Last data update: Dec 02, 2024. (Total: 48272 publications since 2009)
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Prevalence of positive childhood experiences and associations with current anxiety, depression, and behavioral or conduct problems among U.S. children aged 6–17 years
Anderson KN , Okwori G , Hutchins HJ , Donney JF , Swedo EA , Lee N , Niolon PH , Leeb RT , Bacon S . ADV RES SCI 2024 Positive childhood experiences (PCEs) have substantial potential to improve children’s mental health. We examined the prevalence of 26 specific PCEs, overall and by demographics, and the individual and cumulative effects of PCEs with current diagnosis of three mental health conditions using nationally representative, parent-reported data on U.S. children aged 6–17 years from the 2018–2019 National Survey of Children’s Health (n=35,583). The prevalence of each PCE varied, with a range between 22.6% (gets recommended amount of physical activity) to 92.1% (parent(s) have positive mental health). Accounting for demographics, there were associations between most specific PCEs and lower prevalence of current childhood anxiety (22 of 26 PCEs), depression (22 of 26 PCEs), and behavioral or conduct problems (21 of 26 PCEs). There was a dose-response relationship between children in higher cumulative PCE quartiles and lower proportions of anxiety, depression, and behavioral or conduct problems. Findings generally did not attenuate after further adjusting for adverse childhood experiences. PCEs are common among U.S. children, but vary substantially by type of PCE and subpopulation. This has critical implications for focusing prevention and intervention strategies to bolster PCEs in ways that could improve health equity and children’s mental health. © This is a U.S. Government work and not under copyright protection in the US; foreign copyright protection may apply 2024. |
Mental health in undergraduate students several months into the COVID-19 pandemic compared to before the pandemic
Jacobs EJ , Spiker S , Newsome KB , Danielson ML , Bhupalam S , Leeb RT . J Am Coll Health 2023 1-10 OBJECTIVE: To compare mental health indicators among undergraduates in Fall 2019, before the COVID-19 pandemic, and Fall 2020, when many students returned to campus amidst restrictions on in-person contact. PARTICIPANTS: Analyses included 26,881 undergraduate students, aged 18-24, from 70 U.S. institutions. METHODS: Students completed the National College Health Assessment-III survey in Fall 2019 or Fall 2020. RESULTS: The prevalences of high stress, loneliness, a low flourishing score, and serious psychological distress increased in 2020 compared to 2019. Serious psychological distress increased substantially in 2020 among students not living with family (adjusted prevalence ratio (aPR)=1.36, 95% CI 1.29-1.45) but not among students living with family (aPR = 1.09, 95% CI 0.95-1.26). CONCLUSIONS: These results suggest prevalences of several indicators of poor mental health were elevated among U.S. undergraduates several months into the pandemic. The pandemic may have had greater impact on mental health among students not living with family. |
Seasonal trends in emergency department visits for mental and behavioral health conditions among children and adolescents aged 5-17 years - United States, January 2018-June 2023
Radhakrishnan L , Carey K , Pell D , Ising A , Brathwaite D , Waller A , Gay J , Watson-Smith H , Person M , Zamore K , Brumsted T , Price C , Clark PM , Haas GA , Gracy L , Johnston S , Chen Y , Muñoz K , Henry M , Willis B , Nevels D , Asaolu I , Lee S , Wilkins NJ , Bacon S , Sheppard M , Kite-Powell A , Blau G , King M , Whittaker M , Leeb RT . MMWR Morb Mortal Wkly Rep 2023 72 (38) 1032-1040 Mental and behavioral health conditions among school-aged children, including substance use disorders and overall emotional well-being, are a public health concern in the United States. Timely data on seasonal patterns in child and adolescent conditions can guide optimal timing of prevention and intervention strategies. CDC examined emergency department (ED) visit data from the National Syndromic Surveillance Program for 25 distinct conditions during January 2018-June 2023 among U.S. children and adolescents aged 5-17 years, stratified by age group. Each year, during 2018-2023, among persons aged 10-14 and 15-17 years, the number and proportion of weekly ED visits for eight conditions increased in the fall school semester and remained elevated throughout the spring semester; ED visits were up to twice as high during school semesters compared with the summer period. Among children aged 5-9 years, the number and proportion of visits increased for five mental and behavioral health conditions. Seasonal increases in ED visits for some conditions among school-aged children warrant enhanced awareness about mental distress symptoms and the challenges and stressors in the school environment. Systemic changes that prioritize protective factors (e.g., physical activity; nutrition; sleep; social, community, or faith-based support; and inclusive school and community environments) and incorporate preparedness for increases in conditions during back-to-school planning might improve child and adolescent mental health. |
Emergency department visits involving mental health conditions, suicide-related behaviors, and drug overdoses among adolescents - United States, January 2019-February 2023
Anderson KN , Johns D , Holland KM , Chen Y , Vivolo-Kantor AM , Trinh E , Bitsko RH , Leeb RT , Radhakrishnan L , Bacon S , Jones CM . MMWR Morb Mortal Wkly Rep 2023 72 (19) 502-512 The U.S. adolescent mental and behavioral health crisis is ongoing,* with high pre-COVID-19 pandemic baseline rates(†) (1) and further increases in poor mental health (2), suicide-related behaviors (3), and drug overdose deaths (4) reported during 2020-2021. CDC examined changes in U.S. emergency department (ED) visits for mental health conditions (MHCs) overall and for nine specific MHCs,(§) suicide-related behaviors (including suspected suicide attempts), and drug-involved overdoses (including opioids) among children and adolescents aged 12-17 years (adolescents) during January 2019-February 2023, overall and by sex. Compared with fall 2021, by fall 2022, decreases in weekly ED visits were reported among all adolescents, and females specifically, for MHCs overall, suicide-related behaviors, and drug overdoses; weekly ED visits among males were stable. During this same period, increases in weekly ED visits for opioid-involved overdoses were detected. Mean weekly ED visits in fall 2022 for suicide-related behaviors and MHCs overall were at or lower than the 2019 prepandemic baseline, respectively, and drug overdose visits were higher. Differences by sex were observed; levels among females were at or higher than prepandemic baselines for these conditions. These findings suggest some improvements as of fall 2022 in the trajectory of adolescent mental and behavioral health, as measured by ED visits; however, poor mental and behavioral health remains a substantial public health problem, particularly among adolescent females. Early identification and trauma-informed interventions, coupled with expanded evidence-based, comprehensive prevention efforts, are needed to support adolescents' mental and behavioral health. |
Communication preferences of parents and caregivers of children and youth with special healthcare needs during a hypothetical infectious disease emergency
Hipper TJ , Popek L , Davis RK , Turchi RM , Massey PM , Lege-Matsuura J , Lubell KM , Pechta L , Briseo L , Rose DA , Chatham-Stephens K , Leeb RT , Chernak E . Health Secur 2022 20 (6) 467-478 Children and youth with special healthcare needs are at risk for severe consequences during infectious disease emergencies. Messages for parents and caregivers from trusted sources, via preferred channels, that contain the information they need, may improve health outcomes for this population. In this mixed methods study, we conducted a survey (N=297) and 80 semistructured interviews, with 70 caregivers of children and youth and 10 young adults with special healthcare needs, between April 2018 and June 2019 in Pennsylvania. The survey presented 3 scenarios (ie, storm, disease outbreak, radiation event); the interviews included questions about storms and an outbreak. This article addresses only the disease outbreak data from each set. Participants were recruited through convenience samples from an urban tertiary care children's hospital and practices in a statewide medical home network. In this article, we summarize the preferred information sources, channels, and content needs of caregivers of children and youth with special healthcare needs during an infectious disease emergency. Nearly 84% of caregivers reported that they believe their child's doctor is the best source of information. Other preferred sources include medical experts (31%); the US Centers for Disease Control and Prevention (30%); friends, family, and neighbors (21%); and local or state health and emergency management (17%). Pediatric healthcare providers play an important role in providing information to parents and caregivers of children and youth with special healthcare needs during an infectious disease emergency. Public health agencies can establish health communication plans that integrate medical practices and other reliable sources to promote the dissemination of accurate information from trusted messengers. |
Changes and Inequities in Adult Mental Health-Related Emergency Department Visits During the COVID-19 Pandemic in the US.
