Archives ofDisease in Childhood 1996; 74: 115-120

The effect of a child's disability on mother'smental health

K Lambrenos, A M Weindling, R Calam, A D Cox

AbstractThe prevalence of maternal depressionwas investigated in the mothers of 96children: 30 premature infants at risk forthe development ofcerebral palsy; 35 pre-mature infants considered not to be at riskfor the development ofcerebral palsy; and31 healthy fullterm infants. There wereequally high levels of depression in allthree groups of mothers, regardless ofbirth status, prediction of disability, orpresence of actual disability, throughoutthe first year of the children's lives.Depressed mothers were, however, foundto have significantly more psychosocialstress. An early physiotherapy interven-tion had no effect on the prevalence ofdepression in mothers whose childrenwere at risk for the development of cere-bral palsy.(Arch Dis Child 1996; 74: 115-120)

Keywords: maternal depression, preterm, cerebralpalsy, motor disability.

Department ofChildand AdolescentPsychiatry andPsychology, UniversityofLiverpoolK Lambrenos

Department of ChildHealth, University ofLiverpoolA M Weindling

School ofPsychiatryand BehaviouralSciences, University ofManchesterR Calam

Departnent of Childand AdolescentPsychiatry, UMDS,Guy's Hospital,LondonA D Cox

Correspondence to:Dr K Lambrenos,Department of ChildPsychiatry, Alder HeyChildren's Hospital, EatonRoad, LiverpoolL12 2AP.

Accepted 4 October 1995

Several studies have indicated that thepresence in a family of a child with a physicaldisability may be detrimental to maternalmental health. 1-4 If these adverse effects are tobe prevented, there needs to be an understand-ing of the processes involved and a knowledgeof when and how a mother's mental health ismost likely to be affected. In previous studies,this was often not possible because childrenwith different disabilities were groupedtogether45 or samples included children ofwidely differing ages.46 Often children havebeen identified from a clinical population butthese can differ from children with similar dis-abilities in the community. Birth and earlychild rearing can have an adverse effect onmaternal mental health even where there is nodisability in the child,7 so a comparison withhealthy children without disability is necessaryto understand the specific effects of particulardisabilities.

Ultrasound scanning of the neonatal brainhas made it possible to detect intracraniallesions which are associated with the develop-ment ofmotor problems. Scans with no abnor-malities are usually a reasonably reliableindicator of subsequent normal motor devel-opment.8 9 Using this technique infants at riskfor the development of cerebral palsy canbe identified during the weeks after birthwhile they are still on a neonatal intensive careunit (NICU). Because parents are routinelyinformed of the results of such scans andpredicted outcomes, it is possible to study

prospectively the impact of predicted andactual child disability on the mental health ofthe mothers. Questions raised include whethermaternal depression is precipitated by medicalstaff communicating their predictions aboutthe later development of the child during theneonatal period; or whether it is only when theparent recognises actual disability in the childat a later date that depression ensues. Perhapsthe recognition of delay itself is not sufficient,but rather a growing awareness of how thechild might have been as its development fallsbehind that of peers. The burden of care canbe expected to weigh differently according tothe child's disability and age and social devel-opment. Other factors include the adequacy ofsupport systems, restriction of social life, andthe impact of the child's disability on otherfamily relationships. All these can contribute toalterations in maternal mental state.

Preterm birth has also been associated withpsychological, social, and environmentalstressors, known collectively as conditions ofpsychosocial deprivation.10-2 Such conditionshave themselves been associated with higherlevels of depression in mothers.'3 14 The presentstudy provided an opportunity to examine someof these issues during the first year of life, bycomparing preterm infants predicted to be atrisk for the development of cerebral palsy byneonatal ultrasound scans (half of whom hadreceived an early physiotherapy intervention)with preterm infants not predicted to be at riskfor the development of cerebral palsy, and withhealthy infants.

This study was designed to test the followinghypotheses: (1) that when disability is pre-dicted in preterm infants more mothers willbecome depressed than when it is not, or incomparison with mothers of healthy terminfants; (2) that rates of maternal depressionwill be higher when their children have aphysical disability; (3) that mothers living withhigh levels of psychosocial adversity will bemore depressed than mothers living in lessstressful conditions; (4) that predicted oremerging disability combined with psycho-social adversity will result in more mothersbecoming depressed; and (5) that the rates ofdepression in mothers whose children receiveearly physiotherapy intervention will be lowerthan for mothers whose children are at risk ofimpaired neurodevelopment but who are notoffered intervention.

