PEDIATRICS Vol. 109 No. 6 June 2002, pp. 1136-1142
Enhancing Their Likelihood for a Positive Future: The Perspective of Inner-City Youth
* Craig-Dalsimer Division of Adolescent Medicine University of Pennsylvania School of Medicine
Division of Biostatistics and Epidemiology, Department of Pediatrics, Children’s Hospital of Philadelphia; University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
Urban Initiative and the Mayor’s Children and Families Cabinet, Philadelphia, Pennsylvania
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ABSTRACT |
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 TOP ABSTRACT INTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Inner-city youth must overcome many environmental challenges as they strive for success. Their outcome is influenced by the interplay of protective forces and risk factors.
Objective. To learn directly from youth what solutions they believe would most influence their likelihood of achieving a positive future.
Design. In-school 8th-, 9th-, and 12th-graders in north Philadelphia generated, prioritized, and explained their own solutions through a 4-stage hierarchical process facilitated by AmeriCorps workers. In Stage 1, 60 randomly selected students participated in 8 focus groups to develop the study question. In Stage 2, youth in Nominal Group Technique sessions generated and prioritized solutions. In Stage 3, a survey for each grade that included their top prioritized ideas was distributed, and youth rated each idea on a Likert scale (5= Definitely would make me more likely to have a positive future to 1 = Would definitely not...). One thousand twenty-two ninth-graders (69% of in-school youth at 5 high schools) returned usable surveys. Ninety-three percent of responders were 14 to 16 years old, 44% were male, 54% were black, and 32% were Latino. Four hundred seventeen 8th-graders and 322 12th-graders returned usable surveys. In Stage 4, youth in 10 focus groups added meaning and context to the ideas.
Results. The highest rated items in all grades were solutions that promoted education or increased job opportunities. Ninth-graders ranked helping youth get into college first by the Marginal Homogeneity Test. The creation of more jobs was ranked second. Third rank was shared by more job training, keeping youth from dropping out of school, and better books for schools. The next tier of items focused mostly on opportunities for youth to spend their free time productively and to have interactions with adults. Many items calling for the reduction of risk behaviors or disruptive surroundings were rated lower. The Kruskal-Wallis test found little variation in rating of the ideas by gender, race, or socioeconomic status.
Conclusions. Youth believe that supportive solutions would do more to enhance their likelihood of reaching a positive future than would attempts to reduce "negative" behaviors or disruptive surroundings. This suggests that research and policies should consider how best to augment the protective influences of education, employment, meaningful use of time, and connection to adults.
Key Words: adolescent • poverty • education • resiliency • focus groups • survey
Abbreviations: NGT, Nominal Group Technique
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INTRODUCTION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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All adolescents face challenges as they fulfill their developmental task of achieving autonomy and independence. Youth living in urban areas of concentrated poverty need to overcome all of the challenges inherent in adolescence while navigating through the obstacles imposed by an often precarious environment.
The factors that have greatest effect on the morbidity and mortality of adolescents are behaviorally related.1–3 It is known that there is a wide range of risk within all cohorts of youth, with those at greatest risk participating in multiple interrelated risk behaviors, whereas others maintain a healthy lifestyle.2 There is an increasing interest in looking at youth that have successfully negotiated risky environments to learn from them what protective factors may have promoted their healthier development.4–9 Furthermore, there is growing acknowledgment that although the absence of risk may diminish morbidity and mortality, it cannot be the final goal. A popular motto within the youth development field is "problem-free is not fully prepared."10,11
As part of the planning process for a Robert Wood Johnson Urban Health Initiative grant, the Mayor’s Children and Families Cabinet of the City of Philadelphia considered strategies to address violence and teen pregnancy in north Philadelphia. An advisory panel that included city officials, representatives from the school district, and community members concluded that although adults perceived violence and teen pregnancy as the 2 major problems affecting youth well-being, it was not clear that adolescents agreed. In response, this team was charged to uncover the factors youth perceived impeded or promoted adolescent success.
