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Davis K, Iosif AM, Nordahl CW, Solomon M, Krug MK. Video Game Use, Aggression, and Social Impairment in Adolescents with Autism Spectrum Disorder. J Autism Dev Disord 2023; 53:3567-3580. [PMID: 35821547 PMCID: PMC10465670 DOI: 10.1007/s10803-022-05649-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/14/2022] [Indexed: 11/29/2022]
Abstract
We used parent report data to investigate video game playing, aggression, and social impairment in adolescents with autism spectrum disorder. Parents of autistic adolescents were more likely to report that their child plays video games as a hobby compared to parents of adolescents with typical development and also reported that their children spent more time playing video games. For autistic participants, we found no differences in aggression levels or social impairment when comparing players versus non-players. However, playing video games "more than average," as compared to "average" was associated with greater aggression and greater social impairment on "awareness" and "mannerisms" subscales. Future studies should focus on how type of video game(s) played is associated with these clinically important variables.
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Affiliation(s)
- Konnor Davis
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, USA
- MIND Institute, University of California Davis, 2825 50th Street, Sacramento, CA, 95817, USA
| | - Ana-Maria Iosif
- Department of Public Health Sciences, University of California Davis, Sacramento, USA
| | - Christine Wu Nordahl
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, USA
- MIND Institute, University of California Davis, 2825 50th Street, Sacramento, CA, 95817, USA
| | - Marjorie Solomon
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, USA
- MIND Institute, University of California Davis, 2825 50th Street, Sacramento, CA, 95817, USA
- Imaging Research Center, University of California Davis, Sacramento, USA
| | - Marie K Krug
- Department of Psychiatry and Behavioral Sciences, University of California Davis, Sacramento, USA.
- MIND Institute, University of California Davis, 2825 50th Street, Sacramento, CA, 95817, USA.
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Barbaro J, Winata T, Gilbert M, Nair R, Khan F, Lucien A, Islam R, Masi A, Diaz AM, Dissanayake C, Karlov L, Descallar J, Eastwood J, Hasan I, Jalaludin B, Kohlhoff J, Liaw ST, Lingam R, Ong N, Tam CWM, Woolfenden S, Eapen V. General practitioners' perspectives regarding early developmental surveillance for autism within the australian primary healthcare setting: a qualitative study. BMC PRIMARY CARE 2023; 24:159. [PMID: 37563549 PMCID: PMC10416397 DOI: 10.1186/s12875-023-02121-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 08/01/2023] [Indexed: 08/12/2023]
Abstract
BACKGROUND Significant challenges remain in the early identification of child developmental disabilities in the community. Implementing supports and services early in the life course has been shown to promote positive developmental outcomes for children at high likelihood of developmental disabilities, including autism. As part of a cluster randomised controlled trial, this study seeks to examine and compare the perspectives and experiences of Australian general practitioners (GPs) in relation to a digital developmental surveillance program for autism and usual care pathway, in general practice clinics. METHODS A qualitative research methodology with semi-structured interviews and thematic inductive analysis underpinned by grounded theory was utilised. All GPs from South Western Sydney (NSW) and Melbourne (Victoria) who participated in the main program ("GP Surveillance for Autism") were invited to the interview. GPs who provided consent were interviewed either over online or in-person meeting. Interviews were audio-recorded, transcribed, and coded using NVivo12 software. Inductive interpretive approach was adopted and data were analysed thematically. RESULTS Twenty-three GPs across the two sites (NSW: n = 11; Victoria: n = 12) agreed to be interviewed; data saturation had reached following this number of participants. Inductive thematic coding and analysis yielded eight major themes and highlighted common enablers such as the role of GPs in early identification and subsequent supports, enhanced communication between clinicians/professionals, relationship-building with patients, and having standardised screening tools. Specific facilitators to the feasibility and acceptability of a digital screening program for the early identification of developmental disabilities, including the early signs of autism, and encouraging research and education for GPs. However, several practical and socioeconomic barriers were identified, in addition to limited knowledge and uptake of child developmental screening tools as well as COVID-19 lockdown impacts. Common and specific recommendations involve supporting GPs in developmental/paediatrics training, streamlined screening process, and funding and resources in the primary healthcare services. CONCLUSIONS The study highlighted the need for practice and policy changes, including further training of GPs alongside sufficient time to complete developmental checks and appropriate financial remuneration through a Medicare billing item. Further research is needed on implementation and scale up of a national surveillance program for early identification of developmental disabilities, including autism.
