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Keywords:

  • childhood emotional/behavioral problems;
  • comorbid patterns;
  • maternal psychological distress;
  • prenatal/perinatal factors

Abstract

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Aim:  To investigate the effects of age, gender, prenatal/perinatal factors, and maternal psychological distress on childhood emotional/behavioral problems, and the gender difference in the patterns of comorbid emotional/behavioral problems.

Methods:  The sample included 1391 children aged 4–9 in Taipei using a multi-stage sampling method. Their mothers completed questionnaires including demographics, prenatal/perinatal variables, the Child Behavior Checklist, and the Chinese Health Questionnaire. The linear and non-linear mixed model was used for data analysis.

Results:  Boys scored higher on externalizing problems, and girls scored higher on internalizing problems. Gender also modified the comorbid patterns of emotional/behavioral problems. Aggressive behaviors decreased, but attention and thought problems increased with age. Prenatal/perinatal exposure to alcohol and coffee, vaginal bleeding, and gestational diabetes, low birthweight, and postnatal incubation and resuscitation, and maternal psychological distress predicted the risk for several childhood emotional/behavioral problems.

Conclusion:  Prenatal/perinatal and maternal care, and gender-specific measures are important for prevention of childhood emotional/behavioral problems.

CHILDHOOD BEHAVIORAL PROBLEMS are common and related to impairments in self-competence and family function.1 Early behavioral problems are predictive of poor adjustment and psychopathology in late adolescence.2 Therefore, it is essential to identify correlates and risk factors of childhood behavioral problems for the delivery of mental health services.

Literature has documented more externalizing problems in boys, and more internalizing problems in girls;3,4 and increased somatic complaints and withdrawal with age for boys, but decreased for girls.5

There is accumulating evidence that prenatal/perinatal exposure may have long-lasting adverse consequences on the brain development and increased behavioral problems of the offspring. For example, low birthweight predicts inattention/hyperactivity symptoms and clinically significant behavioral problems over time during childhood.6,7 In addition, prenatal exposure to maternal substance use such as nicotine and illicit drugs may be linked causally to childhood behavioral problems in a positive dose–response relationship.7,8 These findings, however, are not supported by others.9

Several studies have suggested an association between parental mental distress and children's emotional/behavioral problems.10–12 For example, the most powerful predictor of high scores on the Child Behavioral Checklist (CBCL) among premature preschoolers is maternal self-reported depressive symptoms.11,12 Although previous work has shown that maternal psychological distress is associated with several types of sleep problems in children,13 no study has been done to examine its relationship with children's emotional/behavioral problems.

Similar to the findings in adolescent and adult populations, several studies also report a high comorbidity of behavioral problems in children,14,15 and gender differences in comorbid patterns.15 Outcome of comorbid behavioral problems is worse than that of the components alone.16 These findings highlight the importance of identifying comorbid behavioral patterns in childhood to offset future development of psychopathology and adverse social outcome.16

Despite several epidemiological studies on Taiwanese child and adolescent populations,13,17–19 there has been no specific study to investigate the age and gender difference in the comorbid behavioral problems patterns, or to examine the effect of prenatal/perinatal factors on behavioral problems in young children of an ethnic Chinese population. Hence, we conducted an epidemiological survey of childhood behavioral problems in Taiwan to investigate the effects of age, gender, prenatal/perinatal factors, and maternal psychological distress on childhood emotional/behavioral problems, and the gender difference in the patterns of comorbid emotional/behavioral problems. We hypothesized that there would be age trends and gender differences in the rates and comorbid patterns of childhood emotional/behavioral problems, and that childhood emotional/behavioral problems would be associated with some prenatal and perinatal exposure, and maternal psychological distress.

METHODS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Participants and procedure

We recruited 1391 children (boys, 52.4%) aged 4–9 from nine kindergartens and three elementary schools using a multistage sampling method in 1998 in Taipei. The Institutional Review Board of National Taiwan University Hospital approved this study before recruitment. According to socioeconomic status, we categorized the 12 school districts in Taipei into three groups: high, middle, and low; and randomly selected one elementary school (at least six classes for each of grades 1–3) from each school district selected from each group. The annexed kindergarten and another two kindergartens close to the selected elementary school within each of the three districts were selected. We further randomly selected three classes from each grade level (grades 1–3). All children in the selected nine kindergartens (at the preschool and kindergarten levels) and in the 27 selected classes were recruited into this study, generating an eligible population of 1519 child participants. Among them, parents of 1391 children (response rate, 91.6%) consented to the study and completed the questionnaires at home or school under investigators' instruction.

