Author: Jodi Snare

ECHO Awards More Than $157 Million for Observational Research Into Environmental Influences on Child Health

Posted on by Jodi Snare

The Environmental influences on Child Health Outcomes (ECHO) Program in the Office of the Director of the National Institutes of Health has made 49 awards totaling over $157 million for the first year of the second seven-year cycle of the ECHO Cohort Consortium.

Forty-five ECHO Cohort Study Sites will recruit and continue to follow participants across the country. A Coordinating Center, Data Analysis Center, Laboratory Core, and Measurement Core will help facilitate the science. Together, as the ECHO Cohort Consortium, they will conduct observational research to further investigate the roles of a broad range of early exposures, including during the preconception period, on five key child health outcomes among diverse populations.

“What makes ECHO special is our commitment to informing programs, policies, and practices that enhance the health of children for generations to come,” said Matthew W. Gillman, MD, SM, Director of the Environmental influences on Child Health Outcomes (ECHO) Program. “We look forward to another seven years of the ECHO Cohort, to find meaningful answers to big questions in child health that only large and diverse studies like ours are able to answer.”

ECHO funded these awards after a competitive peer review process. View a list of each prime awardee.

Extending and Expanding the ECHO Cohort

From September 2023 through May 2030, the ECHO Cohort Consortium will follow more than 30,000 current ECHO Cohort child and adolescent participants and their families, while adding more than 30,000 new pregnant participants and their offspring. In addition, researchers will follow at least 10,000 women and, when available, their partners, to examine how preconception exposures may influence child health outcomes. The enhanced ECHO Cohort will include about 60,000 total children and adolescents by 2030.

Following this large and diverse population will enhance ECHO’s ability to answer solution-oriented questions about the effects of a broad range of early environmental exposures, from society to biology, on child health and development. Scientific opportunities in the second cycle are nearly limitless and may include effects of novel chemicals, addressing health equity, impact of media use, assessing natural experiments, influences of preconception exposures, and consequences of social determinants of health, among others.

Building on Seven Years of Success

Since 2016, more than 1200 ECHO Cohort researchers at more than 180 institutions have collaborated to weave data from 69 pre-existing longitudinal maternal-child health studies into a single national resource. Data from more than 107,000 child and parent participants in the ECHO Cohort have powered more than 1200 peer-reviewed articles across five pediatric areas of high public health impact: pre-, peri- and postnatal health; upper and lower airways; obesity; neurodevelopment; and positive health. The geographic, socioeconomic, racial, and ethnic diversity of participants amplifies the sheer size of the ECHO Cohort to present unique opportunities to promote long-lasting health by informing programs, policies, and practices.

NIH Study Finds Association Between Elevated Phthalate Levels and Increased Risk of Postpartum Depression

Posted on by Jodi Snare

FOR IMMEDIATE RELEASE

In a new study from the NIH’s Environmental influences on Child Health Outcomes (ECHO) Program, higher prenatal phthalate levels were associated with a slightly increased risk of postpartum depression.

Postpartum depression affects up to 20% of new mothers, making it the most common pregnancy complication to occur after delivery. ECHO Cohort researchers wanted to examine how chemicals such as phenols, phthalates, and parabens—commonly found in plastics and personal care products—might play a role in postpartum depression symptoms, alongside other factors like genetics and stress. Exposure to these chemicals can affect hormone levels, potentially influencing the development of postpartum depression.

The presence of these man-made chemicals in people is common due to frequent exposure through diet, absorption through the skin, and inhalation. Researchers noted that among study participants all had parabens and nearly all had phthalates in their urine samples.

“Finding new ways to prevent postpartum depression is crucial because most of the known risk factors, like genetics and stressful life events, can’t be altered,” said Melanie Jacobson, PhD, MPH of New York University’s Grossman School of Medicine. “Therefore, focusing on prenatal exposure to these types of chemicals represents a novel interventional target.”

Researchers measured the concentrations of these chemicals in urine samples of 2,174 pregnant individuals at five ECHO Cohort Study Sites. Those same individuals also completed depression assessments between two weeks and 12 months after delivery to check for postpartum depression symptoms. Screening instruments indicated the presence or absence of postnatal depressive symptoms. Researchers then harmonized data to the Patient-Reported Measurement Information System (PROMIS) Depression scale.

