Behavioral Problems Research Articles

The Impact of Maternal Childhood Trauma on Children’s Problem Behaviors: The Mediating Role of Maternal Depression and the Moderating Role of Mindful Parenting

The Impact of Maternal Childhood Trauma on Children’s Problem Behaviors: The Mediating Role of Maternal Depression and the Moderating Role of Mindful Parenting

Drugs to Treat Behavioral Symptoms and Problems Associated with Neurodevelopmental Disorders.

Drugs to Treat Behavioral Symptoms and Problems Associated with Neurodevelopmental Disorders.

Detecting and Classifying Problematic Behavior: A Method Based on Multi-Dimensional Software Modeling Behavioral Characteristics

Detecting and Classifying Problematic Behavior: A Method Based on Multi-Dimensional Software Modeling Behavioral Characteristics

Protective factors for externalising behaviour problems in children and adolescents living in out-of-home care: A systematic review

Children and young people in out-of-home care (OOHC) often display disproportionate levels of externalising behaviour problems compared to the general population, which are further linked with detrimental outcomes. Yet, despite similar levels of vulnerability, not all young people in OOHC develop these behaviours. The aim of this systematic review was to identify and synthesise knowledge on protective factors for externalising behaviour problems in young people between 0 and 19 years old residing in OOHC. A systematic search was conducted in PubMed, PsycINFO, Embase, CINAHL, and the Proquest Social Abstracts and Social Services databases, with 31 studies meeting inclusion criteria (n = 8310 individual participants across the studies). Results indicated that protective factors associated with fewer and/or lower levels of externalising behaviour problems included: individual (e.g., better self-concept), relationship (e.g., quality relationships with family members and peers), and contextual (e.g., higher neighbourhood income) factors. Given the short and long-term consequences associated with externalising behaviours, professionals working with young people in OOHC should focus on identifying protective factors that can be targeted in prevention and intervention efforts. This review indicated that strengthening individual, relational, and contextual factors may be most beneficial for reducing risk of externalising behaviours.

Harsh parenting, amygdala functional connectivity changes across childhood, and behavioral problems.

Harsh parenting in early childhood is related to offspring's adverse behavioral outcomes. Due to the scarcity of longitudinal neuroimaging data, few studies have explored the neurobiological underpinnings of this association, focusing on within-person variability. This study examined the temporal associations among harsh parenting, later behavioral problems, and the developmental trajectories of amygdala volume and amygdala resting-state functional connectivity (RSFC) profiles, using longitudinal neuroimaging data. The study was embedded in the Growing Up in Singapore Towards healthy Outcomes (GUSTO) cohort. T1-weighted (296 children, 642 scans) and resting-state functional scans (256 children, 509 scans) were collected at ages 4.5, 6, 7.5, and 10.5 years. Amygdala volume and RSFC between the amygdala and six brain regions that have leading roles in emotional regulation were extracted. Harsh parenting at 4.5 years and child behavioral problems at 10.5 years were assessed via parent-report questionnaires. Linear regression and linear mixed models were applied. Harsh parenting was associated with more severe externalizing problems in girls (β = 0.24, 95% CI 0.08-0.40) but not boys (pint = 0.07). In the overall sample, harsh parenting was associated with the developmental trajectories of amygdala-ACC, amygdala-OFC, and amygdala-DLPFC RSFC. In addition, the developmental trajectory of amygdala-ACC RSFC mediated the harsh parenting-externalizing problems association in girls (indirect effect = 0.06, 95% CI 0.01-0.14). Harsh parenting in early childhood was associated with amygdala neurocircuitry development and behavioral problems. The developmental trajectory of amygdala-ACC RSFC is a potential neural mechanism linking harsh parenting and externalizing problems in girls.

Maternal support in preschool and child behavior problems: The mediating role of childhood emotion knowledge.

