The Copenhagen Infant Mental Health Programme – Development and testing of a pragmatic service-setting-based approach to screening and intervention

The Copenhagen Infant Mental Health Programme – Development and testing of a pragmatic service-setting-based approach to screening and intervention | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Research Article The Copenhagen Infant Mental Health Programme – Development and testing of a pragmatic service-setting-based approach to screening and intervention Anne Mette Skovgaard, Clara Barfod Parellada, Lotte Finseth, Stine Kjær Wehner, and 1 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-6698283/v1 This work is licensed under a CC BY 4.0 License Status: Under Review Version 1 posted 11 You are reading this latest preprint version Abstract Background: Universal programmes that systematically address mental health problems in infancy are needed. This study describes the development and testing of a community-based programme combining screening with standardized guidelines for feedback and intervention to be completed by educated community health nurses (CHNs). Methods: The manual of the previously validated Copenhagen Infant Mental Health Screening, CIMHS, was updated in collaboration with experts in the field and practising CHNs to systematically include parents in child assessment and in intervention planning intervention. Furthermore, formalized training for CHNs was included. The resulting programme, the Copenhagen Infant Mental Health Programme (CIMHP), was evaluated in a multi-method study in seventeen municipalities using data from the municipality database and Danish National registries. Qualitative data included questionnaires and interviews with CHNs. Results: The CIMHP comprises a manual for educated CHNs’ screening 9-10 months infants in dialogue with the parents and guidelines providing suggestions for action to address infant regulatory and developmental vulnerabilities within community settings. A total of 280 CHNs used CIMHP at home visits to a total of 7,079 infants and found two problems of regulation (feeding, sleep, emotional regulation) or development (cognitive and motor functions) in 12.1% (N=860) of the infants and 10.4% (N=736) having three or more problems. A pattern of risks associated with regulatory and developmental problems at 9-10 months were associated male gender and being exposed to pre- and perinatal and family-related adversities. Qualitative data suggest face validity, usability, and parental acceptance of the programme as evaluated by CHNs. Conclusions: CIMHP integrates a global screening of mental health vulnerabilities, to be completed in dialogue with parents, together with guidelines to support CHNs’ feedback and actions to promote child health. Validity and feasibility seem promising. Still, further improvements to the guidelines for action in community settings and education of health professionals are needed. Mental health infancy universal preventive intervention community health nurses child health surveillance Figures Figure 1 Figure 2 Figure 3 Background Childhood mental health problems and disorders affect more than every tenth child (1-3). They are associated with an increased risk of persistent developmental, educational, physical, and social problems in older ages, underscoring the importance of preventive strategies that begins in early childhood (4-6). Epidemiological research from recent decades has identified possible targets of intervention to address developmental psychopathology in early ages (2, 7). Infancy problems of contact and communication, and problems of activity and language development have thus been found associated with autism spectrum disorders, general developmental disorders, and disorders of inattention and hyperactivity in older ages, suggesting that early pathways of neuro-developmental disorders may start in infancy (8-11). Also, infancy problems of feeding and eating, sleep, and emotional and behavioural regulation have been found associated with emotional, behavioural, and hyperactivity problems in older ages, in particular when co-occurring (12-15). These early difficulties are suggested to initiate developmental cascades of dysregulation that track into internalizing and externalizing disorders, including inattention and hyperactivity disorders highly influenced by the quality of parenting (13, 15, 16). Epidemiological findings on developmental psychopathology in the first years of living (2) are consistent with the phenomenology of clinical symptoms and syndromes described in textbooks (17) and in the Diagnostic Classification of mental disorders of infancy and early childhood, DC:0-5 (18). Examples include symptoms and diagnostic entities of sleep disorders, feeding and eating disorders, emotional and behavioural disorders, pervasive developmental disorders, and disorders of attention deficit, hyperactivity and impulsivity (17). The rationale and needs of preventive intervention that starts in early infancy (4-7), underscore the importance of effective measures addressing the entire population and including possibilities of indicated or selective interventions targeting children at particularly increased risk (5, 19-21). To be effective, intervention strategies should be implemented systematically (6) and consistently involve the parents (21). Most universal strategies that address early child development focus on populations of pre-, perinatal or psycho-social risks (19). These are often integrated within the primary or municipality health care and delivered by health care professionals, e.g. general practitioners or community health nurses (5, 22). However, universal interventions that address the range of mental health vulnerabilities in infancy are scarce (23, 24) with several methodological challenges highlighted (23, 24) e.g. limitations in available measures that are feasible for practical use and psychometric robust (25). The Copenhagen Infant Mental Health Screening, CIMHS (26), was developed to capture the range of mental health vulnerabilities seen among young children (26-28) . The CIMHS addresses a window of opportunity for the valid identification of targets of intervention at child ages 9-10 months within the municipality health care provided by community health nurses (CHNs) (29). The psycho-metric properties are well-established (26-28) and overall, the CIMHS is suggested to have potentials for use in universal services (25, 28). Still, a screening of infant mental health should not stand alone, with the risk of leaving parents behind without help (21, 30, 31). So far, however, no measures have been published that combine a comprehensive and validated infant mental health screening with a standardized approach to help parents in case of identified child vulnerabilities (23, 24). In this paper, we describe the development and pilot-implementation of a standardized approach of infant mental health screening by educated CHNs to be delivered at child ages 9-10 months and including guidelines for action within municipality settings. Aims The main goal was to optimize validity and extend the usability of the CIMHS within the community settings. The specific aims were to create a standardized manual for child assessment and guidelines for action that systematically involve the parents, as well as a formalized education of the health professionals involved, CHNs. Finally, we aim to explore the validity and usability of the combined programme within the municipality child health care. METHODS Setting The study is embedded within the settings of CHNs in seventeen Danish municipalities. The CHNs participated in the development of the CIMHP and in the pilot implementation and feasibility testing the programme. The CHNs are part of the community health care in Denmark, and they offer home visits free of charge to all infant families, which is attended by more than 90% of the population. The CHNs follow guidelines set by the National health authorities to monitor child health and development and support infant families, within the frame of the municipality services or via referral to other services such as general practitioners and hospitals (26), but so far, no standardized guidelines have been available to address the range of mental health vulnerabilities seen in young children (32). In the participating municipalities, the CHNs complete standardized recordings at home visits including information on child health and development (26, 33) with data being stored in the Child Health Database (33). The screening of child health and development at child ages 9-10 months – further validation of the CIMHS The CIMHS comprises a standardized scheme for the CHNs evaluation of the child’s sleep, feeding and eating, emotional expression and regulation, curiosity and interests, attention and concentration, motor development and activity, communication and social interaction, and language. Within each domain, the CHN conclude whether the child’s development and functioning are within the normal range or not (26). Previous validation has identified an overall construct valid global scale and six subscales that are predictive of later psychopathology (26, 28). Still, a more elaborated manual and formalized education of the CHNs have been considered necessary to ensure validity and feasibility. For this study, we established an expert group of developmental psychologists, infant-toddler psychiatrists, and experienced CHNs to update scientific evidence and best practices among CHNs and review the validity and usefulness of the CIMHS. Consequently, an item on overall motor development was added and minor revisions were suggested to specify the wordings of items and the accompanying descriptions. Emphasizing the importance of parents The communication with parents has a core position in the routines of Danish CHNs, but the work in the expert group highlighted considerable variations in how CHNs involve the parents. Consequently, throughout creation of the CIMHP guidelines the parents’ perspectives and experiences were included systematically, e.g. by combining the parents’ knowledge from the daily life with the child observations obtained by the CHN at the home visit. This systematic inclusion of information from both parents and CHNs, was considered important to optimize the validity of measuring the child’s development and functioning. Equally important, by sharing knowledge on the child, the dialogue is promoted when the CHN provides feedback to parents on the evaluation of the child’s current development and functioning. The benefit of this approach could pave the way for planning interventions in case of identified vulnerabilities (See below). Guidelines for action addressing infant vulnerabilities The guidelines for action were based on reviews of the literature on early developmental psychology and psychopathology with aiming to provide CHNs with an evidence-based platform of knowledge, that captures the range of regulatory and developmental vulnerabilities seen in early childhood (17) (Figure 1 shows an overview of the CIMHP-Program). Figure 1 here. The guidelines cover eight main areas of infants mental health conceptualized in current textbooks in the field, e.g. Zeanah CH 2018 (17) and current classification schemes (DC:0-5) (18). Each area is described with a short summary on developmental variations and the epidemiology of problems within the general population. The most common co-occurring problems from other developmental areas and the influences of the parent-child relations are systematically described for every domain. A checklist guides the CHNs in further elaborating on the child’s functioning in each area of possible vulnerabilities and includes suggestions on how the CHN can support the child’s development and to inspire their guidance of the parents. The guidelines include suggestions for graded interventions spanning from one to six weeks, depending on the number and complexity of the infant’s problems and the parents’ needs, as well as proposals for involving daycare professionals and other municipality services when needed. Appendix 1 provides an example of the CIMHP guidelines related to motor development and activity. Education and training CHNs in delivering the CIMHP The programme of education was created to provide CHNs with knowledge on infant development and mental vulnerability across main areas of infant and toddler mental health and training in using the CIMHP. It included two one-day courses with lectures on infant development and mental vulnerability and case-based training in using the CIMHP manual and guidelines over a three-month period. For an overview of the education programme, see Appendix 2. Exploring validity and feasibility of the CIMHP Seventeen Danish municipalities from the Capital Region of Denmark, the Region of Zealand and the Region of Southern Denmark joined the pilot implementation of the CIMHP in 2018 and 2019. These municipalities included suburban, urban, and rural areas and have an overall composition of inhabitants comparable to the average Danish population. The implementation of CIMHP was preceded by an educational course to be completed by all CHNs in participating municipalities (see Appendix 2). Thereafter, the CIMHP was planned to be integrated within the CHNs existing routines at home visits at child ages 9-10 months, with the CHNs recording the results of the child assessment in the municipality database (33). The CIMHP assessment is offered to all infants aged 9-10 months. For infants born before gestational week 37, the CHNs’ evaluation included adjustment for gestational age. Excluded for the present study were infants having congenital severe somatic and developmental disabilities or disorders, and infants of parents, who did not speak or understand Danish or English language. Practical procedures of the CHNs CHNs informed parents about the study being a part of quality development within the municipality health care at a previous visit or by mail or phone. The CIMHP was added to the usual routines during the home visit at child ages 9-10 months. The CHNs were instructed to follow the manual and guidelines of the CIMHP, which include feedback to parents regarding the results of the child assessment and support to the parents in case of identified vulnerabilities. Data Data from the municipality Child Health Database (CHD) and National registries were used to validate the identification of child health vulnerability when using the CIMHP. For details of data sources and variables, see Appendix 3. The municipality Child Health Database (CHD) holds information recorded by CHNs including the results of the CHNs’ child examinations at child ages 9-10 months after implementation of the CIMHP (see Appendix 3). The Danish National registries including the Medical Birth Register (MBR) hold information on child and family factors recorded during pregnancy, birth, and perinatal period (see Appendix 3). Qualitative data included focus group interviews and questionnaires answered by CHNs. The focus group interviews included two municipalities with three CHNs each, and one interviewer (LF). The interviews lasted 37 and 45 minutes, respectively and were recorded and transcribed verbatim. The usefulness and face validity of CIMHP was explored via questions on whether the programme helped the CHN to 1) detect mental vulnerabilities in children aged 9-10 months, 2) prepare interventions for families with children showing vulnerabilities, 3) improve communication with parents regarding the child’s development and functioning, and further, 4) to obtain the CHNs’ evaluation on the parents’ appreciation of the programme. Feasibility was operationalized through questions addressing: 1) whether and to what extent the CHNs had implemented CIMHP as intended among all eligible families and with the use of the manual and guidelines; 2) the CHNs' perspectives on potential benefits and advantages of the CIMHP, as well as any barriers and challenges encountered; 3) the programme’s alignment with current practice and knowledge. Questionnaire items were developed by the research group, most of them with the response category yes/no. Several items also included a section for additional comments (see questionnaire in Appendix 4), data from which were also included in the analysis. Analyses Statistical analyses The identification of mental health vulnerabilities using CIMHP were examined as frequencies (%) with chi-square tests used to explore gender differences. Venn diagrams were applied to illustrate the co-occurrence of mental health vulnerabilities. Associations between child and family variables and mental health vulnerabilities were calculated as odds ratios (OR), 95% confidence intervals (CI) with a significance level of 5% using the log likelihood ratio where appropriate. Statistical analyses were carried out using the SAS version 9.3 and RStudio version 2024.12.1 . Analyses of questionnaire and interview data Questionnaire data was reported descriptively and without further analysis. Transcripts of interviews and questionnaire comments were analysed through a pragmatic deductive process building on thematic content analysis (34). The material was categorised according to the predefined themes of the operationalization of the concepts of feasibility and usefulness and