A systematic review of hormone treatment for children with gender dysphoria and recommendations for research.

AIM: The aim of this systematic review was to assess the effects on psychosocial and mental health, cognition, body composition, and metabolic markers of hormone treatment in children with gender dysphoria. METHODS: Systematic review essentially follows PRISMA. We searched PubMed, EMBASE and thirteen other databases until 9 November 2021 for English-language studies of hormone therapy in children with gender dysphoria. Of 9934 potential studies identified with abstracts reviewed, 195 were assessed in full text, and 24 were relevant. RESULTS: In 21 studies, adolescents were given gonadotropin-releasing hormone analogues (GnRHa) treatment. In three studies, cross-sex hormone treatment (CSHT) was given without previous GnRHa treatment. No randomised controlled trials were identified. The few longitudinal observational studies were hampered by small numbers and high attrition rates. Hence, the long-term effects of hormone therapy on psychosocial health could not be evaluated. Concerning bone health, GnRHa treatment delays bone maturation and bone mineral density gain, which, however, was found to partially recover during CSHT when studied at age 22 years. CONCLUSION: Evidence to assess the effects of hormone treatment on the above fields in children with gender dysphoria is insufficient. To improve future research, we present the GENDHOR checklist, a checklist for studies in gender dysphoria.

Life Events and Coping Strategies Among Young People Who Died by Suicide or Sudden Violent Death.

Objective: Most empirically anchored psychological models of suicide focus either on the perceived situational stress or on vulnerability factors and coping deficits. The interaction between life stressors and vulnerability factors is less explored. Methods: This case-control study examines interactions between life events and coping strategies in three groups of young people: cases of suicide, cases of other sudden violent death (SVD), and control cases. Results: Four coping strategies, two more adaptive and two more maladaptive, were identified. Distinctive of the suicide and the SVD group was significantly less Planful Problem-Solving, and more Escape-Avoidance and Confrontive Coping than among the controls. Furthermore, Confrontive Coping had significantly higher level in the SVD group than in the suicide group. Between-group differences were partly accounted for differences in negative life events, early and late in life. Both target groups experienced significantly more adverse childhood experiences and recent stressful life events than the controls-the suicide group being more exposed to recent stressful life events even in comparison with the SVD group. This might indicate that adverse childhood experiences are a risk factor for both causes of death, whereas proximal stressful life events are a risk factor for death by suicide to a higher degree than for SVD. Conclusions: Improved understanding of the interplay between life events, both in the far past and present, and coping styles, may facilitate the identification of young people at risk of suicide and violent death.

Who Is at Risk of Dying Young from Suicide and Sudden Violent Death? Common and Specific Risk Factors among Children, Adolescents, and Young Adults.

OBJECTIVE: Suicides and other sudden violent deaths are the most common causes of death among young people worldwide. This case-control study compared risk factors for suicide and other sudden violent death among young people. METHOD: A total of 436 psychological autopsy interviews with next of kin were performed. The samples aged 10-25 years included 63 cases of suicide, 62 cases of other sudden violent death, and 104 matched living controls. Two stepwise multiple logistic regression analyses were performed. RESULTS: The number of recent stressful life events was the only common risk factor for suicide and other sudden violent death. Specific risk factors for suicide were any form of addiction and being an inpatient in adult psychiatric care. Specific risk factors for other sudden violent death were lower elementary school results, lower educational level, and abuse of psychoactive drugs. CONCLUSIONS: The suicide group seems to have been more vulnerable and exposed to different kinds of stressors, whereas the sudden violent death group seems to have been more acting out and risk-taking. Both groups must be the subject of prevention and intervention programs.

The Sävsjö-school-project: a cluster-randomized trial aimed at improving the literacy of beginners-achievements, mental health, school satisfaction and reading capacity at the end of grade three using an alternative school curriculum.

