The Big Insurance War on Patients – a Personal Story

It was an emergency. It was Sunday, two days before Christmas. She was in excruciating pain. My son took her to urgent/emergency room care. The urgent care doctors said she needed to have her gall bladder removed right away, because they were afraid infection was setting in. As a Type 1 brittle diabetic, she cannot handle this kind of disruption to her system. The Urgent Care doctor made arrangements for her to be seen at the nearest hospital and sent my son and her there immediately.  

She did not have time to think about the network, nor had the insurance company provide her a list of network providers. The hospital accepted her insurance, which she believed meant they were ok. It wasn’t as if she had a choice. She did not have the option of getting it approved by her insurance in advance. She needed surgery now. Within a few hours, she was home, missing a gall bladder. She did not even spend the night at the hospital.

Days and weeks went by. She got the urgent care bills, that were paid for by the insurance, so she owed nothing. Emergency care covered. Certain other bills, covered. Then, a full month after her surgery, she got a bill from the hospital. The insurance company, Anthem, denied her claim. The person who denied her claim is not a doctor, does not realize that diabetics do not take surgery of any kind lightly. Amount due – $21,000. Payable immediately.

She doesn’t make that much money in a year. She is in school. She has monthly insulin costs. She has to take other medications to make her body accept the insulin. She has costs associated with making her pump work. She has to have regular doctor visits to check her numbers, to check her body, to check her pump. There are visits to her GP, to her diabetes doctor, to her eye doctor, and so on and so on. To cover all these costs, she would have to make $4,000 a month after taxes before buying a mouthful of food or paying a nickel for a place to live.

Anthem claimed the surgery was elective. As if she woke up two days before Christmas on a Sunday and decided, hey, I think I’ll get my gall bladder removed today. Except that serious diabetics don’t do elective surgery on a whim. They have to spend days ensuring their numbers are stable enough to have the kind of jolt to the system that surgery causes. And then, after the surgery is scheduled, they check again. If the numbers are off, the surgery is postponed until the numbers are acceptable.

She will have to appeal the denial. This will require more time and expense, and may even require a lawyer. She is working with the patient advocate at the hospital, but there are no guarantees. The last thing she needs is to be fighting this claim while she is going to school.

They say that diabetes is a manageable disease, and that is true. But that doesn’t mean management is easy or inexpensive. Diabetes doesn’t just mean you take a couple shots a day, management is expensive, in terms of both time and money. Time is expended to make regular trips to the doctor to get the body checked, to recalibrate pumps, to recalculate the right doses of insulin to keep the body under control. Money is expended in ways I never imagined before I had a diabetic in my home. The pump costs money (thankfully, because of ACA, it was paid for) to the tune of $44,000. Then there is the insulin. There are drugs needed to help the insulin. The pump requires new sensors every few months. There are copays to the doctor every visit (without ACA, those copays are really high). And the diabetic still has to carry insurance (without ACA, that insurance is really expensive).

The management of the disease does not mean that it is not taking a toll on the body. She needs to check on that body a few times a year. Currently she is taking shots in her eyes to keep diabetes from stealing her sight. Diabetes is also causing neuropathy in her feet. The constant ups and downs in her sugar levels has cost her her gall bladder and her pancreas. It impacts the functioning of the kidneys, to the point where it can shut down the kidneys and put the diabetic on dialysis(thus another expensive drug and a machine to keep the kidneys working). It also causes fits with her teeth, which then get infected and cause problems with her sugars, and becomes a vicious cycle. Yes, the disease is manageable, but it is a full time job that requires hours and dollars.


Here is the thing: she is a smart woman with a lot to offer our society. Keeping her healthy is difficult and expensive, but her contribution will be worth every penny. She is a prime example of why we need regular, complete medical care for every citizen – because the only untapped resource left in this world is the human potential. I talk about diabetes because that is what I know, but there are many diseases that are “manageable,” but require access to health care. And we can’t allow a lack of medical care to prevent us from tapping the human potential.

The Lives of Homeless Children

I saw a news program (sorry, I can’t remember which one and can’t find the link) that suggested homelessness is up by 60%.  They also indicated that the face of homelessness has changed as well.  Many of the newly homeless are intact families who had been working at jobs that paid the bills.  The homeless population is not comprised of the old male drunks we see in the Salvation Army ads.   The number of homeless children is growing and they need help.  The problem is not going away.  Over the summer, they have nowhere to go.

