Risk Factors In School Children Research Articles

709 Spreading of Nourishment Disorders in Schoolchildren Population

GoalStudy of nourishment disorders’ spreading and evaluation of the impact of risk factors in schoolchildren population.Materials and MethodsStudy included 3012 children of 6–15 age: 1654 girls and 1358 boys. By...

Retinal vessel diameter, obesity and metabolic risk factors in school children (JuvenTUM 3)

BackgroundThe prevalence of childhood obesity is high and its association with future cardiovascular disease in adulthood is well established. The cross-sectional data presented analyze the prevalence of obesity and the association between metabolic risk factors, physical inactivity and retinal vessel diameter in young school children. MethodsThe examination included 578 school children aged 11.1±0.6years from secondary schools in the District of Munich, Germany. Anthropometric measurements and blood sampling were conducted using standard protocols for children. Physical activity was evaluated by use of a questionnaire. Retinal microvascular diameters and the arteriolar to venular ratio (AVR) were assessed with a non-mydriatic vessel analyser (SVA-T) using a computer-based program. ResultsIn our population, 128 (22.2%) children were overweight (ow) or obese (ob). The mean retinal arteriolar and venular calibres were 208.0±15.6μm and 236.2±16.2μm, respectively, with a mean AVR of 0.88±0.01. Girls had significantly wider arteriolar and venular diameters compared to boys (p<0.001). ow and ob children had a lower AVR compared to normal weight (nw) children (mean(95% CI); nw: 0.89(0.88–0.89); ow: 0.87(0.86–0.88); ob: 0.85(0.83–0.87); p≤0.05). Wider venular diameters were independently associated with higher BMI and higher hsCRP. Blood pressure was associated with retinal vessel constriction. Higher physical inactivity and BMI were independently associated with a reduced AVR (p=0.032 and p<0.001, respectively). ConclusionsCardiometabolic risk factors and physical inactivity are associated with retinal microvascular alterations in young children, comparable to associations in adults. Retinal vessel imaging seems to be a feasible assessment for the detection of microvascular impairments in children at risk of developing cardiovascular disease in adulthood.

Effect of body mass index‐z score on adverse levels of cardiovascular disease risk factors

Cardiovascular disease (CVD) risk factors are associated with body mass index z-score (BMISD) and/or insulin resistance (IR). However, the correlation between adverse levels of these risk factors and BMISD, and the effect of IR on these associations are not fully understood in children. The aim of this study was to evaluate the association between adverse levels of CVD risk factors and BMISD, and the effect of IR on these associations in schoolchildren. Conventional CVD risk factors, C-reactive protein (CRP), uric acid (UA) and adiponectin were determined in 757 boys and 494 girls aged between 7 and 12 years. IR was assessed by the homeostasis model approximation index. BMISD were linearly associated with relative risks having adverse levels of all factors, except for glucose and low-density lipoprotein cholesterol (LDL-C) in boys, and except for glucose, LDL-C and adiponectin in girls (P < 0.01-0.001). These associations were weakened after adjustment for IR, but still significant in cases of UA and CRP in boys and UA, high-density lipoprotein cholesterol and CRP in girls (P < 0.01-0.001). The relative risk of having adverse levels of most CVD risk factors in school children increased across the entire range of BMISD. IR contributed to most of these relative risks, but BMISD itself also contributed to these relative risks. To prevent future development of CVD, it might be important for schoolchildren to maintain BMISD within normal range. However, in cases of hyper LDL-cholesterolemia, we should consider causes other than BMISD.