Anderson KN , Radhakrishnan L , Lane RI , Sheppard M , DeVies J , Azondekon R , Smith AR , Bitsko RH , Hartnett KP , Lopes-Cardozo B , Leeb RT , vanSanten KL , Carey K , Crossen S , Dias TP , Wotiz S , Adjemian J , Rodgers L , Njai R , Thomas C . JAMA Psychiatry 2022 79 (5) 475-485 IMPORTANCE: The COVID-19 pandemic has negatively affected adult mental health (MH), with racial and ethnic minoritized groups disproportionately affected. OBJECTIVE: To examine changes in adult MH-related emergency department (ED) visits into the Delta variant pandemic period and identify changes and inequities in these visits before and during COVID-19 case surges. DESIGN, SETTING, AND PARTICIPANTS: This epidemiologic cross-sectional study used National Syndromic Surveillance Program data from US adults aged 18 to 64 years from 1970 to 2352 ED facilities from January 1, 2019, to August 14, 2021. All MH-related ED visits and visits related to 10 disorders (ie, anxiety, depressive, bipolar, schizophrenia spectrum, trauma- and stressor-related, attention-deficit/hyperactivity, disruptive behavioral and impulse, obsessive-compulsive, eating, and tic disorders) were identified. EXPOSURES: The following periods of MH-related ED visits were compared: (1) high Delta variant circulation (July 18-August 14, 2021) with a pre-Delta period (April 18-May 15, 2021), (2) after a COVID-19 case peak (February 14-March 13, 2021) with during a peak (December 27, 2020-January 23, 2021), and (3) the Delta period and the period after a COVID-19 case peak with the respective corresponding weeks during the prepandemic period. MAIN OUTCOMES AND MEASURES: ED visits for 10 mental disorders and all MH-related visits. RESULTS: This cross-sectional study included 107761319 ED visits among adults aged 18 to 64 years (59870475 [56%] women) from January 1, 2019, to August 14, 2021. There was stability in most MH-related ED visit counts between the Delta and pre-Delta periods (percentage change, -1.4% to -7.5%), except for eating disorders (-11.9%) and tic disorders (-19.8%) and after a COVID-19 case peak compared with during a peak (0.6%-7.4%). Most MH-related ED visit counts declined in the Delta period relative to the prepandemic period (-6.4% to -30.7%); there were fluctuations by disorder when comparing after a COVID-19 case peak with the corresponding prepandemic period (-15.4% to 11.3%). Accounting for ED visit volume, MH-related ED visits were a smaller proportion of visits in the Delta period compared with the pre-Delta period (visit ratio, 0.86; 95% CI, 0.85-0.86) and prepandemic period (visit ratio, 0.80; 95% CI, 0.79-0.80). After a COVID-19 case peak, MH-related ED visits were a larger proportion of ED visits compared with during a peak (visit ratio, 1.04; 95% CI, 1.03-1.04) and the corresponding prepandemic period (visit ratio, 1.11; 95% CI, 1.11-1.12). Of the 2510744 ED visits included in the race and ethnicity analysis, 24592 (1%) were American Indian or Alaska Native persons, 33697 (1%) were Asian persons, 494198 (20%) were Black persons, 389740 (16%) were Hispanic persons, 5000 (0.2%) were Native Hawaiian or Other Pacific Islander persons, and 1172683 (47%) were White persons. There was between- and within-group variation in ED visits by race and ethnicity and increases in selected disorders after COVID-19 peaks for adults aged 18 to 24 years. CONCLUSIONS AND RELEVANCE: Results of this cross-sectional study suggest that EDs may have increases in MH-related visits after COVID-19 surges, specifically for young adults and individual racial and ethnic minoritized subpopulations. Public health practitioners should consider subpopulation-specific messaging and programmatic strategies that address differences in MH needs, particularly for those historically marginalized. |
Pediatric Emergency Department Visits Associated with Mental Health Conditions Before and During the COVID-19 Pandemic - United States, January 2019-January 2022.