The following may help understand of the life of a homeless child.

Many years ago, I was working with a program that helped homeless children in grades k-5.  It was a tutoring program.  The school buses would bring the children after school to a designated school where we gave them snacks, provided activities and helped with homework or problems they had in school.  Circumstances changed for me and I wasn’t able to continue, but the circumstances for homeless children have not improved for them.  They have gotten worse.
We had about 100 children in the program.  We could have easily had 500, there were that many eligible for the program.  But the woman who ran the program would not take more than her volunteers could handle.  Further, and she refused public money for this reason, there were a number of children in the age group who were already dangerous to other students and the volunteers, and she could not include them.  It broke her heart but she could not allow her students and volunteers to be put at risk.
As I worked with the students, I got to talk to them.  I also learned a great deal from the woman who ran the program.  It was a major eye-opener for this formerly insulated woman.  I learned:

  • That the shelters close for the day at 7:00 am and do not reopen until 6:00 pm.  That meant that without the program, the children would be on the street from the time school let out (2:30 to 3:00) until the shelter reopened.  Even in extreme rain, snow and heat.  Surrounded by pedaphiles, gangs, criminals, prostitutes and drunks.   They had nothing to do but hang out.  No wonder so many joined gangs and/or became mules for drug dealers.  In the shelter, they didn’t even have a pillow that was their own.
  • That many of the children had to get their mothers (rarely fathers) up, dressed, fed and out the door almost every morning because their mothers were hung over or in a drug stupor or just plain exhausted.  Imagine, kindergartners having to feed and dress their mothers (and younger siblings if they were the oldest).
  • That many of the mothers had had many partners because they would find a man to protect her and her children from the rest of the community.  And when these men found someone else, the woman had to as well.  That these men often beat the mother, but she stayed wso the children would not be raped or attacked.  That is one reason why so many had half siblings from multiple fathers.  When I hear GOPers affirm that women have lots of children so they can collect welfare it makes me want to beat them.  Note also that many of these shelters are run by religious organizations who will not offer access to family planning counseling or contraceptics.
  • That almost all of the children I worked with had been raped, molested and attacked so often they thought it was just part of life.  A good day was a day without a beating.  They were numb to it.
  • That a mother (and her children) could stay 30 days in a shelter and then she had to find somewhere else.  Between shelters, they lived on the street.  Then the mother would find a shelter.  Her 30 day clock started ticking.  It took a couple days to register for the local school.  The child would start classes.  In 28 days, it was time to leave.  The children had learned not to bond with classmates or teachers because they knew they would not be able to stay.  There was no continuity to their education.  Most not only did not speak English fluently, they did not speak their native language fluently because they weren’t around people who did.  So they sat in class, but learning was nearly impossible.  Today I hear an even worse story – when they try to enroll in classes and the testing mandated by No Child Left Behind is happening, principals are in a dilemma – do they allow these children in and their test scores to ruin the school average and risk their school and staff being put on a watch list or worse?  Or do they deny a child a chance to be in school (which at least, even if they are not learning, is a safer place than the street)?

There is no way these children can get an education this way.  I talked to my state senator about it, but he said we can’t help everybody.  He also claimed that homeless children were children of illegals, of drug addicts and drunks.  Many were, but that was not the issue.  These were children.  What he left unsaid was that many are racial minorities – African American, Latino, Indian, Vietnamese, etc.  He was, of course, a Republican who wanted these mothers to snap out of it and be good mothers. (This is part of what made me stop being Republican.)

Since this experience, I have become, according to some, a bleeding heart liberal.  But there are also practical reasons for my concern.  Some of these parents were indeed bad parents – drugs, drinking, treating themselves and their children badly.  Some did not know much better, others had given up.  Today, with the unemployment rate skyrocketing and the high foreclosure rate, the many are families that have fallen through the cracks.  How do you find work and get back on your feet if you have to worry constantly about the safety of your children?  Our Republican corporate servants blame the parents for bad decisions or bad behavior (as if losing a job that causes one to lose a home is either a bad decision or bad behavior on the part of the one losing them).  But regardless of the parents’ problems, it wasn’t the children’s fault.  These children are truly being left behind by an indifferent society.

