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Abstract: Background: The development of the fetal endocannabinoid receptor system may be vulnerable to maternal cannabis use during pregnancy and may produce long-term consequences in children. In this study, we aimed to determine the relationship between gestational cannabis use and childhood attention problems and aggressive behavior. Methods: Using a large general population birth cohort, we examined the associations between parental prenatal cannabis and tobacco use and childhood behavior problems at 18 months measured using the Child Behavior Checklist in N =4077 children. Substance use was measured in early pregnancy. Results: Linear regression analyses demonstrated that gestational exposure to cannabis is associated with behavioral problems in early childhood but only in girls and only in the area of increased aggressive behavior (B =2.02; 95% CI: 0.30–3.73; p =0.02) and attention problems (B =1.04; 95% CI: 0.46–1.62; p <0.001). Furthermore, this study showed that long-term (but not short term) tobacco exposure was associated with behavioral problems in girls (B =1.16; 95% CI: 0.20–2.12; p =0.02). There was no association between cannabis use of the father and child behavior problems. Conclusions: Our results suggest that intrauterine exposure to cannabis is associated with an increased risk for aggressive behavior and attention problems as early as 18 months of age in girls, but not boys. Further research is needed to explore the association between prenatal cannabis exposure and child behavior at later ages. Our data support educating future mothers about the risk to their babies should they smoke cannabis during pregnancy. [Copyright &y& Elsevier]

Background: The anterior cingulate cortex (ACC), orbitofrontal cortex (OFC), and basal ganglia have been implicated in pathological aggression. This study aimed at identifying neuroanatomical correlates of impulsive aggression in healthy children. Methods: Data from 193 representative 6- to 18-year-old healthy children were obtained from the National Institutes of Health Magnetic Resonance Imaging Study of Normal Brain Development after a blinded quality control. Cortical thickness and subcortical volumes were obtained with automated software. Aggression levels were measured with the Aggressive Behavior scale (AGG) of the Child Behavior Checklist. AGG scores were regressed against cortical thickness and basal ganglia volumes using first- and second-order linear models while controlling for age, gender, scanner site, and total brain volume. Gender by AGG interactions were analyzed. Results: There were positive associations between bilateral striatal volumes and AGG scores (right: r = .238, p = .001; left: r = .188, p = .01). A significant association was found with right ACC and subgenual ACC cortical thickness in a second-order linear model (p < .05, corrected). High AGG scores were associated with a relatively thin right ACC cortex. An AGG by gender interaction trend was found in bilateral OFC and ACC associations with AGG scores. Conclusions: This study shows the existence of relationships between impulsive aggression in healthy children and the structure of the striatum and right ACC. It also suggests the existence of gender-specific patterns of association in OFC/ACC gray matter. These results may guide research on oppositional-defiant and conduct disorders. [ABSTRACT FROM AUTHOR]

The article presents a study which investigates whether data assessing attention problems were able to provide distinct subtypes of attention problems (AP). The study gathered data containing attention problems from the maternal ratings on the Child Behavior Check List (CBCL). It suggests that the CBCL AP syndrome demonstrates that children with attention deficit hyperactivity disorder (ADHD) are at the extreme of continuum.

Objective The assessment of symptoms of ADHD in children is usually based on a clinical interview or a behavior checklist. The aim of the present study is to investigate the extent to which these instruments measure an underlying construct and to estimate the genetic and environmental influences on individual differences in ADHD. Methods Maternal ratings were collected on 10,916 twins from 5,458 families. Child Behavior Checklist (CBCL) ratings were available for 10,018, 6,565, and 5,780 twins at the ages 7, 10, and 12, respectively. The Conners Rating Scale (4,887 twins) and the DSM interview (1,006 twins) were completed at age 12. The magnitude of genetic and environmental influences on the variance of the three measures of ADHD and the covariance among the three measures of ADHD was obtained. Results Phenotypic correlations range between .45 and .77. Variances and covariances of the measurements were explained mainly by genetic influences. The model that provided the best account of the data included an independent pathway for additive and dominant genetic effects. The genetic correlations among the measures collected at age 12 varied between .63 and 1.00. Conclusions The genetic overlap between questionnaire ratings and the DSM-IV diagnosis of ADHD is high. Clinical and research implications of these findings are presented. [ABSTRACT FROM AUTHOR]

