Left OFC Activation in Functional Near-Infrared Spectroscopy during an Inhibitory Control Task in an Early Years Sample: Integrating Stress Responses with Cognitive Function and Brain Activation.

INTRODUCTION: Previous functional near-infrared spectroscopy (fNIRS) studies using Go/No-Go (GNG) tasks have focused on brain activation in relation to cognitive processes, particularly inhibitory control (IC). The results of these studies commonly describe right hemispheric engagement of the dorsolateral, ventromedial, or inferior frontal regions of the prefrontal cortex. Considering that typical healthy cognitive development is negatively correlated with higher cortisol levels (which may alter brain development), the overarching aim of the current study was to investigate how elevated stress (due to unforeseeable events such as the pandemic) impacts early cognitive development. METHOD: In this study, we examined fNIRS data collected from a sample of children (aged 2-4 years) during a GNG task relative to the response to stressors measured via hair cortisol concentrations. We acquired data in an ecological setting (Early Childhood Education and Care) during the coronavirus pandemic. RESULTS: We found that children with higher stress levels and a less efficient IC recruited more neural terrain and our group-level analysis indicated activation in the left orbitofrontal area during IC performance. CONCLUSIONS: A contextual stressor may disrupt accuracy in the executive function of IC early in development. More research efforts are needed to understand better how an orbitofrontal network subserves goal-directed behavior.

Risk of not being in employment, education or training (NEET) in late adolescence is signalled by school readiness measures at 4-5 years.

BACKGROUND: Not being in employment, education, or training (NEET) is associated with poor health (physical and mental) and social exclusion. We investigated whether England's statutory school readiness measure conducted at 4-5 years provides a risk signal for NEET in late adolescence. METHODS: We identified 8,118 individuals with school readiness measures at 4-5 years and NEET records at 16-17 years using Connected Bradford, a bank of linked routinely collected datasets. Children were categorised as 'school ready' if they reached a 'Good Level of Development' on the Early Years Foundation Stage Profile. We used probit regression and structural equation modelling to investigate the relationship between school readiness and NEET status and whether it primarily relates to academic attainment. RESULTS: School readiness was significantly associated with NEET status. A larger proportion of young people who were not school ready were later NEET (11%) compared to those who were school ready (4%). Most of this effect was attributable to shared relationships with academic attainment, but there was also a direct effect. Measures of deprivation and Special Educational Needs were also strong predictors of NEET status. CONCLUSIONS: NEET risk factors occur early in life. School readiness measures could be used as early indicators of risk, with interventions targeted to prevent the long-term physical and mental health problems associated with NEET, especially in disadvantaged areas. Primary schools are therefore well placed to be public health partners in early intervention strategies.

Risk and Protective Factors for Parental Involvement and Early Indicators of School Achievement in Alaska.

OBJECTIVES: Parental involvement can affect child school readiness, which in turn influences subsequent child learning outcomes. While social support, stress, caregiver psychological distress, and drinking could affect parental involvement, it is unknown whether and how these factors influence downstream child learning outcomes through parental involvement and child school readiness. This study tests those associations. METHODS: Using de-identified data provided by the Alaska Longitudinal Child Abuse and Neglect Linkage project (N = 683), we use Structural Equation Modeling to assess direct and indirect effects of paths embedded in the proposed model. RESULTS: This study found statistically significant indirect effects: (1) path linking stress faced by caregivers to child reading proficiency through caregiver psychological distress, parental involvement, and child school readiness, (2) path linking stress faced by caregivers to child reading proficiency through caregiver drinking, parental involvement, and child school readiness, and (3) path linking social support for caregivers to child reading proficiency through caregiver psychological distress, parental involvement, and child school readiness. Post-estimation showed that the sum of the magnitude of total effects of stress and the magnitude of total effects of support is significantly larger than either alone. CONCLUSIONS FOR PRACTICE: Findings suggest that reducing caregiver stress and offering social support could not only benefit caregivers but learning outcomes of their children as well. For child learning outcomes, simultaneously reducing stress and offering social support for caregivers, rather than just one of them alone, is suggested. These results are important for children, particularly for those raised by caregivers experiencing psychological distress or drinking issues.

School Readiness in Preschool-Age Children with Critical Congenital Heart Disease.