Children's emotion knowledge encompasses abilities to recognize and label emotions in the service of positive adaptation. Drawing on a sociodemographically diverse sample of 250 children (50% female sex assigned at birth; Mage_W1 = 49.02 months, SD = 2.99) and their maternal caregivers (55.6% Latina; 37.6% poverty), this study evaluated a multiple mediation model to integrate heretofore distinct bodies of research examining (a) parenting effects on the development of emotion knowledge and (b) emotion knowledge effects on socioemotional adaptation. Observations of maternal supportive presence at age 4 predicted increases in children's emotion recognition and labeling from ages 4 to 8. However, only emotion labeling skills explained children's behavioral adjustment outcomes with a significant pathway from supportive parenting at age 4 to fewer externalizing and internalizing behavior problems at age 10 via improved emotion labeling skills. These findings suggest that emotion knowledge, particularly labeling skills, partially explains the protective impact of supportive parenting on behavioral adaptation across childhood. Prevention and intervention efforts should target both supportive parenting practices and emotion knowledge skill development to support children's socioemotional functioning and reduce behavior problems. (PsycInfo Database Record (c) 2024 APA, all rights reserved).

Tocolysis and Neurodevelopment of Children Born Very Preterm

Neurodevelopmental outcomes of very preterm children exposed to tocolytics are not well described. To investigate whether tocolysis administered after spontaneous preterm labor is associated with neurodevelopmental outcomes at 5.5 years and to assess whether the type of tocolytic drug is associated with neurodevelopmental outcomes among infants exposed. This prospective, national, population-based cohort study used data from the French Etude Épidémiologique sur les Petits Âges Gestationnels-2 cohort. Children who were alive and participated in an assessment at 5.5 years and whose mothers experienced spontaneous preterm labor without an infectious context and delivered at 24 to 31 weeks were eligible for this study. Recruitment occurred from March to December 2011. Follow-up at age 5.5 years was conducted from September 2016 to December 2017. Data analysis was performed from July 2023 through April 2024. The primary analysis examined tocolytics (yes vs no), and the secondary analysis examined the type of tocolytic (atosiban vs calcium channel blockers [CCBs]). The composite outcome neurodevelopmental disabilities included cerebral palsy; visual, hearing, and cognitive deficiencies; developmental coordination disorders; or behavioral problems. A total of 1055 mothers (mean [SD] age, 29.2 [5.7] years) had preterm labor without fever and gave birth to 1320 children (704 male [weighted percentage, 53.3%; 95% CI, 50.6%-56.1%]; mean [SD] gestational age, 28.8 [2.0] weeks). Overall, 776 mothers (weighted percentage, 73.5%; 95% CI, 70.8%-76.2%) received tocolytics; 136 mothers (weighted percentage, 17.9%; 95% CI, 15.3%-20.8%) received only a CCB, and 295 mothers (weighted percentage, 37.6%; 95% CI, 34.2%-41.0%) received only atosiban. From modified Poisson regression with propensity score matching, the risk of overall neurodevelopmental disabilities (mild, moderate, or severe) at 5.5 years did not differ between preterm children exposed and not exposed to tocolytics (relative risk [RR], 1.11; 95% CI, 0.85-1.45; P = .44) or in preterm infants exposed to atosiban compared with those exposed to CCBs (RR, 0.94; 95% CI, 0.67-1.32; P = .71). In this study, tocolytics were not associated with neurodevelopmental disabilities among very preterm children surviving at 5.5 years.

Parent-Child Interaction Therapy as Applied to Turkish Families: Effectiveness for Children with Behavior Problems and Their Caregivers

This study assessed the impact of Parent-Child Interaction Therapy (PCIT) on caregiver and child outcomes in Türkiye using a non-concurrent multiple baseline design (N = 3). Improvements in child disruptive behavior frequency were observed, with a large effect across participants (Tau-U = −0.74) and perceived problematic child behaviors (Tau-U = −0.87). School refusal, anxiety symptoms, and child emotion regulation improved with reliable change indices indicating clinically significant improvements (>1.96). Clinically significant decreases (RCI >1.96) in parenting stress and parent emotion regulation difficulties were also observed. Parents demonstrated improvements in parenting skills, as outlined by the PCIT protocol. This study highlights PCIT’s efficacy within a novel cultural context.

