Study design: Pathways to Independence - A study of unaccompanied minor refugees settled in a Norwegian city municipality.

AIMS: The aim of the 'Pathways to Independence' study was to gain knowledge of how to facilitate a healthy development for unaccompanied refugee minors (URMs) after settling in Norwegian municipalities. METHODS: The project is located in the URM child welfare services (URM CWS) of the Bergen municipality. We invited 101 URMs older than 15 years connected to the URM CWS to participate in a comprehensive survey. Of the invited, 81 consented to participate. The survey included questions on the user's experiences and satisfaction with the URM CWS, and questions related to schooling, social support and activities after settlement. We also included standardized and validated questionnaires on potential traumatic events, mental and somatic health, protective factors and quality of life. These questionnaires have previously been used in two Norwegian epidemiological studies, the 'Youth@Hordaland' and 'Young in Foster care', facilitating comparison of the results with other youth populations in Norway. CONCLUSION: Results from the project will be valuable in the process of reaching knowledge-based recommendations for successful settlement of URMs.

Potential traumatic events and symptoms of post-traumatic stress in unaccompanied refugee minors-a comparison with youth in foster care.

Building knowledge on how child welfare services (CWS) should tailor services for unaccompanied refugee minors (URMs) is important. URMs and youth in foster care are high-risk groups taken care of by the CWS in Norway. Little is known on whether knowledge gained from youth in foster care can inform services for URMs, and if these groups are comparable in terms of experiences of potential traumatic events (PTEs) and post-traumatic stress disorder (PTSD) symptom load. Eighty-one URMs reported PTEs and PTSD-symptoms using an adapted version of the Child and Adolescent Trauma Screen (CATS). Responses were described and compared with a sample of 303 youth in foster care in linear regression models. We present relative risks (RR) and standardized mean differences (SMD) for the PTEs and the PTSD subscale and total score between the groups in forest plots. URMs had experienced a mean (standard deviation) of 6.4 (3.4) PTEs and 43.9% reported to have PTSD-symptoms at or above the clinical cut off. Compared to the foster youth, URMs reported more exposures of interpersonal violence outside of the family (RRs ranging from 66.4 [95%CI 18.1; 243.5) to 1.3 (1.0, 1.5)], and more PTSD-symptoms in the re-experiencing subscale [SMD = 0.3 (95% CI 0.1, 0.6)]. The frequency and types of PTEs and the PTSD-symptom load and profile among URMs and youth in foster care differed. Findings underscore the importance of qualified and targeted care for URMs, and that this care should differ to that of other high-risk groups in the CWS.

Quality of life among young people in Norway during the COVID-19 pandemic. A longitudinal study.

In this study, we aimed to examine health-related quality of life during the COVID-19 pandemic among a general sample of young people in Norway aged 11-19 years. More specifically, we examine: (1) Change over 2 time-points in five health-related quality of life dimensions, (2) Whether sociodemographic- and COVID-19-related factors contributed to change in these five dimensions, (3) Whether parental stress and socioeconomic status at T1 interacted with change in health-related quality of life across T1 and T2. Data collection lasted from April 27th to May 11th, 2020 (T1), and from December 16th, 2020, to January 10th, 2021 (T2). Youth aged 11-19 years (N = 2997) completed the KIDSCREEN-27, COVID-19 related and sociodemographic items. Parents (N = 744) of youth aged 15 years and younger completed the parental stress scale and sociodemographic items. Physical and psychological wellbeing declined significantly from March to December 2020. Subscale scores for social support and peers increased. Controlling for a broad number of sociodemographic and COVID-19-related factors did not make an overall impact on the estimates. Those worried about infection, older aged, girls, and youth born outside Norway had a steeper decline in health-related quality of life subdimensions from T1 to T2. In the wake of the COVID-19 pandemic, we warrant special attention to the recovery of youth's physical and psychological wellbeing.

Parental stress during the COVID-19 pandemic: A one-year follow-up.

