Child Neglect Research Articles

Postnatal Enrichment Corrects Deficits in Perineuronal Net Formation and Reversal Learning in Adult Mice Exposed to Early Adversity.

Childhood neglect is associated with cortical thinning, hyperactivity, and deficits in cognitive flexibility that are difficult to reverse later in life. Despite being the most prevalent form of early adversity, little is currently understood about the mechanisms responsible for these neurodevelopmental abnormalities, and no animal models have yet replicated key structural and behavioral features of childhood neglect/deprivation. To address these gaps, we have recently demonstrated that mice exposed to impoverished conditions, specifically limited bedding (LB), exhibit behavioral and structural changes that resemble those observed in adolescents who have experienced severe neglect. Here, we show that LB leads to long-term deficits in reversal learning, which can be fully reversed by briefly exposing LB pups to enrichment (toys) in their home cage from postnatal days 14 to 25. Reversal learning failed to induce normal c-fos activation in the orbitofrontal cortex (OFC) of LB mice, a deficit that was normalized by early enrichment. Additionally, LB decreased the density of parvalbumin-positive cells surrounded by perineuronal nets (PV+PNN+) and increased the ratio of glutamatergic to inhibitory synapse densities in the OFC, deficits that were also reversed by enrichment. Degradation of PNN in the OFC of adult mice impaired reversal learning, reduced c-fos activation, and increased the ratio of glutamatergic to inhibitory synapse densities in the OFC to levels comparable to those observed in LB mice. Collectively, our findings suggest that postnatal deprivation and enrichment impact the formation of PV+PNN+ cells in the OFC, a developmental process that is essential for cognitive flexibility in adulthood.

Barriers to health visitors identifying child neglect

Child neglect poses a significant issue in the UK with enduring repercussions for the health and wellbeing of children. Health visitors are responsible for safeguarding and promoting child welfare and play a pivotal role in identifying and addressing neglect, but a multitude of barriers can hinder this. This article explores the complex landscape of health visitors identifying child neglect, outlining the significance of early intervention, with a particular focus on health visiting in Scotland. Challenges faced by health visitors are examined, including organisational barriers, family/carer disguised compliance, and varying professional thresholds for when to intervene. The importance of leadership support, enhanced training and clear thresholds in safeguarding work are highlighted. The concept of ‘respectful uncertainty’ is advocated as an approach for health visitors to navigate the challenges they encounter when protecting and promoting the wellbeing and safety of children in the UK.

Consciouness and Practice of Personal Hygiene among the High School Students of a Rural Area in Chattogram

Backround: Good health is a sign of a country's economic well-being. Personal hygiene should be maintained first and foremost for high accuracy in work, low disease suffering and disease prevention. Maintaining good hygiene is crucial because it can prevent many infectious diseases. Personal hygiene habits may have developed during childhood. Children in school are especially prone to disregarding basic personal hygiene.This study was conducted to assess the consciousness and practice of personal hygiene among the students of a rural high school in Chattogram. Materials and methods: It was a descriptive type of cross-sectionalstudy and data were collected from 314 students of Guman Mardan Pashkarhut High School in Hathazari Upazila, Chattogram from August to October 2023 by interviewer administrative questionnaire. Results: Among the respondents, most of them 141(45%) were in the age group 11-12 years. About 207 (66%) were girls and 302(96%) were Muslims. Maximum 172 (54.8%) respondents were from class VII and class 8 and 36.5% were from lower middle class. About 241(77%) heard about the term personal hygiene and maximum students, 152(63.1%) heard it from school. Most of the students 241(77%) had idea on basic requirement of personal hygiene. It was found that maximum respondents 300 (96%) know about the importance of handwashing. Among all students, 73% brush twice daily, about 307(97.77%) take shower daily in summer and 302 (96%) practiced in winter, 293 (93.31%) used a towel of their own. During tiffin time, 211(67.20%) had taken home made food. Conclusion: As most of the children neglect maintenance of personal hygiene, so their habit should be changed. It should be practiced from early childhood to lead a healthy, disease-free productive life. IAHS Medical Journal Vol 6(2), December 2023; 24-30

Associations between Adverse Childhood Experiences (ACEs) and Complex-PTSD, moral injury and perceived social support: A latent class analysis