This study examined the nature, variability, and predictors of school readiness difficulties in young children with critical congenital heart disease (CCHD). We hypothesized that, compared to a community control (CC) group, children with CCHD would score less well on measures of readiness and that readiness would be associated with CCHD-related risk factors. Children (60 CCHD and 60 CC) were 4 to 5 years of age and not yet attending kindergarten. Readiness measures included tests of cognition, executive function, motor ability, and pre-academic skills. Caregivers provided child behavior ratings. Analyses examined group differences in readiness, readiness profiles, and associations of readiness with CCHD-related medical risk factors. The CCHD group had lower scores than the CC group on testing and higher caregiver ratings of problems in social communication, as well as higher rates of deficits on several of the measures. Latent class analysis provided evidence for different readiness profiles, with more children with CCHD displaying profiles characterized by weaknesses in readiness. CCHD-related medical risk factors associated with readiness problems in the CCHD group included a co-morbid genetic disorder, postnatal diagnosis of CCHD, major perioperative complication, and longer periods of hospitalizations, cardiopulmonary bypass, and aortic cross-clamp placements. Findings document multiple problems in school readiness in young children with CCHD. Deficits vary across individuals and are associated with higher medical risk. Results confirm the importance of screening for school readiness in these children and suggest areas to target in designing screening measures and providing early childhood interventions.

Elucidating Linkages of Executive Functioning to School Readiness Skill Gains: The Mediating Role of Behavioral Engagement in the PreK Classroom.

This study investigated links of executive functioning to gains in school readiness skills and explored the mediating role of children's behavioral engagement in the PreK classroom. We collected direct assessments of executive functioning (EF) and observations of behavioral engagement for 767 children (mean age 52.63 months) from racially/ethnically diverse, low-income backgrounds three times over the PreK year. We also measured school readiness in the domains of language, literacy, and math using direct assessments and collected teacher-report measures of socialemotional-behavioral skills and approaches to learning. Our analyses addressed the following three research questions: 1) To what extent does children's EF predict school readiness skill gains during PreK? 2) To what extent does children's behavioral engagement in PreK classrooms predict school readiness skill gains? 3) To what extent does behavioral engagement mediate the relation of EF with school readiness skill gains? We observed that EF was positively related to gains in language, math, and approaches to learning. Regarding behavioral engagement, Negative Classroom Engagement was negatively related to gains in literacy, math, social-emotionalbehavioral skills, and approaches to learning while Positive Task Engagement was positively related to gains in approaches to learning. Negative Classroom Engagement significantly mediated the effects of EF on gains in the domains of literacy, socialemotional-behavioral skills, and approaches to learning. We describe implications of these findings for promoting children's ability to learn and thrive in PreK contexts with a focus on their engagement with teachers, peers, and learning activities.

Working memory and school readiness in preschool children with sickle cell disease compared to demographically matched controls.

Children diagnosed with sickle cell disease (SCD) are at risk of the development of neurobehavioural problems early in life. Specific impairments in executive function skills, including working memory, have been documented in school-aged children with SCD. These executive skills are known to strongly contribute to early academic skills and preparedness for entering kindergarten. This study examined working memory and school readiness in preschool children with SCD compared to a healthy control group matched for race, sex and parent education. A total of 84 patients diagnosed with SCD (61.9% haemoglobin [Hb]SS/HbSß0 -thalassaemia) and 168 controls completed testing. The mean (SD) ages of patients and controls at testing were 4.53 (0.38) and 4.44 (0.65) years respectively. The SCD group performed worse than controls on measures of executive function, working memory and school readiness (p < 0.01; Cohen's D range: 0.32-0.39). Measures of working memory were associated with school readiness after accounting for early adaptive development. Multiple linear regression models among patients diagnosed with SCD revealed that college education of the primary caregiver was positively associated with school readiness (p < 0.001) after controlling for sex, genotype, age and early adaptive development. These results highlight the need to implement school readiness interventions in young children diagnosed with SCD emphasising executive function skills.

Association between atopic dermatitis and school readiness in preschool children.

