Introdução: Os transtornos de ansiedade na infância e adolescência são prevalentes e geralmente se mantêm até a vida adulta. Podem também ser considerados como fator de risco para o desenvolvimento de outros transtornos psiquiátricos. Portanto, a avaliação, o diagnóstico e o tratamento da ansiedade nesta faixa etária, assim como a detecção de comorbidades associadas, têm uma importância significativa para o alívio do sofrimento e para a prevenção de transtornos mentais em futuras etapas do ciclo vital. Objetivos: Avaliar, em uma amostra comunitária de crianças e adolescentes, a presença de comorbidades nos distintos transtornos de ansiedade em comparação ao grupo controle. Métodos: Em um delineamento de caso-controle, entre agosto de 2008 e dezembro de 2009 foram avaliadas, sucessivamente, 242 crianças e adolescentes pertencentes a escolas estaduais que estão dentro da área de abrangência da Unidade Básica de Saúde do Hospital de Clínicas de Porto Alegre (HCPA). A triagem realizada nas escolas faz parte de um projeto de pesquisa no qual foram aplicados instrumentos de avaliação de ansiedade e outros sintomas psiquiátricos com o objetivo de averiguar possíveis casos (ansiosos) e controles, para um amplo estudo sobre transtornos de ansiedade na infância e adolescência. Os indivíduos selecionados, através da triagem escolar, foram posteriormente avaliados através do K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version Diagnostic Interview), aplicado aos participantes da pesquisa, juntamente com seus pais, por psiquiatras treinados. Resultados: A amostra final foi composta por 138 casos e 104 controles. Entre os casos, 95 (68,8%) preencheram critérios para diagnóstico de ansiedade generalizada (TAG), 57 (41,3%) para transtorno de ansiedade social (TAS), 49 (35,5%) para transtorno de ansiedade de separação (TASep) e nove (6,5%) preencheram os critérios diagnósticos para transtorno de pânico (TP). Os ansiosos apresentaram alta taxa de comorbidade, ao longo da vida, estatisticamente significativa em comparação ao grupo controle, entre os transtornos de ansiedade: transtorno de ansiedade de separação com fobia específica - FE (51%) e TAG (59,2%); transtorno de ansiedade generalizada com TAS (36,8%), FE (52,6%) e transtorno do estresse pós-traumático - TEPT (8,5%); transtorno de ansiedade social com FE (59,6%) e TAG (61,4%). Também apresentaram mais comorbidade com depressão: com TAG (29,3%) e com TAS (30,9%), e enurese com TASep (22,4%). Conclusão: Houve, na amostra comunitária, uma alta prevalência de transtornos de ansiedade, principalmente transtorno de ansiedade generalizada, transtorno de ansiedade social e transtorno de ansiedade de separação. Evidenciou-se maior comorbidade com os demais transtornos de ansiedade, depressão e enurese entre os ansiosos em comparação ao grupo controle. Observou-se que possuir a comorbidade aumenta o risco de ter o desfecho (transtorno de ansiedade). É importante a realização de pesquisas similares com um maior número amostral, e de estudos caso-controle em amostras clínicas, para confirmação dos nossos resultados. / Introduction: Anxiety disorders in childhood and adolescence are prevalent, often remain until adulthood and may also be considered as a risk factor for developing other psychiatric disorders. Therefore, assessment, diagnosis and treatment of anxiety in this age group as well as the detection of comorbidities have a significant importance for the relief of suffering and the prevention of mental disorders in future stages of the lifecycle. Objectives: To evaluate the presence of comorbidities in the different anxiety disorders compared to controls in a community sample of children and adolescents. Methods: 242 children and adolescents were evaluated successively in the state schools which are within the area covered by the primary care unit of Hospital de Clinicas de Porto Alegre (HCPA) in a randomized case-control study, between August 2008 and December 2009. The screening conducted in schools is part of a research project in which instruments were used to evaluate anxiety and other psychiatric symptoms in order to investigate possible cases (anxious) and controls for an extensive study of anxiety disorders in childhood and adolescence. Those selected through the school screening, were subsequently evaluated using the K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version Diagnostic Interview), applied to the research participants, along with their parents by trained psychiatrists. Results: The final sample included 138 cases and 104 controls. Among cases, 95 (68.8%) met diagnostic criteria for generalized anxiety disorder (GAD), 57 (41.3%) for social anxiety disorder (SAD), 49 (35.5%) for separation anxiety disorder (SepAD) and nine (6.5%) met the diagnostic criteria for panic disorder (PD). The forward had a high rate of comorbidity in lifetime, statistically significant compared to the control group, among the anxiety disorders: separation anxiety disorder with specific phobia - SP (51%) and GAD (59.2%); generalized anxiety disorder with SAD (36.8%), SP (52.6%) disorder and posttraumatic stress disorder - PTSD (8.5%), social anxiety disorder with PS (59.6%) and GAD (61.4%). There was also more comorbidity between depression with GAD (29.3%) and SAD (30.9%) and enuresis with SepAD (22.4%). Conclusion: There was a high prevalence of anxiety disorders, particularly generalized anxiety disorder, social anxiety disorder and separation anxiety disorder in the community sample. There has been a higher comorbidity with other anxiety disorders, depression and enuresis among anxious compared to control group and it has been observed that having the comorbidity increases the risk of the outcome (anxiety disorder). It is extremely relevant and important to conduct similar research with a larger sample and case-control studies in clinical samples to confirm the results.

