Effects of individual differences, society, and culture on youth-rated problems and strengths in 38 societies

BACKGROUND

Clinicians increasingly serve youths from societal/cultural backgrounds different from their own. This raises questions about how to interpret what such youths report. Rescorla et al. (2019, European Child & Adolescent Psychiatry, 28, 1107) found that much more variance in 72,493 parents' ratings of their offspring's mental health problems was accounted for by individual differences than by societal or cultural differences. Although parents' reports are essential for clinical assessment of their offspring, they reflect parents' perceptions of the offspring. Consequently, clinical assessment also requires self-reports from the offspring themselves. To test effects of individual differences, society, and culture on youths' self-ratings of their problems and strengths, we analyzed Youth Self-Report (YSR) scores for 39,849 11-17 year olds in 38 societies.

METHODS

Indigenous researchers obtained YSR self-ratings from population samples of youths in 38 societies representing 10 culture cluster identified in the Global Leadership and Organizational Behavioral Effectiveness study. Hierarchical linear modeling of scores on 17 problem scales and one strengths scale estimated the percent of variance accounted for by individual differences (including measurement error), society, and culture cluster. ANOVAs tested age and gender effects.

RESULTS

Averaged across the 17 problem scales, individual differences accounted for 92.5% of variance, societal differences 6.0%, and cultural differences 1.5%. For strengths, individual differences accounted for 83.4% of variance, societal differences 10.1%, and cultural differences 6.5%. Age and gender had very small effects.

CONCLUSIONS

Like parents' ratings, youths' self-ratings of problems were affected much more by individual differences than societal/cultural differences. Most variance in self-rated strengths also reflected individual differences, but societal/cultural effects were larger than for problems, suggesting greater influence of social desirability. The clinical significance of individual differences in youths' self-reports should thus not be minimized by societal/cultural differences, which-while important-can be taken into account with appropriate norms, as can gender and age differences.

Safeguarding Children Subjected to Violence in the Family: Child-Centered Risk Assessments

Assessing risk, planning for safety and security, and aiding recovery for children subjected to violence in a family setting is a complex process. The aim of the article is to synthesize the current research literature about risks for children subjected to violence in the family and outline an empirical base for a holistic and practically usable model of risk assessments placing the individual child at the center. Such assessments need to recognize four different areas of risk: (1) child safety, i.e., known risk factors for severe and dangerous violence aimed at both adults and children and how they play out in the individual case; (2) the child's response in situations with violence; (3) the child's perspective, especially fear and feelings of powerlessness in situations with violence; (4) developmental risks, e.g., instability in the child's situation and care arrangements, lack of a carer/parent as a "secure base" and "safe haven", the child developing difficulties due to the violence (e.g., PTSD), problems in parents' caring capacities in relation to a child with experiences of, and reactions to, violence, and lack of opportunities for the child to make sense of, and create meaning in relation to, experiences of violence. In addition to the four areas of risk, the article emphasizes the importance of assessing the need for immediate intervention and safety planning in the current situation as regards safety, the child's responses, the child's perspectives, and long-term developmental risks.

Child Psychiatric Patients Exposed to Intimate Partner Violence and/or Abuse: The Impact of Double Exposure

Children's exposure to intimate partner violence (IPV) and child abuse (CA) is strongly related to later psychological problems. Few studies exist on patients in child and adolescent mental health services (CAMHS) who have been singly or doubly exposed to IPV and/or CA. The overall aim of the current study was to compare self-reported psychiatric symptoms, post-trauma impact, and post-traumatic stress disorder (PTSD) diagnoses among CAMHS patients who had been singly or doubly exposed or had reported no family violence (NoFV). We expected to find more severe symptoms in both singly and doubly exposed patients than in the NoFV group and that double exposure was associated with more severe symptoms than single exposure (to IPV or CA). Finally, we expected to find that higher frequencies of exposure to IPV or CA were related to more psychiatric symptoms, greater post-trauma impact, and a higher likelihood of PTSD diagnosis. We compared psychiatric symptoms, post-trauma impact, and PTSD diagnosis in 578 patients aged 9-17 years with NoFV (n = 287), single exposure (n = 162), and double exposure (n = 129). The influence of gender, age, age of onset, frequency, and traumatic interpersonal events outside the family (IPE) were regressed on psychiatric symptoms, post-trauma impact, and PTSD diagnoses. Patients with double exposure had more severe symptoms than the NoFV group, and patients with single exposure had more trauma-related symptoms than the NoFV group. Double exposure was associated with more severe symptoms than single exposure, and frequency (of exposure to IPV and/or CA) and IPE influenced trauma symptoms and psychiatric symptoms, respectively. Exposure to more than one type of violence is associated with more severe symptoms, but other factors such as frequency of violent acts and IPE are important factors to focus on in future studies and clinical assessment.

Parenting programs during adolescence: Outcomes from universal and targeted interventions offered in real-world settings

The aim of this naturalistic study was to explore short and long-term outcomes of five different group-based parenting programs offered to parents of 10 to 17-year-olds. Three hundred and fifteen parents (277 mothers and 38 fathers) who had enrolled in a parenting program (universal: Active Parenting, COPE; Connect; targeted: COMET; Leadership training for parents of teenagers [LFT]) answered questionnaires at three measurement waves (baseline, post-measurement, and one-year follow-up). The questions concerned parenting style, parental mental health, family climate and adolescent mental health. Results revealed small to moderate changes in almost all outcome variables and in all parenting programs. Overall, parents in COMET reported the largest short and long-term changes. No substantial differences in change were seen between the other programs. The results support the general effectiveness of parenting programs for parents of adolescents.

