East Asian Children Research Articles

False-positive SARS-CoV-2 serology in 3 children with Kawasaki disease

BackgroundKawasaki disease (KD) is an acute febrile and eruptive disease with systemic vasculitis predominantly affecting young East Asian children. Recent reports showed that children with KD-like disease from KD low prevalence regions had positive SARS-CoV-2 serology despite a negative SARS-CoV-2 polymerase chain reaction (PCR) in respiratory samples. ObjectivesTo describe 3 pediatric Kawasaki Disease patients with false positive SARS-CoV-2 serology. Study designWe retrospectively recruited children with KD diagnosed during the COVID-19 outbreak in Hong Kong. Clinical characteristics and laboratory test results including SARS-CoV-2 PCR results were retrieved. We performed a microparticle-based immunoassay for the detection of IgG against nucleoprotein (NP) and spike protein receptor binding domain (RBD), and a microneutralization assay for the detection of neutralizing antibodies. ResultsThree Chinese children with typical KD were identified. They had no epidemiological links with COVID-19 patients and tested negative for SARS-CoV-2 NPA PCR. They were treated with IVIG and aspirin, and were discharged without complications. Subsequently 2 of them were tested positive against anti-RBD and anti-NP antibodies and 1 was tested positive against anti- RBD antibodies. However, microneutralization assay showed that neutralizing antibodies were absent, suggesting a false-positive IgG result. ConclusionDetection of neutralizing antibodies is recommended to confirm previous SARS-CoV-2 infection in IgG-positive but PCR-negative patients.

Abstract A04: Childhood cancer incidence among specific Asian and Pacific Islander populations in the U.S.

Abstract Background: We sought to explore variation in childhood cancer incidence rates among specific Asian and Pacific Islander (API) groups. Despite high genetic diversity in this region of the world, API groups in the United States are often combined into a single race/ethnic group. Methods: The Surveillance, Epidemiology, and End Results (SEER) Detailed Asian/Pacific Islander (2000-Centered) data was used for this analysis. Cancer diagnoses occurring between January 1998 to December 2002 from 14 SEER registries were included. Detailed racial/ethnic population data from the 2000 census was used to calculate incidence rates for individual races with at least 500,000 individuals. We also combined this data into groups based on geographic regions and genetic similarity, which included East Asia (China, Japan, Korea; n=377 cases), Southeast Asia (Vietnam, Laos, Cambodia; n=136 cases), Asian Indian/Pakistan (n=163 cases), Oceania (Guam, Samoa, Tonga; n=29 cases), and the Philippines (n=199 cases). Incidence rate ratios (IRR) and 95% confidence intervals (CI) were calculated comparing each API regional group to non-Hispanic Whites (NHW), and each API regional group to East Asians. Results: Incidence rates among detailed Asian and Pacific Islander groups varied. Acute lymphoblastic leukemia (ALL) was significantly lower in children of SE Asian (IRR 0.59, 95% CI 0.42, 0.82) and Filipino (IRR 0.73, 95% CI 0.57, 1.00) descent compared to non-Hispanic Whites. Acute myeloid leukemia (AML) was more common among children from Oceania compared to NHW (IRR 3.44, 95% CI 1.63, 7.28). Central nervous system (CNS) cancers were less common among East Asian (IRR 0.74, 95% CI 0.58, 0.96), SE Asian (IRR 0.45, 95% CI 0.28, 0.73), and Filipino (IRR 0.48, 95% CI 0.32, 0.72) children compared to NHW. When comparing the incidence of cancers among API regions, few clear patterns emerged. The incidence of AML in children from Oceania was nearly four times that in East Asians (IRR 3.88, 95% CI 1.64, 9,.11), though roughly the same among all other regions. The incidence rates of ALL (IRR 0.63, 95% CI 0.41, 0.97) and malignant gonadal germ cell tumors (IRR 0.29 95% CI 0.08, 0.97) were lower in SE Asians compared to East Asians. Lymphoma was twice as common in Asian Indians/Pakistani children compared to East Asians (IRR 2.13, 95% CI 1.33, 2.29). Conclusions: The variation observed in cancer incidence patterns among these groups is important and may indicate differences in underlying etiology and/or exposure patterns. These findings highlight possible disparities in cancer incidence between specific API groups. Citation Format: Kristin J. Moore, Aubrey K. Hubbard, Lindsay A. Williams, Logan G. Spector. Childhood cancer incidence among specific Asian and Pacific Islander populations in the U.S. [abstract]. In: Proceedings of the AACR Special Conference on the Advances in Pediatric Cancer Research; 2019 Sep 17-20; Montreal, QC, Canada. Philadelphia (PA): AACR; Cancer Res 2020;80(14 Suppl):Abstract nr A04.