Table 1 presents the equal age and gender distributions of 1391 children with a mean age ± SD of 7.37 ± 1.49 without significant difference in the gender distribution of the child participants across the five school grade levels (P = 0.87). The mean age for boys (7.36 ± 1.50 years) did not differ from that of girls (7.37 ± 1.47 years; P = 0.53). The majority of parents were married and living together (90.8%).

Table 1.  Child Behavior Checklist scores across five school grade levels
 PreschoolKindergartenGrade 1Grade 2Grade 3
Mean ± SDMean ± SDMean ± SDMean ± SDMean ± SD
BoyGirlTotalBoyGirlTotalBoyGirlTotalBoyGirlTotalBoyGirlTotal
(n = 140)(n = 130)(n = 270)(n = 152)(n = 133)(n = 285)(n = 142)(n = 142)(n = 284)(n = 143)(n = 130)(n = 273)(n = 152)(n = 127)(n = 279)
  1. Statistically significant gender difference: *P < 0.05; **P < 0.01; ***P < 0.001; statistically significant linear trend: β = −0.31, t = −2.68, P < 0.01; β = 0.20, t = 3.04, P < 0.01; §β = 0.09, t = 3.82, P < 0.001.

Aggressive behavior9.4 ± 6.68.0 ± 6.58.7 ± 6.68.4 ± 6.96.3** ± 5.17.4 ± 6.27.7 ± 6.16.6 ± 5.57.2 ± 5.88.7 ± 6.16.3*** ± 5.67.6 ± 6.07.6 ± 5.86.4 ± 6.37.1 ± 6.1
Anxiety/depression3.8 ± 3.34.9* ± 4.24.3 ± 3.84.2 ± 4.24.3 ± 3.94.3 ± 4.14.7 ± 4.14.5 ± 3.74.6 ± 3.94.5 ± 4.14.6 ± 3.94.6 ± 4.04.3 ± 3.74.7 ± 4.04.5 ± 3.8
Attention problems4.0 ± 3.03.6 ± 3.13.8 ± 3.14.2 ± 3.63.6 ± 2.93.9 ± 3.34.5 ± 3.43.8 ± 3.04.1 ± 3.25.1 ± 3.54.0* ± 3.94.6 ± 3.74.9 ± 3.63.9* ± 3.44.4 ± 3.5
Delinquent behavior2.3 ± 1.81.9 ± 2.12.1 ± 1.92.2 ± 2.42.1 ± 2.32.1 ± 2.32.4 ± 2.41.9 ± 2.32.2 ± 2.42.8 ± 2.61.8** ± 2.02.3 ± 2.42.4 ± 2.41.9* ± 2.22.1 ± 2.3
Social problems2.8 ± 2.12.7 ± 2.42.8 ± 2.22.8 ± 2.52.8 ± 2.22.8 ± 2.32.8 ± 2.42.7 ± 1.92.7 ± 2.23.0 ± 2.52.5 ± 2.22.8 ± 2.42.9 ± 2.62.7 ± 2.42.8 ± 2.5
Somatic complaints2.8 ± 2.92.3 ± 2.72.6 ± 2.82.0 ± 2.63.3*** ± 3.32.6 ± 3.02.6 ± 3.02.5 ± 2.82.6 ± 2.92.7 ± 2.92.8 ± 3.32.7 ± 3.12.3 ± 2.62.6 ± 2.82.5 ± 2.7
Thought problems§0.5 ± 1.00.5 ± 1.00.5 ± 1.00.8 ± 1.30.7 ± 1.20.8 ± 1.20.8 ± 1.20.7 ± 1.10.7 ± 1.11.2 ± 1.90.7* ± 1.21.0 ± 1.60.8 ± 1.30.9 ± 1.40.8 ± 1.3
Withdrawn2.5 ± 2.42.3 ± 2.32.4 ± 2.32.5 ± 2.72.3 ± 2.32.4 ± 2.62.7 ± 2.62.2 ± 2.42.5 ± 2.52.6 ± 2.42.5 ± 2.52.5 ± 2.43.0 ± 2.32.6 ± 2.62.4 ± 2.5

