The New York Times
The rate at which doctors diagnosed autism and related disorders in 8-year-olds increased between 2008 and 2010 in some parts of the country, a report released by the federal Centers for Disease Control and Preventionon Thursday said. The average rate was one in 68 children, up from one in 88 in 2008. The report — based not on direct diagnoses but on a review of records — was not nationally representative and drew on data gathered three years before a significant tightening in the clinical definition of autism. The likelihood of receiving a diagnosis of autism has increased sharply over the past three decades, and no one knows why, or whether the 2010 numbers are currently meaningful.
Thursday, April 24, 2014
Inside the Mind of a Child With Autism
New York Times
Therapists who specialize in autism often use a child’s own interests, toys or obsessions as a way to connect, and sometimes to reward effort and progress on social skills. The more eye contact a child makes, for example, the more play time he or she gets with those precious maps or stuffed animals.
But now a group of scientists and the author of a new book are suggesting that those favorite activities could be harnessed in a deeper, more organic way. If a child is fascinated with animated characters like Thomas the Tank Engine, why not use those characters to prompt and reinforce social development?
Millions of parents do this routinely, if not systematically, flopping down on the floor with a socially distant child to playact the characters themselves.
“We individualize therapy to each child already, so if the child has an affinity for certain animated characters, it’s absolutely worth studying a therapy that incorporates those characters meaningfully,” said Kevin Pelphrey, director of the child neuroscience laboratory at Yale.
He and several other researchers, including John D. E. Gabrieli of M.I.T., Simon Baron-Cohen of the University of Cambridge andPamela Ventola of Yale, are proposing a study to test the approach.
The idea came from Ron Suskind, a former Wall Street Journal reporter whose new book “Life, Animated” describes his family’s experience reaching their autistic son, Owen, through his fascination with Disney movies like “The Little Mermaid” and “Beauty and the Beast.” It was Mr. Suskind’s story that first referred to ‘“affinity therapy.” He approached the researchers to put together a clinical trial based on the idea that some children can develop social and emotional instincts through the characters they love.
Experts familiar with his story say the theory behind the therapy is plausible, given what’s known from years of studying the effects of other approaches.
“The hypothesis they have put forward is sound, and absolutely worth studying,” said Sally J. Rogers, a professor of psychiatry at the MIND Institute of the University of California, Davis. “If you think about these animated characters, they’re strong visual stimuli; the emotions of the characters are exaggerated, those eyebrows and the big eyes, the music accompanying the expressions. Watching those characters is the way many of us learned scripts that are appropriate in social situations.”
But Dr. Rogers cautioned that using animated characters is hardly the key to reaching all autistic children. Many are fascinated by objects or topics without inherent social content — maps, for instance. But for those who fixate on movies, television shows or animated characters, affinity therapy makes sense, she said.
The researchers brought together by Mr. Suskind have written a proposal for a study of the approach. It calls for a 16-week trial for 68 children with autism, ages 4 to 6. Half the children would receive affinity therapy, using the shows or movies they love as a framework to enhance social interaction, building crucial abilities like making eye contact and joint play.
The other half, the control group, would engage in the same amount of interaction with a therapist but in free play, led by the child’s interest. Therapists have had some success using the latter approach, most notably in a therapy called Floortime, developed by Dr. Stanley Greenspan.
In autism therapy, progress is measured in increments and tends to be slow, especially in severely affected children, experts say. But the disorder — the autism spectrum, as it’s known — includes a very diverse group of children whose prospects for improvement are unpredictable and individual. Some children develop social skills relatively quickly, while others are stubbornly unreachable.
Dr. Pelphrey said that the affinity approach would incorporate many elements of pivotal response treatment, a type of therapy being intensely studied. It incorporates a system of rewards into normal interactions between a therapist (or parent) and the child, playing together.
Sarah Calzone of Stratford, Conn., said her son, now 7 years old, became more socially adept in a pivotal response trial at Yale. “The way it works is that, for instance, one time the therapist was playing with my son, blowing bubbles,” Ms. Calzone said. “Then the therapist stopped and looked away. Of course my son still wanted to see the bubbles, so he had to stop, too, and look in the same direction, then make eye contact and ask to continue.”
Those two responses, making eye contact and so-called perspective taking, recognizing another person’s point of view, developed quickly in the therapy. Her son, who has engaged in various therapies nearly every day for most of his life, is now in regular classes at school.
