Journal of Pediatric Psychology, Vol. 26, No. 4, 2001, pp. 215-224
© 2001 Society of Pediatric Psychology
Observational Assessment of Family Functioning at Mealtime in Preschool Children With Cystic Fibrosis
1 Children's Hospital Boston, Harvard Medical School, 2 Children's Hospital Medical Center, Cincinnati College of Medicine, 3 Bradley Hospital, Brown University School of Medicine, 4 Washington State University, 5 Graduate School of Public Health, San Diego State University
All correspondence should be sent to Lori J. Stark, Division of Psychology, Children's Hospital Medical Center, 3333 Burnet Avenue, Cincinnati, Ohio 45229. E-mail: Lori.Stark{at}chmcc.org .
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Abstract |
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Objective: To examine functioning during a dinner meal in families of a child with a chronic illness that requires dietary treatment recommendations, as compared to families of a child without a chronic illness.
Methods: Ratings of seven dimensions of family functioning on the McMaster Mealtime Family Interaction Coding System (MICS) were obtained on 29 families of children with CF and 29 families of children with no chronic illness, ages 2 to 6 years, during a videotaped dinner meal at home.
Results: Ratings of families with a child with CF were significantly lower than those for families of children without a chronic illness on Overall Family Functioning and five of the six MICS dimensions: Communication, Interpersonal Involvement, Affect Management, Behavior Control, and Role Allocation and approached significance on the Task Accomplishment dimension. The ratings of families of a child with CF were in the "clinically significant" range on all subcales, including Task Accomplishment.
Conclusions: This study suggests that family functioning at mealtimes may be different in families of children with CF in which explicit dietary guidelines exist than in families of children with no illness or dietary guidelines. These results are discussed in terms of global family functioning and treatment approaches to dietary treatment recommendations.
Key words: cystic fibrosis; family functioning; dietary recommendations.
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Introduction |
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Feeding young children is an important aspect of parenting that has universal biological and social implications. The responsibility of feeding young children is especially complex in chronically ill populations, given that the management of many pediatric chronic diseases involves adhering to specific, and sometimes restrictive, dietary recommendations (Kedesdy & Budd, 1998
;
Stark, 2000). Within the
context of a chronic illness, the typical parenting task of feeding a
child is complicated because it is also an illness-specific task
necessary in the management of the illness.
Cystic fibrosis (CF) provides an ideal context for examining how a family
system is affected by dietary regiments to ensure the health of the child.
Parents of children with CF must engage in both management of illness-specific
dietary adherence and the typical parenting tasks of feeding. Despite the
importance of maintaining nutritional status in CF, most children with CF are
not meeting prescribed dietary recommendations of 120% to 150% Recommended
Daily Allowance (RDA) and have an energy intake similar to that of nonill
children (Buchdahl, Fullylove, Marchant,
Warner, & Brueton, 1989;
Daniels, Davidson, & Martin,
1987; Stark et al.,
1995; Stark et al.,
1997; Tomezsko, Stallings,
& Scanlin, 1992). In children with CF, weight has been
correlated with health complications, recovery from pulmonary exacerbation
(Roy, Darling, & Weber,
1984), and morbidity (Gurwitz,
Corey, Francis, Crozier, & Levison, 1979). Thus, meeting
dietary requirements and achieving optimal weight are critical to the health
of children with CF (Ramsey, Farrell,
& Pencharz, 1992). However, mealtimes have been found to be
the most frequently cited problem by parents of young children with CF
(Quittner, DiGirolamo, & Winslow,
1991), and meals are perceived as more problematic by parents of
children with CF than parents of children without CF
(Crist et al., 1994;
Sanders, Turner, Wall, Waugh, & Tully,
1997; Stark et al.,
1995; Stark et al.,
1997). Furthermore, eating problems in children with CF have been
associated with family tension and conflict
(Patterson, McCubbin, & Warwick,
1990), suggesting that stress during mealtimes may be higher in
families in which oral intake is part of the treatment, as is the case with
CF.