Obesity and cardiovascular risk factors in school children from Sorocaba, SP

Obesity and cardiovascular risk factors in school children from Sorocaba, SP

Obesity and cardiovascular risk factors in school children from Sorocaba, SP

OBJECTIVE: To verify the prevalence of obesity, systemic arterial hypertension (SAH), waist circumference and acanthosis nigricans (AN) in school children from Sorocaba, in 2009 and associate them with risk factors. METHODS: A probabilistic sample study was carried out with 680 children (7-11 years) from 13 public schools from the city of Sorocaba, SP. A questionnaire containing questions on physical activity, time spent watching television, playing with videogames and computers (TV/VG/PC), student and parental antecedents of arterial hypertension, renal or cardiac disease, and economic level was applied. On physical examination, weight, height, waist circumference (WC) and blood pressure (BP) were measured; presence of AN was observed. The prevalence of nutritional disorders, SAH, WC increase and presence of AN were calculated. To associate body mass index (BMI) > P85 and BP > P90 with the other variables, chi square or Fisher's exact test (significance p P85 was 22.1% [95% CI: 19.0-25.3%], of BP > P90 10.9% [95% CI: 8.6- 13.5%], increased WC 15.4% [95% CI: 12.9-17.9%] and AN 3.8% [95% CI: 2.6-5.6%]. Paternal antecedents were associated with weight excess in both analysis (POR: 1.76; 95% CI: 1.05-2.95; p = 0.02). High blood pressure was associated with female sex (POR: 1.90; 95% CI: 1.12-3.23; p = 0.01), more time spent with TV/VG/PC (POR: 1.82; 95% CI: 1.00-3.36; p = 0.03), AN (POR: 8.18; 95% CI: 3.37-19.80; p < 0.00), obesity (POR: 4.09; 95% CI: 2.41-6.94; p < 0.00) and WC (POR: 4.83; 95% CI: 2.77-8.41; p < 0.00). After the multivariate analysis, the female sex (adjusted POR = 2.15; 95% CI: 1.17-3.93) and obesity (adjusted POR = 9.51; 95% CI: 4.77-18.97) remained. CONCLUSION: The prevalence of weight excess, SAH, increased WC and AN in these school children was relevant. This fact justifies the use of these measurements.

Waist circumference as screening instrument for cardiovascular disease risk factors in schoolchildren

To propose cutoff points for waist circumference of schoolchildren for the identification of cardiovascular disease risk factors. This school-based cross-sectional study surveyed 1,413 schoolchildren aged 7 to 12 years old, selected by random cluster sampling. Waist circumference, total cholesterol and systolic and diastolic pressures were measured. Reference values for cardiovascular disease risk factors were developed from measures of total cholesterol and systolic and diastolic blood pressures. The receiver operating characteristic (ROC) curve and bivariate analysis, followed by calculation of sensitivity, specificity and odds ratio, were used in data analysis. The cutoff points had area values under the ROC curve ranging between 0.603 and 0.949, while sensitivity and specificity ranged between 0.500 and 1.00. Among all proposals analyzed, the one presented by this study best balanced sensitivity and specificity values. Bivariate analysis followed by odds ratios calculation indicated that subjects with waist circumference above the proposed cutoff points have increased chances of presenting cardiovascular disease risk factors. The cutoff points proposed in the present study seem to be a valid alternative and better balance sensibility and specificity than other proposals for screening students with increased chances of presenting cardiovascular disease risk factors.

Are We There Yet? Pediatric Screening for Inflammatory Biomarkers and Low Cardiorespiratory Fitness to Identify Youth at Increased Risk of Cardiovascular Disease

Are We There Yet? Pediatric Screening for Inflammatory Biomarkers and Low Cardiorespiratory Fitness to Identify Youth at Increased Risk of Cardiovascular Disease

Childhood Obesity Is the Fuel That Fires Adult Metabolic Abnormalities and Cardiovascular Disease

Childhood ObesityVol. 6, No. 5 Childhood Obesity Is the Fuel That Fires Adult Metabolic Abnormalities and Cardiovascular DiseaseMegan Moriarty-Kelsey and Stephen R. DanielsMegan Moriarty-KelseySearch for more papers by this author and Stephen R. DanielsSearch for more papers by this authorPublished Online:11 Nov 2010https://doi.org/10.1089/chi.2010.0504AboutSectionsPDF/EPUB Permissions & CitationsPermissionsDownload CitationsTrack CitationsAdd to favorites Back To Publication ShareShare onFacebookTwitterLinked InRedditEmail FiguresReferencesRelatedDetailsCited bySex differences in the prevalence of multiple cardiovascular disease risk factors in schoolchildren: A cross-sectional studyClinical Nutrition ESPEN, Vol. 52Meeting fruit and vegetable consumption and physical activity recommendations among adolescents intending to lose weightPreventive Medicine Reports, Vol. 13School-Based Health Promotion Initiative Increases Children's Physical Activity17 October 2016 | American Journal of Health Education, Vol. 47, No. 6A mixed-methods exploration of implementation of a comprehensive school healthy eating model one year after scale-up20 May 2015 | Public Health Nutrition, Vol. 19, No. 5Parenting style and obesity risk in childrenPreventive Medicine, Vol. 75Parental attachment insecurity predicts child and adult high-caloric food consumption22 April 2015 | Journal of Health Psychology, Vol. 20, No. 5Is there a critical time window for weight loss intervention?15 May 2013 | Nutrition Bulletin, Vol. 38, No. 2Adolescent Obesity, Change in Weight Status, and HypertensionHypertension, Vol. 61, No. 2Is the obesity epidemic worsening the cardiovascular risk factor profile of children? Evidence from two Québec samples measured 10 years apart21 June 2012 | Annals of Human Biology, Vol. 39, No. 4 Volume 6Issue 5Oct 2010 Information©2010 by Mary Ann Liebert, Inc.To cite this article:Megan Moriarty-Kelsey and Stephen R. Daniels.Childhood Obesity Is the Fuel That Fires Adult Metabolic Abnormalities and Cardiovascular Disease.Childhood Obesity.Oct 2010.250-256.http://doi.org/10.1089/chi.2010.0504Published in Volume: 6 Issue 5: November 11, 2010PDF download

