Cardiovascular Disease and Risk Factors in Individuals With a History of Out-of-home Care.

BACKGROUND: Exposure to childhood out-of-home care (foster family and residential care) is associated with an increased risk of ill-health and disability in adulthood, but the risk for cardiovascular disease has not previously been studied longitudinally. METHODS: This was a national cohort study generated from linkage of a range of population-based registers, resulting in a national cohort of 881 731 of whom 26 310 (3.0%) had a history of out-of-home care. The study population, born 1972 to 1981, was followed from age 18 to age 39 to 48 years for hospitalizations and death. RESULTS: After adjusting for year of birth and maternal education, individuals with a history of childhood out-of-home-care experienced a doubling of the risk for coronary disease (hazard ratio; 95% confidence interval: 2.05; 1.74-2.41) and stroke (hazard ratio 1.85; 1.59-2.15), compared with the general population, with similar estimates for men and women. Women with a history of out-of-home care had a more than doubled risk for cigarette smoking in early pregnancy, with a relative risk of 2.26; (2.18-2.34) and a moderately increased risk for gestational diabetes relative risk 1.49 (1.19-1.86). There was marked attenuation (40% to 90%) in effect estimates for disease and risk factors after further control for cohort members educational achievement at age 15-16 years. CONCLUSIONS: A history of childhood out-of-home care was associated with a doubled risk of early cardiovascular disease events. Cigarette smoking and educational underachievement were the main identified risk factors.

WITHDRAWN: Cardiovascular disease in individuals with a history of out-of-home care: a Swedish national cohort study.

The authors have withdrawn their manuscript owing to errors apparent in the results. Therefore, the authors do not wish this work to be cited as reference for the project. If you have any questions, please contact the corresponding author.

Smoking During Pregnancy Among Immigrant Women With Same-Origin and Swedish-Born Partners.

INTRODUCTION: Although ethnically mixed couples are on the rise in industrialized countries, their health behaviors are poorly understood. We examined the associations between partner's birthplace, age at immigration, and smoking during pregnancy among foreign-born women. METHODS: Population-based register study including all pregnancies resulting in a livebirth or stillbirth in Sweden (1991-2012) with complete information on smoking and parental country of birth. We compared the prevalence of smoking during pregnancy between women in dual same-origin foreign-born unions (n = 213 111) and in mixed couples (immigrant women with a Swedish-born partner) (n = 111 866) using logistic regression. Swedish-born couples were used as a benchmark. RESULTS: The crude smoking rate among Swedish women whose partners were Swedish was 11%. Smoking rates of women in dual same-origin foreign-born unions varied substantially by birthplace, from 1.3% among women from Asian countries to 23.2% among those from other Nordic countries. Among immigrant groups with prevalences of pregnancy smoking higher than that of women in dual Swedish-born unions, having a Swedish-born partner was associated with lower odds of smoking (adjusted odds ratios: 0.72-0.87) but with higher odds among immigrant groups with lower prevalence (adjusted odds ratios: 1.17-5.88). These associations were stronger among women immigrating in adulthood, whose smoking rates were the lowest. CONCLUSIONS: Swedish-born partners "pull" smoking rates of immigrant women toward the level of smoking of Swedish-born women, particularly among women arrived during adulthood. Consideration of a woman's and her partner's ethnic background and life stage at migration may help understand smoking patterns of immigrant women. IMPLICATIONS: We found that having a Swedish-born partner is associated with higher rates of smoking during pregnancy among immigrants from regions where women smoke less than Swedish women, but with lower smoking rates among immigrants from regions where women smoke more. This implies that prevention efforts should concentrate on newly arrived single women from low prevalence regions, such as Africa and Asia, whereas cessation efforts may target women from high prevalence regions, such as other European countries. These findings suggest that pregnancy smoking prevention or cessation interventions may benefit from including partners and approaches culturally tailored to mixed unions.

U-shaped association between maternal age at delivery and dental caries in offspring.

