Carolyn R. Bates1*
Sydney M. Gibson2
Peter R. Johnson3
Sarah L. Hunt4
Patrick M. Dyjak2Courtney A. Gibson5
Christina M. Sharkey4
Kimberly L. Klages5- 1Department of Pediatrics, University of Kansas Medical Center, University of Kansas Cancer Center, Kansas City, KS, United States
- 2Kansas City University College of Osteopathic Medicine, Kansas City, MO, United States
- 3A.R. Dykes Library, University of Kansas Medical Center, Kansas City, KS, United States
- 4Department of Psychology, The Catholic University of America, Washington, DC, United States
- 5Division of Behavioral Medicine and Clinical Psychology, Cincinnati Children's Hospital Medical Center, Cincinatti, OH, United States
Background: Acute Lymphoblastic Leukemia (ALL) is the most common pediatric cancer, with significant advancements in treatment leading to over 90% five-year event-free survival rates in developed countries. However, disruptions in health behaviors during treatment, such as diet, activity, and sleep, can negatively impact treatment tolerance and increase risks of late effects. This scoping review aimed to assess the breadth of existing behavioral health interventions designed to improve immediate and long-term health outcomes for children and adolescents receiving treatment for ALL.
Method: The review focused on behavioral interventions for children (ages 2–18 years) undergoing active treatment for ALL. We followed the JBI Manual of Evidence Synthesis and PRISMA-ScR guidelines, including a comprehensive search across PubMed, Elsevier, and Web of Science databases. Articles were screened, assessed, and data extracted by multiple reviewers to identify behavioral health promotion interventions used during ALL treatment.
Results: A total of 157 full-text articles were screened, and 86 met inclusion criteria. Most interventions targeted physical activity and exercise (n=36), procedural distress (n=24), nutrition (n=8), and symptom reduction/management (n=6), with others targeting pain, sleep, and health-related quality of life. Date of publication, methodology, and behavioral intervention components varied considerably across studies.
Conclusions: The literature on behavioral health promotion interventions during pediatric ALL treatment is broad but lacks depth, with many studies limited by small sample sizes and stalling at the feasibility stage. There is a need for larger, more rigorous trials to assess the effectiveness of these interventions and improve outcomes for youth with ALL.
Introduction
Acute Lymphoblastic Leukemia (ALL) is the most prevalent childhood cancer with an estimated 6,660 new cases annually (1). Treatment advancements have dramatically improved outcomes for children with ALL, with five-year event-free survival rates now reaching 90% for children and 74% for adolescents in developed countries (2). As survival rates have increased, there has been a growing recognition of the importance of behavioral health factors during treatment that may influence both immediate outcomes and long-term survivorship (3). Disruptions in health behaviors, including diet, activity, and sleep, are common during ALL treatment and can lead to lower treatment tolerance, increased toxicity and heightened risk for late effects, morbidity, and mortality (4).
To improve health outcomes in children undergoing ALL treatment, interventions have been developed to target a range of behavioral health concerns. Behavioral interventions are nonpharmacological approaches aimed at improving health outcomes by targeting modifiable behaviors (e.g., physical activity, sleep, nutrition, coping skills) and psychosocial functioning through structured activities, education, or therapeutic techniques. Behavioral intervention targets vary in focus and originate from diverse disciplines, including dietetics, physical therapy, psychology, and nursing. However, the existing literature is highly fragmented, with studies dispersed across discipline-specific journals, making it difficult to synthesize findings and translate them into clinical practice (5–7). Furthermore, most existing behavioral interventions target a single health outcome, such as physical functioning (8–14) or fatigue (11, 15, 16), or health behavior, such as sleep (17) or diet (18, 19) which further complicate efforts to synthesize the literature, given the wide range of distinct behavioral targets and the lack of integrated, multi-component approaches.
Given the breadth and heterogeneity of this literature, a scoping review is warranted to systematically identify, categorize, and map behavioral health promotion interventions implemented during pediatric ALL treatment. Scoping reviews are particularly appropriate for topics with diverse and emerging evidence bases, where a broad overview is needed to clarify key concepts, highlight knowledge gaps, and inform future research and clinical practice. The purpose of this review was to examine the range of behavioral health promotion interventions designed to improve health outcomes for children and adolescents receiving treatment for ALL. The primary review questions were:
1. What behavioral interventions have been implemented with children on active ALL treatment?
2. What health behavior outcomes are targeted?
3. Are these interventions used independently or in combination with other intervention(s)?
i. What component(s) are utilized in each intervention?