Parents' success or failure with properly nourishing their child often
determines how parents perceive their own parenting competence and
satisfaction. Thus, if a child eats and develops well, parents may feel
capable and empowered in their parenting role; however, if a child eats
poorly, parents may feel inadequate
(Kedesdy & Budd, 1998). In
addition, interactions at mealtimes may be critical to family emotional health
and child socialization (Feiring &
Lewis, 1987). In families in which a child has a chronic illness
and must follow explicit dietary recommendations, as in CF, mealtimes may take
on added significance as to how parents view their competency. Parents of
children with CF may experience more pressure in getting their children to eat
than parents of children without dietary recommendations. In addition, parents
of children with CF who have poor weight gain and growth may experience
additional pressure to adhere to dietary recommendations. The goal of this
study was to examine family functioning during the mealtime of children with
CF who have dietary requirements versus families of children without a chronic
illness. We were interested in understanding family interactions as well as
how the mealtime task (i.e., serving the meal and feeding the family) was
accomplished. Participants were restricted to one developmental phase,
preschool years, in order to minimize variance in children's eating behavior.
During the preschool years, children are capable of self-feeding. In addition,
children in this age range demonstrate independence in food preferences, while
eating patterns and food choices are strongly influenced by parental factors,
such as the specific foods served, timing of meals, and mealtime rules.
We hypothesized that, given the nutritional requirements of children with CF, families of children with CF would receive lower family functioning scores than would families of children without a chronic illness. Because of the relationship between nutritional status (i.e., weight percentile) and health in children with CF, and associated parental pressures, we hypothesized that ratings of family functioning would be lower for families whose child with CF was at lower weight percentile for age as compared to those at a higher weight percentile for age.
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Method |
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Participants
A sample of 29 preschool children with CF and their families was drawn from a larger sample of 32 children reported on in Stark et al. (1995
). Three children were
excluded from this study because they did not have a nonchronically ill
age-matched control. In this CF sample, 60% of the children were male. In two
of the families, there was a sibling with CF. As CF is a genetic disorder
primarily affecting Caucasians, all subjects were white. Whereas no formal
measure of disease severity was obtained on the CF sample, none of the
children had acute pulmonary exacerbation at the time of participation. In
addition, the sample consisted of 80% of those eligible for participation and
thus was considered to be typical of families of young children with CF. The
mean age was 4 years, 4 months (range: 2 year, 0 months-5 years, 11 months).
The children's weight for age ranged from below the fifth percentile to above
the ninety-fifth percentile, and 70% of the sample fell at, or below, the
fiftieth percentile weight for age.
Twenty-nine healthy children and their families served as controls. They
were matched to the families of a child with CF on age of child (within 12
months), gender (with one exception), number of parents and siblings present
at the meal, and socioeconomic status (SES) within two categories on the
Hollingshead (1975)
Four-Factor Index of Social Status. Fifty-seven percent of the control sample
was male, and subjects ranged in weight from the thirtieth to the
ninety-fourth percentile weight for age. As expected, given the matching
procedure, the two groups did not differ on any of the child factors assessed
(i.e., child gender, child age, number of others present), or on SES scores.
The mean social status index score was 3.67 (SD =.94) for the CF
sample and 4.00 (SD =.93) for the control sample. Although groups
were not matched on parent marital status, both groups were also similar on
this variable. In the CF sample, 21 of the children's parents were married,
and 8 were divorced/separated. In the control group, 24 of the children's
parents were married, and 5 were divorced. Children in both samples were also
comparable on the number of siblings at the meal and living in the home.
Children with CF had an average of 1.36 siblings (SD =.94) and
controls had an average of 1.27 (SD =.79) siblings.
Procedure
Subject Recruitment. Families were recruited for participation in
a larger investigation designed to assess the eating behaviors of children
with CF. Procedures and findings from the larger study have been reported
elsewhere (Stark et al., 1995)
but will be summarized here as relevant. Children with CF and their families
were recruited from CF centers at Rhode Island Hospital, Massachusetts General
Hospital, and the University of California, San Diego Medical Center. The
matched control families were referred by pediatricians and project staff
members and recruited via day care center notices, newspaper articles, and
radio and television announcements. The announcements stated that the study
involved learning more about nutritional intake and mealtime behaviors in
young children and their families.