Instruments

Child Behavior Checklist

The CBCL is a parental report concerning children aged 4–18 for the previous 6 months.20 Eight narrow-band behavioral/emotional problems and two broad-band dimensions (internalizing and externalizing syndromes) are derived from the 118 emotional and behavioral items. The eight problems include the symptoms of anxious/depressed moods, attention problems, aggressive behavior, delinquent behavior, social problems, thought problems, somatic complaints, and withdrawal. Each was scored 0 if not true, 1 if somewhat or sometimes true, and 2 if very true or often true. The Chinese version of the CBCL, a reliable and valid instrument, has been widely used to measure children's behavioral and emotional syndromes in Taiwanese child and adolescent populations.13,21

Prenatal and perinatal exposure

A questionnaire was designed to elicit suspected prenatal and perinatal risk factors, and the information was collected retrospectively from the mothers.13 Prenatal factors included maternal exposure to regular use of alcohol (at least once per week), regular use of tobacco (at least once per week), coffee (at least one cup every week) and non-prescribed medication, and pregnancy complications (i.e. vaginal bleeding, hypertension, diabetes, viral infection, thyroid disease, and pre-eclampsia). Perinatal factors included artificial delivery, low birthweight (<2500 g), postnatal incubation for more than 3 days, postnatal resuscitation, postnatal jaundice, and blood transfusion for jaundice. The kappas of the test–retest reliability for each exposure at a 2-week interval using 136 children aged 4–9 ranged from 0.64 to 0.85.

Chinese Health Questionnaire

The Chinese Health Questionnaire (CHQ), a 12-item self-reporting questionnaire with a sum score ranging from 0 to 12, is modified from the General Health Questionnaire.22 The CHQ measures the domains of anxiety/depression, sleep disturbance, somatic concerns, and interpersonal difficulties. A score 3/4 out of a total of 12 is used as a cut-off point for cases.22 The CHQ was used to measure maternal psychological distress.

Statistical analysis

We performed statistical analysis using SAS 9.1 (SAS Institute, Cary, NC, USA). A mixed model was also used to address subjects nested within the same class and school due to the multi-stage sampling method. The linear mixed model was used to examine the eight CBCL subscores between girls and boys, across ages, and between presence (CHQ ≥ 4) and absence (CHQ ≤ 3) of maternal psychological distress.

For the binary variable, we used a non-linear mixed-effects logistic regression model to investigate the association between behavioral problems and perinatal factors, and the comorbid patterns of emotional/behavioral problems.

The presence of a particular behavioral problem derived from the CBCL was defined as t-score > 70 in a behavioral syndrome. The t-scores are defined as multiplying the z-score by 10 and adding 50, with a mean of 50 and a standard deviation of 10. The odds ratio (OR) and 95% confidence interval (CI) were calculated and are presented in Tables 2 and 3. These statistical models were controlled for the child's age and gender and maternal psychological distress, measured by the CHQ, to decrease potential confounding effects from these variables.

Table 2.  Comorbid patterns of behavioral problems for boys (upper right) and girls (lower left)
 Behavioral/emotional problemsOdds ratios (%)
Behavioral/emotional problems
12345678
  • *

    P < 0.01;

  • **

    P < 0.001;

  • ***

    P < 0.0001.

  • %, percentage of comorbid pair of two behavioral syndromes, and the presence of a particular behavioral problem from the Child Behavior Checklist is defined as a T-score >70.

  • Significant interaction with sex for the association between anxiety/depression symptoms and aggressive behaviors (parameter estimate = −1.14, χ2 = 5.22, d.f. = 1, P = 0.022).

  • Marginally significant interaction with sex for the association between anxiety/depression symptoms and thought problems (parameter estimate = 0.935, χ2 = 2.81, d.f. = 1, P = 0.094).

  • §

    Marginally significant interaction with sex for the association between anxiety/depression symptoms and withdrawal symptoms (parameter estimate = −0.935, χ2 = 2.78, d.f. = 1, P = 0.096).