analysed looking across data horizontally to describe each theme and in relation to the CHNs perspectives. RESULTS Within the 17 municipalities a total of 280 CHNs participated in the CIMHP education, implementation and recordings at home-visits at child ages 9–10 month, overall leaving data on a total of 7,079 children to be included for this study. The characteristics of the study population is shown in Table 1 . Higher frequencies of parents of non-Danish ethnicity were seen among participants compared to the entire population, whereas no significant differences were found regarding perinatal adversities. Table 1 Characteristics of the entire background (N 70,650) population and the study population (n = 7,079) Entire population Study population (N = 70,650) N (%) (N = 7,079) N (%) Child factors Sex Boys 36,280 (51.4%) 3,600 (50.9%) Girls 34,365 (48.6%) 3,479 (49.2%) Gestational age a < 31 weeks 342 (0.5%) 20 (0.3%) 32–36 weeks 1,884 (2.7%) 125 (1.8%) ≥ 37 weeks 43,198 (61.1%) 2,731 (38.6%) Birth weight <1500 grams 485 (0.7%) 31 (0.4%) 1500–2500 grams 2,645 (3.7%) 272 (3.8%) ≥ 2500 grams 64,174 (90.8%) 6,658 (94.1%) Neonatal complications b Yes 771 (1.1%) 37 (0.5%) No 69,879 (98.9%) 7,042 (99.5%) Parental factors Parental ethnicity Both parents born in Denmark 46,673 (66.1%) 4,454 (62.9%) One parent born in Denmark 7,182 (10.2%) 743 (10.5%) No parents born in Denmark 12,489 (17.7%) 1,523 (21.5%) Parental work status Both working 54,568 (77.2%) 5,690 (80.4%) One parent working, one parent not working 9,178 (13.0%) 894 (12.6%) Both not working 2,184 (3.1%) 129 (1.8%) Parents living together at childbirth No 6,079 (8.6%) 527 (7.4%) Yes 63,522 (89.9%) 6,539 (92.4%) Parent more than 10 years of schooling No 13,359 (18.9%) 1,512 (21.4%) Yes 53,961 (76.4%) 5,494 (77.6%) a Gestational age data was partially missing from the Danish Medical Birth Register; available information included 45,424 individuals from the entire population and 2,876 from the study population. b Neonatal complications are defined as neonatal sepsis and/or the need for neonatal respirator treatment. Table 1 here. In most children, no (52.3%) or only one (25.1%) problem of mental health vulnerability was found, whereas 12.1% (N = 860) were identified with two problems and 10.4% (N = 736) three or more problems (Appendix 5). Table 2 shows the frequency of CIMHP items, and Fig. 2 shows the frequencies of main domains of mental health identified with CIMHP, both stratified on gender. Table 2 Frequency and gender distribution of mental health vulnerabilities in infants 9–10 months of age identified by the CIMHP (n = 7,079) Boys Girls % (n) % (n) p-value Sleep regulation Stable sleeping pattern 2.8 (101) 2.3 (80) 0.178 Falling asleep time 4.4 (157) 3.6 (126) 0.111 Interrupted sleep 5.2 (188) 3.8 (132) 0.004* Any sleeping problem (≥ 1 problem) 9.8 (354) 8.1 (283) 0.013* Feeding and eating Appetite regulation 3.8 (136) 3.1 (109) 0.138 Eats too little 11.6 (417) 12.3 (425) 0.408 Refusal to eat 5.7(204) 6.8 (234) 0.066 Vomiting without otherwise being ill 2.8 (102) 2.7 (95) 0.790 Any eating problem (≥ 1 problem) 17.6 (633) 17.8 (617) 0.866 Emotional regulation and expression Generally happy and satisfied 1.5 (52) 0.8 ( 28 ) 0.011* Often irritable, fussy, dissatisfied 4.9 (177) 3.7 (129) 0.012* Cries often 1.8 (63) 1.2 (40) 0.035* Emotionally blunted 1.2 (43) 1.3 (45) 0.708 Any emotional problem (≥ 1 problem) 7.5 (268) 5.9 (203) 0.007* Curiosity and interests Curiosity, exploring 0.6 ( 22 ) 0.7 ( 25 ) 0.578 Attention and concentration Is able to focus 1.0 ( 36 ) 0.5 ( 18 ) 0.020* Maintain concentration 0.9 ( 32 ) 0.6 ( 20 ) 0.122 Easily distracted 11.4 (409) 10.9 (376) 0.455 Any attention problem (≥ 1 problem) 12.3 (439) 11.1 (386) 0.148 Motor development and activity Motor development 7.8 (281) 7.9 (273) 0.952 Generally increased level of activity 3.2 (113) 3.4 (116) 0.645 Generally reduced level of activity 5.3 (190) 3.0 (105) < 0.001* Impulsiveness 2.8 (101) 1.7 (58) 0.001* Any motor activity problem (≥ 1 problem) 16.5 (590) 14.0 (484) 0.004* Communication and social Eye contact 0.3 ( 24 ) 0.4 ( 19 ) 0.514 interaction Contact smile 0.3 ( 12 ) 0.3 ( 9 ) 0.564 Proximity seeking (parents) 0.2 ( 6 ) 0.2 ( 6 ) 0.953 Mutual communication (parents) 1.9 (69) 1.0 ( 36 ) 0.002* Joint attention 8.9 (321) 7.9 (273) 0.103 Bodily contact 0.1 ( 5 ) 0.2 ( 8 ) 0.372 Selectivity 0.6 ( 22 ) 0.3 ( 11 ) 0.068 Any communication or interaction problem (≥ 1 problem) 11.1 (397) 9.4 (325) 0.019* Language Language understanding 2.1 (76) 1.1 ( 39 ) 0.001* Verbal expression 2.9 (103) 1.8 (64) 0.004* Any language problem (≥ 1 problem) 4.5 (160) 2.7 (95) < 0.001* Three or more problems 11.5 (414) 9.3 (322) 0.002* CIMHP: Copenhagen Infant Mental Health Programme *P < 0.05 Table 2 here. Figure 2 here. The most frequent problems concerned feeding and eating (18%), motor development and activity (15%), attention and concentration (12%), and communication and interaction (10%). Boys were identified with significantly more problems across most domains and items (Fig. 2 and Table 2 ), e.g. interrupted sleep (p = 0.004), generally reduced level of activity (p < 0.001), impulsivity (p = 0.001); as well as problems of emotional regulation: not being generally happy and satisfied (p = 0.011), often irritable, fussy, dissatisfied (p = 0.012), and cries often (p = 0.035), see Table 2 . Additionally, more boys were identified with problems of attention (p = 0.020); mutual communication (p = 0.002), and problems of receptive and expressive language (p < 0.001). Significantly more boys (12%) were identified with three or more co-occurrent problems compared to girls (9%) (p = 0.002). Figure 3 here The Venn diagrams (Fig. 3) illustrate the frequency of co-occurring problems across seven main areas of child vulnerability. Problems related to curiosity and interests were not included because of only a small number of children in this group. In Fig. 3A regulatory problems of feeding and eating, sleep, and emotional regulation are shown. Figure 3B illustrates co-occurrence of problems of attention, motor development and activity, communication, and language. Most problems are solitary, but a subgroup of children showed co-occurring problems across multiple domains. Table 3 shows associations between child and parental factors and mental health vulnerabilities measured by the CIMHP. Male sex, low gestational age, and low birth weight were associated with an increased risk of problems regarding motor development and activity, communication and interaction and language, but also an increased risk of emotional regulation problems. Further, neonatal complications were associated with problems of motor development and activity, of attention and concentration, and of sleep and emotional regulation. Three or more vulnerabilities at the CIMHP assessment at 9–10 months were associated with a broad pre-perinatal risk profile. Table 3 Associations between child and parental factors and main areas of mental health problems identified by the CIMHP (n = 7,079) Sleep regulation OR [95% CI] Eating and feeding OR [95% CI] Emotional regulation and expression OR [95% CI] Curiosity and interests OR [95% CI] Attention and concentration OR [95% CI] Motor development and activity OR [95% CI] Communication and social interaction OR [95% CI] Language OR [95% CI] Three or more problems OR [95% CI] Child factors Sex Girls Ref Boys 1.23 [1.05;1.45]* 0.99 [0.88;1.12] 1.3 [1.08;1.6]* 0.85 [0.48;1.51] 1.11 [0.96;1.29] 1.21 [1.07;1.38]* 1.20 [1.03;1.40]* 1.66 [1.28;2.15]** 1.27 [1.09;1.49]* Gestational age a < 37 weeks 0.67 [0.34;1.33] 1.08 [0.71;1.63] 2.23 [1.37;3.62]** 0.90 [0.12;6.73] 1.29 [0.81;2.04] 1.65 [1.1;2.4]* 2.30 [1.48;3.56]** 2.62 [1.4;4.9]* 2.22 [1.47;3.37]** ≥ 37 weeks Ref Birth weight < 2500 g 0.83 [0.54;1.29] 1.22 [0.91;1.62] 1.52 [1.02;2.26]* 3.94 [1.75;8.7]** 1.06 [0.75;1.51] 1.48 [1.11;1.98]* 1.67 [1.21;2.31]* 2.33 [1.49;3.64]** 1.95 [1.44;2.65]** ≥ 2500 g Ref Neonatal complications b No Ref Yes 2.81 [1.28;6.18]* 1.09 [0.48;2.48] 2.73 [1.13;6.57]* 4.21 [0.56;31.34] 2.82 [1.36;5.84]* 2.07 [1.0;4.29]* 1.70 [0.071;4.09] 2.36 [0.72;7.75] 2.79 [1.3;5.94]* Parental factors Parental ethnicity At least one parent born in Denmark Ref Both parents born outside Denmark 1.27 [1.05;1.53]* 1.47 [1.28;1.70]** 1.16 [0.993;1.45] 1.60 [0.85;3.02] 0.97 [0.81;1.16] 0.98 [0.84;1.15] 1.19 [0.99;1.43] 0.79 [0.57;1.09] 1.44 [1.21;1.72]** Parental work status At least one working Ref Both not working 0.85 [0.44;1.62] 1.26 [0.82;1.94] 1.08 [0.55;2.14] 2.48 [0.59;10.37] 0.51 [0.25;1.04] 0.99 [0.60;1.62] 2.20 [1.41;3.44]** 1.08 [0.44;2.66] 1.34 [0.80;2.24] Parents living together at childbirth Yes Ref No 1.15 [0.86;1.55] 0.99 [0.78;1.25] 1.46 [1.07;2.00]* 1.17 [0.42;3.26] 1.21 [0.93;1.57] 1.121 [0.96;1.54] 1.38 [1.06;1.80]* 1.58 [1.05;2.36]* 1.33 [1.02;1.73]* Parent more than 10 years of schooling Yes Ref No 1.13 [0.93;1.37] 0.92 [0.79;1.07] 1.08 [0.86;1.35] 1.39 [0.73;2.65] 1.00 [0.84;1.20] 1.14 [0.98;1.33] 1.39 [1.16;1.65]** 1.07 [0.80;1.45] 1.08 [0.90;1.29] CIMHP: Copenhagen Infant Mental Health Programme * P < 0.05, ** P < 0.001 a Gestational age data was partially missing from the Danish Medical Birth Register; available information included 2,876 individuals from the study population. b Neonatal complications are defined as neonatal sepsis and/or the need for neonatal respirator treatment. Among family factors, significant associations were seen in children from families of not-Danish ethnicity showing an increased risk of regulatory problems of sleep and feeding and eating, whereas children of parents with short schooling, unemployment, and not living together at childbirth showed an increased risk of problems with communication and interaction. The CHNs evaluation of using the CIMHP Questionnaire data included 251 CHNs (89% response) of whom the majority (82%) had more than five years experiences as practicing CHNs. Likewise, the majority of CHNs participating in the focus group interviews had long experiences as practising CHNs, only one was newly educated. The majority of questionnaire respondents (81%) had conducted more than five CIMHS assessments by the time of the study, and at the time of the interviews, each had conducted between eight and 15 child assessments using the CIMHP. Most (75%) reported to use the CIMHP manual as a standard at home visits (see Table 4 ) and among them, the majority found the manual helpful in identifying areas where the family needed additional support (97%) and when preparing additional support for the family (88%). Still, a considerable part reported difficulties in using the guidelines. Table 4 CHNs’ perspectives on using the Copenhagen Infant Mental Health Programme (CIMHP) Questionnaire item Yes No Number of comments Have you used the manual during feedback of the CIMHS assessment or during planning of additional support/intervention? 187 (75%) 64 (25%) 29 Do you generally think that the CIMHS assessment helps you get an overview of the child's need for extra support/intervention at 9–10 months? 244 (97%) 5 (2%) 42 Do you think that the CIMHP helps you in planning an intervention for the child? 220 (88%) 26 (10%) 44 Do you think that the CIMHP helps you communicate with parents about the child's needs? 227 (90%) 20 (8%) 33 Do you find that parents consider the CIMHS assessment to be an advantage compared to usual practice? 142 (57%) 76 (30%) 85 The focus group interviews confirmed questionnaire data on the frequent use of CIMHP in almost all home visits at child ages 9–10 months, becoming a standard procedure in the participating municipalities. However, limitations in the use of the CIMHP was also reported, and several CHNs did not seem to have integrated the use of manual and guidelines systematically or they considered the guidelines inadequate in their daily practice. Many CHNs expressed a desire to use the guidelines more frequently, and the focus group discussions revealed that the CHNs acknowledged the value of using the guidelines to discussions with colleagues, but time constraints were considered as a significant hindrance. See Table 4 for an overview of the CHNs’ perspectives on using the CIMHP. Table 4 here. In both the questionnaire comments and focus group interviews, CHNs described the CIMHP as a systematic, structured, and tangible tool that enabled them to capture more nuances and relevant aspects of a child’s development, ensuring high quality. One CHN described: “ So, I think the conversation becomes more concrete, and you can more clearly pinpoint the challenges that might exist, and I actually think that it ensures you don’t overlook important factors that play a role " Most (90%) CHNs appreciated the CIMHP as it facilitated communication with parents about the child’s development, helping them articulate the child's needs more clearly and provide more systematic feedback on the assessment. Some CHNs noted that the CIMHP allowed them to ask parents specific questions, making the dialogue more concrete and in-depth. The method also gave CHNs the opportunity to address issues that parents might not have been concerned about themselves. A few CHNs mentioned that they found the communication with parents more rigid when using the programme, hindering a more flexible and present dialogue with parents. Focus group discussions revealed that some CHNs were concerned about how to introduce the CIMHP and present the results of the assessment to parents, particularly when it came to terms like 'mental vulnerability'. One CHN expressed concern that the programme could create a dilemma when the parent was not worried, but the assessment indicated vulnerability for the CHN to address. The majority of CHNs found that parents appreciated the programme, and no resistance or scepticism from parents were reported from the focus groups. Still, 30% of respondents answered 'no' to whether parents valued the CIMHP more than previous practices. In the focus group interview it was noted that the CIMHP assessment likely appeared more valid and credible to parents compared to the CHN's usual methods of assessment and communication: A: "...when someone has set something down on paper, it becomes a bit more serious, ….rather than just casual chatter back and forth. Here, there’s really something we need to check off, right? " Overall, the CHNs found the CIMHP to align well with their existing practices, including the purpose of the home visit at child ages 9–10 months While the CHNs had varying experiences regarding the CIMHP education, all agreed that the programme provided them with a more useful approach to assessing early indicators of mental vulnerability. The CHNs in the focus groups described how the methods substantiated and supported their existing knowledge and way of working, providing " something to base one's intuition on ". DISCUSSION In this paper, we address the knowledge gap on universal strategies to target infants’ mental health and developmental risks ( 23 – 25 ). We describe the creation and testing of a pragmatic, service-setting based programme that combines a validated screening, the CIMHS ( 26 – 28 ), with a standardized manual of child assessments and feedback to parents, and guidelines for action, as well as education of the health professionals involved. The new programme, the Copenhagen Infant Health programme, CIMHP, was developed in collaboration with CHNs in 17 Danish municipalities and implemented at CHNs’ home-visits to infants aged 9–10 months. The population to be studied included 280 CHNs and 7,079 infants being assessed by CIMHP. Compared to the first version of the CIMHS ( 26 ), the use of the current version result in overall lower frequencies of developmental and regulatory problems, with the largest differences seen in emotional problems being identified in 7.4% versus 14.3% in the former CIMHS. Likewise, problems of communication and interaction were identified in 10.2% versus 20.7%, and problems of language development in 3.6% versus 9.2%. These discrepancies reflect that the more precise item definitions, and the addition of a highly standardized manual, as well as the education of CHNs, seem to result in a probably more accurate identification of infant vulnerabilities. Still, this was not explicitly explored in the present study. Also, in accordance with increasing evidence on the importance of early markers of motor development problems ( 35 – 37 ) the actual validation process in CIMHP resulted in adding a new item on general motor development leaving the overall frequency of motor development and activity problems to increase from 9.9% when using the former CIMHS ( 26 ) to 15.8% when using CIMHP. Still, further exploration of sensitivity and specificity are needed regarding this as well as the other items of CIMHP. Our findings show a higher risks in boys across regulatory and developmental functions, and overall more pronounced when compared to previous findings on CIMHS ( 26 ), but in line with findings from other studies ( 7 , 38 ). The identification of co-occurrent markers of neuro-developmental vulnerability is in line with results from longitudinal studies of autism spectrum disorders and disorders of attention deficit and hyperactivity ( 9 – 11 , 38 ). Moreover, our findings on the CIMHP confirm the pre-perinatal risk profile of developmental psychopathology known from research in older