Western Australia Atropine for the Treatment of Myopia (WA‐ATOM) study: Rationale, methodology and participant baseline characteristics

Atropine eyedrops are a promising treatment for slowing myopia progression in East Asian children. However, its effects on children in Australia, including those of non-Asian background, have not been well-studied. The Western Australia Atropine for the Treatment of Myopia (WA-ATOM) study aims to determine the efficacy and long-term effects of low-dose atropine eyedrops in myopia control. This paper describes the study rationale, methodology and participant baseline characteristics. Single-centre, double-masked, randomized controlled trial. Children (6-16 years) with spherical equivalent ≤-1.50 D in each eye, astigmatism ≤1.50 D and myopia progression by ≥0.50 D/year. Enrolled children were randomly assigned 2:1 to receive 0.01% atropine or placebo eyedrops. Participants are examined every 6 months during first 3 years of the study (2-year treatment phase followed by a 1-year washout phase), and then at a 5-year follow-up (2 years after the end of the washout phase). Annual progression rate of myopia and axial length, tolerability to eyedrops and incidence and severity of unwanted effects. Out of 311 children who were referred, 242 were suitable for study participation, and 153 were subsequently enrolled. The baseline characteristics of enrolled participants are presented. Outcomes of the WA-ATOM study will inform on the efficacy, tolerability, safety and long-term effects of low-dose atropine eyedrops in myopia control in Australian children. The impact of ocular sun exposure, iris colour and parental myopia on the efficacy of low-dose atropine will also be assessed.

3 Cases of Acute necrotizing encephalopathy,is this an epidemic or just an incidental?

Acute necrotizing encephalopathy of childhood (ANEC) is a disease, characterized by a respiratory or gastrointestinal infection, accompanied with fever, rapid alteration of consciousness, and seizures. The clinical characteristics of ANEC include acute encephalopathy following a viral infection, seizure, altered consciousness, and absence of cerebrospinal fluid (CSF) pleocytosis, with an occasional increase in the level of proteins. This disease is almost exclusively seen in previously healthy infants and children from East Asia. Serial magnetic resonance imaging (MRI) examinations have demonstrated symmetric lesions involving the thalami, brainstem, cerebellum, and white matter. ANEC has a poor prognosis with high morbidity and mortality rates. Herein, we present three cases of ANEC, who were referred to Bu-Ali Hospital of Ardabil, Iran during two weeks. Report of these three cases promoted the idea of an epidemic. The purpose of this case series was to raise the issue that ANEC may occur as an epidemic.

Human Herpesvirus 7-Related Acute Encephalopathy with Biphasic Seizures and Late Reduced Diffusion

Acute encephalopathy with biphasic seizures and late reduced diffusion (AESD) is a recently described entity so far exclusively in East Asian children. AESD diagnosis is based on clinicoradiologic criteria, often without pleocytic CSF and characterized by hyperglycemia and transaminasemia. Here, we present the first case of human herpesvirus 7-related AESD in an immunocompetent child >2 years old and of Caucasian origin.

Electroencephalographic features in pediatric patients with moyamoya disease in China

BackgroundMoyamoya disease (MMD) is a relatively important and common disease, especially in East Asian children. There are few reports about EEG in children with MMD in China till now. This study is aimed to analyze the electroencephalographic features of MMD in pediatric patients in China preliminarily.MethodsPediatric patients with MMD who were hospitalized in Peking University International Hospital and Beijing Tiantan Hospital from January 2016 to December 2018 were collected. Clinical and electroencephalography (EEG) findings were analyzed retrospectively.ResultsA total of 110 pediatric patients with MMD were involved, and 17 (15.5%) cases had a history of seizure or epilepsy. Ischemic stroke was associated with a 1.62-fold relative risk of seizure. A subset of 15 patients with complete EEG data was identified. Indications for EEG in patients with MMD included limb shaking, unilateral weakness, or generalized convulsion. Abnormal EEG was seen in 14 (93.3%) cases, with the most common findings being focal slowing 12 (80.0%), followed by epileptiform discharge 10 (66.7%), and diffuse slowing 9 (60.0%). “Re-build up” phenomenon on EEG was observed in one patient.ConclusionsSeizure and abnormal background activity or epileptiform discharge on EEG were common in pediatric patients with MMD. EEG may play a role in differential diagnosis among the transient neurological events in MMD such as transient ischemic attack and seizure.