The aim of this study was to investigate the prevalence of cross-gender behavior during childhood, to estimate the influence of genotype and environment on variation in cross-gender behavior, and to explore the association of cross-gender behavior with maternal ratings of behavior problems as indexed by the Internalizing and Externalizing scales of the Child Behavior Checklist (CBCL). Cross-gender behavior was assessed by two items from the CBCL: “behaves like opposite sex” and “wishes to be of opposite sex.” As part of an ongoing longitudinal study of the Netherlands Twin Registry, mothers were asked to complete the CBCL for their twins when they were 7 ( n∼14,000 twins) and 10 years old ( n∼8,500 twins). The prevalence of cross-gender behavior (as measured by maternal report of behaving like or wishing to be the opposite sex) was 3.2% and 5.2% for 7-year-old boys and girls, respectively, and decreased to 2.4% and 3.3% for 10-year-old boys and girls. Surprisingly, the prevalence rate of cross-gender behavior of girls with a male co-twin was lower than of girls with a female co-twin. At both ages, the similarity for cross-gender behavior was greater in monozygotic than in dizygotic twins pairs. Genetic structural equation modeling showed that 70% of the variance in the liability of cross-gender behavior could be explained by genetic factors, at both ages and for both sexes. Cross-gender behavior was associated with higher scores on Internalizing and Externalizing problems, both in boys and in girls. [ABSTRACT FROM AUTHOR]

Background: The purpose of this study was to determine a score on the Obsessive Compulsive Scale (OCS) from the Child Behavior Checklist (CBCL) to screen for obsessive compulsive disorder (OCD) in children and to rigorously test the specificity and sensitivity of a single cutpoint. Methods: A receiver operating characteristic (ROC) curve analysis was applied to data from 61 patients with clinically determined OCD, 64 clinical controls and 73 general population controls to determine the best sum score on the CBCL-OCS to predict confirmed OCD in children. Using the ROC-determined cutoff, this score was applied to a national sample of CBCL data from 2460 singleton children ages 4–18 and to 20,016 children ages 7–18 from three large general population twin samples to determine the estimated prevalence in the general population. Results: Using a CBCL-OCS score of 5 demonstrated an area under the curve (AUC) of .88 with high sensitivity (92%) and moderate specificity (67%) compared to clinical controls. Compared to the general population controls, the AUC was .96 with high sensitivity (92%) and specificity (89%). In the twin samples, the number of participants with CBCL-OCS scores above this cutpoint was 2.3–7.1%. Conclusions: These findings suggest that the OCS of the CBCL may provide a highly effective way to screen for childhood OCD, and that the prevalence of childhood OCD may have been underestimated, thus prompting the need for further research into screening children for this condition. [ABSTRACT FROM AUTHOR]

Background: No consensus has been reached yet on how best to characterize children with juvenile bipolar disorder (JBD). Several groups have shown that children on the attention problems (AP), aggressive behavior (AGG), and anxious-depressed (AD) syndromes of the Child Behavior Checklist (CBCL) are likely to meet criteria for DSM-JBD. We aimed to use a large population-based twin sample to evaluate the prevalence and genetic architecture of the CBCL-JBD (deviant on AP, AGG, and AD) phenotype and compare these data to children who are deviant on just the CBCL-AP syndrome. Methods: Structural equation modeling (SEM) was applied to CBCL data from 5418, 3562, and 1971 Dutch twin pairs at ages 7, 10, and 12 years. Results: The CBCL-JBD phenotype occurs in ∼1% of children at each age. Among the children who meet criteria for the CBCL-AP phenotype (∼ 5%), between 13 and 20% also meet criteria for CBCL-JBD. The best SEM for CBCL-JBD includes additive genetic, shared and unique environmental factors. The best SEM for CBCL-AP includes dominant and additive genetic and unique environmental factors. Conclusions: These data suggest that CBCL-JBD is common, and even more common among children who have severe attention problems. CBCL-JBD shows familial aggregation due to both genetic and shared environmental factors. [Copyright &y& Elsevier]

