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. Author manuscript; available in PMC: 2025 Nov 1.
Published in final edited form as: Child Neuropsychol. 2024 Feb 13;30(8):1203–1214. doi: 10.1080/09297049.2024.2314957

Differences between Parent- and Teacher-Reported Executive Functioning Behaviors after Traumatic Injuries

Lisa M Gies 1,2, James D Lynch 2,3, KellyAnn Bonanno 1,2,*, Nanhua Zhang 4,5, Keith Owen Yeates 6, H Gerry Taylor 7, Shari L Wade 1,2,5
PMCID: PMC11323218  NIHMSID: NIHMS1966123  PMID: 38348682

Abstract

Deficits in executive functioning (EF) behaviors are very common following pediatric traumatic brain injury (TBI) and can linger well after acute injury recovery. Raters from multiple settings provide information that may not be appreciated otherwise. We examined differences between parent and teacher ratings of EF using data examining longitudinal outcomes following pediatric TBI in comparison to orthopedic injury (OI). We used linear mixed models to determine the association of rater type and injury type with scores on the Behavior Rating Inventory of Executive Functioning (BRIEF). After controlling for demographic variables, rater type and injury type accounted for a small but significant proportion of the variance in EF. Teachers’ ratings on the BRIEF were significantly higher than parent ratings for global EF and metacognition, but not for behavior regulation, regardless of injury type, indicating greater EF concerns. All BRIEF ratings, whether from teachers or parents, were higher for children with TBI than for those with OI. Results suggest that parents and teachers provide unique information regarding EF following traumatic injuries and that obtaining ratings from persons who observe children at school as well as at home can result in a better understanding of situation-specific variability in outcomes.

Keywords: pediatric traumatic brain injury, executive functioning, Behavior Rating Inventory of Executive Function, parent-report measures, teacher-report measures, environmental factors

Introduction

Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in children and adolescents. Fifteen percent of all children will experience a TBI before the age of 15 years (McKinlay, 2014), with a prevalence of over 2.3 million children in the United States (CDCMMWR, 2023). TBI has long-term effects on social, behavioral, and cognitive functioning that persist past childhood and into adolescence and adulthood (Catroppa et al., 2012; McKinlay, 2014).

Social, behavioral, and cognitive outcomes are impacted by executive functioning (EF) deficits, which are among the most common and persistent impairments following TBI (Keenan et al., 2017; Krasny-Pacini et al., 2017; Narad et al., 2017). EF deficits interfere with the child’s ability to effectively and efficiently complete everyday tasks (e.g., navigating social situations, organizing school assignments; Anderson et al., 2012; Perna et al., 2012; Shultz et al., 2016; Treble-Barna et al., 2017). Therefore, impairments in EF often translate into disrupted daily adaptive functioning.

Functional impairment due to EF deficits may depend on the nature of the environmental demands placed on a child. In a school environment, cognitive demands can strain foundational cognitive skills, such as attention and processing speed, as well as EF (Spiegel et al., 2021). Deficits in EF skills can impact learning and contribute to long-term global cognitive deficits and behavioral challenges (Babikian et al., 2015). Cognitive, academic, and interpersonal expectations increase as the child progresses through school (Babikian et al., 2015; Ryan et al., 2016). Though cognitive, social, and behavioral expectations also increase with age in the home setting, schools may impose greater demands on these skills than families, which may result in differences between teacher and parent ratings of children’s EF behaviors.

Previous research suggests that parents may report more impairment in emotion regulation than teachers, whereas teachers report more impairment in metacognitive functioning (e.g., Germano et al., 2017; Silberg et al., 2015; van den Berg, et al., 2018). Schools provide an environment with greater cognitive demands but also more structure and predictability than the typical home environment (Mares et al., 2007; McCann et al., 2014), allowing children to better anticipate transitions and regulate their actions within the school setting. In contrast, children are more likely to express intense emotions of anger and sadness in the comfort of their home rather than in front of peers, possibly because of the emotional connection with their parent after their medical journey (McCann et al., 2014). Thus, the types of EF difficulties identified following pediatric TBI are likely to vary across reporters and settings due to the varying opportunities to observe executive behaviors and the different demands placed on EF in the home and school environments (e.g., with classmates compared to siblings).

