range of diagnosed psychiatric and neurodevelopmental disorders among children in OHC. We also estimated RRs for OHC among those with diagnosed disorders. We used descriptive methods to explore the timing of first entry into OHC relative to the first diagnosis. Among children in OHC, 61.9% were diagnosed with any psychiatric or neurodevelopmental disorder, compared with 18.0% among those never in OHC (RR: 3.7; 95% CI 3.6-3.8). The most common diagnosed disorders among children in OHC were depression and anxiety disorders, neurodevelopmental disorders, and oppositional defiant disorder/conduct disorder (ODD/CD). Among all children with any diagnosis, 18.1% experienced OHC, compared with 2.5% among those without a diagnosis (RR: 7.4; 95% CI 6.9-7.9). Of those diagnosed with self-harm and suicidality, ODD/CD, substance-related disorders, and psychotic and bipolar disorders, 43.5-61.2% experienced OHC. Of the children in OHC receiving psychiatric services, half were diagnosed before first placement in OHC. The majority of children with experience in OHC were diagnosed with psychiatric or neurodevelopmental disorders. They comprised a significant proportion of individuals treated for severe and complex psychiatric disorders and self-harm.

Psychotic Disorders in Adolescence and Later Long-term Exclusion From Education and Employment.

BACKGROUND AND HYPOTHESIS: Psychotic disorders have been associated with not being in education, employment, and training (NEET). There is a lack of knowledge on the importance of risk markers for NEET among people with psychotic disorders and what rehabilitation they receive. STUDY DESIGN: We based our research on the register-based 1987 Finnish Birth Cohort study, which included all live births in Finland during that year. The study cohort were 288 people who had been diagnosed with psychotic disorders during 2004-2007, when they were 16-20 year old, and 55 883 who had not. We looked at the national register data for those subjects in 2008-2015, when they were 20-28 year old, and compared any associations between sociodemographic factors and NEET status. STUDY RESULTS: NEET for more than 5 year affected 2.2% of those without psychosis, 35.8% of those with any nonaffective psychotic disorder, and 57.0% of those with schizophrenia or schizoaffective disorders. Family-related risk factors were weaker predictors of long-term NEET in subjects with psychotic disorders than other cohort members. Having a psychotic disorder plus long-term NEET was associated with not applying for upper secondary education, not finishing upper secondary education, parents receiving welfare benefits, being diagnosed with schizophrenia or schizoaffective disorders and being hospitalized for psychosis. Only 24.3% with psychotic disorders had participated in vocational rehabilitation. CONCLUSIONS: A diagnosis of psychosis in adolescence is independently associated with serious long term functional disability. Among those with psychotic disorders, educational problems are markers for adverse labor market outcomes. Despite this, vocational rehabilitation is seldom provided.

Long-term Health and Social Outcomes in Children and Adolescents Placed in Out-of-Home Care.

Importance: Children who are placed in out-of-home care may have poorer outcomes in adulthood, on average, compared with their peers, but the direction and magnitude of these associations need clarification. Objective: To estimate associations between being placed in out-of-home care in childhood and adolescence and subsequent risks of experiencing a wide range of social and health outcomes in adulthood following comprehensive adjustments for preplacement factors. Design, Setting, and Participants: This cohort and cosibling study of all children born in Finland between 1986 and 2000 (N = 855 622) monitored each person from their 15th birthday either until the end of the study period (December 2018) or until they migrated, died, or experienced the outcome of interest. Cox and Poisson regression models were used to estimate associations with adjustment for measured confounders (from linked population registers) and unmeasured familial confounders (using sibling comparisons). Data were analyzed from October 2020 to August 2021. Exposures: Placement in out-of-home care up to age 15 years. Main Outcomes and Measures: Through national population, patient, prescription drug, cause of death, and crime registers, 16 specific outcomes were identified across the following categories: psychiatric disorders; low socioeconomic status; injuries and experiencing violence; and antisocial behaviors, suicidality, and premature mortality. Results: A total of 30 127 individuals (3.4%) were identified who had been placed in out-of-home care for a median (interquartile range) period of 1.3 (0.2-5.1) years and 2 (1-3) placement episodes before age 15 years. Compared with their siblings, individuals who had been placed in out-of-home care were 1.4 to 5 times more likely to experience adverse outcomes in adulthood (adjusted hazard ratio [aHR] for those with a fall-related injury, 1.40; 95% CI, 1.25-1.57 and aHR for those with an unintentional poisoning injury, 4.79; 95% CI, 3.56-6.43, respectively). The highest relative risks were observed for those with violent crime arrests (aHR, 4.16; 95% CI, 3.74-4.62; cumulative incidence, 24.6% in individuals who had been placed in out-of-home care vs 5.1% in those who had not), substance misuse (aHR, 4.75; 95% CI, 4.25-5.30; cumulative incidence, 23.2% vs 4.6%), and unintentional poisoning injury (aHR 4.79; 95% CI, 3.56-6.43; cumulative incidence, 3.1% vs 0.6%). Additional adjustments for perinatal factors, childhood behavioral problems, and traumatic injuries, including experiencing violence, did not materially change the findings. Conclusions and Relevance: Out-of-home care placement was associated with a wide range of adverse outcomes in adulthood, which persisted following adjustments for measured preplacement factors and unmeasured familial factors.