Radhakrishnan L , Leeb RT , Bitsko RH , Carey K , Gates A , Holland KM , Hartnett KP , Kite-Powell A , DeVies J , Smith AR , van Santen KL , Crossen S , Sheppard M , Wotiz S , Lane RI , Njai R , Johnson AG , Winn A , Kirking HL , Rodgers L , Thomas CW , Soetebier K , Adjemian J , Anderson KN . MMWR Morb Mortal Wkly Rep 2022 71 (8) 319-324 In 2021, a national emergency* for children's mental health was declared by several pediatric health organizations, and the U.S. Surgeon General released an advisory(†) on mental health among youths. These actions resulted from ongoing concerns about children's mental health in the United States, which was exacerbated by the COVID-19 pandemic (1,2). During March-October 2020, among all emergency department (ED) visits, the proportion of mental health-related visits increased by 24% among U.S. children aged 5-11 years and 31% among adolescents aged 12-17 years, compared with 2019 (2). CDC examined changes in U.S. pediatric ED visits for overall mental health conditions (MHCs) and ED visits associated with specific MHCs (depression; anxiety; disruptive behavioral and impulse-control disorders; attention-deficit/hyperactivity disorder; trauma and stressor-related disorders; bipolar disorders; eating disorders; tic disorders; and obsessive-compulsive disorders [OCD]) during 2019 through January 2022 among children and adolescents aged 0-17 years, overall and by sex and age. After declines in weekly visits associated with MHCs among those aged 0-17 years during 2020, weekly numbers of ED visits for MHCs overall and for specific MHCs varied by age and sex during 2021 and January 2022, when compared with corresponding weeks in 2019. Among adolescent females aged 12-17 years, weekly visits increased for two of nine MHCs during 2020 (eating disorders and tic disorders), for four of nine MHCs during 2021 (depression, eating disorders, tic disorders, and OCD), and for five of nine MHCs during January 2022 (anxiety, trauma and stressor-related disorders, eating disorders, tic disorders, and OCD), and overall MHC visits during January 2022, compared with 2019. Early identification and expanded evidence-based prevention and intervention strategies are critical to improving children's and adolescents' mental health (1-3), especially among adolescent females, who might have increased need. |
Pediatric Emergency Department Visits Before and During the COVID-19 Pandemic - United States, January 2019-January 2022.
Radhakrishnan L , Carey K , Hartnett KP , Kite-Powell A , Zwald M , Anderson KN , Leeb RT , Holland KM , Gates A , DeVies J , Smith AR , van Santen KL , Crossen S , Sheppard M , Wotiz S , Johnson AG , Winn A , Kirking HL , Lane RI , Njai R , Rodgers L , Thomas CW , Soetebier K , Adjemian J . MMWR Morb Mortal Wkly Rep 2022 71 (8) 313-318 Emergency departments (EDs) in the United States remain a frontline resource for pediatric health care emergencies during the COVID-19 pandemic; however, patterns of health-seeking behavior have changed during the pandemic (1,2). CDC examined changes in U.S. ED visit trends to assess the continued impact of the pandemic on visits among children and adolescents aged 0-17 years (pediatric ED visits). Compared with 2019, pediatric ED visits declined by 51% during 2020, 22% during 2021, and 23% during January 2022. Although visits for non-COVID-19 respiratory illnesses mostly declined, the proportion of visits for some respiratory conditions increased during January 2022 compared with 2019. Weekly number and proportion of ED visits increased for certain types of injuries (e.g., drug poisonings, self-harm, and firearm injuries) and some chronic diseases, with variation by pandemic year and age group. Visits related to behavioral concerns increased across pandemic years, particularly among older children and adolescents. Health care providers and families should remain vigilant for potential indirect impacts of the COVID-19 pandemic, including health conditions resulting from delayed care, and increasing emotional distress and behavioral health concerns among children and adolescents. |
How right now: The role of social determinants of health as they relate to emotional well-being amidst the COVID-19 pandemic
Burke-Garcia A , Johnson-Turbes A , Mitchell EW , Vallery Verlenden JM , Puddy R , Mercado MC , Nelson P , Thomas C , Crick C , Leeb R , Rabinowitz L , McCutchan L , Xia K , Wagstaff L , Feng M , Caicedo L , Tolbert E . J Emerg Manag 2021 19 (9) 17-62 Pandemics are stressful times, full of uncertainty and fear. During the COVID-19 pandemic, many Americans have experienced feelings of stress, grief, and loss. How Right Now (HRN) – and its Spanish-language counterpart, Qué Hacer Ahora (QHA) – is an evidence-based, culturally-relevant communication campaign designed to promote and strengthen the emotional well-being and resiliency of populations adversely affected by the COVID-19 pandemic and beyond. Developed by the Centers for Disease Control and Prevention (CDC) with support from the CDC Foundation, the campaign aims to help all Americans but has a specific focus on some of the disproportionately affected groups, including adults over 65 and their caregivers, individuals with pre-existing physical and mental health conditions, people experiencing violence, and those experiencing economic distress. Based on rapid, but robust, formative research, HRN offers audience-centric messages representing the real, everyday experiences and emotions that these audiences are having and addresses them in actionable ways. These include messages that address the social and structural barrier that disproportionately-affected groups have been facing long before the pandemic — and which are felt more acutely now. This paper provides an overview of the rapid, mixed-method, culturally-responsive formative research process undertaken to inform the development of HRN. Specifically, it describes how HRN’s disproportionately-affected audiences describe and discuss their emotiona well-being during COVID-19 through the lens of Social Determinants of Health (SDOH). We introduce a secondary theory, Vital Conditions for Health and Well-Being (VCHW), which conceptualizes holistic well-being and the conditions that give rise to it and identifies levers for community change and improvement. Data collection methods included an environmental scan (n≥700 publications); social listening (n≥1 million social media posts); partner needs-assessment calls (n=16); partner-convened listening sessions with community members (n=29), online focus groups (n=10), and a national probability survey (n=731), all in English and Spanish. Findings suggest that HRN’s priority audiences’ emotional well-being and SDOH are interconnected. Disruptions in SDOH du to the COVID-19 pandemic can lead to emotional well-being challenges (e.g., anxiety) for HRN’s priority audiences. While some disruptions may lead some people to adapt, connect with others, and be more resilient, there is a disparate impact of emotional well-being amid COVID-19 for those already experiencing disparities linked to SDOH. Understanding the perspectives and experiences of disproportionately affected populations through the lens of SDOH is vital to identifying the kinds of supports and services – like How Right Now/Qué Hacer Ahora – required for these populations. © 2021 Weston Medical Publishing. All rights reserved. |
Mental Health-Related Emergency Department Visits Among Children Aged <18 Years During the COVID-19 Pandemic - United States, January 1-October 17, 2020.
