Abstract
In society today, there is a tendency towards over-diagnosing. This tendency in society at large seems to reflect the normalization of a diagnostic culture. Some researchers have claimed that this normalization could be defined as the ‘medicalization of childhood’. There would seem to be a need for a sociocultural analysis of this phenomenon in schools – and it is in relation to this background that the present study hopes to generate new knowledge for the research field. This article explores how professionals in student welfare teams relate to and use neuropsychiatric diagnoses. The study draws on interviews with key officials working in student welfare teams in three urban secondary schools in southern Sweden. The main aim has been to investigate how the school officials talk about diagnoses such as attention deficit hyperactivity disorder and autism spectrum disorder, and what kind of explanatory value is awarded to these diagnoses. The results indicate that the professional culture in schools plays a key role in how diagnoses are integrated or not integrated into the schools’ work with students’ behavioural problems. The results also show that the narratives about diagnoses were framed by ideas related to the students’ social-class background and gender.
Keywords
Introduction
In Swedish schools, the proportion of pupils with a neuropsychiatric diagnosis has increased considerably since the early 1990s. Furthermore, the most common among this spectrum of diagnoses – attention deficit hyperactivity disorder (ADHD) – has previously shown a high prevalence primarily among boys, but lately we have also seen an increasing prevalence among girls (Carlberg, 2014). Since the 1990s, the use of medical treatments for ADHD and similar diagnoses has also increased significantly among children and youth (Socialstyrelsen, 2015). There is great geographical variation in the use of ADHD and similar diagnoses in Sweden. Consequently, there has been a discussion on the over-diagnosis of ADHD. Diagnostic criteria in the Diagnostic and Statistical Manual of Mental Disorders (American Psychiatric Association, 2017) manual have been criticized for blurring the line between behaviours that warrant diagnosis and the spectrum of unruly behaviours.
ADHD and similar diagnoses are the latest developments in the catalogue of neuropsychiatric disorders. In the 1950s, MBD (minimal brain dysfunction) was used as a means to diagnose behavioural and attention-related disorders. This diagnosis was heavily criticized, not least for its stigmatizing effects on children and youth labelled as ‘MBD children’. In 1980, the term ADD (attention deficit disorder) replaced MBD and other similar diagnoses. Today, the most common term used internationally is ADHD. In Sweden, Gillberg promoted the diagnosis DAMP (deficits in attention, motor control and perception) in the 1980s, and even though it was replaced by ADHD in the 1990s, it is still discussed as part of this spectrum of neuropsychiatric disorders. Recently, Gillberg (2014) also introduced ESSENCE (early symptomatic syndromes eliciting neurodevelopmental clinical examinations), where a number of different but related early onset neurodevelopmental/neuropsychiatric diagnoses are gathered under a common umbrella term.
There have been repeated controversies in Sweden and internationally regarding these kinds of neuropsychiatric diagnoses (Hinshaw and Scheffler, 2014; Kärfve, 2000; Mayes et al., 2009; Timimi, 2005; Timimi and Leo, 2009). Moreover, concerns have been expressed about the tendency to over-diagnose and over-medicalize children and young people (Timimi and Leo, 2009). In addition, there have been discussions on the medicalization of childhood, not least due to the increasing tendency to treat these kinds of disorders with medicine (Hinshaw and Scheffler, 2014). Looking at the great variation in the prevalence of, for example, ADHD across countries, contexts and schools, there would seem to be a need for a sociocultural analysis of this phenomenon.
In the present article, we will focus on how professionals in student welfare teams relate to and use neuropsychiatric diagnoses. Using an extensive case study of student welfare teams and principals at nine schools in different urban areas in Sweden, we have investigated differences and similarities in these nine professional groups and contexts. By using the three most significant case studies, we will look more closely at the following questions:
How do the professionals in the student welfare teams at three different Swedish schools talk about diagnoses such as ADHD and autism spectrum disorder? What kind of explanatory value is awarded to these kinds of diagnoses? In what ways is the diagnostic culture incorporated into the schools’ strategies for dealing with conduct and behaviour problems?
The article is structured as follows: first, we will provide a survey of this research field, especially the educational research; second, we will situate the article in a social scientific theoretical field and framework; third, we will also relate the study to issues of method/methodology; fourth, the results will be presented in the form of three shorter case studies and analysis of the relevant empirical material; and, finally, we will discuss the analysis performed and draw some preliminary conclusions.
