Validation of the Swedish version of the safe environment for every kid (SEEK) parent screening questionnaire

BACKGROUND

Psychosocial risk factors in the home may impair children's health and development and increase the risk of maltreatment. The Safe Environment for Every Kid (SEEK) model was developed to provide pediatric primary care professionals with a structured way to identify common psychosocial problems. The SEEK model includes use of the Parent Screening Questionnaire (SEEK-PSQ) at routine preventive child health visits, discussion with parents about their responses and, when indicated, referral to relevant services. The SEEK-PSQ has not previously been available in Swedish. The aim of the present study was to evaluate the psychometric properties of an adapted Swedish version of the SEEK-PSQ (PSQ-S).

METHODS

This study is part of a cluster-randomised controlled trial of SEEK in the Swedish child health services. To validate the PSQ-S, parents (n = 852) with children 0-18 months of age were invited to complete a survey including the PSQ-S as well as evidence-based standardized instruments for the targeted psychosocial risk factors: economic worries, depressive symptoms, parental stress, alcohol misuse and intimate partner violence (IPV). Baseline data from 611 (72%) parents were analysed regarding sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV) for each risk factor.

RESULTS

As a whole, the PSQ-S had a sensitivity of 93%, specificity of 52%, PPV of 67% and NPV of 87%. For mothers and fathers combined, sensitivity was 80% for economic worries, 89% for depressive symptoms, 78% for parental stress, 47% for intimate partner violence (IPV) and 70% for alcohol misuse. Specificity was highest for IPV and alcohol misuse (91%) and lowest for depressive symptoms (64%). NPV values were high (81-99%) and PPV values were low to moderate (22-69%) for the targeted problems. Sensitivity was higher for mothers compared to fathers for economic worries, depressive symptoms and IPV. This difference was particularly evident for IPV (52% for mothers, 27% for fathers).

CONCLUSION

The SEEK-PSQ-S demonstrated good psychometric properties for identifying economic worries, depressive symptoms, parental stress and alcohol misuse but low sensitivity for IPV. The PSQ-S as a whole showed high sensitivity and NPV, indicating that most parents with or without the targeted psychosocial risk factors were correctly identified.

TRIAL REGISTRATION

ISRCTN registry, study record 14,429,952 ( https://doi.org/10.1186/ISRCTN14429952 ) Registration date 27/05/2020.

Unintentional Injuries Are Associated with Self-Reported Child Maltreatment among Swedish Adolescents

Injuries constitute a large share of childhood morbidity and mortality. This study examines whether adolescents with self-reported experiences of different types of child maltreatment more frequently reported unintentional injury events requiring health- or dental care during the last year and/or hospitalization at any time during childhood. Cross-sectional data from a Swedish national representative school survey (2016) including 4741 adolescents were used (78.5% response rate). Data were analyzed with univariate tests and multiple logistic regression. Statistically significant associations between reported experiences of physical, psychological and sexual abuse, neglect, and witnessing partner violence during childhood and reported unintentional injuries requiring health- or dental care during the last year were found (aOR:s between 1.39-1.77). The corresponding association for poly-victimization was aOR 1.91 (95% CI 1.39-2.62). Furthermore, a linear-by-linear association was seen for degree of victimization and number of episodes of unintentional injuries that required care in the last year (p = 0.000), as well as lifetime hospitalizations (p = 0.000). This study shows significant associations between child maltreatment and unintentional injuries requiring health- and/or dental care and hospitalization. To improve both injury and child maltreatment prevention, healthcare professionals need to pay particular attention to children and adolescents who repeatedly seek healthcare services due to injurious events.

[Great need of improved training of paediatricians on children at risk of abuse]

In 2009 the Swedish Paediatric Society carried out a national survey that examined the training of paediatric specialty registrars concerning child abuse and neglect. The survey was repeated in 2016. Both surveys highlighted considerable deficits. In 2020 a slightly revised version of the original survey was sent to training leads for paediatrics and paediatric surgery in Sweden. The results showed that most paediatric specialty registrars received their clinical training in social paediatrics with actual patients. Most of the clinics cooperated with a Children's Advocacy Centre (»Barnahus« in Swedish) and some were situated in an area with a Child Protection Team. Similar results were obtained for specialty registrars in paediatric surgery. Our survey shows that the training has partly improved and that university hospital clinics perform better than other paediatric clinics. Major educational investments are needed to obtain an equivalent education throughout the country.

Childhood exposure to physical and emotional violence over a 57-year period in Sweden

AIMS

The aim of the present study was to examine the prevalence of childhood experiences of physical violence (CPV) and emotional violence (CEV) at the hands of parents over a 57-year period among adults born between 1937 and 1993.

METHODS

In 2012, a survey among women and men aged 18-74 years in Sweden was undertaken to examine the lifetime prevalence of physical, psychological and sexual violence and associations with current health in adulthood. Questionnaires were based on the Adverse Childhood Experiences study and a previous national survey of violence exposure. Descriptive statistics were used to analyse the frequency of exposure to CPV and CEV, and changes over time were analysed using analysis of variance and logistic regression.

RESULTS

A total of 10,337 individuals participated (response rates: 56% for women and 48% for men). CPV decreased significantly over the time period studied, particularly for those born after 1983. This decrease was more evident for male respondents. Throughout the time period studied, the proportion of women reporting CEV was higher than for men. Among both genders there was a steady rise in CEV rates from those born in the late 1930s to those born in the mid-1980s, after which there was a decline that was more marked for men.

