Japanese School-aged Children Research Articles

Effects of wearing an opaque or transparent face mask on the perception of facial expressions: A comparative study between Japanese school-aged children and adults.

The negative side effects of mask-wearing on reading facial emotional cues have been investigated in several studies with adults post-2020. However, little is known about children. This study aimed to determine the negative influence of mask-wearing on reading emotions of adult faces by Japanese school-aged children, compared to Japanese adults. We also examined whether this negative influence could be alleviated by using a transparent face mask instead of an opaque one (surgical mask). The performance on reading emotions was measured using emotion categorization and emotion intensity rating tasks for adult faces. As per the findings, the accuracy of emotion recognition in children was impaired for various facial expressions (disgust, fear, happy, neutral, sad, and surprise faces), except for angry faces. Conversely, in adults, it was impaired for a few facial expressions. The perceived intensity for happy faces with a surgical mask was weaker in both children and adults than in those without the mask. A negative influence of wearing surgical masks was generally not observed for faces wearing a transparent mask in both children and adults. Thus, negative side effects of mask-wearing on reading emotions are observed for more facial expressions in children than in adults; transparent masks can help remedy these.

Gakuryoku, shinri, katei kankyō no keizai bunseki: Zenkoku shōchūgakusei no tsuiseki chōsa kara miete kita mono (An Economic Analysis of Academic Ability, Non-cognitive Ability, and Family Background: Primary Findings from a Panel Survey of Japanese School-Age Children)

Gakuryoku, shinri, katei kankyō no keizai bunseki: Zenkoku shōchūgakusei no tsuiseki chōsa kara miete kita mono (An Economic Analysis of Academic Ability, Non-cognitive Ability, and Family Background: Primary Findings from a Panel Survey of Japanese School-Age Children)

Estimating the Prevalence of Specific Learning Disorder, Attention-Deficit/Hyperactivity Disorder, and Autism Spectrum Disorder in Japanese School-Age Children Who Stutter

Purpose: This study aimed to predict special educational needs in children who stutter (CWS) using a screening test for three neurodevelopmental disorders (specific learning disorder [SLD], attention-deficit/hyperactivity disorder [ADHD], and autism spectrum disorder [ASD]). While most previous studies have been conducted by speech-language pathologists, this study was conducted in an educational setting. Additionally, we investigated correlations between children's scores in scales for assessing neurodevelopmental disorders and stuttering severity. Method: Participants were 116 CWS (ages 6–12 years) from resource rooms for speech-language disorders in Japan. Speech-language teachers in resource rooms were asked to evaluate CWS and respond to the Learning Disabilities Inventory–Revised, ADHD Rating Scale, and Autism Spectrum Screening Questionnaire. Results: We received 90 valid responses with no missing values. Among them, 32 (35.5%) children were judged as having difficulties related to SLD, ADHD, and ASD in school life. Among them, 23 (25.6%) were SLD suspected, 12 (13.3%) were ADHD suspected, and nine (10.0%) were ASD suspected. Difficulty in speaking, writing, math, and hyperactivity/impulsivity was significantly and positively correlated with stuttering severity. Moreover, in the group of CWS with suspected neurodevelopmental disorders, the distribution of scores related to SLD was skewed toward high scores. Conclusions: CWS in this study showed higher rates of suspected SLD, ADHD, and ASD within a school setting compared with the rates for typically developing children surveyed in Japan in 2012 through another prior study. In addition, the effect of stuttering severity on academic skills is discussed.

Changes in self-efficacy in Japanese school-age children with and without high autistic traits after the Universal Unified Prevention Program: a single-group pilot study

BackgroundResearch has shown the efficacy of school-based programs for mental health problems in children. However, few studies have focused on the strengths of children, such as resilience, which is essential in preventing mental health problems. Moreover, no research has investigated the effect of a universal school-based program on children with increased autistic traits in mainstream classes. We examined the changes in children's self-efficacy, social skills, and general mental health after the implementation of a newly developed universal program, the Universal Unified Prevention Program for Diverse Disorders (Up2-D2), and whether similar changes occurred in children with and without higher autistic traits.MethodsTo assess possible changes associated with the program, questionnaires were collected from 396 children (207 boys and 189 girls) aged 9–12 years old before (T1), immediately after (T2), and three months after (T3) the implementation of the program.ResultsResults from a linear mixed-effects model showed a significant increase in children's self-efficacy at T2 (adjusted difference 0.49, 95% CI 0.03–0.94; p < 0.05) and T3 (0.78, 95% CI 0.32–1.23; p < 0.001). There were also significant positive changes in social skills and general mental health. Similar changes were observed in children with high autistic traits. Autistic traits at T1 did not contribute to the degree of change in self-efficacy.ConclusionsOur pilot study suggests that a universal program has the potential to promote positive attitudes and mental health in both at-risk and not-at-risk children.