School-based Fitness Testing Is Associated With Metabolic Risk Factors In Schoolchildren Independent Of Weight Status

School-based fitness testing has not been well examined in relationship to cardiometabolic risk factors in schoolchildren. PURPOSE: To determine the relationship between physical fitness, blood lipids and circulating inflammatory biomarkers independent of body mass index (BMI) in school-aged children. METHODS: Phlebotomy was performed on 278 socioeconomically and racially diverse children (11.4 ± 1.6 yr; 51% female; 36% Caucasian, 30% Hispanic, 8% Asian, 7% Black, 19% other; 70% free/reduced lunch) to measure blood lipids (total cholesterol, triglycerides, HDL, LDL, VLDL) and biomarkers of inflammation (IL-6 and CRP). Height and weight were measured to determine the child's BMI-for-age category (overweight/obese vs. normal weight) based on CDC growth charts. Schools provided data on cardiovascular physical fitness as measured by the shuttle run. Linear regression analyses were used to examine the effect of fitness and weight status on blood lipids after controlling for the covariates of gender, age, ethnicity, free/reduced lunch, and pubertal status. RESULTS: Forty-five percent of children examined were overweight/obese, 50% "did not pass" the shuttle run (unfit), and 30% had one or more blood lipids that fell outside of the healthy range. Fifty percent of the fit children and 60.5% of the unfit children were overweight/obese, respectively. Triglycerides, VLDL, CRP and IL-6 were higher in both unfit students and overweight/obese students, while HDL was lower in these groups (P<0.001 for all). HDL levels were associated with both fitness and weight status (B=3.7, P<0.05 and B=-4.4, P<0.01, respectively). IL-6 was associated with lower fitness (B=-0.29, P<0.01) but not weight status. When stratified by weight status, fitness was associated with lower triglycerides (B=-0.37, P<0.001), VLDL (B=-0.37, P<0.001), and CRP (B=-0.12, P<0.001) in overweight/obese children, while there was no effect of fitness on these variables in normal weight children. CONCLUSION: A simple school-based endurance fitness test is associated with metabolic risk factors in a diverse group of overweight/obese school-aged children. These results suggest that it may be possible to identify overweight/obese children in a community setting who are at increased cardiometabolic risk based on school-based fitness testing.

Coronary risk factors in school children in relation to their family history of coronary heart disease and hyperlipidemia.

A school-based study was implemented to assess the family history of coronary heart disease (CHD) and hyperlipidemia (HL) in relation to serum lipoprotein and apolipoprotein levels. One hundred and twenty-five elementary school students (aged 9-10 years) and 297 junior high school students (aged 12-13 years) participated. Family history was evaluated by the following scoring method: positive family history in a parent, 2 points; in a grandparent, 1 point; and onset of CHD before age 60, 1 additional point. Family history of HL was positive in 8.2% of elementary school students, and 4.2% in junior high school students. Family history of CHD was positive in 11.5% of elementary students, and 11.0% in junior students. Family history score (FHS) for HL was related to serum total cholesterol (TC), low density lipoprotein cholesterol (LDLC), high density lipoprotein cholesterol, apolipoprotein A-I, apolipoprotein B (apoB) and lipoprotein (a) in elementary students, and to TC, LDLC, triglyceride and apoB in junior students. There was no relationship between FHS for CHD and serum lipoprotein or apolipoprotein levels in any student. The children with a positive FH of HL already demonstrated an atherogenic lipid profile while those with FH of CHD did not, which was probably because lipid profiles in children are more genetically mediated by a FH of HL than of CHD.

