Early emotional and behavioural problems predict use of habilitation services among children: Findings from a longitudinal follow-up study.

PURPOSE: To explore the association between early emotional and behavioural problems and use of habilitation services among children in Sweden. METHODS: In this longitudinal cohort study, we used data on children, 3-5 years of age, whose mothers (n = 7343) and fathers (n = 6322) had responded to the Strengths and Difficulties Questionnaire (SDQ) for assessment of emotional and behavioural problems, and who were followed for approximately 6.5 years with regard to use of habilitation services. The relations between emotional and behavioural problems and use of habilitation services were explored through cox regression models. RESULTS: In unadjusted models, children with identified emotional and behavioural problems were more likely to utilise habilitation services compared to those with no identified problems. These associations were shown for both mothers' (HR: 5.02) and fathers' (HR: 4.25) SDQ ratings. In adjusted cox-regression models, the associations remained significant for both mothers' (AHR: 4.24) and fathers' (AHR: 4.03) ratings. CONCLUSIONS: Early emotional and behavioural problems predict later habilitation service use among children in Sweden. Assessment of these problems in all children at child health services could facilitate early identification and timely interventions. Habilitation centres in Sweden could integrate mental health care into the standard treatment for children using these services.

"Daddy comforts me"-Young Swedish children's perspectives on their family relations before and after their parents' participation in a parenting programme.

Despite extensive research assessing parenting support, there is a lack of knowledge about the perspectives of the youngest children. In this study, we explored changes in preschool children's emotional and relational experiences at home before and after their parents participated in a parenting intervention, the Triple P parenting programme. Nine children in total were interviewed, aged 3-6 years, whose parents participated in a group parenting intervention. The interviews were conducted during the first and final group sessions attended by the children's parents. Data were analysed qualitatively, using a longitudinal approach, resulting in a deductive mapping of the children's statements onto four themes, based on the parenting intervention's main objectives. Further, changes in content for each of the four themes were assessed. Before the programme, children described conflicts with siblings, parents' negative emotions, and punitive parenting behaviours. After the programme, sibling conflicts remained, but parents' negative emotions decreased and parent threats and violence ceased. Positive family interactions and quality time increased, along with experiences of tenderness and being comforted. Parents also implemented new strategies such as verbal management and more comforting or soothing behaviours. Clinical implications of the results include promoting positive sibling relationships, emphasising parental self-regulation, encouraging empathy and reconciliation, and highlighting the importance of spending quality time with children. These findings contribute to a better understanding of children's perspectives and provide implications for clinical practice and future research.

Implementation of the Infant-Toddler Checklist in Swedish child health services at 18 months: an observational study.

BACKGROUND: Communication and language disorders are common conditions that emerge early and negatively impact quality of life across the life course. Early identification may be facilitated using a validated screening tool such as the Infant-Toddler Checklist (ITC). We introduced the ITC at the 18-month visit to child health services (CHS) in a Swedish county. Using the RE-AIM implementation framework, this study assessed the implementation of the ITC according to five key dimensions: reach, effectiveness, adoption, implementation and maintenance. METHODS: This observational study used medical records at CHS as data source. Data were collected from children who visited a child health nurse at 17-22 months. The sample included 2633 children with a mean age of 17.8 months, 1717 in the pre-implementation group and 916 in the post implementation group. We calculated the ITC completion rate (reach) and use at each site (adoption). We compared rates of referral to speech and language therapy (effectiveness) before and after implementation of the ITC using OR and 95% CIs. We described actions to facilitate implementation and maintenance of ITC screening over time. RESULTS: The overall screening rate was 93% (reach) which increased from 80% initially to 94% at the end of the 2-year period (maintenance). All centres used the ITC (adoption). The ITC screen positive rate was 14%. Of children who had reached at least 24 months (n=2367), referral rate was 0.4% pre-implementation versus 6.9% post implementation (OR=18.17, 95% CI 8.15, 40.51, p<0.001) (effectiveness). Implementation strategies included training sessions, collaboration, written and automatic procedures and modifications to the medical records system. CONCLUSION: The implementation of the ITC was associated with high reach, higher referral rate, complete adoption, and sustained maintenance over time.

A higher proportion of children aged 4 years were referred to speech and language therapists after the introduction of a new language screening tool.