Introdução: Os transtornos de ansiedade na infância e adolescência são prevalentes e geralmente se mantêm até a vida adulta. Podem também ser considerados como fator de risco para o desenvolvimento de outros transtornos psiquiátricos. Portanto, a avaliação, o diagnóstico e o tratamento da ansiedade nesta faixa etária, assim como a detecção de comorbidades associadas, têm uma importância significativa para o alívio do sofrimento e para a prevenção de transtornos mentais em futuras etapas do ciclo vital. Objetivos: Avaliar, em uma amostra comunitária de crianças e adolescentes, a presença de comorbidades nos distintos transtornos de ansiedade em comparação ao grupo controle. Métodos: Em um delineamento de caso-controle, entre agosto de 2008 e dezembro de 2009 foram avaliadas, sucessivamente, 242 crianças e adolescentes pertencentes a escolas estaduais que estão dentro da área de abrangência da Unidade Básica de Saúde do Hospital de Clínicas de Porto Alegre (HCPA). A triagem realizada nas escolas faz parte de um projeto de pesquisa no qual foram aplicados instrumentos de avaliação de ansiedade e outros sintomas psiquiátricos com o objetivo de averiguar possíveis casos (ansiosos) e controles, para um amplo estudo sobre transtornos de ansiedade na infância e adolescência. Os indivíduos selecionados, através da triagem escolar, foram posteriormente avaliados através do K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for School-Age Children – Present and Lifetime Version Diagnostic Interview), aplicado aos participantes da pesquisa, juntamente com seus pais, por psiquiatras treinados. Resultados: A amostra final foi composta por 138 casos e 104 controles. Entre os casos, 95 (68,8%) preencheram critérios para diagnóstico de ansiedade generalizada (TAG), 57 (41,3%) para transtorno de ansiedade social (TAS), 49 (35,5%) para transtorno de ansiedade de separação (TASep) e nove (6,5%) preencheram os critérios diagnósticos para transtorno de pânico (TP). Os ansiosos apresentaram alta taxa de comorbidade, ao longo da vida, estatisticamente significativa em comparação ao grupo controle, entre os transtornos de ansiedade: transtorno de ansiedade de separação com fobia específica - FE (51%) e TAG (59,2%); transtorno de ansiedade generalizada com TAS (36,8%), FE (52,6%) e transtorno do estresse pós-traumático - TEPT (8,5%); transtorno de ansiedade social com FE (59,6%) e TAG (61,4%). Também apresentaram mais comorbidade com depressão: com TAG (29,3%) e com TAS (30,9%), e enurese com TASep (22,4%). Conclusão: Houve, na amostra comunitária, uma alta prevalência de transtornos de ansiedade, principalmente transtorno de ansiedade generalizada, transtorno de ansiedade social e transtorno de ansiedade de separação. Evidenciou-se maior comorbidade com os demais transtornos de ansiedade, depressão e enurese entre os ansiosos em comparação ao grupo controle. Observou-se que possuir a comorbidade aumenta o risco de ter o desfecho (transtorno de ansiedade). É importante a realização de pesquisas similares com um maior número amostral, e de estudos caso-controle em amostras clínicas, para confirmação dos nossos resultados. / Introduction: Anxiety disorders in childhood and adolescence are prevalent, often remain until adulthood and may also be considered as a risk factor for developing other psychiatric disorders. Therefore, assessment, diagnosis and treatment of anxiety in this age group as well as the detection of comorbidities have a significant importance for the relief of suffering and the prevention of mental disorders in future stages of the lifecycle. Objectives: To evaluate the presence of comorbidities in the different anxiety disorders compared to controls in a community sample of children and adolescents. Methods: 242 children and adolescents were evaluated successively in the state schools which are within the area covered by the primary care unit of Hospital de Clinicas de Porto Alegre (HCPA) in a randomized case-control study, between August 2008 and December 2009. The screening conducted in schools is part of a research project in which instruments were used to evaluate anxiety and other psychiatric symptoms in order to investigate possible cases (anxious) and controls for an extensive study of anxiety disorders in childhood and adolescence. Those selected through the school screening, were subsequently evaluated using the K-SADS-PL (Schedule for Affective Disorders and Schizophrenia for School-Age Children - Present and Lifetime Version Diagnostic Interview), applied to the research participants, along with their parents by trained psychiatrists. Results: The final sample included 138 cases and 104 controls. Among cases, 95 (68.8%) met diagnostic criteria for generalized anxiety