Journal of Pediatric Psychology, Vol. 25, No. 3, 2000, pp. 171-178
© 2000 Society of Pediatric Psychology
Response to Hypo- and Hyperglycemia in Adolescents With Type I Diabetes
University of Florida Health Sciences Center
All correspondence should be sent to Suzanne Bennett Johnson, Center for Pediatric Psychology and Family Studies, University of Florida Health Science Center, P.O. Box 100165, Gainesville, Florida 32610-0165. E-mail: sjohnson{at}hp.ufl.edu .
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Abstract |
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Objective: To assess the appropriateness of adolescents' responses to hypo- and hyperglycemia and to examine the relationship of patient age, gender, diabetes duration, diabetes knowledge, parental supervision, and glycemic control to response appropriateness.
Methods: We assessed 125 adolescents' responses to daily episodes of hypo- and hyperglycemia by 24-hour recall interviews; responses were coded for type and appropriateness.
Results: Adolescents responded inappropriately to 38% of hypoglycemic and 29% of hyperglycemic episodes. Parental supervision of blood glucose testing did not increase the likelihood of an appropriate response; in the case of hyperglycemic episodes, it appeared to be counterproductive. Adolescents who responded inappropriately to hyperglycemia were also older but not different from those who responded appropriately by gender, disease duration, diabetes knowledge, or glycemic control.
Conclusions: Health providers and family members may underestimate adolescents' difficulty managing hypo- and hyperglycemia appropriately. The presence of parental supervision does not ensure an appropriate response; parents may be particularly misinformed about the management of hyperglycemia.
Key words: Type I diabetes; hypoglycemia; hyperglycemia; adolescents; parental supervision.
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Introduction |
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Blood glucose levels in individuals without diabetes are maintained within a relatively consistent and narrow range (80-120 mg/100 ml) because the pancreas automatically produces insulin in response to any rise in blood glucose. Youths with Type I (insulin-dependent) diabetes mellitus (DM) suffer from pancreatic failure, and insulin replacement by daily injections is necessary for their survival. Although the goal of treatment is to maintain near normal blood glucose levels, exogenous insulin therapy only approximates normal pancreatic function. Consequently, overdosing and underdosing of insulin does occur, leading to hypoglycemia (excessively low blood glucose levels) and hyperglycemia (excessively high blood glucose levels) (Beaser, Garbus, & Jacobson, 1996
). Due to the interactions between food intake, exercise,
illness, stress/emotional state, and insulin availability, blood glucose
levels in children and adolescents with Type I DM can and do vary.
Hypoglycemia can have rather immediate, neurologically adverse effects
because the brain depends on glucose for normal functioning
(Holmes, O'Brien, & Greer,
1995); negative mood states and cognitive dysfunction are common.
If not treated with a high-carbohydrate food or drink, severe hypoglycemia may
lead to seizures, coma, and possibly death. Unfortunately, severe hypoglycemia
is relatively common. Daneman, Frank, Perlman, Tamm, and Ehrlich
(1989) found that 31% of
children experienced one or more severe hypoglycemic episodes (involving coma
or convulsions) since Type I DM diagnosis. A more recent study found that
severe hypoglycemic events occurred in 8.5% of children and moderate events
(requiring outside assistance but not leading to coma or seizures) occurred in
26.9% over a 3-year period (Davis, Russell,
Keating, Jones, & Byrne, 1997). Studies estimating the yearly
incidence of hypoglycemia have reported rates of 13.1 per 100 children for
moderate events and 4.4-7.4 per 100 children for hypoglycemic coma
(Davis et al., 1997;
Egger, Gschwend, Smith, and Zuppinger,
1991).
Although hypoglycemia can be avoided by maintaining high blood glucose
levels, such an approach is medically contraindicated. There is now good
evidence that hyperglycemia results in a number of serious complications
associated with diabetes of long duration: blindness, heart disease, kidney
failure, neuropathies, and limb amputations
(Diabetes Control and Complications Trial
Research Group, 1993).
