[Show abstract][Hide abstract] ABSTRACT: Objective: The purpose of this study was to examine the acute effectiveness of manualized exposure-based CBT with a family-based treatment, as an initial treatment for pediatric OCD delivered in regular community child and adolescents outpatient clinics. The report summarizes outcome of the first treatment step in the NordLOTS, which was conducted in Denmark, Sweden and Norway.
Method: 269 participants, age 7–17, with OCD, received treatment for 14 weekly sessions. Treatment response was defined as CY-BOCS score of ≤15 at post treatment.
Results: 241 participants (89.6%) completed all 14 weeks of treatment. Treatment response, among the participants was 72.6% (95% CI 66.7%-77.9%). Mixed effects model revealed a statistically significant effect of time F(1,479)=130.434. Mean symptom reduction on the CY-BOCS was 52.9% (SD=30.9). The estimated within-group effect size between baseline and post treatment was 1.58 (95% CI: 1.37-1.80).
Conclusion: This study found that manualized CBT can be applied effectively in community mental health clinics. These findings underscores the feasibility of implementing exposure-based CBT for pediatric OCD in a regular child and adolescent mental health setting.
Clinical Trials Registration Information: This study was registered in Current Controlled Trials; Nordic Long-term Obsessive compulsive disorder (OCD) Treatment Study (www.controlled-trials.com ISRCTN66385119).
Keywords: Child and adolescent; obsessive-compulsive disorder; Cognitive-behavioral therapy; Exposure and response prevention; Treatment outcome.
Behaviour Research and Therapy 11/2014; · 3.85 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims:Overweight and obesity in children and adolescents are major public health challenges associated with psychosocial adversity and unfavourable lifestyle. Exposure to interpersonal violence, such as sexual abuse, violence and bullying, could represent precursors, accelerating or sustaining factors. Methods: The Young-HUNT 3 study, 2006-2008, is a population-based, cross-sectional, cohort study of Norwegian youth that includes self-report data on exposure to interpersonal violence; pubertal status and timing; socioeconomic, psychosocial, and lifestyle factors; and clinical anthropometric measures. A cohort of 10,464 adolescents aged 12-20 years from Nord-Trøndelag County were invited to participate. Body mass index served as the outcome in the simple and multiple linear regression analyses. Results: The response rate was 72.3% (7564), and 49.9% (3777) of the respondents were girls. A robust and significant relationship between interpersonal violence and increased BMI for both genders was found. Importantly, interpersonal violence remained significantly correlated with higher BMI following adjustment for pubertal development, socioeconomic and psychosocial adversity and unfavourable lifestyle factors in both genders, although most evident in girls. Adjusted regression coefficients (95% confidence intervals) for the relationship between interpersonal violence and BMI were 0.33 (0.01, 0.65) for 1 type and 0.89 (0.37, 1.41) for 2 types, compared to no exposure in girls, and 0.40 (0.09, 0.71) for 1 type and 0.35 (-0.09, 0.79) for 2 types of interpersonal violence in boys. Conclusions: The empirical evidence of consistent associations between interpersonal violence, related psychosocial and lifestyle factors, and body fatness, indicates that these features play important roles for adolescents struggling with overweight.
[Show abstract][Hide abstract] ABSTRACT: The aim of this study was to investigate the development of mother–infant interaction patterns from 3 to 12 months among three groups of mother–baby pairs recruited during pregnancy: one group from residential substance abuse treatment (n = 28), a second group from psychiatric outpatient treatment (n = 22), and a third group from well-baby clinics (n = 30). The mother–infant interaction at 3 and 12 months was assessed by the Parent–Child Early Relational Assessment (PCERA), which consists of maternal, child and dyadic subscales ( Clark, 2006). Linear mixed effects models were used to analyze group differences and the changes in mother–infant interaction from 3 to 12 months.At 3 months, pairwise comparisons showed that the group with psychiatric problems had significantly more difficulties in the mother–infant interaction than the two other groups. The group with substance abuse problems was not significantly different from the two other groups. At 12 months, the mother–infant pairs in the substance abuse group showed significantly more relational disturbances than the non-clinical pairs, as well as a poorer affective quality of interaction than the dyads in the group with psychiatric problems. Analysis of change from 3 to 12 months showed that difficulties in the interaction increased among the mother–baby pairs in the substance abuse group, while improvements were displayed in the two other groups. These results underline that mother–infant pairs at double risk due to maternal substance abuse and other non-optimal factors, are in need for long-term follow up in order to prevent the development of negative interactional patterns.
