Complementary and Alternative Medicine Use in a Large Pediatric Autism Sample

Abstract

Background and objective:
Children and adolescents with autism spectrum disorder (ASD) often use complementary and alternative medicine (CAM), usually along with other medical care. This study aimed to determine associations of ASD diagnostic category, co-existing conditions, and use of medications with use of CAM.

Methods:
We used the Autism Speaks Autism Treatment Network patient registry, which collects information on CAM use, medical conditions, and psychotropic medication at enrollment. CAM was categorized as special diets versus "other" CAM; ASD was defined as autism, pervasive developmental disorder (PDD), or Asperger's. Gastrointestinal symptoms, seizure disorders, sleep problems, and medication use were determined from parent report. Child Behavior Checklist (CBCL) scores were used to measure behavioral symptoms. Logistic regression was used to determine associations of diagnostic category, other medical conditions, and medication use with CAM treatments, controlling for demographic characteristics.

Results:
Of 3413 subjects in the registry as of April 2011, 3173 had complete data on CAM use: 896 (28%) reported any use; 548 (17%), special diets; and 643 (20%), other CAM. Higher rates of CAM use were associated with gastrointestinal symptoms (odds ratio [OR] = 1.88), seizures (OR = 1.58), and CBCL total score >70 (OR = 1.29). Children with PDD (OR = 0.62), Asperger's (OR = 0.66), or using medications (0.69) had lower rates.

Conclusions:
Children with ASD use more CAM when they have co-existing gastrointestinal symptoms, seizure disorders, and behavior problems. This study suggests the importance of asking about CAM use in children with ASD, especially those with complex symptoms.

Full text

Complementary and Alternative Medicine Use in
a Large Pediatric Autism Sample
abstract
BACKGROUND AND OBJECTIVE: Children and adolescents with autism
spectrum disorder (ASD) often use complementary and alternative med-
icine (CAM), usually along with other medical care. This study aimed
to determine associations of ASD diagnostic category, co-existing
conditions, and use of medications with use of CAM.
METHODS: We used the Autism Speaks Autism Treatment Network pa-
tient registry, which collects information on CAM use, medical condi-
tions, and psychotropic medication at enrollment. CAM was categorized
as special diets versus “other”CAM; ASD was defined as autism,
pervasive developmental disorder (PDD), or Asperger’s. Gastrointes-
tinal symptoms, seizure disorders, sleep problems, and medication
use were determined from parent report. Child Behavior Checklist
(CBCL) scores were used to measure behavioral symptoms. Logistic
regression was used to determine associations of diagnostic cate-
gory, other medical conditions, and medication use with CAM treat-
ments, controlling for demographic characteristics.
RESULTS: Of 3413 subjects in the registry as of April 2011, 3173 had
complete data on CAM use: 896 (28%) reported any use; 548 (17%),
special diets; and 643 (20%), other CAM. Higher rates of CAM use were
associated with gastrointestinal symptoms (odds ratio [OR] = 1.88),
seizures (OR = 1.58), and CBCL total score .70 (OR = 1.29). Children
with PDD (OR = 0.62), Asperger’s (OR = 0.66), or using medications
(0.69) had lower rates.
CONCLUSIONS: Children with ASD use more CAM when they have co-
existing gastrointestinal symptoms, seizure disorders, and behavior
problems. This study suggests the importance of asking about CAM
use in children with ASD, especially those with complex symptoms.
