Nordic Child & Adolescent Psychiatric (NordCAP) Research Meeting August 30 - 31, 2018 Turku, Finland

Child and adolescent psychiatry in Iceland: reflexion on recent developments and current situation

Bertrand Lauth;

University of Iceland, Landspitali University Hospital, Iceland

History of child and adolescent psychiatry (CAP) in Iceland started in 1960 with the foundation of a mental health department within the municipal pediatric health center in Reykjavík. The first and only department of CAP was then opened at university hospital in 1970. Outpatient, as well as inpatient and day-treatment units were opened, with emphasis on team work, family treatment approaches, group therapy as well as interest in autism. Strong accent has always been placed on professionals’ education and training, as well as on efforts to implement new diagnostic and treatment methods and strategies. A shift of theoretical and reference models occurred during the nineties, along with the rejection of psychoanalytic theories and psychodynamic models of thinking. Autism was then “taken“ from CAP to be placed under the authority of ministry of Social Affairs, with other handicaps. At the same time, the rapidly growing influence of psychopharmacological approaches led to a situation where very high rates of psychotropic prescriptions have rapidly become a serious matter of concern for Icelandic public health authorities. Resources of CAP developed significantly but a severe economic crisis occurred in 2008, which had and still has consequences on child protection services and social systems of care, as well as on primary health care and on school system, especially specialized education services. Probably in relation to this situation, an increased number of requests for emergency CAP care has been observed since 2009, which led to reorganization of both outpatient and inpatient units, with implementation of new treatment strategies for this group of young patients. In parallel, the CAP department initiated and developed progressively an effective, systematic, multi-disciplinary and patient-centered consultative guidance with general care medical centers and child protection services. Another challenge has been represented by an exponential increasing number of youths diagnosed with autism spectrum disorders within the social system of care. Many of them being finally referred to CAP for treatment, new treatment strategies have also been implemented for this group of patients. Finally, challenges are now represented by an increasing number of patients presenting severe substance abuse problems. The remarkable success obtained in Iceland with primary and secondary prevention programs at the beginning of this century has been sadly compromised by budget cuts following 2008 financial crisis. CAP in Iceland is now developing also at the academic level, with the opening in 2013 of first CAP teaching position at the faculty of medicine of the university of Iceland. Finally, recent effort within Icelandic society for CAP has led to the development of a post-graduate residency training program in our country, starting in 2018.

Towards developing school mental health services in Kenya – why school mental health

David M. Ndetei;

University of Nairobi, Kenya, Africa Mental Health Foundation, Kenya

Background: Most mental illnesses start early in life during school going age. Schools are therefore an important forum to address child and adolescent mental health. However, the approach needs to be inclusive of all the stakeholders: the children, parents, teachers and service providers in the surrounding communities.

Objectives: 1. To test the efficacy and feasibility of a proposed model for school mental health in a Kenyan setting; 2. To document barriers, enablers, experiences, challenges and lessons learnt in the process of implementing the model.

Methods: We identified, approached and dialogued with stakeholders in school health so as to include mental health wellbeing for primary school going children 6-13 year olds. Together we developed a Theory of Change (ToC). This was followed by implementation of the proposed model in line with the outcomes of the collective ToC. We used following instruments: 1. The WHO mhGAP-IG version 1 children section to create awareness and promote mental health seeking behavior; 2. The WHO Life Skills training as the intervention tool; 3. The Youth Self Rating Scale to monitor change of symptoms in the children.

Results: 1. Successful engagement with stakeholders; 2. ToC in place; 3. Capacity of the schools and peer clubs to provide life skills training to the children in place; 4. Capacity of the surrounding health facilities to respond to any needed clinical interventions in place; 5. Monitoring, supervision, support and quality control implemented; 6. Outreach to 5429 children in 24 schools in two administrative counties in Kenya; 7. Documented challenges and opportunities to inform expanded implementation.

Discussion: School mental health is feasible using currently available resources. However, there are context appropriate logistical issues and challenges, but these can be successfully addressed.

Child Psychiatry in the Arabian Gulf Countries: Challenges and future directions

Ahmed Malallah Al-Ansari;

Department of School Health, Ministry of Health, Kingdom of Bahrain

Background: Review the history and services proceed to children and adolescents with psychiatric problems in Bahrain. During presentation, the focus is on workforce, training opportunities and future challenges.

Does mental health in low income countries contribute to the achievement of the SDGs?

Lars Lien, Ragnhild Dybdahl;

Inlandet University of Applied Science & University of Tromsø, Norway; OsloMet-Oslo Metropolitan University, Norway

Background: The UN Sustainable Development Goals have bold targets on eradication of poverty, hunger and to ensure healthy lives for all.

Objectives: The objective of this talk is to pinpoint the importance of mental health as a key factor to progress in the achievements of the SDGs.

Methods: Study all the 17 SDGs with a focus on possible contribution from mental health.

Results: For the first time, mental health is explicitly included in universally agreed goals, providing an opportunity to enhance mental health and well-being across countries and professional disciplines. To fully use this opportunity, care for people with mental illness and psychosocial disabilities, as well as promotion of resilience and mental health generally, must be prioritized.

A prominent aspect of the SDGs is that they are multisectorial, and that innovations and progress in one sector will impact another. If we are to reach the SDGs we will need to develop the human potential so that more people can contribute to the work and changes needed. To achieve this, increased resilience is central. Resilience points both towards promoting mental health in communities, families, schools and work places, and to prevent and treat mental health disorders and substance abuse.

Discussion: In order to reach the Sustainable Development Goals, it will be necessary to collaborate across sectors and disciplines and mental health must have a prominent focus of interest. In fact, the WHO definition of mental health - a state of wellbeing where individuals realize their potential, can cope with normal challenges in life, can work productively, and contribute to their community – sums up much of what is needed if we are to reach the SDGs by 2030.

Overview of the developments in child and adolescent psychiatry in Lithuania

Sigita Lesinskienė;

Faculty of Medicine, Institute of Clinical Medicine, Clinic of Psychiatry, Vilnius University, Vilnius, Lithuania

Background: Child and adolescent psychiatry has a comparatively long history of 55 years in Lithuania, comprising of various periods of development. When Lithuania restored its independence in 1990, a clear goal of creating new types of services and joining the international research community was supported by the Nordic countries.

Prior to 1990, child and adolescent psychiatry (CAP) in Lithuania was strongly influenced by the Soviet school, where the biological model was dominant and the role of psychosocial problems was under-recognized. The removal of CAP stigma required a long transformation process of changing views and attitudes in Lithuanian society, with formulation and implementation of mental health promotion, prevention, intervention and multidisciplinary treatment modalities in CAP.

The presentation will be an overview of the training of child psychiatrists, the CAP Society, regulations, intersectoral collaboration, and the development of CAP in-patient and out-patient services in Lithuania. The strong and weak points of the still going process will be presented for discussion and analysis.

The delivery of adequate CAP services is strongly dependent on political and administrative support, the presence of qualified personnel, and adequate funding. When planning the future of CAP, the issues of identity and the boundaries of the specialty together with a clear selection of priorities are of great importance. International experience and broad variety of different pathways of CAP development bring possibilities for broader understanding and flexibility in finding relevant programs for every individual country.

Gestational Exposure to Selective Serotonin Reuptake Inhibitors and Offspring Psychiatric Disorders

Heli Malm, MD;

Teratology Information, Helsinki University and Helsinki University Hospital, Dept. Emergency Medicine, Helsinki, Finland; University of Turku, Department of Child Psychiatry, Turku, Finland

Prenatal depression is common and 4-8 % of pregnant women use selective serotonin reuptake inhibitors (SSRIs). SSRIs pass freely the placenta and concentrations in the fetus correspond to maternal drug concentrations. SSRIs act by increasing central serotonin (5-HT). 5-HT plays a key role in early brain development, and manipulation of 5-HT levels during fetal life may have lasting neurobiological and behavioral consequences. Studies in rodents have reported that exposure to SSRIs during sensitive periods of development induce permanent changes in brain maturation, manifested as persistent depression-like behavioral phenotypes. In humans, no previous studies have been conducted to investigate the association of intrauterine SSRI exposure with depression in age groups beyond childhood. Previous research has reported vastly conflicting results for autism spectrum disorders (ASD) and attention deficit hyperkinetic disorders (ADHD).

We investigated the association between prenatal SSRI exposure and neuropsychiatric and neurodevelopmental outcomes in a large national Finnish birth cohort, years 1996-2010. This was a collaborative project between researchers from the University of Turku and the Columbia University, NY. We included over 15,000 pregnancies of mothers who purchased SSRIs during pregnancy. Controls were mothers with depression unexposed to antidepressants during pregnancy, mothers exposed to SSRIs only prior to pregnancy, and mothers unexposed to SSRIs and depression. Compared to each control group, prenatal exposure to SSRIs was associated with a significantly increased rate of adolescent depression, with a sharp rise at age 12-14. Continuous use of SSRIs during pregnancy was also associated with an increased risk of speech and language disorders in offspring. We found no association between prenatal SSRI exposure and ASD or ADHD. To achieve a better understanding of prenatal SSRI exposure on the developing brain, basic research, clinical cohorts and epidemiological studies with advanced methods to quantify unbiased, causal drug effects are all needed.

The study was funded by NIH Grant P50MH090966.