The objective of this study was to learn directly from a cohort of urban youth what factors they believed would make the most difference in influencing whether they would have a positive future. It used a teen-centered methodology that allowed adolescents to develop, prioritize, and explain their own ideas.12,13
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METHODS |
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Study Population
The study population consisted of all 9th- (N = 2800) and 12th-grade (N = 995) students in 5 high schools and all 8th-grade students (N = 905) in 4 middle schools in Philadelphia in 1997. The eighth grade was chosen to attain the views of the region’s oldest middle school students. The ninth grade was chosen because it is the most inclusive high school grade, including higher-risk youth likely to drop out. The senior class was included, because its members represent some of the most successful adolescents in the community.
According to the Youth Risk Behavior Survey, Philadelphia’s adolescents participate in risk behaviors at rates comparable with the national mean, although they report higher than mean rates of behaviors related to violence and sex.14 However, Youth Risk Behavior Survey data are not available for the particular schools that participated in this study. All are located in North Philadelphia, an area of extreme concentrated poverty. See Table 1 for a brief profile of the participating high schools offered by Pennsylvania’s Department of Education.15 The participating middle schools had between 89.7% and 95.7% low income students, as defined by eligibility for free or reduced cost lunch.
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Study Design
The study used a 4-stage, teen-centered methodology. The mixed qualitative-quantitative methodology allowed adolescents to frame the question in Stage 1 exploratory focus groups, generate ideas in Stage 2 Nominal Group Technique (NGT) sessions,16,17 prioritize their ideas in Stage 3 surveys, and describe the rationale behind their ideas in Stage 4 explanatory focus groups. Parallel processes occurred for each grade. The institutional review boards of the Children’s Hospital of Philadelphia and the Philadelphia School District approved the research protocol. Student participation served as assent, and passive parental consent was obtained.
In all stages involving group techniques, the principal was asked to select students from class rosters in a random manner. Groups were convened until generated ideas were repetitive. Nine AmeriCorps workers facilitated the first 3 stages. The facilitators were a diverse group, aged 19 to 45, that included 4 males, 1 white, 1 Latino, and 7 African American individuals. They facilitated the group processes in pairs assigned to maximize diversity of background and interpersonal style. The AmeriCorps workers also facilitated the distribution of surveys in schools they had been assigned as part of their service commitment. Stage 4 was facilitated by 1 of the authors (P.A.), a female African-American social worker. All facilitators received 24 hours of training in group dynamics and effective facilitation, including techniques to limit imposition of their own biases. (Details on facilitating the teen-centered process within the schools are available on request.)
In Stage 1, 60 students participated in 8 mixed-grade exploratory focus groups designed to develop a single NGT question that would be capable of generating the universe of ideas needed to fulfill the study objective. The adolescents discussed problems in their community and considered what question and accompanying definitions would best elucidate items that either impede or promote adolescent success. The final question was "What would you like to see happen in your community that would make things better for teenagers and make it more likely that they would have a positive future?" Community was defined as "the area you live in, and all the people who live there with you." Positive future was defined as a future where "teenagers would grow up feeling respected, feeling good about themselves, and capable of taking care of themselves and their loved ones."
In Stage 2, different adolescents participated in NGT sessions to generate responses to the adolescent-designed study question. NGT requires no expertise and has been used successfully in previous teen-centered research.11,12 It allows each individual to share his/her ideas, build on others’ ideas, and then prioritize each item’s importance. Its highly structured process diminishes the biases that group dynamics create in other group techniques, assuring all members equal input into the groups’ decisions. Its prioritization process assures the group highlights the best answers, rather than those its members find most interesting. The 98 8th-grade NGT participants in 13 groups generated 251 different solutions that they thought would affect the likelihood of their having a positive future, 104 9th-graders in 14 groups generated 227 solutions, and 96 12th-graders in 12 groups generated 160 solutions. Each group gave priority scores only for those solutions generated within their own group.
To have the population generate a standard prioritization, a survey for each grade was developed that included the ideas with the highest mean priority scores from the grade’s NGT groups. Because of different literacy levels between the grades, the surveys included varying numbers of items (the 8th-grade survey included 21 items; the 9th-grade survey included 24 items; and the 12th-grade survey included 28 items). All surveys were written at below the fifth-grade reading level in both English and Spanish. The surveys were self-administered after the teachers read standard instructions. All surveys included items on age, gender, race, grade, and zip code as a proxy for socioeconomic status. They also asked each student "Do you think you will have a positive future?" and "Not including school, are you in any program or activity run by adults?" The students then rated each affirmatively stated item (eg, "There would be less drugs on the street") on a 5-point Likert scale ranging from 1 = "Definitely would make me more likely to have a positive future" to 5 = "Would definitely not make me more likely to have a positive future."