Sports Specialization and Sports-Related Injuries in Japanese School-Aged Children and Adolescents: A Retrospective Descriptive Study.

Although early sports specialization is associated with sports-related injuries, relevant quantitative studies on young non-elite athletes, the majority of sports participants, are scarce. We described sports specialization time points and the characteristics of sports-related injuries. Undergraduate students at a university in Japan (n = 830) recalled their history of sports participation from elementary to high school and sports-related injuries in a self-administered questionnaire. Of 570 valid respondents, 486 (85%) engaged in sports at least once. Significantly more respondents played multiple sports in upper elementary school (30%) than in other school categories (1–23%). In junior high and high schools, 90% and 99% played only one sport, respectively. Of the 486 respondents who played sports, 263 (54%) had experienced acute or overuse injuries. The proportion of injured participants significantly differed by school category: lower elementary school (4%), upper elementary school (21%), junior high (35%), and high school (41%). The proportions of acute or overuse injuries in males were higher than those in females. In conclusion, this study clarified a slight variation in sports items, particularly in junior high and high schools, which demonstrates 13 years as the age of beginning specialization in a single sport. More than half of the non-elite athletes experienced sports-related injuries. Injuries were frequently observed in males and those in junior high and high schools.

Erratum: The association between participation in sports activities and grit in Japanese school-aged children: a cross-sectional study [Japanese Society of Health Education and Promotion, Vol. 26, No. 4, pp. 353-362 (2018)

Erratum: The association between participation in sports activities and grit in Japanese school-aged children: a cross-sectional study [Japanese Society of Health Education and Promotion, Vol. 26, No. 4, pp. 353-362 (2018)

The development, validation, and psychometric properties of the Japanese version of the Child Oral Health Impact Profile-Short Form 19 (COHIP-SF 19) for school-age children

BackgroundThis study was performed to develop and validate a Japanese version of Child Oral Health Impact Profile-Short Form (COHIP-SF) 19 and to assess its psychometric properties in Japanese school-age children.MethodsThe original English COHIP-SF 19 was translated into Japanese (COHIP-SF 19 JP) using a standard forward and backward translation procedure. The psychometric properties of the COHIP-SF 19 JP were assessed in 379 public school students between 7 and 18 years of age in Fukuoka, Japan. Internal consistency (Cronbach’s alpha) and test-retest reliability (intraclass correlation coefficient, ICC) were the metrics used for evaluation of this questionnaire. The discriminant validly was examined using the Wilcoxon rank sum test to identify significant differences in COHIP-SF 19 JP scores according to the results of dental examinations. The convergent validity was examined using the Spearman correlations to determine the relationships between COHIP-SF 19 JP scores and the self-perceived oral health ratings. Confirmatory factor analyses (CFA) were performed to verify the factor structure of the questionnaire.ResultsThe COHIP-SF 19 JP revealed good internal consistency (Cronbach’s alpha, 0.77) and test-retest reliability (ICC, 0.81). Discriminant validity indicated that children with dental caries or malocclusion had significantly lower COHIP-SF 19 JP scores (P < 0.05); convergent validity indicated that the self-perceived oral health rating was significantly correlated with the COHIP-SF 19 JP total score and subscores (rs = 0.352–0.567, P < 0.0001), indicating that the questionnaire had a sufficient construct validity. CFA suggested that the modified four-factor model had better model fit indices than the original three-factor model.ConclusionThe collected data showed that the COHIP-SF 19 JP possesses sufficient psychometric properties for use in Japanese school-age children.

