Forensic psychiatry in Finland: an overview of past, present and future.

Despite a recent contrary trend, Finland has been for decades one of the most violent countries in Western Europe. Also, Finland has had one of the highest number of psychiatric beds per capita in Europe, although this, too, has seen a sharp decline. Against this background, among other national idiosyncrasies, Finland has developed its forensic psychiatric services. Here, we describe the legal, organizational and clinical structure of these services, and outline the historical and current issues that have shaped them. Finally, we consider future challenges facing the Finnish forensic service system, as part of wider European and global trends.

Attention-deficit/hyperactivity disorder and risk for psychiatric and neurodevelopmental disorders in siblings.

BACKGROUND: Probands with attention-deficit/hyperactivity disorder (ADHD) are at increased risk for several psychiatric and neurodevelopmental disorders. The risk of these disorders among the siblings of probands has not been thoroughly assessed in a population-based cohort. METHODS: Every child born in Finland in 1991-2005 and diagnosed with ADHD in 1995-2011 were identified from national registers. Each case was matched with four controls on sex, place, and date of birth. The full siblings of the cases and controls were born in 1981-2007 and diagnosed in 1981-2013. In total, 7369 cases with 12 565 siblings and 23 181 controls with 42 753 siblings were included in the analyses conducted using generalized estimating equations. RESULTS: 44.2% of the cases and 22.2% of the controls had at least one sibling diagnosed with any psychiatric or neurodevelopmental disorder (risk ratio, RR = 2.1; 95% CI 2.0-2.2). The strongest associations were demonstrated for childhood-onset disorders including ADHD (RR = 5.7; 95% CI 5.1-6.3), conduct and oppositional disorders (RR = 4.0; 95% CI 3.5-4.5), autism spectrum disorders (RR = 3.9; 95% CI 3.3-4.6), other emotional and social interaction disorders (RR = 2.7; 95% CI 2.4-3.1), learning and coordination disorders (RR = 2.6; 95% CI 2.4-2.8), and intellectual disability (RR = 2.4; 95% CI 2.0-2.8). Also, bipolar disorder, unipolar mood disorders, schizophrenia spectrum disorders, other neurotic and personality disorders, substance abuse disorders, and anxiety disorders occurred at increased frequency among the siblings of cases. CONCLUSIONS: The results offer potential utility for early identification of neurodevelopmental and psychiatric disorders in at-risk siblings of ADHD probands and also argue for more studies on common etiologies.

Relative age within the school year and diagnosis of attention-deficit hyperactivity disorder: a nationwide population-based study.

BACKGROUND: Findings are mixed on the relationship between attention-deficit hyperactivity disorder (ADHD) and younger relative age in the school year. We aimed to investigate whether relative age is associated with ADHD diagnosis in a country where prescribing rates are low and whether any such association has changed over time or relates to comorbid disorders (eg, conduct disorder [CD], oppositional defiant disorder [ODD], or learning disorder [LD]). METHODS: We used nationwide population-based registers to identify all Finnish children born between Jan 1, 1991, and Dec 31, 2004, who were diagnosed with ADHD from age 7 years onwards (age of starting school). We calculated incidence ratios to assess the inter-relations between relative age within the school year, age at ADHD diagnosis, and year of diagnosis (1998-2003 vs 2004-11). FINDINGS: Between Jan 1, 1998, and Dec 31, 2011, 6136 children with ADHD were identified. Compared with the oldest children in the school year (ie, those born between January and April), the cumulative incidence of an ADHD diagnosis was greatest for the youngest children (ie, those born between September and December); for boys the incidence ratio was 1·26 (95% CI 1·18-1·35; p<0·0001) and for girls it was 1·31 (1·12-1·54; p=0·0007). The association between relative age and age at ADHD diagnosis reflected children diagnosed before age 10 years, and the strength of this association increased during recent years (2004-11). Thus, compared with children born between January and April, for those born between May and August, the ADHD incidence ratio was 1·37 (95% CI 1·24-1·53; p<0·0001) and for those born between September and December, the incidence ratio was 1·64 (1·48-1·81; p<0·0001). The relative age effect was not accounted for by comorbid disorders such as CD, ODD, or LD. INTERPRETATION: In a health service system with low prescribing rates for ADHD, a younger relative age is associated with an increased likelihood of receiving a clinical diagnosis of ADHD. This effect has increased in recent years. Teachers, parents, and clinicians should take relative age into account when considering the possibility of ADHD in a child or encountering a child with a pre-existing diagnosis. FUNDING: Academy of Finland, Finnish Medical Foundation, Orion Pharma Foundation, Finnish Cultural Foundation.

Parental psychopathology and offspring attention-deficit/hyperactivity disorder in a nationwide sample.