In the final stage, 41 8th-grade students in 4 focus groups, 24 9th-grade students in 3 groups, and 26 12th-grade students in 3 focus groups added context and meaning to the prioritized items.
Statistical Analysis
The items generated in the NGT sessions were each assigned a mean priority score, and the items with the highest scores were included in the survey. Statistical analysis focused on the survey data.
The survey items were first ordered by their mean Likert scale ratings. The Marginal Homogeneity Test was used to compare the mean ratings of consecutive items until a statistically significant difference was found (P < .05). Items demonstrating no significant difference were assigned the same rank. The first item with a statistically different mean was assigned the next rank. The Kruskal-Wallis test was used to compare the ratings between subgroups. The Fisher exact test was used to measure the association between participation in an adult administered program and the students’ belief in a positive future. Principal Component Analysis was performed to uncover predominant themes among items.
Because the survey results clearly prioritize items and because facilitator bias holds the potential of altering the time spent discussing items, the research team chose not to quantify focus group results. The qualitative data are presented in another article to explain and enrich the quantitative results offered here.18
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RESULTS |
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Usable surveys were returned by 1022 ninth-graders. Although 2800 ninth-graders enrolled in school, by May when the surveys were distributed 16% had dropped out and the daily absentee rate for the remaining students was 37%. Therefore, 69% of approximately 1481 in-school students responded with usable surveys. Eighth-graders returned 417 usable surveys representing 54% of in-school youth, and 12th-graders returned 322 usable surveys, representing 49% of in-school students. Generally, nonparticipation was reflective of teachers choosing not to distribute the surveys.
Table 2illustrates the demographic breakdown of survey respondents for each grade. Socioeconomic status here is estimated for each student by the percentage of families in his/her residential zip code that live under the federal poverty level. The racial and poverty distribution of the eighth-grade sample differs from the high school sample, primarily because 1 feeder middle school with a large Latino population declined participation. A significant majority of respondents stated that they believed they had a positive future (85% of 8th-graders, 76% of 9th-graders, and 90% of 12th-graders). A smaller proportion reported participation in a program, other than school, run by adults (54% of 8th-graders, 38% of 9th-graders, and 41% of 12th-graders).
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All survey items had been previously rated by youth as very important ideas. Each item’s inclusion in the survey was based on its having one of the highest mean priority scores among the ideas generated in the NGT sessions. The surveys allowed for the broader population to rate the items and for subgroup analyses. Tables 3 through 5 offer the results of the 8th-, 9th-, and 12th-grade surveys respectively by mean rating and by rankings derived from The Marginal Homogeneity Test. The items are listed precisely as worded on the surveys. Because the surveys reflect the students’ own wording, similar items differ slightly between the grades.
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The top items in all 3 grades relate to educational or job opportunities. The eighth-graders suggest that the items most likely to enhance their likelihood for a positive future are more jobs, better education, more scholarships, and safer schools. The ninth-graders list better college opportunities, more jobs, more job training programs, dropout prevention efforts, and better books and computers. The seniors’ top answers include help to get into college, more jobs, and more job training programs.
All grades prioritized opportunities for youth to use their time positively, including items focused on adult-adolescent interaction. Recreation programs, community centers, and after-school activities were mentioned in all grades. The freshmen added that teenagers would benefit from working together with adults for their community and by participating in religious programs. The seniors call for more sports activities and safer playgrounds. The seniors also suggest programs that would enhance cultural, ethnic, and racial awareness. The seniors add the need for adult role models, both directly and by calling for more minority leaders in government.
The need for more police involvement was prioritized by all grades. Although the 12th-graders rated stronger punishments for serious criminals as one of their very top items, they rated the importance of the police not being racist or corrupt higher than they rated the importance of their presence.
Items that addressed social problems were ranked below the items that related to education and generally were ranked lower than those solutions that involved creating alternative safe places for youth and fostering connections between adults and adolescents. All grades included the following items: violence, guns, and crime; drugs and drug dealing; abandoned buildings; graffiti; and homelessness. Teen pregnancy as an impediment to a positive future was rated in the middle of included items by the eighth-graders, near the bottom of items by seniors, and not even rated highly enough by ninth-graders in the NGT sessions to be included in their survey. The eighth-graders’ included "there would be less rape and streets would be safer for girls" in the third of their 5 ranks.
