School performances in children with cataract: results from a population-based cohort study.

OBJECTIVES: Childhood cataract is a chronic condition that may interfere with the child's learning capacities. We aimed to investigate whether childhood cataract influences academic development by comparing school performance in reading and mathematics in children with cataract to a matched control group. DESIGN: Nationwide registry-based cohort study. SETTINGS: Two surgical centres that perform all treatments for childhood cataract in Denmark. PARTICIPANTS: Children born between 2000 and 2009 diagnosed with cataract before 10 years of age (n=275) and an age-matched and sex-matched control group (n=2473). MAIN OUTCOME MEASURES: School performance was assessed as test scores in national tests performed at regular intervals from grade 2 to grade 8 in reading and mathematics. Analyses were corrected for birth origin, child somatic and mental disorder and parental socioeconomic status and mental disorders. RESULTS: Of 275 children, 85 (30.9%) were operated for bilateral cataract, 79 (28.7%) unilateral cataract and 111 (40,4%) were not operated. We found that children with cataract have lower participation rate in the tests (62.5%) compared with the control cohort (77.2%) (p value=0.0001). After adjusting the pooled analyses for birth origin, somatic and mental disease in the child and parental socioeconomic status and mental disorders, we found that the children with cataract scored significantly lower in mathematics compared with those without cataract (mean difference=-4.78, 95% CI: -8.18 to -1.38, p value=0.006), whereas no difference was found regarding scores in reading (p=0.576). The lower score in mathematics was driven by children who had been operated for bilateral cataract (p-value=0.004). CONCLUSION: Children with cataract without somatic or neurodevelopmental comorbidities or psychosocial adversities seem to do well in school, whereas children operated for bilateral cataract have higher frequencies of difficulties in mathematical tasks.

Peripapillary Hyperreflective Ovoid Mass-like Structures (PHOMS) in Children: The Copenhagen Child Cohort 2000 Eye Study.

PURPOSE: To determine the prevalence of peripapillary hyperreflective ovoid mass-like structures (PHOMS) in a population-based child cohort and to study their association with other optic nerve head features and myopia. DESIGN: Observational, population-based cohort study of 1407 children aged 11-12 years. METHODS: Optical coherence tomography scans of optic nerve heads were graded for PHOMS, disc tilt, prelaminar hyperreflective lines, and scleral canal diameter and investigated for associated prenatal and ocular parameters. Children with optic disc drusen or optic disc edema were excluded. RESULTS: PHOMS were found in 8.9% of children. The location of PHOMS was predominantly in the superonasal section of the optic disc. Myopia and optic nerve head tilt were more common in children with PHOMS than in children without PHOMS (P < .001 and P < .001, respectively). Prelaminar hyperreflective lines were found in 17.9% of children with PHOMS compared to 7.3% of children without PHOMS (P < .001). Prelaminar hyperreflective lines with and without PHOMS were associated with a shorter axial length of the eye (P < .001). There were no prenatal factors associated with PHOMS. Prelaminar hyperreflective lines were associated with higher birth weight and continued maternal smoking during pregnancy (P = .01 and P = .02, respectively). CONCLUSIONS: PHOMS had a prevalence of 8.9% in healthy children without optic disc drusen or optic disc edema and was associated with increasing myopic refraction and the presence of a tilted optic nerve head and prelaminar hyperreflective lines. Given the high prevalence of PHOMS, they should not unreservedly be taken as evidence of optic neuropathy.

Smoking in pregnancy is associated with increased adiposity and retinal arteriolar wall-to-lumen ratio in adolescence: The Copenhagen Child Cohort Study 2000.