CONCLUSIONS

A significant group of children in Sweden experience violence at the hands of parents. However, our data corroborate previous national studies that children's exposure to violence has decreased. Clear gender differences indicate that these changes have affected girls and boys differently.

Children's exposure to psychological abuse and neglect: A population-based study in rural Bangladesh

AIM

We aimed to estimate the prevalence and risk factors of child psychological abuse and neglect in a rural area of Bangladesh.

METHODS

Data were obtained from interviewing 1416 children aged 11-17 years administering the International Society for the Prevention of Child Abuse and Neglect Child Abuse Screening Tool for Children between March and April 2017. Linear regression analysis was used to estimate the risks of child psychological abuse and neglect.

RESULTS

The prevalence rates of at least one form of psychological abuse both in the past year and lifetime were more than 97 per cent. Moreover, the rates of at least one form of neglect were about 58 per cent during the past year and 78 per cent over lifetime. Living separately from parents posed children to significant risks of neglect and psychological abuse. Working children and greater number of siblings in a family were risk factors for neglect, whereas witnessing family violence and being bullied were risk factors for psychological abuse. Children with more years of schooling experienced less neglect and psychological abuse.

CONCLUSION

The high prevalence of child psychological abuse and neglect in this study shows child maltreatment as an ignored issue in Bangladesh.

Children's exposure to physical abuse from a child perspective: A population-based study in rural Bangladesh

Background

Although child physical abuse (CPA) is considered as a major global public health problem, it has not yet been recognized as such in Bangladesh. Very few studies have assessed the prevalence and victims’ characteristics of multiple forms of CPA.

Objective

This population-based study assessed the prevalence of CPA committed by adults in a rural area of Bangladesh and examined its association with demographic and socio-contextual factors.

Methods

Data were obtained using ISPCAN Child Abuse Screening Tool for Children (ICAST-C) in a random sample of 1416 children (49% girls, 51% boys) aged 11 to 17 years by face-to-face interviews during March-April 2017. The response rate was 91.5%. To estimate predictors of CPA, physical abuse was categorized into frequent and less frequent groups.

Results

The prevalence of at least one form (≥ 1), two forms (≥2) and three or more forms (≥ 3) of CPA were estimated approximately to 99%, 95% and 83% in their lifetime and 93%, 79%, and 57% in the past year respectively. Hitting (except on buttocks), standing/kneeling and slapping were the most common physical abuse whereas given drugs or alcohol, pinched, burned or scalded, beaten-up and locked up were less reported. Female children were faced severe forms of CPA more than that of males. Male children, younger age groups, witnessing adults using weapons at home, bullied by siblings and low level of maternal education were found to be significant risk factors for both ≥ 1 form and ≥ 2 forms of frequent CPA whereas adding also adult shouting in a frightening way was found as a significant risk factor for ≥ 2 forms of frequent CPA.

Conclusion

Self-reported prevalence of CPA is extremely common in the Bangladeshi rural society. The prevalence was associated with demographic and socio-contextual characteristics of the children such as being younger, witnessing domestic violence and maternal low education. The findings provide evidence to support parents and policy-makers to take effective measures to implement policy and programme on alternative up-bringing methods and creating awareness of negative effects of CM which in turn help Bangladesh to line up with UN Convention on the Rights of the Child, which the country signed in 1990.

Childhood death rates declined in Sweden from 2000 to 2014 but deaths from external causes were not always investigated

AIM

Countries that conduct systematic child death reviews report a high proportion of modifiable characteristics among deaths from external causes, and this study examined the trends in Sweden.

METHODS

We analysed individual-level data on external, ill-defined and unknown causes from the Swedish cause of death register from 2000 to 2014, and mortality rates were estimated for children under the age of one and for those aged 1-14 and 15-17 years.

RESULTS

Child deaths from all causes were 7914, and 2006 (25%) were from external, ill-defined and unknown causes: 610 (30%) were infants, 692 (34%) were 1-14 and 704 (35%) were 15-17. The annual average was 134 cases (range 99-156) during the study period. Mortality rates from external, ill-defined and unknown causes in children under 18 fell 19%, from 7.4 to 6.0 per 100 000 population. A sizeable number of infant deaths (8.0%) were registered without a death certificate during the study period, but these counts were lower in children aged 1-14 (1.3%) and 15-17 (0.9%).

CONCLUSION

Childhood deaths showed a sustained decline from 2000 to 2014 in Sweden and a quarter were from external, ill-defined or unknown causes. Systematic, interagency death reviews could yield information that could prevent future deaths.

Lifetime history of sexual and physical abuse among competitive athletics (track and field) athletes: cross sectional study of associations with sports and non-sports injury

OBJECTIVE

To examine associations between lifetime sexual and physical abuse, and the likelihood of injury within and outside sport in athletes involved in competitive athletics.

METHODS

A cross sectional study was performed among the top 10 Swedish athletics athletes using 1 year prevalence of sports and non-sports injuries as the primary outcome measure. Associations with sociodemographic characteristics, lifetime abuse history and training load were investigated. Data were analysed using simple and multiple logistic regression models.

RESULTS

11% of 197 participating athletes reported lifetime sexual abuse; there was a higher proportion of women (16.2%) than men (4.3%) (P=0.005). 18% reported lifetime physical abuse; there was a higher proportion of men (22.8%) than women (14.3%) (P=0.050). For women, lifetime sexual abuse was associated with an increased likelihood of a non-sports injury (OR 8.78, CI 2.76 to 27.93; P<0.001). Among men, increased likelihood of a non-sports injury was associated with more frequent use of alcoholic beverages (OR 6.47, CI 1.49 to 28.07; P=0.013), while commencing athletics training at >13 years of age was associated with a lower likelihood of non-sports injury (OR 0.09, CI 0.01 to 0.81; P=0.032). Lifetime physical abuse was associated with a higher likelihood of sports injury in women (OR 12.37, CI 1.52 to 100.37; P=0.019). Among men, athletes with each parents with ≤12 years formal education had a lower likelihood of sustaining an injury during their sports practice (OR 0.37, CI 0.14 to 0.96; P=0.040).