OBJECTIVE: To determine the association between maternal age at delivery and caries in offspring. MATERIALS AND METHODS: This registry-based cohort study included all children born between 2000 and 2003 and who were residing in Stockholm County, Sweden, at 7 years of age. Between 2007 and 2010, the cohort (n = 65,259) was examined to determine caries experience (deft scores) at 7 years of age. Age of mother at childbirth was retrieved from the patient histories. Data were analysed using linear regressions. RESULTS: The lowest mean deft occurred in children born to mothers aged 25-34 years. The final model - adjusted for sex, income, educational level, migration background, family situation, smoking, obesity, small for gestational age, and number of siblings - found that young mothers and older mothers were significant risk indicators for caries experience at 7 years of age. CONCLUSIONS: The present study found a U-shaped relationship between maternal age at childbirth and caries experience in the offspring at age 7 years. The offspring of mothers under 25 or over 34 years of age are at greater risk of having more teeth with caries experience.

Adverse birth outcomes and the risk of dental caries at age 3 years.

BACKGROUND: Since birth outcome is associated with maternal and newborn health, it can be a predictor of the future health of the child. AIM: To investigate the association between adverse birth outcomes and dental caries. DESIGN: The present registry-based cohort study included all children born in 2000-2003, residing in Stockholm County, Sweden and who received a dental examination at the age of 3 years (n = 74 748). National registries supplied data on socioeconomic conditions, maternal health, maternal health behavior, and birth outcomes. Forward stepwise binary logistic regression was performed to determine predictors of caries experience in the 3-year-olds. RESULTS: Of the subjects, 6.0% had caries experience (decayed, extracted, and filled teeth [deft] ≥ 1), 5.6% were born preterm (<37 weeks); 2.2% were born small (SGA) and 3.7% large (LGA) for gestational age. Of the studied adverse birth outcomes, only SGA was significantly associated with caries experience at 3 years of age, and only for mothers who had refrained from smoking during pregnancy. CONCLUSIONS: SGA is associated with caries experience in 3-year-old children; however, this relationship occurs only in mothers who did not smoke during pregnancy.

Acculturation or unequal assimilation? Smoking during pregnancy and duration of residence among migrants in Sweden.

A growing corpus of evidence reveals that smoking patterns of migrant women tend to converge with that of the host population over time ('acculturation paradox'). In this paper we aim to adopt a health equity perspective by studying the extent to which this pattern reflects a convergence with the group of natives who are more socioeconomically disadvantaged. Using population-based registers, we study 1,194,296 women who gave birth in Sweden between 1991 and 2012. Using logistic regression, we estimated odds ratios to assess the effect of duration of residence on the association between smoking during pregnancy and women's origin (classified according to inequality-adjusted Human Development Index (iHDI) of the country of birth). Sibling information and multilevel models were used to assess the extent to which our results might be affected by the cross-sectional nature of the data. Smoking during pregnancy increases with duration of residence among migrants from all levels of iHDI to such an extent that they tend to converge or increase in relation to the levels of the Swedish population with low education and low income, leaving behind the native population with high education and income. The results are robust to possible selection bias related to the cross-sectional nature of the data. Our findings indicate the need of a health equity perspective and suggest the use of 'unequal assimilation' rather than 'acculturation paradox' as a more suitable framework to interpret these findings.

Child mortality in England compared with Sweden: a birth cohort study.

BACKGROUND: Child mortality is almost twice as high in England compared with Sweden. We aimed to establish the extent to which adverse birth characteristics and socioeconomic factors explain this difference. METHODS: We developed nationally representative cohorts of singleton livebirths between Jan 1, 2003, and Dec 31, 2012, using the Hospital Episode Statistics in England, and the Swedish Medical Birth Register in Sweden, with longitudinal follow-up from linked hospital admissions and mortality records. We analysed mortality as the outcome, based on deaths from any cause at age 2-27 days, 28-364 days, and 1-4 years. We fitted Cox proportional hazard regression models to estimate the hazard ratios (HRs) for England compared with Sweden in all three age groups. The models were adjusted for birth characteristics (gestational age, birthweight, sex, and congenital anomalies), and for socioeconomic factors (maternal age and socioeconomic status). FINDINGS: The English cohort comprised 3 932 886 births and 11 392 deaths and the Swedish cohort comprised 1 013 360 births and 1927 deaths. The unadjusted HRs for England compared with Sweden were 1·66 (95% CI 1·53-1·81) at 2-27 days, 1·59 (1·47-1·71) at 28-364 days, and 1·27 (1·15-1·40) at 1-4 years. At 2-27 days, 77% of the excess risk of death in England was explained by birth characteristics and a further 3% by socioeconomic factors. At 28-364 days, 68% of the excess risk of death in England was explained by birth characteristics and a further 11% by socioeconomic factors. At 1-4 years, the adjusted HR did not indicate a significant difference between countries. INTERPRETATION: Excess child mortality in England compared with Sweden was largely explained by the unfavourable distribution of birth characteristics in England. Socioeconomic factors contributed to these differences through associations with adverse birth characteristics and increased mortality after 1 month of age. Policies to reduce child mortality in England could have most impact by reducing adverse birth characteristics through improving the health of women before and during pregnancy and reducing socioeconomic disadvantage. FUNDING: The Farr Institute of Health Informatics Research (through the Medical Research Council, Arthritis Research UK, British Heart Foundation, Cancer Research UK, Chief Scientist Office, Economic and Social Research Council, Engineering and Physical Sciences Research Council, National Institute for Health Research, National Institute for Social Care and Health Research, and the Wellcome Trust).