Prevalence and factors related to malocclusion and orthodontic treatment need in children and adolescents in Italy

The purpose of this study was to determine prevalence of malocclusions, normative and perceived orthodontic treatment need and related risk factors in schoolchildren in Italy. A random sample of 1000 11-15 years old children was selected from randomly selected schools in Catanzaro (Italy). Parents completed a questionnaire on sociodemographic, orthodontic history and perception of their child orthodontic treatment need. Children were interviewed on utilization of dental services, perception of orthodontic treatment need and use of orthodontic devices. The Decayed, Missing, Filled Teeth (DMFT) index and the Dental Health Component (DHC) of the Index of Orthodontic Treatment Need (IOTN) were assessed. The Aesthetic Component (AC) of IOTN was assessed by parents, children and dentist. A total of 546 children participated in the study. Three hundred and twenty-five subjects (59.5%) were assigned a 4 or 5 IOTN score, thus requiring orthodontic treatment. Definite treatment need (AC score 8-10) was reported for 8.6% of subjects by the orthodontist, 5.4% by parents and 3.2% by children. Higher DMFT significantly predicted orthodontic treatment need according to IOTN. Perceived orthodontic treatment need was significantly predicted by orthodontic treatment need for crowding/spacing and overjet. A high proportion of children needs normative orthodontic treatment and perceptions of orthodontic treatment do not overlap with normative need.

High blood pressure in school children: prevalence and risk factors.

BackgroundThe purpose of this study was to determine the prevalence of high blood pressure (HBP) and associated risk factors in school children 8 to 13 years of age.MethodsElementary school children (n = 1,066) were examined. Associations between HBP, body mass index (BMI), gender, ethnicity, and acanthosis nigricans (AN) were investigated using a school based cross-sectional study. Blood pressure was measured and the 95th percentile was used to determine HBP. Comparisons between children with and without HBP were utilized. The crude and multiple logistic regression adjusted odds ratios were used as measures of association.ResultsFemales, Hispanics, overweight children, and children with AN had an increased likelihood of HBP. Overweight children (BMI ≥ 85th percentile) and those with AN were at least twice as likely to present with HBP after controlling for confounding factors.ConclusionTwenty one percent of school children had HBP, especially the prevalence was higher among the overweight and Hispanic group. The association identified here can be used as independent markers for increased likelihood of HBP in children.

Prevalencia de obesidad y tendencia de los factores de riesgo cardiovascular en escolares de 1992 a 2004: estudio de Cuenca

The assess the prevalence of overweight and obesity in school children from the province of Cuenca in 2004, and to examine changes in the main cardiovascular risk factors in school children from the city of Cuenca from 1992 through 2004. Cross sectional survey of 1166 schoolchildren 9-10 years old from 22 public schools of the province of Cuenca. We also analyzed data from 3 earlier, methodologically similar, cross-sectional surveys of school children from the city of Cuenca carried out in 1992, 1996 and 1998. In 2004, among children aged 9-10 years from the province of Cuenca, 22.0% (95% confidence interval [CI], 19.53-24.37) were overweight and 8.8% (95% CI, 7.16-10.50) were obese. From 1992 through 2004, among children aged 9-10 years from the city of Cuenca, we registered a 12.2% absolute increase in the prevalence of overweight or obesity among males, which did no reach statistical significance (p > 0.05). Among women, changes in body mass index were of lower magnitude and with no statistical significance. Systolic blood pressure (SBP) and diastolic blood pressure (DBP) decreased (p < 0.05) in both sexes, with a greater decline in females. Among the latter, SBP decreased -9.22 mmHg (95% CI, -7.0 to -11.5) and DBP -5.9 mmHg (95% CI, -4.23 to -7.50). Non high density lipoproteins-cholesterol decreased among males (-18.1 mg/dl; 95% CI, -26.0 to -10.1 mg/dl) and among females (-23.7 mg/dl; 95% CI, -30.8 to -16.6 mg/dl). High density lipoproteins-cholesterol increased 6.3 mg/dl (95% CI, 2.6-10.0 mg/dl) in males and 5.1 mg/dl (95% CI, 1.9-8.2 mg/dl) in females. Triglycerides did not show substantial changes over the study period. Prevalence of overweight or obesity in schoolchildren of Cuenca is among the highest in Europe. From 1992 through 2004 in the city of Cuenca, frequency of overweight or obesity might have increased among males, while blood pressure and the lipid profile improved in both sexes.