Survey of previous research
The greater part of the research on neuropsychiatric diagnoses belongs to the biomedical field. In this survey of the research, we will focus on studies relevant to our investigation and to the field of the sociology of education.
One Swedish study showed a correlation between diagnoses such as ADHD, autism spectrum disorder and Asperger’s syndrome and the occurrence of situations in which students are harassed. It revealed that students diagnosed with ADHD had a three-times-higher risk of harassing other students, as well as a ten-times-greater risk of being harassed in school (Holmberg, 2009). There is an ongoing discussion on how diagnoses affect students. For example, studies have demonstrated that students diagnosed with ADHD are excluded from the peer group. Even preschool children have been shown to make negative social evaluations of children with an ADHD diagnosis (Law et al., 2007). Consequently, there is a risk that children with different neuropsychiatric diagnoses will become stigmatized. Research (Heiman et al., 2015) has also revealed that students diagnosed with ADHD and exposed to cyberbullying report greater emotional loneliness and lower self-efficacy compared to non-ADHD students.
Since the 1990s, Swedish schools have had strong obligations to report different kinds of disturbances and harassment (Estrada et al., 2012). Consequently, there is a pressure on schools to handle unruly behaviour. This new situation has led to an increase in police reports, on the one hand, and great demand for medical and psychiatric competence and collaboration, on the other. In Sweden, we can see an increased use of psychiatric diagnoses in schools (Hjörne and Säljö, 2004; Rafalovich, 2005).
There are significant differences of prevalence in the populations of different countries. In the USA, there is generally a high prevalence of neuropsychiatric diagnoses, whereas the prevalence is lower in countries such as Great Britain, Brazil and France. There are also significant regional and contextual differences within nations (Arruda et al., 2015; Cormier, 2012; Visser et al., 2015). One common pattern revealed in international research is that children with single and poor parents (often mothers), living in segregated urban districts, often receive a diagnosis (Russell et al., 2014). Allan and Harwood (2016: 197) state that: ‘“Race”, class and gender heighten the risk of psy-diagnosis, while at the same time the very process of psy-diagnosis deflects attention from racialized, or gender discrimination, or poverty in the lives of children and young people’.
One reason for the increase in diagnoses in Swedish schools may be related to economic factors. Diagnoses sometimes lead to the allocation of better resources to deal with students’ unruly behaviour in schools. Another reason may be that teachers’ workload and problems dealing with students result in increasing demands on the student welfare team to deal with a spectrum of behavioural ‘disorders’ (Isaksson, 2016). Diagnoses can also be seen as a solution to the troubling fact that an increasing proportion of students are failing in school. Diagnoses help to individualize and locate the ‘problem’ to the individual (Hjörne and Säljö, 2008; Macdonald, 2002; Thornberg et al., 2012). Today, there are also discussions on the need for teachers to have substantially better knowledge about the aetiology, prognosis and treatment of ADHD (Mohr-Jensen et al., 2015).
During the 1990s, a critical discussion was pursued on the status of different neuropsychiatric diagnoses in Sweden (Kärfve, 2000). The essence of this discussion was the argument that there is a danger in medicalizing different kinds of unruly behaviour. There have also been similar discussions in the international literature (see Timimi, 2005; Timimi and Leo, 2009). However, during more recent years, it has become increasingly difficult to criticize the diagnostic culture. Neuropsychiatric diagnoses, such as ADHD and Asperger’s, have also become more common in schools. We can probably talk about a ‘normalization’ of this diagnostic culture.
The study
The present study is part of a national research project that includes case studies from nine secondary schools located in different demographic areas in southern Sweden. The study draws from semi-structured interviews with school officials working in the schools’ student welfare teams. In order to cover the present research questions, the interview guide included five main sections: (1) questions on the schools’ catchment areas and students’ social backgrounds; (2) questions on the schools’ work with students who have exposed other students to violence, abusive acts or harassment; (3) questions on the schools’ work to create a safe and positive environment for all students; (4) questions on the schools’ collaboration with families, the social services, and/or the youth and psychiatric care system; and (5) questions on equality plans and other types of action plans. The interviews lasted for 45 minutes to an hour and were audio-recorded and later transcribed on a computer.