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Affiliation(s)
- Josephine Barbaro
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
- Cooperative Research Centre for Living with Autism (Autism CRC), The University of Queensland, Indooroopilly, QLD, Australia
| | - Teresa Winata
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Sydney, NSW, Australia
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Melissa Gilbert
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
- Cooperative Research Centre for Living with Autism (Autism CRC), The University of Queensland, Indooroopilly, QLD, Australia
| | - Radhika Nair
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
- Cooperative Research Centre for Living with Autism (Autism CRC), The University of Queensland, Indooroopilly, QLD, Australia
| | - Feroza Khan
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Abbie Lucien
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Raisa Islam
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Anne Masi
- Cooperative Research Centre for Living with Autism (Autism CRC), The University of Queensland, Indooroopilly, QLD, Australia
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Antonio Mendoza Diaz
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Sydney, NSW, Australia
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - Cheryl Dissanayake
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Bundoora, VIC, Australia
- Cooperative Research Centre for Living with Autism (Autism CRC), The University of Queensland, Indooroopilly, QLD, Australia
| | - Lisa Karlov
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Sydney, NSW, Australia
| | - Joseph Descallar
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Sydney, NSW, Australia
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia
| | - John Eastwood
- Faculty of Medicine and Health, School of Medicine, University of Sydney, Sydney, NSW, Australia
- Faculty of Medicine, School of Women and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Iqbal Hasan
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Bin Jalaludin
- Faculty of Medicine, School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Jane Kohlhoff
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia
| | - Siaw-Teng Liaw
- Faculty of Medicine, School of Population Health, University of New South Wales, Sydney, NSW, Australia
| | - Raghu Lingam
- Population Child Health Research Group, Faculty of Medicine, School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Natalie Ong
- Children's Hospital Westmead Clinical School, University of Sydney, Sydney, NSW, Australia
| | - Chun Wah Michael Tam
- Faculty of Medicine, School of Population Health, University of New South Wales, Sydney, NSW, Australia
- Primary and Integrated Care Unit, South Western Sydney Local Health District, Liverpool, NSW, Australia
| | - Sue Woolfenden
- Faculty of Medicine, School of Women and Children's Health, University of New South Wales, Sydney, NSW, Australia
- Population Child Health Research Group, Faculty of Medicine, School of Women's and Children's Health, University of New South Wales, Sydney, NSW, Australia
| | - Valsamma Eapen
- Cooperative Research Centre for Living with Autism (Autism CRC), The University of Queensland, Indooroopilly, QLD, Australia.
- Discipline of Psychiatry and Mental Health, School of Clinical Medicine, University of New South Wales, Sydney, NSW, Australia.
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Sydney, NSW, Australia.
- Ingham Institute for Applied Medical Research, Liverpool, NSW, Australia.
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Eapen V, Winata T, Gilbert M, Nair R, Khan F, Lucien A, Islam R, Masi A, Lam-Cassettari C, Mendoza Diaz A, Dissanayake C, Karlov L, Descallar J, Eastwood J, Hasan I, Jalaludin B, Kohlhoff J, Liaw ST, Lingam R, Ong N, Tam CWM, Woolfenden S, Barbaro J. Parental experience of an early developmental surveillance programme for autism within Australian general practice: a qualitative study. BMJ Open 2022; 12:e064375. [PMID: 36442896 PMCID: PMC9710335 DOI: 10.1136/bmjopen-2022-064375] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
OBJECTIVES Implementing support and services early in the life course has been shown to promote positive developmental outcomes for children at high likelihood of developmental conditions including autism. This study examined parents'/caregivers' experiences and perceptions about a digital developmental surveillance pathway for autism, the autism surveillance pathway (ASP), and usual care, the surveillance as usual (SaU) pathway, in the primary healthcare general practice setting. DESIGN This qualitative study involves using a convenience selection process of the full sample of parents/caregivers that participated in the main programme, 'General Practice Surveillance for Autism', a cluster-randomised controlled trial study. All interviews were audio-recorded, transcribed and coded using NVivo V.12 software. An inductive thematic interpretive approach was adopted and data were analysed thematically. PARTICIPANTS Twelve parents/caregivers of children with or without a developmental condition/autism (who participated in the main programme) in South Western Sydney and Melbourne were interviewed. SETTINGS All interviews were completed over the phone. RESULTS There were seven major themes and 20 subthemes that included positive experiences, such as pre-existing patient-doctor relationships and their perceptions on the importance of knowing and accessing early support/services. Barriers or challenges experienced while using the SaU pathway included long waiting periods, poor communication and lack of action plans, complexity associated with navigating the healthcare system and lack of understanding by general practitioners (GPs). Common suggestions for improvement included greater awareness/education for parents/carers and the availability of accessible resources on child development for parents/caregivers. CONCLUSION The findings support the use of digital screening tools for developmental surveillance, including for autism, using opportunistic contacts in the general practice setting. TRIAL REGISTRATION NUMBER ANZCTR (ACTRN12619001200178).