BackgroundAdverse Childhood Experiences (ACEs), including childhood abuse and neglect, are consistently linked to poorer mental health and psychosocial outcomes in adulthood. Complex-posttraumatic stress disorder (C-PTSD) and moral injury are two conditions which can cause significant distress and functional impairment in individuals affected by trauma. However, not much is known about the complex relationships between ACEs, C-PTSD and moral injury. Furthermore, while perceived social support is a commonly cited protective factor for C-PTSD, there is little understanding about how it relates to ACEs in traumatised populations. The aim of this study was to investigate ACEs in a trauma-affected sample of UK military veterans using latent class analysis. Secondly, the study tested for associations between latent classes of ACEs, severity of C-PTSD and moral injury, and levels of perceived social support. MethodData was collected from a UK military veterans mental health charity, from a clinical sample (N = 336) who were receiving treatment for mental health difficulties. Participants completed standardised measures of ACEs, C-PTSD, moral injury, and perceived social support. Data was analysed using a bias-adjusted 3-step approach latent class analysis. Wald statistics were used to test for associations between classes of ACEs and C-PTSD, moral injury and perceived social support. FindingsA two-class model was found to be the best fit for the data, which depicted two classes of ACEs within the sample. The classes showed a distinction between a group of participants who were more likely to endorse experiencing high levels of ACEs, and a separate group who endorsed relatively lower levels of ACEs. As such, the model was interpreted as depicting a low-ACEs (class 1) vs. high-ACEs (class 2) distinction. 56 % of participants fell into class 1 (low ACEs) with 44 % in class 2 (high ACEs). Participants in class 2 (high ACEs) were significantly more likely to score highly for symptoms of C-PTSD and moral injury, and to report lower levels of perceived social support. ConclusionThe present study is the first to report a two-class model of low vs high-ACEs in a clinical sample of UK military veterans. It also describes how membership of the high-ACEs class was significantly associated with higher scores for key mental health and psychosocial variables in C-PTSD, moral injury and perceived social support. The findings have important clinical implications in highlighting the possible role of ACEs in understanding the aetiology of psychopathology in military populations affected by trauma. It also adds to the growing literature which demonstrates how many military personnel experience significant levels of pre-existing trauma and adversity before entering service, and how this can contribute to the development of complex mental health outcomes in adulthood.

Childhood trauma distribution and behavioural problems among Pakistani adolescents.

Childhood trauma adversely impacts adolescents, and consequently, they develop behavioural problems. Understanding the distribution of childhood traumas and their association with behavioural problems among adolescents is paramount for the preventive efforts. The present research aimed to investigate this association among adolescents. This association was investigated among adolescents (N = 200) between 12 and 18 years. Childhood Trauma Questionnaire and Strength and Difficulty Questionnaire was used to assess the distribution of trauma and internalizing and externalizing behavioural problems among adolescents through purposive and convenience sampling technique. The findings across trauma distribution indicated higher distribution of childhood abuse and neglect across males as compared to females. Males further significantly scored higher on sexual abuse and emotional neglect. Apparently, a large number of adolescents experienced all five sub types of childhood traumas (sexual abuse, emotional abuse, physical abuse, emotional and physical neglect). Additionally, across the severity continuum of childhood traumas, male scored higher on the severe to extreme continuum for all subtypes except physical abuse, where females scored higher. Lastly, logistic regression analysis indicated higher peer problems among those adolescents who have experienced all types of childhood traumas. These findings could be beneficial for intervention-based programs and policies to help trauma-exposed adolescents cope with their lives.

The scale and timing of child protection system contacts from 0-18 years: a study of 1.9 million Australian children

IntroductionTo prevent abuse, neglect and poor outcomes for children and families, including child protection intervention, maltreatment, and removals, it is critical to understand the scale and timing of child protection system contacts to identify opportunities for early prevention. Objectives and ApproachWe quantified the cumulative incidence of child protection contacts during childhood, including initial reports, screened-in reports, investigations, substantiations and removal into out-of-home-care, among all children in two Australian states. We used child protection system data linked for the South Australian (SA) BEBOLD and NSW Child E-Cohort data platforms as the numerator, and census data for the denominator, for 571,497 SA children (birth-years 1991-2019) and 1,362,505 NSW children (birth-years 2005-2018). ResultsOf children born in 2005 (NSW SA): Two in five children were reported to child protection by age 14; one in ten children were the subject of a child protection investigation in NSW and SA; one in twelve children in NSW and one in 17 in SA, were substantiated at least once; and one in 35 children in NSW and one in 40 in SA were removed into out-of-home care at least once by age 14. Approximately half of all types of child protection contact first occurred by the child’s fourth birthday. Conclusions/implicationsThe scale of lifecourse child protection contact underscores the opportunities for early health and social supports to prevent child maltreatment and escalating child protection intervention. Child protection reports also represent an asset to generate public health intelligence to inform early prevention.