Smoking during pregnancy among immigrants to Sweden, 1992-2008: the effects of secular trends and time since migration.

BACKGROUND: Smoking during pregnancy has been declining in the past decades in high-income countries, including Sweden. Paradoxically, increasing trends associated with duration of residence have been reported among immigrants. We aimed to clarify how these two contrasting trends have shaped smoking patterns among immigrants. METHODS: We conducted a population-based study of 1 598 433 pregnancies in Sweden in the period 1992-2008. We used multinomial logistic regression to estimate the odds of mild and heavy smoking relative to no smoking associated with year of delivery, years since migration, maternal region of birth and their interaction, after controlling for potential confounders. RESULTS: The prevalence of smoking decreased for the Swedish-born and for immigrants during the study period. Among immigrants, duration of residence was independently associated with increases in smoking and varied according to maternal region of birth (P-value for interaction <0.001). The odds ratio associated with a 10-year increase in duration of residence was weakest for mild smoking among former Yugoslav women (adjusted odds ratio; 95% confidence interval: 1.10; 1.04-1.17) and those from other Nordic countries (1.22; 1.17-1.26) and strongest for heavy smoking among East African (4.46; 3.23-6.16) and sub-Saharan African (3.56; 2.68-4.72) women. The association between duration of residence and smoking was attenuated after stratifying by cohorts of arrival among European but not among non-European immigrants. CONCLUSIONS: Declines in smoking during pregnancy among immigrants from various regions of the world were differentially affected by opposite increasing trends throughout their residence in Sweden.

Policies of access to healthcare services for accompanied asylum-seeking children in the Nordic countries.

AIMS: Asylum-seeking children constitute a vulnerable group with high prevalence and risk for mental health problems. The aim of this study was to compare policies of access to healthcare services, including physical examination and screening for mental health problems on arrival, for accompanied asylum-seeking children in the Nordic countries. METHODS: This study was based on the national reports "Reception of refugee children in the Nordic countries" written by independent national experts for the Nordic Network for Research on Refugee Children, supplemented by information from relevant authorities. RESULTS: In Sweden, Norway and Iceland, asylum-seeking children had access to healthcare services equal to children in the general population. On a policy level, Denmark imposed restrictions on non-acute hospitalisations and prolonged specialist treatments. Regarding health examinations, Sweden deviated from the Nordic pattern by not performing these systematically. In Denmark, Iceland, and some counties in Sweden, but not in Norway, screening for mental health problems was offered to asylum-seeking children. CONCLUSION: Access to healthcare services for asylum-seeking children differs in the Nordic countries; the consequences of these systematic differences for the individual asylum-seeking child are unknown. For asylum-seeking children, access to healthcare has to be considered in a wider context that includes the core conditions of being an asylum-seeker. A comparative study at policy level needs to be supplemented with empirical follow-up studies of the well-being of the study population to document potential consequences of policies in practice.

ADHD after fetal exposure to maternal smoking.