[Show abstract][Hide abstract] ABSTRACT: This prospective, longitudinal study with data collected at four time points investigated how maternal psychiatric symptoms, substance abuse and maternal intrusiveness in interaction were related to early child language skills. Three groups of mothers were recruited during pregnancy: One from residential treatment institutions for substance abuse (n = 18), one from psychiatric outpatient treatment (n = 22) and one from well-baby clinics (n = 30). Maternal substance abuse and anti-social and borderline personality traits were assessed during pregnancy, postpartum depression at 3 months, maternal intrusiveness in interaction at 12 months, and child language skills at 2 years. Results showed that the mothers in the substance abuse group had the lowest level of education, they were younger and they were more likely to be single mothers than the mothers in the two other groups. There was a significant difference in expressive language between children born to mothers with substance abuse problems and those born to comparison mothers, however not when controlling for maternal age, education and single parenthood. No group differences in receptive language skills were detected. Results further showed that maternal intrusiveness observed in mother-child interaction at 12 months was significantly related to child expressive language at 2 years, also when controlling for socio-demographic risk factors. This suggests that in addition to addressing substance abuse and psychiatric problems, there is a need for applying treatment models promoting sensitive caregiving, in order to enhance child expressive language skills.
Child Psychiatry and Human Development 10/2014; · 1.93 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Expert guidelines recommend cognitive-behavior therapy (CBT) as a first-line treatment in pediatric obsessive-compulsive disorder (OCD) and the addition of selective serotonin reuptake inhibitors when CBT is not effective. However, the recommendations for CBT non-responders are not supported by empirical data. Our objective was to investigate the effectiveness of sertraline (SRT) versus continued CBT in children and adolescents that did not respond to an initial course of CBT. Randomized controlled trial conducted in five sites in Denmark, Sweden and Norway, 54 children and adolescents, age 7-17 years, with DSM-IV primary OCD were randomized to SRT or continued CBT for 16 weeks. These participants had been classified as non-responders to CBT following 14 weekly sessions. Primary outcomes were the CY-BOCS total score and clinical response (CY-BOCS <16). The study was a part of the Nordic Long-Term OCD Treatment Study (NordLOTS). Intent-to-treat sample included 50 participants, mean age 14.0 (SD = 2.7) and 48 % (n = 24) males. Twenty-one of 28 participants (75 %) completed continued CBT and 15 of 22 participants (69.2 %) completed SRT. Planned pairwise comparison of the CY-BOCS total score did not reveal a significant difference between the treatments (p = .351), the response rate was 50.0 % in the CBT group and 45.4 % in the SRT group. The multivariate χ (2) test suggested that there were no statistically significant differences between groups (p = .727). Within-group effect sizes were large and significant across both treatments. These large within-group effect sizes suggest that continued treatment for CBT non-responders is beneficial. However, there was no significant between-group differences in SRT or continued CBT at post-treatment.
European Child & Adolescent Psychiatry 09/2014; · 3.70 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Negative physical and psychological long-term consequences of abuse and bullying are well documented. It is reasonable to assume that abuse and bullying early in life also may have an impact on the ability to work and stay economically independent later in life, but such prospective studies are lacking. This study investigates the consequences of exposure to abuse and bullying in junior high school, as measured by receiving long-term social welfare benefits in young adulthood. In addition, it explores the potential protective role of social support. Self-reported data from 13,633 (50.3 % female) junior high school students were linked to registry data on their use of social welfare benefits from the age of 18 and for eight consecutive years. Cox regression analyses were applied to test the relationship between exposure to life adversities and the use of social welfare benefits, and the potential moderating role of social support. The analyses showed that individuals exposed to abuse and bullying had an increased likelihood of receiving social-welfare benefits compared with individuals not exposed to these types of abuse. Exposure to multiple types of abuse led to a higher likelihood of using social welfare benefits compared with single types of abuse and no abuse. The findings on the potential moderating role of social support were mixed, depending on the source of social support. Family support and classmate relationships were protective in reducing the likelihood of the use of social welfare benefits, whereas peer and teachers' support showed inconsistent patterns. These results are promising in terms of preventing the long-term negative consequences of abuse and bullying.
