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Attitudes and Beliefs of Adolescents and Parents Regarding Adolescent Suicide

Kimberly A. Schwartz, Sara A. Pyle, M. Denise Dowd and Karen Sheehan


Pediatrics 2010;125;221-227; originally published online Jan 11, 2010;
DOI: 10.1542/peds.2008-2248

The online version of this article, along with updated information and services, is
located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/125/2/221

PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthly


publication, it has been published continuously since 1948. PEDIATRICS is owned, published,
and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, Elk
Grove Village, Illinois, 60007. Copyright © 2010 by the American Academy of Pediatrics. All
rights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275.

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ARTICLES

Attitudes and Beliefs of Adolescents and Parents


Regarding Adolescent Suicide
AUTHORS: Kimberly A. Schwartz, MD,a Sara A. Pyle, PhD,b WHAT’S KNOWN ON THIS SUBJECT: Suicide is the third leading
M. Denise Dowd, MD, MPH,c and Karen Sheehan, MD, cause of death for adolescents in the United States. Suicide
MPHd prevention efforts often involve environmental modification, such
aDepartment of Pediatrics, UMass Memorial Children’s Medical
as limiting access to lethal methods, and education, such as
Center, Worcester, Massachusetts; bDepartment of Preventative recognizing individual risk factors.
Medicine, Kansas City University of Medicine and Biosciences,
Kansas City, Missouri; cDivision of Emergency Medicine,
Children’s Mercy Hospital, Kansas City, Missouri; and dDivision WHAT THIS STUDY ADDS: This study examines the perceptions of
of Emergency Medicine, Children’s Memorial Hospital, Chicago, adolescents and their parents regarding the risk, predictability,
Illinois and preventability of teen suicide and explores what participants
KEY WORDS think about how to prevent suicide.
suicide, adolescents, focus groups
www.pediatrics.org/cgi/doi/10.1542/peds.2008-2248
doi:10.1542/peds.2008-2248
Accepted for publication Aug 15, 2009
Address correspondence to Kimberly A. Schwartz, MD, Child
abstract
Protection Program, UMass Memorial Children’s Medical Center, OBJECTIVE: The goal was to understand the attitudes, beliefs, and per-
55 Lake Ave North, Worcester, MA 01655. E-mail: ceptions of adolescents and parents of adolescents, from a variety of
kimberly.schwartz2@umassmemorial.org
backgrounds, regarding adolescent suicide.
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
METHODS: This qualitative study used focus groups to elicit the
Copyright © 2010 by the American Academy of Pediatrics
thoughts of distinct sociodemographic groups. A professional moder-
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose. ator guided the sessions by using a semistructured script. All groups
were audiotaped. The transcripts and transcript summaries were an-
alyzed for recurrent themes. The study was performed in community
centers and schools in Chicago, Illinois (urban), and the Kansas City,
Kansas, area (suburban and rural). A total of 66 adolescents (13–18
years of age) and 30 parents of adolescents participated in 13 focus
groups.
RESULTS: Both adolescents and parents recognized adolescent sui-
cide as a major problem, but not for their own communities. All parent
and adolescent groups identified many risk factors for suicide. Most
adolescents reported drug and alcohol use as risk factors for suicide.
However, parents often viewed drug and alcohol use as normal adoles-
cent behavior. Both adolescent and parent groups suggested securing
or removing guns if an adolescent was known to be suicidal. All partic-
ipants requested information about adolescent suicide.
CONCLUSIONS: Adolescents and parents need help understanding
that suicide is an underidentified problem in their own communities.
Both adolescents and parents are interested in learning more about
how to identify and to intervene with a suicidal adolescent. Pediatri-
cians are well positioned to provide this information in the office and in
the community. Pediatrics 2010;125:221–227