Pediatrics 2012;130:S77–S82
AUTHORS: James M. Perrin, MD,
a
Daniel L. Coury, MD,
b
Susan L. Hyman, MD,
c
Lynn Cole, PNP,
c
Ann M. Reynolds,
MD,
d
and Traci Clemons, PhD
e
a
Department of Pediatrics, Harvard Medical School, MassGeneral
Hospital for Children, Boston, Massachusetts;
b
Nationwide
Children’s Hospital, The Ohio State University School of Medicine,
Columbus, Ohio;
c
Golisano Children’s Hospital, University of
Rochester School of Medicine, Rochester, New York;
d
Children’s
Hospital Colorado, University of Colorado, Aurora, Colorado; and
e
EMMES Corporation, Rockville, Maryland
KEY WORDS
autism spectrum disorders, complementary and alternative
medicine
ABBREVIATIONS
ADOS—Autism Diagnostic Observation Schedule
ASD—autism spectrum disorder
ATN—Autism Treatment Network
CAM—complementary and alternative medicine
CBCL—Child Behavior Checklist
CSHQ—Child Sleep Health Questionnaire
DSM-IV—Diagnostic and Statistical Manual of Mental Disorders,
Fourth Edition
GI—gastrointestinal
OR—odds ratio
PDD-NOS—pervasive developmental disorder not otherwise spec-
ified
www.pediatrics.org/cgi/doi/10.1542/peds.2012-0900E
doi:10.1542/peds.2012-0900E
Accepted for publication Aug 8, 2012
Address correspondence to James M. Perrin, MD, Department of
Pediatrics, Harvard Medical School, MassGeneral Hospital for
Children, 100 Cambridge St, #1542, Boston, MA 02114. E-mail:
jperrin@partners.org
PEDIATRICS (ISSN Numbers: Print, 0031-4005; Online, 1098-4275).
Copyright © 2012 by the American Academy of Pediatrics
FINANCIAL DISCLOSURE: The authors have indicated they have
no financial relationships relevant to this article to disclose.
PEDIATRICS Volume 130, Supplement 2, November 2012 S77
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Complementary and alternative medi-
cine (CAM) treatments are widely used
to promote health, often as adjuncts to
conventional medical treatment. CAM
may be defined as a group of diverse
medical and health care systems,
practices, and products that are not
generally considered part of conven-
tional medicine.
1
Parents often use
CAM in the care of children who have
autism spectrum disorder (ASD), most
typically in combination with conven-
tional medical treatments, a practice
sometimes labeled as integrative medi-
cine. Data from the National Health In-
terview Survey indicate that 38.3% of
US adults and 12% of US children use
CAM,
2
although a 2008 review indicated
higher rates, with 20% to 40% of chil-
dren using some CAM.
3
Use of CAM
is higher in children and adults who
have chronic health conditions. Among
families represented in the Interactive
Autism Network, more than one-half
of children and youth who have ASD
receive supplements. Families who
choose to use CAM for their children
who have ASD report an average of 7
CAM therapies.
4
At the time of a diag-
nostic visit for ASD, almost one-third of
children were already treated with a
dietary intervention.
5
Most previous work on CAM in children/
youth with autism has come from small
samples or large national data sets
lacking substantial clinical data. Ear-
lier work has associated increased
CAM use among children with chronic
conditions, higher socioeconomic
status, and parental use of CAM for
themselves.
3
Valicenti-McDermott et al
6
examined
the associations of CAM with parent
stress and clinical symptoms of gas-
trointestinal (GI), sleep, and behavioral
problems. They found higher use of
CAM among families of children with
ASD compared with children with
other developmental disabilities. Higher
rates of CAM use were associated with
higher parenting stress, reports of
food allergies, and child behavioral
problems.
We examined CAM use in a large and
diverse population of children who have
ASD for whom a clinical database
documented medical diagnosis and
care. Given previous work in this area,
we were particularly interested in the
associations of CAM use with diagnostic
categories of ASD, co-occurring con-
ditions including other mental health
conditions, and use of other treatments,
while controlling for child demographic
characteristics.
METHODS
This study was a cross-sectional anal-
ysis of data from a large multisite
registry of children and adolescents
with ASD involved in a North American
collaborative to improve health care for
children who have ASD. The Autism
Speaks Autism Treatment Network
(ATN), a collaboration among 17 aca-
demic health centers in the United
States and Canada, has developed
a common registry protocol for chil-
dren enrolled in all sites. Main registry
inclusion criteria are age 2 to 18 years
as well as an Autism Diagnostic Ob-
servation Schedule (ADOS) -supported
and Diagnostic and Statistical Manual
of Mental Disorders, Fourth Edition
(DSM-IV) diagnosis of ASD. Sites enroll
new patients and collect data on re-
turning patients who have continuing
care at the site. Enrollment (based
on the date of consent) for the reg-
istry began in December 2007. We
included all children enrolled in the
ATNregistryasoftheendofApril
2011.
