Total Problem Scale Research Articles

Dysfunctional Behaviors in Children and Adolescents with Neurocardiogenic Syncope

Objective: We evaluate a large sample of children and adolescent with suspected neurocardiogenic syncope (NCS) and we compared the results with a healthy sample, with the aim to reveal a possible correlation between syncopal events and dysfunctional behaviors. Methods: A total number of ninety two patients with NCS (median age 14.7 years) were evaluated with Head-Up Tilt Test (HUTT) and psychological assessment at the same time. The results of the ninety two patients who underwent HUTT and completed psychological tests were compared with a normative group. The risk of psychosocial dysfunctions was assessed by using the standardized Italian version of the Child Behavior Checklist in Youth Self Report (YSR). Results: Compared with normative group, patients with NCS reported worse scores to the internalizing and total problem scales and to the syndrome scales of anxiety problems, depressive withdrawal problems, somatic complaints, social problems and thought problems. Conclusions: Patients with NCS present major emotional and behavioral dysfunctions than healthy sample. Our findings call for additional investigations on the possible pathophysiological association between psychosocial problems and the reflex mechanism that produces syncope. Furthermore, future clinical studies are necessary to plan an interventional strategy and optimize the clinical management.

Screening for suicidal ideation in children with epilepsy

Given the FDA's warning regarding the potential connection between suicidal behavior and antiepileptic drugs, this study examined methods by which to detect suicidal ideation in children with epilepsy. It compared the sensitivity, specificity, and area under the curve for identifying children with suicidal behavior using the Child Behavior Checklist (CBCL) and a structured psychiatric interview. Parent-completed CBCLs provided behavioral problem scores on 177 children with epilepsy, aged 5–16years. Psychiatric diagnoses were made based on separate child and parent structured psychiatric interviews about the child. The children answered questions on suicidal behaviors during the interview. A clinically elevated score in the CBCL Total Problems scale and having more than one psychiatric diagnosis, irrespective of the type of diagnosis, were significant predictors and correctly classified children with suicidal ideation in 79% of the cases based on the CBCL and 80% of the cases with more than one psychiatric diagnosis. These findings indicate that elevated CBCL Total Problems scores, a commonly used instrument, can screen and identify risk for suicidal behavior in children with epilepsy. Additionally, irrespective of diagnosis, if a child with epilepsy has more than one psychiatric diagnosis, further assessment of suicidal behavior is warranted. Importantly, the results underscore the utility of having parents complete a questionnaire in the waiting room in order to identify children with epilepsy at risk for suicidal behavior.

Using Teacher Ratings to Assess the Association Between Mental Health Symptoms and Impairment in Children

The current study aimed to determine the extent of association between mental health symptoms and impairment in children using teacher ratings. Strengths and Difficulties Questionnaires (SDQ) data were extracted from an administrative database for consecutively referred children to a school mental health service between 2004 and 2009 (n = 480). Incremental increases in symptoms predicted increasing impairment levels in the sample using both linear and dichotomized impairment outcomes (both p < 0.0001). Unexpectedly, high estimated probabilities of abnormal impairment were observed well within the normal symptom range, particularly for younger elementary school-aged boys. The findings suggest that screening efforts that depend on cut-points on the SDQ total problem scale may be missing many substantially impaired children. Methodological limitations are discussed.

Influence of psychosocial risk factors on the trajectory of mental health problems from childhood to adolescence: a longitudinal study.

BackgroundLongitudinal epidemiological studies involving child/adolescent mental health problems are scarce in developing countries, particularly in regions characterized by adverse living conditions. We examined the influence of psychosocial factors on the trajectory of child/adolescent mental health problems (CAMHP) over time.MethodsA population-based sample of 6- to 13-year-olds with CAMHP was followed-up from 2002–2003 (Time 1/T1) to 2007–2008 (Time 2/T2), with 86 out of 124 eligible children/adolescents at T1 being reassessed at T2 (sample loss: 30.6%). Outcome: CAMHP at T2 according to the Child Behavior Checklist/CBCL’s total problem scale. Psychosocial factors: T1 variables (child/adolescent’s age, family socioeconomic status); trajectory of variables from T1 to T2 (child/adolescent exposure to severe physical punishment, mother exposure to severe physical marital violence, maternal anxiety/depression); and T2 variables (maternal education, child/adolescent’s social support and pro-social activities).ResultsMultivariate analysis identified two risk factors for child/adolescent MHP at T2: aggravation of child/adolescent physical punishment and aggravation of maternal anxiety/depression.ConclusionsThe current study shows the importance of considering child/adolescent physical punishment and maternal anxiety/depression in intervention models and mental health care policies.