OBJECTIVE: To study the associations between a wide range of parental psychiatric disorders and offspring attention-deficit/hyperactivity disorder (ADHD). METHOD: This study is based on a nested case-control design. The association between parental registered psychiatric diagnoses and offspring ADHD was examined adjusting for socioeconomic and prenatal factors. Data was linked from Finnish nationwide registers. The cases (n = 10,409) were all the children born between years 1991 and 2005 in Finland and diagnosed with ADHD by the end of 2011. Four controls without ADHD (n = 39,124) were matched for every case by sex, age and place of birth. Main outcomes were adjusted odds ratio (aOR) for parental diagnosis of cases vs controls. Analyses were further stratified by sex. Disorders diagnosed before and after birth were analyzed separately. RESULTS: The odds ratio for ADHD increased when only mother (aOR 2.2, 95% CI 2.0-2.3), only father (aOR 1.7, 95% CI 1.6-1.8) and both parents (aOR 3.6, 95% CI 3.3-4.0) were diagnosed. Maternal diagnosis showed stronger association than paternal. The weight of association between several parental disorders and offspring ADHD were similar. Maternal psychopathology overall showed stronger associations with girls than boys with ADHD. The diagnoses registered after birth did not show stronger association than the diagnoses registered before. CONCLUSIONS: Maternal psychopathology showing stronger association than paternal implies that environmental factors or their interaction with genetic factors partly mediates the risk of parental psychopathology. Similar associations between several maternal psychiatric disorders and offspring ADHD points towards the need for investigating some common mother-related risk factors.

Prenatal smoking exposure and neuropsychiatric comorbidity of ADHD: a finnish nationwide population-based cohort study.

BACKGROUND: Prenatal smoking exposure has been associated with attention-deficit/hyperactivity disorder (ADHD). ADHD is commonly associated with a wide spectrum of psychiatric comorbidity. The association between smoking and neuropsychiatric comorbidity of ADHD has remained understudied. The aim of this study is to examine the association between prenatal exposure to maternal smoking and offspring ADHD, and test whether the smoking-ADHD associations are stronger when ADHD is accompanied by other lifetime neuropsychiatric comorbidities. METHODS: The study is based on a nested case-control design and includes all Finnish singletons born between 1991 and 2005 and diagnosed with ADHD by 2011 (n = 10,132), matched with four controls (n = 38,811) on date of birth, sex and residence in Finland. RESULTS: The risk for ADHD with or without comorbidity was significantly increased among offspring exposed to maternal smoking on adjusting for potential confounders (OR = 1.75, CI 95 % = 1.65-1.86). Compared to the only ADHD cases, subjects with comorbid conduct disorder or oppositional defiant disorder had a significantly stronger association with smoking exposure (OR = 1.80, CI 95 % = 1.55-2.11). CONCLUSIONS: Prenatal smoking represents an important risk factor for the ADHD comorbid with CD/ODD. Further research on the association between prenatal smoking exposure and neuropsychiatric comorbidity of ADHD is needed considering the increased risk among these subjects of an overall poor health outcome as compared to only ADHD. In particular, studies utilizing biomarkers or including subjects with neuropsychiatric conditions with and without comorbid ADHD are needed.

Demographic Characteristics and Psychiatric Comorbidity of Children and Adolescents Diagnosed with ADHD in Specialized Healthcare.

Recent studies have shown an increasing incidence of attention-deficit/hyperactivity disorder (ADHD) among children diagnosed in specialized services. This study aims to describe children with ADHD in Finnish specialized healthcare by reporting the demographic characteristics, time trends in diagnosis, psychiatric comorbidity, and the validity of register-based diagnoses. All the singletons born in Finland between 1991 and 2005 and diagnosed with ADHD by 2011 were identified and their psychiatric comorbidity data was obtained from the Finnish Hospital Discharge Register (FHDR). Parents of 69 patients were interviewed via telephone for a diagnostic validation. A total of 10,409 children were identified with ADHD, with a male: female ratio of 5.3:1 and a psychiatric comorbidity rate of 76.7 %. Of the validation sample 88 % met the diagnostic criteria of ADHD for DSM-IV. There is an increasing trend of ADHD diagnosis among both males and females. Psychiatric comorbidity is common and includes a wide range of disorders among children with ADHD. There was an increase of ADHD diagnoses especially among boys. More attention is needed to detect ADHD among girls in health services. Diagnoses in the FHDR show diagnostic validity and their sociodemographic patterns are in line with previous studies.

Prenatal Maternal Smoking and Tourette Syndrome: A Nationwide Register Study.