KiVa antibullying program: Bullying prevention and mental health promotion

Christina Salmivalli;

University of Turku, Finland and Shandong University, China

Bullying, defined as repeated negative actions directed at a (physically or socially) less powerful person, continues to be a pervasive problem in schools worldwide. The need for effective anti-bullying interventions is motivated first of all by the multitude of psychosocial problems among victimized children and youth. They experience depression and anxiety and tend to be highly rejected by classmates. For a number of victims, such experiences continue to affect their lives in adulthood: there is evidence of a higher likelihood of mental health problems among adults who were targeted by bullying in their schooldays. However, bullying has negative outcomes also for the perpetrators as well as classmates merely witnessing bullying, constituting a threat to the healthy development of numerous children and youth and causing considerable costs for societies. The presentation introduces the KiVa anti-bullying program (www.kivaprogram.net), a bullying prevention program that was developed at the University of Turku and is now widely implemented in schools in Finland and elsewhere. Theoretical background, the key components, and the findings concerning the effects of the program are presented. Besides program effects on the prevalence of bullying and victimization, evidence concerning mental health benefits is presented and discussed.

Tourette’s syndrome research in Sweden: from genetic epidemiology to remote behavioural interventions

David Mataix-Cols;

Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden

Background: Tourette’s syndrome (TS) and chronic tic disorders affect around 0.3-1% of the population. They are highly comorbid with a range of psychiatric disorders, which are often more impairing than the tics themselves. Little is known about their causes and long-term consequences. Current pharmacological treatments are modestly efficacious and associated with undesirable side effects. Behavioural interventions (habit reversal and exposure/response prevention) are more acceptable to patients and recommended as first line treatments, but are largely unavailable.

Objectives: To describe our on-going TS research programme at the Karolinska Institutet.

Methods: We employ a range of advanced epidemiological methods to understand the risk factors (genetic, environmental) and consequences (medical, social) of TS at the population level. We have recently developed and pilot tested a therapist-guided, Internet-based behavioural intervention for young people with TS and chronic tic disorders.

Results: TS and chronic tic disorders are amongst the most heritable of neuropsychiatric disorders but specific genetic and environmental risk factors are still poorly understood. Using the Swedish national registers, we have shown that these disorders are associated with a range of adverse medical and socioeconomic consequences, such as increased suicide risk, increased risk of medical complications, and pervasive educational underachievement. The preliminary results of our therapist-guided Internet-based behavioural intervention are encouraging. If these results are confirmed in controlled clinical trials, the availability and cost-effectiveness of behavioural interventions for TS could increase dramatically.

Discussion: With their large population-based registers, relatively homogeneous populations, and high degree of digitalisation, Nordic countries offer unique opportunities to advance our understanding of the causes and consequences TS and chronic tic disorders, and contribute to the broader dissemination of evidence-based treatments.

Internet-delivered cognitive behaviour therapy for children and adolescents – experiences from clinical trials in Sweden

Eva Serlachius^1,2, Per Andrén^1,2, Erik M Andersson¹, Kristina Aspvall^1,2, Johan Bjureberg^1,2, Marianne Bonnert^1,2, Fredrik Enoksson^1,3, Clara Hellner^1,2, Stefan Hrastiniski³, Jens Högström^1,2, Maral Jolstedt^1,2, Maria Lalouni^1,2, Mats Lekander^1,4, Fabian Lenhard^1,2, Brjánn Ljótsson¹, David Mataix-Cols^1,2, Martina Nordh^1,2, Ola Olén^5,6,7, Tove Wahlund^1,2, Lie Åslund^1,2, Sarah Vigerland^1,2;

¹Department of Clinical Neuroscience, Karolinska Instituttet;²Stockholm Health Care Services, Stockholm County Council, Sweden; ³KTH Royal Institute of Technology, Division of Digital Learning, Stockholm, Sweden; ⁴Stress Research Institute, Stockholm University; ⁵Sachs’ Children and Youth Hospital, Stockholm South General Hospital, Stockholm, Sweden; ⁶Clinical Epidemiology Division, Department of Medicine Solna, Karolinska Institutet, Stockholm, Sweden; ⁷Department of Clinical Science and Education Södersjukhuset, Karolinska Institutet, Stockholm, Sweden

Background: Despite the fact that cognitive behavior therapy (CBT) is effective for a range of child- and adolescent conditions, and is considered a prioritized psychological treatment option in many national guidelines, few children and adolescents get access to CBT. The treatment gap between the demands for evidence-based psychological treatment in contrast to CBT trained therapists is a well-known problem. Internet-delivered CBT (ICBT) is a novel, efficient and cost effective treatment alternative for children and adolescents with psychiatric conditions (such as anxiety disorders) and somatic conditions (such as IBS), which could increase availability to evidence based treatments.

Objectives: To describe our research programme on therapist-supported internet-delivered CBT (ICBT) for children and adolescents with mental health disorders.

Methods: The Child internet project (BIP) was formed in 2010 with the objective to increase the availability of evidence-based treatment for children and adolescents with anxiety disorders. BIP has grown into a program comprised of several research groups and has developed therapist-supported internet-delivered cognitive-behavioral therapies (ICBT) for children and adolescents with anxiety disorders, obsessive compulsive disorder, irritable bowel syndrome, Tourette’s syndrome as well as specific treatments for social anxiety and generalized anxiety disorder. So far, several pilot trials and six RCTs have been completed, five trials are ongoing and additional studies are being planned. More than 1000 participants have been treated with ICBT in these trials and the number of researchers involved in the BIP-program has grown substantially.

Results: ICBT for youth seems to reduce symptoms and increase functioning in the short as well as long-term (<12 months after treatment). Furthermore, ICBT seems to be a feasible and acceptable treatment, even though therapists spend on average 20-30 minutes on each family (patient + parents), per week. On-going trials include a non-inferiority trial where ICBT is compared to regular face-to-face CBT as well as implementation studies of ICBT in regular care in rural Sweden.

Discussion: BIP has developed and evaluated ICBT treatments for a wide array of mental health disorders. The efficacy of these treatments in a research setting has been confirmed and the next line of studies is moving toward investigating the effectiveness in real-world settings. Plans for and challenges with dissemination will be discussed.

Social skills training in Autism Spectrum Disorder

Sven Bölte;

Center of Neurodevelopmental Disorders (KIND), Division of Neuropsychiatry, Department of Women’s and Children’s Health, Karolinska Institutet & Child and Adolescent Psychiatry, Center for Psychiatry Research, Stockholm County Council.

Background: Autism spectrum disorder (ASD) has been diagnosed increasingly in recent years, posing a major issue to educational, social and public health services. Several important areas of adaptive social functioning are challenging in ASD, even in individuals with average to high IQ. This is associated with an elevated risk of peer conflicts, social exclusion, and psychiatric comorbidity. Therefore, evidence-based interventions aiming to enhance social skills are of pivotal importance to ASD.

Objectives: Social skills group training (SSGT) is an umbrella term for interventions applying socially instructive techniques and behavioral modification principles in a group setting. Despite the frequent use of SSGT in the clinical management of ASD, few approaches have been rigorously evaluated for efficacy, and effectiveness remains largely unknown.

Methods: We conducted the largest pragmatic randomized controlled multicenter (13 sites) trial of SSGT in ASD without intellectual disability to date (N =296 + 52; NCT01854346). Trials were run on a short (12 sessions) and long (24 sessions) training using the manualized SSGT training KONTAKT. Effects were calculated in relation to age group (children vs adolescents), and gender. Preliminary findings from moderator and mediator analyses on the effects of other individual characteristics (e.g. IQ, severity, comorbidity, medication, verbal abilities, genetic variants) were also analyzed. A qualitative responder analyses on the KONTAKT training completed the evaluation.

Results: The long KONTAKT RCT indicated large effects post-treatment on the primary outcome measure Social Responsiveness Scale-2 (-19.2; 95% CI, -29.9 to -8.5; p < .001, effect size [ES] = 0.76), which were maintained at follow-up (-20.7; 95% CI, -31.7 to -9.7; p < .0001, ES = 0.82). These estimates indicate substantially larger improvement than previously reported for shorter SSGT. These preliminary results indicate a dose-response relationship, and imply that service providers can reach better results by optimizing the length of SSGT. In addition, moderator/mediator and therapy genetic analyses indicate a higher benefits of KONTAKT on participants with comorbid depressive mood and those without copy-number variants.

Discussion: These results indicate a dose-response relationship, and imply that service providers can reach better results by optimizing the length of social skills training. In addition, future research may corroborate that participants with co-existing depressive symptoms and those without CNVs might a prioritized ASD subgroup for KONTAKT.

Prenatal origins of Neuropsychiatric Disorders

Alan S. Brown, Andre Sourander, Helja-Marja Surcel, Ian W. McKeague, Keely Cheslack-Postava, David Gyllenberg;

Columbia University, New York, NY, USA

Background: Birth cohort studies have revealed that several prenatal, perinatal, and other early life factors are related to an increased risk of neuropsychiatric disorders. These risk factors may operate by disrupting normal neurodevelopmental events involving fetal programming. We and other groups have utilized this study design to demonstrate that maternal exposures predispose to risk of neuropsychiatric outcomes including autism spectrum disorders, schizophrenia, bipolar disorder, and attention deficit hyperactivity disorder. Other early life antecedents also appear to predict risk of these outcomes.

Objectives: First, I shall review an earlier body of literature on epidemiologic studies of prenatal and perinatal complications and neuropsychiatric disorders with a focus on the limitations and inconsistencies in that work and the conceptual basis supporting a role of early life environmental factors in these conditions. Second, I will review the methodologic strengths of two birth cohort studies that we have conducted, aiming to relate prenatal and other early life factors to neuropsychiatric outcomes. Third, I will discuss findings in which we have related prospectively measured maternal biomarkers of gestational exposures and other developmental antecedents to these outcomes. Finally, I will discuss future directions of this work including our ongoing efforts in several new research projects.