I saw the sun come up this morning

Note:  This has not been my experience.  It is the result of conversations I have had with battered women.

I saw the sun come up this morning
And found myself wishing
That things were simple and easy so
Like they used to be

I watched the early light tint the clouds
As litter scattered across the skies
Leaves wrenched from branches thrown randomly on the lawn
Papers, a broken glass hurled around my room

I still felt the storm of last night
The house shaking in the wind’s fury
And in the rage in your voice
The slapping of rain on the window
And your hand against my face
The branch from the spruce beat the roof
While your fists beat my shoulders and arms
And an unknown object hit the outside wall
As I hit the dresser and fell
The thunder did not quite drown out
The slamming of your car door or the tires raking the gravel
As you drove away

I watched the fire-orange-that –hurt-my-eyes slip the skyline
Illuminating the red blotches on my face as reminders of your anger
And Jesus knew I ached and throbbed with all your hurts and empty cups, and missed (oh, god) I missed what used to be

And then the all over blue washed the sky
Saying, hoity-toity like, it always goes this way and drops of water
Don’t care if it’s streets or cheeks they spatter

© Julia F. Varnell-Sarjeant 6/13/2010

“But he loves me so much he can’t help it”

Today the feather I pull out of the featherbed as I look at abusers and their many faces.  This diary is not about lies conservatives tell, although I must admit that in my personal experience abusers are more apt to spew conservative talking points than not.  This is a universal problem that knows no particular demographic, not in terms of income, ethnic background, education, religion, or sexual orientation.  All demographics have this challenge.  One, in particular, financial abuse, is rarely discussed.

One thing we do not do enough, and we need to do routinely, is discuss the warning signs of an abuser.

When I was a speaker for Planned Parenthood, I spoke at battered women’s shelters.  This also meant I listened.  Before I could speak there, I underwent training from Planned Parenthood.  Their training was excellent, and I have been very aware of the warning signs since, I needed a refresher to do this diary.  I will be sharing from sites I found last night throughout this diary.

There is no big A on the forehead, no telltale ugliness in the eyes or countenance.  As stated in Hidden Hurt:Domestic Abuse Information, from which I have pulled much of today’s information (although there are many sites, some of which I list later)

In actual fact one of the main problems encountered by victims, friends, family and various agencies dealing with the consequences of an abusive relationship, is how ‘normal’ the abuser seemed, how unlike the image so frequently portrayed by the media. We may expect an abuser to be male, big, working-class, prone to being drunk, un-shaven, heterosexual, … (fill in the blanks!). However, an abuser is just as likely to be gay, a white-collar worker, a religious leader or clean-shaven. Sometimes the abuser is also a woman.

In other words, he OR she could be the nice neighbor next door who shovels your walk or brings you homemade cookies, your coworker, or your cousin.  The same could be said about the abused.  When you meet someone new, it is hard to recognize this person could be one who would wind up trying to abuse you.  Here, from the same website along with commentary from my own observations and other resources,  is what to look for:

Jealousy This manifests in the abuser getting abnormally angry or annoyed when the victim speaks to anybody of the opposite sex (or same sex in the case of gay abusers, that will be understood through the rest of this diary), or even looks at them.  The abuser also gets upset when the victim is noticed by somebody of the opposite sex either by speaking or just looking (often the abuser will say someone is looking when they actually may not be).  The abuser will check cell phone messages, car mileage, look at the clothes in the closet to ensure the victim is not dressing outside of the abuser’s boundaries when the abuser is not there.  The abuser will try to control what the victim wears to discourage any interest.  He/she makes accusations based on the flimsiest of evidence, such as a casual remark or a glance from a stranger.  The abuser justifies this behavior by saying, “I just can’t help it, I love you so much that the thought of you with anybody else makes me crazy.”  The abuser can become jealous of friends and family, trying to limit interactions with them.  This ties in with the Isolation behavior.

Controlling Behavior  This manifests with the abuser telling the victim what to do, when to do it, how to do it.  As mentioned before, it includes control over what the victim wears, eats, drinks, where they go to dine, where and when to shop (even for groceries).  While most of the abuse situations I have seen involve an abusive man with a woman victim, this is an area that goes both ways.  The abuser creates a set of rules for the victim to follow, but does not have to follow him/her self.  He/she also sets up  a set of definitions and expects the victim to adhere to them.  For example, in last night’s diary, the abuser defined “respect” in a very restrictive way and then complained about the lack of respect.  Nobody could enforce this definition of respect on a stranger, but the victim is expected to enforce it anyway.