Family Violence and Other Potentially Traumatic Interpersonal Events Among 9- to 17-Year-Old Children Attending an Outpatient Psychiatric Clinic

Among children visiting child and adolescent mental health care (CAM), the prevalence of exposure to family violence (FV) is reported to exceed prevalence in community samples, as are potentially traumatic interpersonal events (IPE) outside the family. The aim of the study was to relate CAM patients' self-reported experiences of violence exposure to their current psychiatric symptoms and to compare patients exposed to violence with patients who reported no exposure. We asked 305 consecutive 9- to 17-year-old patients in CAM about their current and previous exposure to violence in and outside of the family. Prevalence of exposure to any kind of violence was 67%. Reported exposures were 19% to IPE, 21% to FV, and 27% to both. Children exposed to both FV and IPE were more negatively affected by the events than children exposed to FV or IPE only. Children in the FV + IPE group reported more mental health symptoms than those in the no violence (33%) group. In general, IPE was related to the outcome measures only in combination with FV. Degree of violence exposure seemed to have a dose-response relationship with the diagnosis of post-traumatic stress disorder.

Personality Development between 1 and 8 Years of Age in Swedish Children with Varying Child Care Experiences

In this longitudinal study, 122 Swedish children were followed from an initial assessment at 16 months until they were 8.5 years of age. Parental ratings of field independence, ego-resilience, and ego-control were obtained using the California Child Q-set when the children averaged 28, 40, 80, and 101 months of age. These assessments of personality were then examined in the context of contrasting child care experiences. There was virtually no difference between the developmental trajectories of the children in home care and in centre-based day care. In contrast, ego-undercontrol decreased less, whereas ego-resilience and field independence increased less, in children who attended family day care than in the children in either centre care or exclusive parental care. The quality of home and out-of-home care, as well as socioeconomic status and family background, did not moderate or qualify these effects of the type of care experienced. The results are discussed in relation to previous work on the effects of early out-of-home care on child development.

Aggression and Noncompliance among Swedish Children in Centre-based Care, Family Day Care, and Home Care

The relations between individual, family, and child care characteristics and children's aggressive and noncompliant behaviours were examined in this study of 140 first-born Swedish children assessed at 16,28,40, and 80 months of age. All of the parents involved in the study had attempted to enrol their children in centre-based day care, but some were accepted instead into family day care settings, while others remained in the exclusive care of their parents. Composite measures of aggression and noncompliance were constructed using data obtained from multiple sources (i.e. mothers, teachers, observers). Child care arrangements and histories were not associated with levels of aggression or noncompliance. Multiple regression analyses suggested that the quality of home care was the best predictor of both aggressive and noncompliant behaviour. Boys were more aggressive than girls, and children with more controlling parents were more noncompliant. Individual differences in aggression (but not noncompliance) were moderately stable over time. Aggression and noncompliance were modestly but reliably related to one another. These results suggest that alternative care of high quality does not lead to noncompliance and aggression.

Traumatic and Adverse Attachment Childhood Experiences are not Characteristic of OCD but of Depression in Adolescents

We investigated whether adverse attachment experience might contribute to the development of obsessive-compulsive disorder (OCD). We interviewed 100 adolescents, 25 each with primary OCD, depressive disorder (DD), OCD plus DD and general population controls (CTRs) using the adult attachment interview to assess attachment experiences (AEs), including traumatic and adverse AE (TAE). Adolescents with OCD, OCD+DD and DD had little evidence of secure base/safe haven parental behaviour and their childhood attachment needs judged to be rejected as compared to the controls. Overprotection was not characteristic of OCD, and parents using the child for their own needs (elevated levels of involving/role reversal) occurred only in DD, with low levels in OCD, OCD+DD and CTR. Traumatic experiences, often multiple, and/or attachment related were reported significantly more often in the DD group, and was less common in OCD+DD, CTR and particularly in the OCD group. In OCD, little TAE was reported and adverse AE were less serious and seem unlikely to contribute directly to OCD aetiology. In DD and to some degree in OCD+DD serious AE/TAE may have some etiological significance for the depressive states.

An explorative analysis of the recruitment of patients to a randomised controlled trial in adolescents with dental anxiety

Randomised controlled trials (RCTs) are considered to provide the most reliable evidence on the efficacy of interventions. The aim of this study was to describe the recruitment process of an RCT study set up to evaluate a Cognitive Behavioural Therapy (CBT) intervention programme for adolescent patients with dental anxiety (DA). The participants were recruited from a consecutive sample of adolescent patients (12-19 yrs old) referred for DA to a specialised pediatric dentistry clinic. Age, gender, and reason for referral were recorded for the possible eligible patients as part of the drop-out analysis of the recruitment process. Participants were then randomized to the intervention (CBT integrated with dental treatment) or control (adapted dental treatment) condition. In the recruitment process, 138 possible eligible patients met inclusion criteria, of these 55 were enrolled, 44 declined participation and 39 patients were excluded.The patients enrolled in the RCT did not differ from the non-participants with regard to age, gender or cause of referral. As a result of difficulties in the recruitment process, the study period was extended. The considerable proportion of non-participants as evident from the recruitment process may pose a threat to the external validity of the clinical trial. From a clinical perspective, the reasons for the lack of motivation to participate in behavioural interventions and the failure to appear warrant further investigation.