Further, when hyperglycemia is associated with underdosing of insulin,
ketosis (the breakdown of body fat) occurs; in severe cases, diabetic
ketoacidosis (DKA) may result. DKA is a very serious acute complication of
Type I DM and is particularly common in youths, with annual incidence rates of
5.4 per 100 youngsters younger than 15 years of age
(Faich, Fishbein, & Ellis,
1983). It is the major cause of hospitalization in this population
(Fishbein & Palumbo,
1995). As many as 9%-14% of youngsters in DKA die, a sobering
statistic (Harris, 1995). In
contrast, youngsters rarely die of hypoglycemia. DKA can generally be
prevented as ketones appear in the urine before full-blown DKA develops
(Travis, Brouhard, & Schreiner,
1987).
Managing Type I DM clearly requires a "balancing act" in which
blood glucose is regularly monitored and appropriate action taken when
episodes of hypo- or hyperglycemia occur. Adolescents are usually expected to
monitor their own blood glucose levels and make management decisions on their
own (Ingersoll, Orr, Herrold, &
Golden, 1986). Although adolescents often have better cognitive
understanding of their disease than younger children, they experience less
parental supervision and are generally less adherent with the numerous daily
requirements of diabetes management (see
Johnson, 1995, for a review).
Clinical practice recommendations published by the American Diabetes
Association (1996,
1998) address the importance of
having the patient make appropriate management decisions based on regular
blood glucose monitoring. However, there are no published studies examining
adolescents' actual behavior in this regard.
This study examined adolescents' responses to episodes of hypo- and hyperglycemia that occurred over a 3- to 6-week study interval. Adolescents who responded appropriately were then compared to those who responded inappropriately in an effort to discern possible differences in patient age, gender, disease duration, knowledge about diabetes, parental supervision, and glycemic control. We expected that adolescents who were more knowledgeable about diabetes might respond more appropriately. Because diabetes knowledge increases with age and girls mature more quickly than boys, we expected older youngsters and girls might exhibit more appropriate responses. We expected those who were more closely supervised by their parents might be more likely to respond appropriately. We expected those in better glycemic control might be more experienced with hypoglycemic episodes and, as a consequence, might evidence more appropriate responses. Because the youngsters in this study all had diabetes for two or more years, we did not expect disease duration to be related to the appropriateness of the adolescents' responses.
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Method |
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Participants
The participants in the study were 125 (62 males, 63 females) 10-17-year-old (M = 13.6 ± 2.0 years) adolescents with Type I DM; they were part of a larger, National Institute of Health-supported study examining the impact of change in pubertal status and diabetes management behaviors on glycemic control during the adolescent developmental period. Youngsters were required to have Type I DM for at least 2.0 years (M = 6.4 ± 2.9) so as to exclude those who might have some remaining endogenous insulin. Other inclusion criteria included access to a telephone to allow adherence data to be collected by 24-hour recall interview. Adolescents were recruited from diabetes clinics in north Florida; 91% of all adolescents and parents approached agreed to participate. Over 90% of the adolescents were Caucasian (Type I DM is more common in Caucasians than other racial groups), 79% were living in twoparent families, and 58% of mothers had at least some college education. The project was approved by the University of Florida Health Science Center Institutional Review Board. Informed consent was obtained from parents; assent from the adolescents.
Measures
24-Hour Recall Interview. The 24-hour recall interview has
previously been employed to assess 13 different adherence behaviors in this
population; both reliability and validity data have been reported
(Freund, Johnson, Silverstein, &
Thomas, 1991; Johnson, Freund,
Silverstein, Hansen, & Malone, 1990;
Johnson et al., 1992;
Johnson, Silverstein, Rosenbloom, Carter,
& Cunningham, 1986;
Reynolds, Johnson, & Silverstein,
1990). The procedure requires the youth and a parent to
independently recall the previous day's events in temporal sequence from the
time the youngster woke up in the morning until the time the youngster retired
to bed. The youngster describes his or own behavior; the parent describes the
youth's behavior.
