RESEARCH TO IMPROVE CARE FOR DYING CHILDREN AND THEIR FAMILIES
RELEASE DATE: July 29, 2002
RFA: NR03-003
National Institute of Nursing Research
(http://www.ninr.nih.gov)
National Institute of Mental Health
(http://www.nimh.nih.gov)
LETTER OF INTENT RECEIPT DATE: October 28, 2002
APPLICATION RECEIPT DATE: November 22, 2002
THIS RFA CONTAINS THE FOLLOWING INFORMATION
o Purpose of this RFA
o Research Objectives
o Mechanisms of Support
o Funds Available
o Eligible Institutions
o Individuals Eligible to become Principal Investigators
o Where to Send Inquiries
o Letter of Intent
o Submitting an Application
o Peer Review Process
o Review Criteria
o Receipt and Review Schedule
o Award Criteria
o Required Federal Citations
PURPOSE OF THIS RFA
The National Institute of Nursing Research (NINR) and the National
Institute of Mental Health (NIMH) invites applications for research
grants to encourage research that will improve the quality of life for
children who are approaching the end of life and the quality of the
dying process and bereavement following the death for the children"s
families, friends and other care providers. For this RFA, family is
defined broadly in terms of traditional families and non-traditional
families including children being cared for in foster situations, by
distant relatives, or friends.
RESEARCH OBJECTIVES
Background
A recent Institute of Medicine (IOM) report, "When Children Die:
Improving Palliative and End of Life Care for Children and Their
Families," highlights the importance of facing the challenges of caring
for dying children and their families (IOM, 2002). (Hyperlink:
http://www.iom.edu). In 1997, the five leading causes of death in
children under the age of 15 were accidents, congenital anomalies,
cancer, homicide and diseases of the heart (National Vital Statistics
Report, 1999). While these deaths are relatively uncommon in the
United States (55,000 in 1999), the international burden of childhood
death is staggering. For example, the Joint United Nations Program on
HIV/AIDS (UNAIDS) estimates that 580,000 children under the age of 15
succumbed to HIV/AIDS during 2001. Regardless of the number of deaths,
the death of a child can be a devastating event for the family, friends
and care providers. Despite the importance of this issue, there is
very little science to guide the care of dying children and their
families. What is known is primarily anecdotal. For example, many, if
not most, care providers avoid discussing the possible death of a child
with the families and the children themselves. This reluctance leads
to care that focuses so single-mindedly on cure or life-prolongation
that the possibility (or even likelihood) of death is ignored and the
potential burdens of treatment are not adequately weighed against
potential benefits. Consequently, opportunities to combine curative
therapies, such as anticancer regimens, with palliative therapies that
will prevent or relieve a child"s suffering are neglected.
The cause of the child"s death is important to consider. When a child
dies of a sudden and unexpected event, the parents, siblings, extended
family and friends become the focus. Interactions between the family
and the health care providers in the emergency room or between the
family and other emergency response personnel can leave a lasting, and
often unpleasant memory with the survivors. When a child dies of a
chronic condition, such as cancer, it is likely that the family and the
health care providers have established relationships that are truncated
when the child dies. Loss of this ongoing support system can impair the
family"s ability to cope with the loss of their child, particularly if
health care providers have served as the primary support, as can be the
case with stigmatized illnesses such as HIV/AIDS. The death of a child
due to a genetic illness or to HIV/AIDS adds further complexity because
parents sometimes feel guilty for passing the life-threatening illness
to their child. Genetic illnesses or HIV/AIDS may be one of the few
scenarios where there can be foreknowledge of impending death in a
child who is currently in good health or where a fatal congenital
condition can be diagnosed prenatally. Children dying from stigmatized
diseases such as AIDS may face significant barriers to high-quality
end-of-life care.
No matter the cause of death, health care providers need to focus on
promoting the quality of life of the child and family. Managing
symptoms, such as cancer related pain or chemotherapy induced nausea
and vomiting, can be particularly difficult in children because of
dosing uncertainties, side effects and the reluctance of care providers
to give opiate medications to children. Communication with the child
and family that focuses on cure, rather than the potential for death,
can also affect the quality of life at the end of life because the
child may be unaware that he/she is dying. Age appropriate
communication that includes the child and family can prevent unwanted
interventions and facilitate a peaceful death. The siblings of
chronically ill children are often isolated and grieve in silence or
harbor feelings of anger and guilt as family attention and resources
are focused on the ill child. Ways to appropriately include and
support siblings throughout the dying process need to be elucidated.