Children exposed to intimate partner violence and the reported effects of psychosocial interventions

Using a repeated measures design posttraumatic stress (PTS), psychological and behavioral problems significantly decreased following intervention in children exposed to intimate partner violence (IPV), with use of traditional group analyses. Analyses using the reliable change index (RCI), however, revealed that few children were improved or recovered, implying that interventions in common use should be evaluated for their significant impact on the individual level in addition to group level statistics. Positive changes in children's behavioral problems were related to the mother's improvement of their own mental health. Direct victimization by the perpetrator was not associated with treatment changes but with higher symptom levels at study entry. Amount of contact with the perpetrator was neither related to symptom load nor to changes following treatment.

Evaluation of "the incredible years" in Sweden: the transferability of an American parent-training program to Sweden

Structured parent training has been proven to be effective in reducing disruptive behavior problems (DBP) in children. Most of the programs that are used in Sweden have their origin in North America, and there is an ongoing debate over the transferability to Sweden of manual-based programs developed in other contexts. The goal of the present study was to study effectiveness of the Incredible Years parent-training program (IY), developed in the US, in regular clinical work in Sweden, using a randomized controlled design. Parents of 62 four to eight-year-old children diagnosed with Oppositional Defiant Disorder participated in the study. Parents of 38 children were assigned to parent training (PT) and 24 to a waiting list (WL). The results indicate that the IYS retains the positive effects on children's disruptive behavior problems when translated and transferred to Swedish. There was a statistically significant difference in reduction of DBP in children between the groups in favor of the PT. The improvement in the PT group was sustained at the one-year follow-up. The improvement also, at least to some extent, generalized over time to the school context. There was also a statistically significant difference in mothers' report of pre to post change in parenting alliance between the PT and WL groups. The IYS program was appreciated and well received by the participating mothers.

Maternal report on child outcome after a community-based program following intimate partner violence

BACKGROUND

This study examined the perceived effectiveness of a 15-week community-based program for 46 children exposed to intimate partner violence (IPV) and their mothers.

AIMS

The primary aims were to describe the children who entered one of the existing community-based programs in terms of behavioral problems and to evaluate the impact of the program on children's general behavioral functioning as assessed by their mothers.

RESULTS

Children's rated behavioral problems (SDQ) dropped following treatment; the effect size was in the medium range. The social impairment caused by the problems decreased as well. The effect regarding behavioral problems was not related to the degree of exposure to IPV or the mothers own changes in trauma symptoms following treatment. Results were analyzed as well at the individual level with the Reliable Change Index (RCI), which showed that the majority of children were unchanged following treatment.

CONCLUSIONS

One implication from the study is the need for baseline screening and assessment. About half of the current sample had a clinical symptom picture indicating the need for specialized psychiatric/psychotherapeutic treatment. Furthermore, the reduction in behavioral problems was significant but many children still had high levels of behavioral problems after treatment, indicating a need of a more intense or a different type of intervention.

Five Facets Mindfulness Questionnaire--reliability and factor structure: a Swedish version

Two studies were conducted to assess the Swedish version of the Five Facets Mindfulness Questionnaire (FFMQ), which was originally created by Baer et al. (2006). The aim of Study 1 was to examine the psychometric properties of the FFMQ using data from 495 individuals. Quantitative and qualitative analyses resulted in a reduction of the scale by 10 items. Psychometric properties, including internal consistency of the revised instrument, were examined. The Swedish FFMQ provides results comparable to those obtained by Baer. Cronbach's alphas were high for all the facets. The Swedish FFMQ appears to be a potentially useful tool in measuring mindfulness among Swedish participants. The aim of Study 2 was to test the suggested hierarchical five-factor solution and construct validity, using a confirmatory factor analysis (CFA). Similar to findings for the English version of the FFMQ, the CFA showed that the Observing facet was not a significant part of an overall self-reported mindfulness structure in a Swedish population with little meditation experience.

Theoretical orientation and therapists' attitudes to important components of therapy: a study based on the valuable elements in psychotherapy questionnaire

The authors describe the inception and subsequent testing of a questionnaire on attitudes regarding how psychotherapy ought to be pursued: the Valuable Elements in Psychotherapy Questionnaire (VEP-Q). A sample of 416 Swedish therapists (161 psychodynamic, 93 cognitive, 95 cognitive behavioral, and 67 integrative/eclectic) responded to the 17-item VEP-Q. A factor analysis of these items resulted in three subscales: PDT, CBT, and Common Factor, as validated by analyses of covariance. The internal consistency and test-retest reliability of the scales were excellent. In addition to theoretical orientation, variables such as gender and basic professional training influenced how respondents answered the VEP-Q. The authors conclude that the VEP-Q seems to be an appropriate instrument for describing similarities as well as differences among practitioners of various schools of psychotherapy.

Young children traumatized by organized violence together with their mothers – The critical effects of damaged internal representations

Three examples of young Kosovar children who were exposed to brutal violence together with their mothers are presented to illustrate how important it is to understand the impact of traumatic events on young children's development from the perspective of the parent-child relationship. The traumatized mothers' internal representations of self and self-being-together-with-child were damaged, and this in turn led to their care-giving system and internal representations of the children being negatively affected. No longer being able to see themselves as protective and loving parents, the mothers were unable to respond to their children with care-giving behaviour. The traumatized children's increased attachment behaviour and posttraumatic symptoms functioned as a trigger for posttraumatic symptoms in the mothers and contributed to a disengagement of the care-giving system. The on-going process disrupted the previous attachment pattern in mother-child interaction and a disorganized attachment pattern developed.