This is the first nationwide register-based study to examine the relationship between prenatal maternal smoking and Tourette syndrome. A total of 767 children diagnosed with Tourette syndrome were identified from the Finnish Hospital Discharge Register. Each case was matched to four controls. Information on maternal smoking during pregnancy was obtained from the Finnish Medical Birth Register. Conditional logistic regression models were used for statistical analyses. Prenatal maternal smoking was associated with Tourette syndrome when comorbid with ADHD (OR 4.0, 95 % CI 1.2-13.5, p = 0.027 for exposure during first trimester, OR 1.7, 95 % CI, 1.05-2.7, p = 0.031 for exposure for the whole pregnancy). There was no association between maternal smoking during pregnancy and Tourette syndrome without comorbid ADHD (OR 0.5, 95 % CI 0.2-1.3, p = 0.166, OR 0.9, 95 % CI 0.7-1.3, p = 0.567). Further research is needed to elucidate the mechanisms behind the association between prenatal maternal smoking and Tourette syndrome with comorbid ADHD.

Preterm Birth and Poor Fetal Growth as Risk Factors of Attention-Deficit/ Hyperactivity Disorder.

BACKGROUND: Previous studies have shown an association between prematurity and attention- abstract deficit/hyperactivity disorder (ADHD). Results concerning late preterm infants are controversial, and studies examining fetal growth represented by weight for gestational age are scarce. Our objective was to examine the association between gestational age by each week of fetal maturity, weight for gestational age, and ADHD. METHODS: In this population-based study, 10 321 patients with ADHD, diagnosed according to the International Classification of Diseases and 38 355 controls individually matched for gender, date and place of birth, were identified from Finnish nationwide registers. Perinatal data were obtained from the Finnish Medical Birth Register. Conditional logistic regression was used to examine the association between gestational age, weight for gestational age, and ADHD after controlling for confounding factors. RESULTS: The risk of ADHD increased by each declining week of gestation. The associations were robust after adjusting for confounders. An elevated risk also was seen among late preterm and early term infants. As for fetal growth, the odds ratio showed a U-shaped curve with an increased risk seen when the weight for gestational age was 1 SD below and 2 SD above the mean. CONCLUSIONS: Our findings suggest that each gestational week has significance for child's subsequent neurodevelopment and risk for ADHD. We also showed that poor fetal growth increased the risk of ADHD. This highlights the importance of taking into account both prematurity and poor fetal growth when planning the timing of birth as well as later follow-up and support policies.

Parental age and the risk of attention-deficit/hyperactivity disorder: a nationwide, population-based cohort study.

OBJECTIVE: An increasing number of studies has shown an association between parental age and psychiatric disorders. However, there are inconsistent results regarding whether age at parenthood is associated with attention-deficit/hyperactivity disorder (ADHD). The aim of this study is to examine whether low or advanced parental age is associated with ADHD. METHOD: In this nested case-control study, we identified 10,409 individuals with ADHD born in Finland during 1991 to 2005 and diagnosed with ADHD between 1995 and 2011, along with 39,125 controls matched on sex, date, and place of birth, from nationwide population-based registers. Conditional logistic regression was used to examine the association between parental age and ADHD in offspring, adjusting for potential confounding due to parental psychiatric history, maternal socioeconomic status, marital status, maternal smoking during pregnancy, number of previous births, and birth weight for gestational age. RESULTS: Fathers younger than 20 years had a 1.5-fold (odds ratio [OR] = 1.55, 95% CI = 1.11-2.18, p = .01) increased risk of having offspring with ADHD as compared to fathers aged 25 to 29 years. Mothers of the same age group had a 1.4-fold (OR = 1.41, 95% CI = 1.15-1.72, p =.0009) increased risk. Advanced maternal age was inversely associated with ADHD (OR = 0.79, 95% CI = 0.64-0.97, p = .02). CONCLUSION: ADHD was associated with young fathers or mothers at the time of birth. Health professionals working with young parents should be aware of the increased risk of ADHD in offspring. This will improve early detection; however, for the development of preventive measures and appropriate interventions, more information on the developmental pathways is needed.

Treatment costs and productivity losses caused by traumatic brain injuries.

OBJECTIVE: To estimate the magnitude and relative importance of hospital treatment costs and productivity losses caused by traumatic brain injuries (TBIs). PATIENTS: A total of 155 patients with new TBI diagnoses admitted to Turku University Hospital were systematically sampled. METHODS: Hospital costs were determined by collecting detailed data from patient records and applying the actual cost from the hospital administration. For estimating the productivity losses, the age of retirement was adjusted according to the age- and sex-specific retirement probability. RESULTS: Median treatment costs per TBI patient were €5429, surgery €1600 and other costs €3651. Overall treatment costs for severe brain injuries were significantly (p < 0.01) higher than for less severe cases. Median production losses due to early retirement were estimated to be €1.19 million per TBI patient, significantly (p < 0.03) lower among less severe than among the severe cases. Age, sex and severity of TBI could explain only 9% of the variation in treatment costs, but explained 73% of the variation in production losses. CONCLUSIONS: Indirect productivity losses form the great majority of the overall economic burden of TBI to society. The direct treatment costs in tertiary level hospitals also impose a considerable burden on the healthcare sector.