Where the child dies can have a profound impact on his/her quality of
life at the end of life and the family"s experience of the dying
process. When the possibility of death has not been discussed until
very late in the dying process, dying children are often admitted to
intensive care units and die a "high tech" death. Such deaths can
isolate the family from the dying child and prevent a peaceful death.
Research is needed to identify and test approaches that care providers
can implement to improve the care of dying children in all settings,
including children dying from a stigmatized illness such as HIV/AIDS in
areas with limited resources.
Research Scope
The chapter on research directions in the IOM report (2002) offers
suggestions for future research directions regarding care for dying
children and their families. Examples of potential research topics
include, but are not limited to the following:
o Identify age specific end-of-life issues from preterm babies through
adolescents and determine how the age of the parents influences the
dying process.
o Test ways of integrating palliative care with life prolonging
therapies in children with life threatening illnesses.
o Identify the dying trajectories of children (e.g., sudden death vs.
life threatening condition) and determine if interventions can and
should be structured according to the trajectories.
o Test interventions to facilitate communication among health
professionals and the extended family in different situations such as
prenatal diagnosis of a fatal condition, premature birth, and death of
a child from traumatic injury or chronic illness such as cancer.
o Evaluate the role of health care providers in the lives of
chronically ill children and their families, especially when the
emphasis changes from cure to end-of-life care, or when families have
few supports outside of the health care system.
o Study school-based interventions to assist teachers and classmates
who are continuing to interact with the child through a life
threatening illness. Interventions may include ways to reduce stigma
and improve palliative care in this environment.
o Determine ways to help a child cope with the visible signs (e.g.,
hair loss, fatigue, frequent absences, medication regimes) of their
illness or treatments.
o Evaluate effective bereavement interventions for siblings, parents,
and other family members or caregivers and determine the effect the
type of death (e.g., violence, suicide, cancer, stigmatized illness)
has on the bereavement process.
o Study hope versus uncertainty in the rapidly evolving field of
genetics where advances such as transplants and gene therapy are
prolonging life well beyond expectations.
o Identify specific issues in vulnerable children (e.g., those who are
from resource poor settings, handicapped, stigmatized or who have
experienced multiple losses, ) who are diagnosed with life threatening
conditions. Develop and test culturally relevant interventions to
support the child and family through death and bereavement in domestic
and international settings.
o Determine approaches appropriate to the cognitive and emotional
maturity of the child, to assess and manage physical and psychological
symptoms associated with conditions that are likely to be fatal.
o Test culturally sensitive communication models, appropriate to the
cognitive and emotional maturity of the child, that involve him/her in
decision making throughout a life threatening illness and death.
o Evaluate the effect of a child"s death on the family unit,
especially siblings, including the financial impact and long-term
consequences.
o Develop and test culturally sensitive individual, peer, family,
community and structural interventions that promote a peaceful death
for the child within the cultural context of the family.
MECHANISMS OF SUPPORT
This RFA will use the NIH R01 and R21 award mechanisms. As an
applicant, you will be solely responsible for planning, directing, and
executing the proposed project. The objective of the
exploratory/developmental mechanism (R21) is to encourage applications
from individuals who are interested in testing innovative or
conceptually creative ideas that are scientifically sound and may
advance our understanding of the end of life for children and their
families. Investigators are encouraged to explore the feasibility of
an innovative research question or approach that will provide a basis
for future research project applications. Exploratory/developmental
grants (R21) are limited to 3 years of support and up to $125,000 per
year in direct costs. For further guidance on the R21 mechanism,
please see: http://grants1.nih.gov/grants/guide/pa-files/PA-99-134.html.
This RFA is a one-time solicitation. Future unsolicited, competing
continuation applications based on this project will compete with all
investigator-initiated applications and will be reviewed according to
the customary peer review procedures. The anticipated award date is
July 1, 2003.
This RFA uses just-in-time concepts. It also uses modular and non-
modular grant formats. (see
https://grants.nih.gov/grants/funding/modular/modular.htm). If you are
submitting an application with direct costs in each year of $250,000 or
less, use the modular format. Otherwise, follow the standard PHS 398
application instructions for detailed budgets.