The Kruskal-Wallis Test found very few items that differed between ninth-grade students from varied zip codes, races, ages, or genders. The only items in which zip code produced a difference were those on police corruption (P = .04) and drugs in the community (P = .03). Interestingly, youth living in the zip code with the most poverty rated "drugs would stop coming into the communities" lower than did other youth. There was no clear pattern related to poverty that explained the differences in how youth from different areas rated reducing police corruption. Several items varied by racial background of the respondent, with minority students always rating the items higher: dropout prevention (P = .03); religious programs (P = .004); adults and teenagers working together (P = .03); and a stop to black-on-black crime (P = .003). Females rated several items higher than males, including the items related to more job opportunities (P = .03), preventing school dropout (P = .02), eliminating abandoned buildings (P = .01), police corruption (P = .03), guns (P = .03), and graffiti (P = .04). Age did not significantly affect the ratings.
Because of smaller sample sizes, the Kruskal-Wallis test was able to demonstrate fewer distinctions between groups in the 8th and 12th grade samples. Among eighth-grade participants no items varied by race. The desire to have fewer drug dealers in the community differed by age (P = .05), with the oldest students rating it higher. Females rated less violence as more important than did males (P = .04). Among the senior participants, African Americans rated school security lower than did students of other races (P = .04). Females rated stronger punishments for serious criminals (P = .02), more job training (P = .05), and the presence of town watch patrols (P = .03) higher than did males, whereas males rated sports activities higher (P = .02).
Ninth-grade students who participated in programs run by adults rated the items related to participation in religious programs (P = .007) and fewer drug dealers (P = .02) significantly higher than those who did not participate. Eighth-grade students who participated in adult-run programs rated the importance of fixing up the schools higher than did other students (P = .02). Senior participants in adult-run programs rated the desire for more minority leaders (P = .01), more police (P = .02), and more security in schools (P = .003) higher than did the nonparticipants.
Students who responded affirmatively to the question "Do you think you will have a positive future?" rated items differently than those who held an uncertain or pessimistic outlook. The 76% of ninth-grade students who responded optimistically rated 11 of the 24 items higher, including the items related to college entrance (P = .006), job opportunities (P = .014), job training (P = .009), better books (P = .01), after school activities (P = .01), increased police presence (P = .02), more recreation centers (P = .04), adults and teens working together (P = .001), less violence (P = .004), less drug use (P = .0001) and dealing (P = .0003). The optimistic 8th- and 12th-graders also rated 3 items and 19 items, respectively, higher at statistically significant levels than did their less optimistic cohorts. Although youth who held a pessimistic outlook rated many items lower, they ordered them very similarly to optimistic youth.
The Fisher exact test (P = .018) demonstrated an association between ninth-grade youth who participate in adult run programs and those who believe in a positive future for themselves. It found 17% fewer ninth-graders (than randomly predicted) with a pessimistic outlook among those youth that participate in adult run programming. The data are limited in their ability to state whether the program instills hope or whether hopeful youth seek programming. The association did not reach statistically significant levels in the other grades.
Principal Component Analysis found that the items clustered in 4 latent factors. The first factor included items that enhanced personal stature, such as education and employment. The second factor included those suggestions that would give youth meaningful things to do with their time, such as after school activities. The third factor consisted of those suggestions that would improve the community, such as town watch patrols and minority owned businesses. The final factor was the elimination of environmental or personal risks, including drug dealing and easily accessible guns. Detailed results of this analysis are available on request.
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DISCUSSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Adolescent advocates, clinicians, researchers, and program planners have a shared desire to guide adolescents living in challenging environments toward positive futures. The imminent danger many challenges pose to youth has prompted a great deal of research and intervention efforts to target attention directly toward elucidation and amelioration of risk factors. Many efforts to easily categorize and target risk have explored demographic variables such as gender, race, family structure, and socioeconomic status. Blum et al19 demonstrated that these factors explain a small amount of the variability that differentiates youth that engage in risk behaviors from those that do not. This supports the idea that other less easily categorized, but perhaps more easily acted on, variables may better answer how to enhance the well-being of our youth. Success may be determined by each individual’s ability to negotiate his/her environment by drawing from protective resources while avoiding the challenges inherent to a risky environment.
