Petra Waris had studied comorbidity between schizophrenia and pervasive developmental disorders in adolescence. My Department had participated in one of the studies included in the dissertation, the one where she studied neurocognition and social cognition between adolescents suffering from schizophrenia, schizophrenia with pervasive developmental disorder and pervasive developmental disorder alone. As the disputant pointed out, schizophrenia and pervasive developmental disorders have a long common history. For decades now, they have been considered separate entities, but they share in common certain features in symptom presentation as well as genetic and neuroimaging findings. Petra Waris and her coworkers found that 44% of adolescents with early onset schizophrenia also had a pervasive developmental disorder from childhood. Early onset schizophrenia alone is a very severe condition. Petra’s studies revealed that when comorbid with pervasive developmental disorder, it is more challenging still. Those presenting with both displayed more severe and earlier onset catatonic symptoms and more developmental delays than those with either disorder alone. My clinical observations in our adolescent forensic unit are in agreement with these findings. Particularly violent behaviours displayed by young people with comorbid schizophrenia and autism spectrum disorder are most difficult to understand, and with difficulties in understanding the young person, offering help that reduces violent behaviours is also difficult.

When we were opening our adolescent forensic unit in 2003, nobody talked about autism in adolescent psychiatry. We were perplexed when young people with autism and severe problems with violent behaviours started to come in. Since then we have in all our Department of Adolescent Psychiatry systematically developed our skills in diagnosing and treating adolescent psychiatric disorders in the context of autism spectrum disorders. Little epidemiological research is available of psychiatric comorbidities of autism spectrum disorders in adolescence, but in clinical practice, aggression problems, depression, social anxiety and psychotic episodes are common. Associations between autism spectrum and eating disorders have been noticed. We were the first in Finland to start a special service for adolescent neuropsychiatric problems – and also the first to stop it. Years have shown that there is no reason to think of adolescent neuropsychiatric problems a rarity that is best handled by placing the problem in a very special service in service. I nowadays consider autism spectrum disorders a one of the core topics in adolescent psychiatry that everybody working in adolescent psychiatry has to master. And ADHD, the other big topic in adolescent neuropsychiatry? ADHD is so common that without complex comorbidities it is not an issue of specialist level adolescent psychiatry at all.

But October had still more academic inspiration to offer! I also attended the 9th European congress on violence in clinical psychiatry in Copenhagen.
http://eviprg.eu/events/9th-european-congress-on-violence-in-clinical-psychiatry1

That was really a good meeting. I decided very late to participate in it, so I had no presentation myself. But I was most active in listening! The programme was so good that shopping and sight-seeing in Copenhagen did not cross my mind. (We visited Christiania and I also had a satisfying workout night in a wellness center, but that was all after the lectures!). I think that the most important message of the conference was respect. Helping an agitated and angry patient to de-escalate and avoid use of violence starts from showing respect. Another lesson to learn was the role of leadership. Brilliant ideas and great new approaches simply die down if they are not the matter of the heart for the leaders whose personal presence demonstrating their interest and commitment is the more required, the more difficult the challenge. And indeed, violent behaviours in the context of adolescent severe mental disorders are a difficult challenge. The congress really gave me new insights, and I definitely want to attend the next time in Dublin.

Finally I had the honor of giving a lecture in a symposium arranged to celebrate an important anniversary of a colleague and a friend of mine, professor Nina Lindberg (University of Helsinki). I discussed the problem whether repeated, intentional and malignant violent behaviour can occur in the context of healthy adolescent development (it can’t).

All this kept me so busy that I had not energy to think about removing autumn leaves from the garden. And why bother when there were still so many leaves in trees, one would need to do it again soon anyway! I really love autumn leaves! They are so pretty. Today I finally decided to remove them from our garden. How could there be so incredibly much of them? Certainly more than in earlier autumns! I don’t mind raking the leaves, even if I do enjoy more walking in them or taking photos of them, but where to put them? I really do not have expertise in gardening. I like working in the garden but I am bothered by a feeling that I am doing it all wrong and neighbours – who always do season’s garden work earlier than I – will see and think I am a disaster. After putting quite a load to composter and some under the bushes I had to cram them in waste bags and go consulting my more clever gardened friends in Facebook, whether there is a right solution…

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In all the Nordic countries, like everywhere in the Western world, all the more people experience gender dysphoria and seek contacts with services desiring medical interventions for gender reassignment. The origins of gender dysphoria, be it mild or extreme, are currently not known. Very likely both biological, psychological and social phenomena play a role in the gender identity issue itself and in the increasing request for services. However, with increasing number of referrals, all the services are also increasingly meeting people who suffer from gender dysphoria in the context of mental disorders that cannot automatically be assumed secondary to gender issues, and complicate or hinder making conclusions on consolidated identity. Particularly among adolescent SR applicants, a share is struggling with large scale identity confusion and long term developmental and mental health difficulties. We recently discussed these topics in an article of ours in the CAPMH http://www.capmh.com/content/9/1/9