PEDIATRICS Volume 125, Number 2, February 2010 221


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In the United States in 2006, 1771 chil- tion, and environmental modifications son from the organization assisted
dren and adolescents 10 to 19 years of such as removal of lethal means. Fire- with the identification of volunteer par-
age committed suicide, which made arms are used in ⬎40% of adolescent ticipants through e-mail messages,
this the third leading cause of death in suicides,1 and safely storing house- meetings, and after-school programs.
this age group. Firearms (43.1%) and hold firearms significantly decreases All individuals who arrived at the focus
suffocation (44.9%) were the primary firearm-involved suicide rates for ado- group locations and met the eligibility
means for these suicides.1 Although lescents ⬍20 years of age.11 It is diffi- requirements participated. Four dis-
the incidence of teen suicide was high- cult to assess whether family mem- tinct sociodemographic groups (ur-
est among Native American/Alaska Na- bers appreciate this environmental ban black, urban Hispanic, suburban
tive adolescents, at 15.4 cases per risk. white, and rural white) were identified;
100 000, white, Hispanic, and black ad- Because a successful suicide preven- the 2 urban groups were from Chicago,
olescents had significant rates of 4.7, tion program should reflect the atti- and the rural and suburban groups
3.0, and 2.7 cases per 100 000, respec- tudes and beliefs of those to whom the were from the Kansas City area. Each
tively.1 Completed suicides reflect a intervention is targeted, we set out to participant received a $20 gift card for
small (albeit significant) part of the gather information for better under- participation. Each adolescent and
problem. According to the Youth Risk standing of what interventions might parent/guardian gave written consent
Behavior Survey, ⬃14.5% of all US ad- be perceived as most effective. Focus for participation. Institutional review
olescents in ninth to 12th grade seri- groups were used because of their board approval was obtained from
ously considered suicide and 11.3% of ability to explore efficiently the atti- Children’s Memorial Hospital (Chi-
all youths surveyed had made a plan tudes and beliefs of participants. A cago, IL) and Children’s Mercy Hospital
during that year, which is similar to few international studies used focus (Kansas City, MO).
rates in Illinois and Kansas.2 groups previously to study adolescent
Adolescents frequently are the first to suicide.5,10,12 Focus Groups
know of a peer’s suicidal thoughts but The primary goal of this formative re- A professional moderator conducted
are unsure what to do with the infor- search study was to describe the atti- semistructured sessions by using a
mation.3,4 Responses of adolescents to tudes and beliefs of adolescents and discussion guide developed by the
peer disclosures vary and are related parents of adolescents, from a variety project team (Appendix 1). A bilingual
to their gender, knowledge about sui- of backgrounds, regarding adolescent interpreter assisted with the urban
cide, personal history of suicidal ide- suicide. Specifically, we sought to un- Hispanic focus groups. Focus groups
ation, and perceptions of mental ill- derstand their perceptions of risk, were held in community centers and
ness.5–10 Gould et al8 found that predictability, and preventability of schools the participants routinely at-
adolescents with maladaptive coping teen suicide. Furthermore, we ex- tended. Separate focus groups with
skills displayed dysfunctional atti- plored what participants thought adolescents (13–18 years of age) and
tudes toward a suicidal friend, would be helpful for the prevention of parents of adolescents were con-
whereas those with healthy coping adolescent suicide. ducted in each location. The adoles-
skills were likely to demonstrate help- cent groups were gender-specific,
seeking behaviors. Although adults METHODS whereas parent groups were of mixed
may consider it imperative that ado- Participants gender.
lescents report at-risk peers to In 2006, participants were recruited Before the start of each focus group,
adults, a minority actually do.4,7 Rea- through stratified (urban, rural, or each participant provided the follow-
sons for teens not reporting to suburban) sampling through Chicago ing information: age, gender, ethnicity,
adults include a lack of basic knowl- Youth Programs, Centro Romero com- zip code, level of education attained,
edge and self-efficacy, the belief that munity center (Chicago, IL), Mill Valley and, for the parents, ages and number
discussing suicide is taboo, and def- High School (suburban Kansas City, of children. At the beginning of each
erence toward their peers’ requests KS), and Basehor Linwood High School session, the moderator introduced the
for nondisclosure.3,8 (rural Kansas). Eligible subjects in- project and explained the purpose of
Youth suicide prevention takes many cluded children 13 to 18 years of age the focus group. For each idea dis-
forms. Education may focus on the rec- and parents/guardians of children 13 cussed, general open-ended questions
ognition of individual risk factors, the to 18 years of age. Flyers were posted were followed by probing questions. A
importance of disclosure and interven- at the centers and schools, and a liai- pediatrician attended each focus group