A governance framework for facilitating cross-agency data sharing

Linking data across local authorities and health boards has the potential to reduce inequalities and improve outcomes. However, cross-agency data sharing leads to complexities around data ownership, legal conditions for processing, organisational controls and risk assessments to ensure privacy and confidentiality of subjects whilst facilitating research and service improvements. We share a governance framework for cross-agency data sharing between a local authority and regional health board in Scotland. A cross-sector Child Neglect working group was established with representation from public sector agencies, the NHS, University researchers and a Trusted Research Environment to support research on children’s mental health prescribing and secondary specialist services provision and linking to the Aberdeen City Council Child Protection Register. Lessons learned were captured throughout the governance, data transfer and data linkage phases. Communication is the most important driver, with key individuals, deputies and routes of escalation agreed and involved throughout for clarity of roles and expectation setting. Key lessons learned include requiring input from all parties at the project initiation stage, particularly IG teams, including agreements on necessary templates. Knowledge exchange is required between the research team, data owners and data processors to ensure research protocol requirements are correctly understood and data transfer is supported. If possible, internal and/or external validation of data should also be performed before data is linked. Cross-agency data sharing is a vital means to understanding and improving outcomes for individuals and populations. Critical to this is establishing an action plan and formalised project process to achieve outcomes.

Molecular mechanisms and behavioral relevance underlying neural correlates of childhood neglect

BackgroundChildhood neglect is associated with brain changes, yet the molecular mechanisms and behavioral relevance underlying such associations remain elusive. MethodsWe calculated fractional amplitude of low-frequency fluctuations (fALFF) using resting-state functional MRI and tested their correlation with childhood neglect across a large sample of 510 healthy young adults. Then, we investigated the spatial relationships of the identified neural correlates of childhood neglect with gene expression, neurotransmitter, and behavioral domain atlases. ResultsWe found that more severe childhood neglect was correlated with higher fALFF in the bilateral anterior cingulate cortex. Remarkably, the identified neural correlates of childhood neglect were spatially correlated with expression of gene categories primarily involving neuron, synapse, ion channel, cognitive and perceptual processes, and physiological response and regulation. Concurrently, there were significant associations between the neural correlates and specific neurotransmitter systems including serotonin and GABA. Finally, neural correlates of childhood neglect were associated with diverse behavioral domains implicating mental disorders, emotion, cognition, and sensory perception. LimitationsThe cross-sectional study design cannot unequivocally establish causality. ConclusionsOur findings may not only add to the current knowledge regarding the relationship between childhood neglect and mental health, but also have clinical implications for developing preventive strategies for individuals exposed to childhood neglect who are at risk for mental disorders.

Replantation After Dental Avulsion: A Scoping Review and Proposal of a Flow Chart.

Dental avulsion, the complete displacement of a tooth from its socket, is a severe dental trauma with a prevalence of 0.5% to 16% of all dental injuries. Replantation of avulsed teeth is common, yet recent studies show high failure rates and unpredictable long-term outcomes. This review examines clinical variables influencing intentional dental replantation decisions and proposes a treatment flow chart. A comprehensive literature search was conducted in PubMed-Medline, Scopus, WoS, and Cochrane databases using the keywords "tooth avulsion," "tooth replantation," and "tooth ankylosis." Inclusion criteria encompassed studies from January 2018 to February 2024. From 752 identified articles, 9 systematic reviews including 3 meta-analyses were selected for this scoping review. Immediate replantation is the gold standard for avulsed teeth, yet delayed replantation is more common in practice, impacting survival rates. Adherence to guidelines from the International Association on Dental Traumatology improves outcomes, especially in paediatric patients. Factors such as multiple caries, severe periodontal disease, advanced age, psychological conditions, immunodeficiency, and lack of cooperation are contraindications for replantation. Despite the high failure rate, replantation remains recommended in literature due to its potential advantages over prosthetic implants. This review highlights the complexities in decision-making for dental replantation, emphasising the need for a comprehensive approach considering individual clinical cases. A proposed treatment flow chart aims to support clinicians in predicting prognosis and making informed decisions. The review also underscores the link between dental trauma, poor oral health, and potential neglect in children, highlighting the importance of preventive measures and parental awareness.

