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Children are defined as hypertensive when their blood pressure values equal or exceed the 95th percentile of the blood pressure value distribution in a pediatric population, according to gender, age and height. The population on which reference tables are based is of fundamental importance to establish the threshold values for the diagnosis of hypertension in pediatric age. Before 2017, both American and European guidelines used nomograms created in the same reference population which included children of all weight classes. Given the close and well-known association between hypertension and excess weight in childhood, the 2017 American guidelines proposed new reference nomograms excluding subjects with overweight and obesity from the "historical" reference population. Furthermore, the new American guidelines suggested a fixed cut-off of 130/80 mmHg, starting from 13 years and regardless of gender and height, to make the diagnosis of hypertension. In this document, the Italian Hypertension Society (SIIA) and the Italian Pediatric Society (SIP) jointly discuss a number of issues raised by the new American guidelines that involve the entire medical community, and also address the definition of arterial hypertension in the transition phase between childhood and adulthood. [ABSTRACT FROM AUTHOR]

Mental health challenges have been recognized as one of the most prevalent issues impacting children and families within the United States. Children and families of color are disproportionately affected by this due to lack of access to preventative and ongoing supports, and programs that can help address their overall well-being. These issues are even more severe for those that are at risk or interact with the child welfare system. Social workers use various clinical modalities to assess and support them. In the recent years, child welfare agencies have turned to Evidence based programs (EBPs) as a best practice to meet the needs of children and families. The Title IV-E Prevention Services Clearinghouse, established by the Administration of Children and Families is a landmark effort to review and promote such EBP's that prevents foster care placements, including mental health programs. While the Clearinghouse has reviewed 141 programs and services, out of which 71 have been rated as promising, supported, or well-supported, there is a dearth of culturally responsive programs that have met the Clearinghouse criteria. Given the overrepresentation of African American and Native American Families in the child welfare system, and the critical role of the Clearinghouse in reviewing and promoting EBPs, this paper highlights the philosophical, administrative, cultural and logistical barriers for culturally relevant programs to be accepted into the Clearinghouse. It also provides specific recommendations on how the Clearinghouse and researchers can build EBPs that account for the intersection between mental health, social location and cultural identities of the children and families that social workers serve. [ABSTRACT FROM AUTHOR]

Heated debate over the necessity, efficacy, and legality of public single-sex schooling continues in communities across the U.S. In this introduction to the second part of a special issue on the topic, we provide illustrative descriptions of issues that are common in U.S. school board deliberations on the topic, including issues of ideology, money, race, and science, and legal battles over the outcomes of such decisions. We then summarize the nine papers that appear in the issue. Four papers provide reviews of the laws, neuroscience, and critical race theorizing relevant to single-sex schooling. In addition, two papers present sophisticated re-analyses of important data sets on the topic, and three papers present new empirical data on non-academic outcomes (gender attitudes, peer relations, and body image) associated with single-sex schooling. Finally, we offer conclusions for educational practice and policy based on the current state of scientific evidence. [ABSTRACT FROM AUTHOR]

The aim of the present study was to perform a critical reflection about intervention options for bruxism reduction in children and adolescents. Search was conducted based on the PICO-structured question: "What are the intervention options to reduce bruxism in children/adolescents?". No language, year, or study design restrictions were imposed. Studies reporting interventions to reduce bruxism in children (< 10) and adolescents (10 to 19 years old) were included. Reviews and letters to editors were not included. From 2723 records, 17 papers were included. Included studies were primarily randomized clinical trials performed in Brazil (35.3%) and using different criteria for the diagnosis of bruxism. Reduction in self-reported bruxism and headaches associated with bruxism were observed in studies that used medications (hydroxyzine/trazodone/flurazepam), occlusal splints, orthodontic interventions, and psychological and physical therapy interventions. Reduction in Rhythmic Masticatory Muscle Activity was observed with the use of the occlusal splint and in orthodontic interventions. Alternative treatments (medicinal extracts such as Melissa officinalis-L) have shown inconclusive results.Conclusions: Several intervention options are available to inhibit or reduce bruxism activity. The respective indication, contraindications, and side effects of each treatment option must be assessed individually and carefully, taking into account that bruxism is not considered a disorder in otherwise healthy individuals.What is known• Biological and psychological factors have been strongly correlated to the development of bruxism• Bruxism prevalence ranging from 6 to 50% in childrenWhat is new• Reduction in self-reported bruxism and headaches associated with bruxism were observed in studies that used medication (Hydroxyzine/ Trazodone/ Flurazepam), occlusal splints, orthodontic interventions, psychological, and physical therapy interventions• A reduction in Rhythmic Masticatory Muscle Activity was observed with the use of the occlusal splint and orthodontic interventions. Alternative treatments (medicinal extracts such as Melissa officinalis L) show inconclusive results in respect of the reduction in bruxism. [ABSTRACT FROM AUTHOR]

The subject of computer science (CS) and computer science education (CSE) has relatively recently arisen as a subject for inclusion within the compulsory school curriculum. Up to this present time, a major focus of technologies in the school curriculum has in many countries been on applications of existing technologies into subject practice (both software such as office applications, and hardware such as robots and sensors). Through uses of these applications, information and communications technologies (ICT) have focused on activities to support subject and topic learning (across wide age and subject ranges). Very recently, discussions for including computers in the curriculum have shifted to a much greater focus on computing and CS, more concerned with uses of and development of programming, together with fundamental principles of problem-solving and creativity. This paper takes a policy analysis approach; it considers evidence of current implementation of CSE in school curricula, the six main arguments for wider-scale introduction of the subject, the implications for researchers, schools, teachers and learners, the state of current discussions in a range of countries, and evidence of outcomes of CSE in compulsory curricula. The paper concludes by raising key questions for the future from a policy analysis perspective. [ABSTRACT FROM AUTHOR]