A 7-year follow-up study on untreated deep or mixed facial infantile hemangioma in East-Asian patients: When propranolol was not yet an option.

Infantile hemangioma (IH) is a type of benign tumor that develops during infancy and spontaneously involutes after 1year of age. Before the introduction of propranolol in 2008, some patients with IH were instructed to wait for the involution without treatment. This long-term follow-up study was conducted to assess the prognosis of East-Asian children with untreated deep or mixed facial IH. Skin sequelae were assessed by comparing images obtained during the patients' first and last visits in our clinic. Possible factors were assessed for their association with IH prognosis. The mean follow-up time was 7.4years. Among the 48 patients with deep or mixed facial IH, 26 (54%) achieved complete involution without sequelae and 22 encountered various sequelae, including telangiectasia (36.3%), fibrofatty residue (68.2%), and scars (4%). The complete regression rate of deep or mixed IH occurring in the central facial region was significantly lower than for those in the perifacial region (33.3% vs 66.7%, respectively, χ2 , P=0.025). Further, the most common sequelae in this area are fibrofatty residue.

The development and validation of the Emotional Cultivation Scale: An East Asian cultural perspective.

Research on emotion regulation in East Asian children and adolescents is limited. One obstacle hindering the development of emotion regulation for East Asian children and adolescents is the lack of a culturally sensitive measure. To fill this gap, we have developed and validated the Emotional Cultivation Scale using samples of Taiwanese children and adolescents. In Study 1, an exploratory factor analysis (n = 341) identified two factors: Cultivating Emotion Strategies and Understanding Emotion Connotations. A confirmatory factor analysis (n = 358) confirmed this two-factor structure. Coefficient αs were .69 to .88 for Emotional Cultivation. Convergent validity was evidenced by positive associations with cognitive reappraisal and cognitive flexibility. Discriminant validity was supported by a nonsignificant association with suppression. Concurrent validity was revealed by positive associations with positive affect, basic psychological need satisfaction, gratitude, responsiveness from teachers, responsiveness from parents, and academic self-efficacy. Incremental validity was evidenced by the finding that emotional cultivation significantly accounted for an additional 2 to 20% of the variance in predicting cognitive flexibility, positive affect, basic psychological need satisfaction, gratitude, responsiveness from teachers, responsiveness from parents, and academic self-efficacy above and beyond cognitive reappraisal and suppression. Results from the multigroup analysis further indicated factor loading invariance and validity invariance between boys and girls and between elementary and middle schools. The factor structure was cross-validated by a clinical sample of Taiwanese children and adolescents (N = 161) and their parents in Study 2 (N = 159). The counseling implications were discussed. (PsycINFO Database Record (c) 2019 APA, all rights reserved).

Novel PANK2 mutation discovered among South East Asian children living in Thailand affected with pantothenate kinase associated neurodegeneration

Pantothenate kinase-associated neurodegeneration (PKAN) is linked to brain iron accumulation caused by PANK2 gene mutation. Despite the importance of genetic testing to confirm PKAN and identify at risk parents, genetic screening is financially burdensome for developing countries like Thailand. Because genetic screeners are expensive and not reimbursed by the universal health care coverage system, they are not typically performed. To investigate clinical symptoms, radiological findings and mutation analysis for patients based in Thailand with unknown genetic status but suspected PKAN based on clinical symptoms. Genetic testing was performed for cases suspected for PKAN and their biological parents by direct genomic sequencing of PANK2 at Maharat Nakhon Ratchasima Hospital during 2017–2018. Clinical evaluation and documentation were performed by pediatric neurologists. Five children had classical onset form of PKAN. Most presented with gait dystonia. Three patients diagnosed after 4 years showed the eye-of-the-tiger sign in their brain MRI, whereas two younger patients revealed only isolated hyperintensity bilateral globus pallidus. However, PANK2 mutations were identified in all cases: the most common mutation was c.982-1G>C. This mutation was detected in four unrelated individuals but not reported in other studies. Genetic testing is recommended to confirm diagnoses in cases with supporting clinical features of PKAN with or without the classical ‘eye-of-the-tiger-sign’. A novel PANK2 mutation (c.982-1G>C) was identified in South East Asian populations based in Thailand, suggesting that this genetic variant is a founder genotype in this population. Moreover, genetic diagnosis is helpful to provide appropriate genetic counseling to families.