Variables
CAM Usage
The medical history questionnaire com-
pleted by the parent at entry to the
registry includes a series of questions
about CAM use, addressing both special
diets and other CAM treatments. Parents
were queried as to whether their chil-
dren use various treatments such as
acupuncture, chelation, chiropractic, or
hyperbaric oxygen therapy; dietary sup-
plements (vitamin supplements, probiotics,
antifungal agents, digestive enzymes,
glutathione, sulfation, amino acids, or
essential fatty acids); and special diets
(classified as gluten free, casein free,
Feingold, no processed sugars, no sali-
cylates, or other). Because of the infre-
quentendorsementofmostoftheCAM
therapies, the variables were collapsed
into a primary outcome of any CAM use
versus no CAM use and 2 subgroup
outcomes of (1) special diets versus no
CAM use; and (2) “other”CAM use versus
no CAM use.
Clinical Diagnosis
All children entered into the registry
had clinical diagnoses of ASD with
documentation of DSM-IV criteria and
completion of the ADOS. ADOS and DSM-
IV criteria scores were used to define
categories of ASD (autism, pervasive
developmental disorder not otherwise
specified [PDD-NOS], or Asperger’s).
Co-occurring Conditions
The initial medical history questionnaire
queriedGIsymptoms,specifically con-
stipation, diarrhea, abdominal pain, and
GI allergy. We dichotomized children into
those with reported GI symptoms and
those without. To determine presence of
sleep disorders, the Child Sleep Health
Questionnaire (CSHQ), a 33-item parent
questionnaire, was used.
7
Insofar as the
CSHQ has been studied well only to age
10 years, we limited analyses of sleep
disorder associations with CAM use to
children ,11 years old.
8
Total CSHQ
scores .41 have been reported as a
sensitive cutoff for clinically significant
sleep problems. Presence or absence
of seizures according to parent report
was also included. The Child Behavior
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Checklist (CBCL) was used to determine
presence of co-existing mental health
symptoms, using cutoff scores of 70 on
the CBCL internalizing, externalizing, and
total scores denoting risk for behavioral
problems.
9
Finally, we used parent re-
port of use of medication, specifically for
behavior problems.
Previous research has documented re-
lations of age, race, and parental edu-
cation with use of CAM.
3
Thus, these
variables were included as control vari-
ables in our analyses. We categorized
age as 2 to 5 years, 6 to 11 years, and 12
to 18 years. Maximum education level,
collected from the child’s primary and
secondary caregivers, was grouped as
follows: high school graduate or less,
some college, college graduate, or post-
graduate work. Race and ethnicity came
from parent report. Race was categorized
as white, black, Asian-American, or other;
ethnicity was categorized as Hispanic
or non-Hispanic origin.
Analyses
We determined associations with the
use of any CAM through a 3-stage pro-
cess by using logistic regression (SAS
procedure LOGREG). In all analyses, use
of any CAM was compared with the
referent control group (no CAM usage).
In stage 1, each factor (diagnostic cat-
egory, co-occurring conditions, and use
of medications) was included sepa-
rately in bivariate analyses. Variables
associated with CAM use at a level of
P,.20 or less were retained as factors
for further analysis. Multilevel cate-
gorical variables were retained if any
of the comparisons (eg, high versus
low, top versus bottom) were signifi-
cant. Parent education and race/ethnicity
were included as controls in the mul-
tivariable analyses.
In stage 2, all variables retained from
stage 1 analyses were entered as
a group into a multivariable model,
along with the control variables (age,
race/ethnicity, and parental education).
In stage 3, model simplification con-
sistent with x
2
tests of change in de-
viance was performed. Variables not
statistically significant were excluded
from the model. Model simplification
continued until the reduced model
yielded a significant (P#.05) worsen-
ing of fit according to the likelihood
ratio criterion.
A similar staged modeling approach
was also used for the 2 subgroup
comparisons of interest: (1) any special
diet usage versus no CAM usage; and
(2) “other”CAM usage versus no CAM
usage.
Prevalence odds ratios (ORs) and 95%
confidence intervals, which describe
the association between use of any CAM,
special diets, or other CAM and the risk
factors, were computed relative to the
control group of no CAM usage.
RESULTS
A total of 3413 participants were en-
rolled in the ATN registry as of April 28,
2011. A total of 3173 had available data
on CAM usage. Children with no avail-
able CAM data were more likely to have
a diagnosis of autism (73% vs 67%; P=
.01) and be of Hispanic ethnicity (15%
vs 6%; P= .02). The demographic
characteristics of the 3173 partic-
ipants who were included in the anal-
ysis are shown in Table 1, grouped
according to usage of CAM (any CAM
usage versus no CAM usage). A total of
896 (28%) participants reported use of
any CAM; 548 (17%) reported use of
a special diet; and 643 (20%) reported
use of other CAM treatment (Table 2).