BACKGROUND: A curriculum was planned using modern concepts based on the "old" principles to test if such an educational intervention provided pupils with good mental health and a solid basis for good reading and writing skills, as well as generated a positive attitude to learn. These "old" principles were based on previous knowledge derived from school psychiatry (which in Sweden was a branch of child and adolescent psychiatry 1915-1970), educational psychology and the educational approach from the differentiating Swedish School system of 1946-1970 (itself based on the principles of curative education "Heilpädagogie", which was later renamed mental health care). METHODS: All six available schools in the small Swedish city of Sävsjö participated in the study. In these six schools there were eight preschool classes that included every 6-year old child living in the city. In total there were 184 families with 186 children (including 2 pairs of twins) who belonged to these preschool classes and were invited to take part in the study. One family moved just before school-start and 8 decided not to participate, thus 177 children (84 boys and 93 girls, aged 5.6-6.6 years) entered the study. The preschool classes were randomized into an experimental group with four preschool classes and a comparison group with four preschool classes. The experimental group followed a teaching program from the start of the preschool year until the end of grade 3 that was tailored to each student's individual capacity based on the concepts of school maturation and curative education used in the Swedish schools during the period 1946-1970. The comparison group followed today's average Swedish school curriculum. The project was planned as an intervention study covering the preschool year and the first 3 years of elementary school, which was to form a basis for a follow-up when the pupils had left senior high, the 12th year in Swedish public school. The outcome and the achievements were measured at end of grade 3 using standardized tests on reading, writing and mathematical skills. Behavior was assessed at school start and at end of grade 3 using the Child Behavior Check List (CBCL-scales) in addition to a questionnaire on Attention Deficit Hyperactivity Disorder (AD/HD) with criteria from DSM-IV. The children made a self-evaluation of their attitude towards learning. RESULTS: At the end of school year 3, the children in the experimental group had an improved reading capacity (p = 0.002, effect size(es) = 4.35) and reading comprehension (p = 0.03, es = 0.04). They evaluated their own reading (p = 0.02, es = 0.23), writing (p = 0.007, es = 0.35) and mathematical skills (p = 0.003, es = 0.48) as going "very well" when compared to comparison group. Differences regarding intelligence quotas between the groups at the start of school had disappeared by the end of grade 3. No differences referring to CBCL were found at end of grade 3. One child in the comparison group fulfilled criteria for AD/HD, according to parents and teachers. CONCLUSIONS: The alternative curriculum covering the preschool year through the first 3 years of elementary school based on the old principles from curative education ("Heilpädagogie"), educational psychology and school psychiatry gave the children in the experimental group a better reading capacity and reading comprehension.Trial registration The study started in 1998. The data were collected longitudinally and prospectively but have not been analyzed until now, with the children having left senior high. A retrospective registration in the ISRCTN is pending.

Innovations and changes in the ICD-11 classification of mental, behavioural and neurodevelopmental disorders.

Following approval of the ICD-11 by the World Health Assembly in May 2019, World Health Organization (WHO) member states will transition from the ICD-10 to the ICD-11, with reporting of health statistics based on the new system to begin on January 1, 2022. The WHO Department of Mental Health and Substance Abuse will publish Clinical Descriptions and Diagnostic Guidelines (CDDG) for ICD-11 Mental, Behavioural and Neurodevelopmental Disorders following ICD-11's approval. The development of the ICD-11 CDDG over the past decade, based on the principles of clinical utility and global applicability, has been the most broadly international, multilingual, multidisciplinary and participative revision process ever implemented for a classification of mental disorders. Innovations in the ICD-11 include the provision of consistent and systematically characterized information, the adoption of a lifespan approach, and culture-related guidance for each disorder. Dimensional approaches have been incorporated into the classification, particularly for personality disorders and primary psychotic disorders, in ways that are consistent with current evidence, are more compatible with recovery-based approaches, eliminate artificial comorbidity, and more effectively capture changes over time. Here we describe major changes to the structure of the ICD-11 classification of mental disorders as compared to the ICD-10, and the development of two new ICD-11 chapters relevant to mental health practice. We illustrate a set of new categories that have been added to the ICD-11 and present the rationale for their inclusion. Finally, we provide a description of the important changes that have been made in each ICD-11 disorder grouping. This information is intended to be useful for both clinicians and researchers in orienting themselves to the ICD-11 and in preparing for implementation in their own professional contexts.

Children's abilities to communicate with both parents in infancy were related to their social competence at the age of 15.

AIM: Studies of children's early ability to communicate have mainly focused on mother-child dyads. That is why this study analysed the long-term effects of triadic interactions involving both parents. METHOD: This prospective pilot study monitored child-mother-father communication in 19 families from the general population in Sweden using the standardised Lausanne Trilogue Play method in a video studio. The families and their first-born child were initially followed from three months to 48 months of age. Preschool teachers assessed the children at the age of four using the Preschool Behaviour Questionnaire and then their teachers assessed the subjects at the age of 15 using the Strengths and Difficulties Questionnaire. Early communication was analysed in relation to the children's social competence at the age of 15. RESULTS: The child's skills in initiating turn-taking sequences and their parents' responses to this correlated with the child's social competence at the age of four, as reported in a previous study from our group, and at the age of 15, as reported here. CONCLUSION: The results of this study indicated that stimulating children's capacity to initiate turn-taking sequences in infancy improved their social competence at the age of 15, confirming positive results at four years of age.