MethodsOur study was embedded within an interven-tion study designed to assess the impact ofearly physiotherapy on the motor development

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of preterm infants predicted to developcerebral palsy on the basis of ultrasound scans.The sample therefore included a subset ofmothers involved in that study, with the addi-tion of two contrast groups, namely mothers ofa group of preterm infants not predicted todevelop cerebral palsy and mothers of a groupof healthy term infants.

SELECTION OF THE SAMPLEPreterm infants at risk for development of cerebralpalsyAll babies admitted to the NICUs of three largeurban hospitals were routinely screened bycranial ultrasound. The scans were reviewedby a single observer (AMW) for evidence ofporencephalic cysts, cystic periventricular leuco-malacia, hydrocephalus, and persistentechodensities.

Before babies with abnormal scans were dis-charged from the NICU, the scans were shownto the parents and possible neurodevelopmen-tal consequences were explained. The parentswere invited to take part in a study that wouldexamine the effects of an early physiotherapyintervention.At discharge all these infants were con-

sidered to be neurologically normal, that isnot in a coma, not fitting, and with no overtdisturbance of muscle tone, and feeding andresponding appropriately for their post-menstrual age. There were no overt signs ofphysical disability so far as the parents and themedical staff were concerned.

Half of this group of preterm infants withabnormal cranial scans was randomly allocatedto a group receiving standard community care,that is, monitoring by their own general practi-tioners and health visitors as well as attendingregular hospital follow up clinics. As and whensigns of neurological dysfunction appeared,they were referred to the local child develop-ment centre for assessment and treatment bythe form of physiotherapy routinely practisedthere, usually Bobath based.'5 16The other half of the infants with abnormal

cranial scans was randomly allocated to agroup receiving an early physiotherapy inter-vention. When these babies reached term, theywere seen in their own homes by a physiother-apist, at first weekly and then at increasingintervals over the first year of their lives . Thephysiotherapist used Bobath techniques toadvise the mothers on holding and positioningtheir babies to promote normal posture, withthe aim of developing normal muscle tone,inhibiting abnormal postural reactions, andminimising contractures. Later advice wasgiven about handling and playing with thebaby to enhance normal movement patterns.

Over a two year period, we recruited all 40eligible singleton infants and their mothersfrom the physiotherapy intervention study.Five of these infants died before the first inter-view at 6 weeks. Of the remaining 35 infants,three died during the course of the study, onefamily moved and could not be traced, and onefamily decided to leave the study after 6months. This left a sample of 30 infants, all

Table 1 Results of cranial ultrascans for 30 babies bornprematurely, considered to be at risk for the development ofcerebral palsy

NoScan result of babies

Cystic periventricular leucomalacia 14Intraventricular haemorrhage and ventricular

dilatation 2Intraventricular haemorrhage and parenchymal

involvement 4Hydrocephalus (arrested and shunted) 6Persistent echodensities 4

with abnormal cranial ultrasound scans (table1). All had been ventilated during the neonatalperiod. Of these 30 babies, 16 received earlyphysiotherapy and 14 received standard carewith the introduction of physiotherapy whensigns of neurological dysfunction weredetected. We examined the effect on themother of predicting disability and of the earlyintroduction of physiotherapy.

Community group of healthy preterm infantsEach of the 40 infants we recruited from thephysiotherapy study was matched for gesta-tional age, birth weight, and sex with the nextpreterm infant admitted to any of the threeNICUs who did not have an abnormal brainscan. All had been mechanically ventilated.Forty healthy preterm infants were thusrecruited during the same time period as the atrisk group. Of these 40, two died during thestudy period, two families moved away andcould not be traced, and one family refused toparticipate after the initial interview. This left35 infants in the preterm community group.

Community group of term infantsThirty one 12 month old children and theirmothers were recruited from the communitywith the help of health visitors from one sectorof the city. We examined birth books for theyear before the month of recruitment and con-tacted all eligible babies' mothers. Criteria forrecruitment were that there had been noreported complications during the pregnancyor labour. None of the infants had been bornprematurely or spent time on an NICU. Allwere considered by their health visitors to bedeveloping normally. None was suffering froma chronic illness or disability.

