Parenting After a Natural Disaster: A Qualitative Study of Norwegian Families Surviving the 2004 Tsunami in Southeast Asia

Parent-Child Communication About Potentially Traumatic Events: A Systematic Review

Social support plays an important role in children's well-being after experiencing a potentially traumatic event (PTE). One such source of support is the parent-child relationship, specifically by discussing the event. However, current literature provides no consensus on whether parents and children communicate about PTEs, in what way they might communicate and how this affects the child. Hence the goal of the current study is threefold, to explore: (a) whether parents and children communicate about PTEs, (b) what this communication looks like, and (c) how this affects children's well-being. These questions are answered by means of a systematic literature review. Articles were eligible for inclusion if it was an empirical study on communication between parents and children about a PTE that the child (under 18 years) had experienced. Initial searches in electronic databases provided 31,233 articles, of which 26 were deemed eligible for inclusion. Results show that most parents and children have discussed PTEs, but that this may depend on cultural background. What the parent-child communication looks like depends on various factors such as, age of the child, tone, and child's initiation of discussion. Parental post-traumatic stress symptoms seem to negatively impact communication. The results of the impact of communication are less clear-cut, but it seems to have a predominantly positive effect on the child's well-being, depending on parental sensitivity. Clinicians should be watchful for parental symptoms of post-traumatic stress disorder and can focus on promoting parental sensitivity and responsiveness when discussing PTEs with their child or on creating a joint narrative within families.

Parent-child relationship, parenting behaviors, and adolescents' depressive symptoms after an earthquake: unraveling within-adolescent associations from between-adolescent differences

This study assessed temporal associations between parent-child relationship, parenting behaviors (i.e., warmth, rejection, and overprotection), and adolescents' depressive symptoms after trauma, using random-intercept cross-lagged panel models to distinguish between- and within-adolescent differences. We surveyed Chinese adolescents 12 (Aug 2018; T1), 21 (May 2019; T2), 27 (Nov 2019; T3) months after the Jiuzhaigou earthquake that occurred in August 2017. Of the 585 adolescents who participated in at least two waves of the study, mean age at T1 was 15.50 years old (SD = 1.58 years) and 57.8% were girls. Controlling adolescents' gender, age, ethnicity, trauma exposure at T1, and parents' marital status, between-adolescent results showed that parent-child relationship and parenting behaviors, parent-child relationship and depressive symptoms were correlated across models of parental warmth, rejection, and overprotection, whereas depressive symptoms were only correlated with parental rejection and overprotection. Within-adolescent results indicated that parent-child relationship and adolescents' depressive symptoms had bidirectional associations via the mediation of parental warmth from T1 to T3. Over the longer term following the earthquake, we found that parental rejection was bidirectionally associated with adolescents' depressive symptoms, whereas parental overprotection was unidirectionally influenced by adolescents' depressive symptoms from T2 to T3. In addition, more depressive symptoms in adolescents were associated with worsening parent-child relationship from T2 to T3. In conclusion, shortly after trauma, interventions should focus on improving parent-child relationship and relieving adolescents' depressive symptoms. Over the longer term after trauma, relieving adolescents' depressive symptoms should be prioritized to avoid its eroding effects on parent-child relationship and parenting behaviors, and to break the "vicious cycle".

Parent and child adjustment dual trajectories at the beginning of the COVID-19 syndemic

Children and their families have been significantly impacted by the unfolding of the COVID-19 syndemic. We sought to identify (1) groups of families with distinct profiles of joint trajectories of parental anxiety and child emotional distress and (2) protective and risk factors associated with these dual-trajectory profiles. A sample of 488 parents (65% White; 77% mothers) with 3- to 8-year-old children (M_Age  = 5.04, SD_Age  = 1.59) was followed from late March to early July in 2020. Survey data on parent (i.e., anxiety symptoms) and child (i.e., emotional distress) adjustment were collected at three time points. Using multivariate growth mixture modeling, we identified one group with low parental anxiety and child emotional distress (42.7%) and three other distinct groups with varying risk levels among parents and/or children. We also identified protective (e.g., positive parenting) and risk (e.g., child negative affect, negative parenting, perceived stress with racism) factors in predicting parent and child adjustment. It can be concluded that, overall, our sample (mostly middle- and high-socioeconomic status families) demonstrated family resilience amid COVID-19, consistent with prior disaster coping literature. At the same time, our findings also indicated the need to identify at-risk families and modifiable factors for post-disaster public health interventions.