[Dramatic increase of gender dysphoria in youth]. / Kraftig ökning av könsdysfori bland barn och unga - Tidigt insatt behandling ger betydligt bättre prognos.

Dramatic increase of gender dysphoria in youth In the past decade there has been a dramatic increase in the number of young people with gender dysphoria seeking help for gender-confirming medical interventions. From a situation of no more than a few patients annually, there were almost 200 referrals of gender dysphoria to the Astrid Lindgren Children's Hospital in 2016. This child and adolescent psychiatric unit has the whole country as a catchment area for patients <16 years. Gender-confirming medical interventions are regulated by a special law that sets a minimum age for legal and surgical gender reassignment to 18 years. The law, which is under revision, does not prevent medical investigations, hormonal therapy, and some surgical procedures before the age of 18. Gender dysphoria is defined as a persistent desire to live and be accepted as the opposite sex, usually accompanied by a perceived inconsistency with the sex assigned at birth and a desire to change the body in accordance with the perceived sex. The cause is unknown despite attempts of etiological mapping including genetic analyses, hormonal studies and modern brain imaging techniques. Repeated studies have shown that only a minority (about 20 %) of prepubertal children with gender dysphoria will have a persistent desire for later gender-confirming medical interventions, while the majority of those whose gender dysphoria is reinforced during puberty will later meet the diagnostic criteria for gender dysphoria (DSM-5) and transsexualism (ICD-10) (so called persisters). Persisters can be offered treatment with puberty stopping hormones to avoid the development of undesirable secondary sexual characteristics. Gender-confirming medical interventions are the only recommended treatment for gender dysphoria, and early treatment facilitates the ability to successfully pass in the desired sex, which is associated with a significantly better prognosis.

Relative Immaturity in Childhood and Attention-Deficit/Hyperactivity Disorder Symptoms From Childhood to Early Adulthood: Exploring Genetic and Environmental Overlap Across Development.

OBJECTIVE: Attention-deficit/hyperactivity disorder (ADHD) has been linked to immaturity relative to peers in childhood, yet it is unclear how such immaturity is associated with ADHD across development. This longitudinal twin study examined the genetic and environmental contributions to the association between parents' perception of their child's immaturity relative to peers (RI) in childhood and ADHD symptoms across development. METHOD: 1,302 twin pairs from the Swedish Twin Study of Child and Adolescent Development were followed prospectively from childhood to early adulthood. Parent ratings of RI were collected at 8 to 9 years and parent and self-ratings of ADHD symptoms were collected at 8 to 9, 13 to 14, 16 to 17, and 19 to 20 years using the Child Behavior Checklist Attention Problems scale. In addition, ADHD symptoms corresponding to DSM criteria were used for sensitivity analysis. Analyses were conducted using longitudinal structural equation modeling with multiple raters. RESULTS: RI-related etiologic factors, predominantly influenced by genes, explained 10-14% of the variance in ADHD symptoms from 8 to 9 up to 16 to 17 years. The influence of these RI-related factors on ADHD symptoms attenuated to 4% by 19 to 20 years of age. The remaining variance in ADHD symptoms was primarily explained by genetic factors independent of RI, which remained relatively stable across development, explaining 19% to 30% of the variance in ADHD symptoms from 13 to 14 up to 19 to 20 years. CONCLUSION: The results show that RI is significantly associated with ADHD symptoms, particularly during childhood and adolescence, and that the association is primarily explained by a shared genetic liability. Nevertheless, the magnitude of associations across development was modest, highlighting that RI is merely one aspect contributing to the complex etiology of ADHD symptoms.

Somatic symptoms and psychological concerns in a general adolescent population: Exploring the relevance of DSM-5 somatic symptom disorder.