OBJECTIVE: This two-wave longitudinal study aimed at increasing knowledge about levels of parental stressors and rewards among mothers and fathers of children aged 1-18 during the first year of the COVID-19 pandemic in Norway. BACKGROUND: The COVID-19 pandemic and infection-control measures have caused changes to family life. Managing homeschooling or caring for younger children while working from home may have posed significant strain on parental stress, negatively impacting the quality of parent-child relationships and parents' sensitivity to their children's needs. METHOD: We employed data collected in April 2020 and April 2021 from the longitudinal population-based survey in Bergen/Norway (Bergen in ChangE-study). 7424 parents participated (58.6% mothers and 41.5% fathers). RESULTS: The overall levels of parental stressors and rewards did not change significantly. Over the two time points, the factors associated with decreased parental stressors were being male, aged 40-49 years, having a relatively high income, and reporting initial difficulties with closed kindergartens or schools. For parents aged 18-29 years, the level of parental stressors increased. CONCLUSION: The study suggests that the overall levels of parental stress remained unchanged during the first year of the pandemic. Even so, the study also uncovered that younger parents represented a vulnerable subgroup. IMPLICATIONS: To prevent detrimental consequences in the wake of the pandemic, it could be important to increase awareness and competence among professional staff in kindergartens, primary schools, and child health clinics targeting young parents and their children.

Increased Gaming During COVID-19 Predicts Physical Inactivity Among Youth in Norway-A Two-Wave Longitudinal Cohort Study.

Background: A concern for the COVID-19 measures and the potential long-term consequences the measures may have on physical inactivity and gaming among youth. Objectives: Examine the stability and change in internet and offline gaming and the association with physical inactivity among adolescents in Norway during the pandemic. Methods: A total of 2940 youth (58% girls) aged 12-19 years participated in an online longitudinal two-wave survey during the first Norwegian national lockdown in April 2020 (t1) and in December 2020 (t2). Gaming behavior and physical activity status were assessed at both time points. Age, gender, and socioeconomic status were included as covariates. Results: Among boys, 41% reported gaming a lot more and 35% a little more at t1 compared to before the national lockdown. The corresponding numbers for girls were 14 and 23%, respectively. In fully adjusted analysis, a pattern of increased gaming at t1 followed by an additional increase in gaming reported at t2 was associated with physical inactivity at t1 (OR = 2.10, p < 0.01) and t2 (OR = 2.45, p < 0.001). Participants gaming more at t1 followed by a reduction at t2 had higher odds of inactivity at t1 (OR = 1.88, p < 0.01). Youth reporting no gaming at t1 had lower odds for inactivity at this time point (OR = 0.67, p < 0.05). Conclusions: Increased gaming among many youths and a relationship with physical inactivity was observed during the first phase of the COVID-19 pandemic. To counteract the negative long-term impacts of COVID-19 restrictions, public health initiatives should emphasize the facilitation of physical activity in youth and develop effective strategies to prevent problematic gaming.

Emerging mental health problems during the COVID-19 pandemic among presumably resilient youth -a 9-month follow-up.

BACKGROUND: The COVID-19 pandemic may have multifarious adverse effects on the mental health of some youth. To our knowledge, no study has followed young people beyond the first 6 months of the pandemic outbreak. The aim of this study was to examine 1) Change in internalizing, externalizing, and total mental health problems over two time-points with a nine-month interval during the COVID-19 outbreak and 2) Whether contextual and COVID-19-related factors contribute to change in mental health problems. METHODS: Youth within the municipality of Bergen aged 11-19 years were invited via SMS to participate in an online survey in April and again in December 2020. A total of 2997 (40% response rate) youth participated at baseline in the present study, and 1598 (53.3%) completed the second survey. At baseline, the mean age was 16.0 (standard deviations 1.7) years, about 60% were girls, and 93% were born in Norway. Comparison across time was approached using inferential statistics and mixed linear models with maximum likelihood estimation and mixed-effects logistic regression models. RESULTS: There was an overall increase in total mental health problems from the first weeks into lockdown to 9 months after the pandemic outbreak. The overall increase seems to be exclusively driven by internalizing difficulties, i.e., increases in emotional problems and peer problems. The level of externalizing difficulties, i.e., conduct problems and hyperactivity/inattention remained stable between the two time-points. CONCLUSIONS: Our results imply that in the wake of the pandemic, one should be aware of emerging mental health problems among presumably resilient youth, in addition to the more expected and pronounced mental health needs of vulnerable groups. Efforts to reach out to the general youth population with preventive measures in schools may be important actions to normalize the situation for young people, and to identify those in need of more targeted mental health interventions.