PURPOSE: To investigate the association between prenatal exposures and anthropometric data and cardiovascular risk factors including retinal arteriolar wall-to-lumen ratio in adolescence. METHODS: This longitudinal observational study included all 1445 adolescents from the Copenhagen Child Cohort 2000 who attended the 2016-2017 examination. Outcome measures included retinal arteriolar wall-to-lumen ratio, height, body mass index, waist-to-hip ratio, body composition measured by bioimpedance, and blood pressure. Information on prenatal exposures (birth weight, gestational age, maternal smoking during pregnancy) as well as sex, parental age, household income and parental educational levels were obtained from national registries. Associations between exposures and outcome measures were analyzed using general linear models. RESULTS: Maternal smoking during pregnancy was associated with a higher retinal arteriolar wall-to-lumen ratio (0.004 or 1.9%, P = 0.009) at age 16/17 years, an association driven exclusively by the female participants (0.008 or 3.7%, P < 0.0001). Maternal smoking during pregnancy was also associated to higher body-mass index (1.43 kg/m2, P < 0.0001), waist-to-hip ratio (0.02, P < 0.0001) and fat mass index (0.93 kg/m2, P < 0.0001). Birth weight, gestational age, and parental age had no detectable impact on retinal arteriolar wall-to-lumen ratios. CONCLUSION: Prenatal exposure to tobacco smoking is associated with a higher risk of obesity and, predominantly in girls, to a greater retinal arteriolar wall thickness, which suggests that maternal smoking may induce an unfavorable cardiovascular and metabolic risk profile in the child.

Trajectories of dysregulation in preschool age.

Dysregulation of emotions, behaviour and attention is involved in several areas of childhood psychopathology, but knowledge about early developmental trajectories remains scarce. This study aims to explore continuity and associations of dysregulation in preschool age. Dysregulation was measured at age 2½ years and again at 5 years in a community-based birth cohort of 1099 children using the Child Behavior Checklist, preschool version (CBCL1½-5), answered by mothers. Based on the Dysregulation Profile (CBCL-DP) score, we defined four trajectory groups, using the 75th percentile from the Danish norm material as a cut-off. Associations between the four CBCL-DP trajectory groups and potential covariates, including child, parental and family factors, were analysed using univariate and multiple multinomial logistic regression. Nearly half (54%) of the children showed persistent low scores of CBCL-DP, 17% displayed continuing dysregulation problems, 13% had problems that increased from 2½ years to 5 years, whereas 16% of the children showed reduced problems across preschool age. Persistent dysregulation was associated with maternal postpartum depressive symptoms RRR = 2.20 (95% CI 1.29-3.75), low maternal educational level RRR = 1.69 (95% CI 1.08-2.66), and mothers' smoking during pregnancy RRR = 2.87 (95% CI 1.09-7.55). Persistent problems of emotional, behavioural and attention regulation in children aged 2½ years to 5 years is influenced by maternal educational level and post-partum depression symptoms. The study draws clinical attention to early symptoms of dysregulation and to the importance of addressing the specific needs of mentally vulnerable parents in intervention planning.

Cone photoreceptor density in the Copenhagen Child Cohort at age 16-17 years.

PURPOSE: To examine cone density in relation to gestational and morphological parameters in the Copenhagen Child Cohort (CCC2000). METHODS: The macula was imaged using adaptive optics in 1,296 adolescents aged 16-17 years. Axial length and distance visual acuity were determined. Absolute and angular cone photoreceptor density were analysed for an 80 × 80-pixel area, 2 degrees temporal to the fovea. Association with axial length was analysed with linear regression. Correlation with visual acuity was described with a Pearson correlation coefficient. Associations of cone density with gestational parameters, maternal smoking, sex and age were analysed using multiple regression adjusted for axial length. RESULTS: Mean absolute cone density was 30,007 cones/mm2 (SD ± 3,802) and mean angular cone density was 2,383 cones/deg2 (SD ± 231). Peri- and postnatal parameters, sex and age had no statistically significant effect on cone density (p > 0.05). Absolute cone density decreased with longer axial length (-2,855 cones/mm2 per mm or -9.7% per mm, p < 0.0001). For angular density, which included a correction for the geometrical enlargement of the eye with axial length, a decrease with axial length was detectable, but it was small (-20 cones/deg2 per mm or -0.84% per mm, p = 0.009). CONCLUSIONS: The decrease in cone density per unit solid angle with increasing axial length was small, less than 1 percent per mm, indicating that expansion of the posterior pole during the development of refraction takes place without a clinically significant loss of cones. Perinatal parameters, within the spectrum presented by the study population, had no detectable effect on cone density.

Incidence of cilioretinal arteries in 11- to 12-year-old children and association with maternal smoking during pregnancy: the Copenhagen Child Cohort 2000 Eye Study.