Home Visits. Home visits were conducted during the family's
evening meal and the entire meal was videotaped. A videocamera was set up by a
research assistant, who then left the room during the meal. To ensure that
videotaped meals were representative, parents rated the similarity of each
videotaped meal to their typical meals on a scale of 1, "not at all
typical" to 4, "very typical." In completing these ratings,
parents were asked to consider the target child's eating behavior and the
general interaction of the family. Evening meals were videotaped until three
meals rated as typical (rating of 3 "typical," or 4 "very
typical") were obtained. The average number of home visits needed to
collect three representative meals was 3.2 (range = 3-6). As previous analysis
of parent and child behavior during mealtime interactions in these families
revealed no significant differences across the three meals
(Stark et al., 1995
Stark et al., 2000), one
videotaped meal (of those rated as typical) was randomly selected and coded
for each family in this study.
Measures
Mealtime Family Interaction Coding System (MICS). Family
functioning ratings were obtained by coding videotaped observations of dinner
meals using the Mealtime Family Interaction Coding System (MICS)
(Dickstein, Hayden, Schiller, Seifer, &
San Antonio, 1994; Hayden et
al., 1998). The MICS is an observational coding system based on
the McMaster Model of Family Functioning
(Epstein, Bishop, & Levin,
1978) and family systems theory. The MICS was adapted from the
McMaster Structured Interview of Family Functioning (MCSIFF) in order to
assess family functioning during an unstructured, naturalistic situation
(i.e., family mealtimes). Construct validity is supported by the fact that the
MICS is correlated with other widely used measures of family/parent
functioning, including the MCSIFF (r =.52), Family Assessment Device
(r =.33), Dyadic Adjustment Scale (r =.29-.33), and
Parent/Caregiver Involvement Scale (r =.38-.56)
(Hayden et al., 1998). The
dimensions coded within the MICS parallel those assessed by other McMaster
assessment devices: Task Accomplishment, Communication, Affective Interaction,
Interpersonal Involvement, Behavior Control, Roles, and Overall Family
Functioning. The final dimension, Overall Family Functioning, is rated in its
own right, according to specified criteria, and does not represent an
averaging of the six preceding dimensions. Definitional criteria of these
dimensions of family functioning are summarized in
Table I. Each of these
dimensions is scored on a 7-point scale ranging from 1 ("very
unhealthy") to 7 ("very healthy"). Each dimension of the
MICS has a clinical cutoff score paralleling those established on the MCSIFF.
Ratings of less than "5" are considered in the "unhealthy
range" and indicative of problematic functioning (e.g., families are
chaotic, there is significant conflict, children/adults have poor behavioral
control, assignment of tasks is ineffective, meals may appear
"forced"). Scores of "5" and greater are considered in
the "healthy range" and are indicative of adequate/good
functioning (e.g., meals are well-planned and well-managed, communication is
clear and direct, basic levels of concern and care are demonstrated, family
members do not seem overburdened by the meal). Data are being collected to
establish the validity of these cutoffs for the MICS. However, one study has
found the MICS useful in discriminating families with maternal depression
(mean rating on the dimension of overall family functioning = 4.75) from
families with no maternal psychopathology (mean rating = 5.36)
(Dickstein et al., 1998).
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In rating the dimensions of the MICS, coders are taught to take notes of significant family interactions observed during the meal and to note their relevance to each of the dimensions. At the first level of coding, coders are trained to first determine for each dimension whether family scores fall in the "unhealty" (score <5) or "healthy" (score >5) range. The second level of coding is to determine for each dimension, where on the "healthy" or "unhealthy" continuum the family's score lies. Families who receive ratings in the "unhealthy" range might be characterized by poor behavior control (or parental disagreements about discipline), indirect and masked communication, explosive affective responsiveness, or inefficient role allocation. To the contrary, families in the "healthy range" show adequate to excellent functioning as they are able to manage behavior and affect, communicate directly and effectively, and coordinate the meal and members' roles. Thus, while ratings are made on a Likert scale of 1 to 7, the distinction between scores of less than 5 are viewed as categorically different than scores of 5 or greater. Coding of interactions begins when the meal starts, as indicated by the presence of food on the table and the initiation of eating by several family members. Coding terminates at the end of the meal or after 20 consecutive minutes.