Internalizing Symptoms Among Youth in Foster Care: Prevalence and Associations with Exposure to Maltreatment.

Among youth in foster care (N = 303, aged 11-17 years), we investigated prevalence of internalizing symptoms; associations between symptom level and maltreatment types and numbers; and the interaction between gender and maltreatment, on internalizing symptoms. Youth completed Spence Children Anxiety Scale, Short Mood Feelings Questionnaire, and Child and Adolescent Trauma Screen. Compared to community samples, symptom levels above clinical cut-off was more frequent, with social- and generalized anxiety (ES = 0.78-0.88) being most prevalent among youth in foster care. Girls reported more internalizing symptoms (ES = 0.59-0.93). Sexual abuse and neglect were associated with a broader range of internalizing symptoms (ES = 0.35-0.64). Increased incidence of maltreatment was associated with increased levels of symptoms (ES = 0.21-0.22). Associations between maltreatment and symptom level were stronger for girls. This study stresses the importance of broad screening of maltreatment and internalizing symptoms to meet the needs of youth in foster care.

Mental health and use of health care services in opioid-exposed school-aged children compared to foster children.

Given the concerns raised regarding the effects of prenatal exposure to methadone and buprenorphine on the developmental outcomes of the children, this study assessed mental health and use of services in a national sample of school-aged children (N = 78) born to women enrolled in opioid maintenance treatment during pregnancy, compared with a group of foster children (N = 140). The majority of the opioid-exposed children lived with their birth parent(s) at the time of assessment (N = 62), while 16 lived in foster homes. Caregivers completed the Strengths and Difficulties Questionnaire (SDQ) and the Reactive Attachment Disorder scale. Teachers completed the SDQ. Three kinds of services were included in measuring service use: school-based education services, child mental health services, and hospital-based habilitation services. The main finding of the study is that children prenatally exposed to methadone or buprenorphine living with their family of origin had significantly better mental health status than their foster-placed counterparts and that of the comparison group of foster children. In addition, the exposed children living at home had less child welfare involvement, and only half of them were using any of the three services measured. The odds for using services increased significantly in accordance with increasing mental health problems, independent of group affiliation, indicating a need-based access to services. In line with other studies, we found that the odds for using one or more services was 2.3 times greater for boys than for girls. Our results contribute to a more-nuanced understanding of the developmental outcomes of prenatal exposure to methadone and buprenorphine, and factors associated with increased service use in groups of at-risk children.

Development and Validation of a Measure of Attachment Disorders Based on DSM-5 Criteria: The Early TRAuma-Related Disorders Questionnaire (ETRADQ).

BACKGROUND: A review of the scientific literature showed few valid tools for assessing reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED), two diagnostic entities traditionally grouped under "attachment disorders." The Early TRAuma-related Disorders Questionnaire (ETRADQ), a caregiver report, was developed to assess attachment disorders in school-age children based on the Diagnostic and Statistical Manual of Mental Disorders-Fifth edition criteria. This study sought to validate this instrument. METHOD: Caregivers of school-age children from the community (n = 578) and caregivers of at-risk children adopted or in out-of-home care (n = 245) completed a sociodemographic questionnaire, the ETRADQ, the Relationship Problem Questionnaire, the RADA (RAD and DSED Assessment) interview, and the Barkley Functional Impairment Scale for Children and Adolescents. RESULTS: Confirmatory factor analysis of the ETRADQ items supported the expected organization of the measure, that is, two second-order factors and five subfactors: (1) RAD scale (three subscales: Low selective attachment, Low social and emotional responsiveness, Emotional unpredictability) and (2) DSED scale (two subscales: Interactions with unfamiliar adults, Social disinhibition). All scales showed excellent internal consistency, test-retest reliability, convergent validity, and known-group validity. CONCLUSIONS: Results support the reliability and validity of the ETRADQ.

How the Norwegian population was affected by non-pharmaceutical interventions during the first six weeks of the COVID-19 lockdown.