Positive experiences in the parent-child relationship during the COVID-19 lockdown in Poland: The role of emotion regulation, empathy, parenting self-efficacy, and social support

Despite the impact of the COVID-19 outbreak being largely negative on parents and children, for some families, lockdown could also bring about some positive effects, for example, increased emotional closeness, and more time for joint activity. The aim of the current study was to investigate cross-sectionally the most important correlates of the positive experiences in the parent-child relationship among Polish mothers and fathers during the lockdown in the initial phase of the COVID-19 outbreak. In May 2020, 228 mothers and 231 fathers completed the Brief version of the Empathic Sensitivity Questionnaire, Difficulties in Emotion Regulation Scale Short Form, Social Support Scale, Parenting Self-Agency Measure, and Scale of Positive Experiences in Parent-Child Relationship during the COVID-19 lockdown. Our results showed that parenting self-efficacy and social support were the strongest correlates of positive experiences in the parent-child relationship in both mothers and fathers during the lockdown. Perspective-taking was positively related to the positive experiences in mothers, whereas personal distress was positively associated with the positive experiences in the parent-child relationship in fathers. Our results point to factors of potential importance in designing preventive and therapeutic interventions for mothers and fathers to enhance positive experiences in the parent-child relationship during the pandemic.

Impacts of Urban Terror Attacks on Turkish Mothers' Daily Experiences

This phenomenological study aims to provide a deeper understanding of the day-to-day experiences of Turkish women with caregiving responsibilities in terms of (a) how they respond to and regulate their lives around the fear of terror, (b) how their caregiving roles affect their reactions, and (c) how they cope with terrorism induced distress in their day-to-day life. A total of 21 women were interviewed for the study about their daily experiences following terrorist attacks that occurred in their urban hometowns. The qualitative analysis program called Atlas.ti was utilized for the coding procedure. Four main themes (the nature of the terrorist attacks, reactions to the event, coping strategies, and the role of the media) and several subcategories emerged from the data. The participants were emotionally affected by these events as they were shocked and confused, their sense of security was shaken, and they felt anxious not only during the events but they also continued to perceive such danger days or weeks after the events. All participating mothers reported some degree of shock, anxiety, fear, threat, risk alertness, and a shaken sense of security even though none of the mothers themselves or their loved ones were direct victims of the events. Overall, the results reveal that Turkish mothers feel terror threat perception and security-related stress even around 6 months after the events. Having a caregiving responsibility exacerbates the women's distress level. The unpredictability, uncertainty, and physical proximity/familiarity of the location of the event appear to have vital impacts on participants' cognitive, emotional, and behavioral reactions as well as in their coping. Similarly, the media, including social media, play significant roles in meaning making and responses as well as the coping process. The results were discussed in the light of the related literature.

Adolescent Positivity and Future Orientation, Parental Psychological Control, and Young Adult Internalising Behaviours during COVID-19 in Nine Countries

The COVID-19 pandemic disrupted many young adults’ lives educationally, economically, and personally. This study investigated associations between COVID-19-related disruption and perception of increases in internalising symptoms among young adults and whether these associations were moderated by earlier measures of adolescent positivity and future orientation and parental psychological control. Participants included 1329 adolescents at Time 1, and 810 of those participants as young adults (M age = 20, 50.4% female) at Time 2 from 9 countries (China, Colombia, Italy, Jordan, Kenya, the Philippines, Sweden, Thailand, and the United States). Drawing from a larger longitudinal study of adolescent risk taking and young adult competence, this study controlled for earlier levels of internalising symptoms during adolescence in examining these associations. Higher levels of adolescent positivity and future orientation as well as parent psychological control during late adolescence helped protect young adults from sharper perceived increases in anxiety and depression during the first nine months of widespread pandemic lockdowns in all nine countries. Findings are discussed in terms of how families in the 21st century can foster greater resilience during and after adolescence when faced with community-wide stressors, and the results provide new information about how psychological control may play a protective role during times of significant community-wide threats to personal health and welfare.