children ( 7 ). Taken together, our findings point to the potential of the CIMHP for the valid identification of infancy markers of early onset neuro-developmental disorders as early as 9–10 months of age. Regarding regulatory problems of eating, sleeping and emotional regulation (RPs), the CIMHP seems to identify these problems with frequencies in line with findings from studies of other populations ( 12 , 13 , 15 ), particularly regarding a minor group affected by multiple or complex RPs. Available research points to a poor prognosis of children with these difficulties and underscores the need of intervention to help parents regulate their child early in life ( 15 ). By systematically including the parents in the child assessment and intervention planning completed by educated CHNs, the CIMHP has potentials to address infants’ regulatory or developmental vulnerabilities ( 21 ) through tailoring the parents’ understanding and knowledge on needs of their child. Health professionals’ evaluation The pilot implementation of the CIMHP shows broad use and appreciation among CHNs, who evaluated the programme as a structured and concrete method for assessing all aspects of child development, while also supporting communication with parents about the child’s needs. Despite these positive findings and the alignment with their existing practices and knowledge, the study highlights areas for further exploration in the ongoing implementation and development of the CIMHP. These include addressing dilemmas in providing feedback and supervision to parents, as well as time constraints related to using the guidelines for action and engaging in colleague discussions. Together, the findings from the present study highlight the needs of improvements in the overall education of the health professionals involved, as well as elaboration of guidelines for action in municipality settings. Strengths and limitations The strengths of this study include the thorough description of the creation of a comprehensive programme, CIMHP, that integrate a validated screening, and research evidence on early developmental psychopathology, as well as the best practices from clinical work, which all together enables transparency and inspiration for other researchers. Further, the CIMHP was tested in a pilot implementation in a large representative child population assessed by CHNs with a high participation and with comprehensive data from national registries and a clinical municipality database. Moreover, supplementary qualitative data provide information on the perspectives of involved health professionals, the CHNs, with high response rate. Overall, these strengths contribute with important knowledge on issues of validity and usefulness of the CIMHP. Still, the study has not explored feasibility or validity of single items systematically; and overall, a longer period of studying implementation including a thorough process evaluation would have been optimal ( 39 ). CONCLUSION The new programme, CIMHP, combines a validated infant mental health screening in dialogue with parents, accompanied by a manual for subsequent feedback and guidelines for actions to promote child health. While the overall validity of the CIMHP seem promising, further refinement of the guidelines for action and enhanced education for CHNs are recommended. Abbreviations CHN Community health nurse CIMHS Copenhagen Infant Mental Health Screening CIMHP Copenhagen Infant Mental Health Programme CHD the Child Health Database MBR the Danish Medical Birth Register Declarations Ethics and approval The implementation of the CIMHP is part of the quality development within the existing community health care (33) offered free of charge to all infant families. Parents are free to withdraw from these services, including participation in particular assessments. Parents were informed about the study on CIMHP by the CHNs and their participation in testing the CIMHP at home -visits were fully voluntary. The study has been presented for the Research Ethics Committee of the Capital Region of Denmark and has been approved by the SDU Research & Innovation Organization (RIO), University of Southern Denmark, No. 10.371. Being based on data from municipality health databases and National registries, with no individual contacts with the study population beyond existing municipality routines, no further demands on individual consent to participate have been required. Content to publication Not applicable Clinical trial number Not applicable Availability of data and materials Data will not be publicly available because they contain sensitive material. Permission to access data for scientific purposes on reasonable request is possible for researchers meeting the criteria for access to confidential information. For researchers in a European country, permission to access these data for scientific purposes can be obtained from the personal data agency SDU Research & Innovation (RIO), University of Southern Denmark. Information on how to apply for data access can be obtained by emailing [email protected] . For researchers outside a European country, permission to data access can be obtained for scientific purposes on reasonable request from the Danish Data Protection Agency by emailing kd.tenyslitatad@td. Competing interests The authors declare that they have no competing interests. Funding The development and implementation of CIMHP was co-financed by the participating municipalities and the Centre of Infant and Toddler Research at the National Institute of Public Health, University of Southern Denmark. Authors’ contributions AMS is the principal investigator. AMS and JA developed the CIMHP and led the design of the study. AMS led the preparation of the manuscript for submission and wrote the first draft. JA and LF carried out the data collection and the acquisition of data. JA & CBP carried out the statistical analyses and LF & SKW the qualitative analyses. All authors contributed to the drafting of the manuscript and critical revisions of the manuscript. All authors read and approved the final manuscript. Acknowledgements The project group would like to thank the group of professionals for their contribution to the development of CIMHP: Developmental psychologists Susanne Landorph and Tina Tingleff ; Child psychiatrists Anne Lise Olsen, Jette Asmussen and Male Moskowicz; Community health nurses Anne Lorentzen, Annette Hvidberg Larsen, Dorthe Svendsen, Ellen Blemmer, Eva Hellebek, Hannah G. Nielsen, Helga Bohm, Jette Lützen, Lene Kjær, Lisbeth Sander, Lisbet Holst, Lende Caspersen, Lilly Friberg Wulff, Majbritt Vonsild, Pia Jønsson and Sine Bregn Machon; and leading health nurses Helle Erstling Rasmussen, Lone Dahlstrøm, Marika Jensen and Ulla Dupont . Further, thanks to all leading and practicing CHNs and parents and children from the participating municipalities (Allerød, Dragør, Egedal, Fredensborg, Gladsaxe, Glostrup, Herlev, Hillerød, Høje-Taastrup, Ishøj, Kalundborg, Køge, Roskilde, Rudersdal, Taarnby, Vallensbæk, Vejle). Authors’ information AMS , MD, DM SCI, Professor in Child Psychiatry, NIPH, SDU, experienced in clinical child psychiatry and epidemiological research in developmental psychopathology. CBP , MD, PhD student, experienced in quantitative methods and paediatrics. JA, Health nurse, MPH, PhD, Researcher, NIPH, SDU, experienced in community health nursing, and research collaborations with CHNs. LF, Health Nurse, MPH, NIPH, SDU, experienced in community health nursing. SKW, MSc, PhD, Researcher, NIPH, SDU, experienced in qualitative methods and process evaluation. References Vasileva M, Graf RK, Reinelt T, Petermann U, Petermann F. Research review: A meta-analysis of the international prevalence and comorbidity of mental disorders in children between 1 and 7 years. J Child Psychol Psychiatry. 2021;62(4):372-81. Skovgaard AM. Mental health problems and psychopathology in infancy and early childhood. An epidemiological study. Dan Med Bull. 2010;57(10):B4193. Polanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345-65. Conti G, Heckman JJ. The developmental approach to child and adult health. Pediatrics. 2013;131 Suppl 2(Suppl 2):S133-41. Beckwith L. Prevention science and prevention programs. Handbook of infant mental health, 2nd ed. New York, NY, US: The Guilford Press; 2000. p. 439-56. Britto PR, Lye SJ, Proulx K, Yousafzai AK, Matthews SG, Vaivada T, et al. Nurturing care: promoting early childhood development. Lancet. 2017;389(10064):91-102. Meaney MJ, O'Donnell KJ. Epigenetics and the developmental origins of vulnerability for mental disorders (Chapter 25). Rutter's Child and Adolescent Psychiatry 2018. p. 317-29. Skovgaard AM, Olsen EM, Christiansen E, Houmann T, Landorph SL, Jørgensen T. Predictors (0-10 months) of psychopathology at age 11/2 years - a general population study in The Copenhagen Child Cohort CCC 2000. J Child Psychol Psychiatry. 2008;49(5):553-62. Elberling H, Linneberg A, Olsen EM, Houmann T, Rask CU, Goodman R, et al. Infancy predictors of hyperkinetic and pervasive developmental disorders at ages 5-7 years: results from the Copenhagen Child Cohort CCC2000. J Child Psychol Psychiatry. 2014;55(12):1328-35. Jaspers M, de Winter AF, Buitelaar JK, Verhulst FC, Reijneveld SA, Hartman CA. Early childhood assessments of community pediatric professionals predict autism spectrum and attention deficit hyperactivity problems. J Abnorm Child Psychol. 2013;41(1):71-80. Johnson MH, Gliga T, Jones E, Charman T. Annual research review: Infant development, autism, and ADHD--early pathways to emerging disorders. J Child Psychol Psychiatry. 2015;56(3):228-47. Asmussen J, Davidsen KA, Olsen AL, Skovgaard AM, Bilenberg N. The longitudinal association of combined regulatory problems in infancy and mental health outcome in early childhood: a systematic review. Eur Child Adolesc Psychiatry. 2023. Winsper C, Wolke D. Infant and toddler crying, sleeping and feeding problems and trajectories of dysregulated behavior across childhood. J Abnorm Child Psychol. 2014;42(5):831-43. Galling B, Brauer H, Struck P, Krogmann A, Gross-Hemmi M, Prehn-Kristensen A, et al. The impact of crying, sleeping, and eating problems in infants on childhood behavioral outcomes: A meta-analysis. Frontiers in Child and Adolescent Psychiatry. 2023;1. Jaekel J, Sorg C, Breeman L, Baumann N, Bilgin A, Bauml JG, et al. Early regulatory problems and parenting: life-long risk, vulnerability or susceptibility for attention, internalizing and externalizing outcomes? Eur Child Adolesc Psychiatry. 2021;30(10):1523-31. Beauchaine TP, Cicchetti D. Emotion dysregulation and emerging psychopathology: A transdiagnostic, transdisciplinary perspective. Dev Psychopathol. 2019;31(3):799-804. Zeanah CH. Psychopathology. In: Zeanah CH, editor. Handbook of Infant Mental Health. New York: The Guilford Press; 2018. p. 297-479. Zero to Five: National Center for Infants, T. F., Washington D. C. (2016). Diagnostic classification 0-5: Diagnostic classification of mental health and developmental disorders of infancy and early childhood (DC:0-5). Vitaro F, Tremblay R. Clarifying and Maximizing the Usefulness of Targeted Preventive Interventions. In: Rutter M, Bishop D, Pine D, Scott S, Stevenson J, Taylor E, et al., editors. Rutter's Child and Adolescent Psychiatry. 5 ed. Oxford: Blackwell Publishing; 2008. p. 989-1008. Rose G, Khaw K-T, Marmot M. Rose's Strategy of Preventive Medicine: Oxford University Press; 2008 01 Sep 2009. Zeanah CH. The Clinical Science of Early Experiences. . In: Zeanah CH, editor. Handbook of Infant Mental Health. New York: The Guilford Press; 2018. p. 5-24. Groach C, McCall R. Community Based Interventions and Services. In: Rutter M, Bishop D, Pine D, Scott S, Stevenson J, Taylor E, et al., editors. Rutter's Child and Adolescent Psychiatry. 5 ed. Oxford: Blackwell Publishing; 2008. p. 971-88. Izett E, Rooney R, Prescott SL, De Palma M, McDevitt M. Prevention of Mental Health Difficulties for Children Aged 0-3 Years: A Review. Front Psychol. 2020;11:500361. Hare MM, Landis TD, Hernandez ML, Graziano PA. A Systematic Review of Infant Mental Health Prevention and Treatment Programs. Evid Based Pract Child Adolesc Ment Health. 2024;9(1):138-61. Hogg S, Moody J. Understanding and supporting mental health in infancy and early childhood– a toolkit to support local action in the UK. UNICEF UK. 2023. Ammitzbøll J, Holstein BE, Wilms L, Andersen A, Skovgaard AM. A new measure for infant mental health screening: development and initial validation. BMC Pediatr. 2016;16(1):197. Ammitzbøll J, Skovgaard AM, Holstein BE, Andersen A, Kreiner S, Nielsen T. Construct validity of a service-setting based measure to identify mental health problems in infancy. PLoS One. 2019;14(3):e0214112. Ammitzbøll J, Thygesen LC, Holstein BE, Andersen A, Skovgaard AM. Predictive validity of a service-setting-based measure to identify infancy mental health problems: a population-based cohort study. Eur Child Adolesc Psychiatry. 2018;27(6):711-23. Skovgaard AM, Houmann T, Christiansen E, Olsen EM, Landorph SL, Lichtenberg A, et al. 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. Eur Child Adolesc Psychiatry. 2008;17(5):290-8. Godoy L, Carter AS, Silver RB, Dickstein S, Seifer R. Mental health screening and consultation in primary care: The role of child age and parental concerns [corrected]. J Dev Behav Pediatr. 2014;35(5):334-43. Holland WW, Stewart S. Screening in Disease Prevention: What Works? . Oxford: Radcliffe Publishing. 2005. Holstein BE, Henriksen TB, Rayce SB, Ringmose C, Skovgaard AM, Teilmann GK, et al. Mental health and psychiatric illness among children aged 0-9 years. Copenhagen: The Danish Council for Health Promotion and Disease Prevention; 2021. Skovgaard AM, Wilms L, Johansen A, Ammitzbøll J, Holstein BE, Olsen EM. Standardised measuring the health of infants and toddlers in community health services. Ugeskrift for laeger. 2018;180(34). Green J, Thorogood N. Qualitative methods for health research. 4th edition. ed. Los Angeles: SAGE; 2018. Lemcke S, Juul S, Parner ET, Lauritsen MB, Thorsen P. Early signs of autism in toddlers: a follow-up study in the Danish National Birth Cohort. J Autism Dev Disord. 2013;43(10):2366-75. West KL. Infant Motor Development in Autism Spectrum Disorder: A Synthesis and Meta-analysis. Child Dev. 2019;90(6):2053-70. Athanasiadou A, Buitelaar JK, Brovedani P, Chorna O, Fulceri F, Guzzetta A, et al. Early motor signs of attention-deficit hyperactivity disorder: a systematic review. Eur Child Adolesc Psychiatry. 2020;29(7):903-16. Koch SV, Andersson M, Hvelplund C, Skovgaard AM. Mental disorders in referred 0-3-year-old children: a population-based study of incidence, comorbidity and perinatal risk factors. Eur Child Adolesc Psychiatry. 2021;30(8):1251-62. Bartholomew L, Parcel G, Kok G, Gottlieb N, Fernández M. Planning Health Promotion Programs: An intervention mapping approach. 3 ed. San Francisco: Jossey-Bass; 2011. Additional Declarations No competing interests reported. Supplementary Files Appendix1ExampleofthecontentoftheCIMHPguidelines.docx Appendix2OverviewoftheCIMHPeducationandtraining.docx Appendix3.Overviewofvariables.docx Appendix4QuestionnaireCHNs.docx Appendix5FrequencyofCIMHPmeasuredinfantmentalhealthvulnerabilities.docx Cite Share Download PDF Status: Under Review Version 1 posted Reviewers agreed at journal 14 May, 2026 Reviewers agreed at journal 11 May, 2026 Reviewers agreed at journal 05 Aug, 2025 Reviews received at journal 28 Jul, 2025 Reviewers agreed at journal 25 Jul, 2025 Reviewers agreed at journal 25 Jul, 2025 Reviewers invited by journal 15 Jul, 2025 Editor invited by journal 24 May, 2025 Editor assigned by journal 23 May, 2025 Submission checks completed at journal 23 May, 2025 First submitted to journal 19 May, 2025 You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. 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Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-6698283","acceptedTermsAndConditions":true,"allowDirectSubmit":false,"archivedVersions":[],"articleType":"Research Article","associatedPublications":[],"authors":[{"id":487063730,"identity":"055cca2c-734a-49ff-a3e0-2b635310fa70","order_by":0,"name":"Anne Mette Skovgaard","email":"","orcid":"","institution":"National Institute of Public Health, University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Anne","middleName":"Mette","lastName":"Skovgaard","suffix":""},{"id":487063731,"identity":"85a2dced-444c-4683-869f-2d573b0871d5","order_by":1,"name":"Clara Barfod Parellada","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAAlElEQVRIiWNgGAWjYDACdiD+wMAMJNOI1QJUzDiDZC3MPCRp4W9mfvbZ5o91YgN7WgJxWiQOsxnPzm1LT2zgeXaAOC0GzAzGzLkNhxMbJNIbiNXC/pnZ4g9pWniMmRnYQFrSiHSYxGGeYsbetnTjNp5nCcRp4W9v38zw44+1bD97mgFxWuCAjUT1o2AUjIJRMArwAQBk2CSXZbjxMQAAAABJRU5ErkJggg==","orcid":"","institution":"National Institute of Public Health, University of Southern Denmark","correspondingAuthor":true,"prefix":"","firstName":"Clara","middleName":"Barfod","lastName":"Parellada","suffix":""},{"id":487063733,"identity":"57a9a574-9876-4356-9a60-3ff124d527d5","order_by":2,"name":"Lotte Finseth","email":"","orcid":"","institution":"The municipality of Frederiksberg","correspondingAuthor":false,"prefix":"","firstName":"Lotte","middleName":"","lastName":"Finseth","suffix":""},{"id":487063734,"identity":"60197350-6c2d-42a4-82f6-95d12b4fbb5a","order_by":3,"name":"Stine Kjær Wehner","email":"","orcid":"","institution":"National Institute of Public Health, University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Stine","middleName":"Kjær","lastName":"Wehner","suffix":""},{"id":487063735,"identity":"4d226b12-1b36-44a3-abdb-7bed9c4f3027","order_by":4,"name":"Janni Ammitzbøll","email":"","orcid":"","institution":"National Institute of Public Health, University of Southern Denmark","correspondingAuthor":false,"prefix":"","firstName":"Janni","middleName":"","lastName":"Ammitzbøll","suffix":""}],"badges":[],"createdAt":"2025-05-19 11:08:07","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-6698283/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-6698283/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":87319497,"identity":"175f0c6c-6e17-4b0a-b5a8-836519ff0049","added_by":"auto","created_at":"2025-07-22 16:22:11","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":56430,"visible":true,"origin":"","legend":"\u003cp\u003eshows an overview of the CIMHP-Program\u003c/p\u003e","description":"","filename":"figure1CIMHPoverview.png","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/49cf8a954b023bfd3dc9a471.png"},{"id":87319496,"identity":"bd9598dd-b94f-4570-9ff8-c36aede6bb0e","added_by":"auto","created_at":"2025-07-22 16:22:11","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":55258,"visible":true,"origin":"","legend":"\u003cp\u003ethe frequencies of main domains of mental health identified with CIMHP, both stratified on gender.