Improvement in Symptoms of Depression and Anxiety and Cardiometabolic Risk Factors in Children and Adolescents with Overweight and Obesity Following the Implementation of a Multidisciplinary Personalized Lifestyle Intervention Program

Background/Objectives: Childhood obesity is one of the most challenging contemporary public health problems. Children and adolescents with obesity experience multiple psychosocial difficulties, such as low self-esteem, depression, anxiety, and behavioral problems, which persist for a long time. The aim of the study was to assess the effect of a multidisciplinary personalized lifestyle intervention for depressive and anxiety symptoms, as evaluated by psychometric questionnaires, and their effect and association with cardiometabolic parameters in children and adolescents with overweight and obesity conditions before and after the intervention. Methods: Six hundred and eleven (n = 611) children and adolescents (mean age ± SE: 10.39 ± 0.10 years; 51.5% females, 46.6% pubertal) were studied prospectively. Subjects were classified as being obese (50.2%), overweight (33.5%), or having a normal BMI (16.2%) according to IOTF criteria. All participants entered a 1-year lifestyle intervention program; laboratory investigations were obtained at the beginning and end of the study and two psychometric questionnaires were completed, the CDI and SCARED, which evaluate symptoms of depression and anxiety, respectively. Results: Following the lifestyle intervention, a significant decrease was noted in anxiety scores in all subjects and in depression scores in youth with obesity, as well as in adolescents with obesity, while females presented a reduced response to the intervention. Insulin resistance and metabolic syndrome parameters, cortisol, PRL, and LH concentrations were positive predictors for depressive and anxiety symptoms. Conclusions: The implementation of a multidisciplinary personalized lifestyle intervention program in the management of childhood obesity is associated with a significant decrease in cardiometabolic and psychosocial comorbidities in children with and without excess adiposity. The improvement in mental health is speculated to be mediated by an improvement in energy metabolism with subsequent improvement in neuroinflammation owing to lifestyle changes.

Video-feedback intervention to promote positive parenting and sensitive discipline in early elementary education (VIPP-School): a randomized controlled trial

ABSTRACT The VIPP-SD (Video-feedback Intervention to promote Positive Parenting and Sensitive Discipline) program has been shown to promote positive interactions between parents and children with behavior problems. This study evaluated an adapted version for teachers (VIPP-School) through a parallel-group randomized controlled trial involving 58 teacher–child dyads from kindergarten to second grade. Teacher–child dyads were randomly assigned to VIPP-School (n = 28) or an active control group (n = 30). Intention-to-treat analyses showed improvements in teacher sensitivity (d = 0.87) and supportive teacher classroom interactions (d = 0.53) in the VIPP-School condition compared to the control condition. VIPP-School had no significant effect on teachers’ observed sensitive discipline (although changes were in the expected direction), nor on reported child externalizing behavior, overall relationship quality, school happiness or teacher self-efficacy. These findings show that the intervention, originally developed for families, could be effectively applied to early elementary education. The limited number of sessions increases the feasibility of VIPP-School.

Validity of the Strengths and Difficulties Questionnaire for Screening and Diagnosis in Western Australian Adolescents

Background/Objectives: The Strengths and Difficulties Questionnaire (SDQ) is a widely used 25-item screening and diagnostic tool for behavioral and emotional problems in young people. Despite its popularity, evaluations of the SDQ’s factor structure in adolescent populations have produced disparate results, and its relationships with theoretically related variables are rarely evaluated. In the present study, these two elements of validity were evaluated based on a large sample of Western Australian adolescents. Methods: Participants were 1489 adolescents, n = 623 males with a mean age of 13.79 years (SD = 1.61) and n = 866 females, with a mean age of 14.29 years (SD = 1.51). Participants completed the SDQ alongside measures of loneliness, sense of belonging, depression, bullying, and diagnostic status to evaluate its internal structure and correlations with theoretically related variables. Results: Confirmatory factor analyses supported the internal structure of the SDQ both for males and for females. Relationships between the SDQ subscale scores and those from theoretically related variables were also aligned with the instrument’s underpinning framework. Conclusions: Despite the somewhat disparate results of previous studies, overall, this study supported the validity of the SDQ for use in the Western Australian context.

Behaviour Problems of Children with ADHD

Behaviour Problems of Children with ADHD

Hikikomori in the Middle East: The role of problematic gaming, social media use, and loneliness

Hikikomori, a form of severe social withdrawal has been found to be associated with behavioral addictions such as gaming addiction and problematic social media use (PSMU). Since literature related to hikikomori is lacking in the Middle East, this study aimed to determine whether there are significant differences in hikikomori-like traits between two different types of social media users and gamers and investigate loneliness as a potential mediator between hikikomori and the two types of problematic behaviors. A cross-sectional, correlational design was employed, collecting a final sample of 220 participants residing in Middle Eastern countries using a mixture of convenience and snowball sampling. Results showed that passive social media users demonstrated significantly greater hikikomori-like traits compared to active users. Furthermore, hikikomori-like traits exhibited significant positive associations with problematic gaming, PSMU, and loneliness. Two separate mediation analyses, the first with PSMU and a second with problematic gaming as predictors, revealed that loneliness acted as a significant mediator between both these problematic behaviors and hikikomori-like traits.