Objective: Studies on 3-, 7-, and 10-year-old twins' internalizing and externalizing problems have emphasized the importance of understanding sources of agreement and disagreement between maternal and paternal ratings. A psychometric model that assumes that each parent assesses rater-specific aspects of the child's behavior provided the best explanation for parental disagreement. This study investigates two models that have been used to explain the agreement and disagreement between mothers and fathers in the ratings of their children. Method: Child Behavior Checklists filled in by mothers and fathers were collected for a sample of 1,481 twelve-year-old twin pairs. Genetic and environmental influences on Internalizing and externalizing problems were estimated using models that corrected for rater bias, rater-specific effects, and unreliability. Results: The psychometric model fitted the data significantly better than a rater bias model. Significant influences of genetic, shared, and nonshared environmental factors were found for internalizing and externalizing behavior. Parent-specific views, rater bias, and unreliability were significant. Conclusions: The best-fitting model implies that disagreement between parents is due to the fact that mothers and fathers provide information from their own perspective. This information should be seen as important and adding to the diagnostic formulation rather than as a point of disagreement. The finding that internalizing and externalizing problems are influenced by genetic and environmental factors fosters the understanding that it is the interaction of nature and nurture that puts children at risk for common behavioral disorders. Key Words: parental rating; rater bias; problem behavior; twins. [ABSTRACT FROM AUTHOR]

Objective: Previous studies have demonstrated substantial genetic influences on many child psychiatric disorders, including autism. In this study the authors attempted to quantify the degree to which genetic influences on deficits in reciprocal social behavior (a defining feature of pervasive developmental disorders) are shared with genetic influences on other domains of behavior in children. Method: Child Behavior Checklists (CBCL) and Social Responsiveness Scales (SRS) were completed for an epidemiological sample of 219 pairs of male twins. The SRS (formerly known as the Social Reciprocity Scale) is a measure of social impairment that distinguishes children with autism spectrum disorders from those with other child psychiatric disorders. Results: Regression analysis indicated that CBCL syndromes account for 43% of the variance in SRS scores. Bivariate analyses revealed that SRS scores are affected, in part, by phenotypic influences from the CBCL Social Problem syndrome. Forty-four percent of the causal influences on SRS scores, however, are independent from those on CBCL syndromes and are genetic in nature (90% confidence interval: 0.38-0.49). Conclusion: These results support the existence of a continuous distribution of deficits in reciprocal social behavior in the population, which are substantially genetically independent from other domains of child psychopathology. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(4):458-467. [ABSTRACT FROM AUTHOR]

Objectives: To compare the prevalence and agreement of DSM-IV diagnoses based on Diagnostic Interview Schedule for Children Version IV (DISC-IV) and clinician assignment for youths receiving public mental health services between 1996 and 1997 and to examine potential predictors of diagnostic agreement. Method: Participants included 240 youths aged 6-18 years. Past-year prevalence rates and κ statistics were calculated for four diagnostic categories: anxiety, mood, attention-deficit/hyperactivity disorder (ADHD), and disruptive behavior disorders (DBD). Potential predictors of diagnostic agreement were examined with logistic regression analysis. Results: The prevalence of ADHD, DBD, and anxiety disorders was significantly higher based on the DISC-IV, while the prevalence of mood disorders was significantly higher based on clinician assignment. Diagnostic agreement was poor overall. The κ values ranged from -0.04 for anxiety disorders to 0.22 for ADHD. Significant predictors of agreement varied by diagnosis and included symptom severity, comorbidity, youth age and gender, and school-based problem identification. Conclusions: Consistent with previous findings of poor diagnostic agreement between structured interviews and clinicians, these results call for a better understanding of factors affecting diagnostic assignment across different methods. This is especially important if researchers continue to use structured interviews to determine prevalence, establish diagnosis-based treatment guidelines, and disseminate evidence-based treatments to community mental health settings. J. Am. Acad. Child Adolesc. Psychiatry, 2003, 42(3):349-356. [ABSTRACT FROM AUTHOR]

Provides information on a study which examined the ways diagnostic techniques may bias the results of a twin behaviors study. Estimation of genetic, environmental, and rater contrast which may have influenced parental report on behavioral problems in twin pairs; Analysis of the parental report on the Child Behavior Checklist.

Performs latent class analyses (LCA) of items from the Attention Problems scale of the Child Behavior Checklist (CBCL) to test whether problems in children are continiously distributed or categorically discrete. Merits of categorical versus continous approaches in psychiatric diagnosis; Factor analysis as one advantage of LCA to other approaches; Description of LCA as a statistical technique.