Parent-adolescent relationship quality as a moderator of links between COVID-19 disruption and reported changes in mothers' and young adults' adjustment in five countries

The COVID-19 pandemic has presented families around the world with extraordinary challenges related to physical and mental health, economic security, social support, and education. The current study capitalizes on a longitudinal, cross-national study of parenting, adolescent development, and young adult competence to document the association between personal disruption during the pandemic and reported changes in internalizing and externalizing behavior in young adults and their mothers since the pandemic began. It further investigates whether family functioning during adolescence 3 years earlier moderates this association. Data from 484 families in five countries (Italy, the Philippines, Sweden, Thailand, and the United States) reveal that higher levels of reported disruption during the pandemic are related to reported increases in internalizing and externalizing behaviors after the onset of the COVID-19 pandemic for young adults (Mage = 20) and their mothers in all five countries, with the exception of one association in Thailand. Associations between disruption during the pandemic and young adults' and their mothers' reported increases in internalizing and externalizing behaviors were attenuated by higher levels of youth disclosure, more supportive parenting, and lower levels of destructive adolescent-parent conflict prior to the pandemic. This work has implications for fostering parent-child relationships characterized by warmth, acceptance, trust, open communication, and constructive conflict resolution at all times given their protective effects for family resilience during times of crisis. (PsycInfo Database Record (c) 2021 APA, all rights reserved).

Social-Ecological Factors Associated With Higher Levels of Resilience in Children and Youth After Disaster: The Importance of Caregiver and Peer Support

Children and youth are among the most vulnerable to the devastating effects of disaster due to the physical, cognitive, and social factors related to their developmental life stage. Yet children and youth also have the capacity to be resilient and act as powerful catalysts for change in their own lives and wider communities following disaster. Specific factors that contribute to resilience in children and youth, however, remain relatively unexplored. This article examines factors associated with high levels of resilience in 100 children and youth aged 5- to 18-years old who experienced the 2016 Fort McMurray, Alberta wildfire. A mixed-methods design was employed combining quantitative and qualitative data. Quantitative data was obtained from the Children and Youth Resilience Measure (CYRM-28) which measured individual, caregiver, and context factors influencing resilience processes among the participants. Qualitative data was collected through semi-structured interviews to gain further insight into the disaster experiences of children and youth. Quantitative findings reveal higher than average levels of resilience among the participants compared to normative scores. Qualitative findings suggest high levels of resilience were associated with both caregiver factors (specifically physical caregiving), and individual factors (primarily peer support). We discuss how physical caregiving and peer support during and after the wildfire helped mitigate the negative effects of disaster, thus bolstering children and youth's resilience. Implications for understanding the specific social-ecological factors that facilitate and support resiliency processes and overall recovery of children and youth following disaster are also discussed.

Understanding at-the-moment stress for parents during COVID-19 stay-at-home restrictions

RATIONALE

In spring 2020, many states in the United States enacted stay-at-home orders to limit the spread of COVID-19 and lessen effects on hospitals and health care workers. This required parents to act in new roles without much support. Although studies have asked parents about stress before and during the pandemic, none have examined how stress may have fluctuated throughout the day and the characteristics related to those daily changes.

OBJECTIVE

Our study assesses how time-varying (e.g., presence of a focal child) and day-varying (e.g., weekend vs. weekday) factors were related to parents' level of stress.

METHODS

We use Ecological Momentary Assessment to examine stress three times a day (10 a.m., 3 p.m., and 9 p.m.) for 14 days. We include two different dates hypothesized to be related to parents' stress levels: (1) when Ohio announced schools would go virtual for the rest of the academic year and (2) when most retail businesses were allowed to re-open. Our sample of 332 individuals, recruited via Facebook, Craigslist, and word of mouth, completed 13,360 of these brief surveys during April-May 2020. Data were analyzed using generalized ordered logit models.

RESULTS

Parents report lower levels of stress when completing the 9 p.m. survey, but higher levels when they were at work, during weekdays (compared to weekends) or when they were with the focal child. COVID-19 milestone dates were not related to stress levels.

CONCLUSIONS

Parents need some form of respite (e.g. child care, child-only activities) to reduce stress, especially during the week when parents are juggling their outside employment and their child(ren)'s schooling. Providing parents with skills and tools to identify and reduce stress, such as apps monitoring heart rate or providing deep breathing techniques, may be one way of helping parents cope with extremely stressful situations.