BACKGROUND: Although atopic dermatitis (AD) in children affects diverse stages of life, no studies have reported on the association between school readiness and AD. METHODS: This study used Korean National Health Insurance data and the Health Screening Program for Infants and Children. Among all children born between 2008 and 2012 in Korea, those who were assessed for school readiness through questionnaires in a health screening program performed at 54 and 60 months old were enrolled. AD was defined based on the International Classification of Diseases codes, with two or more prescriptions of topical corticosteroids during the first 54-60 months of life. The primary outcome was the association between school readiness and AD. The questionnaire relating to school readiness comprised six items - cognitive skills, social development, activeness, concentration, emotional development, and language skills. Logistic regression analysis was used to identify the associations between school readiness and AD. RESULTS: This study included 239,673 children without AD and 38,229 children with AD. The average age at which school readiness was assessed was 4.8 years. AD was associated with vulnerability in activeness (adjusted odds ratio: 1.127; 95% confidence interval: 1.071-1.186) and concentrations (1.170; 1.093-1.254). The impact of AD on concentrations showed consistent results regardless of sex, exposure to systemic corticosteroids and antihistamines, and age at the diagnosis of AD. CONCLUSIONS: Children with AD have vulnerability in school readiness in the aspects of activeness and concentration.

Understanding academic readiness for kindergarten: The interactive role of emotion knowledge and teacher-child closeness.

One goal of this study was to test the role of emotion knowledge and teacher-child closeness and conflict in predicting academic readiness for kindergarten over and above demographic factors and executive functioning skills (especially inhibitory control) known to predict readiness. Another goal was to test teacher-child closeness as a moderator of the association between emotion knowledge or executive functioning and academic readiness. A total of 141 4- and 5-year-old children completed emotion knowledge, academic readiness, and inhibitory control measures. Preschool teachers reported their perceived relationship closeness and conflict with individual students. Accounting for child age in months, family income, and inhibitory control, emotion knowledge and teacher-child closeness were positively associated with academic readiness. Teacher-child closeness moderated the relationship between emotion knowledge and academic readiness, suggesting that teacher-child closeness may be especially important in promoting academic readiness for preschool students with low emotion knowledge.

Material incentive motivation and working memory performance of kindergartners: A large-scale randomized controlled trial.

This study investigated the effect of material incentive motivation on the working memory performance of kindergartners using a large-scale randomized controlled trial covering 7123 children aged 50 to 144 months (M = 75.85 months) from 19 provinces in Thailand. This study measured the working memory of young children using the digit span task. The first finding is that material incentive motivation raised the working memory performance of young children by 4% of the mean of the control group. The second finding is that young children with different background characteristics responded to material incentive motivation uniformly except for the children's age. The third finding is that school readiness was the most predictive variable for the working memory performance of young children.

Longitudinal association between children's mastery motivation and cognitive school readiness: Executive functioning and social-emotional competence as potential mediators.

This study investigated the direct relationships between kindergarten children's object and social mastery motivation and future cognitive school readiness and the indirect relationships mediated through executive functioning and social-emotional competence in the school context. The participants were 103 Hong Kong kindergarten children (45.6% girls; mean age = 60.4 months) and their teachers. The teachers reported the children's demographic information and object and social mastery motivation at Time 1 (in the middle of the school year). They rated the children's executive functioning, social-emotional competence and cognitive school readiness at Time 2 (at the end of the school year). The results from the path analysis model revealed that the children's object mastery motivation at Time 1, but not their social mastery motivation, directly predicted their cognitive school readiness at Time 2. The indirect relationships between (a) object mastery motivation at Time 1 and cognitive school readiness at Time 2 mediated through executive functioning (indirect effect: ß =.32, SE =.05, p <.001) and (b) social mastery motivation at Time 1 and cognitive school readiness at Time 2 mediated through social-emotional competence (indirect effect: ß =.09, SE =.03, p <.01) were significant. The findings highlight the differential roles of object and social mastery motivation in predicting children's cognitive school readiness and propose children's executive functioning and social-emotional competence as processes mediating the relationships. The results also suggest the desirability of providing kindergarten children with extensive play opportunities and materials to support their mastery motivation and cognitive school readiness.

Examination of school readiness and factors related to developmental vulnerability in children born very low birth weight.