INTRODUCTION: Smoking during pregnancy has been reported to be associated with a twofold to fourfold increased risk of attention-deficit hyperactivity disorder (ADHD) in the offspring. Genetic and socioeconomic confounders may contribute to this association. The aim of this study was to investigate the association between fetal exposure to maternal smoking during pregnancy and ADHD, taking such potential confounders into consideration. METHODS: A register study in a population of 982,856 children, 6-19 years of age, born at term, and residents in Sweden in 2006 was conducted. Logistic regression was used to calculate odds ratios (ORs) of maternal smoking habits during pregnancy on ADHD medication in the 927,007 study subjects where maternal smoking habits were available from the Medical Birth Register in the presence of socioeconomic and parental psychiatric morbidity confounders. To adjust the analysis also for genetic confounding, we used a within-mother between-pregnancy approach in offspring of 26,292 mothers with inconsistent smoking habits (smoking/non-smoking) between pregnancies. RESULTS: The OR for ADHD medication in offspring of mothers who smoked >or=10 cigarettes/day was 2.86 (2.66-3.07) in the entire study population after adjustment for sex and age, while this same exposure yielded an OR of only 1.26 (0.95-1.58) when two pregnancies of the same mother were analyzed in a within-subjects design. DISCUSSION: Smoking during pregnancy has a strong association with ADHD in the offspring in the general Swedish population, but this risk is primarily explained by genetic and socioeconomic confounding.

Long-term outcomes of childhood cancer survivors in Sweden: a population-based study of education, employment, and income.

BACKGROUND: Studies of different national populations were indispensable for estimating the impact of illness-related disability on social outcomes in adult childhood cancer survivors. The effects of childhood cancer on educational attainment, employment, and income in adulthood in a Swedish setting were studied. METHODS: The study population was a national cohort of 1.46 million Swedish residents, including 1716 survivors of childhood cancer diagnosed before their 16th birthday, followed up in 2002 in registries at >25 years of age. Main outcomes were educational attainment, employment, and net income. Markers of persistent disability were considered, and outcomes were analyzed with multivariate linear and logistic regression models adjusted for age, sex, and socioeconomic indicators of the childhood households. RESULTS: Non-central nervous system (CNS) cancer survivors had similar education, employment, and income as the general population in adjusted models, whereas survivors of CNS tumors more often had no more than basic (< or =9 years) education (relative risk [RR], 1.80 [95% confidence interval (95% CI), 1.45-2.23]), less often attained education beyond secondary school (RR, 0.69 [95% CI, 0.58-0.81]), and less often were employed (RR, 0.85 [95% CI, 0.77-0.94]). Predicted net income from work was lower in CNS tumor survivors (P <.001) than in the general population, even after the exclusion of individuals who received economic disability compensation. CONCLUSIONS: CNS tumor survivors had poorer social outcomes compared with the general population, whereas outcomes for survivors of other childhood cancers were similar to the general population. Established late effects highlighted the importance of improved, safer pediatric CNS tumor treatment protocols and surveillance that identified individual needs for preventive and remedial measures.

Routine developmental screening at 5.5 and 7 years of age is not an efficient predictor of attention-deficit / hyperactivity disorder at age 10.

AIM: The aim of this study was to assess the efficiency of developmental screening for deficits in attention, motor control and perception or attention-deficit/hyperactivity disorder (DAMP/ADHD) at 5.5 and 7 years of age for diagnosing ADHD in grade 4. METHOD: The study population consisted of 442 children from a cohort study of ADHD in 10-year olds in one municipality in Stockholm County. Sensitivity, specificity and positive predictive value of a developmental screening at 5.5 and at 7 years of age for being diagnosed with ADHD at 10 years of age was calculated. RESULTS: The sensitivity was 44%, the specificity 85% and the positive predictive value for having a diagnosis of pervasive ADHD in 4th grade was 15%, when at least two deviations in nine items was used as the cut-off point in 5.5-year screening at Child Health Centres (CHCs). With a cut-off score of at least two deviations in four items rated by parents or and teachers in 1st grade, these estimates were 58%, 81% and 15% respectively. CONCLUSION: This study demonstrates that developmental screening for DAMP/ADHD at 5.5 and 7 years of age does not identify children who are diagnosed with ADHD in grade 4 with a high degree of selectivity.

Short stature, smoking habits and birth outcome in international adoptees in Sweden.