A dearth of research exists that directly compares parent- and teacher-reported EF deficits in the TBI population (Gioia et al., 2010). However, parent-teacher comparisons of reported EF deficits in other pediatric populations suggest important differences. This difference may be due to teachers being in a better position to evaluate a child’s metacognitive functioning relative to peers (McCann et al., 2014). In a study comparing children with brain tumors to healthy children, teacher reports revealed more impairment in the children with brain tumors in nearly all aspects of EF—emotion regulation, internal motivation to begin tasks, metacognitive skills (i.e., working memory, planning, and organization), and cognitive and behavioral flexibility—while parent ratings indicated that the brain tumor group had more difficulties only in cognitive and behavioral flexibility (Wochos et al., 2014). Similarly, higher overall levels of difficulties in EF were evident on teacher compared to parent ratings of children with attention deficit hyperactivity disorder (ADHD), which often shares many of the EF impairments as seen in children with TBI (McCandless & O’Laughlin, 2007). In another study of children with ADHD, both parents and teachers recognized difficulties in inhibition and metacognitive skills (e.g., planning and organization), but teacher reports were more elevated (Mares et al., 2007).

The primary aim of the present study was to better understand differences between teacher and parent ratings of EF in children with TBI compared to children with orthopedic injuries (OI) well after the acute injury period. Ratings of EF were obtained an average of 6.8 years postinjury. We hypothesized that, as a group, children with TBI would have more EF difficulties than children with OI and that teachers would rate children as having more difficulties in metacognition (compared to parents), whereas parents would rate children as having difficulties in behavior regulation (compared to teachers).

Method

Study Design

We conducted a secondary data analysis on data collected as part of the Ohio Head Injuries Outcomes (OHIO) study, which examined longitudinal outcomes following early childhood TBI in comparison to OI. The rationale for recruiting children with OI as a comparison group is that they have background characteristics similar to those of children with TBI, including predisposition to injury and potential post-traumatic stress related to their injuries (Hanten et al., 2013; Levi & Drotar, 1999; Maloney et al., 2020; Narad et al., 2020; Shultz et al., 2016). Participants were recruited between 2003 and 2008. The OHIO study received approval by the Institutional Review Board at all participating sites and all participants provided informed consent and/or assent. The OHIO study used a prospective, concurrent cohort design. Data were collected at three children’s hospitals and one general hospital in Ohio. Data from the four hospitals were aggregated and later de-identified. Participants completed assessments at up to six follow-ups, including one a minimum of 24 months postinjury, as well as when the children were preparing to enter or already entered middle or high school (age=10.13–16.96 years). Mean time-since-injury at this last follow-up was 6.8 years (range=4.47–10.58 years). For the present study, we used demographic information and injury characteristics collected at baseline (Table 1). Ratings collected at the last follow-up, after children had entered middle or high school, were analyzed in the present study to assess EF when academic demands are increasing as children are entering or preparing to enter middle school.

Table 1.

Participant Characteristics for Retained Sample (n=144)

Characteristic TBI (n=70) OI (n=74)
Mean Age (years) at Injury (SD) 5.11 (1.13) 5.09 (1.07)
Mean Age (years) 6.8 years postinjury (SD) 11.96 (1.17) 11.88 (1.09)
Male, n (%) 40 (57.1) 39 (52.7)
Race
 White, n (%) 48 (68.6) 57 (77.0)
 Non-White, n (%) 22 (31.4) 17 (23.0)
Ethnicity
 Non-Hispanic/Latino, n (%) 68 (97.1) 69 (93.2)
 Hispanic/Latino, n (%) 2 (2.9) 5 (6.8)
Parent Marital Status – Married, n (%) 38 (54.3) 60 (81.1)
Socioeconomic statusa (SD) −0.13 (0.98) 0.11 (0.93)
Parent-Reported BRIEF T-Scores – 6.8 years postinjury, Unadjusted Mean (SD)
 GEC 59.00 (12.60) 49.33 (10.82)
 BRI 58.67 (14.10) 48.96 (10.01)
 MI 58.19 (11.78) 49.75 (10.75)
Teacher-Reported BRIEF T-Scores – 6.8 years postinjury, Unadjusted Mean (SD)
 GEC 60.02 (15.24) 54.35 (16.59)
 BRI 58.70 (17.10) 51.12 (13.35)
 MI 59.59 (14.08) 55.69 (17.90)
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Note. Race and ethnicity were dichotomous variables (e.g., White versus Non-White); BRIEF=Behavior Rating Inventory of Executive Functioning; GEC=Global Executive Composite; BRI=Behavior Regulation Index; MI=Metacognitive Index; Higher BRIEF scores suggest greater executive dysfunction.