International Epidemiology of Child and Adolescent Psychopathology II: Integration and Applications of Dimensional Findings From 44 Societies

To build on Achenbach, Rescorla, and Ivanova (2012) by (a) reporting new international findings for parent, teacher, and self-ratings on the Child Behavior Checklist, Youth Self-Report, and Teacher's Report Form; (b) testing the fit of syndrome models to new data from 17 societies, including previously underrepresented regions; (c) testing effects of society, gender, and age in 44 societies by integrating new and previous data; (d) testing cross-society correlations between mean item ratings; (e) describing the construction of multisociety norms; (f) illustrating clinical applications. Confirmatory factor analyses (CFAs) of parent, teacher, and self-ratings, performed separately for each society; tests of societal, gender, and age effects on dimensional syndrome scales, DSM-oriented scales, Internalizing, Externalizing, and Total Problems scales; tests of agreement between low, medium, and high ratings of problem items across societies. CFAs supported the tested syndrome models in all societies according to the primary fit index (Root Mean Square Error of Approximation [RMSEA]), but less consistently according to other indices; effect sizes were small-to-medium for societal differences in scale scores, but very small for gender, age, and interactions with society; items received similarly low, medium, or high ratings in different societies; problem scores from 44 societies fit three sets of multisociety norms. Statistically derived syndrome models fit parent, teacher, and self-ratings when tested individually in all 44 societies according to RMSEAs (but less consistently according to other indices). Small to medium differences in scale scores among societies supported the use of low-, medium-, and high-scoring norms in clinical assessment of individual children.

Corticosteroids, Behavior, and Quality of Life in Children Treated for Acute Lymphoblastic Leukemia; A Multicentered Trial

The aim of this study was to investigate the effects of high-dose corticosteroids on behavior and quality of life of children with acute lymphoblastic leukemia (ALL) in maintenance therapy. Forty-three families (patient and/or parent) completed the Child Behavior Checklist (CBCL), the Pediatric Quality of Life Inventory (PedsQL) Cancer module questionnaires, a checklist of common complaints, and a descriptive intervention data questionnaire, on and off steroids, each child serving as his/her own control. Children 5 years and younger had higher CBCL scores in the somatic complaints, affective problems, internalizing, externalizing, and total problem scales, when comparing "on-steroid" to "off-steroid" periods (P<0.01). Children 6 years and above had higher CBCL scores in the externalizing, aggressive, and oppositional defiant problem scales on steroids compared with off steroids (P<0.05). Older children had larger changes on dexamethasone, compared with prednisone (P<0.05). On the PedsQL questionnaire, parents reported more pain and hurt (P<0.001), nausea (P=0.042), and procedural anxiety (P=0.013) when children were on steroids compared with off steroids. Corticosteroid treatment during ALL maintenance therapy is associated with behavior and emotional disturbances and adversely affects quality of life. Dexamethasone is associated with more significant behavioral changes in older children.

Behaviour problems in adolescents with cardiac disease: an exploratory study in a paediatric cardiology outpatient clinic

To assess behavioural problems in adolescents with congenital and acquired heart disease in comparison with healthy controls. The perception of behavioural problems by the patients' parents was also assessed and compared. A cross-sectional study was carried out in 130 adolescents with congenital and acquired heart disease and 246 healthy controls. The second part of the Youth Self-Report was applied to the patients and controls, and the Child Behavior Checklist to the patients' parents. Male patients showed significantly fewer behavioural problems compared with male controls. No significant difference was found in the female gender. Healthy male adolescents scored significantly higher in the Internalising, Externalising, and in the Total Problems scales. Patients scored significantly higher only on the Social Problems subscale. Female patients in middle and late adolescence and male patients in early adolescence displayed more problems. No significant difference was found between the diagnostic groups. Operated patients did not differ from the non-operated ones. Patients scored significantly lower than did their parents. Male adolescents with cardiac disease reported fewer behavioural problems when compared with healthy controls, but no difference was observed in the female gender. Patients also reported fewer behavioural problems than did their parents. Adolescents with cardiac disease scored higher than did controls only on the Social Problems subscale. Analysing the patients' behavioural profile, female patients in middle and late adolescence and male patients in early adolescence were the most problematic ones. No difference was observed between the diagnostic groups, nor between operated and non-operated patients.