Methods: The focus will be on nested case-control designs of large population-based birth cohorts which offer key epidemiologic design advantages. The two cohorts to be discussed are the Finnish Prenatal Studies (FiPS) and the Child Health and Development Study (CHDS). The FiPS is a large national birth cohort of over 2 million pregnancies in 1983 in which maternal sera were drawn and biobanked and which were linked with several nationwide, comprehensive Finnish psychiatric registries for diagnoses of neuropsychiatric outcomes, covariates, and effect modifiers in the offspring. Particular strengths of the study include large numbers of cases and the national cohort. The CHDS is a birth cohort consisting of nearly all pregnant women who received prenatal care from a large health care plan in Northern California and who had maternal sera drawn and archived. Strengths of that study include diagnoses of cases by structured research interviews and availability of biobanked sera throughout pregnancy. In both cohorts maternal sera were analyzed for biomarkers of several prenatal exposures.

Results: In the FiPS birth cohort, we demonstrated associations between maternal exposure to inflammation, thyroid autoantibody, and the insecticide metabolite DDE and risk of autism. In this same cohort, we have shown that maternal inflammation, clinical hypothyroxinemia, and smoking are related to risk of schizophrenia. In the CHDS birth cohort, we have demonstrated associations between maternal influenza, Toxoplasma gondii antibody, the chemokine interleukin-8, and deficiency of several micronutrients and risk of schizophrenia; moreover, maternal exposure to influenza was associated with an increased risk of bipolar disorder in this cohort. Additional findings on other reproductive factors and maternal biomarkers will also be discussed.

Discussion: These findings offer substantial methodologic advantages and have provided some of the most robust evidence to date that maternal environmental exposures are associated with neuropsychiatric outcomes in offspring. I shall discuss the potential of these findings for public health efforts aimed at prevention, for identifying specific versus shared risk factors between different neuropsychiatric disorders, and for improving our understanding of the developmental pathogenesis of these outcomes.

Brain imaging in child psychiatry: fancy toy or cool tool? Research findings from the Generation R Study

Henning Tiemeier;

Harvard University, USA

Background: Epidemiological studies showed that early adversities underlie the vulnerability for neurodevelopmental disorders like autism and ADHD. These studies relied on psychiatric assessments and thus our knowledge about how early life adversity shape brain development and whether this mediates behavioral problems is limited. Structural imaging studies designed to optimally evaluate the role of multiple environmental factors on brain development require both large sample sizes and the prospective collection of environmental exposures. Neither functional or structural imaging can currently be used to improve diagnosis in child psychiatry, but it imaging studies may help refine our diagnostic understanding.

Methods: The Generation R Study is a large, prospective, prenatal-cohort study of nearly 10,000 children that began in 2002 in Rotterdam, the Netherlands. From September of 2009, 6–11 year old children from the Generation R Study were invited to participate in a magnetic resonance imaging component of the study. I will provide an overview of the study design and results for the first 6000 children recruited for the neuroimaging component of the study.

Results: The focus of my presentation will be on how prenatal exposure to maternal depression shapes global brain development; the specific effects of insensitive parenting on gray matter development, and ongoing studies of childhood bullying and emotional problems in relation to changes in brain connectivity are discussed. Finally, a series of studies on how imaging can be used to better understand externalizing disorders and help validate diagnostic approaches will be presented. Also, I will discuss methodological challenges such as reversed causality and future plans.

Omega-3 Fatty Acids in Youth with ADHD: Biological and Clinical Aspect

Jane Pei-Chen Chang;

Department of Psychological Medicine, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, UK; Department of Psychiatry, China Medical University & Hospital, Taiwan

Background: Deficiency in omega-3 polyunsaturated fatty acids (n-3 PUFAs), a type of essential fatty acids (EFA), has been associated with cognitive function and emotional regulation, and it has also been associated with the manifestation of attention deficit hyperactivity disorder (ADHD).

Objectives: The study investigated the association between n-3 PUFAs, clinical ADHD symptoms and cognitive function in children with ADHD.

Methods: First part of the study examined the n-3 PUFAs intake, EFA deficiency, ADHD symptom severity and neurocognitive function in 21 children diagnosed with DSM-IV ADHD and 21 typically developing youth (TD). The second part of the study is the meta-analysis of 7 clinical trials of n-3 PUFAs supplementation in youth with ADHD (n = 534).

Results: The children with ADHD, when compared with TD, had a greater severity of EFA deficiency (7.24 + 4.56, p = .02). Moreover, severity of ADHD symptoms was positively correlated with severity in EFA deficiency. Meta-analysis showed children with ADHD had lower levels of total n-3 PUFAs (g = - 0.58, p = 0.0001), and n-3 PUFAs supplementation, compared to placebo, improved total ADHD scores in children with ADHD (g=0.38, p<0.0001).

Discussion: Children with ADHD had a higher EFA deficiency and lower levels of n-3 PUFAs. Moreover, n-3 PUFAs supplementation improved inattention and hyperactivity symptoms in children with ADHD. Our study further supports the role of n-3 PUFAs in ADHD. N-3 PUFAs may serve as a potential alternative treatment option for children with ADHD.

The Importance of Birth Cohort Studies for Child and Adolescent Psychiatry

Hans-Christoph Steinhausen;

Department of Child and Adolescent Psychiatry, University of Southern Denmark, Odense, DK; Child and Adolescent Mental Health Centre, Copenhagen, DK; Department of Child and Adolescent Psychiatry, University of Zurich (CH); Clinical Psychology and Epidemiology, University of Basel (CH)

Background: There is a rich tradition of European studies using data from birth cohort studies to address major issues of child and adolescent mental health.

Objectives: To provide an overview of some general aspects of birth cohort studies including major findings from selected European studies addressing child and adolescent mental health issues.

Methods: Selective review of general aspects and major topics in Northern European birth cohort studies addressing child and adolescent mental health.

Results: Following a brief review of the characteristics, procedures, and advantages of birth cohort studies in general, the design of and selected findings from large Northern European cohort studies are presented. These studies include the Finnish birth cohort studies, the Danish Odense Child Cohort (OCC), and a Danish study by the author on the development, size and risks of mental disorders based on a complete national birth cohort and covering the whole period of childhood and adolescence.

Discussion: Birth cohort studies using epidemiological designs have provided substantial contributions to the understanding of risks and outcomes in the field of developmental psychopathology.

Prevalence and predictors of bullying and cyber bullying among school children in several Asian and European countries–the Eurasian Child Mental Health Study (EACMHS)

Roshan Chudal;

Research Centre for Child Psychiatry, University of Turku

Background: Bullying in general is defined as intentional harmful behavior that involves an imbalance of and subsequent misuse of power by the perpetrator against the affected person through repeated aggressive behavior (CDC. 2014). The aggressive behavior can be physical, verbal, relational and cyber. There are differences in cross-national estimates of prevalence of bullying among children and adolescents which could be due to differences in the study sample, study design, definition of bullying behavior as well as cultural differences in the use and interpretation of the study terms. Another interesting aspect is whether traditional bullying (i.e. physical or verbal etc.) as a phenomenon is the same as cyberbullying.

Methods: The Eurasian Child Mental Health Study (EACMHS) includes child and adolescent mental health experts in eleven Asian and seven European countries: Bahrain, China, Iran, Finland, Greece, India, Indonesia, Israel, Japan, Lithuania, Nepal, Norway, Russia, Singapore, Switzerland, Thailand, Ukraine and Vietnam (Sourander & Chudal, 2017). The overall aim of the group is to conduct cross-cultural, multi-site research on the wellbeing and mental health of children and adolescents. The present study is based on a survey among school children of grades 7-9, from schools among 13 countries in the EACMHS. The questionnaire included various measures including country level measures, school level measures, demographics and items on bullying and cyberbullying.

Results: The survey included 21,437 respondents (51 % girls, 49 % boys) aged between 13-15 years from 13 countries. The number of respondents in each countries ranged from 945 (483 girls, 462 boys) in Vietnam to 2898 (1468 girls, 1424 boys) in Finland. Among the total respondents, 8.8 % (9.4 % boys and 8.2% girls) reported experiencing bullying in the past 6 months. 2.7 % children reported experiencing cyberbullying (2.9 % among boys and 2.5 % among girls). Finally, 1 % of the total sample reported experiencing both traditional and cyberbullying. The prevalence of any bullying in the last 6 months varied from 3.5% in Greece to 16.9 % in Indonesia. Cyberbullying ranged from 0.4 % in India to 5.8 % in Iran.

Discussion: Despite the unanimous acceptance to the global distribution of bullying as well as its long term sequelae, much of the research till date has been conducted in high income western countries (Craig et al. 2009). This study aims to address the dearth of studies on the phenomenon across non-western low- and middle-income countries (LMIC) countries. Findings from this study will also provide a comparative outlook of the phenomenon between high income and LMIC countries.

Psychiatric symptoms experienced by adolescents in Nepal following the 2015 earthquake: a follow-up study

Sanju Silwal, Roshan Chudal, Ragnhild Dybdahl, Lars Lien, Andre Sourander

Background: 2015 Gorkha earthquake caused around 8900 deaths and displaced more than 450,000 people in Nepal. We assessed the effect of the earthquake on mental health of adolescents over a period of one year.

Methods: About 516 adolescents aged between 11-19 years in school grades 8-10 were selected from two regions, one severely affected than the other. The adolescents were interviewed at the 18^th month after the earthquake and re-interviewed at the 31^th month. The same standardized tools were used in each of the two study phases-specifically, the Child PTSD symptom scale (CPSS) and Depression Self-Rating Scale (DSRS) and same socio-demographic information was collected.

Results: There was significant decrease in PTSS prevalence from 26% to 22% but no significant change was found on the prevalence rates of depressive symptoms from 37% to 35%. Residing in severely affected area, mother’s education and house damage were associated with higher odds for PTSS and depressive symptoms.

Conclusions: The earthquake symptoms of PTSS and depression seemed to persist over time. The finding indicated for interventions who had elevated risk for developing persistent course of the symptoms.