As with other research regarding CAM
use in children and adolescents,
3
wealthier households had higher rates
of reported CAM usage in their chil-
dren, as did white families compared
with African-American or Latino fami-
lies. ORs for each risk factor according
to the 3 outcomes from the stage 1 bi-
variate analyses are given in Table 3.
ORs significant at P,.20 are noted.
The stage 3 reduced multivariable lo-
gistic regression model had acceptable
fit. Estimated ORs and significant asso-
ciations (P#.05) from the stage 3 final
models are given in Table 4. We report
here associations that remained signif-
icant in multivariable analyses.
Differences in CAM Use by Autism
Diagnostic Category
Children and adolescents with a di-
agnosis of Asperger’s or PDD-NOS had
significantly decreased use of any CAM
compared with children with a di-
agnosis of autism (OR = 0.62 for
Asperger’s and OR = 0.66 for PDD-NOS).
Those with PDD-NOS or Asperger’shad
significantly lower reports of use of
special diets than those with autism
(ORs = 0.44 and 0.65, respectively),
whereas those with PDD-NOS had sig-
nificantly lower reports of use of other
CAM than those with autism (OR = 0.67).
CAM Use and Co-occurring
Conditions
Parents of children in the ATN registry
reported significantly higher rates of
CAM use when they also reported GI
problems (OR = 1.88 for CAM use in
general; OR = 2.38 for special diets; OR =
1.82 for other CAM). Similarly, children
whose parents reported a history of
seizures also reported higher CAM use
(OR = 1.58 for CAM use in general; OR =
1.97 for special diets; OR = 1.664 for
other CAM). We found no significant
association of CAM use with presence
or absence of sleep problems.
CAM Use and CBCL Scores
Children with CBCL scores (interna-
lizing, externalizing, and total) above
the cutoff of 70 had significantly higher
rates of CAM and special diet usage than
children with lower scores. After con-
trolling for other factors, this associa-
tion remained only for the CBCL total
problem score (OR = 1.29 for CAM; OR =
1.34 for special diets).
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Use of Psychotropic Medications
Children with reported psychotropic
medication use had significantly lower
current use of special diets (OR = 0.69).
DISCUSSION
We found substantially higher rates of
CAM use in children who have classic
autism compared with children and
youth who have Asperger’s or PDD-NOS.
Parents also reported higher rates of
CAM use if their child had certain co-
existing conditions, specifically GI symp-
toms, seizures, or evidence of behavior
problems, although children taking psy-
chotropic medications had lower use of
special diets. This report extends pre-
vious work related to CAM usage among
children and adolescents who have ASD
4–6
by documenting associations of CAM
use with co-existing medical conditions.
The CAM use in this clinical population is
similar to that of children and adoles-
cents who have other chronic health
conditions, although the rates reported
are somewhat lower than in other
studies reporting on children with ASD.