Dr. Pelphrey said that affinity therapy would deploy some of the same techniques, with the therapist playacting a favorite character and inhabiting the scenes with the child.
“Instead of watching Thomas the Tank Engine as a reward, for instance, we would have the child enter the social setting, with Thomas and Percy and the other characters,” and learn through them about eye contact, joint play and friendship, he said. The scientists plan to submit their study proposal to the National Institute of Mental Health for funding.
“The whole thing has been exciting, and a little weird,” said Mr. Suskind, now a senior fellow at Harvard, “having these leading neuroscientists listen to me and say, ‘O.K., what can we do to help?’ ”
Diagnosis in Autism: A Survey of Over 1200 Patients in the UK
The results of a survey of almost I300 parent members of autistic societies in the UK are described. The ages of their children ranged from 2 to 49 years. The survey focused on parents' views of the diagnostic process and data were collected on the age at which diagnosis was made, the time taken to obtain a diagnosis and the professionals involved. Differences in geographical area were also assessed. Overall, the results indicate that children are now being diagnosed earlier than in previous decades, but the average age of diagnosis is still around 6 years. There are also wide regional variations in diagnosis. The survey indicates that many parents continue to experience lengthy and often frustrating delays before they finally receive a diagnosis. Moreover, even when this process is completed, the amount of practical help subsequently provided is generally very limited. Factors related to parental satisfaction with the diagnostic process are discussed in detail.
Reference
doi: 10.1177/1362361397012003
Reference
doi: 10.1177/1362361397012003
Tuesday, April 22, 2014
According to the CDC
The rate of autism has steadily increased, according to the CDC. The CDC estimates that approximately 2% or more of children from birth to 21 years of age have Autism Spectrum Disorder (ASD) in New Jersey.
Autism is a complex condition. No single factor can explain why more children are being identified with ASD, although a combination of genetic and environmental factors play a role. In addition, some of the increase in the rates in the CDC's study may be due to: changes in the diagnosis and treatment, greater awareness, and better record keeping.
Previous CDC Autism Prevalence Study Results
A Decade of Data
With the report released in March 2014, we now have a decade of surveillance data utilizing consistent methodology that presents a clear picture of the trends since 2000. Here are the numbers:
1 in 68 (US); 1 in 45 (NJ)
Report Year: 2014
Surveillance Year: 2010
CDC’s ADDM Network reported that about 1 in 68 children had an ASD (based on children who were 8 years old in 2010). Data from 11 AADM Network Sites were reviewed, including New Jersey. New Jersey's rate was approx. 21.9 per 1,000 or 1 in 45. See 2014 Report.
1 in 88 (US); 1 in 49 (NJ)
Report Year: 2012
Surveillance Year: 2008
CDC’s ADDM Network reported that about 1 in 88 children had an ASD (based on children who were 8 years old in 2008). Data from 14 AADM Network Sites were reviewed, including New Jersey. New Jersey's rate was approx. 20.5 per 1,000 or 1 in 49. See 2012 Report.
1 in 110 (US)
Report Year: 2009Surveillance Year: 2006
CDC’s ADDM Network reported that about 1 in 110 children had an ASD (based on children who were 8 years old in 2006).
Data from 11 AADM Network Sites were reviewed. New Jersey was not included in this report. See 2009 Report.
Data from 11 AADM Network Sites were reviewed. New Jersey was not included in this report. See 2009 Report.
1 in 150 (US); 1 in 94 (NJ)
Report Year: 2007Surveillance Year: 2002
CDC’s ADDM Network reported that about 1 in 150 children had an ASD (based on children who were 8 years old in 2002).
Data from 14 AADM Network Sites were reviewed, including New Jersey. New Jersey's rate was approx. 10.6 per 1,000 or 1 in 94. This report combined results from 2002 with those from 2000. See 2007 Report.
Data from 14 AADM Network Sites were reviewed, including New Jersey. New Jersey's rate was approx. 10.6 per 1,000 or 1 in 94. This report combined results from 2002 with those from 2000. See 2007 Report.
1 in 166 (US); 1 in 101 (NJ)
Report Year: 2007Surveillance Year: 2000
CDC’s ADDM Network first reported that about 1 in 166 children had an ASD (based on children who were 8 years old in 2000).