Methods
A scoping review was developed around the concepts of 'acute lymphoblastic leukemia,' ‘children’ (ages 2-18), and behavioral interventions during active cancer treatment including: behavior therapy, exercise therapy, movement-based therapy, physical therapy, nutrition/diet therapy, cognitive behavioral therapy, relaxation therapy, and muscle stretching therapy. This review was conducted following guidance in the Joanna Briggs Institute (JBI) Manual of Evidence Synthesis and reported according to the Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) extension for scoping reviews (PRISMA-ScR). Following the creation and registration of a reporting protocol (20) in Open Science Framework (OSF) an initial search aligned with the Population, Concept, and Context of the review was drafted for PubMed using appropriate Medical Subject Headings (MeSH) terms and keywords by a health sciences librarian (PJ) in consultation with the review team. This search was then reviewed by another health sciences librarian following the Peer Review of Electronic Search Strategies (PRESS) criteria (21). Recommended changes were applied, and the search was translated to the databases Embase.com (Elsevier) and Web of Science Core Collections - SCI-Expanded 1900-present, SSCI 1956-present, AHCI 1975-present, ESCI 2020-present (Clarivate) using comparable keywords and Emtree terms. No database filters or limits were applied to the search. The references of any literature or systematic reviews identified in the search were screened independently in a hand searching process and added to the title/abstract screening stage. The full search strategy and its translations along with a PRISMA-ScR checklist are available as supplemental material for this review.
Citation files from each database and hand searching results were exported to EndNote 21 (Clarivate) for management/retraction watching and then into Covidence (Melbourne, VIC, Australia) for deduplication, screening, assessment, and data extraction. In Covidence, two reviewers independently screened each included article according to the inclusion/exclusion criteria, and a third resolved any conflict. Published quantitative, qualitative, and case studies were included if (1) they were original research, (2) they included a health behavior intervention, (3) the sample included patients with ALL (2–18 years of age) who were actively receiving treatment with curative intentions, and (4) the article was available in English. Relevant studies investigating a mixture of diagnoses, such as both ALL and other pediatric oncology diagnoses, were included only if ALL diagnoses were represented in the sample and all other inclusion criteria were met. Articles that evaluated health behavior interventions in survivors of pediatric ALL or patients receiving hospice care were excluded. Books and book chapters, dissertations, editorial letters, conference abstracts and articles not available in English were also excluded. While systematic reviews and meta-analyses were not included in this review, these articles and reference lists were evaluated to identify relevant original publications. Screened articles matching the inclusion criteria were added to full text assessment, and full text copies were obtained through library subscriptions or interlibrary loan. Assessed articles matching the inclusion criteria were added to the extraction stage. A data extraction form was developed within Covidence matching inclusion criteria. The form was piloted on three random studies from the extraction pool and modified before being applied to the entire pool. Two reviewers independently extracted data from each article and when disagreements between coders occurred, a third reviewer provided consensus. Data extracted from each article included study design, country of origin, age range, patient diagnoses included (i.e., ALL only, mixed sample of ALL and other cancers, undefined leukemia), cancer treatment type (i.e., active chemotherapy, radiation therapy, stem cell therapy, treatment not specified), total number of participants, intervention target (i.e., physical activity, procedural distress, pain, health-related quality of life/psychological functioning, nutrition/dietary, sleep, and symptom reduction), intervention type (i.e., education, physical activity/exercise promotion, coaching/supportive care , coping strategies, cognitive behavioral therapy, complementary/alternative medicine [CAM]), person receiving intervention (i.e., patient, caregiver), intervention setting, mode of delivery, and outcomes measured. Extracted data was exported out of Covidence as a.csv file for charting in Excel and analysis.
Results
This scoping review included a total of 86 studies describing behavioral health promotion interventions delivered during pediatric ALL treatment (Figure 1). Interventions varied by behavioral target, modality, delivery format, and developmental age group. Findings are summarized below by behavioral domain, with emphasis on intervention types, populations, delivery settings, and areas for future research. See Table 1 for a summary of included intervention studies.