Leeb RT , Bitsko RH , Radhakrishnan L , Martinez P , Njai R , Holland KM . MMWR Morb Mortal Wkly Rep 2020 69 (45) 1675-1680 Published reports suggest that the coronavirus disease 2019 (COVID-19) pandemic has had a negative effect on children's mental health (1,2). Emergency departments (EDs) are often the first point of care for children experiencing mental health emergencies, particularly when other services are inaccessible or unavailable (3). During March 29-April 25, 2020, when widespread shelter-in-place orders were in effect, ED visits for persons of all ages declined 42% compared with the same period in 2019; during this time, ED visits for injury and non-COVID-19-related diagnoses decreased, while ED visits for psychosocial factors increased (4). To assess changes in mental health-related ED visits among U.S. children aged <18 years, data from CDC's National Syndromic Surveillance Program (NSSP) from January 1 through October 17, 2020, were compared with those collected during the same period in 2019. During weeks 1-11 (January 1-March 15, 2020), the average reported number of children's mental health-related ED visits overall was higher in 2020 than in 2019, whereas the proportion of children's mental health-related visits was similar. Beginning in week 12 (March 16) the number of mental health-related ED visits among children decreased 43% concurrent with the widespread implementation of COVID-19 mitigation measures; simultaneously, the proportion of mental health-related ED visits increased sharply beginning in mid-March 2020 (week 12) and continued into October (week 42) with increases of 24% among children aged 5-11 years and 31% among adolescents aged 12-17 years, compared with the same period in 2019. The increased proportion of children's mental health-related ED visits during March-October 2020 might be artefactually inflated as a consequence of the substantial decrease in overall ED visits during the same period and variation in the number of EDs reporting to NSSP. However, these findings provide initial insight into children's mental health in the context of the COVID-19 pandemic and highlight the importance of continued monitoring of children's mental health throughout the pandemic, ensuring access to care during public health crises, and improving healthy coping strategies and resiliency among children and families. |
COVID-19 Mitigation Behaviors by Age Group - United States, April-June 2020.
Hutchins HJ , Wolff B , Leeb R , Ko JY , Odom E , Willey J , Friedman A , Bitsko RH . MMWR Morb Mortal Wkly Rep 2020 69 (43) 1584-1590 CDC recommends a number of mitigation behaviors to prevent the spread of SARS-CoV-2, the virus that causes coronavirus disease 2019 (COVID-19). Those behaviors include 1) covering the nose and mouth with a mask to protect others from possible infection when in public settings and when around persons who live outside of one's household or around ill household members; 2) maintaining at least 6 feet (2 meters) of distance from persons who live outside one's household, and keeping oneself distant from persons who are ill; and 3) washing hands often with soap and water for at least 20 seconds, or, if soap and water are not available, using hand sanitizer containing at least 60% alcohol (1). Age has been positively associated with mask use (2), although less is known about other recommended mitigation behaviors. Monitoring mitigation behaviors over the course of the pandemic can inform targeted communication and behavior modification strategies to slow the spread of COVID-19. The Data Foundation COVID Impact Survey collected nationally representative data on reported mitigation behaviors during April-June 2020 among adults in the United States aged ≥18 years (3). Reported use of face masks increased from 78% in April, to 83% in May, and reached 89% in June; however, other reported mitigation behaviors (e.g., hand washing, social distancing, and avoiding public or crowded places) declined marginally or remained unchanged. At each time point, the prevalence of reported mitigation behaviors was lowest among younger adults (aged 18-29 years) and highest among older adults (aged ≥60 years). Lower engagement in mitigation behaviors among younger adults might be one reason for the increased incidence of confirmed COVID-19 cases in this group, which have been shown to precede increases among those >60 years (4). These findings underscore the need to prioritize clear, targeted messaging and behavior modification interventions, especially for young adults, to encourage uptake and support maintenance of recommended mitigation behaviors to prevent the spread of COVID-19. |
COVID-19 Trends Among School-Aged Children - United States, March 1-September 19, 2020.
Leeb RT , Price S , Sliwa S , Kimball A , Szucs L , Caruso E , Godfred-Cato S , Lozier M . MMWR Morb Mortal Wkly Rep 2020 69 (39) 1410-1415 Approximately 56 million school-aged children (aged 5-17 years) resumed education in the United States in fall 2020.* Analysis of demographic characteristics, underlying conditions, clinical outcomes, and trends in weekly coronavirus disease 2019 (COVID-19) incidence during March 1-September 19, 2020 among 277,285 laboratory-confirmed cases in school-aged children in the United States might inform decisions about in-person learning and the timing and scaling of community mitigation measures. During May-September 2020, average weekly incidence (cases per 100,000 children) among adolescents aged 12-17 years (37.4) was approximately twice that of children aged 5-11 years (19.0). In addition, among school-aged children, COVID-19 indicators peaked during July 2020: weekly percentage of positive SARS-CoV-2 test results increased from 10% on May 31 to 14% on July 5; SARS-CoV-2 test volume increased from 100,081 tests on May 31 to 322,227 on July 12, and COVID-19 incidence increased from 13.8 per 100,000 on May 31 to 37.9 on July 19. During July and August, test volume and incidence decreased then plateaued; incidence decreased further during early September and might be increasing. Percentage of positive test results decreased during August and plateaued during September. Underlying conditions were more common among school-aged children with severe outcomes related to COVID-19: among school-aged children who were hospitalized, admitted to an intensive care unit (ICU), or who died, 16%, 27%, and 28%, respectively, had at least one underlying medical condition. Schools and communities can implement multiple, concurrent mitigation strategies and tailor communications to promote mitigation strategies to prevent COVID-19 spread. These results can provide a baseline for monitoring trends and evaluating mitigation strategies. |
Support for transition from adolescent to adult health care among adolescents with and without mental, behavioral, and developmental disorders - United States, 2016-2017