BACKGROUND: Many children born very low birth weight (VLBW) experience school struggles with preparedness requiring adequate physical, social, behavioural, cognitive and communication skills. A global assessment of proficiency is necessary to identify those at risk in any such area and direct early intervention accordingly. Study objectives were to characterize developmental vulnerability and school readiness scores in these key domains in a sample of children born VLBW versus their provincial public school system peers and identify early-life infant and parent factors related to suboptimal school readiness. METHODS: The Early Development Instrument teacher assessments of school readiness were collected for a Canadian VLBW sample (NCT02759809). Comparisons between children born VLBW and peers were made. Group differences between children born VLBW considered vulnerable (<10th percentile, not developmentally ready for learning) and not vulnerable were tested and linear regression explored associations between early-life factors and domain scores. RESULTS: Of 77 available Early Development Instrument assessments, median (interquartile range) assessment age was 6.0 (5.7, 6.2) years, birth weight 950 (793, 1250) grammes and birth gestation 27.4 (25.6, 29.7) weeks. A higher proportion of children born VLBW versus peers exhibited vulnerability in Physical Health and Well-being (24.7% vs. 16.1%, p = 0.04), Communication Skills and General Knowledge (23.4% vs. 10.2%, p = 0.0001) and vulnerability in ≥2 domains (26.0% vs. 14.4%, p = 0.004). Children born VLBW classified as vulnerable versus not vulnerable had lower birth gestation and 5-min Apgar. Adjusted regression models found Apgar <7 associated with lower scores for Physical Health and Well-being (-0.86; 95%CI: -1.71, -0.00; p = 0.049), Social Competence (-1.77; 95%CI: -2.92, -0.62; p = 0.003), Emotional Maturity (-1.55; 95%CI: -2.43, -0.66; p = 0.0009) and Communication Skills and General Knowledge (-1.63; 95%CI: -3.19, -0.06; p = 0.04). CONCLUSIONS: This VLBW sample exhibited poor school readiness in multiple domains. Identification of lower birth gestation and Apgar may assist targeted early interventions to mitigate vulnerability.

School readiness and social determinants of health: A collaboration with community teachers and parents.

PURPOSE: To explore perceptions of community dwelling caregivers of preschool-aged children regarding the influence of social determinants of health (SDOH) on children's school readiness. Parents' perspectives regarding solutions to enhance school readiness in preschool-aged children are also explored. METHODS: This study employed a qualitative, descriptive design and a community based participatory research (CBPR) approach. An academic institution collaborated with parents, teachers, and administrators at a community-based preschool learning center. Ten young-adult to middle-aged mothers and caregivers attended two separate focus groups and completed open-ended questionnaires. Inductive and deductive thematic analysis of text were employed. FINDINGS: Three themes emerged 1) Families described the vast lack of appropriate community resources and inability to access those resources that are available to prepare their children for school 2). Family members need help processing information about social resources 3) Community, individual and systemic level solutions to enhance school readiness. CONCLUSIONS: Academic-Community partnerships provide an opportunity to (1) identify solutions to remove systemic barriers that impede children's readiness for school, and (2) design interventions to support families through that process. Interventions to enhance school readiness should be family-focused and can be informed by understanding the influence of SDOH during the planning stages. SDOH create barriers and prevent parents from prioritizing their children's school, health-care, and developmental needs. PRACTICE IMPLICATIONS: Interventions to enhance school readiness should be family-based and can be informed by understanding the influence of SDOH during the planning stages. Social advocacy is also needed to enhance the ability of parents to enhance their children's school readiness.

Language Problems and ADHD Behaviors: Unique and Interactive Associations with School Readiness in a Socioeconomically Disadvantaged Preschool Sample.

This study examined the unique and interactive effects of receptive language ability and ADHD behaviors on six school readiness outcomes, over and above the effects of socioeconomic status, in 49 preschoolers (Mage = 3.98, SDage = .58; 53.06% female) recruited from Head Start-affiliated classrooms. Hierarchical regression analyses revealed unique positive associations between receptive language ability and cognitive and mathematics readiness, and unique negative associations between ADHD behaviors and social-emotional, physical, cognitive, and literacy readiness. Moderation analyses indicated that at higher, but not lower, levels of ADHD behaviors, lower receptive language ability was associated with lower social-emotional readiness. Results highlight that, when considered together, children's receptive language ability and ADHD behaviors vary in how they predict school readiness. Further, results provide preliminary evidence for ADHD behaviors as a risk factor in the association between receptive language deficits and social-emotional school readiness. Educational and clinical practice implications are discussed.

Mexican-Origin Adolescent Mothers' Beliefs and Practices Concerning Children's School Readiness.