Psychological management of mental health concerns related to COVID-19: A review of guidelines and recommendations

Many publications have delineated strategies for mental health care to respond to psychological concerns and ramifications related to coronavirus disease 2019 (COVID-19). The current review aims to encapsulate existing guidelines and recommendations of psychological management for mental health care for the general population, health-care professionals, children, and elderly populations, applied to a pandemic in particular reference to COVID-19. The literature on psychological care of such repercussions of COVID-19 was retrieved via a search in PubMed and Google database. Of 91 retrieved initial articles, only 18 were selected for final analysis, which was divided into two categories: (a) guidelines by government/public health bodies (n = 11) and (b) publications in peer-reviewed journals (n = 7). The recommendations can be summed but not limited to psychoeducation from a reliable source, normalization of stress, behavioral activation, scheduling of activities with a bespoke blending of recreational and daily chores, supportive care, staying digitally connected, relaxation techniques, ensuring rest, rotating shifts and short breaks during working hours, curtailing media consumption, fostering community resilience, seeking and sharing support from colleagues/supervisors, avoidance of abusing psychoactive substances, online consultation of mental health professionals on need, and participatory communication in a developmentally appropriate way with children. In the absence of observational and controlled studies on psychological management during pandemic times, we recommend such research soon.

No Associations of Psychological Symptoms and Suicide Risk with Disaster Experiences in Junior High School Students 5 Years After the 2011 Great East Japan Earthquake and Tsunami

INTRODUCTION

Natural disasters such as earthquakes can cause substantial damage and trauma, especially to children. The aim of this study was to examine the effects of disaster experience on psychological symptoms, suicide risk, and associated factors in junior high school students 5 years after the Great East Japan Earthquake (GEJE). The hypothesis of this study was that psychological symptoms and suicide risk of junior high school students are associated with disaster experience.

METHODS

A cross-sectional survey consisting of questionnaires and face-to-face interviews with students at two junior high schools in Ishinomaki city, Miyagi Prefecture, Japan, about psychological symptoms, disaster situations, and their current environment 5 years after the GEJE was conducted. In total, data from 264 (117 boys [44.3%] and 147 girls [55.7%]) students were analyzed.

RESULTS

There were no associations between disaster experience and PTSSC-15, DSRS-C, and SCAS scores. Those with evacuation experience and still living in temporary housing had significantly higher scores on the oppositional defiant behavior inventory (ODBI). Of these students, 29 (11.0%) were considered to have suicide risk 5 years after the GEJE. The presence of depressive symptoms was the only factor related to suicide risk; no associations were found with sex, post-traumatic stress disorder (PTSD) symptoms, or other factors reported in previous studies, including disaster experience.

CONCLUSIONS

Disaster experience was not associated with psychological symptoms (PTSD, depression, anxiety) and suicide risk in junior high school students 5 years after the GEJE. The suicide risk appears to be the same as that in the general population in Japan. However, attention should be paid to externalization problems and depressive symptoms, an important suicide risk factor, even 5 years after the GEJE.

Did kindergarteners who experienced the Great East Japan earthquake as infants develop traumatic symptoms? Series of questionnaire-based cross-sectional surveys: A concise and informative title: traumatic symptoms of kindergarteners who experienced disasters as infants

BACKGROUND

The Great East Japan Earthquake (GEJE) and tsunami of March 11, 2011 left behind many survivors, including children. This study aimed to assess changes in traumatic symptoms with time among kindergarteners who experienced GEJE as infants and to discuss the relationship between these symptoms and the disaster experience.

METHODS

The 15-item Post-Traumatic Stress Symptoms for Children (PTSSC-15) questionnaire were distributed to the parents of kindergarteners (children aged 4-5 years) at 8, 20, 30, and 42 months after GEJE. Questionnaires regarding environmental damage conditions affecting the children were distributed to teachers 8 months after the tsunami.

RESULTS

The number of kindergarteners was 262, 255, 236, and 202 at 8, 20, 30, and 42 months after the disaster. The PTSSC-15 total score was not different between kindergartners with and without environmental damage conditions. After 8 and 20 months, the PTSSC-15 total score of children who usually ate breakfast was significantly higher than that of children who did not. Moreover, after 30 and 42 months, the PTSSC-15 total score of kindergarteners who usually ate breakfast was not significantly higher than that of kindergarteners who did not.