a

z-score considering census tract income and primary caregiver education

Participants

Children ranged from 3 to 7 years of age at the time of injury, and sustained mild, complicated mild, moderate, and severe TBI or OI requiring hospitalization for at least one night due to their injuries. Additional eligibility criteria included the absence of evidence of child abuse as the cause of injury or of a preinjury history of documented neurological problems or developmental delays and English as the primary language in the home. Inclusion in the TBI group required evidence of impaired consciousness—a score less than 15 as measured by the Glasgow Coma Scale (GCS)—or a GCS of 15 if abnormalities on neuroimaging were present. The OI group included children who sustained a bone fracture, other than to the skull, and had no symptoms of TBI.

A total of 102 children with TBI and 119 children with OI were consented to participate in the study at the time of hospitalization. Of the 102 participants with TBI, 15 had a mild TBI (GCS score=13–15 without evidence of a TBI-related neuroimaging abnormality), 64 had either a complicated mild (GCS score=13–15 with a neuroimaging abnormality) or moderate TBI (GCS score=9–13), and 23 had severe TBI (GCS score=3–8). GCS scores were used to define TBI severity, as the GCS has been uniformly applied in grading severity of TBI and was consistently available across participants (Eierud et al., 2014; Williams et al., 1990). We reconsented 144 participants at the 6.8-year follow-up, 93 of whom had complete data (i.e., those with both parent- and teacher-reported data at the 6.8-year follow-up, regardless of GCS). Participants who completed the long-term follow-up did not differ significantly from those lost to follow-up (i.e., those with neither parent- nor teacher-reported data; n=77) on any demographic variables (i.e., age at injury, gender, race/ethnicity, SES, parent marital status). Within the retained sample, participants with complete follow-up data were significantly younger than those with incomplete (i.e., those with either parent- or teacher-reported data; n=51) follow-up data (MComplete=11.7 years, MIncomplete=12.3 years, t=−2.67, p=.009). Additionally, a higher proportion of the participants with complete data were White (82% versus 57%, χ(1) = 9.09, p=.003). Participants with complete versus incomplete data did not differ on any other demographic variables. TBI and OI participants did not significantly differ across any demographic variable aside from parent marital status (χ(1) = 10.68, p < .001). Given the limited number of participants in the TBI group with complete data in the mild and severe TBI subgroups, all participants with TBI were collapsed into a single group for analysis.

Measures

We used the original version of the Behavior Rating Inventory of Executive Function (BRIEF; Gioia et al., 2000) to measure EF behaviors. The parent and teacher versions of the BRIEF both included 86 items that rate EF behaviors by frequency, using “Never”, “Sometimes”, and “Often.” Questions on the BRIEF cover 8 subdomains of EF: Inhibit, Shift, Emotional Control, and Monitor, which comprise the Behavior Regulation Index (BRI), and Working Memory, Plan/Organize, Organization of Materials, and Task Completion, which comprise the Metacognition Index (MI). Combined, the two summary indices form the Global Executive Composite (GEC). Age-normed T-scores on the BRIEF have a mean of 50 with a standard deviation of 10. Higher T-scores suggest higher levels of executive dysfunction, with T-scores greater than or equal to 65 indicating clinically elevated EF behavior problems. The BRIEF has satisfactory internal consistency (α=.80–.98) and validity for parent and teacher forms (Gioia et al., 2000). Scores on the Inconsistency scale indicated acceptable scores (M=1.81, range: 0–9). Scores on the Negativity scale indicated valid BRIEF protocol (M=0.26, range: 0–3). Teacher-reported BRIEF scores were obtained from English-speaking teachers in “core” subjects (e.g., social studies, language arts, math, science) as opposed to elective-based subjects (e.g., art, music, computer class). Parent- and teacher-rated BRI, MI, and GEC scores were analyzed as dependent variables in statistical analyses.