222 SCHWARTZ et al
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ARTICLES

and was available to address partici- TABLE 1 Demographic Characteristics though they may not be perceived ini-
pants’ concerns. A list of local mental Adolescents tially as such.
health resources was provided to all Suburban white
Gender, n
participants. Each session lasted 60 to Parents
Male 8
90 minutes, and all sessions were au- Female 9 The urban black and rural and subur-
diotaped and transcribed. Age, mean (range), y 16 (15–17) ban white parent groups reported that
Rural white
Gender, n adolescent suicide was a problem, but
Analysis Male 9 no groups acknowledged it as a prob-
The transcribed data were entered Female 10 lem in their own community. One black
Age, mean (range), y 16 (14–18)
into NVivo 7 (QSR International, Cam- Urban black
parent commented, “It seems like it’s
bridge, MA) for organization of the Gender, n more of a, you know, race thing. It
transcripts, to allow easier ascertain- Male 10 seems like you hear about that more
Female 7
ment of recurring themes. All authors with the white than with the black.” The
Age, mean (range), y 16 (13–17)
reviewed the transcripts to identify re- Urban Hispanic consensus of the urban Hispanic par-
sponse themes for each focus group, Gender, n ent group was that suicidal thoughts
as well as the groups as a whole. Male 6 were common but acting on them
Female 7
Similarities and differences among Age, mean (range), y 16 (14–18) was not.
the participants and groups were Parents
assessed. Suburban white, n 8 Predictability
Female, n (%) 7 (88)
Age, mean (range), y 45 (37–50) Adolescents
RESULTS High school graduate, % 100
As a whole, adolescents reported that
Focus Groups Some college, % 50
No. of children, median (range) 3 (2–6) they could identify changes in behavior
Eight adolescent focus groups (N ⫽ Rural white, n 7 predictive of suicide in their peers.
66) and 5 parent groups (N ⫽ 30) were Female, n (%) 7 (100) Identified changes included losing in-
Age, mean (range), y 48 (38–56)
conducted. The focus groups ranged in High school graduate, % 100 terest in activities, changing friends,
size from 3 to 11 participants (Table 1). Some college, % 100 withdrawing from social interactions,
The mean age of adolescents was 16 No. of children, median (range) 3 (2–4) and exhibiting mood changes. All of the
Urban black, n 12
years, and one half of the adolescents Female, n (%) 9 (75)
female adolescent groups revealed a
were female; 87% of the parent partic- Age, mean (range), y 38 (23–55) belief that “cutting” is a behavior sug-
ipants were female, with an average of High school graduate, % 75 gestive of suicidal thoughts. A few ad-
Some college, % 50
3 children. Results of the discussion olescents in each group reported that
No. of children, median (range) 4 (1–12)
were grouped into topic areas, that is, Urban Hispanic, n 3 it would be difficult to predict that an
adolescent suicide risk, predictability, Female, n (%) 3 (100) individual was suicidal.
preventability, environment, resources, Age, mean (range), y 36 (37–40)
High school graduate, % 33 All adolescent groups indicated that
and training. Some college, % 0 some suicidal adolescents hide their
No. of children, median (range) 3 (2–4) symptoms and that it was likely that
Risk
many of their peers considered sui-
Adolescents cide without outward signs. Partici-
Views of the pervasiveness of adoles- stated that the problem was one of “a pants thought that adolescents who
cent suicide varied among groups. The lot of white people in distress, killing did not discuss their suicidal thoughts
urban Hispanic adolescents reported themselves.” Suburban and rural were more likely to complete suicide
that they did not think that adolescent white adolescents reported that ado- successfully.
suicide was a large problem. One ur- lescent suicide was a problem some- Overall, adolescent groups thought
ban Hispanic adolescent said, “They where else. Many adolescents thought that suicidal thoughts often were the
think about it . . . but it’s just for a little that suicide attempts might be used result of too many stressors and
while and then it goes away.” Urban to gain attention. However, several not enough support. The adolescent
black adolescents in the study re- groups reported a belief that many ac- groups noted the following as signifi-
ported that adolescent suicide was a tions (eg, extreme risk-taking and dan- cant contributors for suicide: mental
large problem but not for their peers. gerous driving) taken by adolescents illness, low self-esteem, lack of family
One urban, black, male adolescent may represent suicidal gestures, al- support, and negative life experiences.