In this study we adapted the 24-hr recall method to examine the
adolescent's response to any episode of hypo- or hyperglycemia. Hypoglycemia
was defined as a blood glucose testing result 
60 mg/dl and hyperglycemia
was defined as a blood glucose testing result 
240 mg/dl. If, over the
course of a 24-hr recall interview, the adolescent (or parent) reported a
blood glucose testing result in the hypo- or hyperglycemic range, the
interviewer noted any spontaneous mention of a specific response to the blood
glucose testing result. Following standard 24-hr recall interview procedures
(to minimize memory-related omission errors), if no response was spontaneously
described, the interviewer prompted the respondent with a query. The
interviewer also noted whether the youngster (or parent) reported that the
parent observed the youngster's blood glucose test. In this sample, parent and
adolescent reports of blood glucose testing frequency showed moderate
agreement (r =.69, p <.0001). Parent and adolescent
reports as to whether a parent observed a youngster's blood glucose test also
showed moderate agreement (r =.69, p <.0001). Since
failure to recall events is the primary source of error with recall methods,
both parent and adolescent informants were combined in the following manner:
if either informant reported a response, it was accepted. For example, if the
adolescent reported a blood glucose test but the parent did not, the child's
report was accepted. In our adolescent sample, parents were often unable to
provide information as to the actual test result or if the adolescent did
anything specific in response. Consequently, when informant data were
combined, adolescents provided a greater proportion of the information than
did parents.
Glycemic Control. Glycosylated hemoglobin (HgbA1c), an index of
average blood glucose over the past 2 to 3 months
(ADA, 1998) was assayed using
high performance liquid chromatography at a single laboratory (Shands Clinical
Chemistry Labs: reference range: 4.3-6.1%); mean HgbA1c was 9.7% (SD
= 1.9).
Data downloaded from One Touch II blood glucose testing meters, used by the adolescents to monitor their blood glucose levels at home, were used to calculate frequency of blood glucose testing, mean blood glucose, and blood glucose variability (standard deviation). This sample tested an average of 2.8 (SD = 1.0) times per day; mean blood glucose was 215.7 mg/dl (SD = 53.1) and mean blood glucose variability (standard deviation) was 104.4 mg/dl (SD = 19.4).
Diabetes Knowledge. The Test of Diabetes Knowledge (TDK) includes
a 39-item General Information (i.e., facts about diabetes) and a 36-item
Problem Solving (i.e., how to apply those facts in specific situations)
component (Johnson et al.,
1982). Internal consistency estimates for this sample were
adequate (coefficient 
=.90 for Total Score,.87 for General
Information,.83 for Problem Solving). For the purposes of this study, the
eight TDK items relating specifically to knowledge of hypoglycemia and the six
items examining knowledge of hyperglycemia were scored separately. Internal
consistency estimates for the extracted subscales were adequate for
hypoglycemia ( =.71) and hyperglycemia ( =.63).
Procedures
At study entry, adolescents completed the TDK and were instructed in the
use of the One Touch II home blood glucose testing meter. They were given a
home-testing schedule designed to assure a representative sampling of blood
glucose levels across the day.
During a 3-6-week interval, adolescents followed the testing schedule at home using the One Touch II meter. They were contacted by telephone on up to 12 different occasions (M = 10.5 interviews) to conduct a 24-hour recall interview. Each adolescent's parent was interviewed independently about his or her child's behavior during the same 24-hr periods. Two-thirds of the interviews focused on weekdays and one-third focused on weekends. During each 24-hour recall interview, the results of all blood glucose tests and any specific response to a hypo- or hyperglycemic blood glucose test result were recorded. The interviewer also noted whether the parent had observed the blood glucose test. When participants returned to the clinic, data stored in the One Touch II meters were downloaded, blood samples were collected for HgbA1c assay, and adolescents were paid $50 for their participation.
Coding of Responses to Hypo- or Hyperglycemic Test Results
Adolescent responses to hypo- or hyperglycemic test results obtained from
the 24-hr recall interviews were coded by response type (e.g., ate a simple
sugar, drank water, checked ketones) and appropriateness, based on ADA
recommendations (1996). This
behavior coding system is presented in
Table I. All responses were
coded by two raters, with 93% agreement.