The present article draws from and investigates the three most significant case studies on neuropsychiatric diagnosis. A case study means that the researcher investigates separate units – here, three secondary schools (Hammersley and Atkinson, 2007). By investigating the selected cases and comparing and seeking deeper understanding of them, the study aims to contribute knowledge about complex phenomena such as the social relations and social structures at the respective schools. One of the main strengths of the case-study method is that it allows the researcher to tailor the research procedure – i.e. the study design and data collection (Meyer, 2001). For the present study, this means that the empirical analysis starts from an understanding based on a multifaceted social reality, where the school officials’ narratives on neuropsychiatric diagnosis include multiple discourses. With regard to ethical considerations and ensuring confidentiality, all of the names of the informants, as well as the schools, are pseudonyms. The schools in the present article are named Daisy School, Honeysuckle School and Violet School.
Daisy School is a secondary school located in a smaller town in a municipality with 80,000 inhabitants. The school enrols students from grade 7 to grade 9, and includes approximately 460 students. The catchment area of the school consists mainly of single-family homes in a rural setting, with the coast as the predominant geographical feature. The school officials define the catchment area as an upper-middle-class neighbourhood. There is a student welfare team consisting of a school counsellor, a psychologist, a nurse and two special pedagogues. The school also has a security team, consisting of the school counsellor, the school nurse, one of the special education teachers, a teacher and a teaching assistant. Because the two teams consist of almost the same people, their work often overlaps. Most of their work focuses on sorting out conflicts between students related to cyberbullying, but also on helping them to achieve good academic results.
Honeysuckle School is situated in a small town with around 20,000 inhabitants. The catchment area for the school is the city and surrounding areas. The school has 400 students attending grades 7 to 9. The students have diverse socio-economic backgrounds. Some students live in the affluent coastal areas and others come from inner-city working-class areas. Ten years ago, the school had problems with a number of right-wing students, but today the school is described as a secure and peaceful place. There is a student welfare team consisting of a nurse, two special education teachers, a school counsellor and a psychologist. There is also a security team at the school, consisting mainly of teachers and leisure-time pedagogues. The division of labour between the two teams is that the health team deals with more serious problems of different kinds, whereas the safety team tries to sort out conflicts between students on a daily basis.
Violet School is located in one of Sweden’s major metropolitan areas. The school is independent or semi-private and attracts students from all over the city, as well as students from neighbouring municipalities. The school has about 500 students and enrols students from preschool through to ninth grade. The part of the school that is the secondary school includes about 130 students. A majority of students have a middle-class background and about two-thirds have ancestry outside Sweden. Thirty-nine different languages are spoken among the students. At Violet School, the student welfare team consists of the headmaster, a special education teacher, a counsellor, a nurse, a psychologist and a guidance counsellor. There is also a security team at the school. This team includes various school officials as well as teachers. In the security team, the school officials focus on incidents involving bullying, harassment and violence.
Expert systems and categorization processes
The focus of the present study is on what role professional cultures and expert systems play in the use of diagnostic tools, as well as on their attitudes towards neuropsychiatric diagnoses. By studying in detail the narratives of school officials working in the student welfare teams, we also find several central discourses on how to relate to, handle and counteract harassment and other forms of unruly behaviour in schools. Here, we will mainly focus on the medical/psychiatric discourse, but today there is also a strong tendency towards a juridification of schools, where certain behaviours are framed as criminal and, consequently, reported to the police.
‘Professional cultures’ are defined in terms of the ethos, values and commitments of a certain professional group (Ball et al., 2012). This contextual dimension also applies to schools’ norms, values and climate. The professional culture often has an impact on policy management and how schools tend to deal with different challenges. It is developed in relation to the external context, collaboration and support from local authorities, such as the legal system. We will also talk about the professional culture in terms of an expert system that generates institutional reflexivity and knowledge for the school system at large. Expert systems and the knowledge of experts influence many aspects of what we do on a continual basis. Most people working in an institution – for example, a school – have faith in experts such as psychologists, social workers, school nurses and special education teachers. The student welfare team, for example, can be described as an expert system in that it contains competences relevant to assisting children and young people in need of support. This expert system is also tied to other expert and knowledge systems, such as child psychiatry, social work and the police.