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Distinct for the urban adolescents Parents were also concerned about Preventability
were descriptions of gang violence adolescents who lack support at Adolescents
and trouble with law enforcement as home. One urban black parent said, Many girls in each of the female ado-
negative life experiences. One black “Maybe they have a parent they want to lescent groups thought they could help
adolescent girl said, “I think that the talk to but don’t really have the time for prevent suicide in a peer, especially if
only reason they want to kill them- them . . . they think that suicide is the they could identify the situation early.
selves is like some had a real, real, bad only option.” Cited interventions included talking to
experience in their life and they look All of the parent groups agreed that sui- the friend, talking to adults, and help-
like, well, I already feel like I’m dead.” cide could be linked to depression and ing the individual find professional
Most adolescent groups identified other psychological problems. In partic- help. They indicated that they would
peer pressure and romantic relation- ular, they named changes in behavior most likely talk to their own parents,
ships as significant contributors to and mood, loss of interest in activities, but they expressed concern about talk-
suicidal thoughts. Several groups of withdrawal from social situations, ing to the friend’s parents, who might
adolescents cited breakdown of family changes in friends, and reckless behav- be part of the underlying problem.
relationships and lack of parental un- iors as potentially predictive of suicide. The views of the male adolescent
derstanding as contributors to sui- All parent groups described the pres- groups about preventing a friend’s sui-
cide. Family disruption, for example, sure to “fit in” as a stressor for adoles- cide covered a broad spectrum. Some
divorce (suburban settings) and jail or cents. A rural white parent com- urban black male adolescents’ atti-
death (urban settings), was discussed. mented, “I think everyone always looks tudes were fatalistic and permissive.
All of the male adolescent groups ex- at the kids that are not the popular For example, one teen said, “You can’t
pressed the belief that drug and alco- kids; they think those are the ones make nobody live, if they don’t want to
hol use could be indicative of suicidal- most likely to commit suicide, but I live, what you gonna make them for?”
ity. Some identified substance use as a think it’s the popular ones because All adolescent groups acknowledged
form of self-medication or self-harm. they have more pressure on them.” that it would be more difficult to pre-
Female adolescents were more varied Participation in sports was viewed as vent the suicide of someone who hides
in their opinions of drug use and alco- important by the rural parent group. his or her symptoms well.
hol use and how they contribute to sui- Parents also described romantic pres-
cide. One adolescent girl commented sures as possibly contributing to sui- Parents
that “some people use [alcohol] to es- cidal behavior. The parents in this study generally en-
cape everything, to stop their pain.” An- The parent groups described negative dorsed the belief that they could assist
other adolescent thought that drinking life experiences as contributing to ad- in suicide prevention for a suicidal ad-
was socially acceptable and therefore olescent suicide. One urban black par- olescent, specifically if the child was
not predictive of suicide. The urban ent suggested a series of experiences, one of their children’s friends. The
Hispanic adolescents reported that “They might have a parent that’s on adults indicated that suicidal adoles-
use of drugs and/or alcohol was nor- drugs; they may have peer pressure cents needed professional help and
mal among adolescents, and they did that’s going on in school . . . kids that close adult supervision. One rural
not see a relationship between sui- have been beat up all the time and white parent said, “It’s just going to
cidal ideation and substance use. picked on.” Urban black parents de- come down to creating that safety net
scribed not meeting adolescents’ ba- of social support in some way, whether
Parents sic needs (ie, food and clothing) as at school, the community, or the kid’s
Parents in the study generally agreed contributory. Suburban white parents parents.” In contrast, one of the urban
that suicide is difficult to predict. One cited breakdown of the family unit as Hispanic mothers said, “I think that the
rural white parent said, “They are an issue. Many parents stated they solution is often found with the home.”
changing and one minute to the next, thought that drug or alcohol experi-
someone says something bad to them mentation was noncontributory and Environment (Adolescents and
and it just clicks in their mind ‘I can’t commonplace. This nonchalant atti- Parents)
take it anymore’ and it just happens.” tude was illustrated by a suburban In general, all groups reported that, if
Many parents expressed concern re- white parent who commented that there was a suicidal adolescent in the
garding adolescents who do not dis- “some parents smoke pot with their home, then significant changes to the
play any signs of suicidality. kids or allow their kids to drink.” environment would be required. For in-