Parents' academic socialization of their young children is a critical yet understudied area, especially in the context of vulnerable parent-child dyads. The current longitudinal study examined factors that informed mothers' beliefs and practices concerning children's kindergarten readiness in a sample of 204 Mexican-origin adolescent mothers (M age = 19.94). Adolescent mothers' individual characteristics and assets (i.e., parental self-efficacy, educational attainment, educational utility beliefs, knowledge of child development) and sources of stress (i.e., economic hardship, coparenting conflict) were related to the importance they placed on children's social-emotional and academic readiness for kindergarten, their provision of cognitive stimulation and emotional support to their children in the home, and their enjoyment of literacy activities with their child. Moreover, adolescents' perception of parenting daily hassles emerged as a mediator in this process. Findings underscore the importance of considering Mexican-origin adolescent mothers' strengths and assets along with their unique contextual stressors as they relate to beliefs and practices that could have implications for their children's school success.

Pre-K and Kindergarten Teacher Perception of School Readiness During the COVID-19 Pandemic.

In 2020, the COVID-19 pandemic caused a mandatory shift from in-person instruction to online learning for many young children. Teachers needed to adjust to virtual teaching, children were isolated from their peers, and parents played a bigger role in learning during the pandemic. In 2021, the shift back to in-person learning occurred. Research has already shown the negative influence COVID-19 had on students' mental health; however, limited research has examined the impact of the pandemic on school readiness. In this study, using the Head Start domains of school readiness, 154 Kindergarten and Pre-K teachers compared current student school readiness to the readiness of their students prior to the pandemic. Results showed that nearly 80% of teachers felt that overall student functioning was Worse or Much Worse than before the pandemic; no teachers reported functioning was overall much better. Teachers most frequently identified the Ready to Learn and Social-Emotional Development domains as the areas of greatest struggle for their students; Physical Development was the least frequently reported. Chi-square tests were used to examine the association between teacher demographics and overall school readiness and domain of greatest struggle; no significant relationships were found. Future directions and limitations of these results are discussed.

Sleep Patterns and School Readiness of Pre-Kindergarteners from Racially and Ethnically Diverse, Low-Income Backgrounds.

OBJECTIVE: To explore patterns in parent-reported child sleep health and to investigate connections between such patterns and school readiness for newly enrolled prekindergarten (PreK) attendees from racially and ethnically diverse, low-income backgrounds. STUDY DESIGN: In a secondary analysis from a larger multiple-cohort longitudinal observational study of prekindergartners in low-income families, parental reports of sleep health for 351 children (mean age, 52.8 ± 3.5 months) during the first month of PreK were analyzed. Children also had completed direct assessments measuring language, literacy, mathematics, and executive functioning, and teachers rated children's social-emotional-behavioral competencies and approaches to learning at PreK entry. We performed latent class analyses to identify patterns in sleep health and used regression models to examine concurrent associations between child sleep health patterns and school readiness competencies across 6 domains: language, literacy, mathematics, executive functioning, social-emotional-behavioral, and approaches to learning. RESULTS: Two classes emerged reflecting more and less desirable patterns of sleep health. Children classified in the earlier, longer, consistent sleep health class (87% of children) experienced earlier bedtimes, longer night-time sleep durations, more consistent sleep routines, less caffeine consumption ≤3 hours before bedtime, and scored higher on a direct assessment of expressive vocabulary and on teacher-reported measures of social-emotional-behavioral competencies and learning approaches than their peers in the later, shorter, inconsistent sleep health class (13% of children). CONCLUSIONS: Consistent sleep routines and more optimal sleep health may serve as a protective mechanism for the language development, social-emotional-behavioral regulation, and approaches to learning of PreK from racially and ethnically diverse, low-income backgrounds. Clinician-parent discussions regarding optimal sleep health may provide key opportunities for targeted education that promotes school readiness skill development.

Developmental trajectories of executive functions from preschool to kindergarten.