Transfer from goal-directed behavior to stimulus-response habits and its modulation by acute stress in individuals with risky gaming behavior

Habitual responses towards addiction-related cues play a relevant role in the development and maintenance of addictions. Such automatic responses may be more likely under stress, as stress has been shown to induce a shift from goal-directed to habitual behavior. The current study investigated these mechanisms in risky gaming behavior. Individuals with risky gaming behavior (n = 68), as established by a structured clinical interview, and a matched control group (n = 67) completed a Pavlovian-to-Instrumental Transfer (PIT) paradigm with gaming-related cues and rewards. After the Pavlovian training, participants underwent a stress (Trier Social Stress Test) or control condition before performing the instrumental training and the transfer phase of the PIT paradigm. To assess habitual behavior, the gaming-related rewards were devalued after half of the transfer phase. In both groups, gaming-related cues enhanced the choice of the gaming-related reward and this gaming PIT effect was reduced, however, not eliminated by the devaluation. Unexpectedly, stress did not significantly increase responding for the gaming-related reward in participants aware of the stimulus-outcome associations, however seemed to enhance habitual responding in unaware participants. Our findings underline the relevance of gaming-related cues in triggering habitual responses, which may undermine attempts to change a problematic gaming behavior.

Feasibility of a Home-Based Developmental Behavioral Intervention for Children With Autism Spectrum Disorder in Underserved Taiwanese Families

Purpose: This study aims to investigate the feasibility of the home-based parent- mediated intervention Naturalistic developmental behavioral intervention (HB-NDBI) in underserved Taiwanese families of children with Autism spectrum disorder (ASD) and explore its effects on children’s developmental skills and parents’ parenting stress. Method: 24 underserved Taiwanese families of children with ASD (mean age = 46.5 months) received 12-week HB-NDBI programs. Social Responsiveness Scale, Second Edition (SRS-2), Mullen Scales of Early Learning (MSEL), Child Behavior Checklist (CBCL/1.5-5), and Parenting Stress Index (PSI) were administered before and after the HB-NDBI programs. Results: Following the HB-NDBI programs, significant improvements in social cognition, social communication subscales, receptive language subscale, internalizing, externalizing, and total behavioral problems scales of children, and release of parenting stress were observed. Conclusion: This study demonstrated the feasibility of home-based parent-mediated intervention for underserved families in Taiwan. These promising results might facilitate the development of such interventions for underserved families.

It takes three: Parental hostility, brain morphology and child externalizing problems in a parent-offspring neuroimaging trio design.

Hostility often co-occurs in parents and associates with increased aggression and inattention problems in children. In this population-based cohort of 484 mother-father-child neuroimaging trios, we investigated the degree to which associations of prenatal and childhood parental hostility would be associated with maternal, paternal and child brain structural differences. Also, we examined whether hippocampal volumes of the parents or child mediate the association of prenatal parental hostility with child externalizing behaviors. Maternal and paternal hostility was assessed with the hostility subscale of the Brief-Symptom-Inventory at three time points: prenatally at 30 weeks gestation, and when the child was 3 and 10 years old. During adolescence assessment wave (age 14), maternal, paternal, and offspring assessment included a magnetic-resonance-imaging (MRI). Child externalizing problems were assessed with Youth-Self-Report-Child-Behavior-Checklist.Our findings suggest that maternal and paternal hostility were each associated with smaller gray matter, white matter, and hippocampal volumes of their own and their partner's brain. Prenatal maternal but not paternal hostility was associated with smaller total gray matter, white matter, and hippocampal volumes in the offspring. The child's hippocampal volumes partially mediated the associations of prenatal parental hostility (latent-construct) with adolescent externalizing behavior, even after adjusting for prior child externalizing problems. Moreover, parental psychopathology may have long-lasting neurodevelopmental correlates in children that underlie the intergenerational transmission of behavioral problems. The behavior of family members results from a system of interdependent dyadic relationships over time that associate with specific brain structural differences.Significance statement Parental hostility often co-occurs in the parents. Research suggests that what transpires in one family subsystem, e.g. hostility among parents, is related to what transpires in other subsystems, e.g. mother-child or father-child, and can negatively impact child development. To understand the neurobiological effects of parental hostility on the families, these can best be studied with trio analysis as parents and children may all be affected. Overall, the findings elucidate how hostility of a parent negatively relates to different family subsystems and associated brain characteristic, such as the hippocampal volume. Our findings suggest that the behavior of family members results from a system of interdependent dyadic relationships over time that associate with specific brain structural differences.