子どものスポーツ活動とGrit（やり抜く力）の関連：横断研究

子どものスポーツ活動とGrit（やり抜く力）の関連：横断研究

Stressors of School-age Children With Allergic Diseases: A Qualitative Study

PurposeMost studies of stress in children with chronic diseases have been geared toward parents and caregivers have not considered allergic diseases together. This study aimed to identify the stressors associated with allergic diseases in Japanese school-age children. Design and MethodsStressors associated with allergic diseases of 11 school-age children (seven boys and four girls; age range: 9–12 years) were investigated using semi-structured interviews. ResultsIn the qualitative thematic analysis of stressors about allergic diseases, two themes: allergic disease-specific stressors and common stressors in chronic diseases, and 12 categories were identified. A thematic map was applied to four domains of stressor: physiological factors, psychological factors, social factors, and environmental factors. ConclusionsThe results showed that school-age children with allergic diseases have a variety of stressors. Future studies should aim to develop an allergic disease-specific stress management program with school-age children. Practice ImplicationsIn children with allergic diseases, not only is stress management in daily life important, but also stress management for disease-specific matters to control the symptoms and maintain mental health. Stress management should be supported for school-age children with allergic diseases.

Effects of FM system fitted into normal hearing ear on speech-in-noise recognition in Japanese school-aged children with unilateral severe-to-profound hearing loss.

We examined speech recognition ability of elementary school-aged Japanese children with unilateral hearing loss under noisy environments and then examined the effects of the FM system fitted into their normal hearing ear on their speech recognition ability. Twelve children with severe-to-profound sensorineural hearing loss and ten age-matched children with bilateral normal hearing received speech recognition test in quiet and noisy environments. Other nine children with severe-to-profound sensorineural hearing loss received speech recognition test with or without the FM receiver fitted to the normal hearing ear in quiet and noisy environments. Signal-to-noise ratio (SNR) in Japanese elementary school classrooms was estimated to be -6.9 dB at a preferential seat. In noisy environment of -5 dB SNR similar to working classrooms, the correct rates of speech recognition test in children with unilateral hearing loss were significantly lower, compared with those in children with bilateral normal hearing. In the noisy environment, the correct rates in children aided by the FM system with unilateral hearing loss were significantly better, compared with unaided ones. The results suggested that the FM system is recommended as an audiological management for improvement of speech recognition of children with unilateral hearing loss in noisy classrooms. J. Med. Invest. 65:216-220, August, 2018.

School grade and sex differences in domain-specific sedentary behaviors among Japanese elementary school children: a cross-sectional study

BackgroundIt is vital to reduce the proportion of sedentary behavior in children. Understanding the duration and behavioral context is needed. The present study examined school-grade and sex differences in domain-specific sedentary times and concurrence with screen-time guidelines among Japanese elementary school children.MethodsA total of 625 children (330 boys) were surveyed in 2010 and 2014. Using a questionnaire, data regarding participants’ grade (first through third grades: lower grades; fourth through six grades: higher grades), sex, weight, and height were collected in addition to the time spent per day engaging in each specific sedentary behavior separately: (1) reading or listening to music, (2) TV or video viewing, (3) TV game use, (4) internet use excluding class, (5) homework, and (6) car travel. Two-way analysis of covariance and logistic regression analyses, adjusted for BMI and moderate to vigorous physical activity, were used to examine school-grade and sex differences in sedentary behaviors and the independent risk of exceeding recommended total daily screen time (< 2 h).ResultsOn 625 children, mean minutes (SD) of sedentary behavior per week in (1) – (6) were 90.3 (123.4), 535.0 (356.6), 167.3 (222.1), 23.9 (70.9), 264.9 (185.3), and 33.4 (61.2) in weekdays and 42.1 (70.0), 323.9 (232.0), 123.0 (96.4), 15.8 (49.9), 74.4 (96.4), and 71.3 (84.9) in weekends, respectively. There were differences in the minutes of sedentary behavior between participants of 2010 and 2014; e.g., TV game use and homework in weekdays and weekdays and car travel in weekends. Boys spent more time in TV game use, and girls spent more time reading, listening to music, doing homework, and car travel. Higher-grade students spent more time reading or listening to music, using a computer, and doing homework. Higher-grade students were 2.09 times (95% CI: 1.32 − 3.30) in whole week, 2.08 times (95% CI: 1.45 − 3.00) in weekday, and 1.88 times (95% CI: 1.29 − 2.74) in weekend more likely to spend ≥2 h per day in domains (2) − (4) (screen-time) than lower-grade students.ConclusionsTime spent engaging in each domain-specific sedentary behavior differed according to sex and school grade. Higher-grade students were less likely to meet screen-time guidelines. These findings highlight the need for domain-focused strategies to decrease sedentary behavior in Japanese school-age children.