Whole sampleThe total sample thus consisted of 96 mothersand their infants - 30 mothers of infants withabnormal brain scans who were predicted todevelop cerebral palsy, 35 mothers of healthypreterm infants, and 31 mothers of healthyterm infants. Recruitment was based entirelyon child characteristics; mothers wereexpected to vary considerably. The character-istics of mothers and children are described intable 2.

PSYCHOSOCIAL ASSESSMENTEmotional disorder in the mother was assessed

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Table 2 Characteristics of the 96 mothers and babies atrecruitment

At risk Infants not Fuilterminfants at risk infants(n=30) (n=35) (n=31)

Gestational age (weeks)Median 28 29 40Range 23-34 25-34 39-42

No of males 14 (47%) 21 (60%) 24 (70%)Singleton birth 30 35 31Ventilated neonatally 30 35 0Abnormal ultrasound scans 30 0 tMother's age at birth (years)Median 26 25 30Range 21-40 17-35 20-39

Social classaI 0 0 3II 4 5 8III 9 10 10IV 6 11 3V 11 9 7

aSocial class is based on Registrar General's Classification ofOccupations (1980) for father's occupation where currentlyemployed, last occupation where currently unemployed, andmother's current or last occupation if single parent mother.tFull term babies did not receive ultrasound scans duringneonatal period.

in two ways. First, we administered the malaiseinventory, a 24 item self report questionnairewhich uses a threshold of 7 to indicate thepresence of emotional disorder.17 Second, allmothers received a semistructured interviewdesigned to detect depression. Depression wasdiagnosed using the information gathered andthe DSM-III R criteria.'8 In those cases identi-fied by the malaise inventory, the emotionaldisorder detected was defined as depression bythe results of the semistructured interview.The mother's relationship with her partner,

where one existed, was assessed by the selfreport dyadic adjustment scale (DAS). 19

Several psychosocial adversities havebeen shown to be related to depression inwomen.13 1420 A semistructured interview wasconstructed in order to collect data on themother's demographic and social background.(A copy of the interview can be obtained fromKL.) Twelve adversities were considered inthis study.(1) Deprived inner city location: mothers wereconsidered to be at risk if they had an inner citypostal code.(2) Housing problems: these were reported bythe mothers and could be problems with thefabric of the dwelling or problems with neigh-bours or the environment.(3) Unemployed head of household: unem-ployment lasting at least one month before theinterview date.(4) Mother unemployed: mother not workingoutside the home. Many were on maternityleave but did not expect to be able to return towork. If this was so they were regarded asunemployed.(5) Social class: the five classes of the RegistrarGeneral's Classification of Occupations2l wereused for father's occupation if currentlyemployed, or last occupation if currently un-employed, or mother's current or last occupa-tion if she was a single parent.(6) Four or more children living in the home.(7) No stable relationship: a stable relation-ship was one where the mother and her hus-

band or partner had been together for at leastone year before the interview took place.(8) Poor relationship with partner: this wasdefined by a score of 96 or less on the DAS.19(9) Problems with mother's family of origin: asperceived by her.(10) Isolation from social contacts: the mothersaw family or friends less than once a week.(11) Feelings of loneliness: the motherexpressed feeling lonely. She may or may nothave been isolated from social contacts.(12) No confidante: that is, no adult to whomshe could talk about important issues.

Previous research has shown that while eachof these adversities could be coped with alone,there is an additive effect.20 22 23 With this inmind we derived a psychosocial adversity scale.The presence of each risk factor scored 1, itsabsence scored 0. This gave a possible range ofscores from 0 to 12. We considered a score of4 or more to indicate psychosocial disadvan-tage.

INFANT ASSESSMENTThe motor development of the 65 preterminfants was assessed using the Bayley motordevelopment scale,24 which is based on norma-tive maturational developmental data. We paidparticular attention to the achievement ofmajor milestones such as sitting indepen-dently, weight bearing, and walking. The childwas also systematically observed for thepresence or absence of obvious visual or motordisability consistent for example with a diag-nosis of hemiplegia or blindness.

TIMING OF ASSESSMENTSA research psychologist saw each of thepreterm mother-infant dyads three times in thefirst year of the baby's life. Interviews werecarried out in the home when the child was 6weeks, 6 months, and 12 months post term.(Term was considered to be 40 weeks post-menstrual age.) The infant assessment wascarried out at 6 months and 12 months postterm. The same psychologist saw infants bornat term and their mothers when the infantsreached their first birthday. All visits were car-ried out within two weeks of target dates.