CONCLUSIONS

Lifetime sexual and physical abuse were associated with an increased likelihood of injury among female athletes. Emotional factors should be included in the comprehension of injuries sustained by athletes.

Psychological and physical violence towards children with disabilities in Finland and Sweden

This article describes psychological aggression and physical violence by Swedish and Finnish mothers ( N = 3420) towards their 0- to 12-year-old children with disabilities ( N = 286) by comparing such behaviour with the mothers of children without disabilities ( N = 3134). The survey data are based on representative samples from Finland and Sweden of mothers' reports of their behaviour towards their child in conflict situations. Mothers of children with disabilities reported more psychological aggression towards their child than did mothers of children without disabilities. Mothers used psychological aggression, especially towards children with neurological/psychological disabilities. However, the only significant difference regarding physical violence was repetitive use of mild physical violence. Overall, the analysis suggests that children with neurological/psychological disabilities are more exposed to both psychological and physical violence than children without disabilities or children with somatic/developmental disabilities.

Neglected children with severe obesity have a right to health: Is foster home an alternative?-A qualitative study

OBJECTIVE

To explore key person's perspectives of foster home placement or notification of risk of harm to Social Services of children with severe obesity.

METHODS

This case study research was performed in the southwest of Sweden and based on interviews with nine informants: a foster home youth, two foster parents, a social worker, two hospital social workers, a pediatric physician, a pediatric nurse, and a psychologist. Content analysis was used for narrative evaluations, within- and cross case analyses and displays.

RESULTS

Positive health outcomes of the foster home placement were described as a healthy and normalized weight status, a physically and socially active life, and an optimistic outlook on the future. The foster parents made no major changes in their family routines, but applied an authoritative parenting style regarding limit setting about sweets and food portions and supporting physical activity. The professionals described children with severe obesity as having suffered parental as well as societal neglect. Their biological parents lacked the ability to undertake necessary lifestyle changes. Neglected investigations into learning disabilities and neuropsychiatric disorders were seen in the school and healthcare sector, and better collaboration with the Social Services after a report of harm might be a potential for future improvements. Rival discourses were underlying the (in) decision regarding foster home placement.

CONCLUSION

A child's right to health was a strong discourse for acting when a child was at risk for harm, but parental rights are strong when relocation to a foster home is judged to be necessary.

Bangladeshi school-age children's experiences and perceptions on child maltreatment: A qualitative interview study

BACKGROUND

Child maltreatment (CM) is a public health problem and is recognized as a huge barrier for child development. Most of the research and definitions on CM are from the perspective of high-income western countries. Because no major studies have been conducted on CM in Bangladesh, the aim of the current study was to explore the experiences of and perceptions on CM in school-age children in rural and urban Bangladesh in order to understand maltreatment in a local context and from a child perspective.

METHODS

Semistructured individual interviews with 24 children (13 boys and 11 girls), between the ages of 9 and 13 years of which 11 were schoolgoing and 13 non-schoolgoing, were conducted during July 2013 and analysed according to qualitative content analysis.

RESULTS

CM was a common and painful experience with serious physical and emotional consequences but highly accepted by the society. Vulnerable groups were especially young children, girls, and poor children. The children's voices were not heard due to their low status and low position in their families, schools, and working places. The main theme that emerged in the analysis was children's subordination, which permeated the five categories: (a) perception of children's situation in society, (b) understanding children's development and needs, (c) CM associated to school achievement, (d) negative impact of CM, and (e) emotional responses.

CONCLUSIONS

Different kinds of abuse are obviously common in Bangladesh, and the schools do not follow the law from 2011 prohibiting corporal punishment at school. The society has to take further steps to live up to the UN Convention on the Rights of the Child, which was ratified already in 1990, to protect the Bangladeshi children from CM.

Swedish population-based study of pupils showed that foster children faced increased risks for ill health, negative lifestyles and school failure

AIM

This population-based study explored whether foster children faced a higher risk of health problems than children of the same age who were not in foster care.

METHODS

Data for 13 739 pupils aged 10, 13 and 16 years were obtained from the Pupil Health Database in the county of Värmland, Sweden, for the school years 2012/2013 and 2013/2014. These included data on school performance, health, lifestyle and social relationships, based on children's interviews with school nurses.

RESULTS

Of all the pupils, 171 (1.2%) were in foster care. Children in foster care were generally unhealthier than other children. Both girls and boys were at higher risk of chronic health problems, daily smoking, use of drugs and school failure. When the girls in foster care were compared to other girls, we found that they faced a higher risk of psychological and psychosomatic symptoms. This difference was not found for boys. Foster children were also more likely to express a more negative view on life.

CONCLUSION

We confirmed earlier studies that children in foster care tended to have inferior health and well-being than other children. These findings emphasise that health, risky behaviour and school performance should be considered together when assessing foster children.