FUNDS AVAILABLE
NINR intends to commit approximately $2 million in FY 2003 to fund 5-7
applications in response to this RFA. NIMH intends to commit
approximately $500,000 in FY 2003 to fund 1-3 new and/or competitive
continuation grants. For the R01 mechanism, an applicant may request
up to 5 years of support and up to $340,000 per year in direct costs.
For the R21, applicants may request up to 3 years of support and up to
$125,000 per year in direct costs. Because the nature and scope of the
proposed research will vary from application to application, it is
anticipated that the size and duration of each application will also
vary. Although the financial plans of the NINR provide support for this
program, awards pursuant to this RFA are contingent upon the
availability of funds and the receipt of a sufficient number of
meritorious applications.
ELIGIBLE INSTITUTIONS
You may submit (an) application(s) if your institution/organization has
any of the following characteristics:
o For-profit or non-profit organizations
o Public or private institutions, such as universities, colleges,
hospitals, and laboratories
o Units of State and local governments
o Eligible agencies of the Federal government
o Domestic or foreign
o Faith-based organizations
INDIVIDUALS ELIGIBLE TO BECOME PRINCIPAL INVESTIGATORS
Any individual with the skills, knowledge, and resources necessary to
carry out the proposed research is invited to work with their
institution to develop an application for support. Individuals from
underrepresented racial and ethnic groups as well as individuals with
disabilities are always encouraged to apply for NIH programs.
WHERE TO SEND INQUIRIES
We encourage inquiries concerning this RFA and welcome the opportunity
to answer questions from potential applicants. Inquiries may fall into
three areas: scientific/research, peer review, and financial or grants
management issues:
o Direct your questions about scientific/research issues to:
Dr. Ann Knebel
Office of Extramural Programs
National Institute of Nursing Research
6701 Democracy Blvd, Room 710, MSC 4870
Bethesda, MD 20892-4870
Telephone: (301) 594-5966
FAX: (301) 480-8260
Email: ann_knebel@nih.gov
Dr. Nicolette Borek
Center For Mental Health Research on AIDS
National Institute of Mental Health
6001 Executive Blvd., Room 6206, MSC 9619
Bethesda, MD 20892-9619
Telephone: (301) 443-4526
FAX: (301) 443-9719
Email: nborek@mail.nih.gov
o Direct your questions about peer review issues to:
Dr. John Richters
Office of Review
National Institute of Nursing Research
6701 Democracy Blvd, Room 707, MSC 4870
Bethesda, MD 20892-4870
Telephone: (301) 594-5971
FAX: (301) 451-5645
Email: john_richters@nih.gov
o Direct your questions about financial or grants management matters
to:
Ms. Cindy McDermott
Office of Grants and Contracts Management
Division of Extramural Activities
National Institute of Nursing Research
6701 Democracy Blvd, Room 710, MSC 4870
Bethesda, MD 20892-4870
Telephone: (301) 594-6869
FAX: (301) 451-5648
Email: cindy_mcdermott@nih.gov
Brian Albertini
Grants Management Branch
Division of Extramural Activities
National Institute of Mental Health
6001 Executive Blvd, Room 6134, MSC 9605
Bethesda, MD 20892-9605
Telephone: (301) 443-0004
FAX: (301) 443-6885
Email: balberti@nih.gov
LETTER OF INTENT
Prospective applicants are asked to submit a letter of intent that
includes the following information:
o Descriptive title of the proposed research
o Name, address, and telephone number of the Principal Investigator
o Names of other key personnel
o Participating institutions
o Number and title of this RFA
Although a letter of intent is not required, is not binding, and does
not enter into the review of a subsequent application, the information
that it contains allows IC staff to estimate the potential review
workload and plan the review.
The letter of intent is to be sent by the date listed at the beginning
of this document. The letter of intent should be sent to:
Dr. John Richters
Office of Review
National Institute of Nursing Research
6701 Democracy Blvd, Room 707, MSC 4870
Bethesda, MD 20892-4870
Telephone: (301) 594-5971
FAX: (301) 451-5645
Email: john_richters@nih.gov
SUBMITTING AN APPLICATION
Applications must be prepared using the PHS 398 research grant
application instructions and forms (rev. 5/2001). The PHS 398 is
available at https://grants.nih.gov/grants/funding/phs398/phs398.html in
an interactive format. For further assistance contact GrantsInfo,
Telephone (301) 710-0267, Email: GrantsInfo@nih.gov.