Executive functions (EF) are key predictors of long-term success that develop rapidly in early childhood. However, EF's developmental trajectory from preschool to kindergarten is not fully understood due to conceptual ambiguity (e.g., whether it is a single construct or multiple related constructs) and methodological limitations (e.g., previous work has primarily examined linear growth). Whether and how this trajectory differs based on characteristics of children and their families also remains to be characterized. In a primarily low-income, racially and ethnically diverse, typically developing, urban sample, the present study employed confirmatory factor analyses to examine the construct of EF and latent growth curve modeling to examine nonlinear growth across five time points. Results indicated that the development of a single EF construct with partial measurement invariance across time points was best characterized as nonlinear, with disproportionately more growth during the preschool year. There was individual variability in EF trajectories, such that children with higher EF at preschool entry showed relatively steeper growth during preschool compared to low-EF peers. However, children with less EF growth in preschool had steeper growth in kindergarten, attenuating the gains of high-EF preschoolers and resulting in some convergence in EF by the end of kindergarten. Findings have implications for (1) examining EF development in early childhood with more specificity in future studies, (2) informing the timing of EF interventions in early childhood, and (3) identifying children for whom such interventions might be especially beneficial.

Children's screen use and school readiness at 4-6 years: prospective cohort study.

BACKGROUND: The primary aim of this study was to determine if screen use in early childhood is associated with overall vulnerability in school readiness at ages 4 to 6 years, as measured by the Early Development Instrument (EDI). Secondary aims were to: (1) determine if screen use was associated with individual EDI domains scores, and (2) examine the association between screen use and EDI domains scores among a subgroup of high screen users. METHODS: This prospective cohort study was carried out using data from young children participating in a large primary care practice-based research network in Canada. Logistic regression analyses were run to investigate the association between screen use and overall vulnerability in school readiness. Separate linear regression models examined the relationships between children's daily screen use and each separate continuous EDI domain. RESULTS: A total of 876 Canadian participants participated in this study. Adjusted logistic regression revealed an association between increased screen use and increased vulnerability in school readiness (p = 0.05). Results from adjusted linear regression demonstrated an association between higher screen use and reduced language and cognitive development domain scores (p = 0.004). Among high screen users, adjusted linear regression models revealed associations between increased screen use and reduced language and cognitive development (p = 0.004) and communication skills and general knowledge domain scores (p = 0.042). CONCLUSIONS: Screen use in early childhood is associated with increased vulnerability in developmental readiness for school, with increased risk for poorer language and cognitive development in kindergarten, especially among high users.

The Intensity of Formal Child-Care Attendance Decreases the Shared Environment Contribution to School Readiness: A Twin Study.

The purpose of this study was to explore if child-care intensity (hours/weeks) and age of onset could moderate genetic and environmental contributions to school readiness. A sample of 648 (85% Whites; 50% Females) pairs of twins was used to compute a GxE, CxE and ExE interaction analyses. The moderation model showed that shared environment explains 48% of individual differences in school readiness for children not attending formal child-care, and decreased gradually to a mere 3% for children attending formal child-care full time, e.g., 40 h per week. Age of onset exerted no moderation effect. The results support the hypothesis that child-care acts as a normalizing environment, possibly buffering negative effects from low-quality home environments on school readiness.

Supporting immigrant caregivers during the COVID-19 pandemic: Continuous adaptation and implementation of an early childhood digital engagement program.

Digital messaging programs have the potential to be a powerful, low-cost, technological tool to support multiple facets of caregivers' knowledge, and implementation of developmentally appropriate caregiver-child activities among diverse immigrant populations. However, involving caregivers and community stakeholders in the cultural and linguistic tailoring of interventions to optimize utilization and engagement may be critical to ensuring messaging programs' usability and acceptability. The purpose of this mixed-method study was to use the dynamic adaptation process (DAP) within an Exploration, Preparation, Implementation, Sustainment (EPIS) framework to examine the implementation of a digital messaging program, developed at the beginning of the COVID-19 pandemic, aimed at providing Spanish-, English-, and Mandarin-speaking immigrant caregivers with caregiver-child activities that supported children's development and caregivers' knowledge. Building upon the EPIS framework, using DAP, we assessed the feasibility and acceptability of a messaging program via short message service or multimedia message service, WeChat, and Remind and webinar program during the COVID-19 pandemic. The study illustrated how a digital messaging program is a feasible mechanism for sharing developmentally and culturally appropriate information with immigrant caregivers. In addition, the use of the DAP and the EPIS framework allowed us to continuously track the process of cultural adaptation, identify barriers and facilitators of the outreach program, and examine how implementation unfolded across all three groups of caregivers.