AIMS: The aim of this study was to examine how the Norwegian general adult population was affected by non-pharmaceutical interventions during the first six weeks of the COVID-19 lockdown. We assessed quarantine, symptoms, social distancing, home office/school, work status, social contact and health-care contact through digital access and knowledge. METHODS: A cross-sectional survey was performed of 29,535 adults (aged 18-99) in Norway after six weeks of non-pharmaceutical interventions in March/April 2020. RESULTS: Most participants found the non-pharmaceutical interventions to be manageable, with 20% of all adults and 30% of those aged <30 regarding them as acceptable only to some or a limited degree. Sixteen per cent had been quarantined, 6% had experienced symptoms that could be linked to COVID-19 and 84% practiced social distancing. Eleven per cent reported changes in the use of health and social services. Three-quarters (75%) of those who had mental health or physiotherapy sessions at least monthly before the pandemic reported a reduction in their use of these services. A substantial reduction was also seen for home nursing, hospital services and dentists compared to usage before the non-pharmaceutical interventions. Immigrants were more likely to experience a reduction in follow-up from psychologists and physiotherapy. With regard to the use of general practitioners, the proportions reporting an increase and a reduction were relatively equal. CONCLUSIONS: The non-pharmaceutical interventions were perceived as manageable by the majority of the adult general population in Norway at the beginning of the COVID-19 pandemic. A substantial proportion of adults <30 years old experienced difficulties with social distancing, and those >70 years old lacked the digital tools and knowledge. Further, immigrant access to health services needs monitoring and future attention.

'We are unlikely to return to the same world, and I do not want it to destroy my future.' Young people's worries through the outbreak of the COVID-19 pandemic.

This study aims to explore what worries youth were having during the seventh to ninth week of the COVID-19 lockdown. Our findings build on the responses to an open-ended survey question from 1314 youths. The worries covered three main themes: 'That my mom dies, then I am left all alone': worries related to COVID-19 virus infection; 'To me, this is lost youth': worries about the consequences of measures for the present life and near future; and 'I will face a very difficult life in the future': worries about the consequences of measures for the outlook on life. Young people worried that the measures would have a huge impact on their present life and outlook on life. The costs of restriction measures were unevenly distributed and indicated that the measures affected their mental health. Listening to youth voices during the pandemic is important for practitioners, educators and policymakers. The results indicate that the threshold for closing schools also including the provision of distance learning should be kept high. Social and health services for youth should offer early intervention and be prepared for an escalation in mental health problems in the imminent future.

Internalizing Symptom Profiles Among Youth in Foster Care: A Comparison Study.

Background: A high prevalence of anxiety and depression is found among youth in foster care. There is limited knowledge on the anxiety and depression symptom profiles of youth in foster care. We examined latent profiles of anxiety and depression symptoms across three unique youth samples and whether youth in foster care were more or less likely to belong to specific symptom profiles than their peers recruited from clinical or general youth populations. We also investigated if these profiles were predicted by sex and age. Methods: Self-reported anxiety and depression symptoms were assessed by Spence Children's Anxiety Scale and Short Mood and Feelings Questionnaire. Data were pooled from three youth samples (N = 2,005; mean age = 13.9 years, range = 11-18 years) comprising youth in foster care (n = 245), a clinical youth sample (n = 107), and a general population youth sample (n = 1,653). Symptom profiles were identified using latent profile analyses. Multinominal logistic regression was used to predict the latent profile membership. Results: Three profiles that differed both in symptom level and shape were identified and labeled as low, medium, and high symptom profile. Compared to the general population youth sample, youth in foster care had a higher likelihood of belonging to the high symptom profile, but not the medium symptom profile. Youth from the clinical sample had an increased risk of belonging to the medium and high symptom profiles compared to the youth in foster care and general population youth samples. Across samples, girls yielded a higher likelihood of having a medium or high symptom profile. Increasing age was associated with a higher likelihood of being in the high symptom profile. Conclusion: Compared to their counterparts in the general population, youth in foster care are at risk of belonging to a class of youth with high symptom levels across subtypes of internalizing symptoms, indicating the importance of systematic and broad assessment of internalizing symptoms among these youth. Knowledge on the symptom profiles of anxiety subtypes and depression increases our understanding of the treatment needs of youth in foster care.

Perceived consequences and worries among youth in Norway during the COVID-19 pandemic lockdown.