1Aggressive behavior (n = 107)6.41*** (2.2)8.77*** (3.2)19.24*** (2.9)12.85*** (4.0)3.50** (1.5)5.74*** (1.8)6.35*** (2.8)§
2Anxiety/depression (n = 101)19.95*** (3.2)7.89*** (2.3)3.68* (1.0)8.59*** (2.6)6.43*** (1.7)18.25*** (2.5)9.02*** (2.5)
3Attention problems (n = 96)18.25*** (2.3)8.67*** (2.0)7.22*** (1.8)36.29*** (5.2)2.88* (1.3)11.91*** (2.5)7.01*** (2.8)
4Delinquent behavior (n = 61)25.62*** (2.0)4.48* (0.9)15.97*** (1.4)4.78*** (1.5)2.38 (0.7)5.66*** (1.1)6.88*** (1.8)
5Social problems (n = 114)10.60*** (2.3)4.92*** (1.8)31.75*** (3.0)11.89*** (1.5)2.17 (1.1)7.91*** (2.2)8.82*** (3.3)
6Somatic complaints (n = 103)4.24** (1.5)7.53*** (2.6)4.02* (1.2)5.03** (1.1)4.82*** (1.8)7.02*** (1.5)3.72** (1.5)
7Thought problems (n = 72)5.41** (1.1)7.17*** (1.5)14.43*** (1.5)11.12*** (1.1)9.88*** (1.7)4.29** (1.2)10.20*** (2.4)
8Withdrawn (n = 118)9.90*** (2.4)20.10*** (3.8)§7.29*** (1.7)3.98* (0.9)7.16*** (2.3)4.13*** (2.0)10.31*** (2.0)
Table 3.  Odds ratios and 95% confidence intervals for perinatal factors in childhood behavioral problems
Behavioral/emotional problemsOR (95%CI)
Behavioral/emotional problems
Regular alcohol use (n = 11)Regular coffee use (n = 19)Vaginal bleeding (n = 106)Gestational diabetes (n = 11)Low birthweight (n = 56)Postnatal incubation (n = 67)Postnatal resuscitation (n = 16)
  • *

    P < 0.05;

  • **

    P < 0.01;

  • ***

    P < 0.001.

  • The presence of a particular behavioral problem from the Child Behavior Checklist is defined as a t-score >70.

  • CI, confidence interval; NS, not significant; OR, odds ratio.

Aggressive behavior (n = 107)NSNS2.0* (1.1–3.7)4.7* (1.2–17.9)NSNSNS
Anxiety/depression (n = 101)NSNS2.7*** (1.5–4.8)4.9* (1.3–18.6)NSNSNS
Attention/problems (n = 96)NSNSNSNS2.5* (1.1–5.5)2.2* (1.1–4.6)6.5*** (2.2–19.0)
Delinquent behavior (n = 61)8.7** (2.2–33.6)NSNSNSNSNSNS
Social problems (n = 114)NS4.1** (1.5–11.7)NS4.3* (1.1–16.4)NS2.1* (1.0–4.2)3.8* (1.2–12.1)
Somatic complaints (n = 103)7.2** (2.1–25.0)NSNSNSNSNSNS
Thought problems (n = 72)NSNS2.7** (1.4–5.2)NSNSNSNS
Withdrawn (n = 118)NSNSNSNSNSNSNS

In addition to individual main effects, the modifying effects from the child's age and gender on the association between behavioral problems and the major factors were examined. If there was a significant interaction, the parameter estimates and statistics of the interaction terms were given in the footnotes. Alpha was pre-selected at the significant level of two-tailed P < 0.05.

RESULTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

Gender and school grade effects

We found that boys significantly scored higher in aggressive behaviors among the kindergarteners; in aggressive behaviors, attention problems, delinquent behaviors, and thought problems among the second graders; and attention problems and delinquent behaviors among the third graders (Table 1). In contrast, scores indicating anxiety/depression were significantly higher among girls than boys among the preschoolers, and somatic complaints among the kindergarteners (Table 1).

We found that the severity of aggressive behaviors decreased and that of attention problems and thought problems increased with age from 4 to 9. There was no interaction between age and gender in the risk of behavioral problems.

Gender difference in comorbid patterns of behavioral problems

Table 2 summarizes the OR and percentages of comorbid conditions of two behavioral syndromes by sex. For both girls and boys, behavioral problems (no matter whether internalizing or externalizing problems) were significantly comorbid with each other, except that somatic complaints were not significantly associated with delinquent behavior and social problems among boys. Moreover, the magnitude of comorbidities between anxious/depressed and aggressive behaviors was greater in girls than boys; whereas that of comorbidity between anxiety/depression and thought problems was greater in boys than girls. There was no age difference in comorbid patterns.