Please note, when completing an application for the R21 mechanism,
Items a-d in the Research Plan must not exceed a total of 15 pages.
Tables and figures are included in the page limitations. Applications
that exceed the page limitation or NIH requirements for type size and
margins (refer to PHS 398 application for details) will be returned to
the applicant without further consideration. The 15-page limitation
does not include Items e-i (Human Subjects, Vertebrate Animals,
Literature Cited, Consortia and Consultants/Collaborators).
SPECIFIC INSTRUCTIONS FOR MODULAR GRANT APPLICATIONS: Applications
requesting up to $250,000 per year in direct costs must be submitted in
a modular grant format. The modular grant format simplifies the
preparation of the budget by limiting the level of budgetary detail.
Applicants request direct costs in $25,000 modules. Section C of the
research grant application instructions for the PHS 398 (rev. 5/2001)
at https://grants.nih.gov/grants/funding/phs398/phs398.html includes
step-by-step guidance for preparing modular applications. Additional
information on modular applications is available at
https://grants.nih.gov/grants/funding/modular/modular.htm.
USING THE RFA LABEL: The RFA label available in the PHS 398 (rev.
5/2001) application form must be affixed to the bottom of the face page
of the application. Type the RFA number on the label. Failure to use
this label could result in delayed processing of the application such
that it may not reach the review committee in time for review. In
addition, the RFA title and number must be typed on line 2 of the face
page of the application form and the YES box must be marked. The RFA
label is also available at:
https://grants.nih.gov/grants/funding/phs398/label-bk.pdf.
SENDING AN APPLICATION TO THE NIH: Submit a signed, typewritten
original of the application, including the Checklist, and three signed,
photocopies, in one package to:
Center For Scientific Review
National Institutes Of Health
6701 Rockledge Drive, Room 1040, MSC 7710
Bethesda, MD 20892-7710
Bethesda, MD 20817 (for express/courier service)
At the time of submission, two additional copies of the application
must be sent to:
Dr. John Richters
Office of Review
National Institute of Nursing Research
6701 Democracy Blvd, Room 707, MSC 4870
Bethesda, MD 20892-4870
APPLICATION PROCESSING: Applications must be received by the
application receipt date listed in the heading of this RFA. If an
application is received after that date, it will be returned to the
applicant without review.
The Center for Scientific Review (CSR) will not accept any application
in response to this RFA that is essentially the same as one currently
pending initial review. The CSR will not accept any application that is
essentially the same as one already reviewed. This does not preclude
the submission of substantial revisions of applications already
reviewed, but such applications must include an Introduction addressing
the previous critique.
PEER REVIEW PROCESS
Upon receipt, applications will be reviewed for completeness by the CSR
and responsiveness by the (IC).
Incomplete applications will be returned to the applicant without
further consideration. If the application is not responsive to the
RFA, CSR staff may contact the applicant to determine whether to return
the application to the applicant or submit it for review in competition
with unsolicited applications at the next appropriate NIH review cycle.
Applications that are complete and responsive to the RFA will be
evaluated for scientific and technical merit by an appropriate peer
review group convened by the NINR in accordance with the review
criteria stated below. As part of the initial merit review, all
applications will:
o Receive a written critique
o Undergo a process in which only those applications deemed to have the
highest scientific merit, generally the top half of the applications
under review, will be discussed and assigned a priority score
o Receive a second level review by the National Advisory Council for
Nursing Research
REVIEW CRITERIA
The goals of NIH-supported research are to advance our understanding of
biological systems, improve the control of disease, and enhance health.
In the written comments, reviewers will be asked to discuss the
following aspects of your application in order to judge the likelihood
that the proposed research will have a substantial impact on the
pursuit of these goals:
o Significance
o Approach
o Innovation
o Investigator
o Environment
The scientific review group will address and consider each of these
criteria in assigning your application"s overall score, weighting them
as appropriate for each application. Your application does not need to
be strong in all categories to be judged likely to have major
scientific impact and thus deserve a high priority score. For example,
you may propose to carry out important work that by its nature is not
innovative but is essential to move a field forward.