disorder (GAD), 57 (41.3%) for social anxiety disorder (SAD), 49 (35.5%) for separation anxiety disorder (SepAD) and nine (6.5%) met the diagnostic criteria for panic disorder (PD). The forward had a high rate of comorbidity in lifetime, statistically significant compared to the control group, among the anxiety disorders: separation anxiety disorder with specific phobia - SP (51%) and GAD (59.2%); generalized anxiety disorder with SAD (36.8%), SP (52.6%) disorder and posttraumatic stress disorder - PTSD (8.5%), social anxiety disorder with PS (59.6%) and GAD (61.4%). There was also more comorbidity between depression with GAD (29.3%) and SAD (30.9%) and enuresis with SepAD (22.4%). Conclusion: There was a high prevalence of anxiety disorders, particularly generalized anxiety disorder, social anxiety disorder and separation anxiety disorder in the community sample. There has been a higher comorbidity with other anxiety disorders, depression and enuresis among anxious compared to control group and it has been observed that having the comorbidity increases the risk of the outcome (anxiety disorder). It is extremely relevant and important to conduct similar research with a larger sample and case-control studies in clinical samples to confirm the results.

Barn och unga i Sverige mår idag allt sämre, anledningarna är många såsom psykiska och fysiska övergrepp samt högre krav i skolan och den framtida arbetsmarknaden. För att råda bot på barn och ungas psykiska ohälsa krävs många gånger samverkan mellan region och kommun. Samverkan mellan myndigheterna är lagstadgad och syftar till att skapa förutsättningar samt att myndigheter och verksamheter ska arbeta mot samma mål. Syftet med studien var därmed att undersöka hur yrkesverksamma inom dessa verksamheter såg på samverkan dem emellan samt hinder och framgångsfaktorer i den. Studiens syfte undersöktes genom kvalitativ metod där tre yrkesverksamma inom socialtjänstens fält barn och familj, och tre yrkesverksamma inom barn- och ungdomspsykiatrin intervjuades. Resultatet tolkades med hjälp av teorierna och begreppen fält, doxa och symbolisk makt, samverkan samt maktperspektivet enligt Foucault. Resultatet visade att samordnad individuell plan (SIP) gav tydlighet kring ärenden men inte alltid användes rätt. Olika lagstiftningar gav olika perspektiv, varav syn på innebörden av barnets bästa skildes åt i flera fall, därmed var verksamheterna beroende av samverkan och varandras kompetens för att barn inte skulle falla mellan stolarna. Ingen av verksamheterna ville tillskriva den andre mer makt, dock fanns förväntningar på den andre verksamhetens kompetens och handlingsutrymme. Känsla av maktlöshet uppkom då förväntningarna inte uppfylldes. Slutsatsen blev att det krävdes strukturella förutsättningar såsom gemensamma rutiner och transparens för att samverkan skulle förbättras, även rutinerna kring SIP behövde förtydligas. Samtliga respondenter efterfrågade forum för att nätverka och skapa kontakter för att stärka samverkan men med anledning av resursbrist saknades detta. / Young people in Sweden are feeling worse, due to reasons such as mental and physical abuse as well as higher demands at school and in the future labour market. In order to remedy young people's mental illness, cooperation between authorities is required. Cooperation between authorities is statutory and aims to create good conditions. The purpose of this study was to investigate how professionals in these authorities perceive cooperation, also obstacles and success factors in cooperation. The purpose of this study was examined through qualitative method, three professionals within social services and three professionals in child and adolescent psychiatry were interviewed. The result was interpreted using the theories and concepts of field, doxa and symbolic power, collaboration and the power perspective according to Foucault. The results showed that coordinated individual plan (SIP) provided clarity about cases but was not always used correctly. Different legislations gave different perspectives, thus were the concept of the best interests of the child separated, therefore the authorities depended on cooperation and other's competences. None of the respondents wanted to attribute the concept of power, however, there were expectations of other´s competence and room for maneuver. A feeling of powerlessness arised when expectations were not met. The conclusion showed that in order for cooperation to be complete, structural conditions such as common routines and transparency were required, also the routines around SIP required clarification. All respondents requested forums to network and create relationships to strengthen cooperation, but due to lack of resources this failed.