Heritability of dental fear

The objective was to test a hypothesized genetic component (i.e., monozygotic being more similar compared with dizygotic twins) in dental fear/anxiety by comparing the probandwise concordance. We analyzed data based on a dichotomous measure of Dental Fear/Anxiety and a continuous measure of Dental Fear Intensity from over 2000 twins, collected when participants were 13-14 years old and once again three years later. The hypothesis was confirmed, but heritability of Dental Fear/Anxiety was estimated to be higher for girls (0.77 at time 1 and 0.55 at time 2) than for boys (0.14 and 0.0 at times 1 and 2, respectively). Heritability of Dental Fear Intensity, however, was similar for girls (0.30 and 0.40 at times 1 and 2, respectively) and boys (0.47, 0.44). Studies of the etiology of dental fear/anxiety should take genetic vulnerability into account and include molecular biology measures. Possible heritability differences between girls and boys need attention.

Prediction of prolonged pain experiences during orthodontic treatment

INTRODUCTION

In this study, we investigated prolonged pain reactions in teenage orthodontic patients during a common orthodontic treatment. The aim was to examine factors predicting pain at the end of a follow-up week after placement of elastic separators.

METHODS

Fifty-five patients (ages, 12-18 years) were included. Baseline assessments were made of perceived intensity of general and dental pain experiences, motivation for treatment, dental anxiety, and personality factors (self-esteem and temperament). Pain intensity was assessed on a visual analog scale, and pain medications were recorded. The patients were separated into pain and no-pain groups according to pain experiences at day 7.

RESULTS

The pain group (mainly girls) had significantly higher ratings of treatment pain than in the non-pain group at all times measured except for the treatment day. Bivariate and multiple logistic regressions showed significant predictive power from motivation, dental anxiety, activity temperament, and vaccination pain.

CONCLUSIONS

In this adolescent patient sample, low motivation for orthodontic treatment, high ratings of vaccination pain, elevated dental anxiety level, and low activity temperament characterized patients reporting pain 1 week after the elastic separators were placed.

The generalizability of the Youth Self-Report syndrome structure in 23 societies

As a basis for theories of psychopathology, clinical psychology and related disciplines need sound taxonomies that are generalizable across diverse populations. To test the generalizability of a statistically derived 8-syndrome taxonomic model for youth psychopathology, confirmatory factor analyses (CFAs) were performed on the Youth Self-Report (T. M. Achenbach & L. A. Rescorla, 2001) completed by 30,243 youths 11-18 years old from 23 societies. The 8-syndrome taxonomic model met criteria for good fit to the data from each society. This was consistent with findings for the parent-completed Child Behavior Checklist (Achenbach & Rescorla, 2001) and the teacher-completed Teacher's Report Form (Achenbach & Rescorla, 2001) from many societies. Separate CFAs by gender and age group supported the 8-syndrome model for boys and girls and for younger and older youths within individual societies. The findings provide initial support for the taxonomic generalizability of the 8-syndrome model across very diverse societies, both genders, and 2 age groups.

Temperamental reactivity and negative emotionality in uncooperative children referred to specialized paediatric dentistry compared to children in ordinary dental care

BACKGROUND

Current treatment of children with dental behaviour management problems (DBMP) is based on the presupposition that their difficulties are caused by dental fear, but is this always the case?

OBJECTIVE

The aim of this study was to study temperamental reactivity, negative emotionality, and other personal characteristics in relation to DBMP in 8- to 12-year-old children.

METHODS

Forty-six children referred because of DBMP (study group) and 110 children in ordinary dental care (reference group) participated. The EASI tempramental survey assessed temperamental reactivity and negative emotionality, the Child Behaviour Questionnaire internalizing and externalizing behaviour problems, and the Children's Fear Survey Schedule general and dental fears. Cluster analyses and tree-based modelling were used for data analysis.

RESULTS

Among the five clusters identified, one could be characterized as 'balanced temperament'. Thirty-five per cent of the reference group compared to only 7% of the study group belonged to this cluster. Negative emotionality was the most important sorting variable.

CONCLUSIONS

Children referred because of DBMP differed from children in ordinary dental care, not only in dental fear level, but also in personal characteristics. Few of the referred children were characterized by a balanced temperament profile. It is important to consider the dual impact of emotion dysregulation and emotional reactivity in the development of DBMP.

Dental fear/anxiety and dental behaviour management problems in children and adolescents: a review of prevalence and concomitant psychological factors

OBJECTIVES

The objectives of this article were to examine the literature published from 1982 to 2006 and to evaluate prevalence of dental fear and anxiety (DFA) and dental behaviour management problems (DBMP) in children and adolescents, and their relationships to age, sex, general anxiety, temperament, and general behavioural problems.

METHODS

A broad search of the PubMed database was performed using three combinations of search terms.

RESULTS

A large proportion of the identified articles could not be used for the review owing to inadequate endpoints, measures or poor study design. Thirty-two papers of acceptable quality were identified and reviewed. The prevalence of both DFA and DBMP were estimated to 9%, with a decrease in prevalence with age. DFA/DBMP were more frequent in girls. DFA/DBMP were related to general fear and both internalizing and externalizing behavioural problems, although these relationships were not clear-cut. Temperament was related to both DFA and DBMP but with different temperamental characteristics, while general behavioural problems mainly correlated with DBMP.