AIM: Language difficulties in children can have enduring impacts on their academic and emotional well-being. Consequently, early identification and intervention are critical. This study aimed to investigate the impact of introducing Språkfyran, a language screening tool, on the identification and referral rates for speech and language assessment compared to the previous method. METHODS: An observational study was conducted in Gotland, Sweden, using the medical records of 3537 children (53% boys) who were 3-4 years of age. The study period lasted between 5 January 2016 and 29 April 2022, encompassing data collection both before and after the introduction of Språkfyran. RESULTS: Following the introduction of Språkfyran, 15% failed the screening, compared to 20% with the previous speech test. However, referrals for assessment increased significantly with Språkfyran, rising to 7% compared to 3% with the speech test. CONCLUSION: The proportion of children who failed the Språkfyran screening was consistent with findings from previous studies. Children who failed the screening were more likely to be referred for speech and language assessment after the introduction of Språkfyran. This indicates that Språkfyran is a clinically relevant tool that promotes children's language development through increased referral rates.

Preschool-level socio-economic deprivation in relation to emotional and behavioural problems among preschool children in Sweden.

AIMS: The aim of this study was to explore the association between preschool-level socio-economic deprivation and emotional and behavioural problems among preschool children in Sweden using a multilevel approach. METHODS: In this cross-sectional study, we used data on 2267 children whose parents and preschool teachers had responded to items measuring individual-level socio-economic deprivation and the Strengths and Difficulties Questionnaire (SDQ) for assessment of emotional and behavioural problems. Further, the Socioeconomic Structure Compensation Index (SSCI), collected from Uppsala municipality, was used to assess preschool-level socio-economic deprivation. Unadjusted and adjusted multilevel logistic regression models were used to explore the relations between preschool-level socio-economic deprivation and emotional and behavioural problems. RESULTS: In unadjusted models, children who attended preschools classified as highly deprived had elevated odds for emotional symptoms (odds ratio (OR) 1.71) as rated by parents. However, this association did not remain significant after adjusting for individual-level socio-economic deprivation factors. In both unadjusted and adjusted models, children who attended preschools classified as moderately deprived had elevated odds for peer-relationship problems as rated by parents (OR 1.63; adjusted OR 1.48). There were no significant associations between preschool deprivation and emotional and behavioural problems as rated by preschool teachers. CONCLUSIONS: Swedish preschools may have a compensatory capacity in addressing children's emotional and behavioural problems, whereas preschool-level deprivation remained significantly associated with peer-relationship problems after controlling for individual-level socio-economic deprivation factors. This implies that peer-relationship problems in deprived preschools need to be addressed in a broader community context.

Parental burnout among Somali mothers: Associations with mental health, perceived social support, and sociodemographic factors.

Parenthood can be defined by the contradiction that it is one of the most satisfying yet stressful experiences in life. Many parents experience stress during parenthood, and some to the extent that they display symptoms of parental burnout. Nevertheless, research on parental burnout is scant and many studies have only examined the condition in Western settings. The aim of this study was to examine parental burnout among Somali mothers in Mogadishu, Somalia, and its association with certain psychological, psychosocial, and sociodemographic factors. In this cross-sectional study, questionnaire data were collected through the measurements Parental Burnout Assessment and Patient Health Questionnaire 9, as well as through social and demographic questions. A total of 882 Somali mothers in Mogadishu participated. The analysis methods used were univariate, bivariate, and multiple linear regression analysis. The results revealed that the mean parental burnout score was low in the sample. Additionally, a significant association was found between higher levels of parental burnout and higher levels of depression, perceived lack of social support, being unmarried, having a low monthly household income, and when the youngest child was of school-age.

Are We Ready to Really Hear the Voices of Those Concerned? Lessons Learned from Listening to and Involving Children in Child and Family Psychology Research.

A changing view of children, accelerated by the Convention of the Rights of the Child (UN in Convention on the rights of the child, UN Doc. A/RES/44/25, 1989, http://www2.ohchr.org/english/law/pdf/crc.pdf ) has shifted the landscape of child and family research over the last few decades. Once viewed with low credibility and operating outside the interpretive framework of adult researchers, the rights-bearing child is increasingly recognized not only as having the capacity but also the right to participate in research. More recently, this movement has transitioned from the direct engagement of children as research participants-now considered commonplace, although less so for those who are structurally vulnerable-to the involvement of children in research design, review, conduct, and dissemination. Yet, both practical and ethical challenges remain. While children have the right to participation, they also have the right to protection. In this commentary, we set out to: (i) lay forth epistemic, child rights, and child sociology arguments for doing research about, with and by children and youth; (ii) recount our own journey of including children and youth in research to demonstrate the unique knowledge and insights gained through these approaches; and (iii) offer lessons learned on how to engage children and youth in research, including the involvement of structurally vulnerable groups.