Data from 6 AADM Network Sites were reviewed, including New Jersey. New Jersey's rate was approx. 9.9 per 1,000 or 1 in 101. This report combined results from 2000 with the data from 2002. See 2007 Report.
Data from 6 AADM Network Sites were reviewed, including New Jersey. New Jersey's rate was approx. 9.9 per 1,000 or 1 in 101. This report combined results from 2000 with the data from 2002. See 2007 Report.
Other Prevalence Studies/Surveys
National Survey of Children's Health -- 1 in 50 (US)
Report Date: March 20, 2013
Survey Period: 2011 to 2012
Report: http://www.cdc.gov/nchs/data/nhsr/nhsr065.pdf
Survey Period: 2011 to 2012
Report: http://www.cdc.gov/nchs/data/nhsr/nhsr065.pdf
Statistics as reported by parents of school-aged children (ages 6–17 years) in 2011–2012. Data were drawn from the 2007 and 2011–2012 National Survey of Children’s Health (NSCH), which are independent nationally representative telephone surveys of households with children. The surveys were conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics with funding and direction from the Health Resources and Services Administration’s Maternal and Child Health Bureau. Prior report of data from 2007 survey indicated a rate of 1 in 86 children (ages 6-17).
http://www.autismnj.org/prevalence-rates
Center for Disease Control on Autism in NJ
Article from March 27, 2014:
The Centers for Disease Control (CDC) released a report showing 1 in 68 children nationally has an Autism Spectrum Disorder. This newest estimate is based on the CDC's evaluation of health and educational records of all 8-year-old children in 2010 in 11 states, including New Jersey. New Jersey has the highest rates, with 1 in 45, 1 in 28 boys. The national rate marks an increase of 30% from the previous 1 in 88 statistic.
The Centers for Disease Control (CDC) released a report today showing 1 in 68 children nationally has an autism spectrum disorder. This newest estimate is based on the CDC's evaluation of health and educational records of 8-year-old children in 2010 in 11 states, including New Jersey. New Jersey has the highest rates, with 1 in 45, 1 in 28 boys. The national rate marks an increase of 30% from the previous 1 in 88 statistic.
- Gender: The report shows that autism prevalence remains 5 times more likely in boys than girls, with 1 in 42 boys and 1 in 189 girls (nationally) identified with an ASD in this latest report.
- Age of Diagnosis: The average age of diagnosis is still 4 years of age, although autism can be reliably established as early as 18 months.
- IQ: One notable change is that more children identified with an ASD have average or above average intelligence, from one-third in 2002 to half in 2010.
- Methodology: With this report, we now have a decade of surveillance data utilizing consistent methodology that presents a clear picture of the trends since 2000. It should be noted that all studies utilized DSM-IV diagnostic criteria.
Tuesday, April 15, 2014
Sensory Integration for Autism
Sensory Integration
By Cindy Hatch-Rasmussen, M.A., OTR/L
Children and adults with autism, as well as those with other developmental disabilities, may have a dysfunctional sensory system. Sometimes one or more senses are either over- or under-reactive to stimulation. Such sensory problems may be the underlying reason for such behaviors as rocking, spinning, and hand-flapping. Although the receptors for the senses are located in the peripheral nervous system (which includes everything but the brain and spinal cord), it is believed that the problem stems from neurological dysfunction in the central nervous system--the brain. As described by individuals with autism, sensory integration techniques, such as pressure-touch can facilitate attention and awareness, and reduce overall arousal. Temple Grandin, in her descriptive book, Emergence: Labeled Autistic, relates the distress and relief of her sensory experiences.
Sensory integration is an innate neurobiological process and refers to the integration and interpretation of sensory stimulation from the environment by the brain. In contrast, sensory integrative dysfunction is a disorder in which sensory input is not integrated or organized appropriately in the brain and may produce varying degrees of problems in development, information processing, and behavior. A general theory of sensory integration and treatment has been developed by Dr. A. Jean Ayres from studies in the neurosciences and those pertaining to physical development and neuromuscular function. This theory is presented in this paper.
Sensory integration focuses primarily on three basic senses--tactile, vestibular, and proprioceptive. Their interconnections start forming before birth and continue to develop as the person matures and interacts with his/her environment. The three senses are not only interconnected but are also connected with other systems in the brain. Although these three sensory systems are less familiar than vision and audition, they are critical to our basic survival. The inter-relationship among these three senses is complex. Basically, they allow us to experience, interpret, and respond to different stimuli in our environment. The three sensory systems will be discussed below.