The study found that higher levels of phthalates, in particular those found in products such as personal care items and plastic consumer products, were associated with an increased risk of postpartum depression. Those who met the criteria for postpartum depression were more likely to be Hispanic and from the ECHO study site in Puerto Rico, have attained less education, and substantially higher prenatal depression scores.

This collaborative research, which is believed to be the largest study to date examining the effects of environmental chemicals on depression, is published in JAMA Psychiatry.

Jacobson, M. et al. Prenatal exposure to nonpersistent environmental chemicals and postpartum depression. JAMA Psychiatry. DOI: 10.1001/jamapsychiatry.2023.3542.

Media Contacts

For information or to request an interview, contact Rebekah Yeager,  rebekah.yeager@nih.gov.

If you are not a member of the media, but have a general inquiry, please contact  NIHKidsandEnvironment@od.nih.gov.

Connect With Us

echo connectorCheck out the recent issues of our bi-monthly newsletter, the ECHO Connector, for program news and the latest research findings.

To receive the ECHO Connector through email, subscribe here.

Follow @ECHOChildHealth for the latest ECHO Program updates on Twitter.

New ECHO Research Finds Association Between Some Prenatal Chemical Exposures and Postpartum Depression

Posted on by Jodi Snare

Collaborative ECHO research led by Melanie Jacobson, PhD, MPH of the NYU Grossman School of Medicine, investigates the role of prenatal synthetic chemicals in postpartum depression. This research, titled “Prenatal Exposure to Nonpersistent Environmental Chemicals and Postpartum Depression,” is published in JAMA Psychiatry.

Postpartum depression affects up to 20% of new mothers, making it the most common pregnancy complication to occur after delivery. Postpartum depression can impact a mother’s daily functioning, quality of life, and long-term health. Furthermore, it is associated with poor mother-child attachment, which can impact child health and development.

Factors like genetics and stress can make some people more likely to experience postpartum depression, but researchers are still trying to understand how synthetic chemicals might also play a role. Chemicals such as phenols, phthalates, and parabens can be found in plastics and personal care products. While these chemicals are nonpersistent, meaning that they don’t linger in the environment, their presence is widespread due to frequent exposure through diet, absorption through skin, and inhalation.

Researchers used data from 2,174 pregnant individuals across five study sites to examine the extent to which exposure to these chemicals might be associated with postpartum depression symptoms. They measured the concentrations of nonpersistent chemicals in urine samples during pregnancy and collected data using self-reported postnatal depression assessments after delivery completed by the same individuals.

The study found that prenatal phthalate concentrations were associated with increased odds of slightly higher postpartum depression scores. Of the many synthetic chemicals investigated, only phthalate concentrations were associated with increased odds of postpartum depression. This suggests that finding ways to reduce prenatal exposure to phthalates might reduce the frequency of postpartum depression. Researchers also observed that postpartum depression was more likely in people who were Hispanic, had lower educational attainment, and had prenatal depression.

“From a public health perspective, any way to help prevent postpartum depression would be important, since most known risk factors such as genetics, psychiatric history, and stressful life events, cannot be easily changed,” Dr. Jacobson said. “Therefore, focusing on prenatal exposure to these types of chemicals represents a novel interventional target.”

While this is believed to be the largest study to date examining the effects of environmental chemicals on postpartum depression, future studies are needed to replicate this research with larger sample sizes in diverse populations.

Read the research summary.

New ECHO Research Observed Shortened Social Responsiveness Scale to be Comparable to Full Version in Autism Risk Factor Estimation

Posted on by Jodi Snare

Collaborative ECHO research led by Marisa Patti, PhD and Kristen Lyall, ScD of AJ Drexel Autism Institute investigates how a shortened version of the Social Responsiveness Scale (SRS) compares to the full questionnaire in order to potentially decrease the time participants need to take assessments. This research, titled “A Comparative Analysis of the Full and Short Versions of the Social Responsiveness Scale in Estimating an Established Autism Risk Factor Association in ECHO: Do we Get the Same Estimates?” is published in the Journal of Autism and Developmental Disorders.

The SRS questionnaire is used to measure social communication and autism-related traits. Researchers have developed a shortened version with only 16 questions out of the original 65. This shortened version is intended to provide a similar summary of overall traits as the longer version, but take less time to complete.