The effect of adding Coping Power Program - Sweden to Parent Management Training. Two year follow up of effects and moderators in a randomised controlled trial

Maria Helander¹, John Lochman², Jens Högström¹, Brjánn Ljótsson¹, Clara Hellner¹, Pia Enebrink¹;

¹Department of Clinical Neuroscience, Division; of Psychology, Karolinska Institutet, Sweden; ²Department of Psychology, University of Alabama, Tuscaloosa, USA

Background: Children with oppositional defiant disorder (ODD) constitute a risk group for development into more severe behavior problems such as conduct disorder (CD), antisocial personality disorder and criminality. Parent Management Training (PMT) is commonly recommended in clinical guidelines in addition to child Cognitive Behavioral Therapy (child-CBT). There is, however a lack of studies investigating the possibly additive effect of group-based child-CBT for children between 8 and 12 years.

Objectives: In the current study, we investigated the incremental effects of group-based child-CBT, the Coping Power Program, when added to the Swedish group-based PMT program KOMET. Outcomes were child behavior problems and social skills and we also evaluated child characteristics as moderators for treatment outcome.

Methods: 120 children in the ages between 8 and 12 years with ODD and their parents were randomized to either group-based child-CBT in addition to PMT (n = 63) or to PMT only (n = 57) in Swedish Child- and Adolescent Psychiatric settings. Participants were assessed pre- and post-treatment using a semi-structured interview, child- and parent ratings and via parent ratings only at one -and two year follow up. For statistical analysis, mixed effects model were used examining time x group interaction.

Results: At post treatment, behavior problems were reduced in both groups, and no interaction effects (time x group) were found. The combination of child-CBT and PMT was significantly more beneficial in improving social skills. Parenting skills were improved in both groups with no interaction effects. Moderator analyses post treatment and at one year follow up indicated that for children with high levels of ODD symptoms, behavior problems significantly improved in the child-CBT and PMT condition compared to the PMT only condition.

Discussion: The results show that PMT is an effective treatment by itself for the majority of children with oppositional defiant disorder. Adding child CBT to PMT increases social skills post treatment. In subgroup analysis, it was shown that children with a high levels of ODD symptoms benefitted more from the combined treatment than from PMT only which was shown in reduced behaviour problems and increased social skills. Results from the two-year follow-up, presentable in august 2018, will answer questions of long term treatment effects on behavior problems and social skills.

A naturalistic effectiveness study of the Cool Kids Programme in outpatient psychiatric clinics for children in Southern Jutland, Denmark

Ida Drejer Djurhuus¹, Aida Bikic^1,2;

¹Department for Child and Adolescent Psychiatry Southern Jutland, Aabenraa, Denmark; ²Department of Regional Health Research, University of Southern Denmark, Odense, Denmark

Background: The Cool Kids programme is a manualised cognitive behavioural treatment programme for children with anxiety disorders.

Previous efficacy studies find that 60-80% of programme completers show marked improvement. It is unclear if the intervention is as effective in real life clinical treatment as only one previous effectiveness study has ever been conducted. The goal of all evidence-based interventions is the successful transition from research environments to standard care clinical practice, but there can be substantial differences in the environment, therapists’ education and patient population in the two settings.

Objectives: The main objective is to investigate the effectiveness of the Cool Kids programme after implementation in two outpatient psychiatric clinics in Denmark.

Methods: We conducted a naturalistic effectiveness study of the Cool Kids programme using the Child Anxiety Life Interference Scale (CALIS) parent-report (N = 39) and child self-report (N = 40). The therapists at the clinics had different educational backgrounds, received different amounts of training in the Cool Kids programme, and no supervision.

Results: We find that the Cool Kids programme successfully decreases the interference caused by anxiety symptoms in both the children’s and the parents’ lives significantly (p < 0.05). The effect was still present at 3 months follow-up (p < 0.05).

Discussion: The intervention significantly decreased the interference caused by anxiety symptoms in both the children and the parents’ lives from pre- to posttreatment and was maintained during the 3-month follow up. No additional significant reduction in interference was detected in the follow up contrary to the results from previous efficacy studies and the only other effectiveness study, which found further significant reduction for the parents in the follow-up. Our results confirm that the Cool Kids programme can be successfully implemented in clinical practice.

Neuro-scientifically based treatment of adolescent depression – preliminary efficacy and proof of concept

Eva Henje Blom¹, Olga Tymofiyeva², Tony Yang³;

¹Department of Clinical Science, Umeå University, Sweden; ²Department of Radiology & ³Psychiatry University of San Francisco.

Background: “Training for Awareness, Resilience & Action” (TARA) is a novel treatment approach for adolescent depression based on cutting-edge neuroscientific understanding of the teenage brain and organized around the Research Domain Criteria of the NIMH. TARA is comprised of 12 sessions arranged in 4 progressive modules, starting with a bottom-up approach of emotion regulation, where teens learn and use breathing techniques and slow synchronized movements to reduce hyper-reactivity of the limbic system. From there, teens learn additional skills to increase their resilience and well-being. The 12-week TARA training is delivered in groups of 6-12 participants. TARA has educational elements in each session.

Objectives: Study 1: In this single-arm pilot study we aimed to test feasibility, acceptability and preliminary efficacy of TARA.

Study 2: The aim of this study was to assess the effects of the TARA training in healthy youth using MRI-connectomics approach.

Methods: Study 1: 26 teenagers with clinical symptoms of depression/anxiety were recruited and participated in TARA. Assessment was done at base-line after and 3 months follow up.

Study 2: 24 healthy teenagers were scanned with MRI and did self-assessment pre and post TARA.

Results: Study 1: Retention 84.6%, the effect size (proportion of variance) for self-assessed depression symptom reduction from baseline to 3-month follow up was 0.83 (RADS-2).

Study 2: While depressive symptoms did not show a significant change, there was an increase of the node strength of the left caudate in participants with improved RADS-2 scores.

Discussion: A novel approach to treat adolescent depression has proved preliminary feasibility and efficacy. Reduction of depressive symptoms in healthy teens were correlated to increased node strength in the reward circuitry of the brain. On-going studies and future aims and implications will be discussed.

Disseminating Internet-delivered CBT for Children in an Outpatient Clinic in Rural Sweden – an ongoing study

Sarah Vigerland^1,2, Fabian Lenhard^1,2, Kristina Aspvall^1,2, Maral Jolstedt^1,2, David Mataix-Cols ^1,2, Brjánn Ljótsson¹, Eva Serlachius^1,2;

¹Centre for Psychiatry Research, Department of Clinical Neuroscience, Karolinska Instituttet; ²Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden

Background: Internet-delivered cognitive behavior therapy (ICBT) for children with anxiety and related disorders has shown promising results in several randomized clinical trials. At the child- and adolescent psychiatry in Region Jämtland Härjedalen, a rural area of Sweden, there is only one outpatient clinic, resulting in travel times of up to three hours for some families. A pilot-feasibility trial (n=19) in Region Jämtland Härjedalen previously showed that both participants and clinicians accepted the ICBT-treatment and that ICBT was effective for a proportion of the children (Jolstedt et al., 2018).

Objectives: The aim of the present study is to evaluate the effectiveness of ICBT when disseminated at the same rural clinical setting in Region Jämtland Härjedalen.

Methods: During two years (October 2016-September 2018) children and adolescents with anxiety disorders or obsessive compulsive disorder (OCD) will be consecutively included in this open trial and offered 12 weeks of therapist-guided ICBT. Exclusion criteria will be kept to a minimum. Patients are assessed through face-to-face interview and online questionnaires (child and parent ratings) at baseline before inclusion, and again after 12 (post-treatment) and 24 (follow-up) weeks.

Results: Preliminary results will be presented. Between October 1^st 2016 and August 22^nd 2018, 158 patients have been referred to ICBT. So far, 92 (58%) interviews have been conducted and 74 (47%) have started treatment. Of those who have completed treatment so far, 11 (18%) have dropped out of treatment. On average, 8 of 12 internet-modules have been completed by participating families. So far, 48% of patients have been discharged from the clinic after ICBT-treatment and the three-month follow-up period.

Discussion: So far, both clinicians and patients have shown interest in ICBT as a treatment alternative at the clinic. This study will provide important information on the acceptability and effectiveness of ICBT when disseminated in a rural outpatient clinic within Swedish regular health care.

MEGA - Building capacity by developing and implementing mobile application for youth mental health assessment

Heikki Ellilä¹, Elsie Breet², Fabian Chapman³, Marita Coetzee⁴, Gerhard Grobler⁵, Gunter Groen⁶, Ronelle Jansen⁴, Deborah Jonker², Astrid Jörns-Presentati⁶, Joonas Korhonen¹, Irene Mbanga⁷, Patricia Mukwato³, John Mundenda⁸, Lonia Mwape³, Soraya Seedat⁷, Dan Stein ², Thomas Sukwa⁸, Sharain Suliman⁷, Timo-Juhani Turunen⁹, Karlis Valtins⁹, Leigh Van den Heuvel⁷, Ruth Wahila³, Mari Lahti¹;

¹Turku University of Applied Sciences, Finland; ²University of Cape Town, South-Africa; ³University of Zambia, Zambia; ⁴University of Free State, South-Africa; ⁵University of Pretoria, South-Africa; ⁶Hamburg University of Applied Sciences, Germany; ⁷Stellenboch University, South-Africa; ⁸Lusaca Apex Medical University, Zambia; ⁹Riga Technical University, Latvia

Background: Promoting mental health is one of the main targets of UN´s SDG 2030. It has brought a focus to the prevention and treatment of non-communicable diseases, including child and adolescent mental health disorders, which constitute a major challenge for sustainable development. Thus, innovative strategies are needed to find effective solutions to promote good mental health and prevent depression and other relevant mental health problems. The MEGA project is an EACEA funded (no: 585827-EPP-1-2017-1-FI-EPPKA2-CBHE-JP).