Tactile System: The tactile system includes nerves under the skin's surface that send information to the brain. This information includes light touch, pain, temperature, and pressure. These play an important role in perceiving the environment as well as protective reactions for survival.
Dysfunction in the tactile system can be seen in withdrawing when being touched, refusing to eat certain 'textured' foods and/or to wear certain types of clothing, complaining about having one's hair or face washed, avoiding getting one's hands dirty (i.e., glue, sand, mud, finger-paint), and using one's finger tips rather than whole hands to manipulate objects. A dysfunctional tactile system may lead to a misperception of touch and/or pain (hyper- or hyposensitive) and may lead to self-imposed isolation, general irritability, distractibility, and hyperactivity.
Tactile defensiveness is a condition in which an individual is extremely sensitive to light touch. Theoretically, when the tactile system is immature and working improperly, abnormal neural signals are sent to the cortex in the brain which can interfere with other brain processes. This, in turn, causes the brain to be overly stimulated and may lead to excessive brain activity, which can neither be turned off nor organized. This type of over-stimulation in the brain can make it difficult for an individual to organize one's behavior and concentrate and may lead to a negative emotional response to touch sensations.
Vestibular System: The vestibular system refers to structures within the inner ear (the semi-circular canals) that detect movement and changes in the position of the head. For example, the vestibular system tells you when your head is upright or tilted (even with your eyes closed). Dysfunction within this system may manifest itself in two different ways. Some children may be hypersensitive to vestibular stimulation and have fearful reactions to ordinary movement activities (e.g., swings, slides, ramps, inclines). They may also have trouble learning to climb or descend stairs or hills; and they may be apprehensive walking or crawling on uneven or unstable surfaces. As a result, they seem fearful in space. In general, these children appear clumsy. On the other extreme, the child may actively seek very intense sensory experiences such as excessive body whirling, jumping, and/or spinning. This type of child demonstrates signs of a hypo-reactive vestibular system; that is, they are trying continuously to sti mulate their vestibular systems.
Proprioceptive System: The proprioceptive system refers to components of muscles, joints, and tendons that provide a person with a subconscious awareness of body position. When proprioception is functioning efficiently, an individual's body position is automatically adjusted in different situations; for example, the proprioceptive system is responsible for providing the body with the necessary signals to allow us to sit properly in a chair and to step off a curb smoothly. It also allows us to manipulate objects using fine motor movements, such as writing with a pencil, using a spoon to drink soup, and buttoning one's shirt. Some common signs of proprioceptive dysfunction are clumsiness, a tendency to fall, a lack of awareness of body position in space, odd body posturing, minimal crawling when young, difficulty manipulating small objects (buttons, snaps), eating in a sloppy manner, and resistance to new motor movement activities.
Another dimension of proprioception is praxis or motor planning. This is the ability to plan and execute different motor tasks. In order for this system to work properly, it must rely on obtaining accurate information from the sensory systems and then organizing and interpreting this information efficiently and effectively.
Implications: In general, dysfunction within these three systems manifests itself in many ways. A child may be over- or under-responsive to sensory input; activity level may be either unusually high or unusually low; a child may be in constant motion or fatigue easily. In addition, some children may fluctuate between these extremes. Gross and/or fine motor coordination problems are also common when these three systems are dysfunctional and may result in speech/language delays and in academic under-achievement. Behaviorally, the child may become impulsive, easily distractible, and show a general lack of planning. Some children may also have difficulty adjusting to new situations and may react with frustration, aggression, or withdrawal.
Evaluation and treatment of basic sensory integrative processes is performed by occupational therapists and/or physical therapists. The therapist's general goals are: (1) to provide the child with sensory information which helps organize the central nervous system, (2) to assist the child in inhibiting and/or modulating sensory information, and (3) to assist the child in processing a more organized response to sensory stimuli.