Objectives: Population-based recruitment of a cohort of women who are currently pregnant or who may become pregnant in a given timeframe presents challenges unique to identifying pregnancy status or the likelihood of future pregnancy. Little is known about the performance of individual eligibility items on pregnancy screeners although they are critical to participant recruitment. This paper examined the patterns and respondent characteristics of key pregnancy screener items used in a large national study.Methods: Cross-sectional analyses were conducted. Descriptive statistics and multivariable logistic regression models were used to examine nonresponse patterns to three questions (currently pregnant, trying to get pregnant and able to get pregnant). The questions were asked of 50,529 women in 17 locations across the US, as part of eligibility screening for the National Children's Study Vanguard Study household-based recruitment.Results: Most respondents were willing to provide information about current pregnancy, trying, and able to get pregnant: 99.3% of respondents answered all three questions and 97.4% provided meaningful answers. Nonresponse ranged from 0.3 to 2.5% for individual items. Multivariable logistic regression results identified small but statistically significant differences in nonresponse by respondent age, marital status, race/ethnicity-language, and household-based recruitment group.Conclusions for Practice: The high levels of response to pregnancy-related items are impressive considering that the eligibility questions were fairly sensitive, were administered at households, and were not part of a respondent-initiated encounter. [ABSTRACT FROM AUTHOR]

Background: Accurate symptom monitoring is vital when managing pediatric asthma, providing an opportunity to improve control and relieve associated burden. The CHILDHOOD ASTHMA CONTROL TEST (C-ACT) has been validated for asthma control assessment in children; however, there are concerns that response option images used in the C-ACT are not culturally universal and could be misinterpreted. This cross-sectional, qualitative study developed and evaluated alternative response option images using interviews with children with asthma aged 4–11 years (and their parents/caregivers) in the United States, Spain, Poland, and Argentina. Interviews were conducted in two stages (with expert input) to evaluate the appropriateness, understanding and qualitative equivalence of the alternative images (both on paper and electronically). This included comparing the new images with the original C-ACT response scale, to provide context for equivalence results. Results: Alternative response option images included scale A (simple faces), scale B (circles of decreasing size), and scale C (squares of decreasing quantity). In Stage 1, most children logically ranked images using scales A, B and C (66.7%, 79.0% and 70.6%, respectively). However, some children ranked the images in scales B (26.7%) and C (58.3%) in reverse order. Slightly more children could interpret the images within the context of their asthma in scale B (68.4%) than A (55.6%) and C (47.5%). Based on Stage 1 results, experts recommended scales A (with slight modifications) and B be investigated further. In Stage 2, similar proportions of children logically ranked the images used in modified scales A (69.7%) and B (75.7%). However, a majority of children ranked the images in scale B in the reverse order (60.0%). Slightly more children were able to interpret the images in the context of their asthma using scale B (57.6%) than modified scale A (48.5%). Children and parents/caregivers preferred modified scale A over scale B (78.8% and 90.9%, respectively). Compared with the original C-ACT, most children selected the same response option on items using both scales, supporting equivalency. Following review of Stage 2 results, all five experts agreed modified scale A was the optimal response scale. Conclusions: This study developed alternative response option images for use in the C-ACT and provides qualitative evidence of the equivalency of these response options to the originals. Plain English summary: Accurate monitoring of the symptoms associated with pediatric asthma is important when managing the condition. The CHILDHOOD ASTHMA CONTROL TEST (C-ACT) is a questionnaire widely used to measure asthma severity in young children (aged 4–11 years). Each question answered by the child in the C-ACT has four possible answer choices. To help children answer, each choice is presented alongside an image of a male child's face ranging from sad to happy. However, there are concerns that the images used are not culturally universal and could be misinterpreted—due to difficulties translating to electronic formats and a lack of differentiation between the images used. Through interviewing children with asthma, we aimed to address these concerns by developing and testing new images. Alternative image options developed included simpler faces, circles of decreasing size and squares of decreasing quantity. Children aged 4–11 years old were interviewed to test whether they understood the response scale using the new images and if they answered in the same way as with the original images. Interviews were conducted in two stages, with expert guidance at key stages. Results showed that children can interpret and understand the newly developed images and that they answer the questions the same as they would using the original images. These new images have the advantages of being culturally neutral and easier to implement on an electronic device. [ABSTRACT FROM AUTHOR]

Several authors insist on the importance of students' acquisition of spatial abilities and visualization in order to have academic success in areas such as science, technology or engineering. This paper proposes to discuss and analyse the use of educational robotics to develop spatial abilities in 12 year old students. First of all, a course to introduce robotics to 6th grade primary school students was designed. The key intention was to prepare practical and motivating sessions in order to foster the students' involvement in hands-on learning. Hence, during the sessions of the course, challenges were provided for the students, in order to develop their capabilities as proficient problem solvers. The teacher assisted and guided the students, and the students were encouraged to solve the problems by themselves, working in 3-members teams. The main goal of this paper is to discuss and analyse the potential usefulness of educational robotics to develop spatial abilities. To carry out the analysis, students were randomly divided into an experimental group (EG), which participated in the robotics course, and a control group (CG), which did not take part in the robotics course. The extensive existing literature for spatial ability evaluation was analysed and reviewed and a pre-test and a post-test were prepared for use in the research study. Initially, the spatial ability of both EG and CG students was assessed with the pre-test. Then, after finishing the robotics course, the same sets of students were tested with the post-test. An extensive analysis of the results is provided in the paper. Results show that the positive change in spatial ability of the participants in the robotics course (EG) was greater than change evident in the students who did not join the course (CG). The improvement was statistically significant. The results also show that the overall performance of the students depends on the instruments used to evaluate their spatial abilities. Hence, this study manifests clearly the importance of the selection of those instruments. [ABSTRACT FROM AUTHOR]

This special issue is devoted to the topic of tangible user interfaces and children. It emphasizes research on tangibility that transcends system descriptions, focusing on the empirical support of theories and design guidance. The papers result from the organization of a workshop at the CHI 2009 ACM conference in Boston, USA. As an introduction to this issue, empirical evidence is discussed for the potential benefits that using TUIs may have for children. Next, we focus on the impact of tangibility in terms of usability, learning, collaboration, and fun. Finally, we suggest directions for future work and outline the papers that are included in this special issue. [ABSTRACT FROM AUTHOR]

The author reflects several topics that discuss how to build knowledge for the children's well-being in the U.S. The topic focused on the theories behind the development of child social indicators. It is stated that the ability to track the lifestyle of the children would show the positive development in the society.