Leeb RT , Danielson ML , Bitsko RH , Cree RA , Godfred-Cato S , Hughes MM , Powell P , Firchow B , Hart LC , Lebrun-Harris LA . MMWR Morb Mortal Wkly Rep 2020 69 (34) 1156-1160 Clinical guidelines recommend that primary care providers (PCPs) provide guidance and support to ensure a planned transition from pediatric to adult health care for adolescents, beginning at age 12 years (1). However, most adolescents do not receive the recommended health care transition planning (2). This is particularly concerning for adolescents with diagnosed mental, behavioral, and developmental disorders (MBDDs) (3), who account for approximately 20% of U.S. adolescents (4). Childhood MBDDs are linked to increased long-term morbidity and mortality; timely health care transition planning might mitigate adverse outcomes (5,6). CDC analyzed pooled, parent-reported data from the 2016 and 2017 National Survey of Children's Health (NSCH), comparing adolescents, aged 12-17 years, with and without MBDDs on a composite measure and specific indicators of recommended health care transition planning by PCPs. Overall, approximately 15% of adolescents received recommended health care transition planning: 15.8% (95% confidence interval [CI] = 14.1%-17.5%) of adolescents with MBDDs, compared with 14.2% (95% CI = 13.2%-15.3%) of adolescents without MBDDs. Relative to peers without MBDDs and after adjusting for age, adolescents with anxiety were 36% more likely to receive recommended health care transition planning, and those with depression were 69% more likely; adolescents with autism spectrum disorder (ASD) were 35% less likely to receive such transition planning, and those with developmental delay* were 25% less likely. Fewer than 20% of adolescents with MBDDs receiving current treatment met the transition measure. These findings suggest that a minority of adolescents with MBDDs receive recommended transition planning, indicating a potential missed public health opportunity to prevent morbidity and mortality in a population at high risk for health care disengagement (1). Improving access to comprehensive and coordinated programs and services,(†) as well as increasing provider training concerning adolescents' unique mental and physical health care needs (7), could help increase the number of adolescents benefiting from successful health care transitions (4). |
Indicators of social competence and social participation among US children with Tourette syndrome
Bitsko RH , Danielson ML , Leeb RT , Bergland B , Fuoco MJ , Ghandour RM , Lewin AB . J Child Neurol 2020 35 (9) 612-620 Children with Tourette syndrome often have behavioral and social difficulties, which may be associated with co-occurring mental, emotional, or behavioral disorders. This study investigated social competence, including behavioral problems and social skills, and social activities between children with and without Tourette syndrome using a nationally representative sample. In the 2007 National Survey of Children's Health, parents reported on health care provider diagnosis of Tourette syndrome, co-occurring mental, emotional, or behavioral disorders, and indicators of social competence. Children aged 6-17 years with and without Tourette syndrome were compared. Most (78.7%) children with Tourette syndrome had a co-occurring mental, emotional, or behavioral disorder. Children with Tourette syndrome had significantly lower social competence, exhibited by higher levels of behavior problems (mean score 11.6 for Tourette syndrome and 9.0 for no Tourette syndrome) and lower levels of social skills (mean 15.3) than children without a Tourette syndrome diagnosis (mean 17.1); however, these associations were no longer significant after controlling for co-occurring mental, emotional, or behavioral disorders. Moderate to severe Tourette syndrome was associated with the highest ratings of behavioral problems and the lowest ratings of social skills. Children with and without Tourette syndrome were equally likely to participate in social activities; the difference for children with moderate to severe Tourette syndrome being less likely to participate in activities compared to children with mild Tourette syndrome had a chi-square test P value of .05. In conclusion, Tourette syndrome was associated with lower social competence, particularly for children with moderate to severe Tourette syndrome. Monitoring social functioning and co-occurring conditions among children with Tourette syndrome, and referral for evidence-based interventions when needed, may benefit overall health and functioning. |
A framework for coordination between obstetric and pediatric providers in public health emergencies: Lessons learned from the Zika outbreak in the United States, 2015 to 2017
Leeb RT , Cree RA , Aird L , DeBiasi RL , Driggers RW , Garbarczyk E , Mofenson LM , Needle S , Rodriguez J , Curry C , Garcia F , Godfred-Cato S , Hawks D , Rosenblum E , Dziuban E , Hudak M . Am J Perinatol 2020 37 (10) 982-990 Emergency response to emerging threats with the potential for vertical transmission, such as the 2015 to 2017 response to Zika virus, presents unique clinical challenges that underscore the need for better communication and care coordination between obstetric and pediatric providers to promote optimal health for women and infants. Published guidelines for routine maternal-infant care during the perinatal period, and models for transitions of care in various health care settings are available, but no broad framework has addressed coordinated multidisciplinary care of the maternal-infant dyad during emergency response. We present a novel framework and strategies to improve care coordination and communication during an emergency response. The proposed framework includes (1) identification and collection of critical information to inform care, (2) key health care touchpoints for the maternal-infant dyad, and (3) primary pathways of communication and modes of transfer across touchpoints, as well as practical strategies. This framework and associated strategies can be modified to address the care coordination needs of pregnant women and their infants with possible exposure to other emerging infectious and noninfectious congenital threats that may require long-term, multidisciplinary management. KEY POINTS: . Emerging congential threats present unique coordination challenges for obstetric and pediatric clinicians during emergency response.. . We present a framework to help coodinate care of pregnant women/infants exposed to congenital threats.. . The framework identifies critical information to inform care, health care touchpoints, and communication/information transfer pathways.. |
Characteristics associated with presence of pediatric mental health care policies in emergency departments
Cree RA , So M , Franks J , Richards R , Leeb R , Hashikawa A , Krug S , Ludwig L , Olson LM . Pediatr Emerg Care 2019 37 (12) e1116-e1121 OBJECTIVES: The majority of US children do not have access to an emergency department (ED) with a pediatric mental health care policy in place. Our objective was to understand factors associated with whether US EDs have a pediatric mental health care policy. METHODS: We analyzed data from the National Pediatric Readiness Project, a nationally representative cross-sectional survey of US EDs. Nurse managers reported whether their hospitals had a policy to care for children with social/mental health concerns (n = 3612). We calculated prevalence estimates, prevalence ratios (PRs), and confidence intervals (CIs) for regional and ED characteristics (eg, rurality and types of personnel) by whether EDs had a pediatric mental health care policy. RESULTS: Overall, 46.2% (n = 1668/3612) of EDs had a pediatric mental health care policy. Emergency departments located in remote areas were 60% less likely to have such a policy compared with EDs in urban areas (PR, 0.4; CI, 0.3-0.5). Emergency department characteristics associated with having a pediatric mental health care policy included having a policy to transfer children with social/mental health concerns (PR, 5.4; CI, 4.7-6.2), having a policy to address maltreatment (PR, 3.4; CI, 2.6-4.4), and having nurse and physician pediatric emergency care coordinators (PR, 1.6; CI, 1.5-1.8). CONCLUSIONS: Lower prevalence of pediatric mental health policies in rural EDs is concerning considering EDs are often the first point of contact for pediatric patients. This work highlights the importance of pediatric emergency care coordinators in fostering ED capacity to meet children's mental health needs. |
Building children's preparedness capacity at the Centers for Disease Control and Prevention one event at a time, 2009-2018
