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 Serlachius1,2, Per Andrén1,2, Erik M Andersson1, Kristina Aspvall1,2, Johan Bjureberg1,2, Marianne Bonnert1,2, Fredrik Enoksson1,3, Clara Hellner1,2, Stefan Hrastiniski3, Jens Högström1,2, Maral Jolstedt1,2, Maria Lalouni1,2, Mats Lekander1,4, Fabian Lenhard1,2, Brjánn Ljótsson1, David Mataix-Cols1,2, Martina Nordh1,2, Ola Olén5,6,7, Tove Wahlund1,2, Lie Åslund1,2, Sarah Vigerland1,2;

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 18th month after the earthquake and re-interviewed at the 31th 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 Bikic1,2;

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 Vigerland1,2, Fabian Lenhard1,2, Kristina Aspvall1,2, Maral Jolstedt1,2, David Mataix-Cols 1,2, Brjánn Ljótsson1, Eva Serlachius1,2;

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 1st 2016 and August 22nd 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;