A multifaceted risk analysis of fathers' self-reported physical violence toward their children

Existing research has shown that child maltreatment is carried out by both mothers and fathers. There is also an extensive body of literature analyzing reasons for mothers' violent behavior. Among fathers, reasons are less well studied, resulting in the lack of a comprehensive picture of paternal child abuse. In this study, 20 child-, parent-, and family-related factors have been included in a combined analysis to assess which of these may pose a risk for fathers' severe violent behavior toward their children. The study is based on merged data from Finland and Sweden, in which an anonymous survey was answered by parents, based on representative samples of parents with 0-12-year-old children. The merged data set included 679 fathers and analyses were carried out using logistic regression models. Six percent of the fathers had committed severe violent acts, that is, slapped, hit, punched, kicked, bit, hit/tried to hit their child with an object or shook (under 2-year-old) their child at least once during the 12 months preceding the survey. Corporal punishment experienced by the fathers when they were children, or used by the father as a method of discipline, strongly increased the likelihood of severe violent acts. The findings emphasize the importance of preventing all forms of corporal punishment in seeking to minimize the occurrence of severe physical violence by fathers toward their children. Aggr. Behav. 43:317-328, 2017. © 2016 Wiley Periodicals, Inc.

Paediatric approaches to child maltreatment are subject to wide organisational variations across Europe

AIM

Little is known about the organisation of child maltreatment practice in Europe. We therefore explored medical child protection systems and training across Europe.

METHODS

An online survey was completed by physicians working in child maltreatment, identified through professional organisations in 28 member countries of the European Union, Iceland, Norway and Switzerland in 2012-2013. Respondents were questioned regarding management of suspected child maltreatment, mandatory reporting, professional training, patient referral and physician roles in multidisciplinary investigations. Responses underwent a narrative synthesis and descriptive enumerations.

RESULTS

The survey was completed by 88 individuals, unevenly distributed in 22 of 31 countries. Physicians were mandated to report child maltreatment in 16 of 22 countries. All of 88 responding physicians described multidisciplinary involvement in the clinical and forensic management of suspected child maltreatment. Practitioners involved in physical examinations included general physicians, paediatricians, forensic medical examiners, gynaecologists and paediatric surgeons. Paediatricians were required to undergo child protection training according to 30 of 86 respondents in 14 of 22 countries.

CONCLUSION

This survey demonstrates that there were wide variations in the organisation of child maltreatment paediatrics in Europe. The differing legislative frameworks and models of care are pertinent to consider when comparing epidemiology of maltreatment reported from across European countries.

Injury risks in schoolchildren with attention-deficit/hyperactivity or autism spectrum disorder: Results from two school-based health surveys of 6- to 17-year-old children in Sweden

INTRODUCTION

Injuries are one of the leading causes of death and disability among children in Sweden and attention-deficit/hyperactivity disorder (ADHD) has previously been associated with an increased risk of injury in pediatric populations elsewhere in the world. Current evidence regarding the possible link between autism spectrum disorder (ASD) and injury risk appears limited, even though some potentially risk-increasing symptoms overlap. The purpose of this study was thus to study the association between both ADHD and ASD concerning the risk of injury among Swedish schoolchildren.

METHODS

Two samples were used: a population-based register study containing data from 18,416 children ranging from the ages of 6-17years collected by school nurses during 2012/2014 (Survey A), and a national cross-sectional study of 3202 ninth-grade children (~15years old) collected from 92 schools in 2011 (Survey B). The data were analyzed using χ(2)-tests and log-binomial generalized linear models to obtain risk ratios (RR), comparing cases reportedly affected by ADHD or ASD to unaffected controls.

RESULTS

After adjusting for confounders, ADHD was associated with a 65% increased risk of injury (RR 1.65 [95% CI: 1.32-2.05] in Survey A, and a 57% increased risk of injury (RR 1.57 [95% CI: 1.27-1.95]) in Survey B. ASD was not significantly associated with any differences in injury risk (RR 0.81 [95% CI: 0.57-1.14]).

CONCLUSIONS

The results indicate that there is an elevated injury risk among Swedish schoolchildren with ADHD but not for children with ASD. Future studies should focus on causal mechanisms mediating the association between ADHD and injuries in order to facilitate injury prevention strategies.

PRACTICAL APPLICATIONS

Parents and teachers of schoolchildren with ADHD should be made aware of the elevated injury risks associated with the diagnosis. Safety experts and injury control professionals should consider the development of specialized prevention strategies in order to reduce these risks.

Associations between neurodevelopmental disorders and factors related to school, health, and social interaction in schoolchildren: Results from a Swedish population-based survey

BACKGROUND

Children and adolescents with autism spectrum disorder (ASD) or attention-deficit/hyperactivity disorder (ADHD) are more likely to be surrounded by different risk factors. In order to work preventively with decreasing ADHD and ASD symptoms, there is a need of more knowledge concerning risk factors.

OBJECTIVE

This study aimed to investigate school, health, lifestyle and social interactions association with autism spectrum disorder (ASD) and attention-deficit/hyperactivity disorder (ADHD) among schoolchildren aged 6-17 years.

METHODS

Data for 18,416 children and adolescents aged 6-17 years in the county of Värmland, Sweden, from the school year 2012/2013 and 2013/2014 were obtained from the Student Health Database, which includes information on health examinations by school nurses and self-reported information of mental and physical health, social relations, physical activity, and school conditions.

RESULTS

Of all participants, 2.4% reported only ADHD and 1.6% reported only ASD. The results confirmed that ADHD or ASD was significantly associated with worse school experiences, lower socioeconomic status, less physical activity, more substance use, weaker social network and more impairments than those without ADHD or ASD.

CONCLUSIONS

Knowledge of risk or protective factors during school years is needed to develop interventions to reduce symptoms of neurodevelopmental disorders in children and adolescents.