The shorter SRS has been tested to ensure that it measures autism-related traits. Before this study, it was not clear if the short SRS could be used in the same way as the full SRS to study autism risk factors in different research projects and get similar results. In order to address whether the short version can detect associations in the same way as the full version, researchers examined associations with established risk factors for autism- preterm birth and gestational age.

In this study, which included 2,760 child-parent pairs from 11 research sites, younger gestational age and pre-term birth were associated with higher SRS scores, suggesting these may be risk factors for autism-related behaviors in children. The study also found similar associations using the shortened SRS, suggesting both the short and longer versions can detect autism risk factor associations in comparable ways.

Gathering meaningful information for research studies can be time-consuming for participants. This study suggests that shorter assessments can be as useful as longer ones to help reduce the time participants spend answering questionnaires.

“Studies like ours show that the same information can be collected using shorter, less time-consuming assessments to alleviate participant burden by reducing the administration time of assessments,” Dr. Patti said. “In future work, the short SRS can be used without compromising the ability of the assessment to correctly identify associations.”

Future research studies are needed to investigate how comparable estimates are between the full and short SRS using other established risk factors. Researchers may also consider using the short SRS in place of the full SRS in future studies to reduce the overall amount of time participants spend on a research study.

Read the research summary.

Study Shows Association Between Better Neighborhood Conditions and Lower Childhood Asthma Rates

Posted on by Jodi Snare

FOR IMMEDIATE RELEASE

Living in a neighborhood with better access to resources such as high-quality housing, healthy food, parks and playgrounds, and clean air during the early stages of childhood was associated with lower asthma incidence in a new study from NIH’s Environmental influences on Child Health Outcomes (ECHO) Program.

Children born in high-opportunity neighborhoods had an asthma incidence rate of 23.3 cases per 1,000 children, while those born in very low and low-opportunity neighborhoods had rates of 35.3 per 1,000 and 27 per 1,000, respectively.

“Understanding neighborhood conditions could help researchers identify vulnerable children who are at high risk for developing asthma,” said study author Izzuddin Aris, PhD, of Harvard Medical School. “This information can also inform efforts by policymakers, researchers, and community groups to improve children's health and foster equity across neighborhoods.”

Researchers in this study measured neighborhood conditions using the Child Opportunity Index and the Social Vulnerability Index, which link residential addresses at birth, infancy (age 0.5‒1.5 years), and early childhood (age 2.0‒4.8 years) to census-tract data about the opportunities and resources available in the surrounding neighborhood. Only the Child Opportunity Index, which measures neighborhood resources and conditions deemed essential for healthy child development, showed significant associations with childhood asthma incidence. The Social Vulnerability Index measures factors that make a community more vulnerable in the aftermath of natural or human-caused disasters.

This study used data from 10,516 children at 46 research sites participating in ECHO, each having at least one residential address from birth and a parent or caregiver report of a physician’s diagnosis of asthma. These differences in the incidence of asthma persisted even after controlling for sociodemographic characteristics, parental asthma history, and the number of births a mother had.

“These findings emphasize the importance of investigating whether investing in early-life health and environmental or social and economic resources can promote health equity in pediatric asthma,” said Dr. Aris.

Dr. Aris led this collaborative research published in JAMA Pediatrics. An embargoed copy of the study is available upon request.

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About ECHO:

Launched in 2016, the Environmental influences on Child Health Outcomes (ECHO) Program is a research program in the Office of the Director at the NIH with the mission to enhance the health of children for generations to come. ECHO investigators study the effects of a broad range of early environmental influences on child health and development. For more information, visit echochildren.org.

About the NIH: NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information, visit www.nih.gov.

Media Contacts

For information or to request an interview, contact Rebekah Yeager,  rebekah.yeager@nih.gov.

If you are not a member of the media, but have a general inquiry, please contact  NIHKidsandEnvironment@od.nih.gov.

Connect With Us

echo connectorCheck out the recent issues of our bi-monthly newsletter, the ECHO Connector, for program news and the latest research findings.

To receive the ECHO Connector through email, subscribe here.

Follow @ECHOChildHealth for the latest ECHO Program updates on Twitter.