Prevalence of Cardiovascular Risk Factors in Schoolchildren in a Rural Georgia Community

In the context of a national childhood obesity epidemic, this study sought to document the cardiovascular risk status of children in a rural Georgia community. Anthropometrics and blood pressure were measured in 211 children, and fasting glucose and lipid profile in 160, recruited from schools in 2002 (grades 2 to 11, ages 7 to 18 years). Nearly half the schoolchildren (48%) were overweight or at risk of overweight; 15% had metabolic syndrome. Overweight children were at higher risk for metabolic syndrome and had more risk factors. Blood pressure: 19% had elevated systolic blood pressure; 4% had elevated diastolic blood pressure. Glycemia: 14% had impaired fasting glucose levels; no diabetes cases were detected. Lipid profile: 26% had high total cholesterol (>170 mg/dL), 20% had high low-density lipoprotein (>110 mg/dL), 13% had high triglycerides (>150 mg/dL), 43% had low high-density lipoprotein (females, <50 mg/dL; males, <40 mg/dL). Ethnicity, gender, and grade level were not predictive of risk except that fewer black children had low high-density lipoprotein, and blood pressure and body mass index increased with grade, as expected. Results from this study indicate a significant problem with overweight and cardiovascular risk in rural schoolchildren. Notably, younger children were just as likely to have risk factors as adolescents, suggesting that screening and intervention ought to begin by school age. Ethnic and gender differences in prevalence were not found, suggesting that contextual factors in a rural setting may outweigh demographic influences on risk.

Parental educational level and cardiovascular disease risk factors in schoolchildren in large urban areas of Turkey: directions for public health policy.

BackgroundIt is widely accepted that the development of atherosclerosis starts at an early age. However, there are very few studies evaluating the prevalence of the common clinical and behavioral cardiovascular disease (CVD) risk factors among children, especially in developing countries. The aim of the present cross-sectional survey was to evaluate the distribution of blood lipid profile and various behavioral (i.e. dietary habits, physical activity status) factors related to CVD risk and its relationships to paternal (PEL) and maternal educational level (MEL) among primary schoolchildren in Turkey.MethodsIn three major metropolises in Turkey (Istanbul, Ankara and Izmir), a random sample of 1044 children aged 12 and 13 years old was examined. ANOVA was applied to evaluate the tested hypothesis, after correcting for multiple comparisons (Tukey correction).ResultsAfter controlling for energy and fat intake, physical activity status and Body Mass Index (BMI), it was found that mostly PEL had a significant positive effect for most of the subgroups examined (Lower vs. Higher and Medium vs. Higher) on TC and HDL-cholesterol and a negative effect on TC/HDL ratio for both genders. Furthermore, both boys and girls with higher PEL and MEL were found to have higher energy intake derived from fat and protein than their counterparts with Medium and Lower PEL and MEL, while the opposite was observed for the percentage of energy derived from carbohydrates.ConclusionsOur study provides indications for a possible association between an adverse lipid profile, certain dietary patterns and Higher PEL and MEL among schoolchildren in Turkey. These findings underline the possible role of social status, indicated by the degree of education of both parents, in developing certain health behaviors and health indices among Turkish children and provide some guidance for Public Health Policy.

Prevalence of Cardiovascular Risk Factors in Selected Samples of Schoolchildren—Socioeconomic Influence

Few data are available regarding the prevalence of cardiovascular risk factors in schoolchildren in Brazil. Weight, height, body mass index, blood pressure, and serum cholesterol were determined in 366 students, from 6-12 years of age, 209 (57.1%) from a private school and 157 (41.9%) from a public school, 187 (51.1%) female, aged 8.4+/-1.7 years. Prevalence of the risk of being overweight was 14.8%, being overweight/obese 13.1%, and presenting with elevated cholesterol (>/=170 mg/dL) was 28.1%, particularly at the private school: 21.5% vs. 5.7% for the risk of being overweight (p<0.001), 17.2% vs. 7.6% for being overweight/obese (p<0.01), 41.8% vs. 10.2% for cholesterol >/=170 mg/dL (p<0.001), and 14.8% vs. 1.3% for cholesterol >/=200 mg/dL (p<0.001), respectively. The results showed a high prevalence of risk factors among these school children, especially among private students.