According to Giddens (1990), modernity and expert systems work as ‘disembedding mechanisms’. Consequently, these systems ‘lift out’ social activities from their localized contexts. For example, giving a child a diagnosis tends to individualize ‘the problem’ and, in a certain sense, ‘the problem child’ is lifted out of the school system and reintegrated into the child psychiatric system of expertise and knowledge. Instead of treating a child with behavioural problems as part of a social context, social relations and a school system, the focus lies on the individual and his or her cognitive and behavioural disorders. The different knowledge systems involved in tackling conflicts, harassment and other problems in schools also help to reproduce systematic knowledge about social life.
The knowledge and expertise permeating schools today also lead to different kinds of categorization processes. For example, when approaching unruly behaviour in schools, today it is common to think in terms of neuropsychiatric disorders, or, with regard to violence, to see it as a police matter. Incidents and situations are thus framed and categorized through dominant medical, juridical and social discourses. Looking at this from a Foucauldian perspective, it is possible to think in terms of discipline and control systems (Foucault, 1979). To a certain extent, categorizations and diagnoses help to individualize and medicalize ‘school problems’ and unruly behaviour. The focus thus moves from the social context and social relations to the categorized and sometimes also stigmatized individual.
The notion that individualization and knowledge production are involved in framing and categorizing problems of conduct and unruly behaviour in schools is the focus of the present study. Consequently, by focusing on key statements and situations, where talk about diagnosis is present, our ambition is to get closer to the different ways in which schools approach behavioural problems.
Unruly behaviour and ADHD: the three case studies
Honeysuckle School: pro-diagnosis
At Honeysuckle School, the attitude towards diagnosis is generally positive. According to the interviewees, there is a rather high prevalence of diagnoses at the school. There are two principals at the school. One of them describes the situation regarding diagnoses at the school as follows: Principal: We have many students who have psychological problems. There is psychological pressure on students today, not least related to the grading system. Teachers coming from other and tougher segregated areas are surprised to find out that our students, who come from wealthy areas, seem to be more afflicted by psychological stress than students from poorer areas. For this reason, we have lots of contact with child psychiatry. I think there is an increase in diagnoses in society at large today. Interviewer: So, how many kids have a diagnosis? Principal: Before we had, say, one student in each class with a diagnosis, whereas today there are five to seven in each class! Interviewer: That’s a lot! Principal: Yes, I get a lot of information from the student welfare team regarding how to think about different students’ behaviour. Everything is not diagnosed, but maybe five in each class. Interviewer: ADHD? Principal: Yes, and the autism spectrum. Interviewer: Has this increased? Principal: Yes, but it’s the same development everywhere, right? Interviewer: Are there connections between ADHD and harassment in school or other problems? Principal: Some children need an interpreter, someone who can help them to understand the social game. Here we generally favour diagnoses. There is an ambition to investigate and understand difficult situations and to find possible solutions. At other schools there is a tendency to postpone and wait too long, but here it is okay to solve problems. The situation we have today, with an increasing number of diagnostic investigations, is new to me. However, it’s important to gain knowledge about the students’ weaknesses and strengths. The autism and Asperger’s spectrum is very wide, so it’s impossible to describe a person just in terms of the diagnosis. It’s not possible to say that people with Asperger’s behave in this or that way. One can’t put people into boxes. There are actually more differences between students with diagnoses than between diagnosed and not-diagnosed students. Without a diagnosis, it’s actually quite difficult to get help. It’s only when the student has received a diagnosis that adequate help and support can be deployed. Students with diagnoses also have to adapt to different challenges. When they receive a diagnosis, they are seen for who they are. If, for example, a student has reading and writing difficulties, he or she will get extra support in school. You get reading material and help scanning books. Before getting the diagnoses, it’s difficult to get the right support.
Violet School: mixed attitudes towards diagnosis
At Violet School, the attitude towards diagnosis is more mixed and contradictory compared to the situation we observed at Honeysuckle School. In some respects, the school officials express their positive attitudes towards diagnosis, but they also express criticism of current tendencies in society and of labelling students with different diagnoses. At Violet School, they deal with students’ problems and behaviours as either a medical or a psychological issue: Many investigations that return to us include different forms of diagnosis. Quite often it’s ADHD, but we also have students who’ve been diagnosed with autistic characteristics or something within the autism spectrum – Tourette’s syndrome, for example – well yes, those who are most diagnosed, if you know what I mean. Most reports I file to child and youth psychiatric care include requests to make a deeper emotional investigation of the child’s mental health, but when it’s the psychologist who files a report, it’s more often about diagnosis. But quite often these investigations don’t find any signs of students having a diagnosis; instead we receive guidance in how the school and the family can help this child in this particular situation, but there are many borderline cases.