CONCLUSIONS

DFA/DBMP are common, and several psychological factors are associated with the development of these problems. In order to better understand these relationships, a number of issues concerning design of research and measurement of DFA/DBMP have to be dealt with.

Psychosocial concomitants to dental fear and behaviour management problems

BACKGROUND

Children with dental behavioural management problems (DBMP) form a heterogeneous group, where personal characteristics play significant roles. Attention to everyday life and family situation as additional background facets may help to better understand and treat these patients.

AIM

This study describes everyday life and family situation in child/adolescent patients referred because of DBMP, as compared to patients in ordinary dental care.

DESIGN

A study group of 230 referred patients (8-19 years old; 118 girls) was compared to a reference group of 248 same-aged patients (142 girls) without DBMP. Patients and parents were interviewed according to a semistructured protocol.

RESULTS

Patients referred because of DBMP more often lived in low socioeconomic status families, had parents not living together, fewer leisure-time activities, and were assessed as doing worse in social interactions compared to the reference group. Half of the study group had personal professional support, and some had experienced interventions by the social authorities. Whether these findings apply also to children/adolescents with DBMP who are not referred to specialist care remains to study.

CONCLUSIONS

Many children and adolescents referred because of DBMP have a burdensome life and family situation. This should be paid attention to in research and in clinical care.

Examining relations among attachment, religiosity, and new age spirituality using the Adult Attachment Interview

This study was the first to examine relations between attachment and religion-spirituality in adults using a developmentally validated attachment assessment, the Adult Attachment Interview. Security of attachment was expected to be linked to a religiosity-spirituality that is socially based on the parental relationships and reflects extrapolation of attachment experiences with sensitive parents to perceived relationships with a loving God. Insecurity of attachment was expected to be related to religiosity- spirituality via emotional compensation for states of insecurity. Participants (N=84; 40% men; mean age=29 years) were drawn from religious-spiritual groups. Religiousness-spirituality was assessed with questionnaires. Results generally supported the hypotheses (ps<.05). Estimates of parental loving were linked to socially based religiosity, loving God images, and gradual religious changes occurring at early ages and in life contexts indicating a positive influence of close relationships. Estimates of parental rejection and role reversal were related to New Age spirituality and sudden-intense religious changes occurring in life contexts of turmoil. Current attachment state of mind was generally unrelated to traditional religiosity, but current preoccupation, unresolved- disorganized, and cannot classify states were associated with New Age spirituality.

Evaluation of the Incredible Years Series - an open study of its effects when first introduced in Sweden

Behaviour management problems (BMP) are common among children (4-12%) and the prevalence seems to be rising. Persistent antisocial behaviour often leads to poor long-term psychosocial adjustment. Structured parent-training programmes have proven to be the most effective way of treating BMP in young children. The Incredible Years Series (IYS), which is a manual-based programme, was introduced in Sweden in 2001. The aim of the present study was to evaluate the effectiveness of IYS in diverse clinical settings in Sweden. Parents of 113 children (3-9 years), recruited through the IYS-trained group leaders' ordinary services, participated in the study. The parents answered various questionnaires regarding their children's symptoms and their own psychological well-being before and after participating in the parent-training groups. The results are very encouraging; significant reduction of BMP in the children was found on all relevant measures. A significant increase in the self-rated well-being of the mothers was also found. The IYS seems to work in Sweden, even when used by group leaders who are in training. The importance of using a well-documented manualized method when implementing new models is accentuated.

The development of a systemic school-based intervention: Marte Meo and coordination meetings

Antisocial behavior is often persistent, and in addition to causing suffering to children and their families, it also poses considerable costs for society. Children who display externalizing behavior in their early years run a high risk of having severe problems later in life. There is a need for treatment methods that may be used in various settings because these children constitute a group that is hard to reach with conventional treatment methods. In addition, the dropout rate from ordinary treatment is often high. In the present study, a systemic school-based model for early detection and intervention among 4-12-year-old children who displayed externalizing behavior problems was developed and examined in a nonrandomized study in the county of Skaraborg in Sweden. The intervention was collaborative and included a combination of the Marte Meo model and coordination meetings based on systemic theory and practice. Treatment effects in the group who had received the intervention were compared with a group who had received treatment as usual in their ordinary school setting. Assessments were carried out before, and 2 years after, the intervention. For the intervention group (N = 33), there was a significant decrease in the children's reported symptoms in school and in the home. No decrease in externalizing behavior was found in the comparison group (N = 16). There were no dropouts in the intervention group after the intervention had begun. The results are promising; the study demonstrates that it is possible to work effectively with many children who display externalizing behavior problems in a nonclinical setting.

A comparison of sequenced individual and group psychotherapy for patients with bulimia nervosa

OBJECTIVE

The current study examined the effectiveness of individual (IND) versus group (GRP) therapy for patients with bulimia nervosa (BN), using a manual of sequenced treatment with cognitive-behavioral therapy (CBT) followed by interpersonal psychotherapy (IPT).

METHOD

Eighty-six participants with BN were matched and randomized to 23 sessions of IND or GRP. Participants were measured pretreatment and posttreatment and at 1-year and 2.5-year follow-ups using both intent-to-treat and completer samples.