[Show abstract][Hide abstract] ABSTRACT: It is well documented that both anxiety and depression are associated with headache, but there is limited knowledge regarding the relation between recurrent primary headaches and symptoms of anxiety and depression as well as behavioral problems among adolescents. Assessment of co-morbid disorders is important in order to improve the management of adolescents with recurrent headaches. Thus the main purpose of the present study was to assess the relationship of recurrent headache with anxiety and depressive symptoms and behavioral problems in a large population based cross-sectional survey among adolescents in Norway.
The journal of headache and pain. 06/2014; 15(1):38.
[Show abstract][Hide abstract] ABSTRACT: Recurrent headache is the most common and disabling pain condition in adolescence. Co-occurrence of psychosocial adversity is associated with increased risk of chronification and functional impairment. Exposure to interpersonal violence seems to constitute an important etiological factor. Thus, knowledge of the multiple pathways linking interpersonal violence to recurrent headache could help guide preventive and clinical interventions. In the present study we explored a hypothetical causal model where the link between exposure to interpersonal violence and recurrent headache is mediated in parallel through loneliness and psychological distress. Higher level of family cohesion and male sex is hypothesized to buffer the adverse effect of exposure to interpersonal violence on headache.
The journal of headache and pain. 06/2014; 15(1):35.
[Show abstract][Hide abstract] ABSTRACT: Abstract Aims There is a growing documentation that infants exposed to opioids and poly-substances prenatally have an increased risk of aberrant development. In Norway there are several in-patients-clinics that specialize in medically supervised detoxification for pregnant women with substance dependence in a therapeutic setting. As there is virtually no documentation on the perinatal outcome of the infants born to mothers receiving such treatment, this study aims to investigate the perinatal outcome of children born to mothers with opioid- and poly-substance dependence detoxified in a residential setting during pregnancy compared to infants born to mothers women with substance dependence at a time when no such treatment was available. Methods Pregnant women from two time cohorts were followed from pregnancy till birth. Birth weight, head circumference, gestational age and Neonatal Abstinence Syndrome (NAS) were measured in infants born to mothers detoxified in a residential setting during pregnancy, and compared to infants born to mothers receiving no treatment. Both study groups had concurrent comparison groups. Results Infants born to mothers in residential detoxification treatment experience less prenatal drug exposure and show better perinatal outcomes on gestational age and head circumference, as well as no NAS, compared to the infants in the earlier cohort whose mothers did not receive residential treatment. No miscarriages, complications or morbidities were associated with residential detoxification treatment. Conclusions Detoxification in residential treatment can be a preferred treatment form for many pregnant women struggling with drug abuse problems and should possibly be applied to a larger extent in order to ensure the best possible perinatal outcome for these children.
Journal of Addictive Diseases 04/2014; · 1.46 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Trauma-Focused Cognitive Behavioral Therapy (TF-CBT) has been shown to efficiently treat children and youth exposed to traumatizing events. However, few studies have looked into mechanisms that may distinguish this treatment from other treatments. The objective of this study was to investigate whether the parents' emotional reactions and depressive symptoms change over the course of therapy in the treatment conditions of TF-CBT and Therapy as Usual (TAU), and whether changes in the reactions mediate the difference between the treatment conditions on child post-traumatic stress (PTS) symptoms and child depressive symptoms.
A sample of 135 caregivers of 135 traumatized children and youth (M age = 14.8, SD = 2.2, 80% girls) was randomly assigned to receive either TF-CBT or TAU. The parents' emotional reactions were measured using the Parental Emotional Reaction Questionnaire (PERQ), and their depressive symptoms were measured using the Center for Epidemiologic Studies Depression Scale (CES-D). The children's outcomes were post-traumatic stress (PTS) reactions and depression, as measured by the Clinician-Administered PTSD Scale for Children and Adolescents (CAPS-CA) and Mood and Feelings Questionnaire (MFQ), respectively.