Positive assortative matching in terms of traits such as ethnicity and race has been prevalent in marital formation. One possible explanation for this is that spouses in endogamous marriages possess complementary skills and tastes that increase marital surplus. This paper aims to estimate the effects of ethnic assortative matching on a variety of household outcomes by using the exogenous variation in immigrant flows in the USA during the period 1900-1930 to disentangle the selection effect of partners. The major finding is that the complementarities in home production from same ethnic marriage enhances investment in household public goods such as childrearing and home ownership and reduces the market labor supply of wives. The OLS estimates of the sizes of these effects appear to be substantially biased downward, indicating positive selection into intermarriage in terms of unobservable traits that increase marital surplus. [ABSTRACT FROM AUTHOR]

Children are traveling longer distances to school, and the share traveling by car is increasing. This paper examines the effects of school attributes on school choice, which in turn gives rise to travel distance and mode choice. It is well known that school quality is capitalized into residential land values. Households willing and able to pay price premiums may choose to live closer to good-quality schools. In contrast, households with less ability to pay are likely to live in places with schools of lower quality. The California public school system has an open enrollment policy, which allows students to transfer out of their neighbourhood school when places are available. When this option is exercised, students may travel longer distances to school compared with students who attend their neighbourhood schools. We used travel diary data from the 2001 Post Census Regional Household Travel Survey to model school destination choices for K-12 students in the Los Angeles region, California. Parents may choose to send their children to neighbourhood schools, other schools within their home district, or out-of-district schools. We find that location, school quality, and other school features influence the probability of a school being chosen, and the extent to which these factors influence choice varies depending on the characteristics of the residential district and the attributes of the household. [ABSTRACT FROM AUTHOR]

In recent years, unaccompanied minors have been journeying to the United States (U.S.)-Mexico border in great numbers in order to escape violence, poverty and exploitation in their home countries. Yet, unaccompanied children attempting to cross the United States border face treatment at the hands of government representatives which violates their inherent rights as children. The result is a human rights crisis that has severe health consequences for the children. Their rights as children are clearly delineated in various, international human rights documents which merit increased understanding of and recognition by the U.S. government. This paper calls for the improvement of policies and procedures for addressing the rights of unaccompanied immigrant children; it provides specific, rights-based recommendations which work together to safeguard the rights of the child at the U.S. southwestern border. [ABSTRACT FROM AUTHOR]

The Eyberg Child Behavior Inventory (ECBI) is one of the most widely used and well-validated parent rating scales for children’s disruptive behavior. This screening instrument is a short, targetted and easy to implement inventory with good psychometric properties and is normed for different countries, among which the United States, Spain, Sweden and Norway. The ECBI has been successfully used for research and clinical purposes, in several countries including The Netherlands. To date, Dutch studies have relied on Scandinavian or US norm scores. However, this may be problematic because of cross-cultural differences in the degree to which certain behaviors are seen as problematic by parents. The main goal of this paper therefore was to obtain norm scores for The Netherlands among 6462 Dutch children aged 4 to 8 years (Mage = 6.37 years; SD = 1.32; 50.6% boys). In line with previous research, we found small differences on the mean sum scores across children of different ages (intensity scale) and gender (intensity and problem scale). Therefore, Dutch norm scores were provided age- and gender specific. Our results showed that disruptive behavior of children in the most rural areas was reported as occurring less frequently and was seen as less problematic by parents compared to the disruptive behavior of children in less rural areas. Finally, we found that Dutch norm scores on the ECBI were significantly lower than US norm scores, and significantly higher on the intensity scale (but not the problem scale) than Norwegian and Swedish norm scores. [ABSTRACT FROM AUTHOR]

Challenging behavior, such as aggression, is highly prevalent in children and adolescents on the autism spectrum and can have a devastating impact. Previous reviews of challenging behavior interventions did not include interventions targeting emotion dysregulation, a common cause of challenging behavior. We reviewed emotion dysregulation and challenging behavior interventions for preschoolers to adolescents to determine which evidence-based strategies have the most empirical support for reducing/preventing emotion dysregulation/challenging behavior. We reviewed 95 studies, including 29 group and 66 single case designs. We excluded non-behavioral/psychosocial interventions and those targeting internalizing symptoms only. We applied a coding system to identify discrete strategies based on autism practice guidelines with the addition of strategies common in childhood mental health disorders, and an evidence grading system. Strategies with the highest quality evidence (multiple randomized controlled trials with low bias risk) were Parent-Implemented Intervention, Emotion Regulation Training, Reinforcement, Visual Supports, Cognitive Behavioral/Instructional Strategies and Antecedent-Based Interventions. Regarding outcomes, most studies included challenging behavior measures, while few included emotion dysregulation measures. This review highlights the importance of teaching emotion regulation skills explicitly, positively reinforcing replacement/alternative behaviors, using visuals and metacognition, addressing stressors proactively, and involving parents. It also calls for more rigorously designed studies and for including emotion dysregulation as an outcome/mediator in future trials. [ABSTRACT FROM AUTHOR]

Rising levels of childhood obesity in the United States and a 75% decline in the proportion of children walking to school in the past 30 years have focused attention on school travel. This paper uses data from the US Department of Transportation’s 2001 National Household Travel Survey to analyze the factors affecting mode choice for elementary and middle school children. The analysis shows that walk travel time is the most policy-relevant factor affecting the decision to walk to school with an estimated direct elasticity of −0.75. If policymakers want to increase walking rates, these findings suggest that current policies, such as Safe Routes to School, which do not affect the spatial distribution of schools and residences will not be enough to change travel behavior. The final part of the paper uses the mode choice model to test how a land use strategy—community schools—might affect walking to school. The results show that community schools have the potential to increase walking rates but would require large changes from current land use, school, and transportation planning practices. [ABSTRACT FROM AUTHOR]

There is a lack of research on how mental health diagnoses are delivered and explained to children and the effectiveness of these strategies. This qualitative study examines how emerging adults recall the delivery of mental health diagnoses in childhood and how they suggest these diagnoses should be delivered to children. Semi-structured interviews were conducted with 42 emerging adults (aged 18-22) who were diagnosed with attention deficit hyperactivity disorder (ADHD), depressive disorders, generalized anxiety disorder (GAD), and/or bipolar disorder in childhood. Findings reveal that parents, rather than mental health professionals, often inform children of their diagnoses. The data suggest that parents often act as translators of diagnostic information, acting as liaisons between mental health professionals and their children. The paper explores ways in which parents and mental health professionals withhold diagnoses from children, and how this affects children's experiences. Drawing on their own experiences, participants offer suggestions regarding the best ways to deliver diagnoses to children. Findings suggest that adults should share mental health diagnoses openly with children. Implications for social workers and other allied health professionals who support families when children are diagnosed are discussed. [ABSTRACT FROM AUTHOR]