Objectives: The goal of the MEGA project is to contribute to widening access to mental health services and proper care for children and adolescents. Sub-objectives are to: (1) Investigate the mental health literacy of Primary Health Care (PHC) practitioners to identify areas in need of development; (2) Develop a locally relevant m-health application to screen for common child and adolescent mental health problems; (3) Implement and evaluate a tiered education and training program in the use of the m-health application and related mental health content; (4) Evaluate the acceptability and feasibility of the m-health application in PHC centers at sites across South Africa and Zambia.

We hypothesize that: 1) PHC practitioners are lacking in mental health knowledge relating to children and adolescents; 2) The Education/training in the area of child and adolescent mental health care and use of the app will (a) improve mental health literacy among primary health care workers and (b) screening of common psychiatric disorders in youth; 3) Use of the app by PHC practitioners will be acceptable and feasible.

Methods: A combination of action research and mixed methods will be explored. Firstly, we will conduct a survey in South-Africa and Zambia of PHC practitioners. Secondly, we will develop an m-health app assessment tool for youth mental health problems. Lastly, we will pilot the m-health app in five regions in South-Africa and the capital area of Zambia, and conduct a feasibility survey on the usefulness of the app.

Results: Outputs are: 1) Knowledge about South-African and Zambian PHC practitioners mental health literacy, and educational needs; 2) M-health application assessment tool for common mental health problems of young people; 3) Trained HEI personnel and primary health care workers; 4) Results of a pilot study which tested the m-health application assessment tool in primary health care settings in South-Africa and Zambia.

Discussion: By identifying gaps in PHC practitioner knowledge with regard to child and adolescent mental health, providing training to address these gaps and developing a locally relevant m-health tool to screen for these problems, we hope to improve child and adolescent access to mental health services and care in Southern Africa.

Assessment of children entering out-of-home care – A model evaluation

Einar Heiervang;

University of Oslo, Norway

Background: Recent guidelines recommend routine trauma-informed assessment of children entering out-of-home care, but few models exist on what the assessment should cover.

Objectives: Systematic evaluation of a new model for assessment of high-risk children, in collaboration between child welfare and mental health services.

Methods: Two multi-professional teams have been established to assess health and care needs of children entering care. The assessment is performed on a single day, and includes observation, testing, questionnaires and interviews.

Results: To date 60 children aged 0-17 years have been assessed. Process and outcome evaluation of the model starts this year and will continue over the next three years. Informal feedback from team members, youth, carers and child welfare offices have been positive.

Discussion: The model seems to have the potential for national implementation, as a new service for high-risk children.

Development and implementation of a group based mental health intervention for unaccompanied minors

Ferdinand Garoff, Samuli Kangaslampi, Kirsi Peltonen;

University of Tampere, Finland

Background: Unaccompanied refugee minors (UMs) are five times more likely than accompanied refugee minors to experience severe symptoms of anxiety, depression and posttraumatic stress (Derluyn, Broekaert, & Schuyten, 2008). However, research on psychotherapeutic interventions with UMs is very limited (Demazure, Gaultier, & Pinsault, 2017).

Objectives: Trauma-focused CBT interventions are recommended for traumatized youths (NICE, 2014). However, the availability of this kind of treatment for UMs is lacking in Finland. This presentation describes a trial of the first stage of a stepped model of trauma care developed in the Traumatized Adolescents seeking Asylum (TASA)-project (http://www.uta.fi/yky/TASA/en/index.html).

Methods: The full model includes a preventive group intervention as a first stage, followed by an individual trauma focused intervention for those in need as a second stage. A 10-session group-based intervention focused on stabilizing the current situation and preventing the mental health problems of participating unaccompanied minors. The intervention was conducted in 3 accommodation units for UMs in Southern Finland. Quantitative data was collected with questionnaires at baseline and endline with CRIES (Smith et al., 2003), SDQ (Goodman, 1997) and a resilience questionnaire (Kangaslampi et al., 2015) developed in a previous study. Qualitative data was collected through brief ethnographic interviews (Hubbard, 2012) with staff and participants. Focus group discussions (Krueger, 2000) and most significant change stories (Davies and Dart, 2005) were collected from all 10 group facilitators.

Results: The group processes were completed by 18 UMs in 5 groups. Group processes differed, but difficult and important issues were discussed and trust was built between staff and youths. The questionnaires and interviews revealed moderate to high levels of trauma symptoms experienced by the participants. FGDs indicated that by promoting sociability and self-expression in a structured peer-support setting, trust was built between accommodation unit staff and participating UMs. However, no statistically significant changes were detected in any of the mental health variables studied, likely due to the limited sample size.

Discussion: The group model promoted social interaction and built trust in the accommodation units. Further studies are required to confirm the effectiveness and impact of the model, as well as the initial impression that the groups promote help seeking among UMs.

Treating children and adolescents with multiple traumas – A pragmatic randomized controlled trial of Narrative Exposure Therapy

Samuli Kangaslampi, Kirsi Peltonen;

University of Tampere, Finland

Background: Millions of children and adolescents worldwide suffer from posttraumatic stress disorder (PTSD) symptoms due to prolonged exposure to traumatizing events. Forms of cognitive-behavioural therapy are commonly used for treatment. Still, evidence on their effectiveness in clinical settings among children is limited. We also know little about whether different treatments achieve their effects via the same or dissimilar processes.

Objectives: We conducted a multicentre, pragmatic, randomized controlled trial on the effectiveness and mechanisms of change of Narrative Exposure Therapy (NET) in multiply traumatized children and adolescents.

Methods: A total of 50 9–17-year-old participants multiply traumatized by refugeedom or family violence and suffering from PTSD symptoms were randomized into NET (n = 29) and treatment as usual (TAU, n = 21) active control groups. We assessed PTSD symptoms and quality of traumatic memories before, during and after treatment, and at 3-month follow-up with self-report instruments.

Results: ANOVA results revealed that PTSD symptoms decreased regardless of treatment group. Intention-to-treat analyses employing linear mixed models confirmed these results. However, within-group analyses showed that the decrease of symptoms and reduction in the share of participants with clinical-level PTSD was significant in the NET group only. In lagged longitudinal mediation analyses, we found that improvements in the quality of traumatic memories during treatment drove subsequent improvements in PTSD symptoms regardless of treatment group.

Discussion: Despite the substantial shortcomings of the current study, it gives preliminary support for the effectiveness and usefulness of NET among multiply traumatized children and adolescents in clinical settings. Close attention must be paid to the implementation of the new intervention as an everyday tool in health care settings. The study tentatively supports the idea that the problematic, excessively sensory, fragmented or disjointed qualities of traumatic memories may be an important target of treatment, at least among those adolescents with multiple experiences of interpersonal trauma.

Psychiatric Live Animotion Intervention (PLAI) – an eMentalHealth Intervention for young children with Autism Spectrum Disorder (ASD)

Nadia Rønn Nørgaard, Cathriona Cantio, Niels Bilenberg; Research Unit at the Child and Adolescent Psychiatric Department, Odense University Hospital, Denmark

Background: Individuals with Autism Spectrum Disorder (ASD) have deficits in social-communication and a tendency to engage in restricted behaviors and interests. The interests often evolve around technical features and animated characters. Numerous ASD interventions have been proposed in the technical area such as robot interventions. However, robots are not able to monitor and respond to the individual’s social initiatives in the same way as humans, they can be very expensive, and they often have latency during interaction. Telepsyciatric treatments (eMentalHealth), where the interaction is interactive, can be a way to diminish previous methodological and technological limitations seen in robot interventions. However, the effect of eMentalHealth has not yet been explored in individuals with ASD.

Objectives: The objectives of this study are to develop an effective and playful eMentalHealth intervention for preschool children with ASD and to validate this solution scientifically.

Methods: The Danish company Rokoko has developed a new and innovative animation concept-called ‘Animotion’: A therapist puts on a suit that registers every movement of his/her body and transfers them to an animated character in a virtual world. The animated character is streamed live on the Internet to the individual’s computer and a live recording of the individual is projected back to the therapist. It is hypothesized that this may induce social-communication at another level in children with ASD by providing a simplified and interesting playful universe. The current study is a two-armed RCT study with a parallel design. The study will evaluate the effectiveness of the Psychiatric Live Animotion Intervention (PLAI) in improving social, behavioural, and communicative outcomes in preschool school children with ASD.

Results: PLAI won the ‘Young Innovators Competition’ at the European Telemedicine Conference in 2015. The trial will begin in Mai 2018 and the initial results can be presented at NordCAP 2018.

Discussion: For the young ASD children and their families PLAI offers an opportunity to engage in an early intervention, which is currently not provided to this group.

This early intervention may not only calm the parents, who are often in a crisis about the non-existing interventions for their children, but also help the children engage in social interactions and develop their communication and daily living skills in a fun and playful environment.

Organizational skills training for children with ADHD

Aida Bikic, Søren Dalsgaard, Denis Sukhodolsky;

Child and Adolescent Psychiatric Services Aabenraa, Region of Southern Denmark; Department of Regional Health Research, Faculty of Health, University of Southern Denmark; National Center of Register-based research, Department of Economics and Business, Aarhus University, Denmark; The Child Study Center, Yale School of Medicine, Yale University, New Haven, USA

Background: In addition to problems with attention and hyperactivity, children and adolescents with ADHD present with poor organizational skills that are required for managing materials and time demands of academic projects. In addition, problems such as procrastination and failure to plan, prioritize, and organize academic tasks tend to increase from childhood to adolescence. Organizational skills training (OST) is a behavioral intervention that has been increasingly used to address these deficits in children with ADHD as difficulties with time management and organization of materials tend to persist despite medication and behavioral treatments. OST is a developing area of research showing that OST leads to large improvements in organizational skills of children with ADHD as rated by parents and moderate improvements as rated by teachers. Given the strong association between organizational skills and functional outcome, it is very important to address organizational skills early in life. This is the first randomized and controlled trial of organizational skills in Europe and in Denmark and the first trial to use objective cognitive tests to investigate which patients benefit most from the program.