Prenatal Methamphetamine Exposure and Childhood Behavior Problems at 3 and 5 Years of Age

We evaluated behavior problems in children who were prenatally exposed to methamphetamine (MA) at ages 3 and 5 years. The Infant Development, Environment, and Lifestyle study, a prospective, longitudinal study of prenatal MA exposure and child outcome, enrolled subjects postpartum in Los Angeles, California; Honolulu, Hawaii; Des Moines, Iowa; and Tulsa, Oklahoma. Prenatal exposure was determined by maternal self-report and/or meconium results. Exposed and comparison groups were matched on race, birth weight, public health insurance, and education. Mothers in the comparison group denied use and had a negative meconium screen for amphetamines. Prenatal exposures to tobacco, alcohol, or marijuana occurred in both groups. At ages 3 and 5 years, 330 children (166 exposed and 164 comparison) were assessed for behavior problems by using the caregiver report on the Child Behavior Checklist. General linear mixed models were used to determine the effects of prenatal MA exposure, including heavy exposure (≥3 days per week), age, and the interaction of exposure and age on behavior problems with adjustment for other drugs of abuse and environmental risk factors. MA exposure was associated with increased emotional reactivity and anxious/depressed problems at both ages and externalizing and attention-deficit/hyperactivity disorder problems by age 5 years. Heavy exposure was related to attention problems and withdrawn behavior at both ages. There were no effects of MA on the internalizing or total behavior problems scales. This first report of behavior problems in patients as young as 3 years associated with MA exposure identifies an important public health problem. Continued follow-up can inform the development of preventive intervention programs.

An accurate and efficient identification of children with psychosocial problems by means of computerized adaptive testing

BackgroundQuestionnaires used by health services to identify children with psychosocial problems are often rather short. The psychometric properties of such short questionnaires are mostly less than needed for an accurate distinction between children with and without problems. We aimed to assess whether a short Computerized Adaptive Test (CAT) can overcome the weaknesses of short written questionnaires when identifying children with psychosocial problems.MethodWe used a Dutch national data set obtained from parents of children invited for a routine health examination by Preventive Child Healthcare with 205 items on behavioral and emotional problems (n = 2,041, response 84%). In a random subsample we determined which items met the requirements of an Item Response Theory (IRT) model to a sufficient degree. Using those items, item parameters necessary for a CAT were calculated and a cut-off point was defined. In the remaining subsample we determined the validity and efficiency of a Computerized Adaptive Test using simulation techniques, with current treatment status and a clinical score on the Total Problem Scale (TPS) of the Child Behavior Checklist as criteria.ResultsOut of 205 items available 190 sufficiently met the criteria of the underlying IRT model. For 90% of the children a score above or below cut-off point could be determined with 95% accuracy. The mean number of items needed to achieve this was 12. Sensitivity and specificity with the TPS as a criterion were 0.89 and 0.91, respectively.ConclusionAn IRT-based CAT is a very promising option for the identification of psychosocial problems in children, as it can lead to an efficient, yet high-quality identification. The results of our simulation study need to be replicated in a real-life administration of this CAT.

PRegnancy Outcomes after a Maternity Intervention for Stressful EmotionS (PROMISES): study protocol for a randomised controlled trial