Socialbidragstagande och statusbunden skamkänsla – En prövning av ekonomi - sociala band modellen

I den här artikeln studeras skam och skamrelaterade känslor bland socialbidragstagare. Det görs i ljuset av den s.k. ekonomi-sociala band modellen som i sig fogar samman två vetenskapliga framställningar om skam. Den ekonomiska sidan beaktar den sida som knyter skam och skamrelaterade känslor till bl.a. fattigdom.  Den sida som handlar om sociala band förbinder skam och skamrelaterade känslor med kvaliteten i de sociala relationerna.

Bully, bullied and abused. Associations between violence at home and bullying in childhood

Aims: The aim was to examine experiences of bullying among Swedish adolescents and whether victims and perpetrators were also exposed to violence in the home, with particular focus on how abuse severity affected the risk of exposure to bullying. Methods: A nationally representative sample of pupils aged 14–15 responded to a questionnaire exploring exposure to corporal punishment and other types of violence. Results were analysed using Pearson’s chi-square and multiple logistic regression, adjusting for factors regarding the child, the parents and the families’ socioeconomic status. Results: Among the 3197 respondents, a significant proportion reported at least one incident of either bullying victimisation (girls 36%, boys 26%) or bullying perpetration (girls 24%, boys 36%). Physical and emotional violence in the home, including witnessed intimate partner violence, were significantly associated with both bullying victimisation and bullying perpetration. Odds ratios for exposure to bullying rose with increasing frequency and severity of abuse. Adjusted odds ratios ranged from 1.6 for any event of abuse vs. single episodes of bullying to 20.3 for multiple types of abuse vs. many episodes of bullying. The child’s gender and the presence of a chronic health condition were consistently associated with nearly all levels of abuse and bullying. Conclusions: Bullying experiences are common among youth and are clearly associated with abuse. Frequent bullying, whether as victim or perpetrator, warrants particular vigilance, as it appears to be an indicator of severe violence in the home.

Protocol design for large-scale cross-sectional studies of sexual abuse and associated factors in individual sports: feasibility study in Swedish athletics

To ensure health and well-being for their athletes, sports organizations must offer preventive measures against sexual abuse. The aim of this study was to design and evaluate feasibility of a research protocol for cross-sectional epidemiological studies of sexual abuse in athletics. Examination of the requirements on the study of sexual abuse in athletics was followed by iterated drafting of protocol specifications and formative evaluations. The feasibility of the resulting protocol was evaluated in a national-level study among elite athletics athletes (n = 507) in Sweden. The definition of sexual abuse, the ethical soundness of the protocol, reference populations and study of co-morbidity, and the means for athlete-level data collection were identified as particularly complex issues in the requirements analyses. The web-based survey defined by the protocol facilitates anonymous athlete self-reporting of data on exposure to sexual abuse. 198 athletes (39%) fully completed the feasibility survey. 89% (n = 177) reported that they agreed with that the questions in the survey were important, and 95% (n = 189) reported that they answered truthfully to all questions. Similarly, 91% (n = 180) reported that they did not agree with that the questions were unpleasant for them. However, 16% (n = 32) reported that they did not find the survey to be of personal value, and 12% (n = 23) reported that the survey had caused them to think about issues that they did not want to think about. Responding that participation was not personally gratifying was associated with training more hours (p = 0.01). There is a scarcity of research on the prevention of sexual abuse in individual sports. The present protocol should be regarded as a means to overcome this shortcoming in athletics. When implementing the protocol, it is necessary to encourage athlete compliance and to adapt the web-based survey to the particular infrastructural conditions in the sports setting at hand. Key pointsA research protocol for cross-sectional epidemiological studies of sexual abuse in athletics was designed and its feasibility evaluated.The definition of sexual abuse, ethical soundness of the protocol, reference populations and study of co-morbidity, and means for athlete-level data collection were in requirements analyses identified as particularly complex design issues.The feasibility evaluation showed a high non-participation rate (61%), but also that the large majority of participants found the study important and that questions were answered truthfully.Responding that partaking in the study was not personally gratifying was associated with training more hours.When implementing cross-sectional epidemiological studies of sexual abuse in athletics, it is necessary to promote and facilitate athlete participation.

Quality of life among Swedish school children who experienced multitype child maltreatment

AIM

The aim of this study was to examine the overlap between child maltreatment types and their association with quality of life among school children.

METHODS

A national cross-sectional study of 3202 grade nine Swedish pupils of 15 years of age was carried out in 2011 with an 84% response rate. Data were analysed using Pearson chi-square and multiple linear regression analyses.

RESULTS

Of the total sample, 650 children (20%) reported at least one type of maltreatment. There was a large degree of overlap between maltreatment types. In particular, neglect and witnessing intimate partner violence overlapped with most other types of maltreatment. There was a significant relationship between the degree of abuse and multitype maltreatment. Results showed a linear relationship between the number of types of maltreatment and quality of life (p < 0.001), indicating a dose-response relationship.

CONCLUSION

The results emphasise the negative impact of child maltreatment on children's lives and highlight the importance of taking the broad spectrum of child maltreatment into account in both research and practice. A more comprehensive assessment of the width of maltreatment among professionals may help to identify the most seriously maltreated children and lead to an improved ability to target intervention and prevention at these children.

