Compliant Children Research Articles

Modifications to Child Restraints for Children With Disabilities – Experiences of Australian Caregivers and Health Professionals

All children travelling in motor vehicles must be properly secured in a size-appropriate child restraint. However, for many children with a disability, standard child restraints are not suitable, and health professionals or caregivers modify restraints. There is however little data characterising these modifications. This study examined the modifications used to assist with the restraint of children aged 0-16 years with additional needs in motor vehicles. Two anonymous online surveys, one for caregivers and one for health professionals on child restraint use and modifications to seating for children with disabilities were undertaken. The quantitative and qualitative data were analysed with descriptive statistics. Eighty-six responses were analysed (40 caregivers and 46 health professionals). The majority (95.7%) of health professionals and 22.5 percent of caregivers reported having used modifications. Additional padding for postural support was the most frequently used modification (47.7% health professionals, 10% caregivers). Specialised harnesses were the most frequently used accessory used by health professionals (47.8%), with cross chest straps most frequently used by the surveyed caregivers (10%). Challenges for children with disabilities using compliant child restraints continue to persist, despite the use of modifications. There is also a lack of evidence on the impact of the modifications on restraint performance, potentially placing children at risk.

How to remove a tunneled and cuffed central venous catheter quickly and safely? A little trick useful in children.

The aim of this study was to present our experience with a use of own variation of the traditional technique for tunneled and cuffed catheters removal. From July 2021 to March 2023, 110 tunneled cuffed centrally inserted central catheters (CICCs) were removed at the Vascular Access Unit of ASST Spedali Civili of Brescia using our particular technique; pediatric patients were 15 admitted to "Children Hospital" of Brescia. The catheter is cut with its adhesions above the cuff and then pulled out. The cuff is then removed with all adhesions attached. Each procedure was successfully performed to the end with local anesthesia, also in younger children. The maneuver was very short and well tolerated. No related complications were observed. The maneuver has always been considered easy even by less experienced surgeons. The scars were aesthetically good and well accepted by the patients. The technique described has the advantage of not requiring the careful lysis of the adherence from the cuff. If the procedure is quick it can be performed without general anesthesia and without significant psychological trauma also in less compliant children. The skin cut very short leaves an almost invisible scar. It is another notable advantage especially for young girls.

Management of Helicobacter pylori infection in paediatric patients in Europe: results from the EuroPedHp Registry

PurposeThe EuroPedHp-registry aims to monitor guideline-conform management, antibiotic resistance, and eradication success of 2-week triple therapy tailored to antibiotic susceptibility (TTT) in Helicobacter pylori-infected children.MethodsFrom 2017 to 2020, 30 centres from 17 European countries reported anonymized demographic, clinical, antibiotic susceptibility, treatment, and follow-up data. Multivariable logistic regression identified factors associated with treatment failure.ResultsOf 1605 patients, 873 had follow-up data (53.2% female, median age 13.0 years, 7.5% with ulcer), thereof 741 (85%) treatment naïve (group A) and 132 (15%) after failed therapy (group B). Resistance to metronidazole was present in 21% (A: 17.7%, B: 40.2%), clarithromycin in 28.8% (A: 25%, B: 51.4%), and both in 7.1% (A: 3.8%, B: 26.5%). The majority received 2-week tailored triple therapy combining proton pump inhibitor (PPI), amoxicillin with clarithromycin (PAC) or metronidazole (PAM). Dosing was lower than recommended for PPI (A: 49%, B: 41%) and amoxicillin (A: 6%, B: 56%). In treatment naïve patients, eradication reached 90% (n = 503, 95% CI 87–93%) and 93% in compliant children (n = 447, 95% CI 90–95%). Tailored triple therapy cured 59% patients after failed therapy (n = 69, 95% CI 48–71%). Treatment failure was associated with PAM in single clarithromycin resistance (OR = 2.47, 95% CI 1.10–5.53), with PAC in single metronidazole resistance (OR = 3.44, 95% CI 1.47–8.08), and with low compliance (OR = 5.89, 95% CI 2.49–13.95).ConclusionsGuideline-conform 2-weeks therapy with PPI, amoxicillin, clarithromycin or metronidazole tailored to antibiotic susceptibility achieves primary eradication of ≥ 90%. Higher failure rates in single-resistant strains despite tailored treatment indicate missed resistance by sampling error.