Introduction. Anorexia nervosa (AN) is an eating disorder with one of the highest mortalityrates of all psychiatric illnesses. One county hospital in Sweden has seen an increase in theprevalence of adolescent AN over the last year. To meet these heightened demands, thecounty’s child and adolescent psychiatric (CAP) clinic established a new level of care for thesepatients. The main component of the intervention was mealtime support. Aim. The aim of the study was to evaluate the experiences of adolescent patients and theirparents regarding a day-patient treatment for AN in a county hospital in Sweden. Methods. Patients and their legal guardians were interviewed separately or in dyads, accordingto their wishes. An interview guide with open-ended questions was used. The audio files weretranscribed verbatim, and the texts were then studied with inductive content analysis. Fivepatients and nine parents from seven different families participated in the study. Results. The participants painted a nuanced picture of the intervention. The four overarchingthemes that emerged were ambivalence, distinguishing the person from the disease, parentalstruggling and perceptions of the treatment and the staff. Strict rules around food combinedwith an empathetic and flexible attitude towards the child were described as successful carestrategies. The treatment was depicted as time-consuming and strenuous, but parents alsoexperienced the intervention as relieving. Conclusions. The intervention was for the most part experienced as well-functioning, and theintensive nature of the treatment was described as a key factor.

Syftet med studien var att undersöka samverkan mellan skolan och Barn- och ungdomspsykiatrin (BUP) utifrån professionellas upplevelser. För att besvara studiens syfte antogs en kvalitativ ansats där sju halvstrukturerade intervjuer genomfördes med kuratorer och enhetschef från BUP samt skolkuratorer och skolsköterska från skolans elevhälsa. Insamlad data analyserades med hjälp av kvalitativ innehållsanalys. Resultatet visade att den samverkan som sker idag till stor del fungerar väl på individnivå till följd av en vilja bland professionella att samverka. Det som försvårar samverkan återfanns i högre grad på strukturell och organisatorisk nivå, genom faktorer som resursbrist och bristande tillgänglighet. Resultatet tydde på att ökad kunskap om varandra och verksamheternas olika uppdrag, i kombination med respekt och samsyn, var viktiga faktorer för fungerande samverkan. Resultatet visade även hur samverkan kunde göra stor skillnad för individer och uppvisade en önskan hos de professionella att samverka mer, men också att samverkan ibland används felaktigt och initieras trots vetskap om att det inte finns resurser att förändra situationen för barnet. Den fördjupade resultatanalysen gjordes med utgångspunkt i vår teoretiska referensram som baserades på systemteori, frontlinjebyråkraten samt modellen för horisontell- och vertikal integrering och med hjälp av studiens kunskapsöversikt. Studiens slutsats var att samverkan är en stor del av arbetet med att höja barns välmående och funktionsnivå. För att uppnå välfungerande samverkan krävs främst förändringar på strukturell och organisatorisk nivå. / The aim of the study was to examine collaboration between school and Child- and adolescent psychiatry. To achieve the purpose of the study we used a qualitative approach by doing seven semi-structured interviews with professionals from schools and child- and adolescent psychiatry. Our data was analysed by a qualitative content analysis. The result pointed out that collaboration today was well functioning on an individual level due to a strong will among professionals to collaborate. Difficulties with collaboration appeared to be on a structural and organizational level, such as lack of resources and availability. The result suggested that increased knowledge about each other and about the different missions of included actors, combined with respect and consensus, was important to reach well-functioning collaboration. The results also showed how collaboration tends to make a great difference to people and indicated a wish to collaborate more among the professionals, but also that collaboration sometimes tends to be misused and was initiated despite the knowledge that there are no resources to change the situation for the child. Our analysis of the result was made on basis of System theory, the theory of street level bureaucrat and the model of vertical- and horizontal integration, combined with previous research knowledge. The conclusion of the study was that collaboration is an important part of the work to improve children’s well-being and functionality. For a successful collaboration, changes have to be done on a structural- and organizational level.