A cross-cultural examination of selective attention in Canada and Japan: The role of social context

Previous studies have found that East Asian children outperform Western children on executive function tasks; however, cultural differences may depend on the task demands. Particularly, East Asian children may have difficulties in regulating attention within social contexts. Selective attention was tested among four- to seven-year-old Canadian (N = 62) and Japanese (N = 54) children using two Flanker task variants: (a) Social Flanker (i.e., happy/sad faces) and (b) standard Fish Flanker (i.e., right/left) tasks. In the Social Flanker task, Japanese children’s performance was more impaired by flanker interference than that of Canadian children. While the interference effect was similar across cultures in the Fish Flanker task, Japanese children had an overall better performance than Canadian children. In both cultures, the older children (ages 6–7) performed better than the younger children (ages 4–5). These results suggest the importance of social contexts in understanding cultural differences in the development of cognitive control.

Ascending versus Descending Timers: Stress and Motivation

In 2019, the largest population increase occurred as Canada’s population grew by 208, 234 (0.6%) with the majority of people being immigrants and non-permeant residents (Statistics Canada, 2019). Population growth was highest in British Columbia (+0.7%) with the greatest immigrant population coming from China, Hong Kong, South Korea, and Taiwan (Statistics Canada, 2019; Statistics Canada, 2017). The mixing of East Asian and Canadian cultures is not easy and can sometimes be conflicting for children of East Asian immigrants. This paper aims to gain a better understanding of the acculturation gap, intergenerational conflict, coping strategies, and how these experiences may influence future parenting behaviours of East Asian children raised in North American.

(Re)Landscaping early childhood education in East Asia: A neoliberal economic and political imaginary

This article unpacks how neoliberal discourse functions as a dominant but problematic system of reasoning that changes and shifts the ways in which we come to think about early childhood education and care. A post-structuralist lens is deployed to understand the production of fears and hopes under the looming shadows of contemporary education reforms and social policies. Highlighting Taiwan, Hong Kong and Korea as three cases from East Asian cultures, this article seeks to elucidate how a similar neoliberal economic and political imaginary is at work to (re)construct East Asian children as human capital for the alchemy of productive citizens in the 21st century.

A longitudinal study of the infant nasopharyngeal microbiota: The effects of age, illness and antibiotic use in a cohort of South East Asian children

A longitudinal study was undertaken in infants living in the Maela refugee camp on the Thailand-Myanmar border between 2007 and 2010. Nasopharyngeal swabs were collected monthly, from birth to 24 months of age, with additional swabs taken if the infant was diagnosed with pneumonia according to WHO clinical criteria. At the time of collection, swabs were cultured for Streptococcus pneumoniae and multiple serotype carriage was assessed. The bacterial 16S rRNA gene profiles of 544 swabs from 21 infants were analysed to see how the microbiota changes with age, respiratory infection, antibiotic consumption and pneumococcal acquisition. The nasopharyngeal microbiota is a somewhat homogenous community compared to that of other body sites. In this cohort it is dominated by five taxa: Moraxella, Streptococcus, Haemophilus, Corynebacterium and an uncharacterized Flavobacteriaceae taxon of 93% nucleotide similarity to Ornithobacterium. Infant age correlates with certain changes in the microbiota across the cohort: Staphylococcus and Corynebacterium are associated with the first few months of life while Moraxella and the uncharacterised Flavobacteriaceae increase in proportional abundance with age. Respiratory illness and antibiotic use often coincide with an unpredictable perturbation of the microbiota that differs from infant to infant and in different illness episodes. The previously described interaction between Dolosigranulum and Streptococcus was observed in these data. Monthly sampling demonstrates that the nasopharyngeal microbiota is in flux throughout the first two years of life, and that in this refugee camp population the pool of potential bacterial colonisers may be limited.

