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A selection from Stockholm University publication database

• Health Risk Behaviours by Immigrants’ Duration of Residence: A Systematic Review and Meta-Analysis

  2022. Sol P. Juárez (et al.). International Journal of Public Health 67

  Article

  Objectives: The aim was to systematically review and synthesise international evidence on changes in health risk behaviours by immigrants’ duration of residence.

  Methods: We searched literature databases for peer-reviewed quantitative studies published from 2000 to 2019, examining alcohol, drug and tobacco use; physical inactivity; and dietary habits by duration of residence.

  Results: Narrative synthesis indicated that immigrants tend to adopt health risk behaviours with longer residence in North America, with larger variation in effect sizes and directionality in other contexts. Random-effects meta-analyses examining the pooled effect across all receiving countries and immigrant groups showed lower odds of smoking (OR 0.54, 0.46–0.63, I2 = 68.7%) and alcohol use (OR 0.61, 0.47–0.75, I2 = 93.5%) and higher odds of physical inactivity (OR 1.71, 1.40–2.02, I2 = 99.1%) among immigrants than natives, but did not provide support for a universal trend by duration of residence.

  Conclusion: Findings suggest that duration of residence could serve as an effective instrument to monitor immigrants’ health changes. However, differences in receiving country contex

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• Substance use disorder and suicide-related behaviour around dates of parental death and its anniversaries: a register-based cohort study

  2022. Ayako Hiyoshi (et al.). The Lancet Public Health 7 (8), e683-e693

  Article

  Summary

  Background Parental death and its anniversaries, including anticipation of these dates, might cause distress andincrease the risk of substance use disorder and suicide-related behaviour in bereaved adolescents and young adults.We examined whether the risk of substance use disorder and suicide-related behaviour increases around the date ofparental death and subsequent anniversaries.

  Methods Using Swedish national registers, we conducted a cohort study of individuals aged 12–24 years. We includedindividuals aged 12–24 years between Jan 1, 2001, and Dec 31, 2014, whose parents were alive at entry (n=1 858 327)and followed up with them until the end of age 24 years. We excluded individuals with a half-sibling, a history ofemigration, a previous record of the outcome events, a parental death before study entry, two parental deaths on thesame day during the follow-up, or missing data for relevant variables. Follow-up ended on the day of an outcomeevent or on Dec 31, 2014; at age 25 years, emigration, or death; or a year before the second parental death. We studiedsubstance use disorder and suicide-related behaviour outcomes separately and included non-fatal and fatal events inboth outcomes. We used Cox regression to estimate hazard ratios (HRs), controlling for baseline psychiatric,demographic, and socioeconomic characteristics. Parental death was modelled as a time-varying exposure over72 monthly periods, starting from 1 year before the parental death to the fifth year and later after the death.Unmeasured confounding was also addressed in within-individual comparisons using a case-crossover design.

  Findings During follow-up (median 7·5 [IQR 4·3–10·6] years), there were 42 854 substance use disorder events, witha crude rate of 3·1 per 1000 person-years. For suicide-related behaviour, there were 19 827 events, with a crude rate of1·4 per 1000 person-years. Most of the events studied were non-fatal. In the month of parental death, the HR forsubstance use disorder risk was 1·89 (95% CI 1·07–3·33) among male participants, and, for suicide-related behaviour,was 3·76 (1·79–7·89) among male participants and 2·90 (1·61–5·24) among female participants. In male participants,there was an increased risk around the first anniversary (substance use disorder: HR 2·64 [95% CI 1·56–4·46] duringthe anniversary month; 2·21 [1·25–3 ·89] for the subsequent month; and for suicide-related behaviour: 3·18[1·32–7·66] for the subsequent month). Among female participants, an increased risk of substance use disorderrecurred around every year consistently in the month before the anniversary of the death and there was an increasedrisk for suicide-related behaviour in the months of the first and second anniversaries.

  Interpretation Although effect sizes were large in this cohort study, the number of individuals who had the outcomeswas small. Nevertheless, adolescents and young adults, especially women and girls, who had the death of a parentshowed increased risk of substance use disorder and suicide-related behaviour around the first few death anniversaries.Adolescents and young adults, especially women and girls, who had the death of a parent could benefit from preventivemeasures to reduce distress around the first few years of death anniversaries

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• School Outcomes Among Children Following Death of a Parent

  2022. Can Liu (et al.). JAMA Network Open 5 (4)

  Article

  Importance  To better support children with the experience of parental death, it is crucial to understand whether parental death increases the risk of adverse school outcomes.