(1) SIGNIFICANCE: Does your study address an important problem? If the
aims of your application are achieved, how do they advance scientific
knowledge? What will be the effect of these studies on the concepts or
methods that drive this field?
(2) APPROACH: Are the conceptual framework, design, methods, and
analyses adequately developed, well integrated, and appropriate to the
aims of the project? Do you acknowledge potential problem areas and
consider alternative tactics?
(3) INNOVATION: Does your project employ novel concepts, approaches or
methods? Are the aims original and innovative? Does your project
challenge existing paradigms or develop new methodologies or
technologies?
(4) INVESTIGATOR: Are you appropriately trained and well suited to
carry out this work? Is the work proposed appropriate to your
experience level as the principal investigator and to that of other
researchers (if any)?
(5) ENVIRONMENT: Does the scientific environment in which your work
will be done contribute to the probability of success? Do the proposed
experiments take advantage of unique features of the scientific
environment or employ useful collaborative arrangements? Is there
evidence of institutional support?
ADDITIONAL REVIEW CRITERIA: In addition to the above criteria, your
application will also be reviewed with respect to the following:
o PROTECTIONS: The adequacy of the proposed protection for humans,
animals, or the environment, to the extent they may be adversely
affected by the project proposed in the application.
o INCLUSION: The adequacy of plans to include subjects from both
genders, all racial and ethnic groups (and subgroups), and children as
appropriate for the scientific goals of the research. Plans for the
recruitment and retention of subjects will also be evaluated. (See
Inclusion Criteria included in the section on Federal Citations, below)
o DATA SHARING: The adequacy of the proposed plan to share data.
o BUDGET: The reasonableness of the proposed budget and the requested
period of support in relation to the proposed research.
RECEIPT AND REVIEW SCHEDULE
Letter of Intent Receipt Date: October 28, 2002
Application Receipt Date: November 22, 2002
Peer Review Date: February/March 2003
Council Review: May 2003
Earliest Anticipated Start Date: July 2003
AWARD CRITERIA
Award criteria that will be used to make award decisions include:
o Scientific merit (as determined by peer review)
o Availability of funds
o Programmatic priorities.
REQUIRED FEDERAL CITATIONS
MONITORING PLAN AND DATA SAFETY AND MONITORING BOARD: Research
components involving Phase I and II clinical trials must include
provisions for assessment of patient eligibility and status, rigorous
data management, quality assurance, and auditing procedures. In
addition, it is NIH policy that all clinical trials require data and
safety monitoring, with the method and degree of monitoring being
commensurate with the risks (NIH Policy for Data Safety and Monitoring,
NIH Guide for Grants and Contracts, June 12, 1998:
https://grants.nih.gov/grants/guide/notice-files/not98-084.html).
INCLUSION OF WOMEN AND MINORITIES IN CLINICAL RESEARCH: It is the policy
of the NIH that women and members of minority groups and their sub-
populations must be included in all NIH-supported clinical research
projects unless a clear and compelling justification is provided
indicating that inclusion is inappropriate with respect to the health of
the subjects or the purpose of the research. This policy results from
the NIH Revitalization Act of 1993 (Section 492B of Public Law 103-43).
All investigators proposing clinical research should read the AMENDMENT
"NIH Guidelines for Inclusion of Women and Minorities as Subjects in
Clinical Research - Amended, October, 2001," published in the NIH Guide
for Grants and Contracts on October 9, 2001
(https://grants.nih.gov/grants/guide/notice-files/NOT-OD-02-001.html), a
complete copy of the updated Guidelines are available at
https://grants.nih.gov/grants/funding/women_min/guidelines_amended_10_2001.htm.
The amended policy incorporates: the use of an NIH definition
of clinical research, updated racial and ethnic categories in
compliance with the new OMB standards, clarification of language
governing NIH-defined Phase III clinical trials consistent with the new
PHS Form 398, and updated roles and responsibilities of NIH staff and
the extramural community. The policy continues to require for all NIH-
defined Phase III clinical trials that: a) all applications or
proposals and/or protocols must provide a description of plans to
conduct analyses, as appropriate, to address differences by sex/gender
and/or racial/ethnic groups, including subgroups if applicable, and b)
investigators must report annual accrual and progress in conducting
analyses, as appropriate, by sex/gender and/or racial/ethnic group
differences.