Are early emotional and behavioral problems related to subsequent asthma in preschool children?

Abstract Background The most common mental health problems in preschool children are emotional and behavioral problems, and one of the most common chronic inflammatory diseases in children is asthma. Most research on the relationship between emotional and behavioral problems and asthma includes school-aged children. The current study aimed to explore the association between emotional and behavioral problems during preschool years and the risk of asthma in a Swedish context. Methods The study was a longitudinal cohort study, with 6954 children aged 3-5 years for which data on emotional and behavioral problems through the Strengths and Difficulties Questionnaire were collected in Uppsala Region, Sweden, between 2013 and 2017. The cohort was followed with data from the National Patient Register from 2013 to 2022. Asthma was defined as having at least three diagnoses (ICD-10 codes: J45-J46) during follow-up. Unadjusted and adjusted cox regression models were used to analyze data. Results A total of 269 children (3.9%) had diagnosed asthma during follow-up. Preliminary results show that children with emotional symptoms, rated separately by mothers (HR: 1.62, 95% CI: 1.20-2.20), fathers (HR: 1.49, 95% CI: 1.10-2.03), and preschool teachers (HR: 1.53, 95% CI: 1.08-2.16) had increased risk of being diagnosed with asthma according to unadjusted cox-regression models. In addition, children with total emotional and behavioural problems, rated by fathers (HR: 1.51 95% CI: 1.10-2.07) were also at higher risk of being diagnosed with asthma. These associations remained significant when adjusting for background and sociodemographic factors. Conclusions Our findings point to the significance of a clinical awareness of the relation between emotional and behavioral problems and asthma in young children. Our findings highlight the importance of also considering somatic problems, including asthma, in children with early signs of emotional and behavioral problems. Key messages • Emotional and behavioral problems in preschool children is related to being diagnosed with asthma. • Somatic problems, as asthma, needs to be considered in children with emotional and behavioral problems.

Effects of Cognitive Flexibility, Prosocial and Problem Behaviours, Parenting Style and Social Support on Social Adaptation Among Children With Leukaemia: A Structural Equation Modelling Approach.

Leukaemia children often encounter various social adaptation issues stemming from changes in their living environment. Identifying and optimising the factors associated with social adaptation is crucial in improving social adaptation in children with leukaemia. To investigate social adaptation in children with leukaemia and to clarify the impact pathway of cognitive flexibility, problem behaviour, prosocial behaviour, parenting style and social support on social adaptation. Using a convenience sampling method, 264 leukaemia children completed a cross-sectional survey. Data were collected using the Social Adaptation Assessment Scale for Children with Leukaemia, Strengths and Difficulties Questionnaire, Cognitive Flexibility Scale, Short-Egna Minnenav Barndoms Uppfostran and Multi-Dimensional Scale of Perceived Social Support. Structural equation modelling was used to test the influencing factors of social adaptation. Social support directly influenced social adaptation (β = 0.19, p < 0.01) and indirectly influenced social adaptation through prosocial behaviour (β = 0.06, p < 0.01) and problem behaviour (β = 0.18, p < 0.01). Prosocial behaviour (β = 0.17, p < 0.01) and problem behaviour (β = -0.61, p < 0.01) directly influenced social adaptation. Negative parenting directly influenced social adaptation (β = 0.12, p < 0.01) and indirectly influenced social adaptation (β = -0.23, p < 0.01) through problem behaviour. Our finding indicated that there are prominent social adjustment problems in the recovery process of children with leukaemia. These findings suggest that targeted education is needed to enhance social adaptation among children with leukaemia. The final model should serve as a framework to guide intervention research targeting social support and negative parenting to improve the social adaptation of children with leukaemia. During the recovery process, nurses need to regularly follow up on the children's social adaptation and encourage them to participate in social activities to increase social support while providing family guidance based on improving parenting styles. The subjects of this study were children with leukaemia aged 8-18 years. All authors read and approved the final manuscript.