Figure 1. PRISMA flow diagram.
Table 1. Included Studies.
Physical activity/exercise
Thirty-six studies reported on interventions targeting physical activity or exercise. Most focused on structured physical activity (n=34 studies), incorporating aerobic, strength, or mobility training. Additional components included coaching/supportive care (n=7), relaxation (n=1), biofeedback (n=1), and eating/feeding strategies (n=2). Common study designs included pilot/feasibility studies (n=10), single-arm trials (n=6), randomized controlled trials (RCTs; n=9), and non-randomized trials (n=6). Nearly all studies were prospective (n=35), with the majority conducted in the United States (n=10), Spain (n=6), and Germany (n=5). Interventions were primarily delivered in-person during active chemotherapy (n=31), often involving mixed samples of children with ALL and other cancers (n=20). Participant ages ranged from 1 to 22 years. Frequently assessed outcomes included physical activity, functional disability, and health-related quality of life (HRQoL), with additional measures such as body mass index (BMI), anthropometry/body composition, strength, motor skills, posture, endurance, and cardiac or respiratory functioning.
Procedural distress
Twenty-three studies evaluated interventions aimed at reducing procedural distress (e.g., pain or anxiety during lumbar puncture or port access). Cognitive-behavioral therapy (CBT) components, such as distraction, imagery, and relaxation, were most common (n=18). Other modalities included hypnosis (n=3), virtual reality-based distraction (n=2), and behavioral training for motion control (n=1). One study compared a combined pharmacologic and CBT intervention to standard oncology treatment. Coaching/supportive care was included in four studies. Study designs comprised RCTs (n=11), pilot/feasibility studies (n=5), single-arm trials (n=4), non-randomized experimental studies (n=1), case reports (n=1), and case series (n=1). All studies were prospective, with most conducted in the United States (n=17). Interventions were delivered in-person during outpatient visits (n=11) or hospital admissions (n=8), typically involving mixed samples of children with ALL and other cancers (n=13), most of whom were undergoing active chemotherapy (n=12). Participant ages ranged from 3 to 18 years. Common outcomes included pain, procedural distress, psychological distress, and anesthesia usage.
Pain
Five studies addressed non-procedural pain using behavioral interventions. These included healing touch (n=2; e.g., massage, Reiki), yoga (n=1), CBT (n=1), and a multidisciplinary pain treatment program combining physical (e.g., exercise) and psychological (e.g., CBT, mindfulness) components (n=1). All studies were conducted in North America and used case reports (n=2) or pilot/feasibility designs (n=3). Interventions were delivered individually and in-person within medical settings. All participants were undergoing active chemotherapy, with most samples including children diagnosed with various cancers including ALL (n=4). Participant ages ranged from 11 to 26 years. Assessed outcomes included pain, HRQoL, psychological distress, and heart rate variability.
Health-related quality of life/psychological functioning
Five studies targeted HRQoL or psychological functioning. Interventions included CBT (n=2), one paired with physical activity and another with robot-assisted therapy; mindfulness/music therapy (n=1); virtual reality/medical play (n=1); and medication adherence support (n=1). Most interventions were delivered in-person (n=4), with one offering remote access. Participants ranged in age from 5 to 39 years and typically had mixed cancer diagnoses (n=4). Study designs included case reports (n=1), non-randomized experimental studies (n=2), single-arm feasibility/pilot trials (n=1), and RCTs (n=1). Studies were conducted in the United States (n=2), Iran (n=1), The Netherlands (n=1), and China (n=1), with all participants undergoing active chemotherapy. Assessed outcomes included HRQoL, psychological distress, and medication adherence.
Nutrition/dietary
Eight studies targeted dietary behavior, primarily through nutrition education and goal setting. Two interventions integrated additional behavioral approaches, combining nutrition with physical activity (n=1) or supportive care (n=1). Study designs included cohort studies (n=1), non-randomized experimental studies (n=2), single-arm trials (n=3), and RCTs (n=2). Most interventions were delivered individually and in-person (n=8), with two studies offering remote options. Delivery settings included outpatient (n=8), inpatient (n=5), and home-based formats (n=3). Studies were conducted in the United States (n=4), India (n=2), Pakistan (n=1), and Canada (n=1). Participants were primarily caregivers of children with ALL (n=6), ranging from 1 to 21 years of age. Most studies focused on managing nutritional goals during active treatment (n=6). Commonly assessed outcomes included dietary intake, BMI, and anthropometry/body composition.