INCLUSION OF CHILDREN AS PARTICIPANTS IN RESEARCH INVOLVING HUMAN
SUBJECTS: The NIH maintains a policy that children (i.e., individuals
under the age of 21) must be included in all human subjects research,
conducted or supported by the NIH, unless there are scientific and
ethical reasons not to include them. This policy applies to all initial
(Type 1) applications submitted for receipt dates after October 1,
1998.
All investigators proposing research involving human subjects should
read the "NIH Policy and Guidelines" on the inclusion of children as
participants in research involving human subjects that is available at
https://grants.nih.gov/grants/funding/children/children.htm.
REQUIRED EDUCATION ON THE PROTECTION OF HUMAN SUBJECT PARTICIPANTS: NIH
policy requires education on the protection of human subject
participants for all investigators submitting NIH proposals for research
involving human subjects. You will find this policy announcement in the
NIH Guide for Grants and Contracts Announcement, dated June 5, 2000, at
https://grants.nih.gov/grants/guide/notice-files/NOT-OD-00-039.html.
HUMAN EMBRYONIC STEM CELLS (hESC): Criteria for federal funding of
research on hESCs can be found at
https://grants.nih.gov/grants/stem_cells.htm and at
https://grants.nih.gov/grants/guide/notice-files/NOT-OD-02-005.html.
Only research using hESC lines that are registered in the NIH Human
Embryonic Stem Cell Registry will be eligible for Federal funding (see
http://escr.nih.gov). It is the responsibility of the applicant to
provide the official NIH identifier(s)for the hESC line(s)to be used in
the proposed research. Applications that do not provide this
information will be returned without review.
PUBLIC ACCESS TO RESEARCH DATA THROUGH THE FREEDOM OF INFORMATION ACT:
The Office of Management and Budget (OMB) Circular A-110 has been
revised to provide public access to research data through the Freedom of
Information Act (FOIA) under some circumstances. Data that are (1)
first produced in a project that is supported in whole or in part with
Federal funds and (2) cited publicly and officially by a Federal agency
in support of an action that has the force and effect of law (i.e., a
regulation) may be accessed through FOIA. It is important for
applicants to understand the basic scope of this amendment. NIH has
provided guidance at
https://grants.nih.gov/grants/policy/a110/a110_guidance_dec1999.htm.
Applicants may wish to place data collected under this RFA in a public
archive, which can provide protections for the data and manage the
distribution for an indefinite period of time. If so, the application
should include a description of the archiving plan in the study design
and include information about this in the budget justification section
of the application. In addition, applicants should think about how to
structure informed consent statements and other human subjects
procedures given the potential for wider use of data collected under
this award.
URLs IN NIH GRANT APPLICATIONS OR APPENDICES: All applications and
proposals for NIH funding must be self-contained within specified page
limitations. Unless otherwise specified in an NIH solicitation. Internet
addresses (URLs) should not be used to provide information necessary to
the review because reviewers are under no obligation to view the
Internet sites. Furthermore, we caution reviewers that their anonymity
may be compromised when they directly access an Internet site.
HEALTHY PEOPLE 2010: The Public Health Service (PHS) is committed to
achieving the health promotion and disease prevention objectives of
"Healthy People 2010," a PHS-led national activity for setting priority
areas. This RFA is related to one or more of the priority areas.
Potential applicants may obtain a copy of "Healthy People 2010" at
http://www.health.gov/healthypeople.
AUTHORITY AND REGULATIONS: This program is described in the Catalog of
Federal Domestic Assistance Nos. 93.361 (NINR) and 93.242 (NIMH) and is
not subject to the intergovernmental review requirements of Executive
Order 12372 or Health Systems Agency review. Awards are made under
authorization of Sections 301 and 405 of the Public Health Service Act
as amended (42 USC 241 and 284 and administered under NIH grants
policies described at https://grants.nih.gov/grants/policy/policy.htm
and under Federal Regulations 42 CFR 52 and 45 CFR Parts 74 and 92.
The PHS strongly encourages all grant recipients to provide a smoke-
free workplace and discourages the use of all tobacco products. In
addition, Public Law 103-227, the Pro-Children Act of 1994, prohibits
smoking in certain facilities (or in some cases, any portion of a
facility) in which regular or routine education, library, day care,
health care, or early childhood development services are provided to
children. This is consistent with the PHS mission to protect and
advance the physical and mental health of the American people.