Prenatal phthalate exposures and anogenital distance in Swedish boys

BACKGROUND

Phthalates are used as plasticizers in soft polyvinyl chloride (PVC) and in a large number of consumer products. Because of reported health risks, diisononyl phthalate (DiNP) has been introduced as a replacement for di(2-ethylhexyl) phthalate (DEHP) in soft PVC. This raises concerns because animal data suggest that DiNP may have antiandrogenic properties similar to those of DEHP. The anogenital distance (AGD)--the distance from the anus to the genitals--has been used to assess reproductive toxicity.

OBJECTIVE

The objective of this study was to examine the associations between prenatal phthalate exposure and AGD in Swedish infants.

METHODS

AGD was measured in 196 boys at 21 months of age, and first-trimester urine was analyzed for 10 phthalate metabolites of DEP (diethyl phthalate), DBP (dibutyl phthalate), DEHP, BBzP (benzylbutyl phthalate), as well as DiNP and creatinine. Data on covariates were collected by questionnaires.

RESULTS

The most significant associations were found between the shorter of two AGD measures (anoscrotal distance; AGDas) and DiNP metabolites and strongest for oh-MMeOP [mono-(4-methyl-7-hydroxyloctyl) phthalate] and oxo-MMeOP [mono-(2-ethyl-5-oxohexyl) phthalate]. However, the AGDas reduction was small (4%) in relation to more than an interquartile range increase in DiNP exposure.

CONCLUSIONS

These findings call into question the safety of substituting DiNP for DEHP in soft PVC, particularly because a shorter male AGD has been shown to relate to male genital birth defects in children and impaired reproductive function in adult males and the fact that human levels of DiNP are increasing globally.

[All children must be protected from abuse]

Sweden was the first country in the world to introduce a corporal punishment ban in 1979. Corporal punishment was looked upon as a normal part of upbringing in the 1960s, but today more than 90 % of all Swedish parents regard this as a deviant behavior. While the diagnostic tools for establishing of intentional injuries are continuously refined, neglect of children has been more difficult to define and describe. In later years, however, it has been obvious that neglect for many children is chronic and with long-term effects that are just as devastating as corporal punishment and sexual abuse. All over the world a more ecological view on family violence is developing, also taking into account countries' social, cultural and political conditions.

Exploring risk for abuse of children with chronic conditions or disabilities--parent's perceptions of stressors and the role of professionals

BACKGROUND

Children with chronic conditions or disabilities are at an increased risk for abuse. High level of parental stress has been identified as possible trigger for abuse, were a combination of several factors are of importance, as lack of social support and limited resources in the neighbourhood. Suggestions for preventive measures have merely focused on parenting strategies and targeted intervention programmes. So far, little attention has been paid on how the risk for abuse might relate to parent's perceptions of stressors and the role of professionals. The purpose of the current study was therefore to explore risk factors for abuse with focus on both parent-child and parent-professional relationships.

METHOD

Semi-structured in-depth interviews with 15 parents of children with chronic conditions or disability were collected and analysed according to qualitative content analysis.

FINDINGS

Three major themes were found that could be seen as risk factors for child abuse: (1) Emotional demands in precarious situations between parent and child. (2) Gradual shift in responsibility from professionals to parents concerning access to and co-ordination of service and support. (3) Emotionally closed environment between professionals and parents and taboo on talking about abuse. The gradual shift in responsibility had emotional implications, which could reinforce parental stress and thereby also indirect increase the risk of child abuse. The gradual shift in responsibility also seemed to generate an emotionally closed environment and reinforce the taboo on talking about abuse, which in turn hindered preventive measures.

CONCLUSIONS

In the light of parent's perceptions of stressors and the role of professionals the findings indicate that abuse against children with chronic conditions or disability is not only a family matter, but also depending on qualities in service, professional support and social norms. The result pinpoints three challenges for preventive measures, all with emotional implications, parental strategies, organizational efforts and cultural awareness.

The association between medical conditions and gender, well-being, psychosomatic complaints as well as school adaptability

AIM

The aim was to assess the association between medical conditions and gender, well-being, psychosomatic complaints and school adaptability. The second aim was to determine whether self-reported medical conditions should be included in class-room questionnaires that deal with well-being and risk behaviour.

METHODS

A cross-sectional class-room questionnaire was given to all 15- to 16-year-olds within a Swedish county. The questionnaire included background factors, subjective health, well-being, psychosomatic complaints, self image, drug use and also several themes from the school context. In addition, there were 13 medical conditions/problems to tick (yes or no) and an open alternative for other problems/medical conditions.

RESULTS

3108 questionnaires (response rate 84%) were analysed. The majority of the girls and the boys reported no medical conditions; however, 49% of the girls and 39% of the boys reported at least one medical condition. The medical conditions were associated with gender, well-being, psychosomatic complaints and school adaptability. The association was stronger for girls than for boys.

CONCLUSION

Medical conditions among these teenagers were associated with gender, well-being, psychosomatic complaints and school adaptability, particularly for girls. Our results suggest that medical conditions could preferably be included in regular classroom questionnaires.