The parents' emotional reactions and depressive symptoms decreased significantly from pre- to post-therapy, but no significant differences between the two treatment conditions were found. The changes in reactions did not significantly mediate the treatment difference between TF-CBT and TAU on child PTS symptoms. However a mediating effect was found on child depressive symptoms.
The results showed that although the parents experienced reductions in emotional reactions and depressive symptoms when their child received therapy, this was only significantly related to the difference in outcome between TF-CBT and TAU on child depressive symptoms. Possible explanations for these results are discussed along with the implications for clinicians and suggestions for future research.Trial registration: Clinical Trials.gov identifier: NCT00635752.
Child and Adolescent Psychiatry and Mental Health 04/2014; 8(1):11.
[Show abstract][Hide abstract] ABSTRACT: Although crucial, research on nurses' knowledge on the use of implantable cardioverter defibrillators (ICDs) is scant. The aims of the study were to investigate (i) the level of nurses' knowledge on care of patients with ICDs, (ii) whether knowledge level is related to education and type of hospital where nurses practice and (iii) whether knowledge level changes among nurses over time.
We developed a questionnaire comprising 27 items in four parts: (1) Sociodemographics, (2) Technical facts about ICDs, (3) Daily life challenges and (4) Self-evaluation of knowledge. After validation, surveys were conducted during 1-week cardiac educational courses in 2003-2010. In total, 463 nurses working in cardiology-related areas participated, yielding a response rate of 91%.
Practical and technical knowledge about ICDs was lacking. Nurses were unaware or did not know that mobile phones can affect the device (80%), that patients are restricted from driving heavy vehicles (69%), and that ICDs can deliver unintended shock therapy (73%). However, they were aware that ICD patients can resume sexual (87%) and physical activity (85%). There were few significant differences with regard to education and type of hospital where nurses practiced, but significant time trends in correct answers regarding kitchen appliances, resumption of physical activity and shock delivery.
Over an 8-year period, despite the increased usage of ICDs, overall nurses had a lack of knowledge in relation to specific key clinical issues on the care of ICD patients. As a consequence, these patients may fail to receive qualified care. Future research should assess knowledge of other health care professionals and focus on interventions that increase and maintain an appropriate knowledge level in care of ICD patients. Relevance to clinical practice The level of nurses' knowledge on care of patients with ICDs needs to be systematically raised in order to ensure appropriate counselling and nursing care.
Nursing in Critical Care 01/2014; · 0.95 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: School drop-out is a problem all over the world with adverse life-course consequences. The aim of this paper is to study how internalising and externalising problems in the 10th grade are associated with non-completion of upper secondary school, and to examine the mediating role of grade points in the 10th grade across general academic and vocational tracks in upper secondary school. We also study the impact of health behaviour.
Population-based health surveys were linked with Norwegian registries on education and sociodemographic factors (n = 10 931). Mental health was assessed by the self-report Strengths and Difficulties Questionnaire. Logistic regression was used to analyse the relations between mental health and health behaviour in 10th grade and non-completion of upper secondary school. The mediating effect of grade points was studied by causal mediation analysis.
Adolescents not completing upper secondary school reported more externalising problems and girls more internalising problems in the 10th grade, after adjustments. Smoking and physical inactivity increased the odds of non-completion of upper secondary school. Causal mediation analyses showed that a reduction in externalising problems of 10 percentage points led to lower rates of non-completion of 4-5 percentage points, and about three-quarters of this total effect was mediated by grades. For internalising problems the total effect was significant only for girls (1 percentage point), and the mediated effect of grades was about 30%. The effect of mental health problems on school dropout was mainly the same in both vocational and general tracks.
Assuming a causal relationship from mental health problems to school performance, this study suggests that externalising problems impair educational attainment. A reduction of such problems may improve school performance, reduce school drop-out and reduce the adverse life-course consequences.
BMC Public Health 01/2014; 14(1):16. · 2.08 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Objective
Emotional problems are common in adults with diabetes, and knowledge about how different indicators of emotional problems are related with glycemic control is required. The aim was to examine the relationships of diabetes-specific emotional distress, depression, anxiety, and overall well-being with glycosylated hemoglobin (HbA1c).