The underlying structure of obsessive-compulsive disorder (OCD) remains to be confirmed in child and adolescent populations. In this paper we report the first factor analytic study of individual OCD items from Children's Yale-Brown Obsessive Compulsive Scale (CY-BOCS). OCD symptoms were assessed using the CY-BOCS symptom checklist in a sample of 854 patients with OCD (7-18 years of age) recruited from clinics in five countries. Pooled data were subjected to exploratory and confirmatory factor analysis (CFA) to identify the optimal factor structure. Various models were tested for age and gender subgroups. Also, the invariance of the solution across age and gender was tested and associations with demographic and clinical factors were explored. A three-factor model provided the best-fit solution. It consisted of the following factors: (1) harm/sexual, (2) symmetry/hoarding, (3) contamination/cleaning. The factor structure was invariant for age and gender across subgroups. Factor one was significantly correlated with anxiety, and factor two with depression and anxiety. Factor three was negatively correlated with tic disorder and attention-deficit/hyperactivity disorder (ADHD). Females had higher scores on factor two than males. The OCD symptom structure in children and adolescents is consistent across age and gender and similar to results from recent child and adolescents although hoarding may not be a separate factor. Our three-factor structure is almost identical to that seen in early studies on adults. Common mental disorders had specific patterns of associations with the different factors. [ABSTRACT FROM AUTHOR]

Over the past decade there has been a huge increase in the number of behavioral genetic studies looking into anxiety and depression in children and adolescents. There are now enough data in this area to make a review of the results useful. This paper begins with an outline of the methods used in such research and moves on to review the results in extant studies. Overall, these studies indicate modest to moderate genetic influence on both anxiety and depression. However, behavioral genetic methods are also paramount for exploring environmental influences in addition to genetic influences. Shared environment (that which makes family members resemble one another) is rarely identified in adult studies of personality or psychopathology and does not appear to be a significant influence for depression but it is for anxiety. Nonshared environment, which makes family members differ from one another, is found to be a significant influence for both anxiety and depression. Patterns within these results due to rater effects, age effects, sex effects, the precise phenotype measured, and the study design are explored. [ABSTRACT FROM AUTHOR]

Children in low-income neighborhoods tend to be disproportionately exposed to environmental toxicants. This is cause for concern because exposure to environmental toxicants negatively affects health, which can impair academic success. To date, it is unknown if associations between air toxics and academic performance found in previous school-level studies persist when studying individual children. In pairing the National Air Toxics Assessment risk estimates for respiratory and diesel particulate matter risk disaggregated by source, with individual-level data collected through a mail survey, this paper examines the effects of exposure to residential environmental toxics on academic performance for individual children for the first time and adjusts for school-level effects using generalized estimating equations. We find that higher levels of residential air toxics, especially those from non-road mobile sources, are statistically significantly associated with lower grade point averages among fourth- and fifth-grade school children in El Paso (Texas, USA). [ABSTRACT FROM AUTHOR]

Empowering settings are important places for people to develop leadership skills in order to enact social change. Yet, due to socio-cultural constructions of childhood in the US, especially constructions around working class and working poor children of Color, they are often not seen as capable or competent change agents, or in need of being in empowering settings. Based on a 9-month participant observation study of a first grade public charter school classroom in central California, this paper examines how one teacher used an alternative, artist-focused curriculum to take steps to facilitate a more empowering setting for her working class and working poor students, most of whom were Latina/o. We illustrate how this teacher worked to implement the components of an empowering setting within her classroom space: community building, peer-based support, meaningful roles, and shared leadership among her students. Student and teacher interviews are also used to triangulate findings. Implications include providing ways to assist young children as they become social change agents. [ABSTRACT FROM AUTHOR]

This paper is a single case study involving a visit to a diagnostic clinic for autism spectrum disorder. A young boy finds a toy that he can hold with one hand and spin with another. In order to retrieve the toy and leave it in the clinic, the parents engage in a team effort. We describe this achievement in terms of two styles of practice or interactional routines with differing participation frameworks. We examine not only how the parents work as a team using these styles, but also how they improvise to extract the spinning toy from their son's grasp with minimal protest on his part. [ABSTRACT FROM AUTHOR]

The significant number of annual US jail admissions is intricately tied to the increasing population of children with incarcerated parents. Some proportion of these children will visit their parents in jail, and the limited research linking visits to young children's well-being is mixed. Sesame Street developed multimedia educational materials to support young children with incarcerated parents, including specific messages around visiting. The educational materials have been found to positively shape how caregivers talk to children about parental incarceration, though a gap remains regarding young children's self-reported experiences. In a preliminary randomized efficacy trial of these educational materials, the current study examined 67 young children's (aged 3–8) self-reported feelings while at the jail following viewing of the video materials, including their feelings about their caregivers, incarcerated parents, families, and visiting in general. Data were collected when children arrived at the jail (before half were randomized to watch the intervention materials) and then again following the intervention. In the treatment group, the proportion of children reporting positive feelings increased from pre- to post-test, most saliently for feelings about families, while feelings decreased overall for those in the control group. The intervention was associated with positive feelings about family, especially for those children who were told developmentally appropriate information about the parent's incarceration prior to arrival at the jail. The exploratory findings shed light on young children's emotions when visiting parents in jail and the buffering role that intervention materials can have in offering support to help manage feelings during jail visits. Highlights: Exploratory findings suggest that the intervention was associated with positive changes in self-reported feelings for young children visiting parents at jail. Feelings about family were most significantly strengthened for young children following the multimedia intervention at jail. Strengthened feelings about family were most robust for children given developmentally appropriate information about the incarceration. [ABSTRACT FROM AUTHOR]

The debate over universal health insurance (HI) in the U.S., as well as the proper role of the government in the HI market, has been quite heated. Fueling this debate is the uncertainty pertaining to the benefits of HI in general, and the relative benefits of private versus public HI in particular. This uncertainty stems from non-random selection into different types of HI (private, public, or none) in combination with the absence of experimental data. Moreover, the lack of typical exclusion restrictions complicates identification of the causal effects of different HI types. Here, the aim is to assess the causal impact of public HI, relative to private HI, on the insured infant's health. To that end, this study employs the methodology proposed in Altonji et al. (J Polit Econ 113:151-184, ) which trades off what can be learned in exchange for not requiring an exclusion restriction. Nonetheless, the method remains quite informative in the present context. Specifically, using data from the Early Childhood Longitudinal Survey, Birth Cohort, along with several measures of infant health, the results suggest that while public HI is associated with worse infant health, this association disappears once selection on observables and unobservables is considered. In fact, the estimated effects of public HI are predominantly positive once both types of selection are admitted. Further analysis reveals that the likely beneficial effects of public HI are due to greater coverage for infants at a much lower cost. [ABSTRACT FROM AUTHOR]