This study was conducted to give local teenagers in an area of concentrated poverty a voice in determining how resources intended to benefit them would be allocated. The adults who requested the adolescent input had originally assumed that they would most effectively enhance the well being of community adolescents by directly addressing teenage pregnancy and violence. However, because they recognized adolescent wisdom might point them in a different direction, community youth were engaged to determine for themselves what actions would most affect their ability to succeed. These young people presented different priorities than the adults.
The process itself was a tool that engaged youth to build solutions within their communities. Because their insights were used to gain additional funding for programmatic interventions, youth may have gained a sense of empowerment from the process. On the other hand, some youth may have experienced frustration if they did not note any significant changes in their schools or job opportunities. The processes effectiveness as a tool for community building in other locales should be considered in the context of how likely the results are to be acted on.
The NGT question succeeded in both generating positive (ie, protective) strategies and in uncovering the perceived challenges to success. The ranking of items reveals that teenagers believed supportive solutions would increase their likelihood of success more than would addressing the risks generally considered impediments. The message which these inner city youth seem to be sending is "if you want us to be successful, give us the opportunities that come with a good education, good jobs, and meaningful connection with adults." Previous studies have revealed that a good education and connection with responsible adults are critical protective factors in the lives of teenagers.20–24 In fact, the Surgeon General’s report on youth violence names commitment to school as 1 of 2 protective factors proven to buffer exposure to specific risks for violence.25 So too, job opportunities have been shown to have positive impact on the well-being of youth as long as the work hours do not lessen the adolescent’s ability to succeed at his/her schoolwork.26
The protective strategies generated in this study are consistently addressed in the resiliency and youth development literatures. The resiliency paradigm notes that some youth become victims of challenging environments while others succeed despite adversity. It acknowledges risk factors but stresses that an adolescent is better able to avoid risk when buttressed by the protective forces found within the individual, the family, the school and the community.4–9,20–25,27–31 In fact, many of the ideas generated and prioritized by youth in this study are found among the 40 developmental assets delineated by the Search Institute.32
The youth development paradigm makes clear that our societal goals must reach far beyond producing adolescents who are problem free. It points out that because youth tend to live up to our expectations, the focus on risk may do youth a disservice because it is tied to an implicit message that we expect young people to engage in worrisome behaviors. It contends that our goal must be to prepare youth to be creative, competent, contributing members of our society.10,11,33,34
An ongoing discussion exists between youth advocates that believe the most efficient means to improve the well being of youth is to directly address their risk behaviors and those who believe that building on existing resiliencies and developing their competencies will be most effective. Although this research does not provide the needed outcomes data that would respond definitively to this discussion, both the process that initiated this research and its results offer instructive data. It is important, however, to understand that the precise wording of this study’s question limited the ability of the respondents to generate the breadth of items the resiliency paradigm considers protective factors. Because the question focused on "community," it generated items related to school and community, but did not generate personal or family based solutions.
Although it is uplifting to receive such a clear positive message prioritizing education, jobs, and connectedness from inner-city youth, it is unduly idealistic to only hear the optimistic message they offer. The study participants are clearly affected by the devastation they say surrounds them. Much as the resiliency approach considers not just protective factors but also the amelioration of risk factors, the adolescents also seem to recognize this balance.
A combination of several factors may explain why the respondents so clearly prioritized the promotion of protective factors over the elimination of harmful factors. First, adolescents may truly believe that positive actions, like improved education and community supports, will have a greater impact on their life than will the elimination of risks. This hypothesis seems to be supported by youth in the explanatory focus groups when they were asked whether the priority rankings made sense.18 Second, it may be that the manner in which the question was phrased in the survey, "think about how each statement would make a difference in your chances for having a positive future," made some more likely to rank positive strategies higher. Third, the focus groups revealed that some participants viewed risk factors as intractable.18 It may be, therefore, that students with these pessimistic views did not rate items highly that proposed the reduction of risk factors.