Sleep
Two studies targeted sleep behaviors, both caregiver-focused. One employed sleep hygiene techniques, and the other used relaxation strategies. Study designs included a feasibility pilot RCT and a case report. Both studies were conducted in North America, delivered in outpatient settings, with one offering remote access. Samples involved children with ALL undergoing active treatment, ranging in age from 3 to 10 years. Assessed outcomes included sleep quality, number of night terrors, and fatigue.
Symptom reduction/management
Six studies addressed symptoms beyond pain, including nausea, neuropathy, and mucositis. Interventions included hypnosis (n=3), distraction (n=4), and virtual reality (n=2). Most studies were conducted in the United States and delivered individually and in-person, during inpatient (n=3) and/or outpatient care (n=3). Interventions primarily targeted patients with ALL and other cancer diagnoses (n=5), all undergoing active chemotherapy (n=6). Participant ages ranged from 6 to 20 years. Commonly assessed outcomes included symptom presence and psychological distress.
Summary of mapped evidence across domains
Across all behavioral intervention targets, interventions were most frequently conducted in high-income countries (especially the United States), delivered in-person, and included samples of children receiving chemotherapy treatment, with relatively fewer interventions tailored specifically to ALL. Physical activity and procedural distress were the most frequently addressed domains and represented the most methodologically advanced areas, with the highest proportion of RCTs and multidisciplinary interventions. In contrast, interventions for pain, sleep, nutrition, psychological functioning, and symptom management were less common and largely limited to early-stage or descriptive studies (e.g., case reports, pilot/feasibility trials). Caregiver involvement was more prominent in dietary and sleep-related interventions. Few interventions spanned multiple domains or used integrated, biopsychosocial models of care. Gaps were especially evident in digital/remote delivery, interventions for adolescents and young adults, and studies conducted outside North America and Europe. This mapping highlights opportunities to expand behavioral health research across underrepresented symptom domains, populations, and delivery modalities.
Discussion
This scoping review identified a wide range of behavioral interventions that have been implemented during pediatric ALL treatment to date. Interventions most frequently targeted physical activity/exercise and procedural distress, with common strategies including structured physical activity, distraction, relaxation, and other CBT techniques. These two areas also accounted for the highest number of RCTs, indicating they are the most methodologically developed within this population. However, the majority of studies were limited by small sample sizes, and many interventions remained at the feasibility or pilot stage without progressing to full-scale efficacy testing. Consequently, only 31% of studies reviewed included RCTs, reflecting the early and fragmented state of behavioral intervention research in this field.
Our visual map (Figure 2) underscores the uneven distribution of evidence across behavioral domains, intervention types, and delivery settings. For instance, while some domains (e.g., physical activity/exercise) show both high volume and methodological advancement (i.e., more RCTs), others, including sleep, non-procedural pain, and HRQoL/psychological functioning, remain understudied and underdeveloped. In particular, the sleep domain was represented by only two studies, both small in scale and early in design (a pilot feasibility RCT and a case report), despite the well-established role of sleep in recovery and treatment response in pediatric cancer patients. Similarly, the HRQoL/psychological functioning domain, while conceptually broad, lacked a unified focus in the literature and included a small number of heterogeneous studies with mixed samples and intervention formats.
Figure 2. Visual map of study designs across behavioral intervention targets.
Several of these underrepresented domains were primarily addressed through caregiver-targeted interventions, particularly in the nutrition/dietary and sleep areas. These studies often focused on education or coaching and were typically delivered in outpatient or home-based settings. While promising in terms of feasibility, few of these interventions were rigorously tested or evaluated for their downstream impact on child outcomes, such as nutritional status or sleep quality. Likewise, psychological functioning interventions occasionally incorporated novel elements—such as artificial intelligence or music therapy—but their variability in content and delivery hindered cross-study comparisons and limited conclusions about efficacy or scalability. These findings underscore a need for more systematic development and testing of behavioral interventions across underexplored domains.