Adolescent depression is a major public health problem, which is associated with educational problems, long-term psychiatric illness and suicide. One major source of stress during adolescence is peer rejection. In this thesis, I investigate the nature of the relationship between peer rejection and adolescent depression. In a review of longitudinal and experimental studies, I describe a bi-directional relationship between peer rejection and depressive symptoms. I then outline how genetic, cognitive and neural vulnerability may modify the effects of peer rejection on adolescent depression. Finally, I introduce five empirical chapters which test these hypotheses using different methodological approaches. The first study is a molecular genetic analysis of a sample of adolescents with and without a diagnosis of mood disorder. I report an interaction between diagnostic group, environmental stress (though not peer rejection specifically) and 5HTTLPR genotype on symptoms of anxiety, which supports the role of genetic factors in modifying the relationship between environmental stress and adolescent mood disorder. The second study is a behavioural study of negative attention biases in a typically developing sample of adolescents. I report a negative attention bias in adolescents with low (versus high) self-esteem. Although the data do not support a causal role for attention biases in adolescent depression, such biased cognitions could also moderate responses to peer rejection, maintaining affective symptoms. A final set of three fMRI datasets investigates how neural circuitry may influence depressed adolescents’ responses to peer rejection at three distinct stages: i) expectation of peer feedback, ii) the receipt of peer rejection, iii) emotion regulation of peer rejection. Data show distinct behavioural and neural differences between depressed patients and healthy controls during expectation and reappraisal of peer rejection, although heightened emotional reactivity immediately following the receipt of peer rejection did not differentiate behavioural or neural responses in adolescents with and without depression.

Les défis rencontrés dans les soins en santé mentale dans un contexte clinique interculturel sont nombreux, en raison, notamment, des différences de perceptions et de la stigmatisation culturelle de la maladie mentale (Hwang, Myers, Abe-Kim, & Ting, 2008; Alegria, Atkins, Farmer, Slaton, & Stelk, 2010). Les soins infirmiers en santé mentale ne semblent pas toujours adaptés aux besoins particuliers des adolescents et leur famille issus d’origines culturelles diverses (Alegria, Vallas, & Pumariega, 2010; Dogra & Vostanis, 2007; McKenzie et al., 2009). La pratique de soins infirmiers dans ce contexte est très peu documentée dans les écrits scientifiques pour nous permettre d’adresser en profondeur cette problématique. Le but de cette étude de cas multiples, tel que préconisée par Stake (2005), est de décrire la pratique de soins infirmiers en pédopsychiatrie dans un contexte clinique interculturel. Le cadre de référence de cette étude est celui des six volets de compétences requises pour l’infirmière en santé mentale et en soins psychiatriques émis par l’Ordre des infirmières et des infirmiers du Québec (2009). Les résultats de cette étude qualitative proviennent de l’analyse descriptive d’entretiens individuels (n=7) auprès d’infirmières en pédopsychiatrie qui ont accompagné au moins un adolescent et sa famille dans un contexte clinique interculturel. Les données issues de ces entretiens ont été validées lors de deux entretiens de groupe où un cas prototype, composé à partir des données issues des entretiens individuels, a été soumis à la discussion. Les résultats de cette étude révèlent des perceptions de la pratique de soins infirmiers dans un contexte clinique interculturel et des interventions privilégiées par des infirmières. Des recommandations pour la pratique, la formation et la recherche en sciences infirmières ont été formulées. / The challenges in mental health care in an intercultural clinical context are numerous, notably, because of the differences in perceptions and cultural stigma of mental illness (Hwang, Myers, Abe-Kim, & Ting, 2008; Alegria, Atkins, Farmer, Slaton, & Stelk, 2010). Nursing practices in mental health don’t always seem suited to the specific needs of the adolescents and their families from culturally diverse backgrounds (Alegria, Vallas, & Pumariega, 2010; Dogra & Vostanis, 2007; McKenzie et al., 2009). The practice of nursing in this context is poorly documented to address this issue in depth. The purpose of this multiple case study (Stake, 2005), is to describe the practice of nursing in child and adolescent psychiatry in an intercultural clinical context. The six areas of expertise required for the mental health nurses and psychiatric nurses describe by the Quebec Order of nurses (2009) were used as framework. The results of this qualitative study were obtained from descriptive analysis of individual interviews (n=7) with child and adolescent psychiatric nurses who accompanied at least one teenager and his family in an intercultural clinical context. The data from these interviews were validated in two group interviews, where a prototype case, made from data from the individual interviews, was submitted to discussion. The results of this study indicate perceptions of nursing practice in an intercultural clinical context and preferred nursing practices. Recommendations for practice, education and nursing research were made.