RESULTS

The intent-to-treat analysis revealed that the percentage of participants recovered and remitted was equivalent between IND and GRP. Significant group differences were found between completers on binge eating and compensatory behavior with greater improvement for IND. On most measures, effect sizes were larger for IND at 1-year follow-up.

CONCLUSION

Sequencing CBT and IPT worked well in both IND and GRP formats. We found few outcome differences between IND as opposed to GRP.

Emotional and behavioural problems in Swedish 7- to 9-year olds with asthma

BACKGROUND

The purpose of this study is to compare emotional and behavioural problems between preadolescent children with asthma and healthy children, and to explore if disease factors relate to problem scores.

DESIGN

This was a cross-sectional study of 59 children, 34 boys and 25 girls, aged 7-9 years with mild (n = 11), moderate (n = 38) or severe (n = 10) asthma. A normative sample of 306 children in the same age range, 150 boys and 156 girls, was used as a comparison group.

METHODS

Parents assessed emotional and behavioural problems using the Child Behaviour Checklist. Peak expiratory flow rate and urinary eosinophil protein X were used as measures of lung function and inflammation. Children were interviewed about activity restriction and symptoms during the last week using the Paediatric Asthma Quality of Life Questionnaire. Parents scored day, night and exercise-induced symptoms during the same week.

RESULTS

On average, children with asthma were attributed more problems than healthy children of the same age and comparable family socio-economic status. Effect sizes were 0.80 (95% confidence interval 0.52-1.09) for total problems, 0.89 (0.60-1.18) for internalizing problems and 0.67 (0.38-0.95) for externalizing problems. The relative risk for children with asthma exceeding the 95% cut-offpoint for total problems was 4.2 (2.1-8.3) compared to healthy children.

CONCLUSION

Children with parent-reported exercise-induced asthma symptoms were attributed more total problems than asthmatic children without such symptoms. Parent-reported day symptoms and child report of symptoms and restricted activities related with problem scores to a lesser degree. Objective measures of lung function and inflammation were not related to problem scores. Concurrent eczema increased problem scores. It is concluded that asthma in preadolescent children is associated with emotional and behavioural problems. Special attention should be paid to children reported to have exercise-induced symptoms.

The Göteborg discotheque fire: posttraumatic stress, and school adjustment as reported by the primary victims 18 months later

BACKGROUND

On October 29, 1998, around 400 young people were gathered in an old warehouse in Göteborg, Sweden, for a discotheque party. A fire erupted and spread explosively. Adolescents were exposed to dreadful scenes inside and outside the building. In all, 63 young people were killed and 213 physically injured. An 18-month follow-up with 275 adolescents (126 girls) who survived the fire, regarding the effects of the fire on symptoms of posttraumatic stress, school adjustment and performance, is reported.

METHODS

Impact of Events Scale (IES), Clinician Administered Posttraumatic Stress Scale (CAPS) and an interview concerning background factors and issues of public and personal support.

RESULTS

The level of posttraumatic stress was generally high, and highest among adolescents with an immigrant background. In all, 25% of the participants met DSM-IV criteria for PTSD. Twenty-three percent of the participants reported having either dropped out of school or repeated a class because of the fire. Students' ratings of how their own school handled the situation, and school absenteeism, were related to ratings of their own performance in school as well as to the level of posttraumatic stress.

CONCLUSIONS

Traditional talking cures were more sought out by girls than boys. Broad-scale interventions must be complemented with special treatment opportunities for the most severely afflicted. Victims who suffer from high levels of posttraumatic stress need special support for a long period of time to minimise the effects on scholastic achievement and adjustment. Studies of the effects of traumatic events on child and adolescent development should measure school-related effects better than has hitherto been the case.

Children with asthma. Few adjustment problems are related to high perceived parental capacity and family cohesion

A cross-sectional investigation of 59 Swedish 7-9-year-olds with asthma and their parents was undertaken to study family factors of importance to the children's psychological adjustment. Children scored the I Think I Am questionnaire, a measure of global self-worth, parents the Child Behaviour Checklist (CBCL). Parents' report of family cohesion was assessed with the Family Climate questionnaire, perceived parental capacity with a combination of a short form of the Parental Locus of Control questionnaire and the Parenting Efficacy questionnaire. High family cohesion and high perceived parental capacity were both associated with a high average child-reported global self-worth and children having on average few emotional and behavioural problems according to parental ratings. We found no support for the often-held view that high family cohesion (i.e. enmeshment) is associated with poor psychological adjustment of the child. The study, although small and limited by its cross-sectional design, supports the association between family cohesion and perceived parental capacity on the one hand and psychological adjustment of children with asthma on the other.

Bullying in adolescence: psychiatric problems in victims and bullies as measured by the Youth Self Report (YSR) and the Depression Self-Rating Scale (DSRS)

Adolescents in junior high school (n = 237), completed a questionnaire on bullying as it relates to victim and to perpetrator status, suicidality and biographical data. Psychological symptoms were assessed by the Youth Self Report (YSR) and the Depression Self-Rating Scale (DSRS) supplemented by school health officers blind assessments. Bullying was common: bully only (18%), victim only (10%) and victim and bully (9%). Bullies had mainly externalizing symptoms (delinquency and aggression) and those of the victim and bully group both externalizing and internalizing symptoms as well as high levels of suicidality. Adolescents in the bully only group were more likely to be boys and to have attention problems. Moreover, a substantial proportion of the adolescents in the victim only group were judged by school health officer to have psychiatric symptoms and to function socially less well.