Adolescence is a developmental period characterized by identity development. Even if adolescent development, including identity development, is essentially influenced by puberty and its impact on brain maturation with rapid physical and cognitive and clearly slower emotional maturation, it is also and strongly influenced by social relationships and culture around. Identity development has many facets, one of them being gender identity, closely related to but still separate from sexual identity. It is important to allow adolescents to explore identities. As a society, we do not usually have an urge to react on adolescents’ exploring, say, religious or political identities, not to mention cultural commitments such as memberships of subcultures, even if they are sincerely true and important for the adolescent her/himself. Adolescent’s exploring gender and sexual identity sometimes seems to provoke more urge in the society around to classify and categorize them permanently. During adolescence, time may show consolidation but also a change in any facet of identity development. There are young people with consolidated identity not conforming to their biological sex, who benefit of for example hormonal treatments, but also adolescents struggling with gender dysphoria who likely benefit of other interventions during the developmental phase.

A strange coincidence: I travelled to the Nordic gender identity meeting labeled a male… The Norwegian travel agency that arranged the flights had informed the airlines company that I am male, so in all my flight documents there stood Mr. That this would happen exactly when going to a gender identity meeting – a paradox? But indeed, nobody paid any attention.

The autumn’s ballet season has been most rewarding for me. The dance school introduced a new teacher. I feel we all in the class had a need to demonstrate her that we are worth her effort, and on the other hand she has demanded quite a lot from us. Fortunately I had exercised all summer on pointé shoes! Thanks to that I did not completely collapse with the new order… But it is amazing how much one can learn when challenged. I first thought certain changements on pointé shoes are simply beyond my reach forever, but to my great surprise I can do better and better every week. Obviously something matures in the body between the lessons, since I don’t have time for personal extra exercises now. Observing positive developments is rewarding personally and also as a teacher; I enjoy learning so much that having a role in the learning process of others is a great honor for me.

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So I have learned a lot, and also gained new viewpoints. This is what I most like in teaching: the teacher her/himself is challenged to learn more, in order to be able to inspire the students to learn. So rewarding!

The weather has been very displeasing for a holiday-maker this summer, but it has been very good for the garden. I am not at all clever in gardening, in fact I have great difficulties in distinguishing a desirable plants from weed, but I nevertheless like gardening and enjoy  flowers and the richness of green, the more the better. I would say that my gardening philosophy is to not disturb growth. Actually I can see a lot in common in adolescent psychiatry and gardening. Desirable, positive growth needs to be recognized, acknowledged, promoted and supported, and it needs to be given time. Harmful sprouts require intervention. My mentor, emerita chief psychiatrist Päivi Rantanen used to say that growth requires time. Not only the professionals in adolescent psychiatry can benefit of gardening metaphor, but also the adolescents themselves can gain a lot if insight to their own needs and development by caring for plants as an element of treatment relationship.

There is a Clematis in my garden that almost died last summer. It was practically only a brown tangle of rope. But there were green sprouts in some places. As there was still some life, I decided to cut away the brown string parts but let the tiny green growth have another opportunity. (That was quite a lot of cutting.)  I did not know how I should care for the plant, but I decided not to disturb it more. Now it thrives! It is at least tenfold more voluminous than last summer, if not twenty-fold. So do not disturb growth was a good guideline. (Beneficial circumstances = constant rain likely also helped a lot.)

In addition to looking forward to specialist training seminars, I am also looking forward to dance lessons that will start again next week. I have done quite of lot of exercises on pointe shoes by myself during summer, and also in this field it is so rewarding to notice that one can always learn more. I hope all this training will show positively in the ballet class!  I do not hear New York City Ballet calling for my talent, but never mind: pushing the limits further is a pleasure for myself.

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The programme had a strong emphasis on neurodevelopmental aspects of emotional and behavioural disorders in childhood and adolescence. On the other hand, trauma discussion was really not there. Particulary autism was largely discussed, but neurodevelopmental aspect was emphasized regarding practically any disorder. In my department, we became aware of the need to learn more about and provide services for autism spectrum disorders in early 2000’s. At that time, ADHD was not separately diagnosed in the context of autism: ADHD symptoms were considered a part of autism itself. Later we have all been careful to set both the diagnose of autism and ADHD when both types of symptoms are present over diagnostic threshold. Now in ESCAP, professor Jan Buitelaar’s (excellent) keynote lecture focused on weighing whether or not ADHD and autism are actually different manifestations of same disorder.