Health services for children in western Europe

Western European health systems are not keeping pace with changes in child health needs. Non-communicable diseases are increasingly common causes of childhood illness and death. Countries are responding to changing needs by adapting child health services in different ways and useful insights can be gained through comparison, especially because some have better outcomes, or have made more progress, than others. Although overall child health has improved throughout Europe, wide inequities remain. Health services and social and cultural determinants contribute to differences in health outcomes. Improvement of child health and reduction of suffering are achievable goals. Development of systems more responsive to evolving child health needs is likely to necessitate reconfiguring of health services as part of a whole-systems approach to improvement of health. Chronic care services and first-contact care systems are important aspects. The Swedish and Dutch experiences of development of integrated systems emphasise the importance of supportive policies backed by adequate funding. France, the UK, Italy, and Germany offer further insights into chronic care services in different health systems. First-contact care models and the outcomes they deliver are highly variable. Comparisons between systems are challenging. Important issues emerging include the organisation of first-contact models, professional training, arrangements for provision of out-of-hours services, and task-sharing between doctors and nurses. Flexible first-contact models in which child health professionals work closely together could offer a way to balance the need to provide expertise with ready access. Strategies to improve child health and health services in Europe necessitate a whole-systems approach in three interdependent systems-practice (chronic care models, first-contact care, competency standards for child health professionals), plans (child health indicator sets, reliable systems for capture and analysis of data, scale-up of child health research, anticipation of future child health needs), and policy (translation of high-level goals into actionable policies, open and transparent accountability structures, political commitment to delivery of improvements in child health and equity throughout Europe).

Cultural bias in the AAP's 2012 Technical Report and Policy Statement on male circumcision

The American Academy of Pediatrics recently released its new Technical Report and Policy Statement on male circumcision, concluding that current evidence indicates that the health benefits of newborn male circumcision outweigh the risks. The technical report is based on the scrutiny of a large number of complex scientific articles. Therefore, while striving for objectivity, the conclusions drawn by the 8 task force members reflect what these individual physicians perceived as trustworthy evidence. Seen from the outside, cultural bias reflecting the normality of nontherapeutic male circumcision in the United States seems obvious, and the report's conclusions are different from those reached by physicians in other parts of the Western world, including Europe, Canada, and Australia. In this commentary, a different view is presented by non-US-based physicians and representatives of general medical associations and societies for pediatrics, pediatric surgery, and pediatric urology in Northern Europe. To these authors, only 1 of the arguments put forward by the American Academy of Pediatrics has some theoretical relevance in relation to infant male circumcision; namely, the possible protection against urinary tract infections in infant boys, which can easily be treated with antibiotics without tissue loss. The other claimed health benefits, including protection against HIV/AIDS, genital herpes, genital warts, and penile cancer, are questionable, weak, and likely to have little public health relevance in a Western context, and they do not represent compelling reasons for surgery before boys are old enough to decide for themselves.

Case analyses of all children's drowning deaths occurring in Sweden 1998-2007

AIMS

The goal of this research project was to explore circumstances surrounding each drowning death occurring to children and adolescents ages 0-17 in Sweden during the years 1998-2007.

METHODS

Records from the National Board of Forensic Medicine (NBFM) and other sources were analysed. We collected information on children's personal characteristics (sex, age, ethnic background, weight, height, physical condition, and pre-existing health conditions) and the circumstances of deaths (time and place of occurrence, type of drowning, resuscitation efforts and medical care given, for example). We also collected information on prevention factors: the physical environment, adult supervision, whether or not the child could swim, and if the child was using a personal flotation device at the time of death.

RESULTS

Our analysis showed that 109 children had drowned in Sweden during the study period - of this group, 96 had died from unintentional causes. Children from immigrant backgrounds, particularly with families coming from the Middle East and Iran, were inordinately represented in the group of victims who had died from unintentional drowning deaths. Other risk factors included: coming from a single parent-headed family, alcohol use by older victims and a lack of ability to swim.

CONCLUSIONS

Prevention efforts to prevent drowning in the future should focus on preventing alcohol use by young bathers; better fencing around swimming sites; improved coverage of swimming lessons to all children in Sweden, especially children from immigrant families; more education on drowning risks for single parents; and better awareness by adults on the need for constant supervision of children and adolescents in and near water.

Socio-economic risk factors for injuries in Swedish children and adolescents: a national study over 15 years

Few studies have assessed if Sweden's injury prevention work has been equally effective for children of different socio-economic backgrounds. The goal of this paper is to review the country's injury rates for children over time, stratified by socio-economic status (SES), to see if the effects are similar across SES levels. This study employs a retrospective case-control study design, using data from the hospitalisation records of 51,225 children, which were linked to family socio-economic data. Children and adolescents in families receiving social welfare benefits, and those living with single parents and mothers with less education had higher risks of injuries leading to hospitalisation. The population-based safety work over the past decades seems to have had only minor effects on reducing the impact of socio-economic based difference in injury risks to younger Swedes.

The SELMA study: a birth cohort study in Sweden following more than 2000 mother-child pairs

BACKGROUND

 This paper describes the background, aim and study design for the Swedish SELMA study that aimed to investigate the importance of early life exposure during pregnancy and infancy to environmental factors with a major focus on endocrine disrupting chemicals for multiple chronic diseases/disorders in offspring.

METHODS

The cohort was established by recruiting women in the 10th week of pregnancy. Blood and urine from the pregnant women and the child and air and dust from home environment from pregnancy and infancy period have been collected. Questionnaires were used to collect information on life styles, socio-economic status, living conditions, diet and medical history.

RESULTS

Of the 8394 reported pregnant women, 6658 were invited to participate in the study. Among the invited women, 2582 (39%) agreed to participate. Of the 4076 (61%) non-participants, 2091 women were invited to a non-respondent questionnaire in order to examine possible selection bias. We found a self-selection bias in the established cohort when compared with the non-participant group, e.g. participating families did smoke less (14% vs. 19%), had more frequent asthma and allergy symptoms in the family (58% vs. 38%), as well as higher education among the mothers (51% vs. 36%) and more often lived in single-family houses (67% vs. 60%).

CONCLUSIONS

These findings indicate that the participating families do not fully represent the study population and thus, the exposure in this population. However, there is no obvious reason that this selection bias will have an impact on identification of environmental risk factors.