COGMED working memory training in children with Attention Deficit/Hyperactivity Disorder (ADHD): A feasibility study in Saudi Arabia

Working memory training has been proven effective for improving cognitive functioning in patients with Attention Deficit/Hyperactivity Disorder (ADHD). However, the feasibility of this type of training for children in Saudi Arabia has not been previously explored. We investigated the feasibility of implementing Cogmed Working Memory Training (CWMT) in a sample of 29 Saudi children with ADHD. We found no significant demographic or clinical differences between compliant and noncompliant children. Although compliant children were initially better at following instructions and reported better improvements in working memory and math skills compared to those who did not complete the CWMT, all children who participated in the program showed improvements in performing the CWMT tasks. Most parents found the Cogmed training feasible for their children, were satisfied and keen to continue with the program, and felt the training helped them to address their problems. Most children did not encounter any difficulties in using the software, and many families were, therefore, likely to continue using the techniques from the program. We conclude that CWMT for children with ADHD is feasible in Saudi Arabia. Larger case-controlled studies are needed to thoroughly investigate the effects of CWMT compared to other interventions in Saudi children with ADHD.

“My mom just wants to know where I am”: Estonian pre-teens’ perspectives on intimate surveillance by parents

ABSTRACT Inspired by the communication privacy management theory the aim of our study was to explore pre-teens’ viewpoints and experiences related to their parents’ usage of child-tracking technologies. Relying on Q methodology and semi-structured individual interviews with 8- to 13-year-old Estonian pre-teens (n = 20) who were aware of parental tracking, we will present perspectives for understanding children’s viewpoints on intimate surveillance. Three participant perspectives emerged: Compliant Child, Autonomous Child, and Privacy-Sensitive Child. Although children in our sample viewed parents as their confidants and did not consider such tracking to breach their privacy boundaries, they expected these boundaries to be negotiated and collectively set within a family.

Caring dataveillance and the construction of “good parenting”: Estonian parents’ and pre-teens’ reflections on the use of tracking technologies

Abstract Digital parenting tools, such as child-tracking technologies, play an ever-increasing role in contemporary child rearing. To explore opinions and experiences related to the use of such tracking devices, we conducted Q methodology and a semi-structured individual interview-study with Estonian parents (n=20) and their 8- to 13-year-old pre-teens (n=20). Our aim was to study how such caring dataveillance was rationalized within the families, and to explore the dominant parenting values associated with the practice. Relying upon communication privacy management theory, the issues of privacy related to such intimate surveillance were also studied. Three factors relating to the use of tracking technologies were extracted from both parents (Tech-Trusting Parent, Cautious Parent and Careful Authoritarian Parent) and pre-teens (Compliant Child, Autonomous Child, and Privacy-Sensitive Child). Tracking technologies were viewed as parental aids that made it possible to ease anxieties and provide assurance to parents and children alike. Although children did not associate the use of tracking technologies with intrusion on privacy, they expected to have a chance to coordinate their privacy boundaries.

Nasal autoinflation devices for middle ear disease in cleft palate children: are they effective?

SUMMARYObjectiveCleft lip palate (CLP) and cleft palate (CP) patients have a higher incidence of otitis media with effusion (OME) and conductive hearing problems. This article aims to evaluate the effectiveness of a 6-month course of self-administered autoinflation therapy in paediatric CP/CLP patients in terms of conductive hearing loss (CHL) and OME prevalence.MethodsFifty-one patients with surgically corrected CP/CLP and diagnosis of OME received indication to 6-months autoinflation therapy with an Otovent® device. Clinical evaluation, tympanogram and pure tone audiometry were carried out at the time of prescription (T0), at the end of treatment (T1) and at 6-month follow-up (T2). Patients were divided in 2 groups based on therapeutic compliance (29 compliant children, group A, vs 22 non-compliant children, group B).ResultsCase series showed better audiological results and tympanometries at both time points (p < 0.001). Group A showed better outcomes at tympanograms and at each frequency, but were statistically significant only in terms of CHL at 250 and 1000 Hz frequencies at T1 (respectively 0.024 and 0.012).ConclusionsNasal autoinflation therapy accelerates improvement of OME and hearing thresholds at short-/mid-term, leading to an earlier improved hearing performance.