4,5
Our findings may better reflect the
prevalence of CAM use in similar pop-
ulations because interest in the topic
may bias samples of volunteers for
online surveys. Furthermore, our sam-
ple is fairly young, with less exposure to
CAM. Kemper et al
3
reported rates
varying from 30% to 70% among chil-
dren who have chronic conditions. In
another study, 74% of 112 children with
ASD in a referral practice reportedly use
TABLE 1 Characteristics of ATN Participants According to CAM Usage
Characteristic No CAM Usage
a
Any CAM Usage Total
Age, y
2–5 1274 (56) 514 (57) 1788
6–11 765 (34) 297 (33) 1062
12–18 238 (10) 85 (9) 323
Gender
Male 1924 (85) 747 (83) 2671
Female 353 (15) 149 (17) 502
ASD
Autism 1481 (65) 633 (71) 2114
Asperger’s 215 (9) 74 (8) 289
PDD-NOS 581 (26) 189 (21) 770
Caregiver(s)’highest level of education
High school graduate or less 360 (17) 69 (8) 429
Some college 619 (29) 197 (23) 816
College graduate 598 (28) 311 (36) 909
Postgraduate work 573 (27) 275 (32) 848
Missing ——171
Race
White 1738 (76) 732 (82) 2470
Black/African American 195 (9) 31 (3) 226
Asian 116 (5) 46 (5) 162
Other 228 (10) 87 (10) 315
Ethnicity
Hispanic or Latino origin 243 (11) 64 (7) 307
Not of Hispanic or Latino origin 1984 (89) 811 (93) 2795
Missing ——71
Parent-reported GI problems
No 1151 (52) 305 (35) 1456
Yes 1064 (48) 568 (65) 1632
Missing ——85
Parent-reported sleep problems as measured
by using the CSHQ (age ,11 y)
No 566 (33) 219 (31) 924
Yes 1156 (67) 477 (69) 1882
Missing ——367
CBCL internalizing tscore
,70 1632 (76) 602 (71) 2234
$70 523 (24) 249 (29) 772
CBCL externalizing tscore
,70 1796 (83) 688 (81) 2484
$70 359 (17) 163 (19) 522
CBCL total score
,70 1488 (69) 538 (63) 2026
$70 667 (31) 313 (37) 980
Missing CBCL data ——167
Parent-reported history of seizures
No 1916 (85) 678 (76) 2594
Yes 336 (15) 206 (24) 545
Missing 34
Reported psychotropic medication usage
No 1387 (73) 547 (73) 1934
Yes 516 (27) 206 (27) 722
Missing ——517
Data are presented as number (%).
a
Percentages may not add to 100 due to rounding.
TABLE 2 Rates of Specific CAM Usage
Characteristic N
Any CAM 896
Special diets 548
Gluten-free diet 249
Casein-free diet 289
No processed sugars 69
No sugars or salicylates 28
Feingold diet 14
Other specified special diet 293
Other CAM 643
Other vitamin supplements 413
Probiotics 274
Essential fatty acids 171
Digestive enzymes 116
Higher dosing vitamin B
6
and magnesium 99
Chiropractic 77
Amino acids 59
Antifungals 58
Glutathione 33
Chelation 19
Hyperbaric oxygen 12
Acupuncture 10
Sulfation 7
Other specified CAM 173
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CAM, especially dietary supplements
and additions.
10
In 2 pediatric practices,
95% of children used CAM, mainly di-
etary treatments, melatonin, chiropractic
therapy, antifungal agents, and sensory
integration.
11
The initial medical his-
tory regarding CAM use did not specify
melatonin or sensory integration as
CAM treatments, thus leading to lower
rates of identification in this popula-
tion. More than 30% of 284 newly di-
agnosed children with ASD used CAM;
9% of them used potentially harmful
CAM, such as chelation, antibiotics, or
excessive amounts of vitamins.
5
In our
population, a small percentage reported
using CAM treatments that have been
identified as potentially harmful (chela-
tion reported in ,4% of children). In the
report by Levy et al, surprisingly, Latino
children had much higher rates of CAM
use than did white or African-American
children. Our findings are similar to
those of Valicenti-McDermott et al,
6
in a
much smaller sample, in which reports
of food allergies and behavior problems
were associated with increased CAM
use.
How these clinical characteristics of
children affect the use of CAM is unclear,
and our data do not directly address
mechanisms underlying use. Parents of
children who have classic autism may
view their child’s condition as more se-
vere and seek alternative treatments to
complement other care the child re-
ceives. Families seek to address prob-
lematic behaviors or symptoms by using
CAM; therefore, parents whose children
have GI symptoms may particularly try
both dietary changes and other CAM
treatments to improve their child’snu-
trition and symptoms. Dietary and nu-
tritional concerns are among the most
prominent questions that parents ask
about their children who have autism.
Families whose children experience the
feeding problems and food aversion that
are common among children with au-
tism might tend toward nutritional sup-
plementation either to compensate for
perceived dietary deficiencies or as a
primary treatment. Why children who
have seizures have higher rates of CAM
use is unclear, although the presence of
seizures may also indicate more clinical
severity to parents, encouraging them
to seek alternative therapies. Parents
whose children use psychotropic medi-
cations, conversely, may feel that they
have active and somewhat effective
treatments and turn to alternative
treatments less than other families.