Leeb RT , Franks JL , Dziuban EJ , Ruben W , Bartenfeld M , Hinton CF , Chatham-Stephens K , Peacock G . Am J Public Health 2019 109 S260-s262 This issue of AJPH highlights the importance of community preparedness for public health emergencies. An essential component of community preparedness is the capacity to address the needs of children, who comprise nearly one quarter of the US population and are particularly vulnerable to disaster-related morbidity and mortality (Figure 1).1 However, communities may not be well equipped to address children’s needs. |
An evaluation of the literacy demands of online natural disaster preparedness materials for families
So M , Franks JL , Cree RA , Leeb RT . Disaster Med Public Health Prep 2019 14 (4) 1-10 OBJECTIVE: Natural disasters are becoming increasingly common, but it is unclear whether families can comprehend and use available resources to prepare for such emergencies. The objective of this study was to evaluate the literacy demands of risk communication materials on natural disasters for US families with children. METHODS: In January 2018, we assessed 386 online self-directed learning resources related to emergency preparedness for natural disasters using 5 literacy assessment tools. Assessment scores were compared by information source, audience type, and disaster type. RESULTS: One-in-three websites represented government institutions, and 3/4 were written for a general audience. Nearly 1-in-5 websites did not specify a disaster type. Assessment scores suggest a mismatch between the general population's literacy levels and literacy demands of materials in the areas of readability, complexity, suitability, web usability, and overall audience appropriateness. Materials required more years of education beyond the grade level recommended by prominent health organizations. Resources for caregivers of children generally and children with special health care needs possessed lower literacy demands than materials overall, for most assessment tools. CONCLUSIONS: Risk communication and public health agencies could better align the literacy demands of emergency preparedness materials with the literacy capabilities of the general public. |
Effects of prenatal marijuana exposure on neuropsychological outcomes in children aged 1-11 years: A systematic review
Sharapova SR , Phillips E , Sirocco K , Kaminski JW , Leeb RT , Rolle I . Paediatr Perinat Epidemiol 2018 32 (6) 512-532 BACKGROUND: Normalisation of medicinal and recreational marijuana use has increased the importance of fully understanding effects of marijuana use on individual-and population-level health, including prenatal exposure effects on child development. We undertook a systematic review of the literature to examine the long-term effects of prenatal marijuana exposure on neuropsychological function in children aged 1-11 years. METHODS: Primary research publications were searched from Medline, Embase, PsychInfo, CINAHL EbscoHost, Cochrane Library, Global Health and ERIC (1980-2018). Eligible articles documented neuropsychological outcomes in children 1-11 years who had been prenatally exposed to marijuana. Studies of exposure to multiple prenatal drugs were included if results for marijuana exposure were reported separately from other substances. Data abstraction was independently performed by two reviewers using a standardised protocol. RESULTS: The eligible articles (n = 21) on data from seven independent longitudinal studies had high quality based on the Newcastle-Ottawa Scale. Some analyses found associations (P < 0.05) between prenatal marijuana exposure and decreased performance on memory, impulse control, problem-solving, quantitative reasoning, verbal development and visual analysis tests; as well as increased performance on attention and global motion perception tests. Limitations included concurrent use of other substances among study participants, potential under-reporting and publication biases, non-generalisable samples and limited published results preventing direct comparison of analyses. CONCLUSIONS: The specific effects of prenatal marijuana exposure remain unclear and warrant further research. The larger number of neuropsychological domains that exhibit decreased versus increased psychological and behavioural functions suggests that exposure to marijuana may be harmful for brain development and function. |
Intergenerational continuity in adverse childhood experiences and rural community environments
Schofield TJ , Donnellan MB , Merrick MT , Ports KA , Klevens J , Leeb R . Am J Public Health 2018 108 (9) 1148-1152 OBJECTIVES: To understand the role of the community environment on intergenerational continuity in adverse childhood experiences (ACEs) among a rural White sample. METHODS: Parents in 12 counties in rural Iowa reported retrospectively on their own ACEs in 1989. We measured their child's ACEs retrospectively and prospectively across adolescence (n = 451 families). We measured structural and social process-related measures of community environment (i.e., community socioeconomic status, parents' perception of community services, perceived community social cohesion, and neighborhood alcohol vendor density) on multiple occasions during the child's adolescence. RESULTS: The 4 measures of community environment were all correlated with the child's ACEs, but only alcohol vendor density predicted ACEs after inclusion of covariates. Intergenerational continuity in ACEs was moderated by both social cohesion (b = -0.11; SE = 0.04) and alcohol vendor density (b = -0.11; SE = 0.05). CONCLUSIONS: Efforts to increase community social cohesion and manage alcohol vendor density may assist families in breaking the cycle of maltreatment across generations. |
School district crisis preparedness, response, and recovery plans - United States, 2006, 2012, and 2016
Kruger J , Brener N , Leeb R , Wolkin A , Avchen RN , Dziuban E . MMWR Morb Mortal Wkly Rep 2018 67 (30) 809-814 Children spend the majority of their time at school and are particularly vulnerable to the negative emotional and behavioral impacts of disasters, including anxiety, depressive symptoms, impaired social relationships, and poor school performance (1). Because of concerns about inadequate school-based emergency planning to address the unique needs of children and the adults who support them, Healthy People 2020 includes objectives to improve school preparedness, response, and recovery plans (Preparedness [PREP]-5) (2). To examine improvements over time and gaps in school preparedness plans, data from the 2006, 2012, and 2016 School Health Policies and Practices Study (SHPPS) were analyzed to assess changes in the percentage of districts meeting PREP-5 objectives. Findings from these analyses indicate that districts met the PREP-5 objective for requiring schools to include post-disaster mental health services in their crisis preparedness plans for the first time in 2016. However, trend analyses did not reveal statistically significant increases from 2006 to 2016 in the percentage of districts meeting any of the PREP-5 objectives. Differences in preparedness were detected in analyses stratified by urbanicity and census region, highlighting strengths and challenges in emergency planning for schools. To promote the health and safety of faculty, staff members, children, and families, school districts are encouraged to adopt and implement policies to improve school crisis preparedness, response, and recovery plans. |
Successful scientific writing and publishing: A step-by-step approach