Effect of monocular fixation in binocular field (MFBF) on amblyopia – a pilot study comparing it with patching

ABSTRACT Patching is the gold standard in amblyopia therapy. However, all children are not compliant with patching. We compared the efficacy of 2.5 hours per week of HTS Amblyopia I Net software (Amb I Net) using MFBF principle (delivered under binocular viewing conditions where the amblyopic eye is preferentially stimulated) with 14–42 hours per week of patching therapy. 54 children with anisometropic amblyopia of ages 4–15 years were included in the study – 24 children in the patching and 30 children in the MFBF group. The study ran for a period of 6 months with BCVA assessed at each visit of follow up. In the patching group, visual acuity (VA) gain was 0.37 ± 0.26 log Mar over the course of 6 months with continuous improvement in vision across the three time points (0.20 log mar in the first month, 0.11 log Mar from month1 to 3 and 0.06 log Mar from months 3 to 6).In the Amb I Net group, visual acuity gain was 0.54 ± 0.38 log Mar over the same course of time. A continuous improvement in vision was also noted, with gains of 0.16 in the first month, 0.19 from month 1 to 3 and 0.19 from month 3 to 6. The difference in log Mar gains in VA was not statistically significant between the treatment arms and the final VA was similar (0.25 log Mar for patching and 0.18 log Mar for Amb I net). However, clinically the patching group showed 3 log MAR lines, whereas the MFBF group showed 5 log MAR lines of vision improvement at the end of therapy. MFBF was not superior to patching as far as efficacy is concerned in anisometropic amblyopia. However, the combination of more game options to sustain interest, a shorter duration of therapy over the course of a week and software directed compliance monitoring system favors the Amb I Net system from both patient and parental perspective. Amb I Net also negated discomfort, social stigma, and parental monitoring needed with patching regimens. It can be considered as a good alternative to patching in reluctant/non – compliant children with anisometropic amblyopia. This is the first large cohort study based on this therapy.

Does idiopathic congenital talipes equinovarus have an impact on attainment of developmental milestones? A multicentre international study.

PurposeThe Ponseti method is a well-established approach to treating clubfoot. Potentially, both the underlying pathology and adherence to post-correction bracing can affect lower limb function and age of independent standing and walking. This cohort study investigates the age at which infants with idiopathic clubfoot treated using the Ponseti method achieved three selected developmental milestones and whether or not this correlated with treatment compliance.MethodsA prospectively collected database from four centres was visited. Inclusion criteria were patients with idiopathic clubfoot with no comorbidities or prior treatment. Age at attainment of independent standing, walking, nocturnal continence was compared across three groups: I) congenital talipes equinovarus (CTEV) children compliant with treatment; II) CTEV children non-compliant with treatment; and III) typically-developed siblings. Minimum follow-up was five years.ResultsIn all, 130 patients (198 feet) fitted the inclusion criteria: 43:87 (F:M). Standing was achieved by a mean 12.0 months in group I (sd 2.50); 12.0 months (sd 2.0) in II and ten months (sd 3.0) in III. Walking was achieved by a mean 15 months (sd 4.0) in group I, 14 months (sd 1.75) in II and 12 months (sd 3) in III, respectively. Both the compliant and non-compliant CTEV children were significantly slower at achieving standing and walking compared to sibling controls (p < 0.0001). There was no significant difference between age of nocturnal continence between the three groups.ConclusionInfants with idiopathic clubfoot treated according to the Ponseti method achieve independent standing and walking approximately two months later than their typically-developed siblings. The delay is not related to the use of the foot abduction brace.Level of evidence:III

What do we mean by school entry age? Conceptual ambiguity and its implications: the example of Indonesia

ABSTRACTThe age pattern of school entry reflects a complex social and empirical reality that is inadequately captured by a single number. Recognising these complexities in national and international research and policy discourse raises important but neglected questions around the identification of vulnerable groups, the relative value of pre-primary and primary education, as well as the normative powers and responsibilities of governments vis-à-vis parents, and the international educational community vis-à-vis both. This is illustrated by the example of Indonesia, where the official age norm for primary school entry is widely disregarded in practice, with a majority of children starting school one or even two years earlier. Crucially, it is the compliant children entering at the statutory age who tend to be from more disadvantaged households, and enjoy no benefit in educational outcomes from their greater maturity.