  Objectives  To examine whether parental death is associated with poorer school outcomes independent of factors unique to the family, and whether children of certain ages are particularly vulnerable to parental death.

  Design, Setting, and Participants  This population-based sibling cohort study used Swedish national register-based longitudinal data with linkage between family members. Register data were collected from January 1, 1990, to December 31, 2016. Data analyses were performed on July 14, 2021. The participants were all children born between 1991 and 2000 who lived in Sweden before turning age 17 years (N = 908 064).

  Exposure  Parental death before finishing compulsory school.

  Main Outcomes and Measures  Mean school grades (year-specific z scores) and ineligibility for upper secondary education on finishing compulsory school at age 15 to 16 years. Population-based cohort analyses were conducted to examine the association between parental death and school outcomes using conventional linear and Poisson regression models, after adjustment for demographic and parental socioeconomic and health indicators measured before childbirth. Second, using fixed-effect linear and Poisson regression models, children who experienced parental death before finishing compulsory school were compared with their siblings who experienced the death after. Third, the study explored the age-specific associations between parental death and school outcomes.

  Results  In the conventional population-based analyses, bereaved children (N = 22 634; 11 553 boys [51.0%]; 11 081 girls [49.0%]; mean [SD] age, 21.0 [2.8] years) had lower mean school grade z scores (adjusted β coefficient, −0.19; 95% CI, −0.21 to −0.18; P < .001) and a higher risk of ineligibility for upper secondary education than the nonbereaved children (adjusted risk ratio, 1.36; 95% CI, 1.32-1.41; P < .001). Within-sibling comparisons using fixed-effects models showed that experiencing parental death before finishing compulsory school was associated with lower mean school grade z scores (−0.06; 95% CI, −0.10 to −0.01; P = .02) but not with ineligibility for upper secondary education (adjusted risk ratio, 1.07; 95% CI, 0.93-1.23; P = .34). Independent of birth order, losing a parent at a younger age was associated with lower grades within a family.

  Conclusions and Relevance  In this cohort study, childhood parental death was associated with lower school grades after adjustment for familial confounders shared between siblings. Children who lost a parent may benefit from additional educational support that could reduce the risk of adverse socioeconomic trajectories later in life.

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• Parental post-traumatic stress and psychiatric care utilisation among refugee adolescents

  2021. Lisa Berg (et al.). European Child and Adolescent Psychiatry

  Article

  Parental psychiatric morbidity related to experiences of war and trauma has been associated with adverse psychological outcomes for children. The aim of this study was to investigate parental post-traumatic stress in relation to psychiatric care utilization among children of refugees with particular attention on the child's own refugee status, sex of both child and parents, and specific psychiatric diagnoses. This was a register study in a population of 16 143 adolescents from refugee families in Stockholm County born 1995-2000 and followed between 2011 and 2017 (11-18 years old). Parental post-traumatic stress, identified in three levels of care, was analysed in relation to child and adolescent psychiatric care use. Cox regression analysis was used to estimate hazard ratios (HR) and 95% confidence intervals (CI), adjusted for duration of residence and demographic and socioeconomic variables. Having a mother with post-traumatic stress was associated with higher psychiatric care utilization, with adjusted HR 2.44 (95% CI 1.90-3.14) among foreign-born refugee children and HR 1.77 (1.33-2.36) among Swedish-born children with refugee parents, with particularly high risks for children with less than five years of residence (HR 4.03; 2.29-7.10) and for diagnoses of anxiety and depression (HR 2.71; 2.11-3.48). Having a father with post-traumatic stress was not associated with increased HRs of psychiatric care utilization. Similar results were seen for boys and girls. Treatment for post-traumatic stress should be made available in refugee reception programmes. These programmes should use a family approach that targets both parents and children.