OBJECTIVE: To investigate short stature and smoking habits as risk factors for birth outcome in international adoptees in comparison with non-adopted mothers. DESIGN: Prospective cohort study. SETTING: Nationwide study in Sweden. POPULATION: Two study groups were identified from mothers who were born 1968-1979 and gave birth during 1982-2001-3,610 mother-child dyads with a mother adopted from a non-European country and 336,992 mother-child dyads with a mother born in Sweden. METHOD: Register study. OUTCOME MEASURES: Pre-eclampsia, instrumental delivery, preterm delivery, small for gestational age (SGA), Apgar score, cephalhematoma and perinatal mortality and birth weight. RESULTS: Short stature and smoking were more common in international adoptees compared with non-adopted, odds ratios (ORs) 29.07 (95% C.I.: 25.29-33.42) and 1.39 (1.27-1.52), respectively. International adoptees had a slightly increased risk for instrumental delivery (OR: 1.42; 1.32-1.54) and preterm delivery (<37 weeks) (OR: 1.39; 1.24-1.56) and there was a slightly increased risk for SGA (OR: 1.24; 1.01-1.52) in their offspring. However, when we adjusted for maternal height, preterm delivery was the only outcome that remained statistically significant. Adjustment for smoking habits had marginal effects on all outcomes. CONCLUSION: The short stature of international adoptees increased their risk for delivery and birth complications in a predictable manner, but otherwise outcomes were very similar to the general population. No special obstetric monitoring is indicated by adoption status in itself.

Parental region of birth, socio-economic status and infants' exposure to second-hand smoke.

AIM: To investigate the impact of parental region of birth on the risk of exposure to second-hand smoke for infants. METHODS: The smoking habits, according to child health records, of parents of 14 431 infants in Uppsala county, Sweden, born during 1997-2001, were investigated with logistic regression in the presence of socio-economic and demographic confounders from national registers. RESULTS: Fathers born outside of Sweden smoked more often than Swedish-born fathers irrespective of region of birth (adjusted odds ratios [ORs] 1.77-3.02). Mothers born in Africa (adjusted OR 0.29, 95% CI 0.15-0.58) and Asia (adjusted OR 0.53, 95% CI 0.40-0.70) smoked less often than Swedish-born mothers. Single parenthood, low income and mother's age

The neighbourhood they live in: does it matter to women's smoking habits during pregnancy?

Socioeconomic factors in the neighbourhood are associated with smoking habits in various populations. We studied a 10-year cohort to determine whether women's smoking behaviour during pregnancy can similarly be determined by neighbourhood economic and ethnic factors. The cohort included 127,074 primiparous pregnant women in 592 Swedish neighbourhoods during the years 1992-2001. Multilevel technique was used to regress pregnancy smoking on socioeconomic individual-level variables and neighbourhood characteristics. Seven percent of the variation in pregnancy smoking was at the neighbourhood level and the odds of smoking during pregnancy were doubled in poorer areas. Health education and smoking cessation interventions should be directed at maternity care units in deprived neighbourhoods.

Disability in adult survivors of childhood cancer: a Swedish national cohort study.

PURPOSE: We studied the effects of childhood or adolescent cancer and cancer treatment on disability as indicated by persistent aid needs in adult life. PATIENTS AND METHODS: A group of 2,503 survivors of childhood cancer diagnosed before their 16th birthday were studied with data from registers in a national cohort of 1.91 million Swedish residents. Disability indicators were created from information in national registers about income (sickness pension, handicap allowance), personal assistance, and family situation in 2002. Multivariate logistic regression on the log scale was used to estimate relative risk (RR) ratios. RESULTS: A total of 7.6% of survivors received handicap allowance indicating permanent disability, including brain tumors (14.0%), other solid tumors (6.3), and leukemias/lymphomas (2.9%), compared with 0.6% in the general population. Twenty-six percent of survivors of CNS tumor and 10% of survivors of solid tumors had at least one indication of a disability. Younger age at diagnosis suggested a higher risk for disability. CNS tumor survivors had an RR of 10.7 (95% CI, 9.3 to 12.8) for having at least one disability indication compared with the noncancer population, whereas leukemia and lymphoma survivors had an RR of 3.0, and survivors of other cancers had an RR of 3.8. Survivors of CNS tumor only had an increased RR for living in the parental household (RR = 1.6; 95% CI, 1.4 to 1.9). CONCLUSION: Childhood cancer survivors more often have persistent needs of supportive measures provided by community and/or the parental household. The survivors of CNS tumors were at particular risk, indicating a need of safer treatment protocols, and tailored follow-up, prevention, and rehabilitation to address this persistent social disability.