Pediatric Hospital Admissions with Concern for Neglect: Correlations Between Neglect Types and Other Clinical and Environmental Risk Factors.

Child neglect is a public health concern with negative consequences that impact children, families, and society. While neglect is involved with many pediatric hospitalizations, few studies explore characteristics associated with neglect types, social needs, and post-discharge care. Data on neglect type, sociodemographics, social needs, inpatient consultations, and post-discharge care were collected from the electronic medical record for children aged 0-5years who were hospitalized with concern for neglect during 2016-2020. Frequencies and percentages were calculated to determine sample characteristics. The Chi-square Test for Independence was used to evaluate associations between neglect type and other variables. The most common neglect types were inadequate nutrition (40%), inability to provide basic care (37%), intrauterine substance exposure (25%), combined types (23%), and inadequate medical care (10%). Common characteristics among neglect types included age less than 1year, male sex, Hispanic ethnicity, public insurance, past involvement with Child Protective Services, and inpatient consultation services (social work, physical therapy, and occupational therapy), and post-discharge recommendations (primary care, physical therapy, and regional center). Neglect type groups varied by child medical history, social needs, and discharge recommendations. Statistically significant associations supported differences per neglect type. Our findings highlight five specific types of neglect seen in an impoverished and ethnically diverse geographic region. Post-discharge care needs should focus on removing social barriers and optimizing resources, in particular mental health, to mitigate the risk of continued neglect. Future studies should focus on prevention strategies, tailored interventions, and improved resource allocations per neglect type and discharge location.

Enhancing child protection responses in oral health practice: A scoping review of evidence‐based approaches

AbstractChild abuse and neglect represent significant global health challenges with long‐lasting adverse impacts. Oral health practitioners, who often interact with children, play a key role in detecting and responding to suspected cases. Despite this, there is a notable gap in the systematic child protection measures in dental practices globally. This scoping review, utilising the Joanna Briggs Institute methodology, aims to outline current approaches for oral health practitioners and identify gaps in the approaches designed to enhance their responsiveness. Covering studies from January 2000 to May 2023, the review explored educational programmes, guidelines and interdisciplinary training modules. A comprehensive search across multiple databases, including MEDLINE, CINAHL and Scopus, along with grey literature sources, identified 1230 sources, resulting in the inclusion of 20 relevant sources. Findings highlight three main approaches: dental‐specific education programmes, practical guidelines for child protection responses and analysis of legal and professional obligations. These approaches demonstrate a mix of direct educational interventions and policy‐driven strategies aimed at enhancing oral health practitioners' knowledge, attitudes and practices towards child abuse and neglect. Given the identified variability and gaps in training and resources, future research should assess the effectiveness of these approaches and develop comprehensive, culturally safe training for oral health practitioners globally.

Tinjauan Yuridis Normatif Perlindungan Anak dalam Perspektif Konsep Hadhanah dan Undang-Undang Nomor 35 Tahun 2014

This study aims to explain the concept of Islamic law through the concept of hadhanah in the effort to protect Indonesian children. In Law No. 35 of 2014, which has been ratified by the government, it is emphasized that the protection of Indonesian children from all forms of discrimination and violence is a priority. Since the majority of people in Indonesia are Muslim, Islamic values and standards certainly influence the upbringing and education of children. Child neglect is one form of maltreatment and violence experienced by children and constitutes a violation of children's human rights, whether intentional or unintentional. A normative juridical research method, which is based on library research, is used as the research methodology. Based on the research findings, Islamic law itself teaches how to protect children, and the government, society, and parents have a very important role in establishing policies that benefit children and uphold human rights. The results of this study indicate that Law No. 35 of 2014 has fulfilled the concept of hadhanah in Islamic jurisprudence and has involved all parties in protecting children. This law also explains child protection in the fields of religion, health, education, and social matters.