DATA ANALYSISData were analysed using the SPSS-PC statis-tical package: x2, Fisher's exact test, one or twoway analysis of variance (ANOVA), andStudent's t test were used as appropriate.

ResultsOVERALL LEVELS OF DEPRESSIONOn the basis of the malaise inventory scores,the prevalence of depression among themothers of the 65 preterm infants remainedconstant across the first year of the babies'lives: 18 (28%) were depressed at 6 weeks, 19(29%) at 6 months, and 17 (26%) at 12months. Of the 17 depressed at 12 months,three had not shown depression earlier. The

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Table 3 Association ofpsychosocial adversity and depression in 96 mothers when theirbabies were 12 months old

Not Odds 95%Depressed depressed ratio Confidence interval p (a2J

Inner city address 10 24Outer city address 15 47 1-3 0 5 to 3-3 NSSocial class III+IV+V 24 52Social class I+II 1 19 0-1 0-01 to 0 9 0 03Unemployed head of household 14 15Employed head of household 11 56 4-8 18 to 12-6 0003Mother unemployed 19 39Mother employed 6 32 2-3 0 9 to 7-3 NSPoor relationship with partner 13 12Good relationship with partner 11 56 5-5 20 to 15-2 0-001Problems with housing 13 9No problems 12 62 7-5 2-6 to 21-4 0-0002Problems with family of origin 12 11No problems 13 60 5-0 1-8 to 13-9 0 003Isolation of mother 9 8Mother not isolated 16 63 4-4 1-5 to 13-3 0-01Feelings of loneliness 19 29Not lonely 6 42 4-6 1-6 to 12-9 0 005No confidante 9 11Confidante available 16 63 3-2 1 1 to 9-1 0-05

prevalence was similar in the 31 mothers (n= 8,26%) of healthy term infants when theirchildren were 12 months old.

PREDICTED DISABILITY AND MATERNAL

DEPRESSIONAt 6 weeks, 10 (33%) of the 30 mothers ofinfants who had been considered to be at riskfor the development of cerebral palsy were

depressed, compared to eight of the 35mothers of healthy preterm infants (23%).There was no significant difference betweenthe two groups (t=0 99; p=0 33; df=50).

At 6 months, nine (30%) of the 30 mothersof infants predicted to develop cerebral palsywere depressed compared to 10 (29%) of the35 mothers of healthy preterm infants. Therewas no significant difference between the twogroups (t=0-67; p=051; df=56).

At 12 months, it was possible to comparethe group of mothers of infants predicted todevelop cerebral palsy both with the mothersof healthy preterm infants and with themothers of healthy term infants. Eight (27%)of the 30 mothers of infants predicted todevelop cerebral palsy were depressed com-

pared to nine (26%) of the 35 mothers ofpreterm infants not at risk, and eight (26%) ofthe 31 mothers of term infants. A one wayANOVA revealed no significant differencebetween the three groups (F=0-03; p=0Q97;df=2). It appeared that the prediction of dis-ability, which paediatricians based on ultra-sound scan evidence, did not result in mothersbecoming more depressed.

ACTUAL DISABILITY AND MATERNAL

DEPRESSIONA second hypothesis was that the actualappearance of physical disability would havean effect on depression in the mothers.At 6 weeks the babies were not assessed for

delay or for emerging disability. At 6 months itwas difficult to define motor disability. Forexample, if the motor milestone of sitting inde-

pendently is used as an indicator of normaldevelopment,2' then 74% of the 65 prematureinfants were delayed (25 of the 30 babies con-sidered to be at risk for motor impairment, and23 of the 35 of the babies not considered to beat risk). At 12 months, 25 of the 30 infants pre-dicted to develop cerebral palsy showed signsof disability, including failure to use a limb,failure to pull to stand, severe motor incoordi-nation, and lack ofvision. These would be con-sistent with diagnoses of spastic diplegia,hemiplegia, quadriplegia, and blindness. Noneof the 35 healthy preterm infants or of the 31healthy term infants displayed any signs of dis-ability.Of the 25 mothers of infants with disability

at 12 months, 7 (28%) were depressed, com-pared to nine (26%) of the 35 mothers ofpreterm infants not at risk, and eight (26%) ofthe 31 mothers of term infants. A one wayANOVA showed no significant differencebetween this group and the mothers of healthypreterm and healthy term infants (F=0.09;p=0916; df=2 ). Hence the appearance ofdisability was not associated with level ofdepression in the mothers.