An abstract of the article "Early Environmental Exposures as Shared and Unique Risk Factors in Childhood Mental Illness: Results From Large-Scale Epidemiological Studies" by Dorothy E. Grice and colleagues is presented.

We examined the contribution of genetic and environmental influences on the stability of withdrawn behavior (WB) in childhood using a longitudinal multiple rater twin design. Maternal and paternal ratings on the withdrawn subscale of the Child Behavior Checklist (CBCL) were obtained from 14,889 families when the twins were 3, 7, 10 and 12 years old. A longitudinal psychometric model was fitted to the data and the fit of transmission and common factor models were evaluated for each variance component. WB showed considerable stability throughout childhood, with correlation coefficients ranging from about .30 for the 9-year time interval to .65 for shorter time intervals. Individual differences in WB as observed by the mother and the father were found to be largely influenced by genetic effects at all four time points, in both boys (50–66%) and girls (38–64%). Shared environmental influences explained a small to modest proportion (0–24%) of the variance at all ages and were slightly more pronounced in girls. Non-shared environmental influences were of moderate importance to the variance and slightly increased with age, from 22–28% at age 3 to 35–41% at age 12 years. The stability of WB was largely explained by genetic effects, accounting for 74% of stability in boys and 65% in girls. Shared environmental effects explained 7% (boys) and 17% (girls) of the behavioral stability. Most shared environmental effects were common to both raters, suggesting little influence of rater bias in the assessment of WB. The shared environmental effects common to both raters were best described by a common factor model, indicating that these effects are stable and persistent throughout childhood. Non-shared environmental effects accounted for the remaining covariance over time. [ABSTRACT FROM AUTHOR]

Background: No clear consensus has been reached yet on how best to characterize children who suffer from pediatric bipolar disorder (PBD). The CBCL-PBD profile on the Child Behavior Checklist (CBCL) has been consistently reported showing deviant findings on the Attention Problems, Aggressive Behavior, and Anxious-Depressed subscales. Aim: To examine the sensitivity and specificity of the proposed CBCL-PBD profile for determining DSM diagnosis of PBD. Methods: We applied receiver operating characteristic (ROC) curve analysis to data from 471 probands from two family studies of attention-deficit hyperactivity disorder and their 410 siblings. Results: The CBCL-PBD score demonstrated an area under the curve (AUC) of 0.97 for probands and 0.82 for siblings for current diagnosis of PBD, suggesting that the CBCL-PBD provided a highly efficient way of identifying subjects with a current diagnosis of PBD in this sample. Conclusions: These findings suggest that the CBCL-PBD may provide a highly efficient way of screening for childhood bipolar disorder. [ABSTRACT FROM AUTHOR]

Withdrawn/depressed behavior (WD) as defined by the Child Behavior Checklist (CBCL) relates to various outcomes in developmental psychopathology such as depression, pervasive developmental disorders, and suicide. We sought to examine the temperamental characteristics of children who concurrently endorse symptoms of WD. Junior Temperament and Characteristic Inventory (JTCI) and CBCL data were collected from 397 children's parents in a family study in the northeastern United States. Linear mixed models were used to test the relations between WD and temperament dimensions (Novelty Seeking, Harm Avoidance, Reward Dependence, Persistence) on the JTCI, while controlling for age, sex, item overlap, and co-occurring aggression and attention problems. When controlling for definitional artifact and CBCL aggressive behavior and attention scores, high harm avoidance and low reward dependence were both significant predictors of childhood withdrawn behavior. This study marks the first characterization of a temperamental profile associated with WD in children and adolescents. [ABSTRACT FROM AUTHOR]