Objectives: The primary objective is to investigate if organizational skills training has a positive effect on organizational skills. Secondary and exploratory outcomes are including cognitive functions, symptoms, behavioral and functional outcomes before and after the intervention period and in a 24 week follow-up. An additional objective is to investigate which cognitive profiles benefit the most from the program.

Methods: We are currently conducting a randomized clinical superiority trial investigating the effect of Organizational Skills Training, a group treatment approach for parents and children. The program is also involving a computerized program, vTime, that will help the children manage time more effectively. We have currently randomized 40 children with ADHD aged 7-13 years to either intervention or control group in a single blind design. Both groups receive treatment-as-usual. The intervention group is participating in a group training for parents and children for 10 weekly sessions.

Results: Preliminary results will be presented at the meeting

Perspectives: This study will provide important new knowledge and expand on existing research in the field of non-pharmacological treatment of children with ADHD. Organizational skills training can make a significant impact on the lives of children with ADHD and help them learn how to compensate for the present deficits. This could help children with ADHD to perform better in everyday life and school and become more independent. This trial is the first European trial on organizational skills training.

Organizational skills training for children with ADHD

Kristoffer Dalsgaard Olsen¹, Aida Bikic^1,2;

Department for Child and Adolescent Psychiatry Southern Jutland, Aabenraa, Denmark; ²Department of Regional Health Research, University of Southern Denmark, Odense, Denmark

Background: Attention Deficit/Hyperactivity Disorder (ADHD) is a common neurodevelopmental disorder that affects approximately 5% of children in the general population. As defined by the Diagnostic and Statistical manual of mental disorders (DSM-IV) four out of the nine ADHD symptoms of inattention relate directly to problems with organization (e.g. loose things, is forgetful, has difficulties organizing tasks and fail to finish tasks). Organizational skills are often of chronic nature and have adverse consequences for the individual with ADHD. It is critical to intervene early and address these impairments in order to prevent some of the adverse outcomes as the organizational challenges increase with age. Organizational Skills Treatment (OST) is a behavioral based intervention that aims to strengthen the development of organizational skills in children with ADHD. OST represents a growing area of research which shows that OST has a positive effect in organizational skills in children with ADHD (Large effect as rated by parents and moderate effect as rated by teachers) research also indicate a lesser but positive effect in areas of attention and in academic results. This will be the first randomized and controlled trial of organizational skills in Denmark and the first trial to use objective cognitive tests to investigate a possible effect of organizational skills training on cognitive functions.

Methods: In addition to the randomized and controlled trial and the use of quantitative and objective measures a small qualitative study is conducted in order to investigate the potential effect of OST in the everyday life and function of the child and the family as experienced by the parents. A semi structured interview protocol is used as the research method. Two pairs of parents are interviewed separately using the same interview protocol. One pair of parents is selected from Child and Adolescent Psychiatric Services Aabenraa and the other from Child and Adolescent Psychiatric Services Vejle. The qualitative semi structured interview approach is used in order to explorer the experienced effect of OST in the everyday life of the child and the family, results that are otherwise difficult to achieve in a RCT-study.

Results: The results are presented in two cases depicting the different information gathered in the two interviews. The results will be presented at the meeting.

Diet interventions in children with attention deficit hyperactivity disorder (ADHD) and comorbidities: review and results from an Icelandic pilot intervention study

Bertrand Lauth, Bryndís Eva Birgisdóttir, Ólöf G. Geirsdóttir, Ingibjörg Karlsdóttir, Elínborg Hilmarsdóttir, Freydís Hjálmarsdóttir, Sigurveig Þ. Sigurðardóttir, Þórhallur Halldórsson, Inga Þórsdóttir;

University of Iceland, Landspitali University Hospital

Background: In the field of child and adolescent psychiatry, the results of several studies on the influence of different diets will be reviewed, with focus on both behavioral and emotional disorders. An Icelandic pilot intervention study will be presented, focusing on compliance and symptoms.

Objectives: The aim was to investigate the impact of two diets of interest, the healthy diet and the temporary few foods diet (few allergens).

Methods: Participants were children who had been diagnosed with ADHD and comorbidities at the two main diagnostic centers in Reykjavik, with 29 children randomized into three groups: healthy diet (n = 10), few foods diet (n = 10) and a control group (n = 9). A three-day food diary and comprehensive questionnaires gave information on diet and symptoms. Direct psychiatric assessments of children were also made. Compliance checklists were designed.

Results: Full participation rate was 68%. Results showed that baseline diet was not in line with dietary recommendations. Compliance to the diets was generally good (70-80%). The use of both broad-band and specific multi-informant questionnaires showed that both diets could impact significantly psychiatric symptoms, in different ways. No changes were seen in the control group.

Discussion: The formulation of possible clinical recommendations will be discussed.

Early medical adversity in twins and environmental etiologies of autism

Torkel Carlssont^1,2,3, Sven Bölte^1,3,4;

¹Center for Neurodevelopment Disorders at Karolinska Institutet (KIND), Division of Neuropsychiatry, Department of Women’s & Children’s Health, Karolinska Institutet &²PRIMA Child & Adult Psychiatry; ³Centre for Psychiatry Research, Stockholm County Council; ⁴Child and Adolescent Psychiatry, Stockholm County Council, Sweden

Background: Autism Spectrum Disorder (ASD) is a neurodevelopmental disorder (NDD) of mostly unknown etiology. Establishing reliable tools for early detection of ASD is a clinical research priority. A limitation of most studies investigating environmental risks for ASD is that the influence of genetic factors on different environmental exposures has not been accounted for.

Objectives: The objective of this doctoral research program, is:

to explore associations between ASD, autistic traits and environmental factors, in particular early medical events

Methods: This series of five studies includes a systematic review on twin and family studies investigating specific early environmental risk factors for neurodevelopment disorders. In addition, 120 twin pairs (including a rare sample of 13 twin pairs discordant for clinical ASD) with varying autistic traits, are examined for intra-pair differences in early medical events. In study 3 and 5, findings from the aforementioned work are attempted to be epidemiologically cross-validated in the large CATSS cohort of >20,000 twins and their association with other NDD:s are examined. In study 4, the Californian ASD twin cohort is examined for intercultural validity.

Results: Early medical events using multisource medical records show an association of intra-pair differences in the MZ-pairs for a cumulative load of early medical events and clinical ASD, autistic traits, and infant dysregulation (Study 2). The other studies are ongoing or in progress.

Discussion: Results of study 2 demonstrate the significance of non-shared environmental contributions to ASD phenoptypes. In clinical practice, these findings may facilitate improved screening and early detection accuracy of ASD. The pending and upcoming study results will help to corroborate and fine-map or reject the preliminary evidence.

School success in childhood and subsequent psychotic-like symptoms and diagnoses in the Northern Finland Birth Cohort 1986

Jouko Miettunen, Meri Lassila, Tanja Nordström, Tuula Hurtig, Pirjo Mäki, Erika Jääskeläinen;

Center for Life Course Health Research, University of Oulu, Finland

Background: Finding childhood predictors for psychosis could provide ways for early intervention and gathering understanding about the mechanism. Low IQ is a known risk factor for psychosis, but evidence about the effect of high IQ is more controversial. Success in certain subjects requires creativity that has also been associated with psychoses in previous studies.

Objectives: To explore the association of school success in childhood assessed by teacher to psychotic-like (prodromal) symptoms in adolescence and to the occurrence of psychoses in adulthood.

Methods: In the general population based Northern Finland Birth Cohort 1986 (n=8 229; 4 193 boys and 4 036 girls) we investigated the relation of learning deficits and special talents at age 8 years both to psychotic-like symptoms measured by PROD-screen at age 15-16 years and the occurrence of psychoses until age 30 years.

Results: Learning deficits were not associated with psychotic-like symptoms. Increase in psychotic-like symptoms was seen with individuals talented in oral presentation (boys: adjusted Odds Ratio (OR) 1.49; 95% confidence interval 1.14-1.96; girls: OR 1.23; 1.00-1.52) or drawing in boys (1.44; 1.10-1.87). Respectively, being talented in athletics was associated with less psychotic-like symptoms with boys (OR 0.72; 0.58-0.90). School success below average predicted less psychotic-like symptoms with boys (OR 0.68; 0.48-0.97). Above average predicted more psychotic-like symptoms with girls (OR 1.22; 1.03-1.44). Occurrence of psychoses was not predicted by learning deficits or special talents.

Discussion: Learning deficits did not seem to increase psychotic-like symptoms or psychosis rate in our sample even though most previous studies have shown this effect. Learning problems are not always connected to increased risk for psychosis, which might be due to special support given in school such as remedial instruction, studying in small groups or in guidance of a school helper, designing personalized curriculums or giving challenged students more time to finish compulsory education. The higher prevalence of psychotic-like symptoms with specially talented can reflect the different kind of relation of creativity and high IQ to psychotic like symptoms compared to full blown psychoses.