OBJECTIVE: DSM-5 somatic symptom disorder (SSD) constitutes a major change for psychosomatic medicine and psychiatry, as well as for epidemiological research in these fields. This study investigates somatic symptoms and psychological concerns among adolescents in order to systematically explore the relevance of SSD for general adolescent populations. METHODS: A cross-sectional population-based design, with a symptoms-based strategy and a symptom-and-psychological-concern-based strategy, was used to estimate the prevalence of somatic symptoms and psychological concerns in a general adolescent population (n=2476, mean age=16years, 49% boys, 51% girls). Somatic symptoms and psychological concerns in relation to gender, and self-reported medical and psychiatric conditions were investigated. The association between somatic symptoms, psychological concerns, and functional impairment in school-, family-, peer- and physical activities was studied. RESULTS: Reporting 3+ persistent distressing somatic symptoms was significantly more common than reporting one or more persistent distressing somatic symptom(s) combined with serious psychological concern. The prevalence of such complaints was significantly higher in girls. The proportion of medical and psychiatric conditions was highest in the group reporting 3+ persistent distressing somatic symptoms combined with serious psychological concern. Belonging to this group most significantly increased odds ratios for functional impairment. CONCLUSION: For large-scale studies on SSD, results suggest the use of measures based on multiple somatic items in combination with psychological concerns, and a methodologically sound standardized measure of functional impairment. To further enhance clinical decision-making, the relation of symptoms to functional impairment, and the substantial overlap of SSD with medical and psychiatric conditions during adolescence should be addressed.

Shame and Gender Differences in Paths to Youth Suicide: Parents' Perspective.

Risk factors, suicidal behavior, and help-seeking patterns differ between young women and men. We constructed a generic conceptual model of the processes underlying youth suicide, grounded in 78 interviews with parents in 52 consecutive cases of suicide (19 women, 33 men) identified at forensic medical autopsy and compared by sex. We found different forms of shame hidden behind gender-specific masks, as well as gender differences in their paths to suicide. Several interacting factors formed negative feedback loops. Finding no way out, the young persons looked for an "emergency exit." Signs and preparations could be observed at different times but recognized only in retrospect. Typically, the young persons and their parents asked for professional help but did not receive the help they needed. We discuss parents' experiences from the theoretical perspective on gender identity and developmental breakdown. Giving voice to the parents' tacit knowledge can contribute to better prevention and treatment.

Early interaction between infants and their parents predicts social competence at the age of four.

AIM: To investigate the impact that the interaction between first-born children and their parents, from the age of 3 months, has on peer and social competence when the children are 4 years of age. METHODS: Fifteen families were videotaped in Lausanne Trilogue Play situations (child-mother-father interactions), when the children were three, nine, 18 and 48 months of age. The findings were then related to peer and social competence assessments carried out by preschool teachers when the children were four. RESULTS: There was a correlation between the parents' responsiveness and the child's capacity to initiate (make contributions to) turn-taking sequences in the family triad early in life. This, in turn, was associated with the child's later peer and social competence. At the age of 3 months, the child's contributions to the triadic interaction were interpreted by the parents as intentional communication. According to the preschool teachers' assessments, children who initiated turn-taking sequences at 9 months of age had better peer competence (p = 0.008) and social competence (p = 0.028) at 48 months. CONCLUSION: The results highlight the opportunities that parents have to stimulate their child's later social competence. They also show that a Lausanne Trilogue Play situation can be used to identify competent children and children/families with communication deficits.

Shame behind the masks: the parents' perspective on their sons' suicide.

Suicides are more frequent among boys than girls. A tentative, conceptual model of processes behind suicide among boys and young men (aged 12-25), grounded in their parents' views, is presented. Extensive interviews with parents in 33 cases of suicide were analyzed using grounded-theory methodology. Family alliances, coalitions, and secrets interacted with the boy concealing problems and "hiding behind a mask," while the professionals did not understand the emergency. Four interwoven paths to suicide were found: the boy was hunted and haunted, addicted, depressed, or psychotic. Different forms of shame were hidden behind the masks of "the clown," "the warrior," and "the prince." Future preventive programs need to address barriers to communication among all parties involved.

Family psychosocial characteristics influencing criminal behaviour and mortality--possible mediating factors: a longitudinal study of male and female subjects in the Stockholm Birth Cohort.