It has long been recognized that human beings exposed to severe stress may develop psychological symptoms. With recent terrorist acts around the world including the New York City World Trade Center September 11, 2001 atrocity, there has been a growing interest in the specific impact of terrorist acts on the victims and witnesses. One area that has received less study is the specific impact on children. This paper reviews some of the general effects of traumatic stress on children and the history of the research in this area including a specific discussion of post-traumatic stress disorder in children. This is followed by a review of how children might react to the trauma of a terrorist attack differentiating between three different subgroups of children (preschool age children, school-age children, and adolescents). Then there is a review of what a comprehensive evaluation of childhood victims of terrorism should entail. Finally, treatment modalities that have been shown to be effective are reviewed. [ABSTRACT FROM AUTHOR]

The aim of this paper was to investigate the association between birthweight and prevalence of food allergies using a national sample of US children. Adult report of birthweight and child food allergies were obtained for years 2005-2009 from the National Health Interview Survey (NHIS), a cross-sectional household survey of the US population. A total of 51,748 children aged 0-17 years were included in the analyses representing over 73 million children. Multivariable logistic regression analyses examined associations between birthweight categories and food allergies stratified by age and gender; accounting for the complex design of NHIS. Children aged 6-12 years who were born very low birthweight (500-1,499 g) were more likely to have reported food allergy compared to referent (3,000-3,499 g), OR = 1.72; 95% CI: 1.02-2.91. However, there was no clear trend of an association between birthweight and food allergy with increasing or decreasing birthweight across all ages. Estimates were generally stronger in younger male children as compared to estimates in females of the same age group. Marginal associations for respiratory allergy (OR = 1.52; 95% CI: 1.02-2.29) and hay fever (OR = 1.54; 95% CI: 0.93-2.54) were observed among very low birthweight children aged 0-5 years. There was limited evidence for a clear association between birthweight and food allergy. Marginal associations observed in children weighing 500-1,499 g at birth support efforts to minimize preterm births and very low birthweight given the increase in pediatric food allergies and the large number of children born low birthweight each year in the US. [ABSTRACT FROM AUTHOR]

Intimate partner homicide-suicide (IPHS) represents the most severe form of domestic violence, and often results in multiple fatalities. This paper examines outcomes of children in households that experience IPHS. Reports of 325 IPHS cases among adults age 18-44 in the U.S. between 1999 and 2004 were collected and examined. Results indicate children were often fatally wounded, but were most likely to witness the eventthen be absent or killed. Difficult financial conditions during times of economic downturn may increase the possibility of stress-related suicide, and subsequent familicide. Children with a suicidal parent are at increased risk of harm, so identification is of vital importance. Children are most likely harmed or killed by a primarily suicidal male perpetrator, who is usually their biological father. Firearms were used more than other methods in IPHS events. Even those perpetrators with protective orders more often utilized a firearm, which reflected a weakness in Violence Against Women Act gun ban enforcement. In this research, regions of the U.S. with less stringent firearm regulations were disproportionately likely to contain IPHS events. Findings illustrate the importance of making distinctions among perpetrators of IPHS, and assessing firearms policies, in order to improve child death prevention efforts. [ABSTRACT FROM AUTHOR]

This paper uses pooled cross-sectional data from the 2000, 2002, 2004, and 2006 General Social Surveys (GSS), a nationally representative sample of the U.S. adult population, to assess how employed parents’ attitudes about affirmative action for women are influenced by their children’s gender. The analytic sample includes 1,695 employed respondents. Findings based on logistic regression indicate that having daughters (and no sons) magnifies employed mothers’ support for affirmative action for women and minimizes employed fathers’ support. Conversely, having sons (and no daughters) does not suppress mothers’ support for affirmative action for women, nor does it differentiate men’s attitudes about affirmative action. We speculate about how these patterns in parents’ attitudes relate to self interest and group interest (i.e., their children’s future work experiences). [ABSTRACT FROM AUTHOR]

The focus of this paper is children with disabilities exposed to a broad range of violence types including child maltreatment, domestic violence, community violence, and war and terrorism. Because disability research must be interpreted on the basis of the definitional paradigm employed, definitions of disability status and current prevalence estimates as a function of a given paradigm are initially considered. These disability paradigms include those used in federal, education, juvenile justice, and health care arenas. Current prevalence estimates of childhood disability in the U.S. are presented within the frameworks of these varying definitions of disability status in childhood. Summaries of research from 2000 to 2008 on the four types of violence victimization addressed among children with disabilities are presented and directions for future research suggested. [ABSTRACT FROM AUTHOR]

This paper analyzes the family structure experiences of children in the U.S. Childbearing and transitions among single, cohabiting, and married states are analyzed jointly. A novel contribution is to distinguish men by their relationship to children: biological father or stepfather. The analysis uses data from the NLSY79. A key finding is that children of black mothers spend on average only 33% of their childhood living with the biological father and mother, compared to 74% for children of white mothers. The two most important proximate demographic determinants of the large racial gap are the much higher propensity of black women to conceive children outside of a union, and the lower rate of “shotgun” unions for blacks compared to whites. Another notable finding is that cohabitation plays a negligible role in the family structure experiences of children of white mothers, and even for children of black mothers accounts for less than one fifth of time spent living with both biological parents. [ABSTRACT FROM AUTHOR]

A key social indicator of the well being of a society is the health and welfare of their children. Child maltreatment is a major problem in the U.S. and the world and the reporting of maltreatment has been the subject of much research and debate. However, little is known about self-reports of child maltreatment. Children face many obstacles that may prevent them from reporting their own maltreatment to authorities. Despite these obstacles, a small percentage of all child maltreatment reports made to child protective services (CPS) in the US are made by the victim. The purpose of this paper is to describe an analysis of reports made to CPS by the child-victim of maltreatment over a three-year period. Results indicated significant differences related to child race, gender and substantiation rate among self-reports and reports made by others. [ABSTRACT FROM AUTHOR]