Data analyses

To examine the associations between rater type (teacher versus parent) and injury type (TBI versus OI) with EF difficulties, we utilized linear mixed models with participant-specific random effect to allow for unbiased parameter estimates. Analyses were performed using the ‘lme4’ and ‘lmerTest’ packages in RStudio (2022.07.0), which utilize restricted maximum likelihood estimation modeling (REML) to account for missing data. REML assumes that incomplete data is missing at random. Thus, all 144 participants re-contacted at the ~6.8-year follow-up were included in analyses. We accounted for differences in participants with complete and incomplete data by age and race by controlling for those variables in the REML model. We also accounted for TBI versus OI differences in parent marital status by including it as a covariate. Family SES was also included as a covariate. Models were analyzed separately for each BRIEF score (GEC, BRI, MI). Rater type (teacher=0; parent=1) was included in analyses as a within-person factor and injury type (TBI=1; OI=0) as a between-person factor, with the participant-specific random effect accounting for the inclusion of both teacher and parent ratings on the same participant. Models also included a rater X injury type interaction term. SES was defined by the mean of sample z scores for caregiver self-reported education level and median census income for the area in which the family resided (Gerring & Wade, 2012).

Results

Descriptive characteristics, including average BRIEF scores, can be found in Table 1. Linear mixed model results are presented in Tables 2–4. Rater type was a significant predictor of GEC and MI scores, with teachers reporting higher scores than parents. However, there was no significant effect of rater type on BRI scores. Conversely, GEC, BRI, and MI scores were all significantly associated with injury type, such that children with TBI had higher BRIEF index scores than those with OI. Lastly, family SES was significantly associated with the GEC and BRI indices, such that children of higher SES had lower scores than children of lower SES. Effect sizes for all significant associations were small (0.03–0.10). Race, age at follow-up, and parent marital status were not significantly associated with any of the BRIEF indices. No significant rater by injury type interactions were found for any of the three BRIEF indices.

Table 2.

Linear Mixed Models of BRIEF GEC Scores

B SE t p η2 (partial)
Intercept 46.58 11.09 4.20 <.001
SES −2.39 1.13 −2.12 .04 0.03
Racea −3.72 2.44 −1.52 .13 0.02
Age at Follow-Up 0.79 0.90 0.88 .38 0.004
Parent Marital Status −4.36 2.45 −1.78 .08 0.02
Injury Typeb 7.80 2.22 3.51 <.001 0.06
Rater Typec −5.54 2.00 −2.77 .007 0.05
Injury*Rater 3.54 2.92 1.21 .23 0.01
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Note. Executive functioning scores are represented as T-scores. BRIEF GEC=Behavioral Rating Inventory of Executive Functioning, Global Executive Composite score. Injury*Rater=interaction between injury type and rater type.

a

Race=White versus non-White.

b

Traumatic brain injury (TBI)=1, orthopedic injury (OI)=0.

c

Parent=1, Teacher=0.

Table 4.

Linear Mixed Models of BRIEF MI Scores

B SE t p η2 (partial)
Intercept 48.06 11.15 4.31 <.001
SES −2.15 1.14 −1.88 .06 0.02
Race −3.49 2.46 −1.42 .16 0.01
Age at Follow-Up 0.65 0.90 0.72 .47 0.003
Parent Marital Status −3.83 2.48 −1.55 .12 0.02
Injury Typea 6.70 2.23 3.01 .003 0.04
Rater Typeb −6.37 1.98 −3.22 .002 0.07
Injury*Rater 3.96 2.89 1.37 .17 0.01
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Note. Executive functioning scores are represented as T-scores. BRIEF MI=Behavioral Rating Inventory of Executive Functioning, Metacognition Index score. Injury*Rater=interaction between injury type and rater type.

a

Traumatic brain injury (TBI)=1, orthopedic injury (OI)=0.

b

Parent=1, Teacher=0.