BackgroundThere is ample evidence from observational prospective studies that maternal depression or anxiety during pregnancy is a risk factor for adverse psychosocial outcomes in the offspring. However, to date no previous study has demonstrated that treatment of depressive or anxious symptoms in pregnancy actually could prevent psychosocial problems in children. Preventing psychosocial problems in children will eventually bring down the huge public health burden of mental disease. The main objective of this study is to assess the effects of cognitive behavioural therapy in pregnant women with symptoms of anxiety or depression on the child's development as well as behavioural and emotional problems. In addition, we aim to study its effects on the child's development, maternal mental health, and neonatal outcomes, as well as the cost-effectiveness of cognitive behavioural therapy relative to usual care.Methods/designWe will include 300 women with at least moderate levels of anxiety or depression at the end of the first trimester of pregnancy. By including 300 women we will be able to demonstrate effect sizes of 0.35 or over on the total problems scale of the child behavioural checklist 1.5-5 with alpha 5% and power (1-beta) 80%.Women in the intervention arm are offered 10-14 individual cognitive behavioural therapy sessions, 6-10 sessions during pregnancy and 4-8 sessions after delivery (once a week). Women in the control group receive care as usual.Primary outcome is behavioural/emotional problems at 1.5 years of age as assessed by the total problems scale of the child behaviour checklist 1.5 - 5 years.Secondary outcomes will be mental, psychomotor and behavioural development of the child at age 18 months according to the Bayley scales, maternal anxiety and depression during pregnancy and postpartum, and neonatal outcomes such as birth weight, gestational age and Apgar score, health care consumption and general health status (economic evaluation).Trial RegistrationNetherlands Trial Register (NTR): NTR2242

International Comparisons of Behavioral and Emotional Problems in Preschool Children: Parents' Reports From 24 Societies

International comparisons were conducted of preschool children's behavioral and emotional problems as reported on the Child Behavior Checklist for Ages 1½–5 by parents in 24 societies (N = 19,850). Item ratings were aggregated into scores on syndromes; Diagnostic and Statistical Manual of Mental Disorders–oriented scales; a Stress Problems scale; and Internalizing, Externalizing, and Total Problems scales. Effect sizes for scale score differences among the 24 societies ranged from small to medium (3–12%). Although societies differed greatly in language, culture, and other characteristics, Total Problems scores for 18 of the 24 societies were within 7.1 points of the omnicultural mean of 33.3 (on a scale of 0–198). Gender and age differences, as well as gender and age interactions with society, were all very small (effect sizes < 1%). Across all pairs of societies, correlations between mean item ratings averaged .78, and correlations between internal consistency alphas for the scales averaged .92, indicating that the rank orders of mean item ratings and internal consistencies of scales were very similar across diverse societies.

Two-Year Follow-up of Girls Adopted from China: Continuity and Change in Behavioural Adjustment.

To determine the developmental course of behavioural adjustment in 842 girls adopted from China. Longitudinal data were collected with the Child Behaviour Checklist (CBCL/1.5-5 or CBCL/6-18) from the same parent with a two-year interval. In data analysis, the entire sample was first treated as a whole, then was divided into three age cohorts, including (1) children who were in preschool ages in both phases (Preschool Cohort) (n = 417, Mage = 2.5 years in Phase I), (2) children who crossed from preschool ages over to school ages (Transition Cohort) (n = 174, Mage = 4.8 years in Phase I), and (3) children who were in school ages in both phases (School-age Cohort) (n = 251, Mage = 8.5 years in Phase I). The data revealed a strong behavioural continuity (rs = .57-.75) from Phase I to Phase II. The whole sample experienced a significant increase in both average score and rate of suboptimal adjustment on the CBCL Internalising and Total Problem scale. For children with suboptimal adjustment in Phase I, the odds for them to remain in suboptimal range in Phase II were very high. Repeated measures ANOVA revealed that the three cohorts changed differently over 2 years.

Validation of a 28‐item version of the Systemic Clinical Outcome and Routine Evaluation in an Irish context: the SCORE‐28

This article describes the development, in an Irish context, of a three‐factor, twenty‐eight‐item version of the Systemic Clinical Outcome and Routine Evaluation (SCORE) questionnaire for assessing progress in family therapy. The forty‐ item version of the SCORE was administered to over 700 Irish participants including non‐clinical adolescents and young adults, families attending family therapy, and parents of young people with physical and intellectual disabilities and cystic fibrosis. For validation purposes, data were also collected using brief measures of family and personal adjustment. A twenty‐eight‐item version of the SCORE (the SCORE‐28) containing three factor scales that assess family strengths, difficulties and communication was identified through exploratory principal components analysis. Confirmatory factor analysis showed that the factor structure of the SCORE‐28 was stable. The SCORE‐28 and its three factor scales were shown to have excellent internal consistency reliability, satisfactory test‐retest reliability and construct validity. The SCORE‐28 scales correlated highly with the General Functioning Scale of the Family Assessment Device, and moderately with the Global Assessment of Relational Functioning Scale, the Kansas Marital and Parenting Satisfaction Scales, the Satisfaction with Life Scale, the Mental Health Inventory – 5, and the total problems scale of the Strengths and Difficulties Questionnaire. Correlational analyses also showed that the SCORE‐28 scales were not strongly associated with demographic characteristics or social desirability response set. The SCORE‐28 may routinely be administered to literate family members aged over 12 years before and after family therapy to evaluate therapy outcome.