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Results |
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Responses to Hypoglycemia and Hyperglycemia
First, the frequency and type of appropriate and inappropriate responses to episodes of hypo- and hyperglycemia obtained from the 24-hour recall interviews were examined for the group as a whole. Adolescents failed to respond appropriately to 38% of the episodes of hypoglycemia. Inappropriate responses included checking ketones (25% of the episodes) or doing nothing at all (14% of the episodes). In response to hyperglycemia, adolescents responded appropriately by checking for ketones 64% of the time, but after 29% of the episodes, the adolescent did nothing at all. Although inappropriate response to hypoglycemia was somewhat more common than inappropriate response to hyperglycemia, this difference was not statistically significant,
2 (1) = 2.37, p <.13.
To examine whether parental supervision influenced the appropriateness of
response, we categorized episodes of hypoglycemia and hyperglycemia as
supervised or unsupervised. Inappropriate responses to hypoglycemia were
somewhat more likely to occur when the adolescent was unsupervised (42% of
inappropriate responses were unsupervised compared to only 24% of the
appropriate responses); however, this effect was not statistically
significant, 2 (1, n = 68) = 2.57, p
<.11. Examination of supervised versus unsupervised responses to
hyperglycemia yielded a highly significant 2 (1, n =
440) = 11.43, p <.001, but the effect was opposite to that
predicted. Inappropriate responses to hyperglycemia occurred in an
unsupervised situation only 35% of the time. In contrast, appropriate
responses to hyperglycemia occurred in an unsupervised situation 53% of the
time. We explored this finding further by examining the most common
inappropriate response to hyperglycemia, doing nothing. Similar findings
emerged: when the child was observed and had a high blood glucose test result,
34% of the time the child did nothing. However, doing nothing was actually
less common when the child's high blood glucose test result occurred
in an unsupervised situation (only 21% of the time the child did
nothing), 2 (1, n = 452) = 10.05, p
<.002. When we examined the most common appropriate response to
hyperglycemia, ketone testing, the same findings emerged. Adolescents were
more likely to test their ketones after a blood glucose result 240 mg/dl
in an unsupervised situation (74% of time) than a supervised situation (51% of
the time), 2 (1, n = 452) = 25.21, p
<.001. It is perhaps worth noting that hypoglycemic episodes were
supervised by parents more often (69% of all such episodes) than hyperglycemic
episodes (52%), 2 (1, n = 508) = 6.74, p
<.009.
Comparison of Appropriate and Inappropriate Responders
Next, the adolescents were divided into two groups: those who were
predominantly appropriate responders to hypoglycemia (defined as responding
with appropriate behaviors to 75% of the hypoglycemic episodes) and those
who were predominantly inappropriate responders to hypoglycemia (defined as
responding appropriately <75% of the time). Appropriate and inappropriate
responders to hyperglycemia were identified in a similar fashion. However, to
eliminate the possibility that an adolescent might be categorized as an
appropriate or inappropriate responder based on only a single hypoglycemic (or
hyperglycemic) episode, we included adolescents in this analysis only if they
reported 2 episodes of hypoglycemia (or hyperglycemia) across all of the
24-hour recall interviews. This procedure reduced the sample size: there were
49 appropriate responders and 15 inappropriate responders to hyperglycemia but
only 7 appropriate responders and 4 inappropriate responders to hypoglycemia.
Table II provides comparison
data for age, gender, disease duration, measures of glycemic control, diabetes
knowledge, and parental supervision. Only age was a significant predictor;
appropriate responders to hyperglycemia were younger than
inappropriate responders, t(62) = 2.09, p
<.04.1 Logistic
regression was used to assess whether a combination of variables would predict
group assignment. Both age (p <.02) and parental supervision
(p <.03) proved to be significant predictors, 2
(2, n = 64) = 9.68, p <.008; older age and greater
parental supervision were associated with classification as an inappropriate
responder to hyperglycemia.