PURPOSE: To estimate the incidence of cilioretinal arteries in a Danish child cohort and associations with birth parameters. METHODS: The population-based Copenhagen Child Cohort 2000 Eye Study examined 1406 children aged 11-12 years. Colour fundus images of both eyes were graded for cilioretinal arteries in the three categories large temporal (defined as supplying the central macula), small temporal and nasal. Data on maternal smoking during pregnancy, gestational ageand birth weight were obtained from the Danish Medical Birth Registry. RESULTS: A total of 463/1338 (35%) children were found to have one or more cilioretinal arteries per child. Large temporal cilioretinal arteries were present in 280/1338 (21%) of children and were associated with tobacco smoking during pregnancy, being present in 70/246 (28%) of children with mothers who were smoking during pregnancy, but only in 191/990 (19%) of children whose mothers did not smoke during pregnancy (p = 0.0022). After adjustments for potential confounders, the odds ratio of having one or more large temporal cilioretinal arteries was 1.72 (CI95% 1.19-2.47; p = 0.0035) in the smoking versus none smoking category. No other associations with birth parameters were found. CONCLUSION: Cilioretinal arteries were present in more than one third of 11- to 12-year-old Danish children. Large temporal cilioretinal arteries were found in one fifth of children and were associated with maternal smoking during pregnancy. This finding suggests that the intrauterine environment may have an impact on the development of retinal vessels during foetal life.

Mental disorders in referred 0-3-year-old children: a population-based study of incidence, comorbidity and perinatal risk factors.

The epidemiology of mental disorders in early childhood is still under-researched. We aim to explore the incidence, comorbidities and risk factors of mental disorders in 0-3-year-olds referred to hospital settings. In a national cohort of 918,280 children born in 1997-2010, we calculated incidence rates per 1,000 person-years (IR) of first-time mental and developmental disorders diagnosed in hospitals before four years of age. Data were obtained from Danish population registries. We used logistic regression to analyse co-morbidity and Cox proportional hazard models to evaluate the influence of pre- and perinatal risk factors. A total of 16,164 children (1.76%) were diagnosed with a mental (0.90%) or developmental disorder (1.05%). Pervasive developmental disorders (PDD) and disorders of hyperactivity and inattention (ADHD) were increasingly diagnosed with age. Feeding and eating disorders and disorders of social functioning were most frequent among the youngest children. Comorbidity was found in 18%, e.g., between PDD and ADHD (OR 135.8; 95% CI 112.0-164.7) or between ADHD and disorders of social functioning (OR 148.0; 95% CI 106.4-205.7). Young maternal age, old paternal age, maternal smoking in pregnancy, boy sex, premature birth and being small for gestational age were associated with highly increased risk of mental and developmental disorders. Mental and developmental disorders diagnosed within the first four years of life show increasing incidence rates and a complex pattern of comorbidities. Study findings point to the need of clinical and research attention towards the manifestations of developmental psychopathology in very young children.

[Standardised measuring the health of infants and toddlers in community health services].

Standardised measures are needed in the general child health surveillance. A standardised record with manualised guidelines have been created for use in the existing services of community health nurses, to collect epidemiological data and improve the quality of regional child health surveillance. The record has been used since 2000, and currently one third of the Danish child population is included. Research findings suggest targets of intervention towards risk trajectories of overweight, weight faltering, eating problems and neuro-developmental disorders.

Predictive validity of a service-setting-based measure to identify infancy mental health problems: a population-based cohort study.

Measures to identify infancy mental health problems are essential to guide interventions and reduce the risk of developmental psychopathology in early years. We investigated a new service-setting-based measure the Copenhagen Infant Mental Health Screening (CIMHS) within the general child health surveillance by community health nurses (CHN). The study population of 2973 infants was assessed by CIMHS at age 9-10 months. A subsample of 416 children was examined at age 1½ years, using parent interviews including the Child Behavior Checklist (CBCL 1½-5), Check List of Autism and Toddlers (CHAT), Infant-Toddler Symptom Checklist (ITSCL), and the Bayley Scales of Infant and Toddler Development (BSID) and observations of behavior, communication, and interaction. Child mental disorders were diagnosed according to ICD-10 and parent-child relationship disorders according to DC:0-3R. Statistical analyses included logistic regression analyses adjusted and weighted to adjust for sampling and bias. CIMHS problems of sleep, feeding and eating, emotions, attention, communication, and language were associated with an up to fivefold increased risk of child mental disorders across the diagnostic spectrum of ICD-10 diagnoses. Homo-type continuity was seen in problems of sleep and feeding and eating being associated with a threefold increased risk of disorders within the same area, OR 3.0 (95% CI 1.6-5.4) and OR 2.7 (95% CI 1.7-4.2), respectively. The sensitivity at high CIMHS problem scores was 32% and specificity 86%. In summary, CIMHS identify a broad range of infants' mental health problems that are amenable to guide intervention within the general child health surveillance.