Coding and Reliability
Coders were trained to reliability of.80 or greater on the MICS by coding
30 previously coded archival videotapes of family meals prior to coding. In
this study, 30% of the meals were double-coded by a second post-doctoral
fellow, who received the training described above. Reliability was assessed
using intraclass correlation. Intraclass correlations are appropriate for
Likert ratings and evaluate exact agreement of ratings, thus avoiding
potentially inflated correlation coefficients resulting from consistent
disagreements between two raters (Winer,
Brown, & Michels, 1991). In this study, intraclass correlation
coefficients were within the acceptable range
(Winer et al., 1991) for each
of the MICS dimensions:.76 (Task Accomplishment),.84 (Communication),.88
(Affective Involvement),.80 (Interpersonal Involvement),.67 (Behavior
Control),.73 (Roles), and.70 (Overall Family Functioning).
Coders were blind to participant health status. However, the blind was broken on five meals when a child with CF took replacement pancreatic enzyme pills during a meal (rather than beforehand). The ratings of these meals were compared to the rest of the sample to evaluate potential bias of rater's codings. The ratings for these five families did not differ from ratings for families in which the blind was maintained on any of the dimensions. For each of the dimensions, the mean rating for the families in which the blind was broken was slightly, but not significantly, higher than for families in which the blind was maintained (t values ranged from.588 to 1.771; all p >.05). Therefore, the data for the families of a child with CF, in which the blind was broken, were included in all analyses.
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Results |
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To examine differences in level of family functioning between the two groups (CF and control families), a Multivariate Analysis of Variance (MANOVA) was conducted using the seven MICS family functioning dimensions as the set of dependent variables. MANOVA results revealed a significant difference between the two groups, Hotellings F(7, 52) = 2.32, p <.05, and indicated significantly lower ratings for the families of children with CF. Subsequent univariate analyses were conducted using one-way analysis of variance (ANOVA). These analyses revealed that the families of children with CF scored significantly lower than the control families on the MICS Overall Rating of Family Functioning, F(1, 56) = 12.56, p =.002, and five of the six dimensions: Communication, F(1, 56) = 10.26, p =.002; Interpersonal Involvement, F(1, 56) = 16.56, p =.002; Affect Management, F(1, 56) = 16.59, p =.001; Behavior Control, F(1, 56) = 4.03, p <.05; and Roles, F(1, 56) = 10.93, p =.002. There was also a trend indicating that the families of children with CF scored lower than control families on Task Accomplishment, F(1, 56) = 3.57, p =.064. The mean rating for each dimension is shown for the families of children with CF and the families of nonchronically ill children in Figure 1. As can be seen in Figure 1, the families of children with CF were consistently rated lower than the families of the nonchronically ill children, and their ratings fell in the "unhealthy" range on all seven of the dimensions.
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The relationship between family functioning and weight status in the CF sample was also examined. Pearson's product-moment correlations indicated no association between weight for age percentile of children with CF and MICS overall rating of family functioning (r =.170).
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Discussion |
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Results from this study extend our previous research on nutrition and CF by using observational methodology to assess family functioning during the dinner meal. The data from this study support and further help us understand behavioral differences during mealtimes between children with and without CF and their families as described in previously published studies (Stark et al., 1995
;
Stark et al., 1997;
Stark et al., 2000).