Of the 319 adults with type 1 diabetes attending the endocrinology outpatient clinic at a university hospital in Norway, 235 (74%) completed the Diabetes Distress Scale, the Problem Areas in Diabetes Survey, the Hospital Anxiety and Depression Scale, and the World Health Organization-Five Well-Being Index. Blood samples were taken at the time of data collection to determine HbA1c. Regression analyses examined associations of diabetes-specific emotional distress, anxiety, depression, and overall well-being with HbA1c. The relationship between diabetes-specific emotional distress and HbA1c was tested for nonlinearity.
Diabetes-specific emotional distress was related to glycemic control (DDS total: unstandardized coefficient = 0.038, P < 0.001; PAID total: coefficient = 0.021, P = 0.007), but depression, anxiety, and overall well-being were not. On the DDS, only regimen-related distress was independently related to HbA1c (coefficient = 0.056, P < 0.001). A difference of 0.5 standard deviation of baseline regimen distress is associated with a difference of 0.6 in HbA1c. No significant nonlinearity was detected in the relationship between diabetes-specific distress and HbA1c.
To stimulate adequate care strategies, health personnel should acknowledge depression and diabetes-specific emotional distress as different conditions in clinical consultations. Addressing diabetes-specific emotional distress, in particular regimen distress, in clinical consultation might improve glycemic control.
[Show abstract][Hide abstract] ABSTRACT: Background
Randomized controlled psychosocial treatment studies on selective mutism (SM) are lacking. Method
Overall, 24 children with SM, aged 3–9 years, were randomized to 3 months treatment (n = 12) or wait list (n = 12). Primary outcome measure was the School Speech Questionnaire. ResultsA significant time by group interaction was found (p = .029) with significantly increased speech in the treatment group (p = .004) and no change in wait list controls (p = .936). A time by age interaction favoured younger children (p = .029). Clinical trail registration: Norwegian Research CouncilNCT01002196. Conclusions
The treatment significantly improved speech. Greater improvement in the younger age group highlights the importance of an early intervention.
Child and Adolescent Mental Health 01/2014; 19(3):192-194. · 0.64 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: To expand our understanding of social support and mental health, we introduce a measure of social support barriers and investigate the relationship between these barriers, social support, mental health and gender in survivors of the terrorist attack on Utøya Island, Norway.
Survivors (N=285) were interviewed face to face. We used confirmatory factor analysis (CFA) to assess the latent factor structure of the Social Support Barriers Scale and perceived social support (FSSQ), and linear regression analyses to investigate the associations between social support variables and mental health (PTSD-RI and HSCL-8).
The CFA indicated that social support barriers and perceived social support were two separable latent constructs. Social support barriers were highly associated with posttraumatic stress reactions (adjusted regression coefficient=0.38, 95% CI=0.29-0.47. p<0.001) as well as with psychological distress (adjusted regression coefficient=0.35, 95% CI=0.26-0.43, p<0.001). In contrast, neither perceived social support nor gender was associated with mental health after adjustment for barriers.
Most analyses were based on cross-sectional data. This is the first study to use a quantitative measure of social support barriers.
Social support barriers may be a new opening to understand the relationship between social support and mental health and may have a role in explaining why women are at increased risk for mental health problems. Clinicians should explore not only perceived social support but also barriers to making use of these resources when consulting young people facing major life adversities.
Journal of affective disorders 12/2013; · 3.76 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This paper investigates whether exposure to violence, sexual abuse, or bullying is associated with later work participation and whether high school completion has a potential mediating role. Self-reported junior high school questionnaire data were linked for eight consecutive years to prospective registry data for the demographics, educational progress, employment activity, and social benefits of 11,874 individuals. Ordinal regression analysis showed that violence and/or bullying at 15 years of age predicted negative work participation outcomes eight years later, independent of high school completion and other relevant factors. Although increasing educational level may have some preventive effect, these results indicate that prevention efforts should be initiated at an early age and should target adverse life experiences.
Journal of Adolescence 12/2013; 36(6):1143-51. · 2.05 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: This study compared the diagnostic utility of the symptom part of the child PTSD symptom scale (CPSS) screening instrument with the clinician-administered PTSD scale for children and adolescents (CAPS-CA).