Controlling behavior can extend to the financial area, where the victim is supposed to turn over the paycheck to the abuser and then seek permission to buy anything, even though the victim is contributing to the total household income.  Often the abuser will not allow the victim to see bills, but the victim is on all the credit lines and shares equal responsibility.  It can even extend to tax returns.  The result is  the victim is left in financial ruin when the relationship ends.

Quick Involvement  When the abuser finds his victim, he/she wants to get into the relationship right away.  He/she does not want the victim to have time to think about what is happening.  This is a reliance on the early “love rush,” trying to circumvent the rational questions that come when a relationship is given time to mature.  The abuser uses the feelings of romantic involvement against the victim.

Unrealistic Expectations  In this behavior, the abuser wants the perfect romantic partner, with perfect sex, perfect home cleanliness, perfectly timed emotional support.  In one case I heard about, the man beat the wife because she burned his toast one morning.  In spite of having two children to watch as she cooked, she was supposed to watch the toaster and pull it out at the exact right time.  Other times she was beat because the eggs were too dry, the dinner was not on the table when he got home, the newspapers had not been put out, or the children were crying.

Isolation  Here the abuser does not want the partner to see anybody but him or her self.  Family visits are either restricted or eliminated, calls to family are on a timer.  The victim cannot visit friends, go for “girl’s night out” or “boy’s night out,” or sometimes even take the children on a play date.  Interestingly, the abuser gets to do all these things.  The abuser uses the phrase, “I am all you need, you shouldn’t need anybody else if you really love me.”

Blame-Shifting For ProblemsThe abuser says, “It is your fault I got laid off.  If I hadn’t had to come home to dinner, they would have kept me.”  “It is your fault I hit you.  Paying for your upkeep has me under too much stress.”  Whatever goes wrong in the abuser’s life is the fault of the partner or some outside entity.  The government is to blame, the boss is to blame, the neighbor is to blame, and on and on.  If the children misbehave, it isn’t that they are children, the victim (or the school, or the caregiver) is too strict, too lenient, too lazy, etc.

Blame-Shifting For Feelings  Here is where the words, “You made me so mad I couldn’t help myself” come in.  “I have told you many times that I want … and you didn’t do it!”  “You just want to annoy me and I will teach you not to.”  The victim becomes responsible for the very emotional state and feelings of the abuser.

Hypersensitivity  The abuser is able to take a simple, meaningless statement and read into it something that he/she feels is an affront.  This not only happens in marriage or partnerships but also between children and parents.  “You gave me that look” may be legitimate, but it may also be an example of hypersensitivity.  (I have had people ask me about a look I gave them when I was trying, through my nearsightedness, to see their faces.  These were not abusers, but if they were, they would have reacted more.)

Cruelty To AnimalsThis speaks for itself.  Someone willing to harm a helpless animal will probably not stop there.  Research is still ongoing about this relationship, but there appears to be a correlation.

Cruelty To ChildrenAn abuser often has expectations of behavior in children that don’t make sense.  They will expect a three year old to act like a perfect lady or gentleman.  They are prepared to take out their frustration on the children because the children are weaker and helpless against the abuser.

‘Playful’ Use Of Force In Sex Abusers often have fantasies in which they have absolute control. In many cases, they feel that they have no control outside the home so they try to enforce control in the bedroom.  The opposite has also been known to be true, in which someone who is always in control in the office (an upper level manager, for example) feels a need to be in control when he/she comes home.  This type of abuse can be manifested in painful “rough” sex, or in demeaning sex.  There is a need to be careful here, because not all who engage in rough sex are abusers, but if the other person is reluctant and needs convincing or coercion, there is apt to be a problem.  Forced sex is always a sign of an abuser (in addition to being rape).

Rigid Gender Roles This is an almost universal trait.  Men will expect to be in total control of the household with the woman serving him hand and foot.  She may be “allowed” to work outside the home, but he controls the right to work and the job she can have, as well as the hours.  Whether she works or not, she is to maintain an immaculate house, have dinner ready when he wants it, have it hot and perfect.  She is in total charge of raising the children, including bathing, dressing, feeding.  Often she will have to serve them separately from him.  In the case of women, she will expect him to provide for her every material need, calling him “not a real man” and a wimp if he cannot earn enough to satisfy her wants.  In addition, she may make him keep house or hire a housekeeper and deal with the children while she does whatever she does.