Many interventions reviewed in the current study were published over a decade ago, particularly those targeting procedural distress and symptom reduction/management. Notably, 89% of procedural distress interventions were more than 10 years old, and 68% were over 20 years old; all symptom management interventions were published more than 20 years ago. This striking lack of recent research highlights a significant lag in behavioral health intervention development compared to advances in medical treatment and technology. For example, procedural management, such as standardized sedation, has evolved significantly in the last 10 years (97). Yet, despite growing evidence for modern nonpharmacological modalities, such as virtual reality, mindfulness, and acceptance-based interventions, these approaches remain underrepresented in the literature (99). Instead, most procedural distress interventions continue to rely heavily on traditional CBT techniques (e.g., distraction, imagery, relaxation), with few studies testing newer, multimodal strategies. This gap is concerning given the increasing emphasis on a biopsychosocial treatment approach in pediatric oncology management (100). The integration of more contemporary, evidence-based behavioral interventions into pediatric cancer care could substantially enhance treatment outcomes and better address the complex evolving needs of patients.
The majority of behavioral interventions included in this review were implemented in isolation, rather than in combination with other behavioral domains. This is an important first step to establish evidence before moving to multi-component interventions. Indeed , very few studies integrated multi-component approaches. Exceptions included the small number of interventions that combined physical activity with CBT or dietary counseling, which demonstrated potential for broader quality-of-life improvements (55). However, these approaches remain the minority, highlighting an area for potential growth in future research and clinical application.
Promising next steps in this field include tailoring and personalizing interventions, examining the impact of behavioral interventions on health outcomes, and establishing specific guidelines for health behaviors during ALL treatment. First, a focus on tailoring and personalizing generalized health behavior interventions for youth with ALL may be useful to increase feasibility and acceptability to move the field toward efficacy testing. Models such as the Obesity-Related Behavioral Intervention Trials (ORBIT) model for behavioral treatment development (101) and the Framework for Reporting Adaptations and Modifications-Enhanced (FRAME) (102) could be particularly useful for adapting interventions to specific types of cancer (such as ALL), phases of treatment, or subpopulations with unique needs. Conducting RCTs to test these tailored interventions is crucial, as it helps overcome feasibility concerns and assess effectiveness. A second important area is examining the impact of behavioral interventions on health outcomes. Most studies to date have concentrated on behavioral outcomes, but it is well-established that these behavioral changes can lead to improved cancer outcomes and overall health. Recent literature highlights the significant role of health behaviors, including nutrition, activity, and sleep in influencing cancer outcomes, such as treatment tolerability and relapse rates (103, 104). However, very few studies have measured these effects directly (91). Finally, the development of established guidelines for health behaviors in pediatric ALL would provide clinically meaningful intervention targets. For physical activity, the International Physical Activity and Exercise Guidelines for youth with cancer–developed Delphi/roundtable consensus approach–provide a useful framework (105). However, widely established guidelines for nutrition, sleep, and other behaviors in the pediatric ALL context are lacking, aside from general recommendations based on age and developmental stage. Addressing these gaps and integrating comprehensive, individualized health behavior interventions could enhance measurement of intervention efficacy, as well as quality of life and long-term outcomes for pediatric cancer patients.
While the current review has multiple strengths, such as the use of multiple coders for data screening and extraction, extraction from multiple databases, and establishment of search terms within each database, findings should be interpreted in the context of several limitations. First, the results of this scoping review may be subject to publication bias as grey literature sources, such as unpublished and non-peer reviewed research (e.g., dissertations, book chapters), were excluded. These sources often contain valuable information, including studies with null or inconclusive results that are less likely to be published in traditional peer-reviewed journals. The exclusion of these types of sources may have resulted in the unintentional omission of behavioral interventions used in pediatric ALL that were not captured in the peer-reviewed literature. Second, while scoping reviews are by design useful for mapping the extent of literature, such as providing a general overview of the types of behavioral interventions implemented during active pediatric ALL treatment, they do not provide the same in-depth analysis or synthesis of evidence as systematic reviews and meta-analyses. As such, additional research is needed to examine the effectiveness or impact of these interventions on the outcomes included in this review. Additionally, the inclusion of studies with diverse methodologies and outcomes may have led to challenges in capturing the finer nuances or subtle findings in the literature. This review aimed to map outcomes of behavioral interventions for children receiving treatment for acute lymphoblastic leukemia. Explicit inclusion of these interventions were subsequently incorporated into the review’s search, and did not necessarily capture novel interventions or more generalized behavior interventions such as physical activity. While this does limit the applicability of the review’s data and analysis to anticipated interventions it still provides a useful mapping of evidence and information that may help inform the design and conduct of subsequent mapping and synthesis. Finally, the variability in study designs, participant characteristics, and intervention types may limit the generalizability of the findings, and the lack of a formal quality assessment of the included studies further reduces the certainty of the conclusions drawn.