Segmental transition of the first syllables of words in Japanese children who stutter: Comparison between word and sentence production

ABSTRACTMatsumoto-Shimamori, Ito, Fukuda, & Fukuda (2011) proposed the hypothesis that in Japanese, the transition from the core vowels (i.e. syllable nucleus) of the first syllables of words to the following segments affected the occurrence of stuttering. Moreover, in this transition position, an inter-syllabic transition precipitated more stuttering than an intra-syllabic one (Shimamori & Ito, 2007, 2008). However, these studies have only used word production tasks. The purpose of this study was to investigate whether the same results could be obtained in sentence production tasks. Participants were 28 Japanese school-age children who stutter, ranging in age from 7;3 to 12;7. The frequency of stuttering on words with an inter-syllabic transition was significantly higher than on those having an intra-syllabic transition, not only in isolated words but in the first words of sentences. These results suggested that Matsumoto et al.’s hypothesis could be applicable to the results of sentence production tasks.

Evaluation of Obesity in School-Age Children.

To prevent obesity in middle age, early precautions and interventions are required during childhood. Therefore, it is very important to accurately evaluate the degree of overweight in children. Body mass index (BMI) is widely used worldwide in adults, but not in children. Because standard BMI, which is calculated using the average height and weight for age, changes widely during growth, a constant cut-off point cannot be set for children. An international unified method defining childhood obesity has not been established. In many countries, BMI-for-age percentile (BMI%) value or Z (standard deviation) score is used, whereas in Japan, the percentage of overweight (POW), which is the modified weight-for-height method, is used. We compared BMI% values with POW values obtained using the anthropometric data of elementary and junior high school students based on the Japanese school survey conducted in 2000 and found that the values for the degree of overweight were significantly different between the two methods. It became clear that tall students were easily defined as being overweight, whereas short students tended to be evaluated as being underweight when using BMI%. POW method seemed to be more appropriate than BMI% for school-age children. Abdominal obesity, excess visceral adipose tissue (VAT), is highly associated with obesity-related complications. Waist circumference (WC) is now accepted as an appropriate guide to VAT accumulation. The cut-off value of WC defining excess VAT is 80 cm at the umbilical level in Japanese school-age children. It is not easy to decide the obesity criteria and optimum WC in school-age children. Childhood obesity should be discussed more internationally.

Developmental trajectories for attention and working memory in healthy Japanese school-aged children.

The aim of this study was to investigate the developmental trajectories of attention, short-term memory, and working memory in school-aged children using a 10 min test battery of cognitive function. Participants comprised 144 typically developing children (TDC) aged 7-12 years and 24 healthy adults, divided according to age into seven groups (12 males and 12 females for each age group). Participants were assessed using CogHealth, which is a computer-based measure composed of five tasks. We measured attention, short-term memory, and working memory (WM) with visual stimulation. Each task was analyzed for age-related differences in reaction time and accuracy rate. Attention tasks were faster in stages from the age of 7-10 years. Accuracy rate of short-term memory gradually increased from 12 years of age and suddenly increased and continued to increase at 22 years of age. Accuracy rate of working memory increased until 12 years of age. Correlations were found between the ages and reaction time, and between ages and accuracy rate of the tasks. These results indicate that there were rapid improvements in attention, short-term memory, and WM performance between 7 and 10 years of age followed by gradual improvement until 12 years of age. Increase in short-term memory continued until 22 years of age. In our experience CogHealth was an easy and useful measure for the evaluation of cognitive function in school-age children.

Normative data and psychometric properties of the strengths and difficulties questionnaire among Japanese school-aged children.