\u003c/p\u003e","description":"","filename":"Figure2mentalhealtproblemsandgender.png","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/9e355569a0ee2378c1b4adfd.png"},{"id":87320567,"identity":"aef4b139-22d5-44c4-bc19-b448c79e94ff","added_by":"auto","created_at":"2025-07-22 16:30:11","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":51520,"visible":true,"origin":"","legend":"\u003cp\u003eIn figure 3A regulatory problems of feeding and eating, sleep, and emotional regulation are shown. Figure 3B illustrates co-occurrence of problems of attention, motor development and activity, communication, and language. Most problems are solitary, but a subgroup of children showed co-occurring problems across multiple domains.\u003c/p\u003e","description":"","filename":"Figure3venndiagram.png","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/ffb0fa3ac9ac2bb82b4d74a4.png"},{"id":87323095,"identity":"4c3acdd0-8cd9-4525-b0ed-582d2ff053f2","added_by":"auto","created_at":"2025-07-22 16:54:12","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":1650677,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/b9b74fbb-8ac8-4a4d-bb00-4ca1b9762969.pdf"},{"id":87320568,"identity":"249fba49-d04b-44b4-bb0e-1d0ff8a7d92f","added_by":"auto","created_at":"2025-07-22 16:30:11","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":19185,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix1ExampleofthecontentoftheCIMHPguidelines.docx","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/a837a8780175509a90728ee0.docx"},{"id":87319507,"identity":"6101ae96-307f-4e9a-bb35-caf2fd9c743d","added_by":"auto","created_at":"2025-07-22 16:22:11","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":25947,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix2OverviewoftheCIMHPeducationandtraining.docx","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/673e5ab3b4c57ca7c7c854cc.docx"},{"id":87319498,"identity":"0f7cc5f9-ad17-4fce-9558-6b8d35b8a3fa","added_by":"auto","created_at":"2025-07-22 16:22:11","extension":"docx","order_by":3,"title":"","display":"","copyAsset":false,"role":"supplement","size":15792,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix3.Overviewofvariables.docx","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/36d2b55c1cfaf298407d061a.docx"},{"id":87320566,"identity":"6d9c00ea-0524-4937-9814-b377a1d1efdd","added_by":"auto","created_at":"2025-07-22 16:30:11","extension":"docx","order_by":4,"title":"","display":"","copyAsset":false,"role":"supplement","size":19712,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix4QuestionnaireCHNs.docx","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/08d50ae892db5272ce8982b7.docx"},{"id":87322325,"identity":"7e75c256-0019-46d5-a66f-d38b7fca0428","added_by":"auto","created_at":"2025-07-22 16:46:11","extension":"docx","order_by":5,"title":"","display":"","copyAsset":false,"role":"supplement","size":14283,"visible":true,"origin":"","legend":"","description":"","filename":"Appendix5FrequencyofCIMHPmeasuredinfantmentalhealthvulnerabilities.docx","url":"https://assets-eu.researchsquare.com/files/rs-6698283/v1/054d78432671f5a015b4c554.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"The Copenhagen Infant Mental Health Programme – Development and testing of a pragmatic service-setting-based approach to screening and intervention","fulltext":[{"header":"Background","content":"\u003cp\u003eChildhood mental health problems and disorders affect more than every tenth child (1-3). They are associated with an increased risk of persistent developmental, educational, physical, and social problems in older ages, underscoring the importance of preventive strategies that begins in early childhood (4-6).\u003c/p\u003e\n\u003cp\u003eEpidemiological research from recent decades has identified possible targets of intervention to address developmental psychopathology in early ages (2, 7). Infancy problems of contact and communication, and problems of activity and language development have thus been found associated with autism spectrum disorders, general developmental disorders, and disorders of inattention and hyperactivity in older ages, suggesting that early pathways of neuro-developmental disorders may start in infancy (8-11). Also, infancy problems of feeding and eating, sleep, and emotional and behavioural regulation have been found associated with emotional, behavioural, and hyperactivity problems in older ages, in particular when co-occurring (12-15). These early difficulties are suggested to initiate developmental cascades of dysregulation that track into internalizing and externalizing disorders, including inattention and hyperactivity disorders highly influenced by the quality of parenting (13, 15, 16).\u003c/p\u003e\n\u003cp\u003eEpidemiological findings on developmental psychopathology in the first years of living (2) are consistent with the phenomenology of clinical symptoms and syndromes described in textbooks (17) and in the Diagnostic Classification of mental disorders of infancy and early childhood, DC:0-5 (18). Examples include symptoms and diagnostic entities of sleep disorders, feeding and eating disorders, emotional and behavioural disorders, pervasive developmental disorders, and disorders of attention deficit, hyperactivity and impulsivity (17).\u003c/p\u003e\n\u003cp\u003eThe rationale and needs of preventive intervention that starts in early infancy (4-7), underscore the importance of effective measures addressing the entire population and including possibilities of indicated or selective interventions targeting children at particularly increased risk (5, 19-21). To be effective, intervention strategies should be implemented systematically (6) and consistently involve the parents (21).\u003c/p\u003e\n\u003cp\u003eMost universal strategies that address early child development focus on populations of pre-, perinatal or psycho-social risks (19). These are often integrated within the primary or municipality health care and delivered by health care professionals, e.g. general practitioners or community health nurses (5, 22). However, universal interventions that address the range of mental health vulnerabilities in infancy are scarce (23, 24) with several methodological challenges highlighted (23, 24) e.g. limitations in available measures that are feasible for practical use and psychometric robust (25).\u003c/p\u003e\n\u003cp\u003eThe Copenhagen Infant Mental Health Screening, CIMHS (26), was developed to capture the range of mental health vulnerabilities seen among young children (26-28) . The CIMHS addresses a window of opportunity for the valid identification of targets of intervention at child ages 9-10 months within the municipality health care provided by community health nurses (CHNs) (29). The psycho-metric properties are well-established (26-28) and overall, the CIMHS is suggested to have potentials for use in universal services (25, 28).\u003c/p\u003e\n\u003cp\u003eStill, a screening of infant mental health should not stand alone, with the risk of leaving parents behind without help (21, 30, 31). So far, however, no measures have been published that combine a comprehensive and validated infant mental health screening with a standardized approach to help parents in case of identified child vulnerabilities (23, 24).\u003c/p\u003e\n\u003cp\u003eIn this paper, we describe the development and pilot-implementation of a standardized approach of infant mental health screening by educated CHNs to be delivered at child ages 9-10 months and including guidelines for action within municipality settings.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAims\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe main goal was to optimize validity and extend the usability of the CIMHS within the community settings. The specific aims were to create a standardized manual for child assessment and guidelines for action that systematically involve the parents, as well as a formalized education of the health professionals involved, CHNs. Finally, we aim to explore the validity and usability of the combined programme within the municipality child health care.\u003c/p\u003e"},{"header":"METHODS","content":"\u003ch2\u003e\u003cstrong\u003eSetting\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe study is embedded within the settings of CHNs in seventeen Danish municipalities. The CHNs participated in the development of the CIMHP and in the pilot implementation and feasibility testing the programme. The CHNs are part of the community health care in Denmark, and they offer home visits free of charge to all infant families, which is attended by more than 90% of the population. The CHNs follow guidelines set by the National health authorities to monitor child health and development and support infant families, within the frame of the municipality services or via referral to other services such as general practitioners and hospitals (26), but so far, no standardized guidelines have been available to address the range of mental health vulnerabilities seen in young children (32).\u003c/p\u003e\n\u003cp\u003eIn the participating municipalities, the CHNs complete standardized recordings at home visits including information on child health and development (26, 33) with data being stored in the Child Health Database (33).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eThe screening of child health and development at child ages 9-10 months \u0026ndash; further validation of the CIMHS\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe CIMHS comprises a standardized scheme for the CHNs evaluation of the child\u0026rsquo;s sleep, feeding and eating, emotional expression and regulation, curiosity and interests, attention and concentration, motor development and activity, communication and social interaction, and language. Within each domain, the CHN conclude whether the child\u0026rsquo;s development and functioning are within the normal range or not (26). Previous validation has identified an overall construct valid global scale and six subscales that are predictive of later psychopathology (26, 28). Still, a more elaborated manual and formalized education of the CHNs have been considered necessary to ensure validity and feasibility.\u003c/p\u003e\n\u003cp\u003eFor this study, we established an expert group of developmental psychologists, infant-toddler psychiatrists, and experienced CHNs to update scientific evidence and best practices among CHNs and review the validity and usefulness of the CIMHS. Consequently, an item on overall motor development was added and minor revisions were suggested to specify the wordings of items and the accompanying descriptions.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eEmphasizing\u003c/em\u003e\u003cem\u003e the importance of parents\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe communication with parents has a core position in the routines of Danish CHNs, but the work in the expert group highlighted considerable variations in how CHNs involve the parents. Consequently, throughout creation of the CIMHP guidelines the parents\u0026rsquo; perspectives and experiences were included systematically, e.g. by combining the parents\u0026rsquo; knowledge from the daily life with the child observations obtained by the CHN at the home visit. This systematic inclusion of information from both parents and CHNs, was considered important to optimize the validity of measuring the child\u0026rsquo;s development and functioning. Equally important, by sharing knowledge on the child, the dialogue is promoted when the CHN provides feedback to parents on the evaluation of the child\u0026rsquo;s current development and functioning. The benefit of this approach could pave the way for planning interventions in case of identified vulnerabilities (See below).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eGuidelines for action addressing infant vulnerabilities \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe guidelines for action were based on reviews of the literature on early developmental psychology and psychopathology with aiming to provide CHNs with an evidence-based platform of knowledge, that captures the range of regulatory and developmental vulnerabilities seen in early childhood (17) (Figure 1 shows an overview of the CIMHP-Program). Figure 1 here.\u003c/p\u003e\n\u003cp\u003eThe guidelines cover eight main areas of infants mental health conceptualized in current textbooks in the field, e.g. Zeanah CH 2018 (17) and current classification schemes (DC:0-5) (18). Each area is described with a short summary on developmental variations and the epidemiology of problems within the general population. The most common co-occurring problems from other developmental areas and the influences of the parent-child relations are systematically described for every domain. A checklist guides the CHNs in further elaborating on the child\u0026rsquo;s functioning in each area of possible vulnerabilities and includes suggestions on how the CHN can support the child\u0026rsquo;s development and to inspire their guidance of the parents.\u003c/p\u003e\n\u003cp\u003eThe guidelines include suggestions for graded interventions spanning from one to six weeks, depending on the number and complexity of the infant\u0026rsquo;s problems and the parents\u0026rsquo; needs, as well as proposals for involving daycare professionals and other municipality services when needed. Appendix 1 provides an example of the CIMHP guidelines related to motor development and activity.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eEducation and training CHNs in delivering the CIMHP \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe programme of education was created to provide CHNs with knowledge on infant development and mental vulnerability across main areas of infant and toddler mental health and training in using the CIMHP. It included two one-day courses with lectures on infant development and mental vulnerability and case-based training in using the CIMHP manual and guidelines over a three-month period.\u003c/p\u003e\n\u003cp\u003eFor an overview of the education programme, see Appendix 2.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eExploring validity and feasibility of the CIMHP\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eSeventeen Danish municipalities from the Capital Region of Denmark, the Region of Zealand and the Region of Southern Denmark joined the pilot implementation of the CIMHP in 2018 and 2019. These municipalities included suburban, urban, and rural areas and have an overall composition of inhabitants comparable to the average Danish population.\u003c/p\u003e\n\u003cp\u003eThe implementation of CIMHP was preceded by an educational course to be completed by all CHNs in participating municipalities (see Appendix 2). Thereafter, the CIMHP was planned to be integrated within the CHNs existing routines at home visits at child ages 9-10 months, with the CHNs recording the results of the child assessment in the municipality database (33).\u003c/p\u003e\n\u003cp\u003eThe CIMHP assessment is offered to all infants aged 9-10 months. For infants born before gestational week 37, the CHNs\u0026rsquo; evaluation included adjustment for gestational age.\u003c/p\u003e\n\u003cp\u003eExcluded for the present study were infants having congenital severe somatic and developmental disabilities or disorders, and infants of parents, who did not speak or understand Danish or English language.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003ePractical procedures of the CHNs\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eCHNs informed parents about the study being a part of quality development within the municipality health care at a previous visit or by mail or phone.