Are there differences in birth weight between neighbourhoods in a Nordic welfare state?

BACKGROUND: The objective of this cohort study was to examine the effect on birth weight of living in a disadvantaged neighbourhood in a Nordic welfare state. Birth weight is a health indicator known to be sensitive to political and welfare state conditions. No former studies on urban neighbourhood differences regarding mean birth weight have been carried out in a Nordic country. METHODS: A register based on individual data on children's birth weight and maternal risk factors was used. A neighbourhood characteristic, i.e. an aggregated measure on income was also included. Connections between individual- and neighbourhood-level determinants and the outcome were analysed using multi-level regression technique. The study covered six hundred and ninety-six neighbourhoods in the three major cities of Sweden, Stockholm, Göteborg and Malmö, during 1992-2001. The majority of neighbourhoods had a population of 4 000-10 000 inhabitants. An average of 500 births per neighbourhood were analysed in this study. RESULTS: Differences in mean birth weight in Swedish urban neighbourhoods were minor. However, gestational length, parity and maternal smoking acted as modifiers of the neighbourhood effects. Most of the observed variation in mean birth weight was explained by individual risk factors. CONCLUSION: Welfare institutions and benefits in Sweden might buffer against negative infant outcomes due to adverse structural organisation of urban neighbourhoods.

A population-based study on the incidence and possible pre- and perinatal etiologic risk factors of biliary atresia.

OBJECTIVE: To study the incidence, etiologic risk factors, and outcome of biliary atresia. STUDY DESIGN: Register study using Swedish national health databases. The study population consisted of 1,204,791 children, corresponding to 99% of the entire cohort of Swedish children born between 1987 and 1997, with an end point of follow-up at 2 years of age. Cases with biliary atresia with and without major heart malformations were identified with indicators from various national health databases. RESULTS: Eighty-five cases with biliary atresia were identified, the incidence being 1 in 14,000. A major heart malformation was found in 13 (15%) cases. In a multivariate analysis, 4 independent risk factors were identified: high maternal age (odds ratio [OR] = 3.0), parity of at least 4 (OR = 2.2), prematurity (OR = 2.9), and low birth weight for gestational age (OR = 4.7). No significant differences were found in the distribution of birth months. The outcome did not differ between the two groups with and without major heart malformations, nor with respect to any of the risk factors. CONCLUSIONS: The Swedish incidence of biliary atresia is similar to that found in other European countries. The identified risk factors may suggest the existence of a maternal vulnerability and the importance of viral infections transmitted from mother to fetus/neonate.

Mortality, severe morbidity and injury among long-term lone mothers in Sweden.

BACKGROUND: Being a lone mother often implies disadvantage in terms of both socioeconomic circumstances and health. Our aim was to examine differences in mortality, severe morbidity and injury between lone mothers and mothers living with partners, on the assumption that the disadvantaged socioeconomic circumstances contribute to poor health. METHODS: The odds for receipt of hospital care or death between 1991 and 1994 were estimated for 26 619 lone mothers and 379 855 partnered mothers from data collected for the Swedish Population and Housing Census of 1990. We computed odds ratios by means of logistic regression, adjusting for confounders, mediators, and factors with an indeterminate position in various models. To control for health-selection effects, we only considered initially healthy women, as measured by non-hospitalization 4 years prior to follow-up. To reduce the impact of distress following divorce on health, we only included mothers who had been either lone or partnered for a period of > or =5 years. RESULTS: Lone mothers showed increased risks of total mortality, lung cancer, suicide/ suicide attempt, inflicted violence, traffic injury and other accident, psychiatric disease, and addiction. The main explanation for increased risks seems for most outcomes to lie in deficient household resources, as indicated here by receipt of social-welfare benefit and housing situation. For all the initially elevated outcomes, except for total mortality, significant risk increases remained unaccounted for even in the full model. Relationships varied according to subgroup. Lone motherhood was not related to accident, suicide and addiction among medium- and high-grade non-manual workers. Although lone mothers in general showed no increased risk of ischaemic heart disease, those receiving social benefit were exposed to a significantly increased risk. CONCLUSIONS: Our findings suggest that lone motherhood entails health disadvantages. Lack of household resources seems to play a major role in accounting for increased risks, but the risks are partly independent of socioeconomic circumstances, selection factors, and distress following divorce.