BACKGROUND: Family psychosocial characteristics in childhood have been associated with children's development into criminal behaviour and mortality. This study explored these possible relationships and examined alcohol and/or drug use and mental problems as possible mediating factors, highlighting gender-specific patterns. METHODS: Data from Swedish subjects born in 1953 (n = 14,294) from the Stockholm Birth Cohort study were examined. Several indicators of adverse family factors and individual problems were included in the present study. The information was derived from various data sources, covering different periods. Gender-specific associations with incidence of criminality (1966-1980) and mortality (1981-2009) were analysed using logistic regression. Furthermore, the population attributable fraction (PAF) was calculated for all variables in the fully adjusted models which were positively related to the outcome. RESULTS: Overall incidence of criminality and mortality was (m/f 32.3/6.6) and (m/f 6.1/3.5), respectively. The results showed that all aspects of family psychosocial and individual problems studied were associated with criminality for both genders. Among males, individual problems seemed to partly mediate these relations, but the associations remained statistically significant. Interestingly, the PAF analysis revealed a reduction in criminality of 17.5% when individual problems with alcohol and/or drug use were considered. Among females, a significant impact of alcohol and/or drug use on the association between family psychosocial characteristics and subsequent criminality was obtained. Inclusion of father's occupational class only somewhat reduced the estimates for the genders. Concerning male mortality, father's alcohol abuse was significantly related to an increased risk. When individual criminality was accounted for, the association was substantially reduced but remained statistically significant. Among females, when adjusting for family psychosocial factors, only the association between parents' mental problems and females' mortality was significant. None of the individual problem variables managed to explain this association. CONCLUSIONS: Family psychosocial characteristics were associated with both subsequent criminal behaviour and mortality. These connections were partly explained by individual risk factors, especially by alcohol and/or drug use. The practical implications of the findings point to the importance of addressing the individual's alcohol and/or drug use in reducing criminal behaviour, which would also lower the mortality rates.

Children with high and intermediate imperforate anus: their experiences of hospital care.

PURPOSE: The purpose of this study was to examine the experiences of children with high and intermediate imperforate anus (IA), and specifically their experiences of hospital care. METHODS: Twenty-five children born with high and intermediate IA participated; 9 boys and 16 girls. The mean age was 10.5 years (range 8.0-13.6). Two control groups were involved in the study. A self-report questionnaire was used to gather the data concerning children's experiences of hospital care. Items were scored on a 5-point Likert scale. RESULTS: The children's responses on hospital care items scored high. The children with IA reported being less satisfied with the information given, and understood less why they needed to visit the hospital than did the children in the two control groups. CONCLUSION: The children's experiences of care seemed to be positive even though the children born with IA are subjected to invasive treatment. More research is called for in the unexplored area of information to the children, and particularly to the children born with a defect. Children's views are important and should always be considered, as their answers most certainly reflect a genuine experience, contributing to the further development of their specific care.

Pathways to child and adolescent psychiatric clinics: a multilevel study of the significance of ethnicity and neighbourhood social characteristics on source of referral.

BACKGROUND: In the Swedish society, as in many other societies, many children and adolescents with mental health problems do not receive the help they need. As the Swedish society becomes increasingly multicultural, and as ethnic and economic residential segregation become more pronounced, this study utilises ethnicity and neighbourhood context to examine referral pathways to child and adolescent psychiatric (CAP) clinics. METHODS: The analysis examines four different sources of referrals: family referrals, social/legal agency referrals, school referrals and health/mental health referrals. The referrals of 2054 children aged 11-19 from the Stockholm Child-Psychiatric Database were studied using multilevel logistic regression analyses. RESULTS: Results indicate that ethnicity played an important role in how children and adolescents were referred to CAP-clinics. Family referrals were more common among children and adolescents with a Swedish background than among those with an immigrant background. Referrals by social/legal agencies were more common among children and adolescents with African and Asian backgrounds. Children with Asian or South American backgrounds were more likely to have been referred by schools or by the health/mental health care sector. A significant neighbourhood effect was found in relation to family referrals. Children and adolescents from neighbourhoods with low levels of socioeconomic deprivation were more likely to be referred to CAP-clinics by their families in comparison to children from other neighbourhoods. Such differences were not found in relation in relation to the other sources of referral. CONCLUSIONS: This article reports findings that can be an important first step toward increasing knowledge on reasons behind differential referral rates and uptake of psychiatric care in an ethnically diverse Swedish sample. These findings have implications for the design and evaluation of community mental health outreach programs and should be considered when developing measures and strategies intended to reach and help children with mental health problems. This might involve providing information about the availability and accessibility of health care for children and adolescents with mental health problems to families in certain neighbourhoods and with different ethnic backgrounds.