The study included a clinical sample of traumatized children and adolescents (mean age 15.1, range 10-18) living in Norway, who were assessed for posttraumatic stress symptoms using the CPSS and the CAPS-CA. Diagnostic utility was investigated using receiver operating characteristic analyses.
The results showed that CPSS reached medium effect sizes (AUC from .63 to .76). The sensitivity was good (.80), but the specificity was relatively low (.56). Kappa between CPSS and CAPS-CA was low (κ=.27).
Findings suggests that CPSS is a good tool for screening purposes, but not as a diagnostic instrument in an early phase of assessment. Implications and limitations of the findings are discussed.
Journal of anxiety disorders 12/2013; 28(1):51-56. · 2.68 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Aims: To investigate the impact of maternal childhood abuse on toddlers' behaviour and assess the potential mediation of maternal mental distress for this pathway. Methods: This study was based on the Norwegian Mother and Child Cohort Study, conducted by the Norwegian Institute of Public Health. The study sample consisted of 25,452 children and their mothers. Maternal childhood abuse was investigated as a potential predictor for child externalizing behaviour at 36 months of age. Maternal mental distress at child age 18 months was assessed as a potential mediator. Hierarchical linear regressions were used for analyses. Results: Childhood emotional abuse alone was reported by 8.3% of the mothers and physical and/or sexual abuse by 8.9%. Mothers with childhood abuse experiences were younger, less educated, more at risk for adult abuse and mental distress, and fewer were married or lived with a partner compared with women not reporting childhood abuse. Children of mothers with childhood abuse experiences showed significantly more externalizing behaviour even after adjusting for maternal age, education, single motherhood, gender and adult abuse experiences. When maternal mental health was entered into the model, the associations remained statistically significant, but were substantially attenuated. Conclusions: Maternal childhood abuse consistently predicted increased externalizing behaviour in the offspring, and this study suggests that childhood abuse impacts subsequent generations. Multiple pathways are possible, but this study identified increased maternal mental distress as a possible pathway between maternal childhood abuse and increased externalizing behaviour in the offspring.
Scandinavian Journal of Public Health 11/2013; · 1.97 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The present study investigated attachment patterns among 60 foster children (FC) and 42 comparison children (CC) at 2 years (T1) and again at 3 years (T2) of age, as well as stability from T1 to T2. Descriptive analyses, including cross-tabulation, were used to present attachment patterns, group differences and stability from T1 to T2. Most FC were securely attached at T1, and no group differences were identified; neither the FC nor CC differed from typical children in their attachment patterns. Furthermore, the majority of children in both groups received the same classification at both time points. Among FC who were securely attached at T1, a majority remained so at T2, while among those classified as disorganized at T1, significantly less remained so at T2. The study suggests that young FC have the possibility to form enduring secure attachments when placed in stable and well-functioning foster homes.
Attachment & Human Development 11/2013; · 2.38 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Background: Dropout from school and work among young adults is common, but the risk factors are not well understood and there is a lack of prospective studies. Purpose: To investigate early predictors of later work marginalization and the potential mediating role of high school completion. Significance: Results will point to areas of importance for long-term prevention of marginalization from education and work. Methods: Self-reported high school questionnaire data were linked to prospective registry data for eight consecutive years on 11 874 individuals' demographics, educational progress, employment activity and social benefits. Ordinal logistic regression were used to investigate the associations between exposure to single as well as multiple forms of victimization and later marginalization, using high school completion within 5 years as a mediator. Results: Self-reported exposure to violence and/or bullying at 15 years of age predicted marginalization from work 8years later, even when adjusted for other relevant factors. The mediating effect of education was minor (Completed high school: Odds Ratio, .26; 95% CI, .084-.298; P <.001). Conclusion: Marginalization from work may be predicted by factors that are present in early life. Exposure to violence and bullying increased the odds of marginalization, independent of high school completion. Increasing education level may have some preventive effect, but these results indicate that prevention efforts should be initiated at an early age and target adverse life experiences.
141st APHA Annual Meeting and Exposition 2013; 11/2013