ECHO Researchers Investigate Link Between Neighborhood Conditions During Childhood and Asthma Incidence

Posted on by Jodi Snare

Izzuddin Aris, PhD

Collaborative ECHO research led by Izzuddin Aris, PhD, of Harvard Medical School examined the association of conditions and resources available in neighborhoods during different development stages with childhood asthma incidence.

Neighborhood conditions, such as access to housing, healthy food, transportation, and education centers, can influence the development of childhood asthma. Researchers often measure these conditions using the Child Opportunity Index and the Social Vulnerability Index, which link residential addresses at birth, infancy (age 0.5‒1.5 years), and early childhood (age 2.0‒4.8 years) to census-tract data about the opportunities and resources available in the surrounding neighborhood.

ECHO researchers used data from 10,516 children at 46 research sites participating in the ECHO Program. The participants had at least one residential address from birth and a parent or caregiver report of a physician’s diagnosis of asthma.

Children born in high-opportunity neighborhoods had an asthma incidence rate of 23.3 cases per 1,000 children, while those born in very low and low-opportunity neighborhoods had rates of 35.3 per 1,000 and 27 per 1,000, respectively.

“Neighborhood conditions could help researchers identify vulnerable children who are at high risk for developing asthma,” said Dr. Aris. “This information can also guide policymakers, researchers, and community groups to improve children’s health and foster equity across neighborhoods.”

Future studies can explore the impact of investing in early life health and environmental, social, and economic resources on improving health outcomes for children in disadvantaged neighborhoods. Follow-up studies can also focus on how these neighborhood-level factors are affecting asthma rates and how moving may alter asthma development.

This research, titled “Associations of Neighborhood Opportunity and Vulnerability with Incident Asthma Among U.S. Children in the ECHO cohorts,” is published in JAMA Pediatrics.

Read the research summary.

Education Levels and Child Age Shaped Caregivers’ Concerns Amid COVID-19, NIH Study Suggests

Posted on by Jodi Snare

FOR IMMEDIATE RELEASE

A caregiver’s education level and their child’s age played large roles in determining their primary sources of stress during the COVID-19 pandemic, researchers found in a recent study by NIH’s Environmental influences on Child Health Outcomes (ECHO) Program. Caregivers who had less than a high school education were less likely to work remotely and were more worried about finances, childcare, and access to necessities like food. Caregivers with a master’s degree or higher reported greater concern about social distancing and impacts on their work.

The social factors that influenced infection rates, disease severity, and financial burden among adults during the pandemic have been broadly documented. However, ECHO researchers wanted to understand the experiences of children and their caregivers.

“Understanding these experiences can help uncover social differences that could worsen conditions for some populations during future public health crises,” said Kaja Z. LeWinn, ScD of the University of California, San Francisco.

Conducting population-based studies during the pandemic was challenging, but by using existing ECHO Program research sites across the United States and COVID-19 questionnaires, researchers were able to see how social and economic factors were affecting families and children throughout the height of the pandemic. The study analyzed data from 14,646 ECHO children and 13,644 ECHO caregivers between April 2020 and March 2022.

Caregivers completed ECHO’s COVID-19 surveys about their child’s and their own experiences during the pandemic. Researchers measured how the pandemic affected caregivers based on three demographic characteristics—caregiver education, their child’s age, and whether they lived in urban or rural settings. Researchers documented different pandemic-related outcomes for children and caregivers and compared these outcomes across demographic groups. For children, researchers documented COVID-19 infection, availability of COVID-19 testing, healthcare changes, and disruptions to school and daycare. For caregivers, researchers asked questions about remote work, childcare challenges, and their personal ranking of pandemic-related stressors.

Education affected caregiver experiences

Researchers found that caregivers with less than a high school education were more likely to report difficulties getting COVID-19 tests for their children. Caregivers also cited financial concerns and access to necessities such as food as primary sources of stress. In contrast, caregivers with a master’s degree or higher were more likely to name social distancing as the top source of their pandemic-related stress.

The study's findings also indicate that caregivers with higher education were significantly more likely to have the option to work remotely. Caregivers with a high school or less education were less likely to be able to work remotely or change work schedules to care for their children compared to those with a master’s degree or greater. Even though those with a bachelor’s degree were less likely than those with a master’s degree to work remotely, they were still more likely than those with lower education to change their work schedule to care for children.