This study examined the stability of internalizing and externalizing problems from age 1.5 to 6 years, while taking into account developmental changes in the presentation of problems. The study comprised a population-based cohort of 7,206 children (50.4 % boys). At ages 1.5, 3, and 6 years, mothers reported on problem behavior using the Child Behavior Checklist/1.5-5 (CBCL/1.5-5). At each age we performed latent profile analysis on the CBCL/1.5-5 scales. Latent transition analysis (LTA) was applied to study the stability of problem behavior. Profiles of problem behavior varied across ages. At each age, 82-87 % of the children did not have problems whereas approximately 2 % showed a profile of co-occurring internalizing and externalizing problems. This profile was more severe (with higher scores) at 6 years than at earlier ages. A predominantly internalizing profile only emerged at 6 years, while a profile with externalizing problems and emotional reactivity was present at each age. LTA showed that, based on profiles at 1.5 and 3 years, it was difficult to predict the type of profile at 6 years. Children with a profile of co-occurring internalizing and externalizing problems early in life were most likely to show problem behavior at 6 years. This study shows that the presentation of problem behavior changes across the preschool period and that heterotypic continuity of problems is very common among preschoolers. Children with co-occurring internalizing and externalizing problems were most likely to show persisting problems. The use of evidence-based treatment for these young children may prevent psychiatric problems across the life course. [ABSTRACT FROM AUTHOR]

Objective: Clinically, attention-deficit/hyperactivity disorder (ADHD) is characterized by hyperactivity, impulsivity, and inattention and is among the most common childhood disorders. These same traits that define ADHD are variable in the general population, and the clinical diagnosis may represent the extreme end of a continuous distribution of inattentive and hyperactive behaviors. This hypothesis can be tested by assessing the predictive value of polygenic risk scores derived from a discovery sample of ADHD patients in a target sample from the general population with continuous scores of inattention and hyperactivity. In addition, the genetic overlap between ADHD and continuous ADHD scores can be tested across rater and age. Method: The Psychiatric Genomics Consortium has performed the largest genome-wide analysis (GWA) study of ADHD so far, including 5,621 clinical patients and 13,589 controls. The effects sizes of single nucleotide polymorphisms (SNPs) estimated in this meta-analysis were used to obtain individual polygenic risk scores in an independent population-based cohort of 2,437 children from the Netherlands Twin Register. The variance explained in Attention Problems (AP) scale scores by the polygenic risk scores was estimated by linear mixed modeling. Results: The ADHD polygenic risk scores significantly predicted both parent and teacher ratings of AP in preschool- and school-aged children. Conclusion: These results indicate genetic overlap between a diagnosis of ADHD and AP scale scores across raters and age groups and provides evidence for a dimensional model of ADHD. Future GWA studies on ADHD can likely benefit from the inclusion of population-based cohorts and the analysis of continuous scores. [ABSTRACT FROM AUTHOR]

Background: Fronto-amygdalar networks are implicated in childhood psychiatric disorders characterized by high rates of externalizing (aggressive, noncompliant, oppositional) behavior. Although externalizing behaviors are distributed continuously across clinical and nonclinical samples, little is known about how brain variations may confer risk for problematic behavior. Here, we studied cortical thickness, amygdala volume, and cortico-amygdalar network correlates of externalizing behavior in a large sample of healthy children. Methods: Two hundred ninety-seven healthy children (6–18 years; mean = 12 ± 3 years), with 517 magnetic resonance imaging scans, from the National Institutes of Health Magnetic Resonance Imaging Study of Normal Brain Development, were studied. Relationships between externalizing behaviors (measured with the Child Behavior Checklist) and cortical thickness, amygdala volume, and cortico-amygdalar structural networks were examined using first-order linear mixed-effects models, after controlling for age, sex, scanner, and total brain volume. Results significant at p ≤ .05, following multiple comparison correction, are reported. Results: Left orbitofrontal, right retrosplenial cingulate, and medial temporal cortex thickness were negatively correlated with externalizing behaviors. Although amygdala volume alone was not correlated with externalizing behaviors, an orbitofrontal cortex-amygdala network predicted rates of externalizing behavior. Children with lower levels of externalizing behaviors exhibited positive correlations between orbitofrontal cortex and amygdala structure, while these regions were not correlated in children with higher levels of externalizing behavior. Conclusions: Our findings identify key cortical nodes in frontal, cingulate, and temporal cortex associated with externalizing behaviors in children; and indicate that orbitofrontal-amygdala network properties may influence externalizing behaviors, along a continuum and across healthy and clinical samples. [ABSTRACT FROM AUTHOR]

The article presents a review of a longitudinal, population-based cohort that studied children from fetal life onward known as the Generation R (Rotterdam) Study. Special attention is paid to the role of the functional polymorphism (5-HTTLPR) in the promoter of the serotonin transporter gene in interacting with prenatal and postnatal maternal anxiety to influence children's emotional development.