224 SCHWARTZ et al
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ARTICLES

stance, several groups discussed a to determine to whom adolescents will however, parents in all groups in this
need for increased supervision of the turn. Some parents expressed concern study acknowledged that they might
at-risk adolescent. However, some that discussing suicide might put the not be able to identify a suicidal teen.
male adolescents expressed concern idea in the minds of adolescents. In gen- This uncertainty suggests that pedia-
that providing too much supervision eral, participants thought that training tricians should routinely advise fami-
might upset the adolescent more. and awareness should be widely avail- lies regarding the proper storage of
Although members of each group able for community members, including firearms.
stated that they thought that guns parents, teachers, counselors, commu-
nity leaders, and adolescents. All groups identified the need for more
needed to be secured within the home
resources and information about ado-
of a suicidal teen, most groups stated
DISCUSSION lescent suicide. Suicide prevention pro-
a belief that there are several ways in
grams aimed at developing adolescents’
which adolescents can commit suicide This research facilitated an in-depth problem-solving, coping, and cognitive
(eg, medications or knives) and teens study of the attitudes and beliefs about
who are serious about committing sui- skills, rather than curricula limited to
adolescent suicide held by adoles- raising awareness of suicide, show
cide will find the means. One teen cents and their parents, representing
pointed out, “Access and convenience promising results.15 Although general
multiple sociodemographic groups.
increase the chance that someone community interventions have not been
Both adolescents and parents identi-
would commit suicide.” Those in rural tested, “gatekeeper” training of teachers
fied adolescent suicide as a major
and urban settings discussed how and other school personnel seems
problem but did not recognize it as a
common guns are in the home. Rural promising.15
problem in their own communities.
participants were most likely to dis- Clinical guidelines from the American Furthermore, pediatricians can help
cuss the presence of guns for hunting, Academy of Pediatrics recommend parents understand the importance of
whereas urban participants discuss- that pediatricians address and evalu- removing lethal means from their
ed the need for guns to provide ate risk for all suicide attempts.13 How- homes and monitoring their adoles-
protection. ever, only 2% of suicide attempts re- cents. Resources such as the Ameri-
ceive medical attention; therefore, can Academy of Pediatrics Connected
Resources and Training pediatricians should recognize suicide Kids program may assist with this goal
Adolescents as a health issue worthy of screening (Table 2). Those who develop and im-
during regular visits.2 All parent and plement suicide prevention strategies
Overall, adolescent participants re- adolescent groups correctly identified should ask the families in their com-
ported needing more readily available many of the known risk factors for ad- munities about the unique beliefs and
resources, including additional train- olescent suicide, including mental ill-
ing in identifying risk factors and inter- experiences of the community, to en-
ness, alcohol and substance abuse,
vention strategies. Adolescents were sure that interventions are culturally
relational or social loss, and hopeless-
particularly interested in peer educa- appropriate and effective.
ness.14,15 However, it is concerning that
tion, because they thought they would many of the parents reported regular This was a qualitative study with a di-
be the first to identify a problem and drug and alcohol use as being a nor- verse sample that sought to elicit a
would be the ones most likely to be mal part of adolescent development, wide range of responses. These quali-
called on by a friend. Adolescents re- rather than problematic behaviors. tative methods were not intended to be
ported that the testimony of a peer Pediatricians need to be aware of how representative of the specific popula-
who had been suicidal in the past parents and adolescents think about tions, and they were not designed to
would be most effective in raising substance use and abuse, to frame determine the exact proportions of ad-
awareness. Some groups also ex- their anticipatory guidance most olescents and parents who held cer-
pressed an interest in hearing from ex- effectively. tain beliefs. The participants were
perts and in multimedia training.
Both adolescent and parent groups self-selected and might have had non-
suggested that guns be secured or re- representative ideas about adolescent
Parents
moved if an adolescent is known to be suicide. However, these groups pro-
The urban black parents specifically in- suicidal. Parent groups suggested vided thoughtful reflections that re-
dicated that everyone in the community close monitoring of adolescents who vealed many common themes and
should be trained, because it is difficult are experiencing suicidal thoughts; ideas.