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Discussion |
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This is the first study, to our knowledge, that specifically examined adolescents' responses to hypoor hyperglycemic events occurring in the youth's natural environment. We were surprised to learn that adolescents responded to 38% of hypo- and 29% of hyperglycemic episodes in an inappropriate manner. The frequency of inappropriate response to hypoglycemia is of concern since untreated blood glucose levels <60 mg/dl can rapidly lead to severe consequences including hypoglycemic seizures. After 14% of the episodes, the adolescent did nothing at all. But, after 25% of these episodes, the adolescent tested for ketones, suggesting substantial confusion as to when ketones should be tested. It was as if the adolescent were trying to respond to the episode but selected the wrong response. Whether this was a product of some confusion associated with the hypoglycemia per se is unknown. However, misconceptions about the purpose of ketone testing may be a more likely explanation.
Doing nothing at all was actually a more common response to hyperglycemia
(29% of episodes). Youngsters responded appropriately by testing for ketones
when their blood glucose was extremely high 64% of the time. Nevertheless,
there were clearly many missed opportunities in this regard, suggesting that
more could be done with this population to better prevent episodes of DKA. As
was indicated previously, DKA is a very serious acute complication of Type I
DM, is particularly common in youths, is the major cause of hospitalization in
this population and a leading cause of death
(Faich et al., 1983;
Fishbein & Palumbo, 1995).
DKA can generally be prevented as ketones appear in the urine before
full-blown DKA develops; hence, the recommendation is that youngsters test for
ketones when their blood glucose values are high
(Travis, Brouhard, & Schreiner,
1987).
Although we expected good knowledge about diabetes and its management would be associated with more appropriate hypo- and hyperglycemia management; this hypothesis was not supported by the data. Even hypo- and hyperglycemia specific knowledge levels were not associated with more appropriate responses. Most youngsters showed excellent knowledge about hypoglycemia as measured by a multiple-choice test, but this knowledge was not translated into daily practice. Test-related knowledge about hyperglycemia was more variable but was unrelated to the appropriateness of youngsters' responses to hyperglycemic episodes in daily life. We expected that parental supervision of blood glucose testing would be associated with more appropriate responses to both hypo- and hyperglycemia. We found that hypoglycemic episodes were more often supervised by a parent than hyperglycemic episodes. It may be the case that parents prompt adolescents to conduct a test when they think the youngster is low or the adolescent is more likely to seek parental assistance when a low blood glucose reading occurs. However, parental supervision was not a strong predictor of whether or not a youngster would respond appropriately to a hypoglycemic episode. Although inappropriate responses to hypoglycemia were somewhat more likely to occur when the adolescent was unsupervised, this effect was not statistically significant.
In contrast, parental supervision was a significant predictor of response to hyperglycemia but in a direction counter to that predicted. Both ways we analyzed the data yielded similar results. When we examined all episodes of hyperglycemia, we found that supervised episodes were associated with more inappropriate responses than unsupervised episodes. When we categorized youngsters as appropriate or inappropriate responders based on their response to multiple hyperglycemic episodes, we also found that inappropriate responders were supervised more than appropriate responders. Because adolescence is a time of transition of responsibility for diabetes care from the parent to the child, it is possible that insufficient time and energy is devoted to ensuring that parents have adequate knowledge about how to respond appropriately to hyperglycemia. During the adolescent years, education is focused primarily on the patient rather than the parent. In an unsupervised situation, the adolescent may be more likely to rely on instruction received in clinic about how to respond to hyperglycemia. In a supervised situation, the adolescent may be more willing to follow the patent's lead; if the parent does not insist that a ketone test be conducted, the youngster may go along with doing nothing at all. Parents, in turn, may not insist on ketone testing because a single hyperglycemic episode does not pose the same immediate threat to the child as a single hypoglycemic episode. Or, since the focus of diabetes education is now on the patient, the parent may be ignorant of the importance of ketone testing and fail to insist on this response in the child. Certainly, the apparent confusion about appropriate hyperglycemia management exhibited by both study adolescents and their parents may create a situation ripe for parent-adolescent conflict. The actual process of how an adolescent and parent arrive at a decision about hyperglycemia (or hypoglycemia) management would make an interesting topic for a future investigation.