The article presents a 14-year follow up study which investigates the adult outcomes of children with severe self-regulation problems in Dutch population. The study conducted Child Behavior Checklist-Dysregulation Profile (CBCL-DP) among 2,076 from 13 birth cohorts 4 to 6 years of age. Results reveal the link between anxiety and disruptive behavior disorders with the CBCL-DP remains after controlling co-occurring disorders in adulthood.

Abstract: The Dysregulation Profile (DP) of the Child Behavior Checklist (CBCL) (previously called the CBCL-Juvenile Bipolar Disorder or CBCL-JBD profile) characterized by elevated scores on CBCL attention problems, aggressive behavior, and anxious/depressed scales is associated with severe psychopathology and suicidal behavior. The stability of this profile across informants has not been established. In this study, agreement across parent, teacher, and self-reports was examined for the Dysregulation Profile phenotype derived using latent class analysis of a national probability sample of 2031 children aged 6–18. The Dysregulation Profile latent class was found for each informant and accounted for 6–7% of the sample. There was mild to fair agreement on the Dysregulation Profile latent class between parents and youth (Kappa=0.22–0.25), parents and teachers (Kappa=0.14–0.24) and youth and teachers (Kappa=0.19–0.28). When parents and youth reports both placed children into the Dysregulation Profile latent class, 42% of boys and 67% of girls reported suicidal thoughts or behavior. We conclude that the Dysregulation Profile latent class is identified across informants although agreement of specific individuals is mild. Children in this class as identified by parental and youth reports have a very high risk for suicidal thoughts and behaviors. [ABSTRACT FROM AUTHOR]

The article reports on the result of the study conducted, which investigates the relation of empirically defined temperament phenotypes with psychopathology and wellness in children. The inquiry was done through Juvenile Temperament and Character Inventory Assessment, as well as an evaluation of wellness and psychopathology using the Child Behavior Checklist, among a number of juveniles from the northeastern area of the U.S. A latent profile analysis in the study revealed that there was a strong link between the steady class, higher functioning and lower levels of psychopathology, whereas the disengaged class showed the opposite associations. The study concluded that temperament may be illuminative in identifying children with the same traits.

We examined the criterion validity of parent and self-report versions of the Junior Temperament and Character Inventory (JTCI) in children with high levels of externalizing problems. The sample included 412 children (206 participants and 206 siblings) participating in a family study of attention and aggressive behavior problems. Criterion validity analyzes included (a) correlations between temperament scales and emotional and behavioral scales and (b) correlations between temperament and intelligence and achievement scales. Temperament scales displayed strong convergent and discriminant validity. Across informants and samples, JTCI scales assessing novelty seeking and harm avoidance discriminated between internalizing and externalizing problems. Reward dependence, persistence, cooperativeness, and self-directedness displayed similar patterns of negative relations to emotional and behavioral scales and positive relations to intelligence, achievement, and competence. [ABSTRACT FROM AUTHOR]

An abstract of the article "Predictive Utility of Child Adversity Ratings: Differences Across Informants" by Hannah Holbrook is presented.

An abstract of the article "Relationship Between Adverse Childhood Experiences and Metabolic and Psychiatric Outcomes Using the Yale-Vermont Adversity in Childhood Scale" by Bailey Holt-Gosselin and colleagues is presented.

The article focuses on the impact of conflict of interest on the content and quality of medical research. Although a conflict of interest is not itself an ethical violation, ethical violations involving conflict of interest occur when the conflicted individual/s bias the scientific process by distorting research methods, presentation of data, and/or the interpretation of results. Such violations can have a significant negative impact on the assessment and treatment of children with psychiatric disorders. It is noted that biased publications undermine clinical judgment, mislead physicians about treatment options, negatively affect public opinion about science and medicine, and cause distrust in physician-patient relationships.

The article discusses the mission statement and advocacy of the "Journal of the American Academy of Child and Adolescent Psychiatry." Accordingly, the periodical's mission statement, which will be incorporated in every issue, is focused on the advancement of research on pediatric mental health and the promotion of mental care among youth and their families. The periodical aims to promote awareness on the mental health needs of children, adolescents and its families in handling human advancement mysteries. The author stresses that the new mission statement will serve as a reminder and inspiration for people to persist and strive hard in achieving knowledge on how to provide proper care to mentally ill people.