A short-term follow-up of treatment outcome in groups of uncooperative child dental patients

AIM

To evaluate the short-term follow-up outcome in four subgroups of uncooperative child dental patients referred to a specialist paediatric dental clinic in Sweden.

METHODS

Seventy children, classified into four groups (based on fear, temperament, behaviour and verbal intelligence), were followed-up at their public dental clinics after termination of specialist dental treatment. Questionnaire assessments of children's dental and general fear, parental dental fear, emotional stress, locus of control and parenting efficacy were made by parents pre and post treatment and at follow-up and were analysed within and between groups. At follow-up, parents rated their children's coping and procedure stress, while treatment acceptance was rated by the dentists.

RESULTS

Decreases in child dental fear were maintained at follow-up, although a third of children still had moderate or high dental fear. For those children who had been classified into the externalising, impulsive group, an increased risk of non-acceptance (RR=3.7) was indicated. The risk of dental fear at follow-up was increased for the group of fearful, inhibited children (RR=3.8). For the study group as a whole a poorer follow-up outcome could be predicted by avoidance behaviour (OR 12.9-16.6) and moderate or high post treatment dental fear (OR 6.5- 21.3).

CONCLUSIONS

Fearful, inhibited child dental patients may need, due to dental fear, extra attention even after successful dental treatment at a specialist clinic. Externalising, impulsive children constitute a special challenge for dentistry. The continued need for adjusted management after termination of specialist treatment can be predicted from avoidance behaviour and post treatment dental fear scores.

The Goteborg discotheque fire, 1998

Findings from a study of 563 adolescents' reactions following a discotheque fire that killed 63 young people in Göteborg in October 1998 are presented. The group answered a questionnaire seven months following the disaster. The questionnaire included the Impact of Event Scale (IES) and the Birleson Depression Self-Rating Scale (DSRS). The level of trauma was found to be very high, while depression scores were less elevated. A little under a third of the students scored above a clinical cut-off point (> 35) on the IES, indicating high posttraumatic stress levels. Girls evidenced more depression and traumatic stress reactions than boys. Levels of reactions increased with more closeness (knowing victims personally) and if the adolescents were of non-Swedish origin.

Self-reported competencies and problems among Swedish girls with eating disorders and a control sample, using the youth self-report

OBJECTIVE

To study self-reported competencies and problems in adolescent girls with eating disorders, anorexia nervosa (AN), bulimia nervosa (BN), and eating disorder not otherwise specified (EDNOS) compared to matched normal controls.

METHOD

The Youth Self-Report (YSR) was completed by 211 girls between 13 and 17 years of age with eating disorders and 211 controls matched for age, sex, and geographical area.

RESULTS

Girls with eating disorders scored lower on all competence scales and higher on most problem 'scales compared to controls. Type of diagnosis had no effect on competence scales, but BN-patients scored higher than AN- and EDNOS-patients on many problem scales. AN-bingers/purgers reported more problems than restrictors on somatic complaints, delinquent behaviour, and the externalizing dimension.

DISCUSSION

We conclude that the YSR gives important information concerning self-reported competencies and concomitant symptoms of general psychopathology in eating disordered adolescent girls.

A measure for the assessment of eating disorders: reliability and validity studies of the Rating of Anorexia and Bulimia interview - revised version (RAB-R)

The Rating of Anorexia and Bulimia interview (RAB) is a Swedish semi-structured interview for clinical and research purposes for a wide range of eating disorder symptoms and related psychopathology. The objectives were to evaluate the reliability and validity of a revised RAB version (RAB-R). The RAB-R was assessed in terms of internal consistency, inter-rater and test-retest reliability, and criterion and convergent validity. Samples included a clinical sample of eating disorder patients (n = 71) and a sample of randomly drawn female controls (n = 31). The RAB-R showed satisfactory internal consistency, inter-rater and test-retest reliability, correlated well with related measures, and discriminated between patients and normal controls. We conclude that the RAB-R is a promising interview instrument and continued evaluation should focus on comparing subgroups of eating disorder patients with other clinical groups.

Treatment outcome in subgroups of uncooperative child dental patients: an exploratory study

OBJECTIVES

The principal aims of this study were to evaluate the treatment outcome in subgroups of uncooperative child dental patients and to test the validity of these subgroups, which were based on fear and personality characteristics.

DESIGN

An exploratory, intervention study using quantified questionnaire, interview and observation data.

SAMPLE AND METHODS

Eighty-six 4 to 12-year-old uncooperative child dental patients (of whom 81 were divided retrospectively into four subgroups) and their accompanying parents were followed up during treatment at a specialist paediatric dental clinic in Sweden. Treatment was based on behaviour management techniques, supported by nitrous oxide/oxygen sedation if necessary. At baseline, parents answered a questionnaire including questions on child dental and general fear, temperament and behaviour, and parental dental fear, emotional stress, locus of control, parenting efficacy and attitudes to dental care, some of which were repeated post-treatment. The treating dentist rated child behaviour according to the acceptance of a maximum of 14 treatment steps at each visit.

RESULTS

Approximately 90% of all children managed to undergo the dental treatment. Child dental fear and parental emotional stress decreased during treatment. Externalizing, impulsive children showed lower acceptance. In fearful, inhibited children, integrated use of sedation appeared to facilitate acceptance. Validity of the subgroups characterized as 'fearful, extrovert, outgoing', 'fearful, inhibited' and 'externalizing, impulsive' was supported, while heterogeneity within the group of 'non-fearful, extrovert, outgoing' children made validation difficult.