Risk factors for treatment failure and recurrence of anisometropic amblyopia.

The aim of this study was to identify factors associated with failed vision improvement and recurrence following occlusion therapy for anisometropic amblyopia in children aged 7-9years. We retrospectively reviewed the medical records of 64 children aged 7-9years who had been diagnosed as having anisometropic amblyopia and were treated with patching. Functional treatment failure was defined as final visual acuity in the amblyopic eye of worse than 20/32. Improvement of fewer than two logMAR lines was considered relative treatment failure. Recurrence was defined as the reduction of at least two logMAR levels of visual acuity after decreased or discontinued patching. Functional and relative success rates were 51.6 and 62.5%, respectively. The most important factor for functional treatment failure [adjusted odds ratio (OR) (95% confidence interval, CI)11.57 (1.4-95.74)] and the only risk factor for recurrence [adjusted OR (95% CI)3.04 (1.13-8.12)] were the same: high spherical equivalent (SE) of the amblyopic eye. A large interocular difference in the best-corrected visual acuity was found to be a risk factor for both functional and relative failure. High SE of the amblyopic eye was the most influential risk factor for treatment failure and recurrence in compliant children aged 7-9years.

Different Methods Yielded Two-Fold Difference in Compliance with Physical Activity Guidelines on School Days.

IntroductionThe aim was to compare the average and the days method in exploring the compliance of children with physical activity guidelines and describe their physical activity patterns in different school day segments.MethodsPhysical activity was objectively measured in 472 children aged 6–13 for one school week. Children were compliant when fulfilling PA recommendations 1) on average over all measured days (average method) or 2) on at least four measured days (days method). To explore the difference in moderate to vigorous physical activity (MVPA) minutes between compliant and non-complaint children (using both the average and days method) in various day segments, linear mixed models was used.ResultsCompliance with physical activity guidelines was significantly higher with the average compared to the days method (51.7% and 23.7%, respectively). In segmented-day analysis, compliant children accrued more MVPA minutes in all day segments, especially during after-school. Gender differences appeared only during the in-school segments, where girls spent less time in MVPA (average method: -4.39 min, 95% CI = -5.36,-3.42, days method: -4.45 min, 95%CI = -5.46,-3.44). Older children accrued more MVPA minutes during physical education classes, but less during breaks, compared to younger children.ConclusionsThe used methods yielded remarkably different prevalence estimates for compliance to physical activity recommendations. To ensure comparability between studies, interventions and reports, there is a need for internationally agreed operationalization and assessment methods of physical activity guidelines. As non-compliant children had lower MVPA during all day segments, greater efforts should be made to provide physical activity opportunities both during and after school.

Parental Discipline Reactions to Child Noncompliance and Compliance: Association with Parent–Child Aggression Indicators

The present investigation examined whether indicators of parent–child aggression (PCA), including two measures of child abuse potential as well as measures of punishment intentions, use of physical aggression with children, and harsh parenting style, were associated with responses to child noncompliance and compliance on an analog task. Prior research suggests abusive parents demonstrate harsh reactions to child noncompliance but results are more mixed on whether abuse risk parents evidence poor response to child compliance. However, the existing research has relied heavily on methods susceptible to participant response distortion. Analog measures evaluate concepts in a manner that is analogous to the behavior of interest in a way that is less subject to distortion. A new analog procedure, the Response Analog to Child Compliance Task, was utilized to determine parental responses to noncompliance and compliance situations. The present investigation involved three parent samples to evaluate parent analog responses to both child compliance and noncompliance. Overall, this investigation supports that parents evidencing greater PCA risk selected harsher responses to noncompliant child behavior, but the findings were more limited regarding parent responses to child compliance. Results from the three samples imply that perhaps those with higher PCA risk may be likely to also show poorer response to compliant child behavior; however, further research is needed with additional high risk samples, preferably adopting alternatives to self-report methods that are less vulnerable to respondent bias.

A morphological study of amblyopic eyes in children failing to achieve normal visual acuity after electronically monitored long-term occlusion treatment.