PEDIATRICS Volume 125, Number 2, February 2010 225


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TABLE 2 Resources for Families ability of adolescents and parents to
Organization Web Site Information identify and to reduce risk factors
American Academy of Child www.aacap.org/cs/root/facts㛭for㛭families/ Facts for families, available in for adolescent suicide. In addition,
and Adolescent teen㛭suicide multiple languages
studies might assess the capacity of
Psychiatry
American Academy of www.aap.org/advocacy/childhealthmonth/ Questions for parents to community-based organizations for
Pediatrics prevteensuicide.htm assess their teens skills training in the identification of
National Alliance on Mental www.nami.org/Content/ContentGroups/ Additional resources and and initial intervention for suicidal ad-
Illness Helpline1/Teenage㛭Suicide.htm book suggestions for
families olescents. Given the varied responses
National Suicide Prevention www.suicidepreventionlifeline.org 24-h hotline; 1-800-273-TALK observed among ethnic and socioeco-
Lifeline (8255) (English) or 1-888- nomic groups, future studies to evalu-
628-9454 (Spanish)
ate approaches to prevention and
education specific to individual demo-
CONCLUSIONS were interested in additional training graphic groups are warranted.
Both adolescents and parents of ado- on how to identify and to intervene
lescents need help to understand bet- with a suicidal adolescent. Pediatri- ACKNOWLEDGMENT
ter the underidentification of suicide in cians are well positioned to assist, in This study was funded by an Injury Free
their own communities. Pediatricians both office and community settings, Coalition for Kids grant from the Rob-
should regularly screen all adoles- in identifying resources in the ert Wood Johnson Foundation. We
cents in their offices and should en- community. would like to thank the adolescents,
courage families to be open to discuss- Future studies of adolescent suicide parents, and organizations who helped
ing depression and suicide. All groups prevention might seek to measure the in this project.
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APPENDIX 1 Question Guide Used for Focus Groups


General information about adolescent suicide
When you hear the words ⬙teen suicide,⬙ what comes to mind?
Among all the problems teenagers have, how big of a problem is suicide?
Predictability
What do you think about the predictability of suicide among teenagers?
Probe: beliefs, developmental knowledge, and reasons why
What ways are there to predict teen suicide? Who is at risk?
Probe: personality changes, behavioral indicators, drugs, and alcohol
Preventability
What do you think about how preventable teen suicide is?
Probe: ways to prevent suicide among young people
What would you say or do to help a suicidal teen?
Probe: talking to the parent of the suicidal teen
Environment
What are your thoughts about guns in the house and suicide? What do you think the presence of a gun
in the house does to the risk of suicide?
If you had a suicidal teen in the home, what about the home environment or routines would you
change?
Probe: securing guns, medicines, schedules, and supervision
Resources
What other resources do you have access to that would be helpful for the suicidal teen?
Probe: in the community and in the family
Training
Do you think there needs to be more education about recognizing and intervening with potentially
suicidal teens?
Probe: Who should be educated? Where should it be offered?

PEDIATRICS Volume 125, Number 2, February 2010 227


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Attitudes and Beliefs of Adolescents and Parents Regarding Adolescent Suicide
Kimberly A. Schwartz, Sara A. Pyle, M. Denise Dowd and Karen Sheehan
Pediatrics 2010;125;221-227; originally published online Jan 11, 2010;
DOI: 10.1542/peds.2008-2248
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/125/2/221
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