CONCLUSIONS

The traumatic symptoms of kindergarteners were not related to disaster experiences.

Violence against children and natural disasters: A systematic review and meta-analysis of quantitative evidence

OBJECTIVES

Reviews of violence against children in disaster settings focus on armed conflict. Little is understood about natural disasters which has implications in planning humanitarian response. We examined the magnitude and direction of the association between exposure to natural disasters and physical, emotional, and sexual violence against children, and assessed the quality of the evidence.

METHODS

We searched 15 health and social science databases from first record until May 16, 2018. Publications describing all types of quantitative study design were eligible for inclusion. We presented study characteristics and quality in a narrative form and generated pooled estimates using a three-level random effects model. We evaluated Cochrane's Q with p-values below 0.10 and radial plots to assess heterogeneity. Planned subgroup analyses explored differential results by violence form, study design, and analysis method.

RESULTS

11 publications met inclusion criteria. The majority were cross-sectional studies examining physical or sexual violence in the United States. We found no evidence of a consistent association or directional influence between natural disasters and violence against children. Combined categorical violence outcomes had substantial heterogeneity [Q (df = 66) = 252.83, p < 0.001]. Subgroups without evidence of heterogeneity had confidence intervals that included a possible null effect. Our findings were mainly limited by inconsistencies in operational definitions of violence, a lack of representative sampling, and unclear establishment of temporal order between natural disaster exposure and violence outcomes.

CONCLUSIONS

Based on the available evidence, we cannot confidently conclude that natural disasters increase the level or severity of violence against children above non-disaster settings, however heterogeneity and study quality hamper our ability to draw firm conclusions. More nuanced and rigorous research is needed to inform practice and policy as natural disasters increasingly affect human populations.

Prediction and Understanding of Resilience in Albertan Families: Longitudinal Study of Disaster Responses (PURLS) - Protocol

Exposure to a natural disaster in childhood can have serious, long-lasting consequences, impacting physical and mental health, development, and learning. Although many children experience negative effects after a disaster, the majority do not, and what differentiates these groups is not well understood. Some of the factors that influence disaster-related outcomes in the midst of adversity include parents' mental health, the home environment, and socioeconomic status. Furthermore, genetics has also a role to play in how children respond to stressors. We had the opportunity to conduct a natural experiment of disaster recovery following the Alberta 2013 Flood. This paper presents the detailed protocol on prediction of resilience in Albertan families, and validation with cortisol data. In addition, data collection procedures, developing resiliency screening tools, candidate gene identification, genotyping, DNA methylation, and genomic analyses are described to achieve the research objectives. This study produced new knowledge by using pre- and post-disaster information on children's health and development, including children's genetics and responses to stress. This information has been identified as important to governments and other organizations invested in early child development. Our comprehensive research plan generates evidence that can be mobilized population-based approaches to improve child and family resiliency.

The Life Process of Children Who Survived the Manjil Earthquake: A Decaying or Renewing Process

INTRODUCTION

Among earthquake survivors, children are more vulnerable than other age groups due to their exposure to harrowing scenes of devastation as well as their drastically new living situations that result from an earthquake disaster. The life process of children survivors undergoes many different changes that are affected by a wide range of factors. Understanding the life process of these children may lead to effective outcomes and interventions. In addition, observing children survivors establishes knowledge and understanding of the challenges that correspond with earthquake disasters. Further, observing this group may be further effective in decision-making and establishing types of assistance in similar circumstances.

OBJECTIVES

This study was done to explain the life process of children who survived the earthquake of Manjil in northern side of Iran. Methods: This qualitative study is based on the grounded theory approach. The sampling involved purposive interviews with 12 children who survived the Manjil earthquake and were under 12 years of age at the time of the earthquake. The initial interviews were followed by continuous comparative analysis, and thus the sampling process adopted a theoretical trend. In the end, by the formation of categories and the central variable of the study, interviews were conducted with 16 subjects and sufficient data was provided. Data was collected through face-to-face, in-depth interviews using an interview guide. In order to enrich the categories formed in data analysis, we had also 6 telephone interviews with the same participants in order to complete missed needed information. Data collection began in 2015 and continued up until 2016. Data was analysed using the Strauss-Corbin approach.