Behavioural and emotional symptoms of preschool children with cerebral palsy: a population‐based study

To describe behavioural and emotional symptoms among Icelandic preschool children with cerebral palsy (CP). Children with congenital CP, assessed with the Child Behavior Checklist/1½-5 (CBCL/1½-5) and Caregiver-Teacher Report Form (C-TRF), were enrolled in the study. A comparison group was recruited from the general population. Thirty-six children (53% males) with CP were assessed at a mean age of 4 years 11 months (SD 5 mo, range 4-6 y); 26 (72%) had bilateral distribution of symptoms and 32 (89%) had spastic CP. Thirty (83%) were at Gross Motor Function Classification System levels I or II and six at levels III or IV. For comparison, 110 (43% males) and 120 (48% males) children were assessed with the CBCL/1½-5 and the C-TRF respectively, at a mean age of 4 years 6 months (SD 6 mo, range 4-6 y). Sixteen children (48%) with CP had high scores on total problems scale of the CBCL/1½-5 and 20 (65%) on the C-TRF compared with 18% of the comparison group, both on the CBCL/1½-5 and the C-TRF (p<0.001). Children with CP had higher scores on all subscales of the CBCL/1½-5 and the C-TRF, except somatic complaints. Attention difficulties, withdrawn, aggressive behaviour, and anxious/depressed symptoms were most pronounced among children with CP. A large proportion of preschool children with CP have substantial behavioural and emotional difficulties, which need to be addressed in their treatment.

Behavioural problems in young children with language problems

Objective Analysis of behavioural problems in young children with language problems. Materials and methods From 38 children diagnosed with a language problem, the opinion of the parents about the behaviour of their child, scored by the Child Behaviour Checklist 1.5–5 was compared with the behavioural problems in the Dutch population with the Chi-square test. T-tests and Mc Nemar tests were used to compare the opinion of the fathers about the behavioural problems with the opinion of the mothers and to compare the scores on internalizing problems with scores on externalizing problems. Plots display the measurement of the mean behavioural problems of the parents against the discrepancy between the parents and of the total behavioural problems against the discrepancy between internalizing and externalizing problems. The relation between the behavioural problems, the language score and the non-verbal intelligence score was also compared and is presented in a bar chart. Results All children had an inadequate language production (GDS). Twenty-seven children had an adequate and 11 children had an inadequate Language Comprehension Quotient (LCQ). Twenty-eight children had an adequate and 10 children had an inadequate non-verbal IQ (SON-IQ). In the clinical population mothers report more internalizing behavioural problems than in Dutch peers. The fathers also experience differences, but these are not significant. There is agreement between the parents in how they experience problems on the internalizing, externalizing and total problem scale. And there are no significant differences between the internalizing and externalizing problem scales, between boys and girls, and in behavioural problems in children with both adequate LCQ and SON-IQ and with inadequate LCQ and/or SON-IQ. Conclusion Compared to their peers in the Dutch population, young children with language problems show more internalizing problems according to their mothers. The fathers also experience differences, but these are not significant. Fathers and mothers agree on the behaviour analysis of their child and there are no differences between the occurrences of internalizing or externalizing problems and between boys and girls. There is also no relation between the behavioural problems and the severity of the language problem or the level of non-verbal functioning.

Frequencies of T-Score Differences Between Achenbach Child Behavior Checklist and Teacher’s Report Form Summary Scales

A table is provided giving observed difference frequencies for caregiver versus teacher ratings of children on the Child Behavior Checklist and Teacher’s Report Form Internalizing, Externalizing, and Total Problems scales per the original normative samples. The table permits accurate evaluation of the empirical rarity of specific cross-informant rating discrepancies. This methodology provides a more direct assessment of interrater summary score differences than does the Q-correlation statistic reported in the Achenbach System of Empirically Based Assessment scoring program.