PSYCHOSOCIAL ADVERSITY AND MATERNALDEPRESSIONInformation was gathered on the 12 adversitiesdescribed above. Initially we examined therelation between the 12 adversities and thelevel of depression for the total sample of 96mothers of 12 month old infants. There weretoo few mothers without a stable relationshipto test for significance. Similarly there werevery few mothers with four or more children.x2 Tests were carried out for each of theremaining 10 adversities (table 3). An innercity address and whether or not the mother wasunemployed were not significantly related todepression. The proportion of mothers withdepression was significantly higher in the pres-ence of each of the remaining eight adversities.When the 65 mothers of 12 month old

babies who had been born prematurely wereexamined alone, similar patterns emerged butwith two differences (table 4). The lack of aconfidante ceased to be significant, and socialclass also failed to reach significance, thoughthis had only just reached significance in thelarger group so the change is likely to be anartefact of sample size.The importance of each of the psychosocial

adversities changed over the course of the yearwhen data were collected (table 5). At 6 weeks,there were no significant differences in thenumbers ofmothers who were depressed in thepresence of each adversity with one exception:the presence of problems with housing. At 6months, the numbers of mothers who weredepressed were significantly different wherethere was unemployment, problems with themother's family of origin, where the motherwas isolated, feeling lonely and without a con-fidante, and having problems with housing.These adversities continued to be significantat 12 months. A poor relationship with apartner only became significant as an adversity

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Table 4 Association ofpsychosocial adversity and depression in 65 mothers when theirpreterm babies were 12 months old (age correctedfor prematurity)

Not Odds 95%Depressed depressed ratio Confidence interval p (g')

Inner city address 5 13Outer city address 12 35 1.1 03 to 38 NSSocial class III+IV+V 16 40Social class I+II 1 8 0 3 0 04 to 2-7 NSUnemployed head of household 9 11Employed head of household 8 37 3-8 1-2 to 12-2 0 05Mother unemployed 13 31Mother employed 4 17 1-8 0 5 to 6-3 NSPoor relationship with partner 10 10Good relationship with partner 7 38 5-4 1-7 to 17 9 0 009Problems with housing 11 7No problems 6 41 10-7 3-0 to 38-5 0 0003Problems with family of origin 10 9No problems 7 39 6-2 1-9 to 207 0 005Isolation of mother 5 3Mother not isolated 12 45 6-3 1-3 to 20-9 0 04Feelings of loneliness 14 22Not lonely 3 26 5-5 1-4 to 21-7 0-02No confidante 6 8Confidante available 11 40 2-7 0-8 to 9 5 NS

associated with depression when the childrenwere 12 months old (table 5).When scores on the psychosocial scale were

examined, levels of psychosocial disadvantage(that is, a score of 4 or more) were high acrossthe whole sample of mothers. At 12 months,44 of the 96 mothers could be classed as disad-vantaged. If levels of psychosocial adversity asmeasured by the adversity scale were high,then the mothers were more likely to bedepressed (x2= 19X82, p= <0X00 1).

INTERACTION OF PSYCHOSOCIAL ADVERSITYAND DISABILITYSince the prediction of presence of disabilityin the child could have caused added stress tothe mothers and might have been associatedwith depression, the data were analysed totest if there was an interactive effect ofpsychosocial adversity and predicted disabil-ity on depression. No effect for the interactioncould be found either at 6 weeks (F=0-01,p=0 93, df=1), or at 6 months (F=089,p=0 35, df=1) for the 65 mothers ofpreterm infants, or at 12 months for the wholesample of 96 mothers (F=0-59, p=0-56,df=2).

Table S Psychosocial variables significantly associated with depression in mothers of 65babies born prematurely using x2 analysis

Age of baby at time ofassessmentl

Adversity 6 Weeks 6 Months 12 Months

Inner city address NS NS NSSocial class III, IV, and V NS NS NSUnemployed head of household NS * *Mother unemployed NS * NSPoor relationship with partner NS NS tProblems with housing *Problems with family of origin NSIsolation of motherFeelings of loneliness *No confidante available - t *No stable relationship24+children living at home2

lAges corrected for prematurity.2Frequencies too small to test reliably.-Data not collected at this age.Significance levels: p<0-001; p<0-01; *p<0.05.