Prenatal and perinatal factors

Table 3 summarizes the association between prenatal/perinatal factors and childhood behavioral problems. Prenatal exposure to coffee and alcohol predicted social problems; and delinquent behavior and somatic complaints, respectively. Vaginal bleeding during pregnancy predicted aggressive behaviors, anxiety/depression symptoms, and thought problems. Gestational diabetes predicted aggressive behaviors, anxiety/depression symptoms, and social problems. Children with low birthweight (<2500 g) were more likely to have attention problems. Postnatal incubation for more than 3 days predicted attention problems and social problems. Postnatal resuscitation predicted attention problems and social problems. There were no effects from gestational hypertension, thyroid disease, pre-eclampsia, maternal smoking, non-prescribed medication, postnatal jaundice, blood transfusion for jaundice and artificial delivery on the risk for childhood behavioral problems.

Maternal psychological distress

Children of mothers with CHQ ≥ 4 had significantly higher t-scores for aggressive behavior, anxiety/depression symptoms, attention problems, delinquent behavior, social problems, somatic complaints, thought problems, and withdrawal (Table 4). There was no interaction between gender and age, and maternal psychological distress on childhood behavioral problems.

Table 4. t-scores on CBCL for children vs parental CHQ score
t-scoreCHQ ≤ 3CHQ ≥ 4Statistics
(n = 1187)(n = 169)
Mean ± SDMean ± SD
  1. All F are significant at P < 0.001.

  2. CBCL, Child Behavior Checklist; CHQ, Chinese Health Questionnaire.

Aggressive behavior49.43 ± 9.8953.86 ± 10.10F(1,1353) = 29.56
Anxiety/depression49.12 ± 9.3655.61 ± 12.07F(1,1352) = 64.74
Attention problems49.27 ± 9.5054.98 ± 11.17F(1,1353) = 51.09
Delinquent behavior49.36 ± 9.4953.87 ± 10.91F(1,1351) = 32.10
Social problems49.35 ± 10.0053.67 ± 10.67F(1,1352) = 27.17
Somatic complaints49.51 ± 9.7153.91 ± 11.91F(1,1345) = 29.04
Thought problems48.98 ± 8.9454.49 ± 14.11F(1,1348) = 47.29
Withdrawn49.18 ± 9.8254.90 ± 11.30F(1,1347) = 48.23

DISCUSSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The present findings lend evidence to support the effect of gender and developmental stage on the manifestation of emotional/behavioral problems. The major findings are that there was an association between childhood behavioral problems and a multiplicity of risk factors, including exposure to alcohol and coffee, antepartum vaginal bleeding, gestational diabetes, low birthweight, postnatal incubation, and postnatal resuscitation and maternal psychological distress. Moreover, the comorbid patterns of emotional/behavioral problems in boys did not differ much from those in girls.

As the first study examining the childhood behavioral problems in Taiwan, the figures of symptom severity of the eight behavioral symptoms measured on the CBCL were more severe than those found in the children aged 6–11 years in China.4 This discrepancy might be explained by the different cultural, educational, and societal context between Taiwan and China despite the similar ethnicity.

Gender effect

Consistent with Western studies, the present findings suggest that boys have more externalizing problems (i.e. aggressive and delinquent behaviors) and girls have more internalizing behaviors (i.e. anxiety/depression symptoms and somatic complaints).3,23 Moreover, the present findings also support the notion that inattention/hyperactivity and thought problems are more prevalent in boys than girls.18,24 Despite the consistent findings across studies, little has been known about the underlying mechanism of the gender differences in childhood behavioral problems.

Age effect

Similar to several studies, the present findings add evidence to support a reduction in aggressive behaviors, indicating the possible relationship with psychosocial maturation from preschool to middle childhood.3–5 The negative finding, however, of significant decrease in delinquent behaviors or social problems with age3 may be explained by the generally low scores of these two syndromes in early and middle childhood in the present sample. Although previous studies on the age trend of attention problems produced inconsistent results,5,25 the present findings indicate that attention problems increased from early to middle childhood. It is highly likely that Chinese parents reported more severe child attentional problems with age due to the increased school load and high expectations of school performance despite the developmental maturation of attention.25 The novel finding is increased score on thought problems with age, which may be attributable to the increased verbal expression and cognitive development with age with which to report their imagination and fantasy.