BackgroundAlthough child mental health problems are among the most important worldwide issues, development of culturally acceptable mental health services to serve the clinical needs of children and their families is especially lacking in regions outside Europe and North America. The Strengths and Difficulties Questionnaire (SDQ), which was developed in the United Kingdom and is now one of the most widely used measurement tools for screening child psychiatric symptoms, has been translated into Japanese, but culturally calibrated norms for Japanese schoolchildren have yet to be established. To this end, we examined the applicability of the Japanese versions of the parent and teacher SDQs by establishing norms and extending validation of its psychometric properties to a large nationwide sample, as well as to a smaller clinical sample.MethodsThe Japanese versions of the SDQ were completed by parents and teachers of schoolchildren aged 7 to 15 years attending mainstream classes in primary or secondary schools in Japan. Data were analyzed to describe the population distribution and gender/age effects by informant, cut-off scores according to banding, factor structure, cross-scale correlations, and internal consistency for 24,519 parent ratings and 7,977 teacher ratings from a large nationwide sample. Inter-rater and test-retest reliabilities and convergent and divergent validities were confirmed for a smaller validation sample (total n = 128) consisting of a clinical sample with any mental disorder and community children without any diagnoses.ResultsMeans, standard deviations, and banding of normative data for this Japanese child population were obtained. Gender/age effects were significant for both parent and teacher ratings. The original five-factor structure was replicated, and strong cross-scale correlations and internal reliability were shown across all SDQ subscales for this population. Inter-rater agreement was satisfactory, test-retest reliability was excellent, and convergent and divergent validities were satisfactory for the validation sample, with some differences between informants.ConclusionsThis study provides evidence that the Japanese version of the SDQ is a useful instrument for parents and teachers as well as for research purposes. Our findings also emphasize the importance of establishing culturally calibrated norms and boundaries for the instrument’s use.

Diagnostic Agreement of Different IgE Assay Methods, Immunocap and ‘Extended Range' Immulite 2000 3gAllergy in Japanese School Age Children

S U N D A Y 417 Diagnostic Agreement of Different IgE Assay Methods, Immunocap and Extended Range' Immulite 2000 3gAllergy in Japanese School Age Children Mari Kondo, Mayumi Sugimoto, MD, Keigo Kainuma, MD, Reiko Tokuda, Mizuho Nagao, MD, Takao Fujisawa, MD, FAAAAI; Mie National Hospital, Tsu, Japan, Mie National Hospital, Mie National Hospital, Mie, Japan. RATIONALE: Quantitative measures of allergen specific IgEantibody (sIgE) using different methods, IMMULITE 2000 3gAllergy (3g) and ImmunoCAP (CAP) assays, have to be interchangeable. Recently, extended measurement range of 3g, 0.1 ‘500IUA/mL, has been evaluated in Japan. METHODS: Serum samples were collected from 144 healthy and allergic children as classified by the ISAAC questionnaire. Samples were tested for total IgE (tIgE) and allergen specific IgE (sIgE) to house dust mite (HDM), Japanese cedar pollen (JCP), egg white and milk using both 3g and CAPassays. RESULTS: tIgE levels for CAP & 3g were almost identical.sIgE levels to various allergens by the two assays were highly correlated with Spearman’s r of >0.9. Values with the 3g assay tended to be higher than those by CAP, possibly a result of the wider 3greportable range. The area under the curve (AUC) determined from analysis of allergic and nonallergic groups were nearly identical between the assays for tIgE, sIgE for HDM and JCP, resulting in similar sensitivity and specificity calculations. Also in both methods, increasing sIgEto HDM correlated with a higher number of co-morbid allergic diseases. In particular, 3gshowed a greater significant difference because of the wider measurement range. CONCLUSIONS: sIgE levels to inhalant and food allergens measured by the 3g and CAP systems are highly correlated. The extended measurement range of the 3g assay may provide additional information for early detection of sensitization and monitoring of highly sensitized patients.

Developmental changes in facial expression recognition in Japanese school-age children

Facial expressions hold abundant information and play a central part in communication. In daily life, we must construct amicable interpersonal relationships by communicating through verbal and nonverbal behaviors. While school-age is a period of rapid social growth, few studies exist that study developmental changes in facial expression recognition during this age. This study investigated developmental changes in facial expression recognition by examining observers' gaze on others' expressions. 87 school-age children from first to sixth grade (41 boys, 46 girls). The Tobii T60 Eye-tracker(Tobii Technologies, Sweden) was used to gauge eye movement during a task of matching pre-instructed emotion words and facial expressions images (neutral, angry, happy, surprised, sad, disgusted) presented on a monitor fixed at a distance of 50 cm. In the task of matching the six facial expression images and emotion words, the mid- and higher-grade children answered more accurately than the lower-grade children in matching four expressions, excluding neutral and happy. For fixation time and fixation count, the lower-grade children scored lower than other grade children, gazing on all facial expressions significantly fewer times and for shorter periods. It is guessed that the stage from lower grades to middle grades is a turning point in facial recognition.