\u003c/p\u003e\n\u003cp\u003eThe CIMHP was added to the usual routines during the home visit at child ages 9-10 months. The CHNs were instructed to follow the manual and guidelines of the CIMHP, which include feedback to parents regarding the results of the child assessment and support to the parents in case of identified vulnerabilities.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eData from \u003cem\u003ethe municipality Child Health Database (CHD) and National registries\u003c/em\u003e were used to validate the identification of child health vulnerability when using the CIMHP. For details of data sources and variables, see Appendix 3.\u003c/p\u003e\n\u003col\u003e\n\u003cli\u003e\u003cem\u003eThe municipality Child Health Database (CHD) \u003c/em\u003eholds information recorded by CHNs including the results of the CHNs\u0026rsquo; child examinations at child ages 9-10 months after implementation of the CIMHP (see Appendix 3).\u003c/li\u003e\n\u003cli\u003e\u003cem\u003e The Danish National registries including the Medical Birth Register (MBR)\u003c/em\u003e hold information on child and family factors recorded during pregnancy, birth, and perinatal period (see Appendix 3).\u003c/li\u003e\n\u003cli\u003e\u003cem\u003e Qualitative data \u003c/em\u003eincluded focus group interviews and questionnaires answered by CHNs. The focus group interviews included two municipalities with three CHNs each, and one interviewer (LF). The interviews lasted 37 and 45 minutes, respectively and were recorded and transcribed verbatim.\u003c/li\u003e\n\u003c/ol\u003e\n\u003cp\u003eThe usefulness and face validity of CIMHP was explored via questions on whether the programme helped the CHN to 1) detect mental vulnerabilities in children aged 9-10 months, 2) prepare interventions for families with children showing vulnerabilities, 3) improve communication with parents regarding the child\u0026rsquo;s development and functioning, and further, 4) to obtain the CHNs\u0026rsquo; evaluation on the parents\u0026rsquo; appreciation of the programme.\u003c/p\u003e\n\u003cp\u003eFeasibility was operationalized through questions addressing: 1) whether and to what extent the CHNs had implemented CIMHP as intended among all eligible families and with the use of the manual and guidelines; 2) the CHNs' perspectives on potential benefits and advantages of the CIMHP, as well as any barriers and challenges encountered; 3) the programme\u0026rsquo;s alignment with current practice and knowledge.\u003c/p\u003e\n\u003cp\u003eQuestionnaire items were developed by the research group, most of them with the response category yes/no. Several items also included a section for additional comments (see questionnaire in Appendix 4), data from which were also included in the analysis.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAnalyses \u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eStatistical analyses\u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eThe identification of mental health vulnerabilities using CIMHP were examined as frequencies (%) with chi-square tests used to explore gender differences. Venn diagrams were applied to illustrate the co-occurrence of mental health vulnerabilities. Associations between child and family variables and mental health vulnerabilities were calculated as odds ratios (OR), 95% confidence intervals (CI) with a significance level of 5% using the log likelihood ratio where appropriate.\u003c/p\u003e\n\u003cp\u003eStatistical analyses were carried out using the SAS version 9.3 and RStudio version 2024.12.1 .\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAnalyses of questionnaire and interview data \u003c/em\u003e\u003c/p\u003e\n\u003cp\u003eQuestionnaire data was reported descriptively and without further analysis. Transcripts of interviews and questionnaire comments were analysed through a pragmatic deductive process building on thematic content analysis (34). The material was categorised according to the predefined themes of the operationalization of the concepts of feasibility and usefulness and analysed looking across data horizontally to describe each theme and in relation to the CHNs perspectives.\u003c/p\u003e"},{"header":"RESULTS","content":"\u003cp\u003e Within the 17 municipalities a total of 280 CHNs participated in the CIMHP education, implementation and recordings at home-visits at child ages 9\u0026ndash;10 month, overall leaving data on a total of 7,079 children to be included for this study. The characteristics of the study population is shown in Table\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e. Higher frequencies of parents of non-Danish ethnicity were seen among participants compared to the entire population, whereas no significant differences were found regarding perinatal adversities.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCharacteristics of the entire background (N 70,650) population and the study population (n\u0026thinsp;=\u0026thinsp;7,079)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEntire population\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eStudy population\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;70,650)\u003c/p\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e(N\u0026thinsp;=\u0026thinsp;7,079)\u003c/p\u003e\u003cp\u003eN (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eChild factors\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoys\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e36,280 (51.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,600 (50.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGirls\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e34,365 (48.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e3,479 (49.2%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGestational age\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt; 31 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e342 (0.5%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20 (0.3%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e32\u0026ndash;36 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e1,884 (2.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e125 (1.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; 37 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e43,198 (61.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e2,731 (38.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth weight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;1500 grams\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e485 (0.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e31 (0.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1500\u0026ndash;2500 grams\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,645 (3.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e272 (3.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge; 2500 grams\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e64,174 (90.8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6,658 (94.1%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeonatal complications\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e771 (1.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e37 (0.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e69,879 (98.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e7,042 (99.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParental factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParental ethnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth parents born in Denmark\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e46,673 (66.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e4,454 (62.9%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne parent born in Denmark\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e7,182 (10.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e743 (10.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo parents born in Denmark\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e12,489 (17.7%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,523 (21.5%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParental work status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth working\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e54,568 (77.2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,690 (80.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eOne parent working, one parent\u003c/p\u003e\u003cp\u003enot working\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e9,178 (13.0%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e894 (12.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth not working\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e2,184 (3.1%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e129 (1.8%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParents living together at childbirth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e6,079 (8.6%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e527 (7.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e63,522 (89.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e6,539 (92.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParent more than 10 years of schooling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e13,359 (18.9%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e1,512 (21.4%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e53,961 (76.4%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e5,494 (77.6%)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"3\"\u003e\u003csup\u003ea\u003c/sup\u003e Gestational age data was partially missing from the Danish Medical Birth Register; available information included 45,424 individuals from the entire population and 2,876 from the study population. \u003csup\u003eb\u003c/sup\u003e Neonatal complications are defined as neonatal sepsis and/or the need for neonatal respirator treatment.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e here.\u003c/p\u003e\u003cp\u003eIn most children, no (52.3%) or only one (25.1%) problem of mental health vulnerability was found, whereas 12.1% (N\u0026thinsp;=\u0026thinsp;860) were identified with two problems and 10.4% (N\u0026thinsp;=\u0026thinsp;736) three or more problems (Appendix 5).\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows the frequency of CIMHP items, and Fig.\u0026nbsp;2 shows the frequencies of main domains of mental health identified with CIMHP, both stratified on gender.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eFrequency and gender distribution of mental health vulnerabilities in infants 9\u0026ndash;10 months of age identified by the CIMHP (n\u0026thinsp;=\u0026thinsp;7,079)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eBoys\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eGirls\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003e% (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003e% (n)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003ep-value\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSleep regulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eStable sleeping pattern\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.8 (101)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.3 (80)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.178\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFalling asleep time\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.4 (157)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.6 (126)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.111\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eInterrupted sleep\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.2 (188)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.8 (132)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.004*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAny sleeping problem (\u0026ge;\u0026thinsp;1 problem)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e9.8 (354)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e8.1 (283)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.013*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eFeeding and eating\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eAppetite regulation\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.8 (136)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.1 (109)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.138\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEats too little\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.6 (417)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e12.3 (425)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.408\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRefusal to eat\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.7(204)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e6.8 (234)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.066\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVomiting without otherwise being ill\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.8 (102)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e2.7 (95)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.790\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAny eating problem (\u0026ge;\u0026thinsp;1 problem)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e17.6 (633)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e17.8 (617)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003e0.866\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eEmotional regulation and expression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGenerally happy and satisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.5 (52)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.8 (\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.011*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eOften irritable, fussy, dissatisfied\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e4.9 (177)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.7 (129)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.012*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCries often\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.8 (63)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.2 (40)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.035*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEmotionally blunted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.2 (43)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.3 (45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.708\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAny emotional problem (\u0026ge;\u0026thinsp;1 problem)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e7.5 (268)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e5.9 (203)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.007*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCuriosity and interests\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eCuriosity, exploring\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.6 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.7 (\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.578\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAttention and concentration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eIs able to focus\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.0 (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.5 (\u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e18\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.020*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMaintain concentration\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.9 (\u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e32\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.6 (\u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e20\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.122\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEasily distracted\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.4 (409)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e10.9 (376)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.455\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAny attention problem (\u0026ge;\u0026thinsp;1 problem)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e12.3 (439)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e11.1 (386)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cem\u003e0.148\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eMotor development and activity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMotor development\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e7.8 (281)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.9 (273)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.952\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGenerally increased level of activity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e3.2 (113)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.4 (116)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.645\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGenerally reduced level of activity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5.3 (190)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e3.0 (105)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eImpulsiveness\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.8 (101)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.7 (58)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAny motor activity problem (\u0026ge;\u0026thinsp;1 problem)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e16.5 (590)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e14.0 (484)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.004*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eCommunication and social\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eEye contact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.3 (\u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e24\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.4 (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e19\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.514\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003einteraction\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eContact smile\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.3 (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3 (\u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.564\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eProximity seeking (parents)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.2 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2 (\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.953\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMutual communication (parents)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.9 (69)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.0 (\u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e36\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.002*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eJoint attention\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e8.9 (321)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e7.9 (273)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.103\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eBodily contact\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.1 (\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.2 (\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.372\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSelectivity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.6 (\u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e22\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e0.3 (\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.068\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAny communication or interaction problem (\u0026ge;\u0026thinsp;1 problem)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e11.1 (397)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e9.4 (325)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.019*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLanguage\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eLanguage understanding\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.1 (76)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.1 (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eVerbal expression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e2.9 (103)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.8 (64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.004*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cem\u003eAny language problem (\u0026ge;\u0026thinsp;1 problem)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cem\u003e4.5 (160)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cem\u003e2.7 (95)\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e\u0026lt;\u0026thinsp;0.001*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eThree or more problems\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e11.5 (414)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e9.3 (322)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e0.002*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"2\" nameend=\"c2\" namest=\"c1\"\u003e\u003cp\u003e\u003cem\u003eCIMHP: Copenhagen Infant Mental Health Programme\u003c/em\u003e\u003c/p\u003e\u003cp\u003e\u003cem\u003e*P\u0026thinsp;\u0026lt;\u0026thinsp;0.05\u003c/em\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e here.\u003c/p\u003e\u003cp\u003eFigure 2 here.\u003c/p\u003e\u003cp\u003eThe most frequent problems concerned feeding and eating (18%), motor development and activity (15%), attention and concentration (12%), and communication and interaction (10%). Boys were identified with significantly more problems across most domains and items (Fig.\u0026nbsp;2 and Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e), e.g. \u003cem\u003einterrupted sleep\u003c/em\u003e (p\u0026thinsp;=\u0026thinsp;0.004), \u003cem\u003egenerally reduced level of activity\u003c/em\u003e (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001), \u003cem\u003eimpulsivity\u003c/em\u003e (p\u0026thinsp;=\u0026thinsp;0.001); as well as problems of emotional regulation: \u003cem\u003enot being generally happy and satisfied\u003c/em\u003e (p\u0026thinsp;=\u0026thinsp;0.011), \u003cem\u003eoften irritable, fussy, dissatisfied\u003c/em\u003e (p\u0026thinsp;=\u0026thinsp;0.012), and \u003cem\u003ecries often\u003c/em\u003e (p\u0026thinsp;=\u0026thinsp;0.035), see Table\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e. Additionally, more boys were identified with problems of attention (p\u0026thinsp;=\u0026thinsp;0.020); \u003cem\u003emutual communication\u003c/em\u003e (p\u0026thinsp;=\u0026thinsp;0.002), and problems of receptive and expressive language (p\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Significantly more boys (12%) were identified with three or more co-occurrent problems compared to girls (9%) (p\u0026thinsp;=\u0026thinsp;0.002).\u003c/p\u003e\u003cp\u003eFigure 3 here\u003c/p\u003e\u003cp\u003eThe Venn diagrams (Fig.\u0026nbsp;3) illustrate the frequency of co-occurring problems across seven main areas of child vulnerability. Problems related to curiosity and interests were not included because of only a small number of children in this group.\u003c/p\u003e\u003cp\u003eIn Fig.\u0026nbsp;3A regulatory problems of feeding and eating, sleep, and emotional regulation are shown. Figure\u0026nbsp;3B illustrates co-occurrence of problems of attention, motor development and activity, communication, and language. Most problems are solitary, but a subgroup of children showed co-occurring problems across multiple domains.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e shows associations between child and parental factors and mental health vulnerabilities measured by the CIMHP. Male sex, low gestational age, and low birth weight were associated with an increased risk of problems regarding motor development and activity, communication and interaction and language, but also an increased risk of emotional regulation problems. Further, neonatal complications were associated with problems of motor development and activity, of attention and concentration, and of sleep and emotional regulation. Three or more vulnerabilities at the CIMHP assessment at 9\u0026ndash;10 months were associated with a broad pre-perinatal risk profile.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eAssociations between child and parental factors and main areas of mental health problems identified by the CIMHP (n\u0026thinsp;=\u0026thinsp;7,079)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"10\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c7\" colnum=\"7\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c8\" colnum=\"8\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c9\" colnum=\"9\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c10\" colnum=\"10\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eSleep regulation\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eEating and feeding\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eEmotional regulation and expression\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eCuriosity and interests\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c6\"\u003e\u003cp\u003eAttention and concentration\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c7\"\u003e\u003cp\u003eMotor development and activity\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c8\"\u003e\u003cp\u003eCommunication and social interaction\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c9\"\u003e\u003cp\u003eLanguage\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c10\"\u003e\u003cp\u003eThree or more problems\u003c/p\u003e\u003cp\u003eOR [95% CI]\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003ctr\u003e\u003cth align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e\u003cp\u003eChild factors\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eSex\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGirls\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoys\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1.23 [1.05;1.45]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.99 [0.88;1.12]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.3 [1.08;1.6]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.85 [0.48;1.51]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.11 [0.96;1.29]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e1.21 [1.07;1.38]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e1.20 [1.03;1.40]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e1.66 [1.28;2.15]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e1.27 [1.09;1.49]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGestational age\u003csup\u003ea\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;37 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.67 [0.34;1.33]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.08 [0.71;1.63]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e2.23 [1.37;3.62]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e0.90 [0.12;6.73]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.29 [0.81;2.04]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e1.65 [1.1;2.4]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e2.30 [1.48;3.56]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e2.62 [1.4;4.9]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e2.22 [1.47;3.37]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;37 weeks\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"7\" nameend=\"c8\" namest=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBirth weight\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026lt;\u0026thinsp;2500 g\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.83 [0.54;1.29]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.22 [0.91;1.62]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.52 [1.02;2.26]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e\u003cb\u003e3.94 [1.75;8.7]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.06 [0.75;1.51]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e1.48 [1.11;1.98]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e1.67 [1.21;2.31]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e2.33 [1.49;3.64]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e1.95 [1.44;2.65]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u0026ge;\u0026thinsp;2500 g\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNeonatal complications\u003csup\u003eb\u003c/sup\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e2.81 [1.28;6.18]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.09 [0.48;2.48]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e2.73 [1.13;6.57]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e4.21 [0.56;31.34]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e\u003cb\u003e2.82 [1.36;5.84]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e\u003cb\u003e2.07 [1.0;4.29]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.70 [0.071;4.09]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e2.36 [0.72;7.75]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e2.79 [1.3;5.94]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colspan=\"10\" nameend=\"c10\" namest=\"c1\"\u003e\u003cp\u003e\u003cb\u003eParental factors\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParental ethnicity\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt least one parent born in Denmark\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth parents born outside Denmark\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e\u003cb\u003e1.27 [1.05;1.53]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e\u003cb\u003e1.47 [1.28;1.70]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.16 [0.993;1.45]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.60 [0.85;3.02]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.97 [0.81;1.16]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.98 [0.84;1.15]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e1.19 [0.99;1.43]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e0.79 [0.57;1.09]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e1.44 [1.21;1.72]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParental work status\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAt least one working\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colspan=\"8\" nameend=\"c9\" namest=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eBoth not working\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e0.85 [0.44;1.62]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e1.26 [0.82;1.94]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.08 [0.55;2.14]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e2.48 [0.59;10.37]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e0.51 [0.25;1.04]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e0.99 [0.60;1.62]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e2.20 [1.41;3.44]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.08 [0.44;2.66]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1.34 [0.80;2.24]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParents living together at childbirth\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.15 [0.86;1.55]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.99 [0.78;1.25]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e\u003cb\u003e1.46 [1.07;2.00]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.17 [0.42;3.26]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.21 [0.93;1.57]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.121 [0.96;1.54]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e1.38 [1.06;1.80]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e\u003cb\u003e1.58 [1.05;2.36]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e\u003cb\u003e1.33 [1.02;1.73]*\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eParent more than 10 years of schooling\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eRef\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e1.13 [0.93;1.37]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e0.92 [0.79;1.07]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e1.08 [0.86;1.35]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e1.39 [0.73;2.65]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e1.00 [0.84;1.20]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c7\"\u003e\u003cp\u003e1.14 [0.98;1.33]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c8\"\u003e\u003cp\u003e\u003cb\u003e1.39 [1.16;1.65]**\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c9\"\u003e\u003cp\u003e1.07 [0.80;1.45]\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c10\"\u003e\u003cp\u003e1.08 [0.90;1.29]\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003ctfoot\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003eCIMHP: Copenhagen Infant Mental Health Programme\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003e* P\u0026thinsp;\u0026lt;\u0026thinsp;0.05, ** P\u0026thinsp;\u0026lt;\u0026thinsp;0.001\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd colspan=\"10\"\u003e\u003csup\u003ea\u003c/sup\u003e Gestational age data was partially missing from the Danish Medical Birth Register; available information included 2,876 individuals from the study population. \u003csup\u003eb\u003c/sup\u003e Neonatal complications are defined as neonatal sepsis and/or the need for neonatal respirator treatment.\u003c/td\u003e\u003c/tr\u003e\u003c/tfoot\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eAmong family factors, significant associations were seen in children from families of not-Danish ethnicity showing an increased risk of regulatory problems of sleep and feeding and eating, whereas children of parents with short schooling, unemployment, and not living together at childbirth showed an increased risk of problems with communication and interaction.\u003c/p\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eThe CHNs evaluation of using the CIMHP\u003c/h2\u003e\u003cp\u003eQuestionnaire data included 251 CHNs (89% response) of whom the majority (82%) had more than five years experiences as practicing CHNs. Likewise, the majority of CHNs participating in the focus group interviews had long experiences as practising CHNs, only one was newly educated. The majority of questionnaire respondents (81%) had conducted more than five CIMHS assessments by the time of the study, and at the time of the interviews, each had conducted between eight and 15 child assessments using the CIMHP.