Successful implementation of parenting support at preschool: An evaluation of Triple P in Sweden.

Although emotional and behavioural problems among young children are common and, if unaddressed, can lead to multi-facetted problems later in life, there is little research investigating the implementation of parenting programs that target these problems. In this study, the RE-AIM framework was used to evaluate the implementation of the Triple P parenting program in a preschool setting at a medium-sized municipality in Sweden. Reach increased over time, showing an overall increase in participating fathers and parents with lower education. Effectiveness outcomes showed an improvement in emotional and behavioural problems in children and less mental health-related symptoms and higher self-efficacy in parents. Adoption rate was 93.3%. To ensure staff "buy-in", designated coordinators made changes in recruitment procedures, and provided supervision and training to all Triple P practitioners. Implementation adaptations were made, such as minor revisions of parenting strategies and other program content, as well as providing child care during seminars and groups, and setting up weekend-groups. Maintenance assessed through 12 month follow-up data suggested that several child and parent outcomes were maintained over time. Uppsala municipality continues to offer Triple P to parents. The reach, effectiveness, adoption, implementation and maintenance of the program were all satisfactory and demonstrated the suitability of delivering evidence-based parenting support using preschools as an arena.

Retinal surgery quality indicators for uncomplicated primary rhegmatogenous retinal detachment without a national registry.

PURPOSE: The objective of this study was to evaluate the possibility of analysing quality indicators for uncomplicated primary rhegmatogenous retinal detachment in a hospital department of ophthalmology without the support of a national registry or need to collect data from referring ophthalmological centres. METHODS: In 2014, we operated 231 consecutive eyes with uncomplicated retinal detachment. Our quality indicators were primary anatomical success, final anatomical success and postoperative endophthalmitis. We reviewed medical records in our university surgical department retrospectively and compared them with medical records from the regional hospitals that had referred most of the operated patients and done their own postoperative examination. Our hypothesis was that any retinal re-detachment and/or serious postoperative complication would be reported back. RESULTS: The medical records at the surgical department revealed primary anatomic success for 91.3% of eyes and final anatomical success of 99.6%. The data from the regional hospitals confirmed that our hypothesis was correct. All patients with adverse outcomes were referred back for reoperation. Patients who were not referred again had an attached retina and showed no signs of endophthalmitis. CONCLUSION: Our hypothesis that data in the surgical department's medical records would closely reflect those in referring hospitals was borne out. This supports, under current conditions, an effective strategy for analysing chosen quality indicators without relying on a national registry or reviewing records from regional hospitals.

An Integrated Care Strategy for Pre-schoolers with Suspected Developmental Disorders: The Optimus Co-design Project that has Made it to Regular Care.

INTRODUCTION: Multiple neurodevelopmental problems affect 7-8% of children and require evaluation by more than one profession, posing a challenge to care systems. DESCRIPTION: The local problem comprised distressed parents, diagnostic processes averaging 36 months and 28 visits with 42% of children >4 years at referral to adequate services, and no routines for patient involvement. The co-design project was developed through a series of workshops using standard quality improvement methodology, where representatives of all services, as well as parents participated.The resulting integrated care model comprises a team of professionals who evaluate the child during an average of 5.4 appointments (N = 95), taking 4.8 weeks. Parents were satisfied with the holistic service model and 70% of children were under 4 at referral (p < 0.05). While 75% of children were referred, 25% required further follow-up by the team. DISCUSSION: The Optimus model has elements of vertical, clinical and service integration. Reasons for success included leadership support, buy-in from the different organisations, careful process management, a team co-ordinator, and insistent user involvement. CONCLUSION: Evaluating multiple neurodevelopmental problems in children requires an integrated care approach. The Optimus care model is a relevant showcase for how people-initiated integrated care reforms can make it into usual care.

Infant-Toddler Checklist identifies 18-month-old children with communication difficulties in the Swedish child healthcare setting.

AIM: At present, there is no reliable method to screen for communication difficulties at age 18-months in the Swedish child health care. This study examined the psychometric properties of the Communication and Symbolic Behavior Scales Developmental Profile Infant-Toddler Checklist (ITC) when used at the 18-month visit in the child healthcare setting. METHODS: Children aged 16-20 months (n = 679) were screened. Children were referred for an assessment if they screened positive screen or if the parent or nurse was concerned about the child's communicative development. Two groups of positive screens were used in the analysis (n = 78 children), one based on the ITC result, and one combining the ITC with contradicting information from the nurses' informal clinical assessment. RESULTS: The AUC ranged from 0.68 to 0.84. The sensitivity was 0.85, and the specificity was 0.59. When the ITC result was combined with the nurses' information, sensitivity increased to 0.88 and specificity to 0.63. The internal consistency was moderate to high, and fit indices were satisfactory. CONCLUSION: The results suggest that the ITC can be used to identify children in need of interventions to enhance communication at 18 months of age, especially in combination with the nurse's assessment.