Dramatic expansions in public health insurance eligibility for U.S. children have only modestly reduced the aggregate number of uninsured at the national level. This paper shows that Medicaid and SCHIP expansions had different impacts on child health insurance coverage patterns based upon local labor market characteristics. Metropolitan areas with high levels of unemployment were most likely to have seen improvements in overall insurance coverage for children between 1990 and 2001. Areas with greater fractions of employment in services, retail or wholesale trade were more likely to have experienced increases in public coverage but not overall coverage rates. [ABSTRACT FROM AUTHOR]

Using a large, U.S. dataset it is shown that children are more likely to receive needed mental health specialty treatment when women have greater decision-making power, as measured by an index of wife-favorable divorce laws and by the sex ratio at the time of marriage. Stratified analyses show that this effect is modified by the degree of marital conflict. Marriages characterized by high conflict conform more closely to the unified household model. The paper then presents a model of household decision-making consistent with these results that incorporates both objective determinants of bargaining power as well as the role of violent coercion in maintaining otherwise unsustainable equilibria. Implications for improving children’s access to mental health treatment are offered. [ABSTRACT FROM AUTHOR]

The increasing number of children with incarcerated parents constitutes perhaps one of the largest at-risk populations in the United States. Short- and long-term effects of parental incarceration are difficult to quantify; however, the current literature indicates that this population is negatively responding to major shifts in family structure, and is vulnerable to economic stress and adverse interpersonal issues. Service providers are seeking appropriate intervention strategies to address the resultant issues of parental incarceration. Unfortunately, there is a paucity of research on effective practice methods. This paper reviews the literature on the potential implications parental incarceration has on children, and discusses service providers’ concerted efforts to allay the consequences. Recommendations for appropriate data collection and identification of relevant gender, developmental, and cultural interventions are provided. [ABSTRACT FROM AUTHOR]

In this paper, we conceptualize and develop an index of sociodemographic risk that we hypothesize will be an improvement over the standard poverty measure as a measure of risk for children’s development. The poverty line is widely used in government statistics and in research but is also widely acknowledged to have multiple shortcomings. Using recent data from the National Survey of America’s Families, we develop and examine a Sociodemographic Risk Index for two potential purposes: (a) to serve as a summary indicator of children’s environments that affect their well-being, and (b) to serve as a variable that can be used to identify at-risk subgroups of children whose well-being should be examined separately in indicator reports. Based on substantial research on children’s development, we chose five variables for the index: family income, family structure, parent education, family size, and home ownership. An additive sociodemographic risk index using these variables is strongly associated with multiple measures of child well-being in both bivariate and multivariate analyses. Hence, it serves as a good marker of risk for children and therefore as an indicator that could be monitored over time, across groups, and across places, as well as a variable that could be used to identify subgroups of at-risk children whose well-being should be monitored. However, analyses do not indicate that it performs better at identifying at-risk children than the current poverty measure. Therefore, we recommend the Sociodemographic Risk Index primarily as an additional summary indicator to be monitored, rather than as a replacement for the poverty measure. [ABSTRACT FROM AUTHOR]

There are many challenges to transporting evidence-based treatments from laboratories into real-world settings. However, if we hope to make our evidence-based treatments accessible and available to children and usable by community professionals, effectiveness research is imperative. We argue that schools represent an ideal real world setting in which to conduct such research. The goals of this paper are to present the advantages of conducting effectiveness research in the school setting and to encourage clinical researchers to engage in effectiveness research in this "location," as there are benefits to children, pre-service professionals, communities, and researchers. We attempt to further advance the literature by discussing the challenges associated with this work and by providing a case example (The Youth Experiencing Success in School [Y.E.S.S.] Program) that demonstrates real world application of our recommendations. [ABSTRACT FROM AUTHOR]

Greater training and specialization in working with children exposed to domestic violence has resulted in new policies, interagency protocols, and legislation in many states. This paper examines court-related responses in criminal, child protection, and family court custody proceedings, which highlight legislative changes and resulting systemic change. Although this legislation originated with the best of intentions to assist and protect children, some of the most striking outcomes have been negative and unintended. Laws that mandate reporting of children exposed to domestic violence can clash with inadequate training and resources, or inadvertently revictimize abused women. Similarly, child custody legislation that raises a rebuttable presumption that a violent spouse will not receive custody or joint custody of children after parental separation has resulted in greater skepticism about abuse allegations We propose that efforts at law reform can be enhanced by a more thoughtful analysis of potential intended and unintended consequences, and should be accompanied by a comprehensive evaluation plan to monitor implementation effects. [ABSTRACT FROM AUTHOR]

Background: Between 2015 and 2021, 3,498 Americans died from unintentional gun injuries, including 713 children 17 years and younger. Roughly 30 million American children live in homes with firearms, many of which are loaded and unlocked. This study assesses the scope of unintentional shootings by children 17 and younger in the US and the relationship between these shootings and state-level secure storage laws. Methods: Demographic and injury data of both perpetrators and victims of unintentional shootings by children 17 and younger in the US from 1/1/2015–12/31/2021 were extracted from the #NotAnAccident Index. The #NotAnAccident Index contains media-report data, which is systematically flagged through Google Alerts. We describe characteristics of incidents and examine incident rates over time. The association between state-level secure storage laws and rates of unintentional shootings by children is assessed in multivariate negative binomial regression models. Results: 2,448 unintentional shootings by children resulted in 926 deaths and 1,603 nonfatal gun injuries over a period of seven years. Most perpetrators (81%) and victims (76%) were male. The mean age was 10.0 (SD 5.5) for shooters and 10.9 (SD 8.1) for victims. Children were as likely to shoot themselves (49%) as they were to shoot others (47%). The majority of victims were under 18 years old (91%). Shootings most often occurred in or around homes (71%) and with handguns (53%). From March to December 2020, coinciding with the COVID-19 pandemic, incidents increased 24% over the same period in 2019, which was driven largely by an increase among shooters ages 0–5. Depending on the type of law, rates of unintentional shootings by children were 24% to 72% lower in states with secure storage laws, compared to states without such laws. Conclusions: Unintentional shootings by children are on the rise, particularly among children 0–5 years old, but are preventable tragedies. Our results show that secure firearm storage policies are strongly correlated with lower rates of unintentional shootings by children. Firearm storage policies, practices, and education efforts are needed to ensure guns are kept secured and inaccessible to children. [ABSTRACT FROM AUTHOR]