Ethnic variations in mercury exposure from seafood consumption and the risk of Kawasaki disease in young children

Kawasaki disease (KD) is an acute febrile illness predominately affecting children <5 years that can result in serious cardiovascular complications such as coronary artery lesion formation. The cause of KD remains unknown 50 years after Kawasaki first described the illness in Japan, while KD has since replaced rheumatic fever as the leading cause of acquired heart disease for children in the developed world. KD has become the most commonly diagnosed pediatric vasculitis with the highest incidence rates of KD reported from East Asian countries such as Japan, Korea, and Taiwan. Even when residing in Western nations, East Asian children still have 10 to 20 times the risk of developing KD than children of other ethnicities. Speculation that genetic differences between ethnic groups account for the ethnic disparity in KD rates led to the discovery and confirmation of numerous susceptibility loci, although these risk alleles only appear to confer risk passively to the currently unknown environmental triggers of KD. Previously, we described how ITPKC susceptibility in KD patients would render these individuals vulnerable to mercury (Hg)‐induced autoimmunity through the induction of intracellular calcium release with downstream effects upon cell signaling, immune proliferation, and gene expression via the Ca2+/NFAT pathway. This led us to hypothesize that the ethnic disparities in KD risk may be accounted for by variations in Hg exposure rates, particularly from significant differences in total methylmercury (MeHg) intake from seafood. We examined two separate cohorts that were nationally representative of either KD hospitalization rates or toxic metal concentrations in the blood in our initial investigations. Our results demonstrated that increasing ethnic KD risk between Caucasian, Hispanic, Black, and Asian children was significantly associated with average blood levels and detection rates of Hg or cadmium (Cd) but not lead (Pb), manganese (Mn), or selenium (Se). In our most recent investigations using the same two datasets, we observed that ethnic KD risk was significantly associated with increasing consumption of total fish and seafood but not shellfish. Further examinations by Hg type demonstrated that MeHg from seafood is the primary source of blood Hg in children, while average blood MeHg levels but not inorganic or ethylmercury were significantly associated with increasing ethnic KD risk. Lastly, ethnic KD risk was significantly associated with molar ratios of Hg and Se in the blood that are indicative of seafood consumption. We conclude that Hg exposure particularly from seafood consumption may increase susceptibility for the development of KD in young children or trigger the disease, itself. However, our hypothesis requires determinations of blood Hg levels and cumulative Hg exposure such as from dietary seafood intake in KD patients, which are currently lacking and that we are presently examining.Support or Funding InformationNone

High incidence of idiopathic nephrotic syndrome in East Asian children: a nationwide survey in Japan (JP-SHINE study).

Little is known regarding the epidemiology of idiopathic nephrotic syndrome (INS) in East Asia. Previous studies have suggested higher incidence of INS in Asian children, though decreasing trend of its incidence has also been shown. We conducted a nationwide study of Japanese children aged 6months to 15years with INS. Children who were newly diagnosed with INS between 1 January 2010 and 31 December 2012 were eligible. Children with congenital nephrotic syndrome or nephrotic syndrome secondary to nephritis were excluded. A total of 2099 children were initially diagnosed with INS and were followed for up to 4years. The estimated incidence of INS was 6.49 cases/100,000 children per year, without clear correlation with geographical region. The male:female ratio was 1.9 and approximately 50% of children were<5years old at diagnosis. During the 1-4years follow-up, 32.7% developed frequently relapsing nephrotic syndrome and steroid-dependent nephrotic syndrome. Based on our nationwide survey, the incidence of INS in Japanese children is approximately 3-4 times higher than that in Caucasians. However, the male:female ratio and the age at onset were similar to those in previous studies. We are now planning a prospective cohort study to examine the course of INS in Japan.

Management of epiblepharon: state of the art.

Epiblepharon is prevalent in East-Asian children. As the population in Asia is increasing, so is the demand for epiblepharon surgery. Surgeons should be familiar with the standards of beauty and needs of Asian people for epiblepharon management. This review provides a comprehensive summary of the published studies on the clinical manifestations, pathophysiology, and management of epiblepharon. Astigmatism is prevalent in epiblepharon patients, which can contribute to amblyopia. Early surgery and visual rehabilitation is important for epiblepharon patients with a high degree of astigmatism and amblyopia. Various etiologic factors play a role in the pathophysiology of epiblepharon. Surgical procedures focusing on creation of a lower eyelid crease have been popular for treating epiblepharon in Western textbooks; however, this is not appropriate for Asian patients in whom, a crease may be undesirable. In selecting surgical methods, it is important to resect a minimal amount of skin-muscle to avoid the adverse effects of ectropion and eyelid retraction. Although epiblepharon may resolve with facial growth, surgical correction is needed for cases in which there is significant corneal injury from the lash touch. Surgical management should focus on techniques that are effective, with little chance of complication, and do not create a lower eyelid crease.