Iskander JK , Wolicki SB , Leeb RT , Siegel PZ . Prev Chronic Dis 2018 15 E79 Scientific writing and publication are essential to advancing knowledge and practice in public health, but prospective authors face substantial challenges. Authors can overcome barriers, such as lack of understanding about scientific writing and the publishing process, with training and resources. The objective of this article is to provide guidance and practical recommendations to help both inexperienced and experienced authors working in public health settings to more efficiently publish the results of their work in the peer-reviewed literature. We include an overview of basic scientific writing principles, a detailed description of the sections of an original research article, and practical recommendations for selecting a journal and responding to peer review comments. The overall approach and strategies presented are intended to contribute to individual career development while also increasing the external validity of published literature and promoting quality public health science. |
Conceptualizing and measuring safe, stable, nurturing relationships and environments in educational settings
Robinson LR , Leeb RT , Merrick MT , Forbes LW . J Child Fam Stud 2016 25 (5) 1488-1504 Most children and adolescents older than five years spend at least six hours of their day in school settings. Like parents, education professionals can promote health and protect youth from harm by providing safe, stable, nurturing relationships and environments. The Centers for Disease Control and Prevention (CDC) has developed a framework which posits that safe, stable, nurturing relationships and environments are Essentials for Childhood and are fundamental to promoting health and well-being; protecting youth from maltreatment and other violence and victimization; and ensuring optimal, healthy development. In this paper, the authors propose an approach to applying safe, stable, nurturing relationships and environments to the school ecology; review select survey measures to examine these constructs within educational settings; and suggest available indicators to measure safety, stability, and nurturance within the school context. |
Mediating and moderating effects of social support in the study of child abuse and adult physical and mental health
Herrenkohl TI , Jung H , Klika JB , Mason WA , Brown EC , Leeb RT , Herrenkohl RC . Am J Orthopsychiatry 2016 86 (5) 573-83 A number of cross-sectional and a few longitudinal studies have shown a developmental relationship between child abuse and adult physical and mental health. Published findings also suggest that social support can lessen the risk of adverse outcomes for some abused children. However, few studies have investigated whether social support mediates or moderates the relationship between child abuse and adult physical and mental health. Structural equation modeling was used to examine data on these topics from a longitudinal study of more than 30 years. While a latent construct of physical and emotional child abuse did not predict adult health outcomes directly, child abuse did predict outcomes indirectly through social support. A test of variable moderation for child abuse and social support was nonsignificant. Results suggest that social support may help explain the association between child abuse and health outcomes at midlife. Implications of the findings for prevention and treatment are discussed. |
The public health model of child maltreatment prevention
Herrenkohl TI , Leeb RT , Higgins D . Trauma Violence Abuse 2016 17 (4) 363-5 Child maltreatment remains an area of concern for child advocates, policy makers, service providers, and researchers across the globe and presents an enduring threat to public health (Herrenkohl, Higgins, Merrick, & Leeb, 2015). In 2013, over 3.5 million referrals were made to child protective services in the United States and over 2 million cases, a rate of almost 29 per 1,000 children in the U.S. population, were investigated out of concern for the health and safety of the children involved (U.S. Department of Health and Human Services [U.S. DHHS], 2016, maltreatment). This figure rises substantially to more than 10% of all U.S. children, when children are asked directly to report their experiences of abuse and neglect (Finkelhor, Turner, Ormrod, & Hamby, 2009). | In other Western countries, the picture is much the same. According to one report from the United Kingdom, nearly 20% of all young people between the ages of 11 and 17 experienced high levels of abuse and neglect prior to adulthood (https://www.nspcc.org.uk/services-and-resources/research-and-resources/2013/how-safe-are-our-children-2013/). In the past decade, the number of children on child protection registers has risen in all four jurisdictions of the United Kingdom and, in Australia. The Australian Institute of Health and Welfare (AIHW, 2016) reported a 35% increase in the number of substantiated maltreatment reports between 2010–2011 and 2014–2015. This pattern is highly concerning because current levels of demand in ‘‘statutory’’ child welfare/protection systems surpass reasonable case load expectations and budgetary affordances. Driven by awareness of the challenges experienced by child welfare agencies overwhelmed and unprepared to accommodate the demand for assistance, many in the social service sector and research community have called for a new model of child welfare—one that places a much stronger emphasis on prevention (Herrenkohl et al., 2015). |
Child maltreatment surveillance: enumeration, monitoring, evaluation and insight
Leeb RT , Fluke JD . Health Promot Chronic Dis Prev Can 2015 35 138-40 Application of epidemiologic surveillance to child abuse and neglect (CAN) presents specific challenges related to varying definitions and incident reporting. Definitions of abuse and neglect differ within and across countries, obscuring estimates of the true magnitude of the problem. Definitions also vary depending on the nature of the child protection system. Countries may lack legal or social systems with specific responsibility for responding to and recording reports of CAN, particularly countries where populations are remote or in flux (e.g. due to conflict). Underreporting of CAN results in underestimates of prevalence. Violence by caregivers toward children is often known only to the perpetrator, and depending on the developmental capacity of the child, the victim. Further, CAN cases may be reported to a wide variety of sentinels (e.g. educators, clergy, physicians, law enforcement, child welfare), or may not be reported to any official source at all. Social stigma and unintended consequences of reporting, as well as cultural and political barriers, also impact reporting both within communities and globally. | Publisher: Abstract available from the publisher. | fre |
Positioning a public health framework at the intersection of child maltreatment and intimate partner violence: primary prevention requires working outside existing systems
Herrenkohl TI , Higgins DJ , Merrick MT , Leeb RT . Child Abuse Negl 2015 48 22-8 Since about the mid-1990s, researchers have been examining the intersection of child maltreatment (CM; also referred to as child abuse and neglect) and children’s exposure to intimate partner violence (IPV; also called domestic violence or DV). Both CM and IPV are major public health concerns that, together, affect a countless number of lives each year in the United States and in other countries around the world. Not only does each form of adversity carry long-term health and psychosocial consequences for those involved, there is increasing evidence of their tendency to cooccur within families. Reviews of research by Todd Herrenkohl and colleagues in 2008 and Daryl Higgins and Marita McCabe in 2001 came to that very conclusion, while underscoring that risk factors like poverty and parental unemployment, parenting stress, social isolation, and drug and alcohol abuse are also present in many cases. For some families with children, community violence and neighborhood social and structural factors add even more stress and trauma into their daily lives. | There is now a sizeable body of research on “adverse childhood experiences,” or “ACEs,” which include CM and IPV. Studies of ACEs have consistently shown a robust, additive effect of these early forms of risk on adult outcomes that include heart and lung disease, diabetes, and certain forms of cancer. Not surprisingly, individuals with more ACEs tend to be the most vulnerable to the early-onset of disease and serious illness. And, studies have shown that adults with this profile can die up to two decades earlier than others with less adversity early on. Twenty-eight states and the District of Columbia now collect data on ACEs using public health surveillance surveys that are part of the Behavioral Risk Factor Surveillance System (BRFSS). Using these data, states are beginning to investigate how ACEs affect life opportunities for their citizens, based on educational attainment, employment, and earnings. |