Verbal Abuse  Again a nearly universal abuser trait, the abuser will begin to eat away at the victim’s self esteem with hateful words.  This is often a form of grooming for more violent abuse.  Things like ugly, fat, lazy and stupid are aimed at the victim.  Pretty soon the abuser will tell the victim that nobody else would put up with the victim and the victim believes it.  I have seen women in the shelters absolutely broken just because of the things they have been told so often they come to believe it.

Dr. Jeckyll And Mr. Hyde  The abuser will have an episode of violence followed by being a very contrite, sweet and charming person.  They will change, they will never let it happen again.  The abuser will bring flowers and candy, take the victim to a nice dinner or prepare a special dinner at home, cry, compliment.  The words “but I just can’t live without you.  If you leave me, I will kill myself” may be used.

Drink Or Substance Abuse  We all have heard about the violent drunk.  We have also heard stories of some things people do when on a drug binge.

History Of Battering Or Sexual Violence  If you hear that the person you are seeing has been arrested for a violent sexual offense or if someone who knows that person tells you of similar events, run.  Enough said.

Negative Attitude Toward Women  Or women.  The abuser is likely to talk about women in derogatory terms, saying they belong pregnant and in the kitchen, should not be taking good work from men, talk about how unstable they are, etc.  I wonder how many congresspersons are closet abusers?

Threatening Violence  In the diary that motivated this one, the person in question showed the diarist that he owned a gun.  He made the showing of it seem quite innocuous, but he did it.  Abusers will let the victim know they have weapons and know what to do with them.  They may couch it in, “I don’t know why I still have this thing but …” but they ensure the victim knows that if she is not compliant, her safety is at risk.

Breaking Or Striking Objects  This is a sign of a temper that is out of control.  However, abusers also use the act of violence against an object to instill fear and obedience.  The message is that the next thing broken could be the victim.

Any Force During An Argument  One thing we always told women at the shelters is that if he hits you once, he will hit you again.  Harder.  Once the abuser gets away with it, he knows he can do it again.  He may even try to see what the limits are.  Even loud shouting and threatening or intimidating behavior is a warning sign.

Types of abuse

Abuse comes in five major categories:

Physical  From the domestic violence websited cited above:

He came upstairs and asked me to get out of bed to help him look for a work shirt. I didn’t get out of bed. I replied that I wanted to go to sleep. He suddenly turned on me. He kicked me out of bed, somehow got me in the position of being flat on my back. He stood on me and spat in my face. (Charlotte’s Story)

I had a client once who was buying a house with her husband.  I got a call one day, he had thrown her across the dresser because the bed wasn’t made properly.  We cancelled the transaction and she got a divorce.

We all know about physical abuse when it results in a hospital visit, but milder forms of violence are also abusive:  kicking, shoving, slapping, spitting, choking, pinching, hair pulling, dragging, burning, use of physical restraints during sex (against the partner’s will), weapon wielding, and even dangerous driving if it is intended to frighten.  It often starts small, almost hard to recognize, and grows.

Verbal  Verbal abuse consists of name calling and degrading statements.  The abuser repeatedly tells the victim that she is unworthy and deserves to be mistreated, that she caused the abuse because of her stupidity, laziness, ugliness, and so on.  The abuser ignores the feelings of the victim.  Many times the verbal attacks occur in front of other people (remember the OJ Simpson trial where Nicole was demeaned at dinner with friends?) in situations where the victim has been taught not to respond.

Emotional Emotional abuse can involve threats about doing harm, calling the police, threats about the children (harming them, running away with them, calling social services and having them removed).  Emotional abusers work to make the victim dependent on them and afraid to leave.  They create in the victim a broken self image and the idea that their survival depends on being compliant to the abuser.  They also create fear that the abuser will harm the victim or the victim’s children.  It may go to the extreme of withholding necessities such as food, locking them up in a closet, not allowing them to leave the house.

Sexual  This was discussed above.