This systematic review aimed to identify factors significantly associated with the occurrence of epilepsy in autistic individuals and to consider the impact of study quality on findings. Electronic databases were systematically searched on October 2nd, 2020 and records retrieved were limited to those published from 2000 onwards. Study quality was categorised as 'good', 'moderate' or 'weak'. Fifty-three studies were included and in studies where the prevalence of epilepsy was reported (n = 257,892), 18,254 (7%) had co-occurring epilepsy. Intellectual disability/cognitive impairment was the most commonly reported risk factor associated with occurrence of epilepsy in autistic individuals. The evidence supporting other, potentially relevant factors was weak and inconsistent and requires further evaluation. Only 9/53 studies were considered 'good' quality. [ABSTRACT FROM AUTHOR]

Validated outcome measures with the capacity to reflect meaningful change are key to assessing potential interventions for autism spectrum disorder (ASD). We derive clinically meaningful change thresholds (MCTs) of the Autism Impact Measure (AIM) and identify factors associated with meaningful change. Baseline and 12-months follow-up survey of caregivers of 2,761 children with ASD aged 3–17 years from the U.S. Simons Foundation Powering Autism Research for Knowledge (SPARK) cohort were analyzed. Using caregiver-reported anchors for change, the 12-month change in estimated AIM MCT (95% confidence interval) for symptom improvement was –4.5 (–7.61, –1.37) points and 9.9 (5.12, 14.59) points for symptom deterioration. These anchor-based MCTs will facilitate future assessments of caregiver-reported change in AIM scores. [ABSTRACT FROM AUTHOR]

Objective: This paper presents a new approach for understanding factors related to physician adoption of clinical guidelines, using children's vaccine recommendations as a case study. Methods: The model traces sequential steps, from awareness to agreement to adoption and, finally, adherence to the guideline. Movement through these stages can be catalyzed or retarded by many influences, grouped into two major categories: environmental characteristics of the physician's practice, and information characteristics of the guideline. Environmental characteristics include sociocultural factors, professional characteristics, and practice organization factors. Information characteristics include the guideline's relative advantage, complexity, and compatibility with existing guidelines and protocols, as well as mechanisms of guideline dissemination. Implications: This model can be used to identify characteristics that will likely impede or facilitate guideline adoption, and to focus dissemination efforts on key issues. [ABSTRACT FROM AUTHOR]

Most research on married women's labor force participation relates characteristics of individual women to their probability of labor force participation. Some studies relate characteristics of geographic areas to average labor force participation rates in those areas, although these aggregate level analyses are usually gross tests of ideas about individual-level processes. Here we take a quintessentially sociological perspective and seek to understand how characteristics of geographic areas structure the relationship between properties of individual women and their probabilities of labor force participation. Our analysis has two steps. In step one, we fit individual-level probit models of married women's probability of labor force participation. A separate model is fitted in each of 409 areas using 1970 Census data, and the relationship between individual characteristics and labor force participation is found to vary substantially across areas. In step two, we attempt to explain areal variation in the effects of women's children on their labor force participation. We hypothesize that the effect of children on their mothers' labor force participation is a function of the cost and availability of childcare , and of the "convenience" of jobs for working mothers in the places where the mothers live. Measures of childcare cost, childcare availability and job convenience are developed. Weighted least squares analyses of probit coefficients from the first stage are, in general, very consistent with our findings, and suggest that the approach taken in this paper is likely to be a fruitful one for future studies. [ABSTRACT FROM AUTHOR]

This paper demonstrates the relation that obtains between the average family size of women and the average family size of offspring of those women. It estimates the value of these two measures for cohorts of American women aged 45-49 in various years from 1890 to 1970. It shows that children born during the post-war baby boom actually derived from smaller families than those born during the low-fertility 1930's; that under current patterns a woman would have to bear an average of almost two children fewer than were borne by her mother merely to keep population fertility rates constant from generation to generation; and that average family size for nonwhite children exceeds that for white by 50 percent, although the racial difference in family sizes of women is only 19 percent. [ABSTRACT FROM AUTHOR]

This is a study of fertility expectations of wives in relation to selected demographic and social and economic characteristics. The data for this study were obtained from a special survey conducted in 1967 from a probability sample of 30,000 households. The analyzed data show that the number of children expected in the next five years is inversely related to parity. Because of the inverse relationship, the expectations of additional children tend to be inversely related to age at marriage of wife, number of years married, and similar temporal variables. The data show also that there exists an inverse relationship between expectations of additional children and selected socio-economic characteristics, such as education of wife, occupation, and income of husband. [ABSTRACT FROM AUTHOR]

Parents of children diagnosed with autism spectrum disorders (ASD) express concern about raising their children bilingually, and often hear advice from professionals against the use of bilingualism. The current study examined the relation between bilingualism and the language and social communication skills of toddlers diagnosed with ASD (N = 353) in the US, while controlling for socioeconomic risk factors. Structural equation modeling showed no differences in language skills between bilingual Spanish–English speaking children and monolingual English-speaking (p =.596) or monolingual Spanish-speaking (p =.963) children and showed a bilingual advantage on socialization skills when comparing bilingual and monolingual English-speaking children (p =.001). Parents of autistic children exposed to Spanish and English should be encouraged to raise their child bilingually if it best suits familial needs. [ABSTRACT FROM AUTHOR]

Purpose: Lesbian, gay, and bisexual (LGB) youth experience disproportionately high rates of suicidality and exposure to traumatic events, such as sexual violence and teen dating violence. Rates of suicidality and exposure to traumatic events also vary by sexual minority subgroup. The purpose of this study was to: (1) explore the impact of LGB identity on the relationship between violence exposure and suicide; and (2) to examine variations by sexual identity. Method: A subsample of respondents who reported on their sexual identity in the Youth Risk Behavior Survey (n = 14,690) was used to examine if the associations between sexual and dating violence with suicide outcomes (suicidal ideation, planning, and suicide attempt) depended on the sexual identity of the respondent. Logistic regression models were fitted with an interaction effect to quantify heterogeneity of associations across identity strata. Results: Overall interaction tests mostly indicated heterogeneity of associations between sexual violence and physical dating violence. Several contrast of strata associations suggested substantive probability differences between sexual minority respondents and their heterosexual peers. Conclusion: While exposure to violence was broadly associated with increased probability of experiencing any type of suicidality, LGB and questioning youth were significantly more likely to experience suicidality compared to their heterosexual peers. Gay and lesbian youth demonstrated the strongest probability of experiencing suicidal thoughts and behaviors among survivors of sexual violence, while bisexual youth may be more at risk following dating violence. Implications for future research and suicide prevention are discussed. [ABSTRACT FROM AUTHOR]