The school officials at Violet School also brought up the importance of investigating and mapping the students’ social environment – i.e. their home environment. The school nurse referred to her own expertise and experience of meeting with the students from the age of six until they are sixteen years old. She also mentioned that she had access to all students’ medical files from the very first day of their lives. This gives her an important and unique insight into whether the child has had any previous problems and what these problems were. Furthermore, in the eighth grade, all secondary school students go through a health check, which also gives the school nurse important insights into their health and well-being. According to the school nurse, it is important to include all of this expertise in the student welfare team: When we have our student welfare team meetings, it’s important that I give my perspective on the matter. Is it lack of language skills, low intelligence or problems in the home environment? Maybe you have recognized something, school counsellor? You need to put everything together and act based on that. We need a holistic picture of the student. I think it’s important that we recognize these students early, regardless of whether it’s a medical matter or something in the home environment. … What I mean is that you shouldn’t put a diagnosis on all children, but it’s important to discover this at an early stage so we can offer the child help and make the parents understand that you sometimes need to conduct an investigation, a pedagogical or medical investigation. … I’ve met students who asked me why we didn’t do this investigation already in the fourth grade. It’s really important that we have the parents’ support; without their support, we don’t get anywhere.
Daisy School: the absence of diagnoses
At Daisy School, a different pattern emerges compared to what is shown in the results from Honeysuckle School and Violet School. At this school, the officials do not talk about neuropsychiatric diagnoses at all. When asked about this, one of the two principals of the school gives the following explanation: Interviewer: Something I’ve thought about is that you don’t talk so much about diagnoses at all at this school, which they tend to do at other schools. Principal: No, no. Interviewer: Maybe you don’t have many diagnoses, or diagnose at all? Principal: Yes, we try not to diagnose! We don’t need to diagnose. To me it doesn’t matter if a student has ADHD; you can see it in the expression; students need different kinds of support, and it doesn’t matter if they have a diagnosis or not. Then it may well be helpful for some students to get assistance with medication. Interviewer: But it’s not important to you? Principal: It is not important to us, no! Interviewer: No, because that’s the impression that I have got at this school namely, and at other schools it’s the opposite, so I find it interesting. Principal: No, I think it’s important that the medical professionals, who are experts in that area, must handle that. And we take care of the school section! And then we cooperate. I started the interview with ‘cooperation’. I think it’s very effective for these students who find it difficult to cope with their schooling. Interviewer: You see it, but you don’t put it in diagnosis? Principal: No, exactly. We don’t need to say that a student has autism, if we see that a student needs visual support, and needs this and that. It doesn’t matter what it’s for … but this is what the student needs right now. Interviewer: You see to the support? Principal: Yes. Mostly, when a student has been assessed and we meet in a school meeting, then one may think: ‘Yes, but we knew this’ – because we’ve already worked with the student so much. Or we didn’t know the exact diagnosis, but we knew what kind of support the student was in need of. I’m not looking for diagnoses! If a teacher comes and says that he/she thinks a student has difficulties with concentration, or finds it difficult to focus and to learn, then I’m not thinking like this: ‘This child must have a diagnosis. Now we have to motivate the parents to turn to the child and youth psychiatric clinic’. Instead, we look at the environment in the classroom, the structure, learning materials – those kinds of things. Interviewer: When it comes to diagnoses, are parents open to the possibility that their child can have a diagnosis? Because in some schools, parents are strongly against diagnoses and don’t want their child diagnosed. Principal: Yes, well, I think they are quite open about that. Actually, they want you to help them get a dyslexia assessment or get in touch with the Department of Child and Adolescent Psychiatry or … Interviewer: So, it’s not difficult? Principal: No, not generally at this school. But I thought so; there is a big difference between when I worked in another area! [The principal refers to another neighbourhood where she previously worked, which is even more homogeneously ‘upper middle class’ than this neighbourhood.] I didn’t work with grade 7–9 but up to grade 6 at a primary school. At that school, I experienced that it was like … at first, it was like getting through a wall, you know, this facade that they have … [holding up her palms in front of her] like that. After that, you could start … it was like that. Interviewer: Yes, that’s what I wondered. But it’s not like that at this school? Principal: No, I don’t think so. Of course, we definitely have those parents too!