In names of the EFCAP, I and my colleagues from Switzerland, the Netherlands and the UK arranged 2 symposia on adolescent forensic research in Europe. The EFCAP symposia attracted a lively audience. It was a pity not to allow all discussion that was emerging, but the time limits were strict! I particularly want to pay attention to the presentation of professor Chis van Nieuwenhuizen (NL) on her research group’s work on whether neurofeedback is an effective treatment for ADHD. Unfortunately, they showed that neurofeedback did not bring additional value to treatment as usual in managing ADHD and behavioural symptoms in adolescents (link!). It is usually very difficult to publish research revealing that the new intervention is not better than the old or the treatment as usual (how boring: treatment as usual, the TAU… who wants to deliver this TAU?… don’t we all want to be the real experts delivering real expert interventions, not any TAUs?), or that the newly thought risk factor does not make a difference, or that the theory created with great enthusiasm does not work in reality. This is a well known bias. However, it is of outmost importance for those working in the field to hear the critical news before uncritically investing resources and adopting a new method. And if the critical news inspire more research, the better. The EFCAP will arrange its 5th international congress in May 2016 in Porto, Portugal. Keep following www.efcap.org !

I must admit that I chose the EFCAP congress partly due to the meeting being held in Madrid. There was a competing option of attending another very interesting meeting in much more rainy place at the same time… Despite that the congress programme exceeded my expectations and really required full-time attention, I managed to discover the city quite a lot in the evenings. I don’t know what to think about the fact that the vivid plaza Puerta del Sol is now called Vodafone Sol. And in Madrid metro there circulate lines like ‘Linea 1’, ‘Linea 5’, ‘Linea 7’ and ‘Linea 2 Vodafone’. I and my colleagues nevertheless adapted and returned several times to relax on Vodafone place. We were also lucky to find out way to a fascinating, emotional, passionate flamenco show in Tablao Flamenco Las Tablas I really recommend! And I owe thanks to Tampereen flamencoyhdistys for tipping me about this tablao.

Looking forward to Tampereen flamencoviikko festival and argentine tango evenings in outdoor place in Mustalahti by Tango aMoroso!

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I take my responsibility as Custos seriously and offer cognac to calm the nerves of the disputant and the opponent.

Juha’s research focused on social phobia and depression in adolescent population. Using the Adolescent Mental Health Cohort Study data he showed, for example, that depression predicted social phobia in girls, but in boys, social phobia predicted depression in 2-year follow up from age 15 to 17. Among boys, decrease in self-esteem during follow-up mediated totally the association between social phobia and subsequent depression. Among girls, however, decrease in self-esteem mediated the association between depression and subsequent social phobia only partially. The dissertation can be seen here: http://tampub.uta.fi/handle/10024/96852

Monica’s research focused on violence risk assessment among adolescents. Using material collected in an adolescent psychiatric ward, in an adolescent forensic unit and two correctional schools, with follow-up within those institutions and in registers, she demonstrated the Structured Assessment of Violence Risk in Youth (SAVRY) is a valid method for predicting not only institutional and community violence but also viewed at http://tampub.uta.fi/handle/10024/96991

I had the honor of being assigned the Custos of the public examinations of these dissertations. It is really exciting to attend the public examination of a dissertation one has supervised. I would also have a point or two to express… Particularly if the PhD student has a moment of not knowing what to say, I feel such a desire to intervene! But The Custos has two sentences, one in the beginning and one in the end, and otherwise s/he remains silent.

Another big effort in which I was involved was that the committee working on reforming the transgender health legislation in Finland finalized its report. The law revision work itself ended up in some map of abandoned ideas, but the committee also worked to recognize further issues perhaps requiring attention in the field in the future, and these are explained in the report that can be found here: http://www.stm.fi/julkaisut/nayta/-/_julkaisu/1908059

Based on the clinical and scientific work of my team in Tampere University Hospital, I felt obliged to add a supplementary statement that is now duly included in the report.

In addition to these projects that were finalized, April was an intensive period piloting a research project that is really on a new field for me. I hope to be able to tell a lot more about that in the future! All these efforts required a lot of dancing to balance the mind. My husband and I had a tango weekend in Berlin, including milongas and private classes with Raimund Schlie http://www.dyrtango.de/. In the classes we focused – again – on the posture and tango walk. The basics can be eternally improved! I have also worked intensively to improve my performance on pointe shoes in ballet. I was feeling greatly satisfied about my success this spring when I happened to see my performance in class on video. That was a reality confrontation! Even if I was indeed on my toes, I cannot name a body part that would not have in bad position… May be my nose? However, when you are really lousy you cannot but improve. I have a goal: to not be clearly the weakest link in the class in the autumn.