Aims: To examine perceived consequences for everyday life, learning outcomes, family relations, sleep problems and worries for infection, for friends and their future, among youth aged 12-19 years during weeks 7 to 9 of the COVID-19 lockdown in Norway. We examine variations by age, gender, socioeconomic status and country of birth. Methods: Youth within the municipality of Bergen were invited via SMS to participate in a 15-minute online survey. A total of 2997 (40%) youths participated. The mean age was 17 years (standard deviation 1.7). Results: Overall, 28% reported feeling somewhat to a lot impacted by schools closing, 63% reported learning less. In total, 62% reported improvement of everyday life. The youth's situation in their family was worse for 13%. Regarding sleep problems, 19% reported difficulties initiating and maintaining sleep, 12% had more nightmares, while 90% reported later bedtime and rise time. Seven per cent worried about getting infected, while 53% worried about infection among family members. A total of 19% worried that the outbreak would lead to a more difficult future, and 32%worried that friends were facing a difficult situation at home. Perceived consequences and worries related to the lockdown varied across sociodemographic groups. Conclusions: The perceived consequences and degree of worries varied by age, gender, socioeconomic status and to a certain degree country of birth. Girls, older youth, youth with lower socioeconomic status and with a migrant background from developing countries seemed to experience the lockdown as more difficult, and thereby possibly accentuating the need for services in these groups.

Meta-Analyses of the Associations Between Disinhibited Social Engagement Behaviors and Child Attachment Insecurity or Disorganization.

Children with disinhibited social engagement disorder show reduced reticence with strangers, do not check back with their caregiver after venturing away, and may willingly leave with an unfamiliar adult. The recent DSM-5 has moved away from an attachment framework to understand disinhibited social engagement behavior (DSEB) due to studies indicating its presence in previously institutionalized children even after these children are adopted and show a selective, more secure attachment with their substitute caregiver (e.g. Chisholm et al., 1998). This meta-analysis aims to clarify the size of the associations between DSEB and attachment insecurity or disorganization. It also examines whether studies effect sizes differ according to various moderators (e.g., child age, type of attachment and DSEB measures). The results (k = 24) showed that the associations between DSEB and attachment insecurity (d = 0.48) or attachment disorganization (d = 0.47) were of small magnitude. There were no publication biases. As for moderator analyses on both attachment insecurity and disorganization, the effect sizes in studies using DSEB observational measures (respectively d = 0.63 and 0.57) were of moderate magnitude and stronger than those in studies not using an observational component (respectively d = 0.28 and 0.32). Given these small-to-moderate associations, attachment can be considered a relationship process associated with DSEB, and attachment-informed interventions could be potential tools to reduce DSEB in children. Nevertheless, given the sizable unshared portion of variance between DSEB and child attachment, future studies should examine other variables related to caregiving and noncaregiving contexts to further understand DSEB.

Predictors of quality of life among youths in foster care-a 5-year prospective follow-up study.

PURPOSE: Few studies have investigated possible predictors of positive outcomes for youths in foster care. The aim of this prospective follow-up study was to examine quality of life (QoL) among youths in foster care and to assess whether contextual and child factors predicted QoL. METHODS: Online questionnaires were completed by carers in Norway in 2012 (T1, n = 236, child age 6-12 years) and by youths and carers in 2017 (T2, n = 405, youth age 11-18 years). We received responses on 116 of the youths at both T1 and T2, and our final sample consisted of 525 youths with responses from T1 and/or T2. Child welfare caseworkers reported preplacement maltreatment and service use at T1. We assessed mental health and prosocial behavior at T1 by having carers complete the Strength and Difficulties Questionnaire and QoL at T2 with youth-reported KIDSCREEN-27. We analyzed the data using descriptive statistics, t-tests and multiple linear regressions, and we used multiple imputation to handle missing data. RESULTS: Youths in foster care had lower QoL across all dimensions compared to a Swedish general youth sample. QoL scores among our sample were similar to Norwegian youths with ill or substance abusing parents and to European norm data. Youths reported the highest QoL scores on the parent relations and autonomy dimension. Male gender, younger age, kinship care and prosocial behavior five years earlier predicted higher QoL. CONCLUSION: Similar to other at-risk youths, youths in foster care seem to have lower QoL than the general Scandinavian population. Despite early adversities, they had good relations with their current carers. Adolescent girls seem especially vulnerable to low QoL and might need extra support to have good lives in foster care.

Potentially traumatic events in foster youth, and association with DSM-5 trauma- and stressor related symptoms.