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Affiliation(s)
- Valsamma Eapen
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Teresa Winata
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Melissa Gilbert
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Cooperative Research Centre for Living with Autism, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Radhika Nair
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Cooperative Research Centre for Living with Autism, The University of Queensland, Saint Lucia, Queensland, Australia
| | - Feroza Khan
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
| | - Abbie Lucien
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
| | - Raisa Islam
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
| | - Anne Masi
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
| | - Christa Lam-Cassettari
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Antonio Mendoza Diaz
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - Cheryl Dissanayake
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Cooperative Research Centre for Living with Autism (Autism CRC), The University of Queensland, Saint Lucia, Queensland, Australia
| | - Lisa Karlov
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Joseph Descallar
- Academic Unit of Infant, Child and Adolescent Psychiatry, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
| | - John Eastwood
- Ingham Institute for Applied Medical Research, Liverpool, New South Wales, Australia
- Faculty of Medicine and Health, School of Medicine, The University of Sydney, Sydney, New South Wales, Australia
| | - Iqbal Hasan
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
| | - Bin Jalaludin
- Centre for Research, Evidence Management and Surveillance, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
- Faculty of Medicine, School of Population Health, UNSW, Sydney, New South Wales, Australia
| | - Jane Kohlhoff
- Faculty of Medicine, Discipline of Psychiatry and Mental Health, UNSW, Sydney, New South Wales, Australia
| | - Siaw-Teng Liaw
- School of Public Health and Community Medicine, UNSW, Sydney, New South Wales, Australia
| | - Raghu Lingam
- Population Child Health Research Group, Faculty of Medicine, School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Natalie Ong
- Children's Hospital Westmead Clinical School, The University of Sydney, Sydney, New South Wales, Australia
| | - Chun Wah Michael Tam
- Faculty of Medicine, School of Population Health, UNSW, Sydney, New South Wales, Australia
- Primary and Integrated Care Unit, South Western Sydney Local Health District, Liverpool, New South Wales, Australia
| | - Susan Woolfenden
- Population Child Health Research Group, Faculty of Medicine, School of Women's and Children's Health, UNSW, Sydney, New South Wales, Australia
| | - Josephine Barbaro
- Olga Tennison Autism Research Centre, School of Psychology and Public Health, La Trobe University, Melbourne, Victoria, Australia
- Cooperative Research Centre for Living with Autism, The University of Queensland, Saint Lucia, Queensland, Australia
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Eapen V, Woolfenden S, Schmied V, Jalaludin B, Lawson K, Liaw ST, Lingam R, Page A, Cibralic S, Winata T, Mendoza Diaz A, Lam-Cassettari C, Burley J, Boydell K, Lin P, Masi A, Katz I, Dadich A, Preddy J, Bruce J, Raman S, Kohlhoff J, Descallar J, Karlov L, Kaplun C, Arora A, Di Mento B, Smead M, Doyle K, Grace R, McClean T, Blight V, Wood A, Raine KH. "Watch Me Grow- Electronic (WMG-E)" surveillance approach to identify and address child development, parental mental health, and psychosocial needs: study protocol. BMC Health Serv Res 2021; 21:1240. [PMID: 34789234 PMCID: PMC8596348 DOI: 10.1186/s12913-021-07243-0] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2021] [Accepted: 10/29/2021] [Indexed: 11/11/2022] Open
Abstract
Background The COVID-19 pandemic and the associated economic recession has increased parental psychosocial stress and mental health challenges. This has adversely impacted child development and wellbeing, particularly for children from priority populations (culturally and linguistically diverse (CALD) and rural/regional communities) who are at an already increased risk of health inequality. The increased mental health and psychosocial needs were compounded by the closure of in-person preventive and health promotion programs resulting in health organisations embracing technology and online services. Watch Me Grow- Electronic (WMG-E) – developmental surveillance platform- exemplifies one such service. WMG-E was developed to monitor child development and guide parents towards more detailed assessments when risk is identified. This Randomised Controlled Trial (RCT) aims to expand WMG-E as a digital navigation tool by also incorporating parents’ mental health and psychosocial needs. Children and families needing additional assessments and supports