This study has several limitations. Es-
sentially all information comes from
parent report, without having confir-
matory information from other observ-
ers or measures of the child’sfindings or
health status. The registry questions
TABLE 3 Associations (ORs) Between Use of Any CAM and Subgroup Categories of Special Diets and “Other”CAM
Factor Exposure Any CAM
(n= 896)
Special Diets
(n= 548)
a
Other CAM
(n= 643)
a
A Versus B
Gender Male Female 0.92 0.96 0.88
ASD Asperger’s Autism 0.81* 0.51* 0.91
PDD-NOS Autism 0.76* 0.70* 0.77*
Parent-reported GI problems Yes No 2.01* 2.46* 1.91*
Parent-reported sleep problems
as measured by using the CSHQ
Yes No 1.07 1.08 0.96
Parent-reported history of seizures Yes No 1.76* 2.16* 1.71*
CBCL internalizing T score Yes No 1.29* 1.39* 1.19*
CBCL externalizing T score Yes No 1.19* 1.29* 1.01
CBCL total score Yes No 1.30* 1.42* 1.14*
Reported psychotropic
medication usage
Yes No 1.01 0.79* 1.14
a
Compared with the no CAM usage group.
* Nominally significant, P,.20.
TABLE 4 Multivariable Associations (ORs) Between Use of Any CAM, Special Diets, or Other CAM
Factor Exposure Any CAM
a
(n= 896) Special Diets
a,b
(n= 548) Other CAM
a,b
(n= 643)
A Versus B
ASD Asperger’s Autism 0.62 (0.46–0.84) 0.44 (0.28–0.69) 0.72 (0.52–1.00)
PDD-NOS Autism 0.66 (0.54–0.82) 0.65 (0.49–0.85) 0.67 (0.53–0.84)
Parent-reported GI problems Yes No 1.88 (1.57–2.25) 2.38 (1.86–3.05) 1.82 (1.50–2.22)
CBCL total score Yes No 1.29 (1.06–1.56) 1.34 (1.04–1.72) NS
c
Parent-reported history of seizures Yes No 1.58 (1.27–1.96) 1.97 (1.50–2.59) 1.66 (1.30–2.10)
Reported psychotropic medication usage Yes No NS
c
0.69 (0.52–0.91) NS
c
a
ORs (95% confidence intervals) from stage 3 model, comparing the outcome with no CAM usage.
b
Compared with the no CAM usage group.
c
Non significant differences.
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regarding CAM did not include a num-
ber of commonly used CAM therapies,
such as melatonin, herbal remedies,
massage, or sensory integration. Thus,
this study may have underestimated
CAM use. Families participating in the
ATN registry represent a population with
generally more access to large medical
centers in large metropolitan areas and
may not be as representative as those
with transportation barriers to re-
ceiving care. Families participating in
the ATN registry may also represent
a group more willing to participate in
clinical research and more oriented to-
ward conventional medicine, which may
not be as representative of CAM users in
general. Several of the measures used
indicate symptoms rather than provide
actual indicators of specific conditions
(eg, the GI symptom questionnaire and
the CBCL). As a cross-sectional study, the
data do not allow any determination of
cause and effect. For example, the study
cannot determine whether GI symptoms
in children led to higher rates of CAM
use or alternatively whether higher
rates of CAM use caused more GI
symptoms. It will help to develop better
longitudinal measures that will allow
determination of the effects of CAM use
on key child outcomes.
This study provides strong evidence
associating certain medical conditions
with differential use of CAM among
families raising children with ASD. As
with other CAM use, it will help to de-
termine more about the potential
synergistic effects of CAM with medical
treatments as well as ways that CAM
use may interfere with improvement
in medical conditions. The review by
Huffman et al
12
also documents the
need for substantially more study of the
efficacy of CAM among children who
have neurodevelopmental disabilities.
The common CAM treatments (ie, spe-
cial diets, vitamin and nutrient supple-
ments) have the potential to affect
conventional treatments recommended
by practitioners operating in the medi-
cal home model, and primary care
providers should inquire about and be
aware of CAM use in their patients and
families.
13
The American Academy of
Pediatrics has called for pediatricians
to establish a dialogue with families
surrounding CAM, encouraged education
of both consumers and clinicians re-
garding CAM, and sought better evidence
of CAM treatments to guide clinical
practice.
14
Our study points out the im-
portance of understanding more about
parents’motivations to use CAM and es-
pecially how their children’s other health
conditions influence those motivations.
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2012;130;S77Pediatrics
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