Multilevel Longitudinal Analysis of Sex Differences in Height Gain and Growth Rate Changes in Japanese School-Aged Children

BackgroundDetermining standard pubertal growth patterns using longitudinal anthropometric measures is important in growth assessment. We used an appropriate repeated-measurements method to identify height growth patterns in Japanese school-aged girls and boys.MethodsThe participants were children born during the period from 1991 through 1999 who had entered the first grade of elementary school in the Enzan district in Koshu City, Japan. This study was part of the Project Koshu cohort study. Height was measured annually in April from the first grade of elementary school (age, 6–7 years) to the third grade of junior middle school (age, 14–15 years). Height gain and growth rate trajectories in boys and girls were constructed using multilevel analysis.ResultsIn total, 1984 children (1036 boys and 948 girls) were included in this study. Height in boys and girls was similar at age 6.5 to 9.5 years. Girls subsequently grew faster and were taller than boys at age 10.5 to 11.5 years. Starting at age 12.5 years, male height caught up and exceeded female height. Height gain trajectories showed that annual height gain among girls increased slowly and peaked during age 9.5 to 11.5 years, while male height gains declined slightly at first and peaked at age 11.5 to 12.5 years. Sex differences in height gains were significant during the period from age 7.5 to 14.5 years (P < 0.0001). Growth rate and height gain trajectories were similar between sexes.ConclusionsSex differences in growth trajectory were significant, and female height gain peaked approximately 2 years earlier than male height gain.

Communication attitudes of Japanese school-age children who stutter

Past research with the Communication Attitude Test (CAT) has shown it to be a valid and reliable instrument for assessing speech-associated attitude of children who stutter (CWS). However, in Japan, the CAT has not been used extensively to examine the communication attitude of CWS. The purpose of this study was to determine if a Japanese version of the CAT could differentiate between the communication attitude of Japanese elementary school CWS and children who do not stutter (CWNS). A Japanese translation of the 1991 version of the Communication Attitude Test-Revised (CAT-R) was used in this study. Eighty Japanese CWS and 80 gender- and grade level-matched CWNS participated in the study. The results showed that CWS had a significantly more negative communication attitude than CWNS. Both CWS and CWNS in 1st grade showed significantly more positive communication attitudes than children in 2nd, 3rd, 4th, 5th, and 6th grades. Furthermore, a link between stuttering severity and CWS’ communication attitude was found. Additional research is needed to confirm the results of the current study, which indicate that the communication attitude of Japanese CWS becomes more negative as they get older.Learning outcomes: The reader will be able to: (1) Describe the process that was used to develop a Japanese version of the Communication Attitude Test (CAT-J). (2) Discuss attitude differences between Japanese children who stutter and those who do not and how grade level impacts a negative attitude toward communication. (3) Explain the link between stuttering severity and attitudes of Japanese children who stutter.

Association between obesity and asthma in Japanese preschool children

Obesity may increase the risk of subsequent asthma. We have previously reported that there is a clear association between obesity and asthma in Japanese school-aged children. To evaluate whether a similar association exists in younger children, a nationwide cross-sectional questionnaire-based survey was performed focusing on children aged 4-5 yr. A child who had experienced wheezing during the past 12 months and had ever been diagnosed with asthma by a physician was defined as having current asthma. Overweight and underweight were defined as BMI ≥90th percentile and ≤10th percentile, respectively, according to the reference values for Japanese children from 1978 to 1981. After excluding 2547 children because of incomplete data, 34,699 children were analyzed. Current asthma was significantly more prevalent in overweight children compared with underweight and normal weight children (13.2% for overweight vs. 10.5% for underweight and 11.1% for normal weight; both p < 0.001). Even after adjusting for other variables, such as gender, other coexisting allergic diseases, and parental history of asthma, there was an association between overweight and current asthma (adjusted odds ratio: 1.23, 95% CI: 1.10-1.38, p < 0.001). Even in preschool children, obesity is already associated with asthma, and there was no gender effect on this association. Physicians should consider the impact of obesity when managing asthma in younger children.