To search for morphological abnormalities in compliant unilaterally amblyopic children with poor occlusion treatment outcomes, for the first time with electronically recorded patching dosage. We included school children with remaining interocular logMAR (logarithm of the minimum angle of resolution) difference ≥ 0.3 after patching time of more than 22 months and 1300 h total in a previous prospective study. Six patients with a mean age of 11.19 years were included. Four patients had anisometropic amblyopia and two patients had a mixed strabismic and anisometropic amblyopia. Best-corrected visual acuity, cycloplegic refraction, dilated fundus examination, optic disc morphology and macular thickness using optical coherence tomography (OCT), retinal visual acuity, color perception, and the presence of a relative afferent pupillary defect (RAPD) were assessed. Paired t tests were performed to compare optic disc values and macular thickness of the amblyopic eyes to those of the fellow eyes. Average (± SD) logMAR VA in the amblyopic eyes was 0.42 (±0.23) with a remaining average interocular difference (IOD) of 0.51 (± 0.23), despite electronically monitored occlusion treatment of more than 1300 h. All patients presented with hyperopia and a significantly different mean spherical equivalent of + 4.73 (± 2.73) D in the amblyopic eye compared with the fellow eye (p = 0.02). A statistically significant difference in macular thickness was found between amblyopic and fellow eyes, with amblyopic eyes having an increased average thickness (p = 0.0062) and total volume (p = 0.0091) of the macula. One patient had familial hereditary primary macrodisc in both eyes. Our results provide evidence that average macular thickness and total macular volume tended to be increased among these compliant amblyopic children with unsatisfactory occlusion treatment outcomes. Further studies are warranted to evaluate whether morphological changes may have an impact on the effectiveness of amblyopia treatment. Moreover, our findings suggest that greater magnitude of hyperopia and anisometropia as well as older age may be risk factors associated with a poor visual acuity outcome among compliant amblyopic children.

Evaluation of the impact of celiac disease and its dietary manipulation on children and their caregivers.

Lifelong dietary abstinence of gluten is the only treatment available for celiac disease. This is not only challenging but also leads to several psychosocial morbidities and affects the quality of life of children and their parents. An observational study was conducted on 50 children (5-18 years) diagnosed with celiac disease on gluten-free diet for at least 6 months and their parents to evaluate of the impact of celiac disease and its dietary manipulation on them. The quality of life was assessed by applying celiac disease-specific questionnaire. Dietary compliant and noncompliant groups were compared to assess the factors leading to poor compliance. Anthropometric parameters were utilized to ascertain clinical response. Fifty children with a mean age of 9.06 years were enrolled. Seventy-four percent of the children were compliant. In the compliant group, height and weight correlated with dietary compliance (p = 0.0087 and p = 0.023). Dietary compliance was found to be better in adolescent males and single child and those living in nuclear families. Quality of life was found to be higher among parents of noncompliant children (quality of life score: 63) as compared to the compliant children (quality of life score: 59). The acceptance of celiac disease was better among children whose parents had a higher level of education. The scale diet proved to be a useful indicator for evaluating compliance among children (p = 0.0036). Noncompliance to gluten-free diet was noted in 24 % of children with celiac disease.

Maternal Depression History Moderates Parenting Responses to Compliant and Noncompliant Behaviors of Children with ADHD.

Maternal depression and parenting are robust predictors of developmental outcomes for children with attention-deficit/hyperactivity disorder (ADHD). However, methods commonly used to examine parent-child interactions in these families do not account for temporal associations between child and parent behavior that have been theorized to maintain negative child behavior. Moreover, studies examining associations between maternal depression and parenting in families of children with ADHD have not compared mothers who were currently depressed, remitted, and never clinically depressed. This study utilized sequential analysis to examine how maternal reinforcement of compliant and noncompliant child behavior differs as a function of maternal depression history. Within the 82 participating mother-child dyads, 21 mothers were currently depressed, 29 mothers had a lifetime history of depression but were in remission for at least 1month, and 32 mothers had never been clinically depressed. 24 girls (29.6%) and 57 boys (70.4%) between the ages of 6-12years old (M = 8.7, SD = 2.0) and were diagnosed with ADHD. Results indicated that all mothers were less likely to respond optimally than non-optimally to child compliant and noncompliant behaviors during observed parent-child interactions; however, currently depressed mothers were least likely to reinforce child compliance and responded most coercively to child noncompliance relative to the other groups. Remitted mothers in this sample were more coercive than never clinically depressed mothers, but were more likely to follow through with commands than never clinically depressed mothers. Implications for behavioral parent training programs aimed at skill development for depressed mothers of children with ADHD are discussed.