will be electronically directed to relevant resources in the ‘care-as-usual’ group. In contrast, the intervention group will receive continuity of care, with additional in-person assessment and ‘warm hand over’ by a ‘service navigator’ to ensure their needs are met. Methods Using an RCT we will determine: (1) parental engagement with developmental surveillance; (2) access to services for those with mental health and social care needs; and (3) uptake of service recommendations. Three hundred parents/carers of children aged 6 months to 3 years (recruited from a culturally diverse, or rural/regional site) will be randomly allocated to the ‘care-as-usual’ or ‘intervention’ group. A mixed methods implementation evaluation will be completed, with semi-structured interviews to ascertain the acceptability, feasibility and impact of the WMG-E platform and service navigator. Conclusions Using WMG-E is expected to: normalise and de-stigmatise mental health and psychosocial screening; increase parental engagement and service use; and result in the early identification and management of child developmental needs, parental mental health, and family psychosocial needs. If effective, digital solutions such as WMG-E to engage and empower parents alongside a service navigator for vulnerable families needing additional support, will have significant practice and policy implications in the pandemic/post pandemic period. Trial registration The trial (Protocol No. 1.0, Version 3.1) was registered with ANZCTR (registration number: ACTRN12621000766819) on July 21st, 2021 and reporting of the trial results will be according to recommendations in the CONSORT Statement.
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Affiliation(s)
- V Eapen
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia. .,South Western Sydney Local Health District, Liverpool, Australia.
| | - S Woolfenden
- Sydney Children's Hospital Randwick, Randwick, Australia
| | - V Schmied
- School of Nursing and Midwifery, Western Sydney University, Sydney, Australia
| | - B Jalaludin
- South Western Sydney Local Health District, Liverpool, Australia.,Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - K Lawson
- School of Business, Western Sydney University, Sydney, Australia
| | - S T Liaw
- Population Child Health Research Group, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia.,WHO Collaborating Centre for eHealth, University of New South Wales, Sydney, Australia
| | - R Lingam
- Population Child Health Research Group, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - A Page
- School of Medicine, Western Sydney University, Campbelltown, Australia
| | - S Cibralic
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - T Winata
- South Western Sydney Local Health District, Liverpool, Australia
| | - A Mendoza Diaz
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - C Lam-Cassettari
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - J Burley
- Population Child Health Research Group, School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - K Boydell
- Black Dog Institute, Sydney, Australia
| | - P Lin
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia.,South Western Sydney Local Health District, Liverpool, Australia
| | - A Masi
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - I Katz
- Social Policy Research Centre, Faculty of Arts, Design, & Architecture, University of New South Wales, Sydney, Australia
| | - A Dadich
- School of Business, Western Sydney University, Sydney, Australia
| | - J Preddy
- Murrumbidgee Local Health District, Wagga Wagga, Australia
| | - J Bruce
- Murrumbidgee Local Health District, Wagga Wagga, Australia
| | - S Raman
- South Western Sydney Local Health District, Liverpool, Australia
| | - J Kohlhoff
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia.,Karitane, Carramar, Australia
| | - J Descallar
- Ingham Institute for Applied Medical Research, Liverpool, Australia
| | - L Karlov
- South Western Sydney Local Health District, Liverpool, Australia
| | - C Kaplun
- Ingham Institute for Applied Medical Research, Liverpool, Australia.,TeEACH -Transforming early Education and Child Health Research Centre, Western Sydney University, Sydney, Australia
| | - A Arora
- School of Health Sciences, Western Sydney University, Sydney, Australia.,Sydney Local Health District, Camperdown, Australia
| | - B Di Mento
- School of Psychiatry, Faculty of Medicine, University of New South Wales, Sydney, Australia
| | - M Smead
- Murrumbidgee Local Health District, Wagga Wagga, Australia
| | - K Doyle
- School of Medicine, Western Sydney University, Campbelltown, Australia
| | - R Grace
- TeEACH -Transforming early Education and Child Health Research Centre, Western Sydney University, Sydney, Australia
| | | | - V Blight
- South Western Sydney Local Health District, Liverpool, Australia
| | - A Wood
- Karitane, Carramar, Australia
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