Is "football for all" safe for all? Cross-sectional study of disparities as determinants of 1-year injury prevalence in youth football programs

BACKGROUND

Football (soccer) is endorsed as a health-promoting physical activity worldwide. When football programs are introduced as part of general health promotion programs, equal access and limitation of pre-participation disparities with regard to injury risk are important. The aim of this study was to explore if disparity with regard to parents' educational level, player body mass index (BMI), and self-reported health are determinants of football injury in community-based football programs, separately or in interaction with age or gender.

METHODOLOGY/PRINCIPAL FINDINGS

Four community football clubs with 1230 youth players agreed to participate in the cross-sectional study during the 2006 season. The study constructs (parents' educational level, player BMI, and self-reported health) were operationalized into questionnaire items. The 1-year prevalence of football injury was defined as the primary outcome measure. Data were collected via a postal survey and analyzed using a series of hierarchical statistical computations investigating associations with the primary outcome measure and interactions between the study variables. The survey was returned by 827 (67.2%) youth players. The 1-year injury prevalence increased with age. For youths with parents with higher formal education, boys reported more injuries and girls reported fewer injuries than expected; for youths with lower educated parents there was a tendency towards the opposite pattern. Youths reporting injuries had higher standardized BMI compared with youths not reporting injuries. Children not reporting full health were slightly overrepresented among those reporting injuries and underrepresented for those reporting no injury.

CONCLUSION

Pre-participation disparities in terms of parents' educational level, through interaction with gender, BMI, and self-reported general health are associated with increased injury risk in community-based youth football. When introduced as a general health promotion, football associations should adjust community-based youth programs to accommodate children and adolescents with increased pre-participation injury risk.

Molecular identification of hybrids of the invasive gibel carp Carassius auratus gibelio and crucian carp Carassius carassius in Swedish waters

Both mitochondrial DNA sequence and two nuclear microsatellite markers were used to confirm the identity of the first record of Carassius auratus gibelio in the western (Swedish) Baltic Sea region. A total of 49 fishes were analysed, where 22 were from three Swedish sites connected to the Baltic Sea. The D-loop mitochondrial DNA sequences showed that 16 of 22 Swedish fishes were related to C. a. gibelio. The phylogenetic analysis of these sequences showed that these fish are probably not native, but represent different lineages of C. a. gibelio from China, Japan and Russia. All except three of these 16 fishes had microsatellite alleles suggesting hybridization with Carassius carassius. These findings suggest that a cryptic invasion of C. a. gibelio might be in progress.

Multiple psychosomatic symptoms can indicate child physical abuse - results from a study of Swedish schoolchildren

AIM

To examine whether children with self-reported experiences of either physical abuse alone or combined with intimate partner violence report more psychosomatic symptoms than other children and to explore whether these possible associations are enhanced by school-related factors, chronic condition and demographic factors.

METHODS

A national cross-sectional study of 2771 pupils in grades 4, 6 and 9 from 44 schools in Sweden was carried out in 2006 (91% response rate). Data were analysed with univariate tests (chi-square), multiple logistic regression analyses and stratified logistic regression analyses, expressed as crude odds ratio (OR) and adjusted odds ratio (AOR) with 95% confidence intervals.

RESULTS

There was a strong association between reported physical abuse and multiple (three or more) psychosomatic symptoms among schoolchildren (AOR 2.12). Chronic condition was the only determinant that had an obvious enhancing effect on the association between physical abuse and psychosomatic symptoms in childhood.

CONCLUSION

This study shows that multiple psychosomatic symptoms are associated with child physical abuse. Health professionals therefore need to pay special attention to schoolchildren who complain about the co-occurrence of psychosomatic symptoms and pattern of symptoms, which could not be easily explained by other causes.

Child maltreatment: variation in trends and policies in six developed countries

We explored trends in six developed countries in three types of indicators of child maltreatment for children younger than 11 years, since the inception of modern child protection systems in the 1970s. Despite several policy initiatives for child protection, we recorded no consistent evidence for a decrease in all types of indicators of child maltreatment. We noted falling rates of violent death in a few age and country groups, but these decreases coincided with reductions in admissions to hospital for maltreatment-related injury only in Sweden and Manitoba (Canada). One or more child protection agency indicators increased in five of six countries, particularly in infants, possibly as a result of early intervention policies. Comparisons of mean rates between countries showed five-fold to ten-fold differences in rates of agency indicators, but less than two-fold variation in violent deaths or maltreatment-related injury, apart from high rates of violent child death in the USA. These analyses draw attention to the need for robust research to establish whether the high and rising rates of agency contacts and out-of-home care in some settings are effectively reducing child maltreatment.

Governance and implementation of sports safety practices by municipal offices in Swedish communities

The objective of this study was to explore whether all-purpose health or safety promotion programmes and sports safety policies affect sports safety practices in local communities. Case study research methods were used to compare sports safety activities among offices in 73 Swedish municipalities; 28 with ongoing health or safety promotion programmes and 45 controls. The offices in municipalities with the WHO Healthy Cities (HC) or Safe Communities programmes were more likely to perform frequent inspections of sports facilities, and offices in the WHO HC programme were more likely to involve sports clubs in inspections. More than every second, property management office and environmental protection office conducted sports safety inspections compared with less than one in four planning offices and social welfare offices. It is concluded that all-purpose health and safety promotion programmes can reach out to have an effect on sports safety practices in local communities. These safety practices also reflect administrative work routines and managerial traditions.