Association of Maternal Smoking During Pregnancy and Birth Weight With Retinal Nerve Fiber Layer Thickness in Children Aged 11 or 12 Years: The Copenhagen Child Cohort 2000 Eye Study.

Importance: Both maternal smoking during pregnancy and low birth weight have been implicated in impaired development of the retina. Objective: To investigate the associations of maternal smoking during pregnancy and low birth weight with retinal nerve fiber layer (RNFL) thickness in preadolescent children. Design, Setting, Participants: The Copenhagen Child Cohort 2000 Eye Study is a prospective, population-based, birth cohort study that included all children (n = 6090) born in 2000 in Copenhagen, Denmark. Maternal smoking data were collected through parental interviews. Birth weight, pregnancy, and medical history data were obtained from the Danish Medical Birth Registry. As a follow-up, the study performed eye examinations on 1406 of these children from May 1, 2011, to October 31, 2012, when the children were aged 11 or 12 years. The participants were predominantly (1296 [92.4%]) of European descent. Study data were analyzed from June 1, 2016, to October 1, 2016. Main Outcomes and Measures: Peripapillary RNFL thickness measured using optical coherence tomography at the 11- or 12-year examination. Results: Of the 1406 children in the study, 1323 were included in the analysis (mean [SD] age was 11.7 [0.4] years; 633 [47.8%] were boys and 690 [52.2%] were girls). The mean (SD) RNFL thickness was 104 (9.6) µm. In 227 children whose mothers had smoked during pregnancy, the peripapillary RNFL was 5.7 µm (95% CI, 4.3-7.1 µm; P < .001) thinner than in children whose mothers had not smoked after correction for age, sex, birth weight, height, body weight, Tanner stage of pubertal development, axial length, and spherical equivalent refractive error. In low-birth-weight children (<2500 g), the RNFL was 3.5 µm (95% CI, 0.6-6.3 µm; P = .02) thinner than in normal-birth-weight children after adjustment for all variables. Conclusions and Relevance: Exposure to maternal smoking during uterine life and low birth weight were independently associated with having a thinner RNFL at age 11 or 12 years. These observations support previous findings that intrauterine and perinatal factors can have long-lasting effects on the retina and the optic nerve. The results of this study add evidence to existing recommendations to avoid smoking during pregnancy and support measures that promote maternal and fetal health.

A new measure for infant mental health screening: development and initial validation.

BACKGROUND: Mental health problems are a major public health challenges, and strategies of early prevention are needed. Effective prevention depends on feasible and validated measures of screening and intervention. Previous research has demonstrated potentials for infant mental health screening by community health nurses (CHN) in existing service settings in Denmark. This study was conducted to describe the development of a service setting based measure to screen for infant mental health problems, to investigate problems identified by the measure and assess the validity and feasibility in existing public health settings. METHODS: Experts within the field developed a short, feasible and comprehensive measure. A consecutive sample of 2973 infants from 11 municipalities around the city of Copenhagen was screened at 9-10 months. Face validity and feasibility were evaluated among CHNs. Data on child and family factors and the results of screening were included in descriptive analyses. Exploratory factor analysis (EFA) was used to assess content validity. RESULTS: The measure identified problems of communication and interaction in 20.7% of the children, problems of eating in 20.1%, attention problems in 15.9% and problems of emotional regulation in 14.3%. Significant gender differences were seen. EFA demonstrated that among 27 items 11 items were clustering into five areas: Problems of eating, emotions, attention, language and communication and attachment, respectively. High face validity and feasibility was demonstrated, and the participation was 91%. CONCLUSIONS: The new measure shows potentials for infant mental health screening. However, further exploration of construct validity and reliability is needed.

Early Predictors of Eating Problems in Preadolescence-A Prospective Birth Cohort Study.