CONCLUSION

Fear and personality characteristics may serve as diagnostic aids when planning treatment of uncooperative child dental patients. Controlled outcome studies using differentiated treatment methods for children with different fear and personality profiles are needed.

[Good esteem among 7-9-year-olds with asthma. The test "I consider myself! shows small differences in comparison with healthy children]

Self esteem as judged by interviewing 47 children between 7 and 9 years of age with asthma treated at a hospital clinic was no different from that of 383 healthy children of the same age. While healthy girls rated their self worth higher than boys, there was no sex difference in self esteem among the children with asthma. Factors including the cohabitation of parents, peak flow rate and presence of exercise-induced asthma was of importance for the self esteem rate among the children with asthma.

Emergence and constructvalidation of the big five factors in early childhood: a longitudinal analysis of their ontogeny in Sweden

Researchers have shown that the five major dimensions of personality (extraversion, agreeableness, conscientiousness, neuroticism, and openness to experience) and two additional factors (irritability and positive activity) are evident from adolescence. This study attempted to replicate and extend these results in a longitudinal study of 102 Swedish children, followed from 2.3 to 15.2 years of age. Item analyses revealed consistently reliable irritability, conscientiousness, and positive activity factors, whereas the internal reliability of the extraversion, agreeableness, neuroticism, and openness to experience factors increased over time. Irritability and positive activity were not independent of the other factors. Scores on most of the personality factors were fairly stable over time. Over time, children became less extraverted, more agreeable, and more conscientious. Neuroticism and openness to experience increased in Phase III, although openness then decreased in Phase V. Validity of the original factors was demonstrated by correlations with independent assessments of the children's cognitive performance and adjustment to school.

Attitudes to dental care among parents of uncooperative vs. cooperative child dental patients

The aim of this cross-sectional questionnaire study was to investigate four aspects of parents' attitudes to dental care (knowledge, child's oral health behavior, priorities and responsibility). One study group (n = 50) of parents of uncooperative child dental patients (aged 8-12 yr) was compared to a reference group (n = 113) of parents of ordinary child dental patients of similar age, and to a second study group (n = 36) of parents of uncooperative younger child patients (aged 4-7 yr). Study group parents had significantly lower socio-economic status and a higher level of dental fear as compared to parents of ordinary child patients. We found indications of a poorer dental knowledge and a differing responsibility-taking profile among study group parents. Their children also had sweets more often. As compared to parents of younger children, the older study group parents had lower socio-economic status and showed a lower responsibility-taking related to the child's treatment refusal. In conclusion, parents of uncooperative children differ from parents of ordinary child dental patients, not only in socio-economic status and dental fear, but also in aspects such as dental knowledge and responsibility-taking. These differences were partly related to the child's age.

Lack of cooperation in pediatric dentistry--the role of child personality characteristics

PURPOSE

This study aimed to investigate fear, temperament, behavioral symptoms and verbal intelligence in a study group of uncooperative child dental patients, partly in comparison with a reference group of ordinary child dental patients. A second aim was to explore a hypothesis of heterogeneity by searching for subgroups within the study group.

METHODS

Parents of 86 study group children (36 aged 4-to 7- years and 50 aged 8- to 12-years) and 117 reference group children (8- to 12-years) answered a questionnaire concerning dental and general fear, temperament and general behavior. Study group children performed a vocabulary test to measure verbal intelligence. Data were analyzed with a variable-based and a person-based approach.

RESULTS

In addition to dental fear, a higher level of impulsivity most clearly discriminated study group from reference group children. Cluster analyses revealed four different fear and personality subgroups within the study group.

CONCLUSIONS

Uncooperative child dental patients constitute a heterogeneous group. Subgroups with different fear, temperament and behavior problem profiles can be identified. These subgroups could be presumed to benefit from different treatment regimens, which should be further investigated.

The Youth Self-Report (YSR) and the Depression Self-Rating Scale (DSRS) as measures of depression and suicidality among adolescents

Two hundred and thirty-seven adolescents from a junior high school in a small community outside Göteborg, Sweden, completed the Youth Self Report (YSR) and the Depression Self Rating Scale (DSRS). Self-reported suicidality and biographical data were also recorded. The school doctor and nurse assessed the adolescents' somatic, psychological and behavioural problems using school health-records. The convergent validity of the YSR total problems scale and syndrome scales were tested against the DSRS. Discriminant validity was assessed by the two measures' ability to predict suicidality and school health problems. The Internalising (r = 0.65**) and Anxious/Depressed (r= 0.61**) syndrome scales of the YSR had the highest correlations with the DSRS. However, all YSR syndrome scales were significantly, though more modestly, correlated with the DSRS. Using stepwise logistic regression analysis, four YSR sub-scales [Social Withdrawal, Anxious/Depressed, Attention problems and Delinquency] predicted mild-severe self-reported depression (DSRS scores 12 and above). The YSR syndrome scales Anxious/Depressed and Delinquency predicted suicide ideation whereas the Self-destructive/Identity problem and Social Withdrawal (low scores) scales predicted Suicide attempts. The YSR Anxious/Depressed sub-scale and the DSRS total score seem to measure a similar dimension. However, the Anxious/Depressed and Selfdestructive/Identity problem scales were superior in predicting suicidality.