Background: Familial hypercholesterolemia (FH) is an inherited disease which causes premature atherosclerotic cardiovascular disease. However, less than 10% of individuals with FH have been identified. Objective: To assess parental perspectives for inclusion of FH on routine newborn screening (NBS) and to highlight potential benefits, harms, and ethical concerns. Methods: Telephone interviews of two groups were conducted: 1) parents of children diagnosed with FH, and 2) parents of children diagnosed with a genetic condition through NBS. Stratified purposive sampling was used to ensure adequate representation. The 11 telephone interviews were conducted in 30-min sessions guided by a semi-structured interview script. At the beginning of the interview, participants were educated on the NBS process and FH. The interviews were transcribed verbatim, and a thematic analysis was performed in multiple steps. Results: All interviewees indicated that they would be interested in having their child be screened for FH on the newborn screen. Reasons supporting screening during the newborn period included knowing their child's diagnosis, the ability to screen family members for FH, incorporation of lifestyle changes, and access to preventive care. Negatives surrounding screening during the newborn period included increased stress or anxiety, knowledge, stigma, and the delay from diagnosis to initiation of pharmacotherapy for FH. Conclusion: While these interviewees were in favor of NBS for FH, further education of parents and clinicians is needed to ensure proper implementation. The results of this study may be useful to formulate family notification and care protocols for newborns diagnosed with FH and other diseases. Significance: What is already known on this subject? Familial hypercholesterolemia is a common inherited disorder that predisposes to early cardiovascular disease, but most affected individuals are not diagnosed. Childhood cholesterol screening is an effective but underutilized diagnostic tool. Previous studies report parents find childhood cholesterol screening acceptable, but it is not known if screening newborns would also be acceptable. What does this study add? Interviewees found screening newborns for familial hypercholesterolemia acceptable and would agree to screen their own newborn. The ability to screen other family members and access to early treatment were important factors in their decision to screen. Education of clinicians about familial hypercholesterolemia was an important concern raised by interviewees. [ABSTRACT FROM AUTHOR]

The Strengths and Difficulties Questionnaire (SDQ) is a screening tool widely used in both pediatric research and clinical practice. Few studies have examined the psychometric properties of the U.S. version of this measure, and none have examined the structure of the measure with children younger than 4 years of age. The goal of this study was to assess the psychometric properties of the parent informant version of the SDQ administered in a pediatric practice serving a low-income, predominately Black, urban population of children ages 2–5 years. Parents routinely completed the SDQ electronically during annual well-child visits from July 2016 to June 2017. Confirmatory factor analysis was used to test 3-factor, 5-factor, and modified 5-factor (with positive construal response style) models. Responses to age-appropriate SDQ forms were analyzed. There were N = 622 for the 4–12 year old version (only collected on 4–5 year olds) and N = 672 of the 2–3 year old version. In both groups, the modified 5-factor model was the best fitting model. The internal consistency for the modified 5-factor model was lower than the original 5-factor model with the alpha coefficient lower on the Conduct Problems, Emotional Problems and Peer Problems subscales. Measurement invariance testing found non-invariance due to gender among the 4–5 year olds on the emotional problems subscale. Our study found that the SDQ shows satisfactory psychometric properties in preschool-aged children in a low-income urban U.S. population. More research is needed to deepen our understanding of the measure's clinical utility. Highlights: Few studies have examined the psychometric properties of the Strengths and Difficulties Questionnaire in the US. No studies have examined the structure of the measure with children <4 years of age. Participants were recruited from a pediatric practice serving a low-income, predominately Black, urban population of children (2–5 years). A modified 5-factor (with positive construal response style) model fit the data best. Internal consistency was low for some subscales and non-invariance due to gender was found for the emotional problems subscale among 4–5 year olds. [ABSTRACT FROM AUTHOR]

Background: There is no streamlined approach for sharing radiologic images among medical institutions. Common methods to transfer imaging between facilities include electronic image-sharing platforms and physical media, such as compact discs (CDs). The prompt and secure transfer of imaging is vital for patient safety as demand for imaging increases. Objective: Use a survey-based study to outline the methods and difficulties of image sharing among U.S. children's hospitals. Materials and methods: A multi-question survey regarding radiologic image sharing was distributed to children's hospital department chairs in the United States in August 2021. Descriptive statistical analyses of the results were performed. Results: Our results reveal 78% of responding U.S. children's hospitals have an electronic image-sharing platform. Twenty-seven percent of surveyed institutions experience daily difficulties with radiologic image sharing. Most of the difficulties are with CDs (67%) and a lack of interoperability among electronic image-sharing platforms (51%). Conclusion: Our study identified the various methods used by U.S. children's hospitals for radiologic image sharing and quantified the ongoing challenges with these systems. [ABSTRACT FROM AUTHOR]

Background: Drowning is a leading cause of unintentional injury-related death for toddlers within the USA. Keeping toddlers within arm's reach while swimming is recommended, yet many caregivers do not. Possibly, caregivers' attitudes are shaped by their expectations about whether they could quickly save a child. The aims of this study are to 1) explore caregivers' views of arm's reach pool supervision in various scenarios and 2) understand whether perceptions of arm's reach pool supervision are impacted by the caregiver's self-reported capability to swim the length of a standard pool. Results: Caregivers generally showed agreement with arm's reach pool supervision; however, arm's reach supervision was viewed as less necessary when a toddler was in shallow water, wearing a flotation device, or with an older child or teen. There was a significant effect of caregiver swimming capability on perceptions of arm's reach pool supervision, with non-swimmers and the strongest swimmers showing more positive perceptions of arm's reach pool supervision than caregivers reporting poor swimming capability. Female caregivers showed significantly more agreement with arm's reach pool supervision compared with male caregivers. Grandparents and parents showed significantly more agreement with arm's reach pool supervision than siblings. Conclusions: Caregivers' views about what constitutes appropriate supervision are impacted by gender, the relationship to the toddler, and the caregiver's swimming capability. Findings suggest that a caregiver's ability to offer close supervision or respond in an emergency may influence their attitudes about what constitutes appropriate supervision. Caregivers may view arm's reach pool supervision as less necessary when additional layers of protection are in place. [ABSTRACT FROM AUTHOR]