Children and adults with autism, as well as those with other developmental disabilities, may have a dysfunctional sensory system. Sometimes one or more senses are either over- or under-reactive to stimulation. Such sensory problems may be the underlying reason for such behaviors as rocking, spinning, and hand-flapping. Although the receptors for the senses are located in the peripheral nervous system (which includes everything but the brain and spinal cord), it is believed that the problem stems from neurological dysfunction in the central nervous system--the brain. As described by individuals with autism, sensory integration techniques, such as pressure-touch can facilitate attention and awareness, and reduce overall arousal. Temple Grandin, in her descriptive book, Emergence: Labeled Autistic, relates the distress and relief of her sensory experiences.
Sensory integration is an innate neurobiological process and refers to the integration and interpretation of sensory stimulation from the environment by the brain. In contrast, sensory integrative dysfunction is a disorder in which sensory input is not integrated or organized appropriately in the brain and may produce varying degrees of problems in development, information processing, and behavior. A general theory of sensory integration and treatment has been developed by Dr. A. Jean Ayres from studies in the neurosciences and those pertaining to physical development and neuromuscular function. This theory is presented in this paper.
Sensory integration focuses primarily on three basic senses--tactile, vestibular, and proprioceptive. Their interconnections start forming before birth and continue to develop as the person matures and interacts with his/her environment. The three senses are not only interconnected but are also connected with other systems in the brain. Although these three sensory systems are less familiar than vision and audition, they are critical to our basic survival. The inter-relationship among these three senses is complex. Basically, they allow us to experience, interpret, and respond to different stimuli in our environment. The three sensory systems will be discussed below.
Tactile System: The tactile system includes nerves under the skin's surface that send information to the brain. This information includes light touch, pain, temperature, and pressure. These play an important role in perceiving the environment as well as protective reactions for survival.
Dysfunction in the tactile system can be seen in withdrawing when being touched, refusing to eat certain 'textured' foods and/or to wear certain types of clothing, complaining about having one's hair or face washed, avoiding getting one's hands dirty (i.e., glue, sand, mud, finger-paint), and using one's finger tips rather than whole hands to manipulate objects. A dysfunctional tactile system may lead to a misperception of touch and/or pain (hyper- or hyposensitive) and may lead to self-imposed isolation, general irritability, distractibility, and hyperactivity.
Tactile defensiveness is a condition in which an individual is extremely sensitive to light touch. Theoretically, when the tactile system is immature and working improperly, abnormal neural signals are sent to the cortex in the brain which can interfere with other brain processes. This, in turn, causes the brain to be overly stimulated and may lead to excessive brain activity, which can neither be turned off nor organized. This type of over-stimulation in the brain can make it difficult for an individual to organize one's behavior and concentrate and may lead to a negative emotional response to touch sensations.
Vestibular System: The vestibular system refers to structures within the inner ear (the semi-circular canals) that detect movement and changes in the position of the head. For example, the vestibular system tells you when your head is upright or tilted (even with your eyes closed). Dysfunction within this system may manifest itself in two different ways. Some children may be hypersensitive to vestibular stimulation and have fearful reactions to ordinary movement activities (e.g., swings, slides, ramps, inclines). They may also have trouble learning to climb or descend stairs or hills; and they may be apprehensive walking or crawling on uneven or unstable surfaces. As a result, they seem fearful in space. In general, these children appear clumsy. On the other extreme, the child may actively seek very intense sensory experiences such as excessive body whirling, jumping, and/or spinning. This type of child demonstrates signs of a hypo-reactive vestibular system; that is, they are trying continuously to sti mulate their vestibular systems.
Proprioceptive System: The proprioceptive system refers to components of muscles, joints, and tendons that provide a person with a subconscious awareness of body position. When proprioception is functioning efficiently, an individual's body position is automatically adjusted in different situations; for example, the proprioceptive system is responsible for providing the body with the necessary signals to allow us to sit properly in a chair and to step off a curb smoothly. It also allows us to manipulate objects using fine motor movements, such as writing with a pencil, using a spoon to drink soup, and buttoning one's shirt. Some common signs of proprioceptive dysfunction are clumsiness, a tendency to fall, a lack of awareness of body position in space, odd body posturing, minimal crawling when young, difficulty manipulating small objects (buttons, snaps), eating in a sloppy manner, and resistance to new motor movement activities.
Another dimension of proprioception is praxis or motor planning. This is the ability to plan and execute different motor tasks. In order for this system to work properly, it must rely on obtaining accurate information from the sensory systems and then organizing and interpreting this information efficiently and effectively.