Mobile App-Assisted Parent Training Intervention for Behavioral Problems in Children With Autism Spectrum Disorder: Pilot Randomized Controlled Trial.

In children with autism spectrum disorder (ASD), problem behaviors play a dysfunctional role, causing as much difficulty with daily living and adjustment as the core symptoms. If such behaviors are not effectively addressed, they can result in physical, economic, and psychological issues not only for the individual but also for family members. We aimed to develop and evaluate the feasibility of a mobile app-assisted parent training program for reducing problem behaviors in children with ASD. This open-label, single-center, randomized controlled trial was conducted among parents of children with ASD aged 36-84 months. Participants were recruited from the Department of Psychiatry at Seoul National University Hospital. Participants were randomly assigned (1:1) by a blinded researcher. Randomization was performed using a stratified block randomization (with a block size of 4). Parents in the intervention group completed the mobile app-assisted parent training program at home over a 12-week period. They continued to receive their usual nondrug treatment in addition to the mobile app-assisted parent training program. The control group continued to receive their usual nonpharmaceutical treatment for 12 weeks without receiving the parent training program intervention. The primary outcome measure was the median change in the Korean Child Behavior Checklist (K-CBCL) scores from before to after the intervention. Lower scores on the K-CBCL indicated a decrease in overall problem behavior. Between November 9, 2022, and December 8, 2022, 64 participants were enrolled. Overall, 42 children (intervention group median age: 49, IQR 41-52.5 months; control group median age: 49, IQR 42-58 months) of the participants joined the program. The intervention group included 20 (48%) participants and the control group included 22 (52%) participants. In the intervention group, the K-CBCL total scores showed a decrease after the intervention, with a median difference of -0.5 (95% CI -4.5 to 3). Pervasive developmental disorder scores also showed a decrease, with a median difference of -2.1 (95% CI -8.5 to 2.5). However, there was no significant difference in Clinical Global Impression-Severity of Illness scores after the intervention for both the control and intervention groups. Scores on the Korean version of the Social Communication Questionnaire showed a further decrease after the intervention in the intervention group (median difference -2, 95% CI -4 to 1). Caregivers' stress evaluated using the Korean Parenting Stress Index Fourth Edition-Short Form did not show any significant differences between the control and intervention groups. There were no adverse events related to study participation. The findings demonstrated the feasibility of using mobile devices for evidence-based parent training to reduce problem behaviors in children with ASD. Mobile devices' accessibility and flexibility may provide a viable alternative for offering early intervention for problem behaviors in children with ASD. CRIS KCT0007841; https://cris.nih.go.kr/cris/search/detailSearch.do?&seq=23112.

Cognitive profile and behavioral problems in cohort of Egyptian children with cystic fibrosis: a single-center study

BackgroundCystic fibrosis (CF) is a debilitating and time-consuming disease that can interfere with or impair typical daily life activities and social interactions. This study aims to identify and evaluate behavioral problems and cognitive dysfunction in children with CF.Methods and proceduresThis study was carried out on a cohort of 40 children diagnosed with CF. Patients were assessed using a child behavior checklist (CBCL) and intelligence quotient (IQ) photograph test. The obtained results were compared with 40 matched controls.ResultsThe male population accounted for 62.5% of the patients included in the study. Patients with CF exhibited elevated somatic, anxious and aggressive behaviors relative to the control group with p values < 0.012, < 0.025, < 0.027 respectively. In addition; there was a statistically significant positive correlation between somatic problems with both age of the patients and disease duration (r value for age = 0.368; r value for duration = 0.468). Furthermore; there was positive correlation between anxious behavior with age of patients and disease duration ( r value for age = 0.358; r value for duration = 0.351). Otherwise, patients had comparable IQs (median of 107.5) with those of the control group (median of 105) with p value = 0.544.ConclusionOur findings indicate that CF has a substantial negative impact on the behavior of affected patients. However, it did not have an impact on the individual’s level of intelligence. There is evidence indicating a connection between patients’ age and disease duration with behavioral problems.