Collaborative Strategies for Enhancing Child Protection Practices in Pre-Primary Schools: A Case Study of Kira Municipality, Uganda

Child protection practices are measures and interventions intended to safeguard children against violence in school. These practices create safe environments that enable children to thrive. Some of these include the prevention of child abuse and neglect. Child protection agencies’ collaboration is a partnership that supports children’s well-being. This study investigated the contribution of child protection agencies’ collaboration on protection practices in Pre-primary schools in Kira Municipality, which has continued to be challenging. This study was informed by the social capital theory emphasizing the significance of social relationships, trust, and mutuality. The study used a descriptive cross-sectional survey design, and data was collected using quantitative and qualitative tools. These included document analysis checklists, interview guides, observation checklists, and questionnaires. The respondents included headteachers, Centre Management Committee members, parents, Local Council members, and Probation officers. The results indicated that schools rarely collaborated with child protection agencies to ensure that protection practices were implemented in pre-primary schools. In contrast, the probation officers reported that the schools didn’t involve them during the planning, though it was when they would know the areas for collaboration. Four significant recommendations for improving child protection practices are given. Child protection workers need to jointly develop plans that promote child safety and protection, train and build the capacity of educators on issues of child protection, increase resources and financial support to promote child safety and protection, and finally, advocate for laws and policies that promote children’s rights.

The Hispanic paradox in child maltreatment: Does it fade over time?

BackgroundThe “Hispanic Paradox” refers to a commonly noted tendency for Hispanic immigrants to have good health outcomes relative to risks faced. This paper demonstrates the presence of the Hispanic Paradox relative to child maltreatment, with a focus on how it appears to “fade” generationally. ObjectivesTo use national child maltreatment and census data to determine if the protective effects of the Hispanic Paradox are weaker (“fade”) for counties with fewer foreign-born Hispanics. DesignCensus data, including the percentage of Hispanics in a county who were foreign-born, was used to predict child maltreatment rates as observed in the National Child Abuse and Neglect Data System. The analysis was done at a county level and included a number of covariates (e.g. Hispanic Median Income, Rural/Urban status…). Participants and settingWe included national child maltreatment data at the county level. ResultsA negative binomial mixed effects model showed that for each point of increase in the percentage of the Hispanic foreign-born population of a county, the county Hispanic child maltreatment rate was expected to drop by 1 %. Variation in Hispanic national origin (i.e. Puerto Rico) was found to significantly moderate this relationship. ConclusionCounties with higher percentages of foreign-born Hispanics have lower child maltreatment rates after controlling for other factors. This is consistent with emerging findings in the child mortality data and suggests that for child maltreatment, the Hispanic Paradox may fade generationally.

Collaborative Strategies for Enhancing Child Protection Practices in Pre-Primary Schools: A Case Study of Kira Municipality, Uganda

Child protection practices are measures and interventions intended to safeguard children against violence in school. These practices create safe environments that enable children to thrive. Some of these include the prevention of child abuse and neglect. Child protection agencies’ collaboration is a partnership that supports children’s well-being. This study investigated the contribution of child protection agencies’ collaboration on protection practices in Pre-primary schools in Kira Municipality, which has continued to be challenging. This study was informed by the social capital theory emphasizing the significance of social relationships, trust, and mutuality. The study used a descriptive cross-sectional survey design, and data was collected using quantitative and qualitative tools. These included document analysis checklists, interview guides, observation checklists, and questionnaires. The respondents included headteachers, Centre Management Committee members, parents, Local Council members, and Probation officers. The results indicated that schools rarely collaborated with child protection agencies to ensure that protection practices were implemented in pre-primary schools. In contrast, the probation officers reported that the schools didn’t involve them during the planning, though it was when they would know the areas for collaboration. Four significant recommendations for improving child protection practices are given. Child protection workers need to jointly develop plans that promote child safety and protection, train and build the capacity of educators on issues of child protection, increase resources and financial support to promote child safety and protection, and finally, advocate for laws and policies that promote children’s rights.