RESULTS

The life process of children earthquake survivors consists of 'unexpected encounter', 'transient relief activities' and 'long-lasting consequences'. The central variable of this study is 'the dark shadow of pain and the light shadow of life expectancy'. The life experience of this group of children is immersed in painful memories and varies under different conditions.

DISCUSSION AND CONCLUSION

According to the results of this study, one of the factors affecting the lives of children earthquake survivors which could threaten their health is providing non-specific and transient services. Training relief staff to consider the specific needs of these children at the time of the rescue operation could contribute to improving their health level in various aspects. Considering the effective and comprehensive rehabilitation program in Disaster Management by policymakers can prevent permanent complications caused by earthquakes. Planning and taking action to identify misbehaviours in this group of children as well as raising public awareness, particularly for parents, on how to manage the outcomes of natural disasters are some of the most significant public health priorities. Providing public mental health services for parents and children who survive an earthquake helps to address potential psychological problems in this group of survivors.

Parental responses to child experiences of trauma following presentation at emergency departments: a qualitative study

OBJECTIVE

Parents are often children's main source of support following fear-inducing traumatic events, yet little is known about how parents provide that support. The aim of this study was to examine parents' experiences of supporting their child following child trauma exposure and presentation at an emergency department (ED).

DESIGN

Semistructured qualitative interviews analysed using thematic analysis.

SETTING

The setting for this study was two National Health Service EDs in England.

PARTICIPANTS

20 parents whose child experienced a traumatic event and attended an ED between August 2014 and October 2015.

RESULTS

Parents were sensitive to their child's distress and offered reassurance and support for their child to resume normal activities. However, parental beliefs often inhibited children's reinstatement of pretrauma routines. Support often focused on preventing future illness or injury, reflective of parents' concerns for their child's physical well-being. In a minority of parents, appraisals of problematic care from EDs contributed to parents' anxiety and perceptions of their child as vulnerable post-trauma. Forgetting the trauma and avoidance of discussion were encouraged as coping strategies to prevent further distress. Parents highlighted their need for further guidance and support regarding their child's physical and emotional recovery.

CONCLUSIONS

This study provides insight into the experiences of and challenges faced by parents in supporting their child following trauma exposure. Perceptions of their child's physical vulnerability and treatment influenced parents' responses and the supportive strategies employed. These findings may enable clinicians to generate meaningful advice for parents following child attendance at EDs post-trauma.

The Role of Parents, Parenting and the Family Environment in Children's Post-Disaster Mental Health

There is widespread support for the hypothesis that, post-disaster, children's mental health is impacted--at least in part--via the impact on parents, parenting, parent-child interactions, and the family environment. To some degree, the enthusiasm with which this hypothesis is held outstrips the evidence examining it. The current paper critically evaluates the empirical evidence for this hypothesis and concludes that although limited (both in terms of number of existing studies and methodological flaws), the extant literature indicates some parent-related variables, as well as some aspects of the family environment are likely to constitute risk or protective factors for children. Given that parenting is modifiable, it is proposed that the identified parent- and family-related factors represent important therapeutic targets, and a universal post-disaster parenting intervention (Disaster Recovery Triple P) is described.

Negotiating a new day: parents' contributions to supporting students' school functioning after exposure to trauma

Parents are advised to get their children back to school soon after exposure to trauma, so that they may receive social support and restore the supportive structure of everyday life. This study explores parents' experiences of supporting adolescents in regaining school functioning after the July 2011 massacre at Utøya summer camp in Norway. One year after the attack, 87 parents of 63 young people who survived the massacre were interviewed using qualitative interviews. The qualitative data were analyzed using thematic analysis. All parents were actively supportive of their children, and described a demanding process of establishing new routines to make school attendance possible. Most parents described radical changes in their adolescents. The struggle of establishing routines often brought conflict and frustration into the parent-adolescent relationship. Parents were given general advice, but reported being left alone to translate this into action. The first school year after the trauma was described as a frustrating and lonely struggle: their adolescents were largely unable to restore normal daily life and school functioning. In 20% of the cases, school-home relationships were strained and were reported as a burden because of poor understanding of needs and insufficient educational adaptive measures; a further 20% reported conflict in school-home relationships, while 50% were either positive or neutral. The last 10%, enrolled in apprenticeship, dropped out, or started working, instead of finishing school. Implications for supporting parents with traumatized adolescent students are indicated.