PURPOSE: The epidemiology of childhood eating problems is far from being fully described. The present study aims to explore early predictors of eating behavior problems in preadolescence. METHODS: The study sample comprised 1,939 children from the birth cohort study, the Copenhagen Child Cohort (CCC2000). Logistic regression models were used to investigate associations among infancy health, developmental and relational factors, maternal mental health problems, socioeconomic factors, parental reported eating behavior patterns in preschool age and eating behavior problems in preadolescence. RESULTS: A number of factors expressing socioeconomic disadvantage across childhood were associated with an increased risk of eating behavior problems at age 11-12 years. In addition, overeating patterns at age 5-7 years predicted restrained eating in preadolescence (odds ratio [OR] = 2.77; 95% confidence interval [CI] = 1.13-6.77; p = .03), with overweight at age 11-12 years and low annual household income as strong explanatory factors (OR = 4.79; 95% CI = 2.81-8.17; p < .0001 and OR = 2.06; 95% CI = 1.19-3.58; p = .02, respectively). No significant associations between perinatal, early child- and relational factors, or maternal mental disorder and eating behavior problems in preadolescence were found. CONCLUSIONS: Our results suggest that overeating at age 5-7 years is prospectively associated with restrained eating in preadolescence, with contemporaneous socioeconomic disadvantages and overweight as strong explanatory factors. Our findings might reflect successful public health interventions toward childhood obesity or might reflect a developmental course of problematic eating fluctuating between over- and undereating. Future studies should focus on the possible pathways from overeating to restrained eating and more severe eating pathology, including possible negative side effects of otherwise successful interventions aimed at reducing childhood obesity.

Perinatal Risk Factors for Feeding and Eating Disorders in Children Aged 0 to 3 Years.

OBJECTIVE: To describe the incidence, age at diagnosis, and associations between perinatal risk factors of feeding and eating disorders (FED) diagnosed at hospital in children aged 0 to 3 years. METHODS: A nationwide cohort of 901 227 children was followed until 48 months of age in the national registers from 1997 to 2010. Multivariable Cox proportional hazards regression was used to estimate hazard ratios (HRs) for FED diagnosis according to the International Classification of Diseases and associations with perinatal risk factors. RESULTS: A total of 1365 children (53% girls) were diagnosed with FED at hospital, corresponding to a cumulative incidence of 1.6 per 1000 live births. High risk of FED was seen in children born before gestational week 28 (HR, 3.52; 95% confidence interval [CI], 2.15-5.78). HRs were 3.74 for children small for gestational age ≤3 SD (95% CI, 2.71-5.17) and 4.71 in those with congenital malformations (95% CI, 3.86-5.74). Increased risk of FED was associated with female gender (HR, 1.2; 95% CI, 1.08-1.34), maternal smoking in pregnancy (HR, 1.24; 95% CI, 1.08-1.42), immigrant status (HR, 2.24; 95% CI, 1.92-2.61), and being the firstborn (HR, 1.33; 95% CI, 1.19-1.50). CONCLUSIONS: FED in referred children aged 0 to 3 years are associated with perinatal adversities, female gender, maternal smoking in pregnancy, being firstborn, and having immigrant parents. The results suggest complex causal mechanisms of FED and underscore the need for a multidisciplinary approach in the clinical management of young children with persistent problems of feeding, eating, and weight faltering.

Can a general health surveillance between birth and 10 months identify children with mental disorder at 1(1/2) year? A case-control study nested in cohort CCC 2000.

UNLABELLED: Mental health surveillance in infancy was studied in an existing child health surveillance programme with child psychiatric disorder at 1(1/2) year as the outcome. METHODS: Children considered of concern by community health nurses were cases in a case control study nested in the Copenhagen Child Cohort (CCC 2000). Outcome was mental health status at 1(1/2) year assessed by clinical and standardised strategies, including videotape recordings, parent interviews and the instruments: CBCL 1(1/2)-5, ITSCL, CHAT, Bayley Scales of Infant Development II, PC ERA and PIR-GAS. RESULTS: The positive predictive value of concern in the first 10 months of living was 24% (CI 17.0-31.9), the negative predictive value was 85% (CI 77.9-89.6) and the sensitivity was 56% (CI 42.4-69.0). Concern about development was significantly associated with the child having a neuro-developmental disorder at 1(1/2) year, and concern about mother-child relationship was associated with emotional, behavioural, eating, and sleeping disturbances. CONCLUSIONS: A general health surveillance program seems to have potentials to identify infants at risk for mental health problems provided standardised measures and specific training of the involved health professionals.