Discussion

EF skills and behaviors are important for functioning following pediatric TBI. The prevalence of long-term EF deficits emphasizes the need to pay particular attention to other factors that may influence reported EF impairment. As such, we set out to examine the effect of parent versus teacher ratings in capturing EF difficulties following pediatric TBI. We hypothesized that teachers would report significantly higher metacognitive difficulties, whereas parents would report significantly higher behavior regulation difficulties. Consistent with hypotheses, we found teachers reported greater difficulties metacognitive skills, as well as in global EF, than parents, regardless of injury type. Contrary to expectations, we did not find differences between parent and teacher ratings of behavior regulation difficulties. Our findings also extend understanding of persistent EF difficulties following TBI. Specifically, we found that TBI was significantly associated with greater EF difficulties in global executive functioning, behavior regulation, and metacognition than OI more than 6 years postinjury. These findings are consistent with previous studies that assess long-term EF deficits following TBI (Keenan et al., 2017; Mangeot et al., 2002; Narad et al., 2017). We also found environmental and demographic factors, such as SES, to be associated with long-term EF difficulties, consistent with previous literature (Lawson et al., 2018; Sarsour et al., 2011; Ursache et al., 2015; Nesbitt et al., 2013; Ready & Reid, 2019). It is important to note that the average BRIEF index scores for both the TBI and OI groups were largely within normal limits; however, they were within the uppermost limits of the normal range for the TBI group, indicating the presence of at least some difficulties. While most children did not demonstrate elevations in EF impairment that are clinically significant, EF difficulties may still be clinically meaningful, especially for those with TBI. These observed difficulties nearing borderline or clinical levels of impairment, although still mostly within normal limits, highlight the persistent, long-term effects of TBI even ~7 years after injury.

The Influence of Rater

The finding of greater teacher-reported metacognitive deficits, compared to parents, suggests that teachers provide a unique perspective in identifying these specific EF deficits. Teachers have more opportunities to observe children’s EF behaviors for tasks that require more metacognitive abilities, like lessons, assignments, or tests. Further, they have a natural reference point of other children in their class when determining whether a specific child’s EF deficits are impairing their performance on cognitive tasks (Chevignard et al., 2017; McCann et al., 2014) which is important when using peer-normed EF measures like the BRIEF. This finding provides important insight into the influence of environmental settings (i.e., school vs. home) on the presentation of EF deficits. Participants were ages 10–16 at this long-term postinjury follow-up, a developmental period typically characterized by more independence as children assume more responsibility for completing tasks with less support from the parent. Academic demands inherently become more difficult as children progress through school, and thus so do cognitive demands. Topics become more complex, and assignments become larger, requiring longer and more extensive study and preparation. As such, EF skills and related cognitive skills such as attentional control, cognitive flexibility, working memory, and planning/organization become more necessary. Importantly, our study demonstrates the unique insights that teachers may have in identifying children, regardless of their injury type, who lack organization, planning, and problem-solving skills relative to their peers, which may be missed by relying solely on parent reports.

Contrary to our hypothesis, we failed to find significant rater differences on BRIEF BRI scores. One explanation is that, while parents and teachers are interacting with children in different settings, behavior regulation is expected both at home and school, and impairments are likely apparent across settings even though manifestations of impairment may be different. Thus, dysregulated behavior could be observed and reported at similar levels by parents and teachers. This result supports a study by Chevignard and colleagues, who also found statistically significant differences between parents and teachers for MI and GEC scores, but not for BRI scores at a mean follow-up period of 4.9 years (Chevignard et al., 2017). Notably, the present study observed a similar pattern of results at a longer follow-up period (6.8 years). Given the consistency between studies regarding this finding, as well as the consistency in rater differences for MI and GEC scores across both studies, these results support the notion that behavioral regulation skills are required to similar degrees across both the home and school settings, making difficulties comparably observable to both types of raters. However, it should be noted that the relative T-score differences between the GEC, MI, and BRI scales (both for parent ratings and teacher ratings) in both the present study and Chevignard et al. 2017 are very small and thus may not be clinically meaningful.

The Influence of Injury Type

Previous research has consistently demonstrated increased EF dysfunction and behavioral and emotional concerns within the first 1–2 years following TBI compared to OI (Keenan et al., 2017; Krasny-Pacini et al., 2017; Mangeot et al., 2002; Narad et al., 2017; Sesma et al., 2008; Wilde et al., 2012). For example, Krasny-Pacini et al. (2017) observed that children who sustained a severe TBI (ages 3 months-14 years) demonstrated persistent GEC, BRI, and MI deficits 24 months post-injury. The results of the present study suggest that initial EF deficits following injury may persist over an extended period across general executive functioning, behavior regulation, and metacognition (Keenan et al., 2018; Mangeot et al., 2002; Narad et al., 2017; Rempe et al., 2023). In the present study, we found that in children who sustained injuries between ages 3–7 years, GEC, BRI, and MI scores were significantly associated with injury type ~6.8 years post-injury. However, we did not find evidence for rater by group differences in the sensitivity of ratings of EF. However, this may be related to the large proportion of missing teacher data that is likely to result in scores closer to the group mean through REML. The few children in the sample with severe TBI may also have contributed to lack of evidence for an interaction effect due to less variation in injury severity. Together, these results suggest a pattern of lingering injury-specific EF deficits over a protracted period in childhood and adolescence following injury. Importantly, this protracted recovery period coincides with the protracted structural and functional development of EF through childhood and adolescence (Anderson et al., 2012; Diamond, 2013; Ferguson et al., 2021).