Implications: In general, dysfunction within these three systems manifests itself in many ways. A child may be over- or under-responsive to sensory input; activity level may be either unusually high or unusually low; a child may be in constant motion or fatigue easily. In addition, some children may fluctuate between these extremes. Gross and/or fine motor coordination problems are also common when these three systems are dysfunctional and may result in speech/language delays and in academic under-achievement. Behaviorally, the child may become impulsive, easily distractible, and show a general lack of planning. Some children may also have difficulty adjusting to new situations and may react with frustration, aggression, or withdrawal.
Evaluation and treatment of basic sensory integrative processes is performed by occupational therapists and/or physical therapists. The therapist's general goals are: (1) to provide the child with sensory information which helps organize the central nervous system, (2) to assist the child in inhibiting and/or modulating sensory information, and (3) to assist the child in processing a more organized response to sensory stimuli.
Gastrointestinal Symptoms linked to Autism
Gastrointestinal disorders and associated symptoms are commonly reported in individuals with ASDs, however, it can be difficult to recognize and characterize gastrointestinal dysfunction due to the communication difficulties experienced by many affected individuals. Watch this presentation by Dr. Alessio Fasano, pediatric gastroenterologist at the University of Maryland School of Medicine (UMDSOM), from a recent ARI Conference discussing the impact of GI problems in children with ASD.
Emerging research is aimed at developing recommendations for diagnostic evaluation and management of gastrointestinal problems for individuals on the spectrum. Valicenti-McDermott, 2006, evaluated children with ASD and two control groups matched for age, sex and ethnicity (one with non-autism-related developmental disorders, and the other developmentally normal). There were 50 children in each group – findings concluded:
- 70% of the children with ASD had GI Issues compared to 42% of the children with developmental disorder other than ASD
- 28% of children with typical development.
Just like everyone else, people with autism may suffer:
- Gastritis
- GERD
- Colitis
- Irritable Bowel Syndrome
- Constipation
- Motility-based disorders
- Food allergy and sensitivity
- Overgrowth syndromes
Food allergy in this population is common - food allergy can affect any site in the GI tract. Research points to the following food allergy prevalence rates in children:
- 5-8% of neurotypical children without autism (Sampson, 1999) suffer food allergies
- 36% of autistic children (Lucarelli, 1995) suffer food allergies
If your child complains of stomachaches, or if he/she adopts unusual positions to put pressure on his/her lower abdomen, try to identify underlying conditions when possible. Baseline testing might help identify factors such as infection, allergy or food sensitivity, and evidence for constipation.
http://www.autism.com/gastrointestinal
Monday, April 14, 2014
Prevalence of Autism in a United States Population: The Brick Township, New Jersey, Investigation
Objective. This study determined the prevalence of autism for a defined community, Brick Township, New Jersey, using current diagnostic and epidemiologic methods.
Methods. The target population was children who were 3 to 10 years of age in 1998, who were residents of Brick Township at any point during that year, and who had an autism spectrum disorder. Autism spectrum disorder was defined as autistic disorder, pervasive developmental disorder-not otherwise specified (PDD-NOS), and Asperger disorder. The study used 4 sources for active case finding: special education records, records from local clinicians providing diagnosis or treatment for developmental or behavioral disabilities, lists of children from community parent groups, and families who volunteered for participation in the study in response to media attention. The autism diagnosis was verified (or ruled out) for 71% of the children through clinical assessment. The assessment included medical and developmental history, physical and neurologic evaluation, assessment of intellectual and behavioral functioning, and administration of the Autism Diagnostic Observation Schedule—Generic.
Results. The prevalence of all autism spectrum disorders combined was 6.7 cases per 1000 children. The prevalence for children whose condition met full diagnostic criteria for autistic disorder was 4.0 cases per 1000 children, and the prevalence for PDD-NOS and Asperger disorder was 2.7 cases per 1000 children. Characteristics of children with autism in this study were similar to those in previous studies of autism.
Conclusions. The prevalence of autism in Brick Township seems to be higher than that in other studies, particularly studies conducted in the United States, but within the range of a few recent studies in smaller populations that used more thorough case-finding methods.
By: J
PEDIATRICS Vol. 108 No. 5 November 1, 2001
pp. 1155 -1161
pp. 1155 -1161
From: Pediatrics, the official journal of the American Academy of Pediatrics
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