The current state of the literature on behavioral health promotion interventions during pediatric ALL treatment is broad and lacks depth in multiple areas. While significant attention has been given to interventions targeting physical activity/exercise and procedural distress, the body of research is constrained by small sample sizes and a tendency for studies to stall at the feasibility stage, limiting the progression to efficacy testing. As a result, relatively few RCTs have been conducted in this field. These findings underscore the need for further research to strengthen the evidence base, particularly through larger, more rigorous trials that assess the effectiveness of behavioral interventions on a broader range of outcomes for children undergoing ALL treatment. Advancing behavioral health research, coupled with more rigorous efficacy testing, will be essential for enhancing the quality of care and improving both immediate and long-term psychological and physical outcomes for pediatric ALL patients.
Author contributions
CB: Project administration, Writing – original draft, Data curation, Supervision, Conceptualization, Writing – review & editing, Investigation, Methodology. SG: Writing – review & editing, Writing – original draft, Data curation, Formal analysis, Investigation. PJ: Writing – original draft, Software, Validation, Investigation, Supervision, Project administration, Methodology, Writing – review & editing. SH: Methodology, Writing – original draft, Writing – review & editing, Investigation, Data curation. PD: Writing – review & editing, Methodology, Formal analysis, Writing – original draft, Investigation. CG: Writing – review & editing, Writing – original draft, Data curation, Investigation. CS: Project administration, Writing – review & editing, Writing – original draft, Supervision, Investigation. KK: Supervision, Methodology, Data curation, Investigation, Conceptualization, Formal analysis, Writing – review & editing, Project administration, Writing – original draft.
Funding
The author(s) declare financial support was received for the research and/or publication of this article. This project was funded by the National Cancer Institute (K08CA279877).
Acknowledgments
Special thanks to Carrie Price (MLS, Information Specialist/Research Librarian, ToxStrategies) for PRESS review of the initial PubMed (NCBI) search strategy and Meghan Tokala (Medical Student, University of Kansas Medical Center School of Medicine) for assisting with data extraction.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Abbreviations
ALL, Acute lymphoblastic leukemia; JBI, Joanna Briggs Institute; PRISMA-ScR, Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for scoping reviews; MeSH, Medical Subject Headings; RCT, Randomized control trial; CAM, Complementary/alternative medicine; CBT, Cognitive-behavioral therapy; HRQoL, Health-related quality of life; ORBIT, Obesity-Related Behavioral Intervention Trials; FRAME, Framework for Reporting Adaptations and Modifications-Enhanced.
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Keywords: acute lymphoblastic leukemia (ALL), pediatric, health behavior, behavioral intervention, behavioral health
Citation: Bates CR, Gibson SM, Johnson PR, Hunt SL, Dyjak PM, Gibson CA, Sharkey CM and Klages KL (2025) Behavioral health interventions for pediatric acute lymphoblastic leukemia: a scoping review. Front. Oncol. 15:1697894. doi: 10.3389/fonc.2025.1697894
Received: 02 September 2025; Accepted: 31 October 2025;
Published: 09 December 2025.
Edited by:
Martin Kaj Fridh, University of Copenhagen, DenmarkReviewed by:
Marie Astrid Neu, Johannes Gutenberg University Mainz, GermanyPeter Schmidt-Andersen, University of Copenhagen, Denmark
Copyright © 2025 Bates, Gibson, Johnson, Hunt, Dyjak, Gibson, Sharkey and Klages. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Carolyn R. Bates, Y2JhdGVzNEBrdW1jLmVkdQ==