Acquaintance molestation and youth-serving organizations.

This article is based not only on the research literature but also on the extensive field experience of the authors in consulting with investigators, attorneys, and organizations on the prevention, investigation, prosecution, and civil litigation of molestation of children within or in connection with youth-serving organizations. Acquaintance molesters have often pursued careers or sought out paid or volunteer work with organizations through which they can meet children. To address the problem of such offenders, it is necessary for youth-serving organizations to recognize the diversity of sexual activity, the phenomena of "nice-guy" offenders and compliant child victims, and the grooming/seduction process, each of which is reviewed here. The four most important protection practices for organizations are screening; management, and supervision; response to suspicions, allegations, and complaints; and prevention and awareness programs. The authors recommend general approaches to each of these and describe the reasons many organizations resist implementing available preventive measures.

Urinary concentration of 8-isoprostane as marker of severity of pediatric OSAS

F2-isoprostanes are considered to be a reliable standard biomarker of oxidative stress in vivo because they are not influenced by the intake of lipids in the diet, and they are chemically stable molecules and easily detected. This study aimed to test the hypothesis that 8-isoprostane level is a useful marker to valuate the severity of pediatric obstructive sleep apnea (OSA). Sixty-five children with sleep-disordered breathing (SDB) (mean age 5.9±2.0 years; 63.1% males) were recruited. The urine sample for the measurement of 8-isoprostane was collected the morning after the polysomnographic recording. Children were divided into two groups according to their apnea-hypopnea index (AHI). Urinary 8-isoprostane levels positively correlated with the sleep clinical record score (r=0.38, p=0.002) and AHI (r=0.24, p=0.05) and negatively correlated with age (r=-0.36, p=0.003) and body surface area (r=-0.38, p=0.002). Urinary 8-isoprostane levels were significantly higher in the group with AHI of ≥5 events (ev)/h than in the group with AHI of <5 ev/h (p<0.01). Urinary 8-isoprostane may be used as a specific inflammatory marker to predict the severity of OSA; this method has the advantage of being noninvasive and easy to use in both compliant and noncompliant children.

Factors associated with spectacle-wear compliance among school children of 7-15 years in South India

Background: Easily correctable refractive errors are the commonest cause of visual impairment in school children in India. Children who need but cannot afford spectacle correction are high in our country. Important factor for the success of the corrective services is compliance to spectacle wear. Objective: To assess the spectacle wear compliance among school children who were provided spectacle free of cost. To study the determinants of spectacle acceptance and reasons for non compliance. Materials and Methods: All (1378) government school children of 7-15 years age group in both rural and urban field practice areas of a medical college in Bangalore were screened and students with refractive error were provided spectacles free of cost. An unannounced follow up was done after 3 months to assess compliance. Data was analyzed to determine the factors associated with spectacle wear compliance. Results: Among 36 boys and 47 girls who received spectacles free of cost, 31 were from rural and 52 from urban schools. 48(57.8%) children were actually wearing the spectacles at the time of follow up. 42(87.5%) compliant children reported improvement of performance in school related activities. Compliance was better in younger children and those from urban schools. Children of father with lower level of education and with power -0.5D were more likely to be non compliant. Conclusion: To achieve the goal of vision 2020 timely detection of refractive errors should be followed by cost effective intervention. The barriers to spectacle acceptance should be studied and addressed.

SURVIVAL AND BETTERMENT: THE ASPIRATIONS OF FOUR MEDIEVAL GENTRY FAMILIES AS REVEALED IN THEIR LETTERS

Covering the period 1290–1584, the Paston, Plumpton, Cely and Stonor letters, although for the most part ‘business letters’, concerned with the administration of their households and estates, nevertheless throw fascinating light on aspects of contemporary society. They reveal that the lives of those who strove to survive and prosper as landowning gentry were played out against a background of civil war, violent Scottish incursions over the northern borders, and military reversals in France. Closer to home, they struggled with predatory lords, tight-fisted dowagers, disgruntled sons, wretched daughters and bitterly contested wills.Faced with many imponderables, they marshalled their defences: judicious marriages and kinship networks, compliant children, the patronage of influential magnates – perhaps even of the king himself, such protection as was afforded by the law and unceasing vigilance.Parental affection and true love and devotion also find welcome expression among what were severely practical concerns.