Length and height percentiles for children in the South-East Asian Nutrition Surveys (SEANUTS).

Health and nutritional information for many countries in the South-East Asian region is either lacking or no longer up to date. The present study aimed to calculate length/height percentile values for the South-East Asian Nutrition Survey (SEANUTS) populations aged 0·5-12 years, examine the appropriateness of pooling SEANUTS data for calculating common length/height percentile values for all SEANUTS countries and whether these values differ from the WHO growth references. Data on length/height-for-age percentile values were collected. The LMS method was used for calculating smoothened percentile values. Standardized site effects (SSE) were used for identifying large or unacceptable differences (i.e. $\mid\! \rm SSE \!\mid$ >0·5) between the pooled SEANUTS sample (including all countries) and the remaining pooled SEANUTS samples (including three countries) after weighting sample sizes and excluding one single country each time, as well as with WHO growth references. Malaysia, Thailand, Vietnam and Indonesia. Data from 14202 eligible children were used. From pair-wise comparisons of percentile values between the pooled SEANUTS sample and the remaining pooled SEANUTS samples, the vast majority of differences were acceptable (i.e. $\mid\! \rm SSE \!\mid$ ≤0·5). In contrast, pair-wise comparisons of percentile values between the pooled SEANUTS sample and WHO revealed large differences. The current study calculated length/height percentile values for South East Asian children aged 0·5-12 years and supported the appropriateness of using pooled SEANUTS length/height percentile values for assessing children's growth instead of country-specific ones. Pooled SEANUTS percentile values were found to differ from the WHO growth references and therefore this should be kept in mind when using WHO growth curves to assess length/height in these populations.

Effect of ethnicity and socioeconomic variation to the gut microbiota composition among pre-adolescent in Malaysia.

Gut microbiota plays an important role in mammalian host metabolism and physiological functions. The functions are particularly important in young children where rapid mental and physical developments are taking place. Nevertheless, little is known about the gut microbiome and the factors that contribute to microbial variation in the gut of South East Asian children. Here, we compared the gut bacterial richness and composition of pre-adolescence in Northern Malaysia. Our subjects covered three distinct ethnic groups with relatively narrow range of socioeconomic discrepancy. These included the Malays (n = 24), Chinese (n = 17) and the Orang Asli (indigenous) (n = 20). Our results suggested a strong ethnicity and socioeconomic-linked bacterial diversity. Highest bacterial diversity was detected from the economically deprived indigenous children while the lowest diversity was recorded from the relatively wealthy Chinese children. In addition, predicted functional metagenome profiling suggested an over-representation of pathways pertinent to bacterial colonisation and chemotaxis in the former while the latter exhibited enriched gene pathways related to sugar metabolism.

Characterization of ethnicity among children with eosinophilic esophagitis in British Columbia, Canada

Characterization of ethnicity among children with eosinophilic esophagitis in British Columbia, Canada

Why do East Asian children perform so well in PISA? An investigation of Western-born children of East Asian descent

A small group of high-performing East Asian economies dominate the top of the Programme for International Student Assessment (PISA) rankings. This has caught the attention of Western policymakers, who want to know why East Asian children obtain such high PISA scores, and what can be done to replicate their success. In this paper I investigate whether children of East Asian descent, who were born and raised in a Western country (Australia), also score highly on the PISA test. I then explore whether their superior performance (relative to children of Australian heritage) can be explained by reasons often given for East Asian students’ extraordinary educational achievements. My results suggest that second-generation East Asian immigrants outperform their native Australian peers by approximately 100 test points. Moreover, the magnitude of this achievement gap has increased substantially over the last ten years. Yet there is no ‘silver bullet’ that can explain why East Asian children obtain such high levels of academic achievement. Rather a combination of factors, each making their own independent contribution, seem to be at play. Consequently, I warn Western policymakers that it may only be possible to catch the leading East Asian economies in the PISA rankings with widespread cultural change.