News from CDC: the Legacy for Children parenting model, partnering to translate research to practice for children in poverty
Robinson LR , Perou R , Leeb RT . Transl Behav Med 2014 4 (3) 232-3 Approximately 16 million US children currently live in poverty [1]. Children living in poverty experience significant disparities on indicators of physical and mental health and academic success [2–6]. The importance of positive early experiences and the benefits of early intervention to mitigate the life-long effects of poverty have been confirmed in biologic [7], economic [8, 9], and social models [10]. Unfortunately, early childhood interventions have historically been limited in producing impacts when taken to scale. This has been attributed in part to a lack of quality assurance when moving from research to practice [11] and poor attention to scalability and dissemination when developing programs [12]. | To promote optimal development for children in poverty, the Centers for Disease Control and Prevention’s (CDC’s) National Center on Birth Defects and Developmental Disabilities (NCBDDD) developed the Legacy for Children™ (Legacy) model. NCBDDD seeks to promote the health of babies, children, and adults and enhance the potential for full, productive living through public health partnership, research, prevention, and education programs (http://www.cdc.gov/NCBDDD/AboutUs/index.html). Legacy is an evidence-based public health prevention approach to promote child health and development among families in poverty via a group-based parenting program [13]. The Legacy parenting curricula are developmentally sequenced sessions that cover themes including children’s physical health, safety and nutrition, responsive and sensitive parenting, fostering children’s development, and maternal self-care. Intervention components include mother and mother/child session time, one-on-one time to reinforce content, and participation in community events. |
Tests of the mitigating effects of caring and supportive relationships in the study of abusive disciplining over two generations
Herrenkohl TI , Klika JB , Brown EC , Herrenkohl RC , Leeb RT . J Adolesc Health 2013 53 S18-24 PURPOSE: To examine evidence of the continuity in abusive discipline across two generations (G1 and G2) and the role of safe, stable, and nurturing relationships (SSNRs) as protective factors. METHODS: Data are from the Lehigh Longitudinal Study, a prospective investigation of the causes and consequences child maltreatment that began in the 1970s with a sample of 457 children and their parents. Data were most recently collected in 2008-2010 from 80% of the original child sample (N = 357) when they were adults age 36 years on average. Of those assessed as adults, 268 participants (G2s) were parenting children and thus comprise the analysis sample. Analyses examined the association between harsh physical discipline practices by G1 parents and G2's reports of similarly severe discipline practices used in parenting their own children. Analyses also investigated the direct and interactive (protective) effects of SSNR variables that pertain to the care, warmth, and support children received from their mothers, fathers, and siblings over their lifetimes. A measure of an adult partner's warmth and support was also included. A case-level examination of G2 harsh discipliners was included to investigate other forms of past and more recent forms of abuse exposure. RESULTS: Results show a significant predictive association between physical discipline by G1 and G2 parents (beta = .30; p < .05; odds ratio, 1.14; confidence interval, 1.04-1.26), after accounting for childhood socioeconomic status and gender. Whereas being harshly disciplined as a child was inversely related to reports of having had a caring relationship with one's mother (r = -.25; p < .01), only care and support from one's father predicted a lower risk of harsh physical discipline by G2s (beta = -.24; p < .05; odds ratio, .74; confidence interval, .59-.92). None of the SSNR variables moderated the effect of G1 discipline on G2 discipline. A case-level examination of the abusive histories of G2 harsh discipliners found they had in some instances been exposed to physical and emotional abuse by multiple caregivers and by adult partners. CONCLUSIONS: There is continuity in physical disciplining over two generations. SSNRs measured in this study did not mediate or moderate the effect of G1 on G2 harsh physical discipline, although care and support from fathers was inversely related to the likelihood of G2 harsh physical discipline. This relationship is independent of abuse in childhood. Research is needed to identify factors that interrupt the intergenerational continuity of harsh physical (abusive) disciplining so that promising interventions can be developed and implemented. |
Examining the role of safe, stable, and nurturing relationships in the intergenerational continuity of child maltreatment-introduction to the special issue
Merrick MT , Leeb RT , Lee RD . J Adolesc Health 2013 53 S1-3 This special issue is the result of a successful collaboration between the Centers for Disease Control and Prevention (CDC) and researchers leading four important longitudinal studies on intergenerational patterns of violence: The Environmental Risk Longitudinal Twin Study (E-Risk) [1]; the Family Transitions Project (FTP) [2]; the Lehigh Longitudinal Study [3]; and the Rochester Youth Development Study [4]. The papers that follow investigate the role of safe, stable, and nurturing relationships and social contexts in the lives of children and their caregivers, provide insight into complex relationship factors that influence the intergenerational continuity of child maltreatment, and point to a number of important avenues to improve the lives of children and families by preventing violence and promoting health and well-being. | Child maltreatment is a significant public health problem that requires a multifaceted approach to prevention. It is estimated that one out of every ten children in the United States experiences one or more forms of physical, sexual, or emotional abuse or neglect by a parent or other caregiver at some point during their lifetime [5], [6], [7]. In 2011, social service workers identified 681,000 children1 in the United States as substantiated victims of maltreatment. This equates to an overall victimization rate of 9.1 per 1,000 children in the U.S. population [8]. It is well-established that experiencing child maltreatment is associated with a variety of negative physical, emotional, and psychological outcomes, including subsequent harsh and/or neglectful parenting in adulthood [9], [10], [11], [12], [13]. Yet, it is also clear that not all maltreated children grow up to become maltreating parents [14], [15]. Thus, identifying factors that distinguish families in which the cycle of violence is maintained from families in which it is interrupted is critical for violence prevention and optimal child development. |
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