Physical Activity and Cardiovascular Disease Risk Factors in Schoolchildren

The aims of this study were (i) to provide descriptive data about variousCVD risk factors (triglycerides [TG], total cholesterol [TC], blood pressureand physical activity patterns) among schoolchildren in a specific sample; (ii) to document the extent to which physical activity is associated with variations in CVD risk factors among schoolchildren. The study comprised 474 children (242 males and 232 females, aged 8–13 years) selected in the Porto area of Portugal. The multiple regression analysis showed that the physical activity index is not associated with the variation in the biological risk factors in girls, while for boys a significant association was found for systolic blood pressure (R2 = .04, p= .05) and diastolic blood pressure (R2 = .03, p= .05). The present study shows that boys were significantly more active than girls, except for the young group (8–9 years old). However, except for SBP and DBP in males, no significant benefit from physical activity was related to the CVD risk factors evaluated. Since girls consistently reduce their levels of physical activity, some further attention should be given to this matter, mainly in the context of physical activity at school.

Parental smoking and cardiovascular risk factors in school children

Smokers have multiple adverse health-related behaviours and an increased risk of cardiovascular disease. We examined whether health behaviours in parents who smoke may influence children's health behaviours. This study analyses the life-style habits of 1015 school children (girls:475 boys: 540; 11-12 years) participating in a screening for cardiovascular risk factors that took place in the suburban area of Pisa. During the baseline children's examination, parents were asked to fill in a questionnaire that included parent's smoking habits and children's demographic data including actual involvement in physical activity. Parent's smoking was additive predictor in children of lower physical activity (p <0.01); furthermore children's body mass index (p<0.001) and blood pressure values (p<0.001) were significantly greater if parents smoked. In conclusions these data seem to suggest that health behaviours associated with smoking in parents should be likely to influence children's long-term risk of having lifestyle diseases. The results may also explain some of the apparent effects attributed to passive smoking in families.

The Prevention Education Program (PEP). A Prospective Study of the Efficacy of Family-Oriented Life Style Modification in the Reduction of Cardiovascular Risk and Disease: Design and Baseline Data

We describe design and baseline data of the Prevention Education Program (PEP), a home-based and family-oriented intervention program, aimed to assess and improve cardiovascular risk factors in school children and their families during an intervention period of 10 years. Started in 1994 in the German town of Nuremberg, currently 37 elementary schools (22 control and 15 intervention schools) are enrolled including 1740 families (1740 first graders, 3046 parents, and 1521 siblings). Major cardiovascular risk factors as well as dietary behavior are evaluated yearly using structured interview, physical examination, laboratory analysis, and seven-day-dietary protocols. The intervention package is applied to all families from intervention schools using regular home visits, health curricula and group sessions. Primary outcome is any reduction in cardiovascular risk factors by dietary intervention and health education compared to the control group getting only written information on the individual risk profile. The presented baseline data showing a high prevalence of cardiovascular risk factors in adults and in their children underline the need for such an intervention program in Germany.

The impact of heart health promotion on coronary heart disease lifestyle risk factors in schoolchildren: lessons learnt from a community-based project

A community health promotion project called Action Heart was undertaken in two electoral wards in Rotherham to try to change lifestyles of people. Schools were included within the project. Coronary heart disease lifestyle risk factors were measured at baseline and after a three year period in the intervention area and a similar control area. Lifestyle factors in schoolchildren were measured separately from adults using a different instrument. The post intervention survey of adults and economic evaluation demonstrated that Action Heart had achieved cost-effective estimated health gains. In the schoolchildren however, a mixture of positive and negative risk factor changes in both areas was demonstrated. Significant changes in lifestyle risk factors in schoolchildren were not elicited using this approach. The possible reasons for the lack of impact on lifestyle risk factors in schoolchildren are examined and the implications for further work explored.