BACKGROUND: In DSM 5, three disorders are related to trauma and/or maltreatment: Post-traumatic Stress Disorder (PTSD), Reactive Attachment Disorder (RAD) and Disinhibited Social Engagement Disorder (DSED) but how these disorders relate to each other and to traumatic events is unknown. OBJECTIVE: We examined 1. Prevalence of Potentially Traumatic Events (PTEs) and poly-victimization for youths in foster care. 2. Associations between single/multiple PTEs and PTSD, DSED, and the two symptom-clusters that constitute RAD: Failure to seek/accept comfort (RAD A), and Low social-emotional responsiveness/ emotion dysregulation (RAD B). PARTICIPANTS, SETTING AND METHODS: Foster youth 11-17 years (N = 303) in Norway completed The Child and Adolescent Trauma Screen. Foster parents completed the RAD and DSED Assessment interview. RESULTS: Foster youth reported experiencing, on average, 3.44 PTEs each (range 0-15, SD 3.33), and 52.9 % reported PTSD symptoms at or above clinical cut off. The PTE sum score was associated with the latent factors PTSD (r = .66, p < 0.001), RAD cluster B symptoms (Low social-emotional responsiveness / emotion dysregulation, r = .28, p < 0.001) and DSED (r = .11, p = 0.046), but not with RAD cluster A symptoms (Failure to seek/accept comfort). CONCLUSIONS: These findings raise new questions about the nature, mechanisms and timing of development of RAD and DSED. Maltreatment assessment needs to encompass a wide range of PTEs, and consider poly-victimization.

Development and Examination of the Reactive Attachment Disorder and Disinhibited Social Engagement Disorder Assessment Interview.

The fifth edition of the Diagnostic and Statistical Manual (DSM) categorizes reactive attachment disorder (RAD) and disinhibited social engagement disorder (DSED) as two separate disorders, and their criteria are revised. For DSED, the core symptoms focus on abnormal social disinhibition, and symptoms regarding lack of selective attachment have been removed. The core symptoms of RAD are the absence of attachment behaviors and emotional dysregulation. In this study, an international team of researchers modified the Child and Adolescent Psychiatric Assessment for RAD to update it from DSM-IV to DSM-5 criteria for RAD and DSED. We renamed the interview the reactive attachment disorder and disinhibited social engagement disorder assessment (RADA). Foster parents of 320 young people aged 11 to 17 years completed the RADA online. Confirmatory factor analysis of RADA items identified good fit for a three-factor model, with one factor comprising DSED items (indiscriminate behaviors with strangers) and two factors comprising RAD items (RAD1: failure to seek/accept comfort, and RAD2: withdrawal/hypervigilance). The three factors showed differential associations with clinical symptoms of emotional and social impairment. Time in foster care was not associated with scores on RAD1, RAD2, or DSED. Higher age was associated with lower scores on DSED, and higher scores on RAD1.

Correction to: Services according to mental health needs for youth in foster care? - a multi-informant study.

Following publication of the original article [1], the authors reported a misaligning of data in Table 3 (weekly results have been put in the column for monthly results).

Services according to mental health needs for youth in foster care? - A multi-informant study.

BACKGROUND: Foster children have a high risk of mental disorders. This has contributed to increased international attention to service utilization for youth in foster care. The aim of this study is to examine whether youth in foster care receive services according to need, by using a multi-informant design. METHOD: Detailed information on the type and frequency of service use during the last 2 years and on youth mental health were collected from foster youths and their carers in Norway (n = 405, aged 11-17 years) through online questionnaires. Mental health was assessed with the Strengths and Difficulties Questionnaire. Statistical analyses were conducted using descriptive statistics and log-binominal regressions. RESULTS: In total, 48.8% of foster youths showed evidence of mental health problems, and 74.5% of foster families had contact with services. Increased mental health problems and living in non-kin foster care were associated with more service use. Youths with mental health problems had twice the probability of receiving services from the child and adolescent mental health service (CAMHS) and primary health care services compared to youths without problems. However, 57.0% of youths with carer-reported mental health problems did not have contact with CAMHS. CONCLUSIONS: Service use among foster youths was associated with service need rather than demographic and placement characteristics. The majority of youths with mental health problems did not receive services from CAMHS. However, many of them were in contact with primary health care services.