This study yielded two main findings. First, as hypothesized, ratings of
family functioning during mealtimes were significantly lower in families of
children with CF than in families of nonill children. These data were
consistent across six of the seven McMaster model dimensions. Specifically,
families of nonill children appeared to function more effectively on Overall
Family Functioning, Communication, Affect Management, Interpersonal
Involvement, Behavior Control, and Role Allocation than did families of
children with CF. Families did not differ on Task Accomplishment, with the
task being defined as "serving the meal/child eating" during the
mealtime. Whereas ratings of family functioning were statistically different
for the two groups, the clinical significance of this difference has not been
fully established. The clinical utility of the MICS has shown promise in
distinguishing clinically relevant dimensions indicative of healthy and
unhealthy functioning (Dickstein et al.,
1998), but the validity of these cutoffs are not as well
established for this system as they are for other McMaster assessment
measures, including the McSIFF, from which it was derived. Nonetheless, the
data from this study are consistent with parent report of mealtime stress
(Crist et al., 1994) and
behavioral observation of parent-child interaction
(Stark et al., 2000).
These data, along with previous reports of mealtime stressors and
behaviors, suggest that having a child with CF (as compared to having a child
without a chronic illness) poses unique challenges to the family system,
particularly in the context of the mealtime
(Crist et al., 1994;
Stark et al., 1995;
Stark et al., 2000). During
the meal, parents of children with CF are required to balance
illness-caregiving and general parenting responsibilities. In our
investigation, mealtime task accomplishment and family interaction indices
were compared across families in which providing dinner was perceived strictly
as a normal parenting task (by control families) and in families in which it
was presumably perceived as an illness-specific task, as well as a normal
parenting task (by families of a child with CF). As is the case in the
management of CF and other pediatric illnesses, parents must not only prepare
the meal and ensure that the child eats an adequate amount but also must
encourage children to adhere to specific dietary recommendations. For example,
parents of children with CF must ensure that the child consumes a high-fat,
high-calorie diet to achieve significantly increased levels of RDA. In this
study, the MICS ratings indicated that although families of children with and
without CF were similar in their ability to accomplish the task (i.e., getting
food on the table), family functioning, interpersonal interaction,
communication, and affect regulation were compromised in families of children
with CF. This finding is consistent with several studies that have found that
children with CF have a caloric intake similar to that of nonill children but
well below levels prescribed for optimal nutritional health and disease
management (Buchdahl et al.,
1989; Daniels et al.,
1987; Stark et al.,
1995; Stark et al.,
1997; Tomezsko et al.,
1992). Therefore, this study provides additional data that
following dietary recommendations for CF complicate an otherwise
"typical parenting" task in ways that may negatively affect the
family system and the quality of interactions. Additionally, these findings
further support prior evidence that illness-specific tasks are associated with
greater distress than are typical parenting tasks
(Carter, Urey, & Eid, 1992;
Eiser, Zoritch, Hiller, Havermans, &
Billig, 1995; Kazak &
Marvin, 1984; Quittner, DiGirolamo, Michel, & Eigen,
1992a,
1992b).
Whereas previous research findings indicate mealtimes are a frequently
cited problem for parents of children with CF
(Quittner et al., 1991), our
results suggest that the entire family system may be affected by challenges
imposed by dietary treatment recommendations. In fact, lower family
functioning scores may be explained, in part, by the higher frequency of
behavior management strategies used by parents of children with CF and the
considerable energy they are expending to help their child adhere to
nutritional recommendations as reported in previous studies
(Crist et al., 1994;
Stark et al., 2000). Even in
cases in which nutritional adherence is good, the quality of family
interactions may be compromised to ensure that this task is accomplished
(Stark, Powers, Jelalian, Rape, &
Miller, 1994).
The second finding, contrary to our hypothesis, revealed that the weight of
the child with CF was not related to family functioning at meals. Because
child weight was used as an indirect measure of health status, child weight
for age percentile was hypothesized to be associated with increased level of
parental distress regarding the caloric intake of the child with CF. The
absence of a relationship between child weight and family functioning in this
sample suggests that the child's illness severity may be less important than
the child's illness status in determining the functional impact of dietary
adherence upon the family. Families of children with CF appear to be
challenged equally in their efforts to get their children to eat, regardless
of the child's actual weight. The data suggest that the goal of "getting
children healthy" and "keeping children healthy" may present
similar pressures and tolls on the family system. Indeed, previous studies
have found similar results. "Adequate weight" neither alleviates
the need for children and families to follow recommendations nor ameliorates
parents' fears that their child may experience health complications as a
result of poor adherence (Stark et al.,
1994).