Interestingly, the opposite relationship existed for arranging childcare. Those with a master’s degree or higher reported more challenges finding childcare than those with less than a high school education. There is evidence suggesting greater rates of childcare center closures in areas where people had higher levels of education. Informal childcare arrangements among families with lower education levels may have been less affected by center closures.

Caregivers of young children faced more challenges

Caregivers with children between the ages of 1 and 5 years reported the least support from school systems, the most difficulty finding childcare, and fewer remote learning options. They were also more likely to have healthcare appointments canceled due to COVID‑19 concerns and were most concerned about how the pandemic would affect their ability to work.

“Our findings suggest that families with young children may need more support related to childcare and work flexibility, especially when school disruptions are involved,” Dr. LeWinn said.

Researchers observed few differences in the experiences of urban and rural residents.

Future research may investigate the long-term effects these pandemic challenges may have on children in the ECHO Program over time.

Dr. LeWinn and Lisa Jacobson, ScD of Johns Hopkins University led this collaborative research published in JAMA Network Open.

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About ECHO: Launched in 2016, the Environmental influences on Child Health Outcomes (ECHO) Program is a research program in the Office of the Director at the NIH with the mission to enhance the health of children for generations to come. ECHO investigators study the effects of a broad range of early environmental influences on child health and development. For more information, visit echochildren.org.

About the NIH: NIH, the nation’s medical research agency, includes 27 Institutes and Centers and is a component of the U.S. Department of Health and Human Services. NIH is the primary federal agency conducting and supporting basic, clinical, and translational medical research, and is investigating the causes, treatments, and cures for both common and rare diseases. For more information, visit www.nih.gov.

Media Contacts

For information or to request an interview, contact Rebekah Yeager,  rebekah.yeager@nih.gov.

If you are not a member of the media, but have a general inquiry, please contact  NIHKidsandEnvironment@od.nih.gov.

Connect With Us

echo connectorCheck out the recent issues of our bi-monthly newsletter, the ECHO Connector, for program news and the latest research findings.

To receive the ECHO Connector through email, subscribe here.

Follow @ECHOChildHealth for the latest ECHO Program updates on Twitter.

New ECHO Research Suggests Caregiver Education Levels and Child Age Shaped Families’ Concerns During the COVID-19 Pandemic

Posted on by Jodi Snare

Collaborative ECHO research led by Kaja LeWinn, ScD of the University of California, San Francisco and Lisa Jacobson, ScD of Johns Hopkins University investigates the influence of a caregiver’s educational background and their child’s age on the experiences of children and families during the COVID-19 pandemic. This research, titled “Sociodemographic Differences in COVID-19 Pandemic Experiences Among Families in the United States,” is published in JAMA Network Open.

The COVID-19 pandemic and resulting public health measures presented unique challenges for families, frequently influenced by factors such as income and caregiver educational background as well as their children’s ages during the pandemic. Using the ECHO Program’s existing research sites and COVID-19 questionnaires, researchers were able to observe the social and economic factors that were affecting families and children at the height of the pandemic while many population-based studies were put on hold. The study analyzed data from 14,646 ECHO children and 13,644 ECHO caregivers between April 2020 and March 2022.

Researchers found that caregivers with less than a high school education were more likely to report difficulties getting COVID-19 tests for their children, were less likely to work remotely, and reported financial concerns and access to necessities such as food as top sources of stress. Caregivers with a master’s degree or higher, on the other hand, were more likely to name social distancing as the top source of their pandemic stress and were more likely to have the option to work remotely.

Caregivers with children between the ages of 1 and 5 years reported the least support from school systems, the most difficulty finding childcare, and fewer remote learning options. They were also more likely to have healthcare appointments canceled due to COVID-19 concerns and were most concerned about how the pandemic would affect their ability to work.

This study underscores the importance of understanding how children and caregivers from various backgrounds experienced the COVID-19 pandemic. This understanding can help uncover social inequities that could worsen conditions for some populations during future public health crises and can be used to create safeguards to protect vulnerable populations.

“Programs and policies that provide financial assistance and mandate more work flexibility for families of lower socioeconomic status during times of crisis may help mitigate their burdens,” said study author Dr. LeWinn. “Our findings also suggest that families with young children may need more support related to childcare and work flexibility, especially when school disruptions are involved.”