\u003c/p\u003e\u003cp\u003eMost (75%) reported to use the CIMHP manual as a standard at home visits (see Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e) and among them, the majority found the manual helpful in identifying areas where the family needed additional support (97%) and when preparing additional support for the family (88%). Still, a considerable part reported difficulties in using the guidelines.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab4\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 4\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eCHNs\u0026rsquo; perspectives on using the Copenhagen Infant Mental Health Programme (CIMHP)\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"4\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eQuestionnaire item\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eYes\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eNo\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eNumber of comments\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eHave you used the manual during feedback of the CIMHS assessment or during planning of additional support/intervention?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e187 (75%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e64 (25%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDo you generally think that the CIMHS assessment helps you get an overview of the child's need for extra support/intervention at 9\u0026ndash;10 months?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e244 (97%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e5 (2%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e42\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDo you think that the CIMHP helps you in planning an intervention for the child?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e220 (88%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e26 (10%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e44\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDo you think that the CIMHP helps you communicate with parents about the child's needs?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e227 (90%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e20 (8%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e33\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDo you find that parents consider the CIMHS assessment to be an advantage compared to usual practice?\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e142 (57%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e76 (30%)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e85\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eThe focus group interviews confirmed questionnaire data on the frequent use of CIMHP in almost all home visits at child ages 9\u0026ndash;10 months, becoming a standard procedure in the participating municipalities. However, limitations in the use of the CIMHP was also reported, and several CHNs did not seem to have integrated the use of manual and guidelines systematically or they considered the guidelines inadequate in their daily practice.\u003c/p\u003e\u003cp\u003e Many CHNs expressed a desire to use the guidelines more frequently, and the focus group discussions revealed that the CHNs acknowledged the value of using the guidelines to discussions with colleagues, but time constraints were considered as a significant hindrance.\u003c/p\u003e\u003cp\u003eSee Table \u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e for an overview of the CHNs\u0026rsquo; perspectives on using the CIMHP.\u003c/p\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab4\" class=\"InternalRef\"\u003e4\u003c/span\u003e here.\u003c/p\u003e\u003cp\u003eIn both the questionnaire comments and focus group interviews, CHNs described the CIMHP as a systematic, structured, and tangible tool that enabled them to capture more nuances and relevant aspects of a child\u0026rsquo;s development, ensuring high quality. One CHN described:\u003c/p\u003e\u003cp\u003e\u0026ldquo;\u003cem\u003eSo, I think the conversation becomes more concrete, and you can more clearly pinpoint the challenges that might exist, and I actually think that it ensures you don\u0026rsquo;t overlook important factors that play a role\u003c/em\u003e\"\u003c/p\u003e\u003cp\u003e Most (90%) CHNs appreciated the CIMHP as it facilitated communication with parents about the child\u0026rsquo;s development, helping them articulate the child's needs more clearly and provide more systematic feedback on the assessment. Some CHNs noted that the CIMHP allowed them to ask parents specific questions, making the dialogue more concrete and in-depth. The method also gave CHNs the opportunity to address issues that parents might not have been concerned about themselves.\u003c/p\u003e\u003cp\u003e A few CHNs mentioned that they found the communication with parents more rigid when using the programme, hindering a more flexible and present dialogue with parents. Focus group discussions revealed that some CHNs were concerned about how to introduce the CIMHP and present the results of the assessment to parents, particularly when it came to terms like 'mental vulnerability'. One CHN expressed concern that the programme could create a dilemma when the parent was not worried, but the assessment indicated vulnerability for the CHN to address.\u003c/p\u003e\u003cp\u003e The majority of CHNs found that parents appreciated the programme, and no resistance or scepticism from parents were reported from the focus groups. Still, 30% of respondents answered 'no' to whether parents valued the CIMHP more than previous practices. In the focus group interview it was noted that the CIMHP assessment likely appeared more valid and credible to parents compared to the CHN's usual methods of assessment and communication:\u003c/p\u003e\u003cp\u003eA: \u003cem\u003e\"...when someone has set something down on paper, it becomes a bit more serious, \u0026hellip;.rather than just casual chatter back and forth. Here, there\u0026rsquo;s really something we need to check off, right?\u003c/em\u003e\"\u003c/p\u003e\u003cp\u003eOverall, the CHNs found the CIMHP to align well with their existing practices, including the purpose of the home visit at child ages 9\u0026ndash;10 months\u003c/p\u003e\u003cp\u003eWhile the CHNs had varying experiences regarding the CIMHP education, all agreed that the programme provided them with a more useful approach to assessing early indicators of mental vulnerability. The CHNs in the focus groups described how the methods substantiated and supported their existing knowledge and way of working, providing \"\u003cem\u003esomething to base one's intuition on\u003c/em\u003e\".\u003c/p\u003e\u003c/div\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this paper, we address the knowledge gap on universal strategies to target infants\u0026rsquo; mental health and developmental risks (\u003cspan additionalcitationids=\"CR24\" citationid=\"CR23\" class=\"CitationRef\"\u003e23\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e25\u003c/span\u003e). We describe the creation and testing of a pragmatic, service-setting based programme that combines a validated screening, the CIMHS (\u003cspan additionalcitationids=\"CR27\" citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e28\u003c/span\u003e), with a standardized manual of child assessments and feedback to parents, and guidelines for action, as well as education of the health professionals involved.\u003c/p\u003e\u003cp\u003eThe new programme, the Copenhagen Infant Health programme, CIMHP, was developed in collaboration with CHNs in 17 Danish municipalities and implemented at CHNs\u0026rsquo; home-visits to infants aged 9\u0026ndash;10 months. The population to be studied included 280 CHNs and 7,079 infants being assessed by CIMHP. Compared to the first version of the CIMHS (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), the use of the current version result in overall lower frequencies of developmental and regulatory problems, with the largest differences seen in emotional problems being identified in 7.4% versus 14.3% in the former CIMHS. Likewise, problems of communication and interaction were identified in 10.2% versus 20.7%, and problems of language development in 3.6% versus 9.2%. These discrepancies reflect that the more precise item definitions, and the addition of a highly standardized manual, as well as the education of CHNs, seem to result in a probably more accurate identification of infant vulnerabilities. Still, this was not explicitly explored in the present study. Also, in accordance with increasing evidence on the importance of early markers of motor development problems (\u003cspan additionalcitationids=\"CR36\" citationid=\"CR35\" class=\"CitationRef\"\u003e35\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e37\u003c/span\u003e) the actual validation process in CIMHP resulted in adding a new item on general motor development leaving the overall frequency of motor development and activity problems to increase from 9.9% when using the former CIMHS (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e) to 15.8% when using CIMHP. Still, further exploration of sensitivity and specificity are needed regarding this as well as the other items of CIMHP.\u003c/p\u003e\u003cp\u003eOur findings show a higher risks in boys across regulatory and developmental functions, and overall more pronounced when compared to previous findings on CIMHS (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e26\u003c/span\u003e), but in line with findings from other studies (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eThe identification of co-occurrent markers of neuro-developmental vulnerability is in line with results from longitudinal studies of autism spectrum disorders and disorders of attention deficit and hyperactivity (\u003cspan additionalcitationids=\"CR10\" citationid=\"CR9\" class=\"CitationRef\"\u003e9\u003c/span\u003e\u0026ndash;\u003cspan citationid=\"CR11\" class=\"CitationRef\"\u003e11\u003c/span\u003e, \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e38\u003c/span\u003e). Moreover, our findings on the CIMHP confirm the pre-perinatal risk profile of developmental psychopathology known from research in older children (\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e). Taken together, our findings point to the potential of the CIMHP for the valid identification of infancy markers of early onset neuro-developmental disorders as early as 9\u0026ndash;10 months of age.\u003c/p\u003e\u003cp\u003eRegarding regulatory problems of eating, sleeping and emotional regulation (RPs), the CIMHP seems to identify these problems with frequencies in line with findings from studies of other populations (\u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e12\u003c/span\u003e, \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e13\u003c/span\u003e, \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e), particularly regarding a minor group affected by multiple or complex RPs. Available research points to a poor prognosis of children with these difficulties and underscores the need of intervention to help parents regulate their child early in life (\u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e15\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eBy systematically including the parents in the child assessment and intervention planning completed by educated CHNs, the CIMHP has potentials to address infants\u0026rsquo; regulatory or developmental vulnerabilities (\u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e21\u003c/span\u003e) through tailoring the parents\u0026rsquo; understanding and knowledge on needs of their child.\u003c/p\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eHealth professionals\u0026rsquo; evaluation\u003c/h2\u003e\u003cp\u003e The pilot implementation of the CIMHP shows broad use and appreciation among CHNs, who evaluated the programme as a structured and concrete method for assessing all aspects of child development, while also supporting communication with parents about the child\u0026rsquo;s needs. Despite these positive findings and the alignment with their existing practices and knowledge, the study highlights areas for further exploration in the ongoing implementation and development of the CIMHP. These include addressing dilemmas in providing feedback and supervision to parents, as well as time constraints related to using the guidelines for action and engaging in colleague discussions.\u003c/p\u003e\u003cp\u003e Together, the findings from the present study highlight the needs of improvements in the overall education of the health professionals involved, as well as elaboration of guidelines for action in municipality settings.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eStrengths and limitations\u003c/h2\u003e\u003cp\u003eThe strengths of this study include the thorough description of the creation of a comprehensive programme, CIMHP, that integrate a validated screening, and research evidence on early developmental psychopathology, as well as the best practices from clinical work, which all together enables transparency and inspiration for other researchers. Further, the CIMHP was tested in a pilot implementation in a large representative child population assessed by CHNs with a high participation and with comprehensive data from national registries and a clinical municipality database. Moreover, supplementary qualitative data provide information on the perspectives of involved health professionals, the CHNs, with high response rate. Overall, these strengths contribute with important knowledge on issues of validity and usefulness of the CIMHP.\u003c/p\u003e\u003cp\u003eStill, the study has not explored feasibility or validity of single items systematically; and overall, a longer period of studying implementation including a thorough process evaluation would have been optimal (\u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e39\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003e The new programme, CIMHP, combines a validated infant mental health screening in dialogue with parents, accompanied by a manual for subsequent feedback and guidelines for actions to promote child health. While the overall validity of the CIMHP seem promising, further refinement of the guidelines for action and enhanced education for CHNs are recommended.\u003c/p\u003e"},{"header":"Abbreviations","content":"\u003cdiv class=\"DefinitionList\"\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHN\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCommunity health nurse\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCIMHS\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCopenhagen Infant Mental Health Screening\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCIMHP\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003eCopenhagen Infant Mental Health Programme\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eCHD\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ethe Child Health Database\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv class=\"DefinitionListEntry\"\u003e\u003cdiv class=\"Term\"\u003eMBR\u003c/div\u003e\u003cdiv class=\"Description\"\u003e\u003cp\u003ethe Danish Medical Birth Register\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eEthics and approval\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eThe implementation of the CIMHP is part of the quality development within the existing community health care (33) offered free of charge to all infant families. Parents are free to withdraw from these services, including participation in particular assessments. Parents were informed about the study on CIMHP by the CHNs and their participation in testing the CIMHP at home -visits were fully voluntary. The study has been presented for the Research Ethics Committee of the Capital Region of Denmark and has been approved by the SDU Research \u0026amp; Innovation Organization (RIO), University of Southern Denmark, No. 10.371. Being based on data from municipality health databases and National registries, with no individual contacts with the study population beyond existing municipality routines, no further demands on individual consent to participate have been required.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eContent to publication\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eNot applicable\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eClinical trial number\u003c/strong\u003e\u003cbr /\u003e Not applicable\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAvailability of data and materials\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eData will not be publicly available because they contain sensitive material. Permission to access data for scientific purposes on reasonable request is possible for researchers meeting the criteria for access to confidential information. For researchers in a European country, permission to access these data for scientific purposes can be obtained from the personal data agency SDU Research \u0026amp; Innovation (RIO), University of Southern Denmark. Information on how to apply for data access can be obtained by emailing [email protected]. For researchers outside a European country, permission to data access can be obtained for scientific purposes on reasonable request from the Danish Data Protection Agency by emailing kd.tenyslitatad@td.