A further two way ANOVA was carried outto test if there was an interactive effect for psy-chosocial adversity and actual disability ondepression for the whole sample of 96 mothersat 12 months; we found no interactive effect(F=0-59, p=0-56, df=2).

IMPACT OF AN EARLY PHYSIOTHERAPYINTERVENTIONOf the 16 mothers of preterm infants where anearly physiotherapy intervention was planned,seven (44%) were depressed at 6 weeks, six(38%) at 6 months, and five (31%) at 12months. For the 14 mothers where standardcare was planned, the numbers were three(21%), three (21%), and three (21%).We analysed mothers' malaise inventory

scores for the two groups using the Student'st test. There was no significant differencebetween the two groups at 6 weeks, 6 months,or 12 months (table 6).

DiscussionOver the first year of the infants' lives neitherthe prediction of disability nor the appearanceof actual disability increased the numbers ofmothers who were depressed. What was evi-dent from this study was the pervasive influ-ence of psychosocial adversity on the mothers'mental health. High levels of psychosocial dis-advantage were associated with depression inall groups and at all times of assessment.The combination of a deprived psychosocial

environment and the presence of a childpredicted to develop disability did not increasethe mothers' vulnerability for depression. Wefound no effect of actual appearance of disabil-ity by one year either. It is possible that thelevels of psychosocial adversity with whichthese mothers were coping were already sohigh that the effect of the added stress of achild with a potential or an actual disabilitycould not be detected.We offer some tentative suggestions about

the process by which depression might be sus-tained in the group of 65 mothers of pretermbabies. At 6 weeks the experience of pretermbirth and bringing the child home to adversehousing conditions were associated withdepression. By 6 months, depression was foundin mothers experiencing a lack of support fromfamily and friends and lack of money fromunemployment. At 12 months, lack of paternalsupport became a salient factor. This suggeststhat the mothers' needs for support changed as

Table 6 Results ofanalysis of malaise inventory scores for30 mothers ofpreterm children with abnormal brain scans

No Mean SD t p

6 WeeksEarly intervention 16 7-25 6-74Standard care 14 4 00 2-54 1-79 0 09

6 MonthsEarly intervention 16 6-12 6-25Standard care 14 4-86 3-61 0-69 0 50

12 MonthsEarly intervention 16 5-12 5-68Standard care 14 4-21 4-64 0-48 0-63

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their infants grew. However, this was probablynot related to the burden of care, because theprevalence of depression in the mothers ofinfants at risk for the development of cerebralpalsy was no different from that in mothers ofhealthy preterms or healthy term infants. Wehypothesise that the burden of care is not so dif-ferent for mothers of children with disabilitiesduring the first year of life. However, there aresome indications that the adequacy of supportand, as time progresses, the interparental rela-tionship are influential.We had hypothesised that early intervention

would be supportive for mothers of childrenwith abnormal brain scans and would decreaserates of depression. In fact the proportion ofmothers who were depressed was higher in thegroup receiving early intervention than in thegroup receiving standard care. It may have beenthat the weekly presence of the physiotherapistdrew attention to the condition of the child,whereas mothers in the standard care groupwere not reminded of the potential disability intheir child, so did not become depressed.Although the rate of depression of mothers inthe early intervention group remained higherthan that for the group of mothers of pretermchildren receiving standard care over the firstyear of life, the difference was not significantand the rate declined with time. Mothers in thestandard care group received increasing levelsof professional support over time, and theirrates of depression did not change.On the basis of the data presented here we

consider that the timing ofphysiotherapy inter-vention needs to be sensitively related to theappearance of disability in the child. Althoughthese findings suggest that mothers mayaccommodate better to physiotherapy if itstarts at the point when disability becomes evi-dent, there could be other important benefitsof early intervention for the child's develop-ment or for the relationship between motherand child. Results from the much largerphysiotherapy study show that there could besome benefit to motor development at 12months for children receiving early physiother-apy intervention (to be published).

This study was financed by Mersey Regional Health Authority,Research Scheme No 583.

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