Future research may look into the long-term effects these pandemic challenges may have on children in the ECHO Program over time.

Read the research summary.

New ECHO Research Develops a National Exposure Index for Combined Environmental Hazards and Social Stressors

Posted on by Jodi Snare

Collaborative ECHO research led by Sheena Martenies, PhD, MPH of the University of Illinois Urbana-Champaign developed a national exposure index for easier analysis of multiple factors at once. This research, titled “Developing a National-Scale Exposure Index for Combined Environmental Hazards and Social Stressors and Applications to the Environmental influences on Child Health Outcomes (ECHO) Cohort,” is published in the International Journal of Environmental Research and Public Health.

There is growing interest in understanding the combined effect of multiple environmental hazards and social stressors on the health and development of children. While there are a number of tools for assessing these factors, they can be limiting when trying to analyze the cumulative effects of various exposures.

In this study, researchers developed a combined exposure index with national coverage that compiled data from several environmental and social indicators during prenatal and early-life periods. The data included variables such as air pollution and neighborhood socioeconomic status and analyzed how combined exposure to several factors during pregnancy may impact health.

The combined exposure index, which facilitated ECHO-wide analyses considering exposures to multiple neighborhood-level hazards and stressors at the same, differed by region. The level of combined exposure was highest in the western and northeastern regions of the United States. Researchers found that pregnant participants who identified as Black and Hispanic were more likely to have higher exposures to hazards compared to White and non-Hispanic participants. Exposure values were also higher for pregnant participants with lower educational attainment.

“Our study results complement those from a previous study that found these combined exposures were associated with a higher risk of adverse birth outcomes for some demographic groups,” Dr. Martenies said. “The results of these studies suggest there is a role for neighborhood quality in healthy pregnancy outcomes. More work is needed to identify interventions that might reduce prenatal exposures and improve pregnancy outcomes.”

Researchers may use this exposure index in future studies to look at how neighborhood features influence child health outcomes. Future studies would benefit from national datasets for key environmental health concerns, such as water contaminants and pesticides, and social stressors that may disproportionally affect certain groups.

Read the research summary.

New ECHO Research Looks into Potential Correlation Between Maternal Stress and Early Childhood Obesity

Posted on by Jodi Snare

Collaborative ECHO research led by Callie Brown, MD, MPH of Wake Forest University, and Charles Wood, MD, MPH of Duke University, investigates how maternal stress can affect children’s later body mass index (BMI). This research, titled “Maternal stress and early childhood BMI among US children from the Environmental influences on Child Health Outcomes (ECHO) program,” is published in Pediatric Research.

Obesity affects millions of adults, adolescents, and children in the United States. Many children in the United States enter their school years with obesity, and children with obesity at 3 years of age have a 90% probability of having overweight or obesity as an adolescent.

While existing literature suggests a relationship between parental stress and childhood body mass index (BMI), the exact way in which parental stress might affect BMI in children isn’t fully understood. Researchers looked at 1,694 mother-child pairs across 15 research sites in the United States over time to evaluate how maternal stress might be associated with the child’s BMI.

The study did not find any significant link between maternal stress measured in the first year after childbirth and the child’s BMI. While the study did not find an association between maternal stress levels and childhood obesity, it did reveal other information about both maternal stress and childhood BMI.  Researchers found that higher stress levels were more likely among Hispanic and Black mothers, and less likely among mothers with private health insurance. Furthermore, higher child BMI was more likely among Hispanic mothers, when a mother’s BMI before birth was higher, and when the child’s birth weight was higher.

The study’s results suggest that factors other than a mother’s stress level appear to be stronger predictors of increased childhood BMI.

“Parental stress has been associated with childhood obesity and may affect stress levels and eating, sleep, and physical activity patterns during childhood,” said study author Dr. Wood. “There are many factors in the first year of life that are related to higher weight gain and earlier obesity in children, but our results suggest that the level of a mother’s stress in the first year of life is not a risk factor. This may be because stress during pregnancy, stress later in childhood, and the child’s own stress level are stronger predictors of differences in childhood BMI.”

Future studies may look at additional factors that influence children’s risk for increased BMI such as BMI in later childhood, other periods of stress, parent or caregiver-measured stress measured, or specific types of stress.

Read the research summary.