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• Parental Posttraumatic Stress and School Performance in Refugee Children

  2021. Lisa Berg (et al.). Journal of Traumatic Stress

  Article

  Refugee children in the Nordic countries have been reported to perform poorly in school and carry a high burden of familial posttraumatic stress. The present study aimed to investigate the impact of maternal and paternal posttraumatic stress on the school performance of refugee children. We used national register data on school grades at age 15-16 along with demographic and migration indicators during 2011-2017 in a population of 18,831 children in refugee families in Stockholm County, Sweden. Parental posttraumatic stress was identified in regional data from three levels of care, including a tertiary treatment center for victims of torture and war. Multivariable linear and logistic regression models were fitted to analyze (a) mean grade point averages as Z scores and (b) eligibility for upper secondary school. In fully adjusted models, children exposed to paternal posttraumatic stress had a lower mean grade point average, SD = -0.14, 95% CI [-0.22, -0.07], and higher odds of not being eligible for upper secondary education, OR = 1.37, 95% CI [1.14, 1.65]. Maternal posttraumatic stress had a similar crude effect on school performance, SD = -0.15, 95% CI [-0.22, -0.07], OR = 1.25, 95% CI [1.00, 1.55], which was attenuated after adjusting for single-parent households and the use of child psychiatric services. The effects were similar for boys and girls as well as for different levels of care. Parental posttraumatic stress had a small negative effect on school performance in refugee children, adding to the intergenerational consequences of psychological trauma.

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• Underutilisation of psychiatric care among refugee adolescents in Stockholm

  2021. Lisa Berg, Gunnar Ljunggren, Anders Hjern. Acta Paediatrica 110, 563-570

  Article

  Aim: Refugee children have been shown to underutilise psychiatric services in Scandinavia. The aim of this study was to investigate determinants of psychiatric care utilisation in adolescents in refugee families.

  Methods: The study used regional data on healthcare use linked to sociodemographic data from national registers in a total population of 93 537 adolescents in the Stockholm County born in 1995‐2000, including 18 831 with a refugee background. Cox regression analyses were fitted to estimate Hazard ratios (HRs) of psychiatric care utilisation in the age‐span 11‐18 years.

  Results: Psychiatric care use was lower in the large majority of adolescents in refugee families that originated in low‐ and middle‐income countries, with adjusted HRs 0.34 (95% CI 0.28‐0.42) and 0.51 (95% CI 0.46‐0.56), respectively, compared with the Swedish majority population. Among the foreign‐born refugee adolescents, psychiatric care use increased with duration of residence in Sweden and was higher in children who obtained residency as asylum seekers compared with those who settled in family reunification.

  Conclusion: Adolescents in newly settled refugee families with a background in low‐ and middle‐income countries should be a priority in mental health assessment of refugee children and referral to psychiatric care facilitated for children in need.

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• Parental death in childhood and pathways to increased mortality across the life course in Stockholm, Sweden

  2021. Ayako Hiyoshi (et al.). PLoS Medicine 18 (3)

  Article

  Background

  Previous studies have shown that the experience of parental death during childhood is associated with increased mortality risk. However, few studies have examined potential pathways that may explain these findings. The aim of this study is to examine whether familial and behavioural factors during adolescence and socioeconomic disadvantages in early adulthood mediate the association between loss of a parent at age 0 to 12 and all-cause mortality by the age of 63.

  Methods and findings

  A cohort study was conducted using data from the Stockholm Birth Cohort Multigenerational Study for 12,615 children born in 1953, with information covering 1953 to 2016. Familial and behavioural factors at age 13 to 19 included psychiatric and alcohol problems in the surviving parent, receipt of social assistance, and delinquent behaviour in the offspring. Socioeconomic disadvantage in early adulthood included educational attainment, occupational social class, and income at age 27 to 37. We used Cox proportional hazard regression models, combined with a multimediator analysis, to separate direct and indirect effects of parental death on all-cause mortality.

  Among the 12,582 offspring in the study (men 51%; women 49%), about 3% experienced the death of a parent in childhood. During follow-up from the age of 38 to 63, there were 935 deaths among offspring. Parental death was associated with an elevated risk of mortality after adjusting for demographic and household socioeconomic characteristics at birth (hazard ratio [HR]: 1.52 [95% confidence interval: 1.10 to 2.08, p-value = 0.010]). Delinquent behaviour in adolescence and income during early adulthood were the most influential mediators, and the indirect associations through these variables were HR 1.03 (1.00 to 1.06, 0.029) and HR 1.04 (1.01 to 1.07, 0.029), respectively. After accounting for these indirect paths, the direct path was attenuated to HR 1.35 (0.98 to 1.85, 0.066). The limitations of the study include that the associations may be partly due to genetic, social, and behavioural residual confounding, that statistical power was low in some of the subgroup analyses, and that there might be other relevant paths that were not investigated in the present study.