Childhood trauma, resilience, psychopathology and social functioning in schizophrenia: A network analysis

The affective pathway to psychosis implicates affective symptoms and neuroticism as mediating steps between childhood trauma and symptoms of schizophrenia. Prior research seldom examined the interplay between childhood trauma, resilience, personality, social functioning and symptoms in schizophrenia patients. This study recruited 290 schizophrenia patients, and constructed a regularized partial correlation network of childhood trauma, resilience, big-five personality traits, symptoms and social functioning. We further applied flow diagram and shortest path analysis to clarify how different childhood trauma types would contribute to and reach different symptoms. In the network, emotional and physical abuse showed the highest expected influence, and resilience showed the highest strength. In flow diagrams, all nodes together contributed two-thirds of variance of social functioning (which had highest predictability). Among childhood trauma types, emotional abuse contributed most to positive symptoms; physical neglect contributed most to negative, depressive and disorganized symptoms. Childhood abuse reached positive symptoms via neuroticism and depressive symptoms, yet it reached negative symptoms via physical neglect and social functioning. Childhood neglect reached positive symptoms via resilience, conscientiousness, neuroticism and depressive symptoms, yet it reached negative symptoms via social functioning. Our findings support that different childhood trauma types contribute to different symptoms, and interacts with resilience, personality and social functioning.

Self-directedness mediates the association of child abuse and neglect experiences with personality pathology

It is well established that the exposure to adverse childhood experiences (ACEs) may alter the the development of personality. Nevertheless, only a part of individuals exposed to ACEs actually develop Personality Disorders (PDs). According to the alternative model of PDs, impairments in dimensional self-aspects, i.e., Identity and Self-direction (SD), may represent potential candidates to promote the transition from ACEs to PDs. We analysed patients’ data from the A.T. Beck Institute of Rome (n = 626) to evaluate the ACEs and SD interplay in PDs patients using Cloninger’s Self-Directedness to assess their SD. First, we explored the presence of ACEs in patients affected by PDs. Secondly, we examined the association between ACEs and SD and subsequently how SD influences the severity of the PDs. Finally, since SD and ACEs were both associated to PDs, we wondered if SD could mediate the relationships between ACEs and PDs. Results evidenced a partial competitive mediation effect of SD on the relationship between child abuse and neglect and the number of PDs. In agreement with the AMPD, Self-functioning dimension may represent a main target for psychotherapeutic intervention.

From Early Trauma to Cardiovascular Risk Among a Nationally Representative Sample of Young Adults.

This study aimed to investigate the connection between childhood abuse history and cardiovascular health indicators among a nationally representative sample of young adults aged 24-32. Using data from waves three and four of the National Longitudinal Study of Adolescent to Adult Health (n = 4, 164) multivariate logistic regression was employed to investigate childhood trauma (i.e., childhood physical abuse, sexual abuse, and neglect) as predictors for cardiovascular disease, hypertension, high cholesterol, diabetes, and obesity. Results showed that adults who reported history of sexual abuse were 4.3 times more likely to report diagnosis of cardiovascular disease and those who reported childhood physical abuse at wave three had 1.4 times the odds of reporting high cholesterol diagnosis. Although trauma history is often calculated as a composite, some forms of childhood abuse may have greater impacts on cardiovascular risk than others.

Harnessing the Power of Machine Learning and Electronic Health Records to Support Child Abuse and Neglect Identification in Emergency Department Settings.

Emergency departments (EDs) are pivotal in detecting child abuse and neglect, but this task is often complex. Our study developed a machine learning model using structured and unstructured electronic health record (EHR) data to predict when children in EDs might need intervention from child protective services. We used a case-control study design, analyzing data from a pediatric ED. Clinical notes were processed with natural language processing (NLP) techniques to identify suspected cases and matched in a 1:9 ratio to ensure dataset balance. The features from these notes were combined with structured EHR data to construct a model using the XGBoost algorithm. The model achieved a precision of 0.95, recall of 0.88, and F1-score of 0.92, with improvements seen from integrating NLP-derived data. Key indicators for abuse included hospital admissions, extended ED stays, and specific clinical orders. The model's accuracy and the utility of NLP suggest the potential for EDs to better identify at-risk children. Future work should validate the model further and explore additional features while considering ethical implications to aid healthcare providers in safeguarding children.

Barriers and facilitators when seeking healthcare for septic children in Ghana: a single-centre qualitative study of patient caregivers and emergency department clinicians

Background/purposeSepsis is a leading cause of morbidity, mortality and healthcare utilisation for children worldwide, particularly in resource-limited regions. In Kumasi, Ghana, organ system failure and mortality in children who present...