The development of WHO ICF Core Sets for ADHD and ASD-results from the preparatory studies

Soheil Mahdi¹, Sven Bölte^1,2;

¹Center of Neurodevelopmental Disorders (KIND), Centre for Psychiatry Research; Department of Women’s and Children’s Health, Karolinska Institutet & Child and Adolescent Psychiatry, Stockholm Health Care Services, Stockholm County Council, Stockholm, Sweden; ²Curtin Autism Research Group, Essential Partner Autism CRC, School of Occupational Therapy, Social Work and Speech Pathology, Curtin University, Perth, Western Australia

Background: ADHD and Autism Spectrum Disorder (ASD) are two common neurodevelopmental conditions associated with significant reduced functioning level. Yet, there are lack of well-established, standardized tools to describe and measure functioning in ADHD and ASD. The WHO’s International Classification of Functioning, Disability and Health (ICF) can bridge this gap by offering a comprehensive biopsychosocial framework to assess functioning in all health conditions, structuring information on Body Functions (BF), Body Structures (BS), Activities and Participation (AP), and Environmental Factors (EF) according to different category levels.

Objectives: To develop ICF Core Sets for ADHD and ASD, i.e. shortlists of ICF categories that are pertinent to individuals with ADHD and ASD, respectively.

Methods: The development of ICF Core Sets for ADHD and ASD comprises four separate international studies, each aiming to capture a specific stakeholder perspective on ADHD/ASD: i) a scoping review (research perspective), ii) an expert survey (expert perspective), iii) a qualitative study with focus groups/individual interviews (client and caregiver perspective), and iv) a clinical cross-sectional study (clinical perspective). Besides descriptive statistics, all studies involved qualitative content analysis (with the exception of study iv), with meaningful concepts extracted and linked to the ICF using established linking rules from the ICF Research Branch.

Results: The ADHD review produced 68 ICF categories (32 AP; 31 BF; 5 EF), while the ASD review yielded 99 categories (63 AP; 28 BF; 8 EF). The ADHD expert survey generated 83 ICF categories (30 AP; 30 BF; 20 EF; 3 BS), which was less than the ASD survey, which comprised 103 categories (37 AP; 35 BF, 22 EF, 9 BS). The ADHD qualitative study identified 82 ICF categories (32 AP; 25 EF; 23 BF; 2 BS), while the ASD study included 110 categories (45 AP; 33 BF; 29 EF; 3 BS). The ADHD clinical study generated 113 ICF categories (50 AP; 33 EF; 30 BF), which was considerably less than the ASD clinical study, which captured 139 ICF categories (64 AP; 40 BF; 35 EF).

Discussion: The broad variation of ICF categories identified in the preparatory studies attest to the heterogeneity of neurodevelopmental conditions. The ICF, with its etiological-neutral approach and focus on functioning and environment, can help professionals derive useful tools from the Core Sets to i) personalize assessments in ADHD/ASD, and ii) facilitate interventions that target individual needs and demands.

Prescribed stimulant use for ADHD rises steadily among children and youth in Finland

Miika Vuori^1,2, Eeva Aronen^3,4; Andre Sourander^2,5, Jaana E. Martikainen¹, Tuulia Jantunen⁴, Leena Saastamoinen¹;

¹Kela Research, Finland, ²University of Turku, Finland, ³University of Helsinki, Finland, ⁴Helsinki University Hospital, Finland, ⁵Turku University Hospital, Finland

Background: Attention-deficit/hyperactivity disorder (ADHD) is one of the most common childhood mental disorders. Recent meta-analyses suggest prevalence rates around 3.4% to 7.2% in children and adolescents.

Objectives: The present study examines the prescribed stimulant use for ADHD in children and youth in Finland between 2006 and 2016.

Methods: Age- and sex-specific population statistics served as denominator in prevalence measures. Data on prescribed stimulants (i.e., methylphenidate, lisdexamfetamine and dextroamphetamine) and atomoxetine in children and youth aged 4–17 from 2006 to 2016 were extracted from the nationwide prescription registry maintained by the Social Insurance Institution of Finland.

Results: Descriptive analysis of the time series indicated that the prescribed stimulant use for ADHD increased steadily. Altogether, 15,036 children and youth aged 4–17 (prevalence 1.8%) received at least one prescribed stimulant medication in Finland in 2016 (boys 2.9%, girls 0.6%). Stimulant use had increased approximately fivefold among boys and sixfold among girls between 2006 and 2016. In 2016, the use of stimulants was most common in boys aged 9–13 (4.3–4.8%; ~ 1.0% in girls). Furthermore, Hospital Districts also showed differences. For example, the prevalence of prescriptions for ADHD drugs in population ranged from 1.0% to 3.8%.

Discussion: Use of stimulants in children and adolescents with ADHD in Finland has increased steadily, yet varies by age, gender and region. For example, despite diminishing gender differences have remained larger when compared to other Nordic countries.

Collecting data on indications, duration of the treatments, adherence, possible adverse effects and other drug-related problems and outcomes should be systematic in Finnish health care. The relative-age effect in the treatment of ADHD in children in Finland also requires closer examination.

Meals, microbiota and mental health of children and adolescents - An observational longitudinal case control study

B. G. Asbjornsdottir, B. E. Birgisdottir, L. S. Gudmundsson, M. Gottfredsson, I. Karlsdottir, O. Smarason, B. Lauth;

University of Iceland, Landspitali University Hospital, Iceland

Background: Recent studies indicate a strong interplay between diet and intestinal microbiota composition, which have been associated with mental health. Chronic low-grade inflammation has been observed in mental health problems such as depression and inflammatory factors are known to affect mood and cognition. These effects might be mediated by alterations in intestinal permeability (IP) where gut microbiota seems to play a critical regulatory role and is affected by dietary factors.

Objectives: The aim of this novel observational longitudinal case-control study is to compare diet, gut microbiota and related metabolic factors among children and adolescents diagnosed with mental disorders and control groups to identify potential patterns.

Methods: All children and adolescents referred to the only outpatient psychiatric clinic in Iceland, over a one-year period, will be offered to participate (N = 150) (5-15 y). Two control groups will be used; same parent siblings close in age (N < 150) as well as age and sex matched children from the same postal area (N = 150). A three-day food diary, rating scales for mental health and multiple questionnaires will be filled out and a fecal sample, buccal swab, urine and saliva samples and blood samples will be collected. Data collection will be repeated in 3 year’s time in same groups. A pilot study will start in autumn 2018 including 15 cases and 15 controls, screening for strengths and weaknesses of the suggested approach. The scientific value is based on a good quality study design, a longitudinal approach and possibilities for subsequent personalized dietary and lifestyle interventions in subgroups.

Discussion: The scientific value is based on a good quality study design, a longitudinal approach and possibilities for subsequent personalised dietary and lifestyle interventions in subgroups. This is a novel approach as more population-based multi-dimensional transdisciplinary studies including longitudinal observational data have been called for as a basis for lifestyle treatment options for improving mental health.

Is experiencing parental separation in childhood or adolescence related to adulthood prenatal depressive symptoms?

Elviira Porthan, Eeva Ekholm, Matti Lindberg, Noora Scheinin, Juho Härkönen, Linnea Karlsson, Hasse Karlsson;

University of Turku, Finland

Background: Experiencing parental separation during childhood or adolescence is associated with depression in adulthood, but it is not yet known whether the separation affects specifically the emergence of depressive symptoms during pregnancy.

Objectives: To study whether experiencing parental separation during childhood or adolescence is associated with prenatal depressive symptoms in adulthood.

Methods: 2923 Finnish women from the FinnBrain Birth Cohort Study were included. FinnBrain data was supplemented with data from Statistics Finland and Finnish Medical Birth Register. Depressive symptoms were assessed with ten-item Edinburgh Postnatal Depression Scale (EPDS). Cut-off value for depressive symptoms was 13, which is commonly used in Finnish maternity health clinics.

The association between exposure to parental separation in childhood or adolescence and adulthood prenatal depressive symptoms was analyzed with multilevel logistic regression. The dependent variable was prenatal depressive symptoms, measured as EPDS total score ≥ 13, and using data from three time points during pregnancy. The independent variable was the separation of the pregnant women’s parents’ during childhood or adolescence. Control variables were age and marital status of the mother during pregnancy, parity and childhood socioeconomic status (childhood household’s reference person’s socioeconomic group).

Results: Pregnant women whose parents had separated were more likely to experience depressive symptoms during their pregnancy than women from intact families (OR 1.52; 95% CI 1.05–2.21) when controlling for age and parity. This association was slightly attenuated being no longer statistically significant at the 5% level after adjusting for childhood socioeconomic status and marital status during pregnancy (OR 1.43; 95% CI 0.97–2.11), while the covariates were not independently associated with the prenatal depressive symptoms.

Discussion: Parental separation in childhood or adolescence was associated with adulthood prenatal depressive symptoms, but the association did not remain significant after adjusting for control variables. Childhood socioeconomic status or marital status during pregnancy were not associated with prenatal depressive symptoms.

The Role of Hair Cortisol Concentration (HCC) as a Biomarker for Prenatal Psychological Distress

Paula Mustonen^1,2, Linnea Karlsson^1,2, Noora M. Scheinin^1,3, Susanna Kortesluoma¹, Bárbara Coimbra⁴, Ana João Rodrigues⁴, Hasse Karlsson^1,3;

¹FinnBrain Birth Cohort Study, Turku Brain and Mind Center, Institute of Clinical Medicine, University of Turku, Finland; ²Department of Child Psychiatry, University of Turku and Turku University Hospital, Turku, Finland;³Department of Psychiatry, University of Turku and Turku University Hospital, Turku, Finland; ⁴Life and Health Sciences Research Institute (ICVS), School of Medicine, University of Minho, Braga, Portugal

Background: Maternal prenatal psychological distress (PD) can have long-lasting effects on the behavior, mental health and neurodevelopment of the offspring. Yet, the mediating mechanisms remain widely unknown. Altered maternal hypothalamus-pituitary-adrenal (HPA) axis functioning is hypothesized to play a key role but the studies assessing short-term cortisol concentrations have yielded inconsistent results. Hair cortisol concentration (HCC), a marker for long-term cortisol levels, could offer new perspective in this field of research.