Despite the challenges they acknowledge they confront—guns, violence, the drug culture, even rape—the most striking finding of this teen-centered process is that the teenagers in this study hold the optimistic view that the protection offered by education and involved adults will help them overcome the odds. These are refreshing results that quite simply, feel good. However, they must be understood in the context of this study’s limitations. First, the teenaged participants in this study are in-school youth. It could be argued that in schools with such high absentee and dropout rates, these students have voted by their presence that they believe school is important. Perhaps many of the nonparticipants would be less likely to be optimistic about their futures. Most importantly, this is a study that reveals adolescent perceptions; it is not an outcome study that measures the impact of the listed suggestions. There is growing consensus that a critical next step is the implementation and rigorous evaluation of initiatives that promote protective factors in the lives of youth.
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CONCLUSION |
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TOPABSTRACTINTRODUCTIONMETHODSRESULTSDISCUSSIONCONCLUSIONREFERENCES |
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Youth in this northeastern urban area of concentrated poverty believe that supportive solutions would do more to enhance their likelihood of reaching a positive future than would attempts to reduce "negative" behaviors or disruptive surroundings. Although they also have a keen awareness of the social problems that impact negatively on their opportunities, they come equipped with potential solutions. These findings suggest that research and policies should continue to address risk factors, but also must look beyond the reduction of risk. It must consider how to enhance the protective effects of education, jobs and job training, connection to caring adults, and community-based programs that offer youth creative outlets. Important next steps must include rigorously evaluated initiatives that explore whether the protective actions suggested by adolescents here will in fact produce more positive outcomes than those strategies that primarily target risk.
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ACKNOWLEDGMENTS |
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The Robert Wood Johnson Foundation and the William Penn Foundation provided financial support for this project.
We would like to extend our sincere thanks to the AmeriCorps’ National School and Community Corps workers who facilitated the project, and to Dr Catherine Balsley of the School District of Philadelphia and ChrisAnne Smith and Brad Baldia of the Urban Initiative for their assistance throughout this project. Above all, we appreciate the Philadelphia students who shared their wisdom with us.
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FOOTNOTES |
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Received for publication Jun 26, 2001; Accepted Jan 9, 2002.
Reprint requests to (K.R.G.) Craig-Dalsimer Division of Adolescent Medicine, Children’s Hospital of Philadelphia, 34th St and Civic Center Blvd, Philadelphia, PA 19104. E-mail: ginsburg{at}email.chop.edu
Ms Alexander is currently with Habitat for Humanity International in South Africa. Ms Hunt is currently with the William Penn Foundation.
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PEDIATRICS (ISSN 1098-4275). ©2002 by the American Academy of Pediatrics
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 D. F. Perkins, L. M. Borden, F. A. Villarruel, A. Carlton-Hug, M. R. Stone, and J. G. Keith Participation in Structured Youth Programs: Why Ethnic Minority Urban Youth Choose to Participate--or Not to Participate Youth Society, June 1, 2007; 38(4): 420 - 442. [Abstract] [PDF]
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 L. M. Borden, D. F. Perkins, F. A. Villarruel, A. Carleton-Hug, M. R. Stone, and J. G. Keith Challenges and Opportunities to Latino Youth Development: Increasing Meaningful Participation in Youth Development Programs Hispanic Journal of Behavioral Sciences, May 1, 2006; 28(2): 187 - 208. [Abstract] [PDF]
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K. R. Ginsburg, C. J. Howe, A. F. Jawad, M. Buzby, J. M. Ayala, A. Tuttle, and K. Murphy Parents' Perceptions of Factors That Affect Successful Diabetes Management for Their Children Pediatrics, November 1, 2005; 116(5): 1095 - 1104. [Abstract] [Full Text] [PDF]
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L. Kelly, J. Sheeder, and C. Stevens-Simon Teen Home Pregnancy Test Takers: More Worried or More Wishful? Pediatrics, March 1, 2004; 113(3): 581 - 584. [Abstract] [Full Text] [PDF]
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C. Stevens-Simon and K. R. Ginsburg Ducks Have Ducks Unless... Pediatrics, February 1, 2003; 111(2): 446 - 447. [Full Text] [PDF]
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E. Goodman and K. R. Ginsburg Enhancing Their Likelihood for a Positive Future Pediatrics, December 1, 2002; 110(6): 1258 - 1259. [Full Text] [PDF]
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