[Can social communication and attention disturbances in small children be detected by the public health nurse screening in the first year of life? The Copenhagen County Child Cohort (CCCC) 2000]. / Kan kontakt- og opmaerksomhedsforstyrrelser hos småbørn opdages ved sundhedsplejerskernes BOEL-prøve? Copenhagen County Child Cohort 2000.

INTRODUCTION: The prevention of disorders in social communication and attention is hampered by the lack of effective tools to screen in the first year of living. In Denmark public health nurses perform screening of physical and mental health in all infants, and at the age of 8-10 months a standardised test, BOEL, is performed to screen for hearing loss plus social communication and attention disturbances. METHOD: The predictive value of abnormal reactions at the BOEL test at 8-10 months of age was investigated in a subpopulation of 211 children from the CCCC 2000. Predictions were calculated in relation to outcome concerning psychopathological disturbances in social communication and attention, diagnosed by child psychiatric assessment at 18 months. RESULTS: Communication and attention disturbances at 18 months were predicted by the BOEL test with predictive validity of positive test (PV pos) 29%, and the predictive validity of negative test (PV neg) 95%. The BOEL test was found superior to the general clinical judgement by the public health nurses. CONCLUSION: The infant mental health screening by public health nurses seems to have potential concerning early identification of social communication and attention disturbances by using the BOEL test, but investigations of larger populations and with a longer time of observation are needed.

[Markers of mental health problems based on public health nurses' assessments of 0- to 1-year-old children: the Copenhagen County Child Cohort 2000]. / Markører for psykiske helbredsproblemer ved sundhedsplejerskernes undersøgelser af 0-1-årige børn. Copenhagen County Child Cohort 2000.

INTRODUCTION: Epidemiological studies of psychopathology in the first years of life are few, and the associations between mental health problems in infancy and toddler age and mental health disturbances later in life have not been systematically investigated. This study aimed to investigate whether markers of mental health problems can be identified in the first years of life and thus increase the scientific foundation for prevention early in childhood. METHODS: The population studied was a birth cohort of children born in Copenhagen County in year 2000, the Copenhagen County Child Cohort 2000 (CCCC 2000), which has been followed prospectively from birth. Mental and physical health are described at baseline based on Danish national registers and standardised records from home visits made by public health nurses. RESULTS: CCCC 2000 covers 6,090 children, of whom 5,624 (92%) have been described in health reports by public health nurses. In 13% of the cohort children, the general development was recorded as not normal, and in 12% language development was deviant. Problems with eating and sleeping were found frequently, in 30% and 20% of the children, respectively, and in 10% of the cases disturbances in the mother-child relationship were recorded. CONCLUSION: The first results from CCCC 2000 show that risk factors and markers of mental disturbances can be identified in at least 10% of children in the general population. The validity of these results is currently being investigated in follow-up studies of CCCC 2000.

The Copenhagen County child cohort: design of a longitudinal study of child mental health.

BACKGROUND: Epidemiological studies of psychopathology in the first years of life are few, and the association between mental health problems in infancy and psychiatric disturbances later in life has not been systematically investigated. The aim of the present project was to study mental health problems and possibilities of intervention from infancy and onward. METHODS: The basic study population consists of a birth cohort of 6,090 children born in the year 2000 in the County of Copenhagen, the Copenhagen County Child Cohort, CCCC 2000. At stage one CCCC 2000 was established on data from the Civil Registration System, Danish national registers, and standardized, longitudinal data from the first year of living obtained by public health nurses. At stage two a subsample was assessed at 1(1/2) years of age concerning child psychiatric illness and associated factors in a case-control study nested in the cohort, including a random sample. Participation rate at stage one was 92%. PERSPECTIVES: Ongoing studies of CCCC 2000 include studies of failure to thrive, register studies, and studies of the predictive validity of public health screening. A follow-up study concerning the prevalence of psychopathology at age 5 is planned. SUMMARY: The Copenhagen County Child Cohort CCCC 2000 is a longitudinal study of mental health from infancy investigating psychopathology in early childhood. Results from this study will add to the knowledge of risk factors and course of mental health problems in childhood and contribute to the validation of the mental health screening made by public health nurses.