Objectives: We review the literature on associations between maternal prenatal HCC and PD. In addition, we briefly present results from the FinnBrain Birth Cohort Study regarding these associations.

Methods: We have conducted a systematic review on the topic. Using the FinnBrain Birth Cohort data, we have analysed maternal HCC at gestational weeks (gwks) 24 (N = 551) and 40 (N = 242). PD has been measured with different self-report questionnaires (EPDS, SCL, PRAQ-R2, Daily Hassles, TADS, RDAS) at gwks 14, 24 and 34.

Results: Six studies assessing the associations between maternal prenatal HCC and different types of prenatal PD have been published, so far. The results on associations between PS and HCC are inconsistent and for example the timing of the measurements and type, duration, and severity of PD seem to affect the association. In FinnBrain, weak associations between HCC and some subtypes of PD were observed in mid-pregnancy, while other types of PD were unrelated to HCC.

Discussion: The existing data imply that with low levels of self-reported prenatal PD, the associations with HCC are rather weak and seen only or most clearly in mid-pregnancy. However, consistent associations with self-report questionnaires are not necessary for HCC to depict important aspects of prenatal PD and to be a biomarker for the developmental risk of the fetus, but to gain more insight on this aspect, prospective and transgenerational studies are needed.

Prenatal stress and postnatal maternal depressive symptoms and their association with toddler offspring psychological problems

Rikke Wesselhoeft;

Research Unit of Child and Adolescent Mental Health, Institute for Clinical Research, University of Southern Denmark, Mental Health Services in the Region of Southern Denmark

Background: Maternal stress during pregnancy affects offspring neurodevelopment giving rise to emotional, behavioral and cognitive problems. Similarly, maternal postnatal depression has severe effects on the emotional development of the child. Postnatal depression is a worldwide phenomenon affecting one in ten new mothers, making it the most common medical complication to giving birth. In spite of the common frequency of these severe conditions, they are often let untreated.

Objective: This study aims to examine if prenatal maternal stress is associated with increased offspring psychological problems, also when controlling for postnatal maternal depressive symptoms and previous maternal psychopathology.

Methods: A prospective cohort study design using the Danish Odense Child Cohort (OCC). Information on maternal stress was collected in pregnancy week 28 using the 10-item Cohen’s Perceived Stress Scale. Maternal depressive symptoms were measured at child age 3 months using the Edinburgh Postnatal Depression Scale. Offspring toddler psychopathology was assessed from mothers and caregivers using the Danish version of the Achenbach System of Empirically Based Assessment (ASEBA) preschool forms. Information on parental psychopathology prior to child birth was withdrawn from the Danish Psychiatric Central Research Register.

Results: Prenatal maternal stress was a significant predictor for toddler psychological problems as reported by both mothers and caregivers, when controlling for various covariates including postnatal depression. Postnatal maternal depressive symptoms were only associated with toddler psychological problems as reported by mothers. There was a pronounced mother/caregiver reporting discrepancy, with mothers reporting more toddler psychological problems than caregivers. The discrepancy was positively correlated to maternal postnatal depressive symptoms.

Conclusions: Maternal stress during pregnancy increases the risk for early offspring psychological problems. Postnatal maternal depressive symptoms affect prospective maternal reporting of offspring psychological problems. Future research should focus on investigating the validity of various informant reports regarding toddler psychopathology.

Trends in childhood and adolescent internalizing symptoms: results from nationwide population based twin cohorts

Linda Halldner Henriksson, Natalie Durbeej, Karolina Sörman, Eva Norén-Selinus, Sebastian Lundström, Paul Lichtenstein, Clara Hellner;

Department of Clinical Sciences, Child and Adolescent Psychiatry, Umeå University, Umeå, Sweden; Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden

Background: Trends of increasing internalizing problems (e.g., depression, anxiety), particularly amongst adolescent girls, have been noted in previous research. Population-based studies that assess both anxiety and depression using repeated cross-sectional assessments are lacking, however.

Objectives: To study secular changes in symptoms of depression and anxiety in children and adolescents.

Methods: In this large (n > 28,000) Swedish twin study, we examined trends in internalizing symptoms in the total sample and for boys and girls separately. Participants were assessed at age 9 (parent-rated) and at age 15 (self-and parent-rated). We examined (i) the relation between birth cohorts and internalizing symptoms using linear regressions, and (ii) whether the percentage of participants exceeding cut-off scores of the scales changed over time, using Cochrane Armitage Trend Tests.

Results: Among nine year olds, there was a significantly increasing percentage of participants (both boys and girls) with scores above cut-off on anxiety symptoms, but not on depressive symptoms. At age 15, there was a significantly increasing percentage of participants (both boys and girls) scoring above cut-off particularly on self-reported internalizing symptoms, but only for girls a corresponding trend on parent-reported internalizing symptoms.

Discussion: The results suggest that trends of higher internalizing symptoms in children and adolescents are not exclusive to girls. The reason for higher levels of reported internalizing symptoms, and whether these reflect worse mental health status or changed propensity to report symptoms, has yet to be elucidated. A clinical implication of the results is that internalizing symptoms should be assessed across genders, from childhood and throughout adolescence.

Specific symptoms in adolescence predict psychosis in the Northern Finland Birth Cohort 1986

Tuula Hurtig, Juha Veijola, Pirjo Mäki;

Research Unit of Clinical Neuroscience, Psychiatry, University of Oulu, Finland

Background: A number of psychological symptoms have been found to predict psychosis. However, studies have found no specificity to separate symptoms predicting non-psychotic psychiatric disorders from those predicting psychotic disorders.

Objectives: To find out childhood and adolescent symptoms predicting first episode psychosis in a general population sample.

Methods: The study is based on prospective Northern Finland Birth Cohort 1986 (NFBC 1986). We connected data from the Rutter B2 questionnaire for teachers at the age of 8 years (N = 8258) and from the PROD-screen self-report on prodromal or psychotic-like symptoms at the age of 16 (N = 6514) to later onset of psychosis. The Finnish Hospital Discharge Register was used to detect psychiatric disorders. The follow-up of psychotic and non-psychotic disorders from 1998 to 2008 for Rutter B2 and from 2002 to 2008 for PROD-screen were used. Multiple confounders were used.

Results: High scores in Rutter B2 neurotic and antisocial subscales did not associate with later psychosis. The highest prevalence of positive symptoms in the PROD-screen were in the group of subjects who developed psychotic disorder (65%) compared to subjects who developed non-psychotic disorder (36%; OR 5.7; 95%CI 2.1-15.4, p < 0.001, adjusted for parents’ psychiatric disorder, family structure, family SES, adolescent’s cannabis use, and gender). Respective figures for negative symptoms were 55% in the group of psychotic subjects compared to 30% in subjects with non-psychotic disorder (OR 3.3; 95%CI 1.4-7.7, p = 0.01). Specific positive symptoms like ‘Difficulty in controlling one’s speech, behaviour or facial expression while communicating’ associated specifically with the development of psychosis (OR 9.72; 95%CI 2.73-34.56, p < 0.001) comparing psychotic disorder vs non-psychotic disorder).

Conclusion: In the large prospective population sample, childhood neurotic or antisocial symptoms did not predict psychosis, but adolescent symptoms did. Both positive and negative symptoms in adolescence associated specifically with development of first episode psychosis. In addition, we found specific symptoms strongly predicting psychosis.

APEX consortium, Transferring child and adolescent mental health treatment to awareness, prevention and early intervention

Andre Sourander, Marjo Kurki, Terja Ristkari, Malin Kinnunen, Tarja Korpilahti-Leino, Terhi Luntamo;

University of Turku

Background: The APEX consortium aims to promote the mental wellbeing of families and children, regardless of their socio-economic environment, geographical location or ethnic background. The consortium’s goals are to bring about permanent improvements in mental health awareness and a decrease in the mental health problems that start in childhood.

Objectives: The objectives are to develop and research low-threshold digitally delivered mental health interventions for children, their families and the professionals involved in their care.

Methods: Targeted prevention and early interventions for disruptive behavioral problems in pre-school children (Strongest Families Smart Website, SFSW), anxiety problems among school aged children and maternal antenatal depression (PPD) have been developed. These interventions have been, are currently or will be studied in randomized clinical trials. The participants are screened from the general population. Digitally delivered universal programs, i.e. a positive parenting program for families of three-year-olds and a mental health literacy program for first year university and polytechnic students, have been developed and will be studied using pre-post design.

Results: In an RCT study, altogether 730 of the 4,656 four-year-old children who attended annual child health clinic check-ups in South-West Finland, met the criteria for high level disruptive behavioral problems. 464 parents participated in the 11-week SFSW intervention or educational control (EC) group. When the SFSW and EC groups were compared between baseline and 24 months follow-up, primary outcome of the Child Behavior Check List (CBCL) externalizing score showed significantly higher improvements in the SFSW group (effect size 0.22; p < 0.001). In addition, most of the child psychopathology measures, including aggression, sleep problems, anxiety and other emotional problems decreased significantly more in the SFSW group than in the EC group. Similarly, parental skills increased more in the SFSW group than in the EC group. The treatment effects were maintained until the 24-month follow-up study. Children in the SFSW group also made significantly less use of child mental health services than the EC group during the 24-month follow-up period (17.5% vs. 28.0%).

Discussion: The findings have important public health and clinical implications. The findings emphasize that identifying children at risk in the community at an early stage enabled us to provide an effective parent training program for a large number of families, including many who would not have participated in clinic-based services. This kind of shift to early prevention and intervention is crucial from the perspectives of reducing human suffering, tackling the secondary issues caused by these problems, and economic efficiency.