Financial  Again discussed above, this is becoming more and more recognized.  The abuser makes the victim financially dependent (how will you raise these kids when you can’t even earn a nickel and you owe so much money?  Nobody will even give you a credit card without me!).  Abusers often forbid the victim the right to work so they cannot earn their own money, enforcing the dependency.  They often hide the money.  This happens with the abuser keeping bank statements and bills from the victim, moving money into secret accounts, putting the victim on all the credit lines but not letting the victim know what they are, what they are for or how much they are.  Again, instances of financial abuse are finally becoming recognized as actual abuse.

One thing to remember in this discussion:  Victims can also be abusers.  In some cases, there is an abuse/abuse situation going on.  One may abuse in some ways victimizing the other, while in turn the other may abuse in the same or another way.  Victims may also become pass-along abusers.  Not having any power in their relationship with the abusers, they in turn regain that power by abusing others.  It escalates, and it becomes a learned behavior.  Some have been around abuse so long they think it is normal.

The lies I wish to pull out of the featherbed here are three fold. First, abuse only happens in certain demographics, in certain types of families, in certain belief systems, in certain ethnic backgrounds, etc.  It can and does happen in almost every neighborhood or community regardless of demographics.   Second, the idea that the abuser loves the victim so much he can’t help himself.  (Note that if the abuser was so enraged he couldn’t control himself, how does he control his blows so there are no visible bruises?)  Third, that the abuser will change.  I talked to many women at the shelter who thought they could love their abusers enough to change them.  The only change that happened, or will happen, is the abuse gets worse.  Finally, if you are a victim, there is nothing you can do about it.  There is.  First … get with a domestic violence organization and make a plan.  Hide away some money – there is always a way to do it.  Pack a small bag for yourself and one for each child.  Figure out a day when you will get out.  Have someone meet you – you can’t do it alone.  Go somewhere he can’t find you.  Get to a shelter whose location is secret.  The domestic violence organization will help with all this, they have done it before.  Finally, remember, no matter what you have been led to believe, you deserve better.

The links I promised:

Hidden Hurt: Domestic Abuse Information,
Signs of an Abuser

Migrant Children

Many years ago, our family was visiting the missions of California.  We were traveling from Mission San Antonio de Padua (or San Miguel, I forget which) to Mission Nuestra Senora de la Soledad.  Since it was well off the highway we were traveling back roads.  We were driving by huge corporate farms.  As we drove by, we passed many people out picking the crops by hand.  Many of the laborers appeared to be children.  Then we drove past the migrant camp where they stayed.  Not only was the camp almost uninhabitable, there were no adults in sight.  It appeared that small children were watching small children.

When I got back home, I asked our parish priest, who had spent time tending to migrant workers, about what I had seen.  What he told me has haunted me ever since.

I was correct that there were no adults at the camp, if it was a day good for picking.  Even if it had been raining, there would have been only the very old in the camp.  Most of the shelters are portable, like tents and adapted trucks.  And yes, I had seen children in the fields beside their parents.

He said that when children turn seven or eight, they go out to pick.  The babies are left with six and seven year olds in charge.  The babies are tended by their siblings all day.  They learn their language from six and seven year olds who never learned any language properly. (In other words, they don’t speak English well enough to get by and they don’t speak good Spanish either.)  Of course, schooling is nonexistent.  If a toddler gets hurt, it is up to his/her young sibling to figure out what to do, because the parents can’t afford to come in from the fields.  There is not good water in the camp for anybody, and there is almost never enough to eat or wear.

Out in the fields, the water sources are far apart and there are few if any toilet facilities.  The work is backbreaking, and goes on from first light to last light.  The pay, of course, is worse than substandard.

At that time, one of my favorite songs became Woodie Guthrie’s Deportee:

Is this the best way we can grow our big orchards?
Is this the best way we can grow our good fruit?
To fall like dry leaves and to rot on the topsoil
And be called by no name except

Deportee by Woodie Guthrie

Later I moved home to Colorado and worked with homeless children, which I covered in another diary.  In both cases, this nation closed its eyes to vulnerable children in this country.  I don’t particularly care whether it is the fault of the parents, although much of me blames the corporate farms for the migrant worker situation.  I do care that the children did not ask for these circumstances, and the only thing they did to be in this plight was be born into the wrong demographic.

While I agree that there are other urgent and important issues to handle during this administration, is there some way we can find occasion to find a solution to these children?