  Conclusions

  Our findings from this cohort study suggest that childhood parental death is associated with increased mortality and that the association was mediated through a chain of disadvantages over the life course including delinquency in adolescence and lower income during early adulthood. Professionals working with bereaved children should take the higher mortality risk in bereaved offspring into account and consider its lifelong consequences. When planning and providing support to bereaved children, it may be particularly important to be aware of their increased susceptibility to delinquency and socioeconomic vulnerability that eventually lead to higher mortality.

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• Intergenerational transmission of alcohol misuse

  2020. Ylva B. Almquist (et al.). Journal of Epidemiology and Community Health 74 (7), 598-604

  Article

  Background Children whose parents misuse alcohol have increased risks of own alcohol misuse in adulthood. Though most attain lower school marks, some still perform well in school, which could be an indicator of resilience with protective potential against negative health outcomes. Accordingly, the aim of this study was to examine the processes of mediation and interaction by school performance regarding the intergenerational transmission of alcohol misuse.

  Methods Data were drawn from a prospective Swedish cohort study of children born in 1953 (n=14 608). Associations between parental alcohol misuse (ages 0–19) and participants' own alcohol misuse in adulthood (ages 20–63) were examined by means of Cox regression analysis. Four-way decomposition was used to explore mediation and interaction by school performance in grade 6 (age 13), grade 9 (age 16) and grade 12 (age 19).

  Results Mediation and/or interaction by school performance accounted for a substantial proportion of the association between parental alcohol misuse and own alcohol misuse in adulthood (58% for performance in grade 6, 27% for grade 9 and 30% for grade 12). Moreover, interaction effects appeared to be more important for the outcome than mediation.

  Conclusion Above-average school performance among children whose parents misused alcohol seems to reflect processes of resilience with the potential to break the intergenerational transmission of alcohol misuse. Four-way decomposition offers a viable approach to disentangle processes of interaction from mediation, representing a promising avenue for future longitudinal research.

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• Labour market participation among young refugees in Sweden and the potential of education

  2019. Hélio Manhica (et al.). Journal of Youth Studies 22 (4), 533-550

  Article

  This register-based study examined the importance of education on labour market participation among young refugees in Sweden. The study population consisted of unaccompanied (n = 1606) and accompanied refuges (n = 4142), aged 23–26 years in 2006–2010, after 7 years of residence in Sweden. Native Swedish, aged 24 years (n = 347,255) constituted the comparison population, with intercountry adoptees (n = 6689) as an alternative reference group. Gender-stratified multinomial regression models indicated that unaccompanied and accompanied male and female young refugees had higher risks of being in insecure work force and NEET compared to native Swedes with comparable levels of education. However, young refugees and intercountry adoptees with primary education had similar risks of poor labour market outcomes. The educational differences within each group concerning the risk of being in insecure work force were comparable. With the exception of unaccompanied females, secondary education seemed to be less protective against being in NEET among young refugees compared to native Swedes and intercountry adoptees. We conclude that while young refugees face employment disadvantages, education has the potential of mitigating poor labour market outcomes in this group.

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• Experience of sibling death in childhood and risk of psychiatric care in adulthood

  2019. Lisa Berg (et al.). European Child and Adolescent Psychiatry

  Article

  Studies have found that sibling loss is associated with an increased risk of death from external causes (i.e. suicides, accidents and homicides). Increased psychiatric health problems following bereavement could underlie such an association. We studied the influence of sibling loss during childhood on psychiatric care in young adulthood, adjusting for psychosocial covariates shared by siblings in childhood. A national cohort born in Sweden in 1973–1982 (N = 701,270) was followed prospectively until 2013. Cox proportional hazards models were used to analyse the association between sibling loss during childhood and psychiatric inpatient and outpatient care identified by the Hospital Discharge Register. After adjustment for confounders, the HRs of psychiatric care in men who experienced sibling loss were 1.17 (95% CI 1.07–1.27) while the associations turned non-significant in women after adjustment for family-related psychosocial covariates, HR 1.07 (95% CI 0.99–1.16). An increased risk was found in men bereaved in early childhood (1.22 95% CI 1.07–1.38) and adolescence (1.27 95% CI 1.08–1.48). Among women, loss of a sibling during adolescence was significantly associated with psychiatric care (1.19 95% CI 1.03–1.36). Increased psychiatric health problems following bereavement could underlie the previously found association between sibling loss and mortality from external causes. Family-related psychosocial conditions shared by siblings in childhood may account for the association between sibling death and psychiatric care in adulthood.