Although adolescence is a time of increased cognitive conceptual capacity,
we did not find appropriate responders to hyperglycemia to be older than the
inappropriate responders. In fact, quite the opposite occurred. Those who
exhibited consistently appropriate responses to hyperglycemia were younger
than those who did not. Although we initially thought the age effect was
actually a supervision effect (i.e., younger adolescents receive more parental
supervision and as a consequence may be more likely to respond to
hyperglycemia appropriately), logistic regression failed to support this
interpretation of the data. Both patient age and parental supervision
predicted who was and who was not an appropriate responder to hyperglycemia.
The addition of supervision to the model only increased the significance of
the age effect, and the supervision effect was counter to what was expected
(i.e., inappropriate responders actually received more parental supervision,
independent of the child's age). Numerous previous studies have documented
poorer diabetes management during adolescence despite increased knowledge
about the disease during this developmental period (see
Johnson, 1995, for a review),
and this may be yet another example of this phenomenon.
Study limitations include the restricted age range and the requirement of diabetes duration of greater than 2 years. This study tells us nothing about the adequacy of parent and child responses to hypo- and hyperglycemia in young children and those with newly diagnosed Type I DM; both are populations that are more likely to receive more intensive education and supervision by the medical staff and as a consequence may respond to hypo- and hyperglycemia more appropriately. The study was also limited by the small number of adolescents who experienced hypoglycemia with sufficient frequency to permit classification as an appropriate or inappropriate responder.
Subsequent to the widespread dissemination of findings from the Diabetes
Control and Complications Trial Research Group
(1993,
1994), there is increasing
pressure on adolescents to adopt a more intensive approach to diabetes
management to produce glycemic control closer to the normal range in order to
prevent the long-term complications associated with diabetes (retinopathy,
neuropathy, nephropathy, heart disease). However, with improved glycemic
control, the incidence of hypoglycemia increases (Diabetes Control and
Complications Trial Research Group,
1993,
1994). We are concerned that
health providers and family members may underestimate adolescents' difficulty
managing hypo- and hyperglycemia appropriately. The appropriate use of urine
ketone testing seems to be one area of particular confusion. Some adolescents
tested for ketones in situations of hypoglycemia, an inappropriate response.
Other adolescents failed to test for ketones when experiencing significant
hyperglycemia, a situation in which ketone testing is recommended. The
parental supervision effects in cases of hyperglycemia, which ran counter to
predictions, are also cause for concern. Parents may need to be better
educated about appropriate responses to hyperglycemia so that their
supervision may be helpful rather than counterproductive. During the
adolescent years, health providers tend to focus their educational activities
on the youngster who is taking increasing responsibility for his or her own
diabetes care. It may be important to continue parental involvement in these
educational sessions to assure that what is taught to the adolescent in clinic
is not inadvertently undermined by well-meaning but misinformed parents.
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Acknowledgments |
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This study was supported by grant no. R01 HD13820 from the National Institute of Child Health and Human Development and General Clinical Research Center grant no. RR00082 from the National Institute of Health. We thank Bobby Chambers, Cheryl Halpern, Mary Halstead, Nelly Mauras, Doreen Radjenovic, Janet Silverstein, Shawn Prichard, Ken Tercyak, Lorraine Weatherspoon, Archana Vasathakumar, and Suresh Venkumahanti for their assistance with data collection, management, and analysis. One Touch II blood glucose testing meters were provided by Lifescan.
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Notes |
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1 Inspection of Table II indicates that those with sufficient numbers of hypoglycemic episodes ((2) to be classified as appropriate versus inappropriate responders to hypoglycemia (n = 11) were in better glycemic control (lower glycosylated hemoglobin levels, lower mean blood glucose, lower blood glucose variability) than those with sufficient numbers of hyperglycemic episodes (
2) to be
classified as appropriate versus inappropriate responders to hyperglycemia
(n = 64). This finding is expected since better glycemic control is
associated with more frequent episodes of hypoglycemia. 
Received November 23, 1998; revision received June 11, 1999; accepted July 28, 1999
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M. M. Black Society of Pediatric Psychology Presidential Address: Opportunities for Health Promotion in Primary Care J. Pediatr. Psychol., October 1, 2002; 27(7): 637 - 646. [Abstract] [Full Text] [PDF]
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