Conclusion: urban contexts, professional cultures and diagnosis
Since the 1990s, ADHD and similar diagnoses have increased significantly among children and youth. Some authors have written about ‘the ADHD explosion’, as well as the growing ‘Americanization of ADHD models of treatment’ – i.e. medication (Hinshaw and Scheffler, 2014). There is considerable geographical and regional variation in the prevalence of ADHD and similar diagnoses. Consequently, there has been a discussion on the over-diagnosis of ADHD. The proportion of pupils in Swedish schools with a neuropsychiatric diagnosis has increased considerably since the early 1990s, and today diagnosis is more or less accepted as a common way of approaching and handling behavioural problems in schools.
In the present study, we have focused on how professionals in student welfare teams and principals talk about and view diagnosis as part of the school’s strategy for dealing with harassment and violence in schools. Three case studies of schools with different profiles and approaches to diagnosis were selected from a larger Swedish study. By comparing these schools, it is possible to discern different professional cultures and ways of using diagnosis. In addition, we have tried to situate the results in relation to issues of class and gender. The talk about diagnosis reveals different nuances at the three schools. Looking more closely at the research questions, we will now try to focus on the similarities and differences between the three schools.
At Honeysuckle School, psychological/psychiatric talk about diagnosis has become part of the school culture. The student welfare team is trained to think in terms of diagnoses. Consequently, ‘problems’ and ‘problem children’ are lifted out of their school context, and made into individual and treatable entities. Diagnoses are not discussed in terms of gender or class. At this school, there is a match between the talk about diagnosis, the explanatory value attached to diagnoses, and the school’s institutional strategy in this respect.
At Violet School, we can discern a somewhat different pattern. Instead of merely talking about diagnoses as a kind of solution to different problems, a more holistic approach is often applied, meaning that the health team relates discussions about different pupils and their ‘problems’ to situational and contextual factors. At this school, some gender patterns do emerge in the narratives. According to our interviewees, it is more common for boys to receive a diagnosis. Instead of lifting out the ‘problems’ from the school context, diagnoses are seen as partly related to social factors.
Daisy School’s catchment area is an upper-middle-class neighbourhood, but the area also includes lower-middle-class families. Apparently, the upper-middle-class parents at this school do not wish to talk about diagnoses, and neither do the school staff. At this school, the upper-middle-class parents – when listening to the members of the student welfare team – play a central role in establishing the dominant discourses, values and norms that determine the school’s approach to diagnosis. Thus, the absence of a neuropsychiatric discourse can be seen as an effect of social class.
The results from the present study indicate that the professional culture at a school plays a central role in the management of harassment, violence and unruly behaviour at the school. In order to understand what explanatory value and importance diagnoses are assigned, we need to analyse the professional culture in terms of a reflexive expert system. Whereas diagnosis plays a key role in institutional thinking about problems of conduct and behaviour at Honeysuckle School, the other schools apply different strategies. We do not have enough data to analyse the relation between the prevalence of ADHD and other diagnoses at the three schools, on the one hand, and social class and gender, on the other. However, we can discern variations in how the three professional cultures talk about and understand the influence of class and gender. Daisy School stands out as a more clear-cut example of how social class can influence the way parents and school officials view diagnosis.
There is a need to investigate this further. Taking our case studies as a point of departure for speculation, there is clearly a need to conduct more social scientific research in this area. If variation in the expert and professional cultures in schools has an independent influence on which children and adolescents will be diagnosed and treated with stimulants, and which will be framed more in terms of a social pedagogical framework, then we are facing a major challenge in schools. There is a real risk that, instead of looking at the institutional and professional level, and trying to create better schools and learning environments, what we are doing is lifting children and youth out of the school context and making their struggle to grow up into individual problems. If this is the case, we need to reflect on professional cultures and expert systems, and their role, if we are to control and maintain social order in schools.
Footnotes
Declaration of Conflicting Interests
The authors declared no potential conflicts of interest with respect to the research, authorship, and/or publication of this article.
Funding
The authors disclosed receipt of the following financial support for the research, authorship, and/or publication of this article: This project is funded with a research grant from the Swedish Research Council.