Predicting the stability of early employment with its timing and childhood social and health-related predictors: a mixture Markov model approach.

To extend work careers, it is important to focus on all working-aged people including young adults. The aim of this study was to identify typical patterns of work participation among young adults after their first entry into the labour market and to examine whether the timing of entry together with parental and own socio-economic position and health predict early work participation. More in-depth understanding of early careers and their early determinants is important to plan targeted interventions and to promote more stable work participation among young adults. We used the Finnish Birth Cohort 1987 including data from several registers from all 59,476 children born in 1987 as well as their parents, followed until 2015. We estimated a mixture Markov model that allowed for joint identification of latent classes of labour-market attachment, estimation of labour-market transitions within classes, and prediction of class membership using childhood social and health-related determinants. We observed that the first entry into the labour market as measured by six months in continuous employment was not a permanent entry for many, not only due to negative reasons such as unemployment and ill health but also due to more voluntary reasons such as studies. Individuals entering the labour market at a later age were more likely to be in continuous employment thereafter. More advantaged background predicted exits due to studies or - when following a late entry - stable employment, while disadvantaged background factors predicted more unstable work and long-term exits from the labour market.

Hospital Presentation for Self-Harm in Youth as a Risk Marker for Later Psychotic and Bipolar Disorders: A Cohort Study of 59 476 Finns.

Expanding clinical strategies to identify high risk groups for psychotic and bipolar disorders is a research priority. Considering that individuals diagnosed with psychotic and bipolar disorder are at high risk of self-harm, we hypothesised the reverse order relationship would also be true (ie, self-harm would predict psychotic/bipolar disorder). Specifically, we hypothesised that hospital presentation for self-harm would be a marker of high risk for subsequent development of psychotic/bipolar disorder and sought to test this hypothesis in a large population sample. This prospective register-based study included everyone born in Finland in 1987, followed until age 28 years (N = 59 476). We identified all hospital records of self-harm presentations, as well as all ICD-10 healthcare registrations of first diagnoses of psychotic and bipolar disorders. Cox proportional hazards models were used to assess the relationship between self-harm and psychotic/bipolar disorders. Of all individuals who presented to hospital with self-harm (n = 481), 12.8% went on to receive a diagnosis of psychosis (hazard ratio [HR] = 6.03, 95% confidence interval [CI] 4.56-7.98) and 9.4% a diagnosis of bipolar disorder (HR = 7.85, 95% CI 5.73-10.76) by age 28 years. Younger age of first self-harm presentation was associated with higher risk-for individuals who presented before age 18 years, 29.1% developed a psychotic or bipolar disorder by age 28 years. Young people who present to hospital with self-harm are at high risk of future psychotic and bipolar disorders. They represent an important cohort for the prevention of serious mental illness.

From care to education and work? Education and employment trajectories in early adulthood by children in out-of-home care.

BACKGROUND: Temporal dynamics during the early adulthood transition among children in out-of-home care is a neglected research area, leaving the possibility of coping with childhood adversity over time a poorly understood topic. OBJECTIVE: To explore early adulthood education and employment trajectories among young adults who experienced out-of-home care during childhood and to examine how various care history factors predict these trajectories. PARTICIPANTS: We use longitudinal birth cohort data comprising individual-level information from national registers of all children born in Finland in 1987 (N = 59,476, of whom 1893 were in care). SETTING AND METHODS: We use trajectory clustering from a previous study on the 1987 birth cohort to compare trajectories between children in care and a propensity score-matched group of peers never in care. We investigated the association between care history factors and trajectories with multinomial logistic regression modeling. RESULTS: Compared with the matched peer group, children in care were less likely to enter trajectories characterized by education and employment (38%) and more likely to enter trajectories involving early parenthood (14%) or long periods of fragmented social assistance benefit receipt and unemployment (21%). Those on early parenthood trajectories were almost exclusively women, whereas those receiving social assistance benefits and experiencing unemployment for lengthy periods were mostly men. Entering disadvantaged trajectories was associated with, inter alia, placement as an adolescent, residential care, and aging out of care. CONCLUSION: The study demonstrates the relevance of examining longitudinal trajectories in children in care's early adulthood. Many young adults with care experience need support in education and employment beyond young adult age.