Comorbid patterns of behavioral problems

Overall, the rates of comorbid conditions of particular behavioral problem pairs in the present study ranged from 0.9% to 4.0%, lower than those reported in the USA (10.5–30.2% in children aged 4–18).14 This discrepancy can be explained by different definitions of comorbidity and the age range of the participants. This presents a challenging issue for the reliable assessment of comorbidity rates of childhood behavioral problems.15 The present findings demonstrated similar comorbid patterns in childhood to Western studies.14 Gender difference in some comorbid behavioral patterns is a unique finding, which has been relatively less studied with mixed findings.15

Prenatal/perinatal factors

In general the present findings provide some evidence of prediction of some prenatal and perinatal factors to childhood emotional/behavioral problems. Consistent with other studies,8,26 the present findings suggest that exposure to alcohol increases the risks for some childhood behavioral problems. Despite the mixed results27 the present findings demonstrate that prenatal exposure to regular coffee use increased social problems in children. Caffeine and ethanol, which can cross the placental barrier and reach the human fetal brain,28 should be investigated as to what extent prenatal exposure to these common substances contributes to the development of child behavioral problems. Unlike other studies,7 the present study does not lend support to the impact of maternal smoking during pregnancy.

Consistent with a previous study, the association between antepartum vaginal bleeding and gestational diabetes, and behavioral problems implies that fetal adaptation to an unfavorable intrauterine environment may increase susceptibility to childhood behavioral problems.29 In addition, the present findings and several lines of data support an association of low birthweight with inattention/hyperactivity in childhood.6 Moreover, the findings of the impact of postnatal resuscitation and incubation on attention problems and social problems suggest a possible consequence of neurodevelopmental disability after neonatal resuscitation.

Overall, the present findings lend some support to increased rates of a variety of behavioral problems in children born with prenatal and perinatal insults, which may not necessarily be causal in nature but have implications for prevention of childhood behavioral problems.4

Maternal psychological distress

The present study demonstrates an association between maternal psychological distress and children's emotional and behavioral problems.7,11 Parental psychological distress may modify the parent–child relationship at a number of levels and in a reciprocal manner to increase the risk of behavioral problems.7 The effect of maternal depression on childhood emotional and behavioral problems has been studied the most;10 this relationship was further supported by a reduction in children's current behavioral symptoms after maternal remission from depression.10 It would be informative to examine whether intervention for maternal psychological stress ameliorates children's behavioral problems, in a future experimental study.

Limitations

Several methodological limitations should be considered when interpreting the present findings. First, the mother was the only informant for reporting on prenatal and perinatal exposure and the child emotional/behavioral problems. Neither medical records nor a second informant was used to validate these data. Studies have shown, however, that the mother is the most appropriate informant to report on these variables;30 recall bias, differential or non-differential, is minimized due to the young age of the child subjects, the mothers were not aware of the study hypothesis. Second, lack of quantity assessment of prenatal substance exposure prevents us from examining the dose–response relationship between prenatal exposure and childhood behavioral problems. Third, although maternal reports on children's emotional/behavioral problems are prone to observer bias and are influenced by subjective expectation and issues related to parent–child interaction, parents' reports on children's behaviors have been documented to be the satisfactory way to measure behavioral problems in children.30 Questionnaires and rating scales with good psychometric properties (e.g. the CBCL) are valuable in the evaluation of children with different kinds of behavioral problems.5 Furthermore, because a home-based interview approach would likely have yielded a lower attrition rate,23 the questionnaire survey method is alternatively satisfactory and cost-effective in achieving an adequate response rate, and interviewer bias can be prevented.

The strengths of the present study were the recruitment of a large-scale epidemiological sample using the multistage sampling method, with a satisfactory response rate and use of reliable and valid measures.

CONCLUSION

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

The present findings suggest that the CBCL is a cross-culturally valid instrument that can be used to identify Taiwanese children at risk of emotional/behavioral problems; that health professionals should be aware of possible prenatal/perinatal factors and maternal psychological distress for the primary prevention of emotional and behavioral problems in young children; and that the identification, prevention, and treatment for childhood emotional/behavioral problems should be carried out in the context of developmental stage and gender difference. Prospective longitudinal studies designed to examine the underlying mechanism of these associations and the possible moderating effects from gender and developmental stage elucidated in the present study will be informative.

ACKNOWLEDGMENTS

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES

This work was supported by grants from the National Taiwan University Hospital (NTUH-S861517-A33) and the National Health Research Institute (NHRI-EX95-9407PC), Taiwan.

REFERENCES

  1. Top of page
  2. Abstract
  3. METHODS
  4. RESULTS
  5. DISCUSSION
  6. CONCLUSION
  7. ACKNOWLEDGMENTS
  8. REFERENCES
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