Limitations

The current findings need to be considered in the context of several important limitations. Within this study, only 27% of participants with complete data were of a minority race, compared to the 35% of the participants with incomplete data. Race, and many other participant characteristics, are intertwined with broader societal constructs that may influence the type of individuals who participate in research and thus the larger population to which findings may generalize. Thus, we were unable to interpret the significant effect of SES since we did not have a robust assessment of social determinants of health. The relatively small number of children with severe TBI (i.e., 23 out of 102 total participants with TBI) may have weakened our ability to examine group comparisons by injury severity. While we know environmental and demographic factors are important to EF skills, the present study did not examine factors other than SES and race. Another limitation to generalization of the findings is that data were collected from hospitals in a Midwestern state, and teacher ratings may have differed had they been collected from a broader range of school systems with greater variability in school structure, supports, and expectations. Finally, this study was conducted prior to the availability of the second edition of the BRIEF (Gioia et al., 2015).

Future Directions

These results address the gap in research on the utility of proxy reports in identifying residual effects of pediatric TBI. Future studies are needed to investigate reporter differences in perceptions of long-term outcomes of TBI in more diverse samples or focus more on associations of EF with environmental factors and social determinants of health, such as SES, race, and ethnicity. Future directions also include analyzing differences between parent and teacher raters at various points in recovery and across all BRIEF subscales to determine effects on specific EF skills in larger samples with increased statistical power. Likewise, parent and teacher reports can be compared across ratings of behaviors besides EF to determine whether rater effects are observed in other aspects of behavior or adaptive functioning following TBI.

The results highlight the usefulness of obtaining ratings of behavior from reporters who have different types of interactions with children with TBI and that account for situational/environmental variability in behavior. By collecting a range of data on a child’s real-world functioning, clinicians can take a more holistic approach to their case considerations. This broad perspective allows for a more thorough interpretation of a child’s deficits, creating insight into the child’s functioning, areas of improvement, and response to interventions designed to target EF deficits in both environments.

Conclusion

Pediatric TBI is accompanied by a range of long-lasting effects, especially impacting complex cognitive skills, such as EF behaviors. Differences in observed deficits reported by teachers and parents highlight the potential utility of obtaining reports from multiple informants. Results showed that different observers provide unique insights into EF skills following both TBI and OI and are thus useful in gaining a better understanding of a child’s range of deficits following injury.

Table 3.

Linear Mixed Models of BRIEF BRI Scores

B SE t p η2 (partial)
Intercept 45.86 10.85 4.23 <.001
SES −2.33 1.09 −2.14 .03 0.03
Race −3.59 2.36 −1.52 .13 0.02
Age at Follow-Up 0.78 0.88 0.89 .37 0.004
Parent Marital Status −4.11 2.36 −1.75 .08 0.02
Injury Typea 8.01 2.22 3.61 <.001 0.10
Rater Typeb −2.82 2.16 −1.30 .20 0.01
Injury*Rater 1.83 3.15 0.58 .56 0.003
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Note. Executive functioning scores are represented as T-scores. BRIEF BRI=Behavioral Rating Inventory of Executive Functioning, Behavior Regulation Index score. Injury*Rater=interaction between injury type and rater type.

a

Traumatic brain injury (TBI)=1, orthopedic injury (OI)=0.

b

Parent=1, Teacher=0.

Disclosures:

The research reported here was supported by grant R01 HD42729 from NICHD, in part by USPHS NIH Grant M01RR 08084, and by Trauma Research grants from the State of Ohio Emergency Medical Services, all to Dr. Wade. The project described was also supported by the National Center for Research Resources and the National Center for Advancing Translational Sciences, National Institutes of Health, through Grant 8 UL1 TR000077-04. The content is solely the responsibility of the authors and does not necessarily represent the official views of the NIH. Dr. Yeates received support from career development grant K02 HD44099 from NICHD. For the remaining authors, no conflicts were declared.

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