The purpose of this thesis was to examine associations between parenting and child callous-unemotional (CU) behavior in a high-risk sample of children aged 2-9 years. First, a narrative review examined the construct of CU behavior, focusing specifically on definitions and measurement of the affective and interpersonal dimensions of psychopathy, and their applicability to youth. Second, a systematic review examined evidence from 30 studies that had investigated associations between dimensions of parenting and CU traits. Studies were classified as testing one of five different research questions. Third, five different empirical studies tested various research questions pertaining to associations between parenting and CU behavior. Data from mother-child dyads N = 731; 49% female) were collected from a multi-ethnic and high-risk sample, and included multi-method observed measures of parenting. Study 1 found that observed harsh and positive parenting predicted child CU behavior from ages 2-4, controlling for earlier child behavior and various demographic covariates. Study 2 employed a moderator design, and found that harsh and warm parenting were more strongly related to the conduct problems of children with high versus low levels of CU behavior. Study 3 tested cross-lagged simultaneous and reciprocal effects models, and found that parental warmth (observed and expressed by parents in speech samples) uniquely predicted child CU behavior versus conduct problems. Study 4 tested the factor structure of Inventory of Callous-Unemotional Traits (ICU; Frick, 2004), finding support for a three-Bifactor structure. Finally, Study 5 found that parent-child affective interactions at ages 2-3 predicted CU traits at age 9, over and above general behavior problems. Taken together, the results of this thesis suggest that CU features are more malleable than previously thought. In particular, aspects of parental affect and warm parenting behavior appear to be important key targets of investigation for future empirical and intervention studies.

Introduction: Prenatal maternal depression is associated with an increased risk of psychopathology in childhood. The understanding of the mechanisms underlying this association is limited. Further, despite high rates of prenatal depression in the developing world, no research investigating this issue exists from these settings. Objectives: The primary objectives of this thesis are to study the association between prenatal maternal depression and the following early offspring outcomes in a non-smoking, non-alcohol consuming prenatal sample from rural, South India: Foetal stress responsivity, measured through foetal heart rate (FHR). Infant stress responsivity, measured through infant cortisol response to immunisation. Infant temperament. Methods: 194 pregnant women from Solur, India were assessed for depression. The first 67 mothers with elevated symptoms of prenatal depression and the first 66 controls underwent FHR monitoring to study foetal stress responsivity. 58 mother-infant dyads returned at 1.5-3 months post birth. Infant salivary cortisol was measured before and after immunisation. Information on infant temperament and maternal postnatal depression (PND) was also collected. Results: Twenty nine mothers (14.9%) met a diagnosis of major depression during pregnancy while 67 (34.5%) had elevated symptoms of prenatal depression. Whilst there were no linear association between prenatal depression and foetal responsivity, a curvilinear (U shaped) association existed with the foetuses of mothers with very high and very low levels of prenatal depression having elevated stress responses compared to those with moderate levels of prenatal depression. Prenatal depression predicted infant cortisol responsivity independent of PND (B=13.08, p=0.02).The relationship between infant cortisol responsivity and prenatal depression was also U shaped. There was no association between prenatal depression and infant temperament. Conclusions: This is the first study from the developing world investigating the relationship between prenatal depression and offspring outcomes. It provides evidence suggestive of the programming influence of prenatal depression on the developing offspring.

The treatment alliance has been described in the field of research to play an important role in the recovery of patients in psychiatric care. However there has been relatively little research concerning the treatment alliance specifically with children. The aim of this study was therefore to examine the role of the treatment alliance and how professionals work with the treatment alliance with children. Data was collected using qualitative interviews with six professionals from different Child and Adolescent Psychiatry Intermediate Care units located in Stockholm. The interviews were analyzed using thematic analysis. The themes that emerged were; The different dimensions of the treatment alliance, To create entrances and To take care of a treatment alliance. The theoretical tools that were used to interpret the results of this study were role theory and concepts from Child Alliance Process Theory. Our conclusions showed that professionals need to develop a treatment alliance not only with the child but also with their parents. Professionals also described the work with the treatment alliance as a two-part process that contains ways for professionals to develop and nurture the treatment alliance with children.