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eCompeting interests\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe authors declare that they have no competing interests.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eFunding\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe development and implementation of CIMHP was co-financed by the participating municipalities and the Centre of Infant and Toddler Research at the National Institute of Public Health, University of Southern Denmark.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; contributions\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003eAMS is the principal investigator. AMS and JA developed the CIMHP and led the design of the study. AMS led the preparation of the manuscript for submission and wrote the first draft. JA and LF carried out the data collection and the acquisition of data. JA \u0026amp; CBP carried out the statistical analyses and LF \u0026amp; SKW the qualitative analyses. All authors contributed to the drafting of the manuscript and critical revisions of the manuscript. All authors read and approved the final manuscript.\u003c/p\u003e\n\u003ch2\u003e\u003cstrong\u003eAcknowledgements\u003c/strong\u003e\u003c/h2\u003e\n\u003cp\u003eThe project group would like to thank the group of professionals for their contribution to the development of CIMHP: Developmental psychologists \u003cem\u003eSusanne Landorph \u003c/em\u003eand \u003cem\u003eTina Tingleff\u003c/em\u003e; Child psychiatrists \u003cem\u003eAnne Lise Olsen, Jette Asmussen\u003c/em\u003e and\u003cem\u003e Male Moskowicz; \u003c/em\u003eCommunity health nurses \u003cem\u003eAnne Lorentzen, Annette Hvidberg Larsen, Dorthe Svendsen, Ellen Blemmer, Eva Hellebek, Hannah G. Nielsen, Helga Bohm, Jette L\u0026uuml;tzen, Lene Kj\u0026aelig;r, Lisbeth Sander, Lisbet Holst, Lende Caspersen, Lilly Friberg Wulff, Majbritt Vonsild, Pia J\u0026oslash;nsson \u003c/em\u003eand\u003cem\u003e Sine Bregn Machon;\u003c/em\u003e and leading health nurses \u003cem\u003eHelle Erstling Rasmussen, Lone Dahlstr\u0026oslash;m, Marika Jensen \u003c/em\u003eand\u003cem\u003e Ulla Dupont\u003c/em\u003e. Further, thanks to all leading and practicing CHNs and parents and children from the participating municipalities (Aller\u0026oslash;d, Drag\u0026oslash;r, Egedal, Fredensborg, Gladsaxe, Glostrup, Herlev, Hiller\u0026oslash;d, H\u0026oslash;je-Taastrup, Ish\u0026oslash;j, Kalundborg, K\u0026oslash;ge, Roskilde, Rudersdal, Taarnby, Vallensb\u0026aelig;k, Vejle).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026rsquo; information\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eAMS\u003c/em\u003e, MD, DM SCI, Professor in Child Psychiatry, NIPH, SDU, experienced in clinical child psychiatry and epidemiological research in developmental psychopathology.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eCBP\u003c/em\u003e, MD, PhD student, experienced in quantitative methods and paediatrics.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eJA, \u003c/em\u003eHealth nurse, MPH, PhD, Researcher, NIPH, SDU, experienced in community health nursing, and research collaborations with CHNs.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eLF, \u003c/em\u003eHealth Nurse, MPH, NIPH, SDU, experienced in community health nursing.\u003c/p\u003e\n\u003cp\u003e\u003cem\u003eSKW, \u003c/em\u003eMSc, PhD, Researcher, NIPH, SDU, experienced in qualitative methods and process evaluation.\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eVasileva M, Graf RK, Reinelt T, Petermann U, Petermann F. Research review: A meta-analysis of the international prevalence and comorbidity of mental disorders in children between 1 and 7 years. J Child Psychol Psychiatry. 2021;62(4):372-81.\u003c/li\u003e\n\u003cli\u003eSkovgaard AM. Mental health problems and psychopathology in infancy and early childhood. An epidemiological study. Dan Med Bull. 2010;57(10):B4193.\u003c/li\u003e\n\u003cli\u003ePolanczyk GV, Salum GA, Sugaya LS, Caye A, Rohde LA. Annual research review: A meta-analysis of the worldwide prevalence of mental disorders in children and adolescents. J Child Psychol Psychiatry. 2015;56(3):345-65.\u003c/li\u003e\n\u003cli\u003eConti G, Heckman JJ. The developmental approach to child and adult health. Pediatrics. 2013;131 Suppl 2(Suppl 2):S133-41.\u003c/li\u003e\n\u003cli\u003eBeckwith L. Prevention science and prevention programs. Handbook of infant mental health, 2nd ed. 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Infancy predictors of hyperkinetic and pervasive developmental disorders at ages 5-7\u0026nbsp;years: results from the Copenhagen Child Cohort CCC2000. J Child Psychol Psychiatry. 2014;55(12):1328-35.\u003c/li\u003e\n\u003cli\u003eJaspers M, de Winter AF, Buitelaar JK, Verhulst FC, Reijneveld SA, Hartman CA. Early childhood assessments of community pediatric professionals predict autism spectrum and attention deficit hyperactivity problems. J Abnorm Child Psychol. 2013;41(1):71-80.\u003c/li\u003e\n\u003cli\u003eJohnson MH, Gliga T, Jones E, Charman T. Annual research review: Infant development, autism, and ADHD--early pathways to emerging disorders. J Child Psychol Psychiatry. 2015;56(3):228-47.\u003c/li\u003e\n\u003cli\u003eAsmussen J, Davidsen KA, Olsen AL, Skovgaard AM, Bilenberg N. The longitudinal association of combined regulatory problems in infancy and mental health outcome in early childhood: a systematic review. Eur Child Adolesc Psychiatry. 2023.\u003c/li\u003e\n\u003cli\u003eWinsper C, Wolke D. Infant and toddler crying, sleeping and feeding problems and trajectories of dysregulated behavior across childhood. J Abnorm Child Psychol. 2014;42(5):831-43.\u003c/li\u003e\n\u003cli\u003eGalling B, Brauer H, Struck P, Krogmann A, Gross-Hemmi M, Prehn-Kristensen A, et al. The impact of crying, sleeping, and eating problems in infants on childhood behavioral outcomes: A meta-analysis. Frontiers in Child and Adolescent Psychiatry. 2023;1.\u003c/li\u003e\n\u003cli\u003eJaekel J, Sorg C, Breeman L, Baumann N, Bilgin A, Bauml JG, et al. Early regulatory problems and parenting: life-long risk, vulnerability or susceptibility for attention, internalizing and externalizing outcomes? Eur Child Adolesc Psychiatry. 2021;30(10):1523-31.\u003c/li\u003e\n\u003cli\u003eBeauchaine TP, Cicchetti D. Emotion dysregulation and emerging psychopathology: A transdiagnostic, transdisciplinary perspective. Dev Psychopathol. 2019;31(3):799-804.\u003c/li\u003e\n\u003cli\u003eZeanah CH. Psychopathology. In: Zeanah CH, editor. Handbook of Infant Mental Health. New York: The Guilford Press; 2018. p. 297-479.\u003c/li\u003e\n\u003cli\u003eZero to Five: National Center for Infants, T. F., Washington D. C. (2016). Diagnostic classification 0-5: Diagnostic classification of mental health and developmental disorders of infancy and early childhood (DC:0-5).\u003c/li\u003e\n\u003cli\u003eVitaro F, Tremblay R. Clarifying and Maximizing the Usefulness of Targeted Preventive Interventions. In: Rutter M, Bishop D, Pine D, Scott S, Stevenson J, Taylor E, et al., editors. Rutter's Child and Adolescent Psychiatry. 5 ed. Oxford: Blackwell Publishing; 2008. p. 989-1008.\u003c/li\u003e\n\u003cli\u003eRose G, Khaw K-T, Marmot M. Rose's Strategy of Preventive Medicine: Oxford University Press; 2008 01 Sep 2009.\u003c/li\u003e\n\u003cli\u003eZeanah CH. The Clinical Science of Early Experiences. . In: Zeanah CH, editor. Handbook of Infant Mental Health. New York: The Guilford Press; 2018. p. 5-24.\u003c/li\u003e\n\u003cli\u003eGroach C, McCall R. Community Based Interventions and Services. In: Rutter M, Bishop D, Pine D, Scott S, Stevenson J, Taylor E, et al., editors. Rutter's Child and Adolescent Psychiatry. 5 ed. Oxford: Blackwell Publishing; 2008. p. 971-88.\u003c/li\u003e\n\u003cli\u003eIzett E, Rooney R, Prescott SL, De Palma M, McDevitt M. Prevention of Mental Health Difficulties for Children Aged 0-3 Years: A Review. Front Psychol. 2020;11:500361.\u003c/li\u003e\n\u003cli\u003eHare MM, Landis TD, Hernandez ML, Graziano PA. A Systematic Review of Infant Mental Health Prevention and Treatment Programs. Evid Based Pract Child Adolesc Ment Health. 2024;9(1):138-61.\u003c/li\u003e\n\u003cli\u003eHogg S, Moody J. Understanding and supporting mental health in infancy and early childhood\u0026ndash; a toolkit to support local action in the UK. UNICEF UK. 2023.\u003c/li\u003e\n\u003cli\u003eAmmitzb\u0026oslash;ll J, Holstein BE, Wilms L, Andersen A, Skovgaard AM. A new measure for infant mental health screening: development and initial validation. BMC Pediatr. 2016;16(1):197.\u003c/li\u003e\n\u003cli\u003eAmmitzb\u0026oslash;ll J, Skovgaard AM, Holstein BE, Andersen A, Kreiner S, Nielsen T. Construct validity of a service-setting based measure to identify mental health problems in infancy. PLoS One. 2019;14(3):e0214112.\u003c/li\u003e\n\u003cli\u003eAmmitzb\u0026oslash;ll J, Thygesen LC, Holstein BE, Andersen A, Skovgaard AM. Predictive validity of a service-setting-based measure to identify infancy mental health problems: a population-based cohort study. Eur Child Adolesc Psychiatry. 2018;27(6):711-23.\u003c/li\u003e\n\u003cli\u003eSkovgaard AM, Houmann T, Christiansen E, Olsen EM, Landorph SL, Lichtenberg A, et al. 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. Eur Child Adolesc Psychiatry. 2008;17(5):290-8.\u003c/li\u003e\n\u003cli\u003eGodoy L, Carter AS, Silver RB, Dickstein S, Seifer R. Mental health screening and consultation in primary care: The role of child age and parental concerns [corrected]. J Dev Behav Pediatr. 2014;35(5):334-43.\u003c/li\u003e\n\u003cli\u003eHolland WW, Stewart S. Screening in Disease Prevention: What Works? . Oxford: Radcliffe Publishing. 2005.\u003c/li\u003e\n\u003cli\u003eHolstein BE, Henriksen TB, Rayce SB, Ringmose C, Skovgaard AM, Teilmann GK, et al. Mental health and psychiatric illness among children aged 0-9 years. Copenhagen: The Danish Council for Health Promotion and Disease Prevention; 2021.\u003c/li\u003e\n\u003cli\u003eSkovgaard AM, Wilms L, Johansen A, Ammitzb\u0026oslash;ll J, Holstein BE, Olsen EM. Standardised measuring the health of infants and toddlers in community health services. Ugeskrift for laeger. 2018;180(34).\u003c/li\u003e\n\u003cli\u003eGreen J, Thorogood N. Qualitative methods for health research. 4th edition. ed. Los Angeles: SAGE; 2018.\u003c/li\u003e\n\u003cli\u003eLemcke S, Juul S, Parner ET, Lauritsen MB, Thorsen P. Early signs of autism in toddlers: a follow-up study in the Danish National Birth Cohort. J Autism Dev Disord. 2013;43(10):2366-75.\u003c/li\u003e\n\u003cli\u003eWest KL. Infant Motor Development in Autism Spectrum Disorder: A Synthesis and Meta-analysis. Child Dev. 2019;90(6):2053-70.\u003c/li\u003e\n\u003cli\u003eAthanasiadou A, Buitelaar JK, Brovedani P, Chorna O, Fulceri F, Guzzetta A, et al. Early motor signs of attention-deficit hyperactivity disorder: a systematic review. Eur Child Adolesc Psychiatry. 2020;29(7):903-16.\u003c/li\u003e\n\u003cli\u003eKoch SV, Andersson M, Hvelplund C, Skovgaard AM. Mental disorders in referred 0-3-year-old children: a population-based study of incidence, comorbidity and perinatal risk factors. Eur Child Adolesc Psychiatry. 2021;30(8):1251-62.\u003c/li\u003e\n\u003cli\u003eBartholomew L, Parcel G, Kok G, Gottlieb N, Fern\u0026aacute;ndez M. Planning Health Promotion Programs: An intervention mapping approach. 3 ed. San Francisco: Jossey-Bass; 2011.\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":false,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true},"keywords":"Mental health, infancy, universal preventive intervention, community health nurses, child health surveillance","lastPublishedDoi":"10.21203/rs.3.rs-6698283/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-6698283/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003e\u003cstrong\u003eBackground:\u003c/strong\u003e Universal programmes that systematically address mental health problems in infancy are needed. This study describes the development and testing of a community-based programme combining screening with standardized guidelines for feedback and intervention to be completed by educated community health nurses (CHNs).\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eMethods:\u003c/strong\u003e The manual of the previously validated Copenhagen Infant Mental Health Screening, CIMHS, was updated in collaboration with experts in the field and practising CHNs to systematically include parents in child assessment and in intervention planning intervention. Furthermore, formalized training for CHNs was included.\u003c/p\u003e\n\u003cp\u003eThe resulting programme, the Copenhagen Infant Mental Health Programme (CIMHP), was evaluated in a multi-method study in seventeen municipalities using data from the municipality database and Danish National registries. Qualitative data included questionnaires and interviews with CHNs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eResults: \u003c/strong\u003eThe CIMHP comprises a manual for educated CHNs’ screening 9-10 months infants in dialogue with the parents and guidelines providing suggestions for action to address infant regulatory and developmental vulnerabilities within community settings.\u003c/p\u003e\n\u003cp\u003eA total of 280 CHNs used CIMHP at home visits to a total of 7,079 infants and found two problems of regulation (feeding, sleep, emotional regulation) or development (cognitive and motor functions) in 12.1% (N=860) of the infants and 10.4% (N=736) having three or more problems. A pattern of risks associated with regulatory and developmental problems at 9-10 months were associated male gender and being exposed to pre- and perinatal and family-related adversities.\u003c/p\u003e\n\u003cp\u003eQualitative data suggest face validity, usability, and parental acceptance of the programme as evaluated by CHNs.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConclusions: \u003c/strong\u003eCIMHP integrates a global screening of mental health vulnerabilities, to be completed in dialogue with parents, together with guidelines to support CHNs’ feedback and actions to promote child health. Validity and feasibility seem promising. Still, further improvements to the guidelines for action in community settings and education of health professionals are needed.\u003c/p\u003e","manuscriptTitle":"The Copenhagen Infant Mental Health Programme – Development and testing of a pragmatic service-setting-based approach to screening and intervention","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-07-22 16:22:06","doi":"10.21203/rs.3.rs-6698283/v1","editorialEvents":[{"type":"communityComments","content":0},{"type":"reviewerAgreed","content":"124964763754457276965813986892090888202","date":"2026-05-14T08:44:02+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74484472450237893034835014843588995057","date":"2026-05-11T13:56:50+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"217182243784377774492545102847430000224","date":"2025-08-05T11:47:13+00:00","index":"hide","fulltext":""},{"type":"editorInvitedReview","content":"","date":"2025-07-28T11:39:58+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"15908251359996652951785805908158202482","date":"2025-07-25T16:42:56+00:00","index":"hide","fulltext":""},{"type":"reviewerAgreed","content":"74933242481631302040574986317265742945","date":"2025-07-25T10:01:51+00:00","index":"hide","fulltext":""},{"type":"reviewersInvited","content":"","date":"2025-07-15T13:57:33+00:00","index":"","fulltext":""},{"type":"editorInvited","content":"","date":"2025-05-24T08:38:06+00:00","index":"","fulltext":""},{"type":"editorAssigned","content":"","date":"2025-05-23T06:13:38+00:00","index":"","fulltext":""},{"type":"checksComplete","content":"","date":"2025-05-23T06:10:20+00:00","index":"","fulltext":""},{"type":"submitted","content":"BMC Pediatrics","date":"2025-05-19T10:53:45+00:00","index":"","fulltext":""}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"bmc-pediatrics","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":false,"externalIdentity":"bped","sideBox":"Learn more about [BMC Pediatrics](http://bmcpediatr.biomedcentral.com/)","snPcode":"","submissionUrl":"https://www.editorialmanager.com/bped/default.aspx","title":"BMC Pediatrics","twitterHandle":"BMC_series","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"em","reportingPortfolio":"BMC Series","inReviewEnabled":true,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"162a675f-056b-4c43-903f-4ce72a64577c","owner":[],"postedDate":"July 22nd, 2025","published":true,"recentEditorialEvents":[{"type":"reviewerAgreed","content":"124964763754457276965813986892090888202","date":"2026-05-14T08:44:02+00:00","index":116,"fulltext":""},{"type":"reviewerAgreed","content":"74484472450237893034835014843588995057","date":"2026-05-11T13:56:50+00:00","index":115,"fulltext":""}],"rejectedJournal":[],"revision":"","amendment":"","status":"under-review","subjectAreas":[],"tags":[],"updatedAt":"2025-07-22T16:22:06+00:00","versionOfRecord":[],"versionCreatedAt":"2025-07-22 16:22:06","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-6698283","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-6698283","identity":"rs-6698283","version":["v1"]},"buildId":"XKTyCvWXoU3ODBz1xrDgd","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}