Asthma and allergies correlate with mental health problems in preschool children.

AIM: To explore the relations between asthma, allergies and mental health problems in preschool children, aged 3-5 years. METHODS: In this cross-sectional Swedish study, we used data on 4649 children in Uppsala municipality whose parents and preschool teachers had responded to questions measuring asthma and allergies, and the Strengths and Difficulties Questionnaire (SDQ) for assessment of mental health problems. Logistic regression models were used to explore the relations between asthma and allergies and mental health problems. RESULTS: Children with asthma (8.5%) had elevated odds of having emotional symptoms as rated by parents (OR: 1.34; 1.02-1.76) and teachers (OR: 1.44; 1.09-1.91). According to parents' ratings, these children also had elevated odds of showing mental health problems in general according to the SDQ total score (OR: 1.42; 1.05-1.94). Children with food allergies or intolerance (4.4%) only had elevated odds of having emotional symptoms (OR: 1.64; 1.16-2.33), as reported by parents. These results remained significant after adjustment for parental background factors. CONCLUSION: Preschool children with asthma and food allergies or intolerance are at risk of having concurrent mental health problems. Mental health problems should be assessed in children with these disorders. Adequate support and/or referral to specialised services should be offered when needed.

Swedish norms for the Strengths and Difficulties Questionnaire for children 3-5 years rated by parents and preschool teachers.

The Strengths and Difficulties Questionnaire (SDQ) is a widespread tool for assessing behavior problems in children and adolescents. Despite being investigated thoroughly concerning both validity and reliability, peer reviewed studies that provide norms, especially for preschool children, are lacking. This paper provides Swedish norms using data from a large community sample of children aged 3-5, based on mothers', fathers', and preschool teacher's ratings. Preschool teachers' ratings were generally lower than parents' ratings, which contradicts some previous studies. Differences between girls and boys were found, suggesting that boys display higher levels of behavior problems. Lower parental education and country of origin outside of Sweden were also associated with more difficulties. Cut-offs are presented for each age group, gender and rater category. Population-specific norms and percentile cut-offs provided in this study facilitate identifying children in need of interventions in paediatric care and enable cross-country comparisons of children's mental health problems.

SDQ in the Hands of Fathers and Preschool Teachers-Psychometric Properties in a Non-clinical Sample of 3-5-Year-Olds.

The Strengths and Difficulties Questionnaire (SDQ) is a well-established instrument for measuring social and behavioural problems among children, with good psychometric properties for older children, but less validity reports on pre-schoolers. In addition, there is a knowledge gap concerning fathers as informants. The present work is one of the few validity studies to include preschool teachers and the first on preschool children where fathers are included as separate informants. In this study, SDQs were collected from a large community sample (n = 17,752) of children aged 3-5, rated by mothers, fathers, and preschool teachers and analysed using confirmatory factor analysis. Our results revealed acceptable fit for all informant groups and measurement invariance across child gender, child age, and parental education level. Our findings suggest good construct validity of the SDQ for a non-clinical preschool population and imply that it may be used for assessing child behaviour problems from different informant perspectives.

In My Shoes - Validation of a computer assisted approach for interviewing children.

Interviewing young children presents a challenge because they tend to provide incomplete accounts and are easily misled. Therefore there is a need for techniques to improve young children's recall, while maintaining accuracy and increasing completeness. The computer-assisted interview In My Shoes (IMS) is an aid that potentially offers a way for young children to provide accounts of their experiences. This study examined the validity of IMS, by comparing it with a forensic best practice interview approach using a real-life clinical situation to ensure high ecological validity. Children were randomly assigned to either method and both accuracy and completeness of statements made by 4- and 5-year-olds (N=54) regarding a video-documented health check-up were assessed. The In My Shoes interviews were as good as best practice interviews on all accuracy measures for both age groups, except for object accuracy that was better in the forensic interview condition. Events description completeness was similar in both interview conditions; however, IMS interviews generated more complete statements about people present at the visit. The findings suggest that the IMS approach yields comparable results to a best practice interview, and it can be used as an alternative aid in child interviews.