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• Parental death during childhood and depression in young adults – a national cohort study

  2016. Lisa Berg, Mikael Rostila, Anders Hjern. Journal of Child Psychology and Psychiatry and Allied Disciplines 57 (9), 1092-1098

  Article

  Background

  There are few prospective, population-based studies on childhood parental death and psychiatric disorders in adulthood, and previous findings are inconclusive. This study investigated the association between parental death from natural and external (suicides, accidents or homicides) causes before 18 years and the risk of clinical depression in young adults, in relation to age at loss and gender of both child and parent.

  Methods

  In this register-based study, a national cohort born in Sweden during 1973–1982 (n = 862,554) was followed with regard to hospital admissions and outpatient care for depression during 2006–2013. Multivariate Cox proportional hazards models were used to estimate the impact of parental death, taking sociodemographic and parental psychosocial covariates into account.

  Results

  Maternal death from natural causes was associated with a hazard ratio (HR) of outpatient care for depression of 1.19 [95% confidence interval (CI), 1.02–1.40] in men and 1.15 (1.01–1.31) in women, after adjustment for sociodemographic confounders, with similar effect sizes for paternal natural death. Death from external causes consistently had higher effect size compared with natural deaths, in particular in relation to risk of hospital admissions for depression where they were as high as HR 3.23 (2.38–4.38) for men, and 1.79 (1.30–2.47) for women after a loss of a mother. Losing a parent in preschool age, compared with losing a parent as a teenager, was associated with higher risks of both hospitalization (p = .006) and outpatient care (p = .001) for depression.

  Conclusions

  This study indicates that parental loss to death from natural causes during childhood is associated with a small increased risk of long-term consequences for psychological health. Children who lose their parents to death from external causes, that is suicides, accidents or homicides, and children losing a parent in young ages are, however, at particular risk and should be given priority in preventive interventions after parental loss.

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• Parental alcohol-related disorders and school performance in 16 year olds - a national cohort study

  2016. Lisa Berg (et al.). Addiction 111 (10), 1795-1803

  Article

  To study the links between parental alcohol-related disorders and offspring school performance and, specifically, whether associations vary by gender of parent or child and whether associations are mediated by other adverse psychosocial circumstances commonly appearing together with parental alcohol problems, such as parental mental health problems or criminal behaviour.

  Register study in a national cohort.

  Setting

  Sweden.

  740 618 individuals born in Sweden in 1990-1996.

  Parental hospital admissions for alcohol-related disorders and school performance in their offspring, in the final year of compulsory school at age 15-16, was analysed in relation to sociodemographic confounders and psychosocial covariates, using linear and logistic regressions.

  Both mothers’ and fathers’ alcohol-related hospital admissions were associated with lower z-scores of grades and national mathematic tests scores. After adjustment for parental education and sociodemographic confounders, beta-coefficients of z-scores of grades were -0.42 (95% CI -0.45, -0.39) and -0.42 (95 % CI -0.43,-0.40), and beta-coefficients of mathematic tests scores were -0.36 (95% CI -0.39, -0.33) and -0.31 (95% CI -0.33, -0.29), for mothers’ and fathers’ alcohol-related disorders, respectively. Adjusted ORs for not being eligible for secondary school were 1.99 (95% CI 1.84-2.15) and 2.04 (95% CI 1.95-2.15) for mothers’ and fathers’ alcohol-related disorders, respectively. Adjusting the analyses for psychosocial factors in the family almost eradicated the statistical effects of parental alcohol-related disorders on offspring school performance to beta-coefficients of 0.03 to -0.10 and ORs of 0.89 to 1.15. The effect of a mother's alcohol-related hospital admission on school performance was stronger in girls than in boys, whereas no gender differences were seen for a father's alcohol-related hospital admission.

  Conclusions

  In Sweden, alcohol-related disorders in both mothers and fathers are associated with lower school performance in their children at age 15-16, with most of the statistical effects being attributed to psychosocial circumstances of the family, such as parental psychiatric disorders, drug use, and criminality and receipt of social or child welfare interventions.

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