A limitation of this study is the lack of a measure of global family
functioning. Such a measure would be useful in elucidating whether the
differences observed in family functioning during the dinner meal were due to
the families of a child with CF functioning less adaptively in general or only
in response to an illness-related task. Without such a measure, it is possible
that these findings may be due to families of children with CF having less
adaptive functioning in general, and not be just specific to mealtimes.
Although this is a possibility, we would argue that previously published
literature has failed to confirm a relationship between general family
functioning and pediatric chronic illness
(Ievers & Drotar, 1996;
Shepherd et al., 1990).
Furthermore, in our previous description of this sample
(Stark et al., 1995), parents
reported problematic behaviors only on questions specific to eating and not
overall child behavior on the Eyberg Child Behavior Checklist. However, in
order to better understand and differentiate global family functioning from
family functioning within a specific domain, future research should provide a
measure of global functioning in addition to measures of family functioning in
the context of a specific task. Multidimensional assessment of family
functioning in CF will help clarify how broadly families are affected by
demands related to disease management and general parenting issues.
Dietary recommendations are part of almost all pediatric chronic illness
treatment regimens. For example, children with Type 1 diabetes are instructed
to eat at prescribed intervals and to limit their intake of concentrated
sugars to regulate glucose levels. Children with phenylketonuria (PKU) must
avoid foods containing phenylketonuria to prevent brain damage, and pediatric
transplant patients are instructed to avoid foods high in salt and potassium
to optimize health. Future research should also investigate whether the
behavioral differences found between families of children with CF and nonill
children reported in previous research
(Stark et al., 1995;
Stark et al., 1996;
Stark et al., 2000) and
differences in family functioning found in this study are unique to CF or
occur more widely across pediatric chronic illnesses with dietary treatments.
It may be that restricting the consumption of preferred food (e.g., high sugar
content foods in diabetes) might pose different challenges than increasing
overall caloric intake.
This study, conducted on preschool age children, ages 2 to 6, also
highlights the importance of assessing family functioning across various
developmental phases in future research. This phase of development is marked
by rapid changes in child independence and food acceptance. By examining
family functioning in other and perhaps more restricted age ranges, we may be
able to obtain richer information on how family patterns emerge over the
course of the illness. Specifically, family functioning may improve following
diagnosis as parents are able to provide pancreatic enzyme replacement therapy
and children begin to gain weight. Alternatively, family functioning at
mealtimes may decline soon after diagnosis as parents are pressured to quickly
and dramatically change their child's diet. Over time family functioning at
mealtimes may deteriorate as parents become overwhelmed with the day-to-day
challenge of following dietary recommendations as a means of keeping their
child healthy, or family functioning may improve as parents and children
better adapt to treatment routines. Understanding when these patterns emerge
will help to guide the development and implementation of psychological
interventions. In addition, guidelines for clinical interventions may be
better identified if variability and clinical differences were examined within
a chronic illness population. Observational coding of mealtime interactions
may be clinically useful in identifying families who are in the
"unhealthy" or "healthy" ranges of family functioning.
Knowing which families are "at risk" for problematic family
functioning will help inform clinical referrals and interventions. Currently,
the only reported psychological treatment for targeting mealtime interactions
is a behavioral intervention for weight gain in CF
(Stark, Bowen, Tyc, Evans, & Passero,
1990; Stark et al.,
1993; Stark et al.,
1994; Stark et al.,
1996). One next step is to determine whether this existing
behavioral intervention for dietary adherence is effective in improving family
interactions. Family communication may be improved as a result of teaching
parents to use verbal praise and direct commands with children. Alternatively,
if behavioral interventions are not found to be effective in improving family
functioning, future research is needed to determine how a family-based
component of treatment may be developed and implemented.
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Acknowledgments |
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This research was supported by grants awarded to Dr. Lori Stark from the National Cystic Fibrosis Foundation (Z-117) and the National Institutes of Health R01 DK 50092. We thank Susan Dickstein, PhD, for her consultation on this project.
Received February 7, 2000; revision received July 3, 2000; revision received September 19, 2000; accepted September 27, 2000
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