Agreement between youth-reported and parent-reported psychopathology in a referred sample

The study examined parent-youth agreement regarding reports on psychopathology among adolescents suffering from psychiatric disorders. A total of 1,718 patients between the age of 11 and 18, as well as their parents, were assessed using the child behavior checklist (CBCL), and the youth self-report (YSR). Poor to low agreement between parent- and adolescent-reported problem behavior on the internalizing scale, the total problem scale and moderate agreement concerning the externalizing scale of the CBCL and the YSR were found. Independent from the amount of psychiatric diagnoses, adolescents reported significantly less behavioral problems than their parents. Concerning externalizing problems, parent-youth disagreement was stronger for patients suffering from comorbid psychiatric disorders, than for adolescents displaying only one psychiatric disorder. In clinically referred children, parents are likely to emphasize the severity of the difficulties, whereas adolescents' under-report symptoms.

Psychological intervention in young brain tumor survivors: The efficacy of the cognitive behavioural approach

Purpose. Cognitive and behavioural therapy (CBT) is often used to treat behavioural and emotional disorders in children, and its efficacy has been described in several studies. As behavioural and emotional disorders are frequent sequelae in brain tumor survivors, the goal of this work is to describe the efficacy of a CBT intervention in the treatment of young brain tumor survivors.Methods. Forty young patients, aged 4–18 years, were included in the study. The treatment group, composed of 17 patients, received sessions of CBT. The Child Behaviour Checklist 4–18 (CBCL/4–18) and the Vineland Adaptive Behavioural Scales (VABS) were administered to parents at the beginning and at the end of the hospitalisation. The statistical significance of changes for clinical subjects during the CBT administration was estimated.Results. With regard to the CBCL/4–18, the clinical group showed a significant advantage on the withdrawn, somatic complaints, social problems, attention problems, internalising and total problem scales. On the VABS, the treatment group improved to a significantly greater extent in the social skills domain.Conclusions. These results substantiate our assumption that CBT is an effective intervention for young patients surviving brain tumors and may be particularly helpful to younger individuals in managing cancer-related limitations.

Caregiver unresolved loss and abuse and child behavior problems: Intergenerational effects in a high-risk sample

This study examines the intergenerational effects of caregivers' unresolved loss and abuse on children's behavior problems from middle childhood to early adolescence in an economically disadvantaged sample. One hundred twenty-four caregivers completed the Adult Attachment Interview (AAI) and a lifetime trauma interview during the age 13 wave of the study. Child behavior problems were assessed at four time points (ages 6, 8, 10, and 13) with teacher-reported Child Behavior Checklist total problem scales. The children of insecure caregivers with unresolved loss showed a consistent pattern of increased behavior problems from middle childhood to early adolescence. Caregivers' AAI status accounted for more variance in child behavior problems than did an alternative model of caregiver psychopathology (depression and dissociation). The results extend the literature on the effects of caregiver unresolved states of mind beyond infancy to older children and adolescents.

Behavior and socioemotional functioning in 9–18-year-old children born after in vitro fertilization

To evaluate the psychosocial well-being of 9-18-year-old IVF children. IVF alters fetal programming, with consequences for physical functioning. This also may apply to behavior. Behavior and socioemotional functioning of children born after IVF and spontaneously from parents with former fertility problems were studied, to control for parental factors and investigate the role of IVF on the children's functioning. Child Behavior CheckList (CBCL) and Teacher Report Form (TRF) reports of 139 IVF and 143 control children. VU University Medical Center, Amsterdam. Children's age ranged from 9 to 18 years; mean age 13.60 (+/-2.12) years in IVF and 13.51 (+/-2.11) years in controls. Child's behavior and socioemotional functioning reported by parents (CBCL) and teachers (TRF). The CBCL and TRF mean scores were within the normal range. Scores of IVF parents versus controls were lower on the total problems scale, externalizing scale and syndrome scales thought problems, attention problems, aggressive and rule-breaking behavior. Less IVF children had scores in the borderline/clinical range on these scales. On the TRF, a tendency was found for lower scores on the externalizing scale in IVF children compared with controls. More IVF children scored in the borderline/clinical range on the syndrome scale withdrawn/depressed behavior. Overall, behavior, and socioemotional functioning of 9-18-year-old IVF children is normal. The reduced behavior of externalizing nature reported by the parents, and teacher ratings of more withdrawn/depressed behavior need further study.