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Both in the hospital and in the university there is an all increasing pressure for effectiveness. Doctors should see more patients and academics write more research papers and teach more students. However, instead of arranging time for clinical and research work, these organizations are making sure that the experts use their time on being their own secretaries. Secretary work has for years now been seen as a suitable target of saving. Certainly the modern technologies can replace secretaries and the experts can handily do the secretary work by themselves with the help of the super practical software options. Not to mention that nobody is to expect service, did you think you were better than someone else? So, instead that a qualified secretary would manage the office work, doctors, psychologists, social workers, specialized nurses, professors and lecturers are fighting travel managers and managing patient appointments, reserving rooms, searching for envelopes, writing case histories and searching for postal addresses so that a letter indicating an appointment time can be sent to a patient. The society really wants to educate doctors to use time in finding postal addresses for people who did not show up when scheduled, so that a new appointment can be offered? There are dozens of tasks is hospitals and universities that are not the responsibility of anyone, so finally they are the task of the professors and the specialists. An eight hour workday of a specialized doctor includes more time in searching envelopes, making room reservations, making copies, waiting for software to open, rescheduling and typing than actually seeing patients.

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It is really pleasing to participate in the learning process of smart students. In January, I acted as a tutor for undergraduate medical students in their learning module “Metabolism”. I have acted as a tutor in this same module many times, but still I don’t seem to learn… But the students are amazing. The module is a part of the Problem Based Learning curriculum that was established in School of Medicine our university in the 1990’s. Each time I act as a tutor I admire the working of the medical students. I think they are much more active and think more comprehensively than for example I did in that phase of my career. The Problem Based Learning really seems a better way to learn. I have tried to adopt some of the principles in my specialist training program in adolescent psychiatry. What does a specialist do when s/he faces a clinical dilemma? S/he consults the Medline! I spend a lot of time in the Medline myself. When I advise an undergraduate or a postgraduate student to consult Medline for this or that problem I often get curious myself and decide to have a quick look. But there are so many fascinating lines of information to follow. Suddenly half day or half evening is gone…

Information proved out to be a key to success in my hobby as well. A class-mate of mine in the ballet school tipped about a website explaining how to choose your pointe shoes. Honestly, I am of course not particularly talented in ballet, but I had also been practicing with most unsuitable pair of pointe shoes. Now I have a much better pair, and I am making great success. I should say I have progressed many degrees, but as my starting level was below zero, I am now perhaps on level one – of at least five – or ten – or… But never mind the pleasure of learning is great even if the results were modest.

The spring’s learning plan with my specialist trainees

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A lot happened also in the field of adolescent gender identity issues last year. We provide an adolescent gender identity service since three years now, and again, in cannot be an extension of adult services. My team has had amazing opportunities to network with the opinion-leading child and adolescent gender identity services in Europe. Last year, a particular pleasure and honor for me was being one of the invited speakers in a C & A gender identity seminar organized to respect the work of professor Domenico Di Ceglie at his retirement from leadership of the unit in Tavistock Clinic in London. The main scientific event in the field of gender identity issues is going to be the EPATH congress in Ghent in March. I am busy doing some data collection in the network of child and adolescent gender identity units in Europe, and I am also excited about the forthcoming presentation of a PhD student of mine in this congress.

In addition to my clinical and academic responsibilities I was in 2014 involved in three important national policy processes, namely in the work of the committee preparing a proposal for updating the legislation on sex reassignment, a work group of child and adolescent psychiatric university clinics making plans for the future of child and adolescent mental health and psychiatric services in the “sote” (a huge rearrangement of health and social services), and the advisory board of the child ombudsman. Child ombudsman Tuomas Kurttila has been really active fighting for the mentally ill adolescents’ right to complete comprehensive school education. It is a disgrace that a young person who due to severe mental illness is delayed in

schoolwork can be kicked out of education at 17. Their municipality of residence can simply refuse to pay the education in hospital school, which is the only opportunity to complete comprehensive school for certain severely mentally ill young people such as those who need the adolescent forensic psychiatric services. Without comprehensive school education you certainly get nowhere in Finland.

In addition to Christmas traditions, this holiday provided me an opportunity to thoroughly enjoy Argentine tango, on a tango course in Mala Junta, Berlin, and in the numerous milongas that take place in the city. Berlin has amazing Argentine tango life! I can’t wait to visit it again.

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