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Background: Youth alcohol consumption has fallen markedly over the last twenty years in England. This paper explores the drivers of the decline from the perspectives of young people. Methods: The study used two methods in a convergent triangulation design. We undertook 38 individual or group qualitative interviews with 96 participants in various educational contexts in England. An online survey of 547 young people in England, was also conducted. Participants were aged between 12–19 years. For both data sources, participants were asked why they thought youth alcohol drinking might be in decline. Analysis of interview data was both deductive and inductive, guided by a thematic approach. Content analysis of survey responses further refined these themes and indicated their prevalence within a larger sample. Results: The research identified eight key themes that young people used to explain the decline in youth drinking: The potential for alcohol-related harm; Contemporary youth cultures and places of socialisation; The affordability of alcohol; Displacement of alcohol by other substances; Access and the regulatory environment; Disputing the decline; Future Orientations; and Parenting and the home environment. Heterogeneity in the experiences and perspectives of different groups of young people was evident, particularly in relation to age, gender, and socio-economic position. Conclusions: Young people's explanations for the decline in youth drinking in England aligned well with those generated by researchers and commentators in prior literature. Our findings suggest that changing practices of socialisation, decreased alcohol affordability and changed attitudes toward risk and self-governance may be key explanations. [ABSTRACT FROM AUTHOR]

Background: Eating disorders are among the most serious mental health problems affecting children and young people and without appropriate treatment often have a protracted course with high levels of morbidity and mortality. While considerable progress has been made in recent years in developing effective evidence-based outpatient treatments, these are not always readily available. In England, until recently, the usual care pathway for young people with an eating disorder was referral from primary care to local generic Child and Adolescent Mental Health Services with varying levels of expertise in eating disorders and a mix of outpatient treatments available. Poor treatment progress or physical deterioration would usually result in inpatient admission. Admission rates were high, with children and young people with an eating disorder accounting for nearly a quarter of all child and adolescent psychiatric hospital admissions. Inpatient treatment is costly and has high relapse rates with some evidence that it may contribute to poorer long-term outcomes in eating disorders. Accumulating clinical and research evidence that early expert outpatient treatment can significantly reduce the need for inpatient care indicates,+ that investing in dedicated community-based eating disorders services is likely to be both clinically and economically beneficial. Overview of paper: This paper describes a large-scale transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community-based eating disorders services for children and young people. Plain English summary: Eating disorders are among the most serious mental health problems affecting children and young people. There has been accumulating clinical and research evidence that early expert outpatient treatment is effective and can also significantly reduce the need for costly inpatient care, indicating that investing in community-based eating disorder services is likely to be both clinically and economically beneficial. This paper describes a large-scale service transformation programme following a major government investment (initially £30 million/year, since then increased to over £50 million/year) aimed at service level change in the provision of eating disorder services for children and adolescents in England. We describe the history, background, political context, and clinical and research evidence that contributed to the government's decision to invest in new services for eating disorders. We also provide a brief account of the implementation of an England-wide whole team training to support the creation of a network of over 70 dedicated community eating disorders services for children and young people. [ABSTRACT FROM AUTHOR]

This paper explores the role of family trajectories during childhood in explaining inequalities by maternal education in children's math and reading skills using harmonized, longitudinal, and nationally representative surveys, which follow children over the course of primary and lower secondary school in four high‐income countries (England, France, Germany, and the United States). As single parenthood and family transitions are more likely among less educated parents and are associated with fewer resources for children, we explore whether growing up outside a stable two‐parent family mediates educational inequalities in math and reading scores. Results show a strong educational gradient in family trajectories in the four countries, but this varies by child age and by country. Children who experience a family transition record lower test scores, although the magnitude differs by the type of postseparation arrangements. Overall, family trajectories are strongly associated with children's math and reading scores but, because of the importance of selectivity in family trajectories, they play only a modest role in explaining the skills gaps by maternal education, considerably less than determinants such as income. The penalties associated with not living within a stable two‐parent family are always larger in the United States and England than in France and Germany. [ABSTRACT FROM AUTHOR]

Objective: A variety of paediatric tracheostomy tubes are available. This article reviews the tubes in current use at Great Ormond Street Hospital for Children and Evelina London Children's Hospital. Methods: This paper outlines our current preferences, and the particular indications for different tracheostomy tubes, speaking valves and other attachments. Results: Our preferred types of tubes have undergone significant design changes. This paper also reports further experience with certain tubes that may be useful in particular circumstances. An updated sizing chart is included for reference purposes. Conclusion: The choice of a paediatric tracheostomy tube remains largely determined by individual clinical requirements. Although we still favour a small range of tubes for use in the majority of our patients, there are circumstances in which other varieties are indicated. [ABSTRACT FROM AUTHOR]

While school food initiatives across England support children's nutritional intake during school term time, there is no universal state provision during the school holidays to reduce the risk of children experiencing food insecurity. In the absence of a national program of holiday provision, community organizations in disadvantaged communities have established holiday clubs offering free food and activities to children. This paper examines how these holiday clubs source food and the challenges of procuring food and delivering healthy meals that adhere to UK School Food Standards. Results indicate that holiday clubs adopt a variety of procurement strategies including relying upon donated food. While club leaders have sought opportunities to source food cost-effectively, the findings suggest significant challenges for these clubs to achieve their aim of delivering healthy meals. Findings point to needs for sustainable funding and the developing healthy food procurement policies and processes that align with a wider food strategy. [ABSTRACT FROM AUTHOR]

Background: Childhood respiratory tract infections (RTIs) are common and can lead to unnecessary antibiotic use and antimicrobial resistance. The CHIldren with COugh (CHICO) intervention incorporates a clinician-focused algorithm (STARWAVe) to predict future hospitalisation risk, elicitation of carer concerns, and a carer-focused personalised leaflet recording treatment decisions and safety-netting information. Aim: To examine the implementation of the CHICO intervention by primary care clinicians. Design and setting: A qualitative study with primary care clinicians in England taking part in the CHICO randomised controlled trial. Method: Interviews explored the CHICO intervention's acceptability and use. Clinicians from a range of practices with high and low antibiotic dispensing rates were recruited. Normalisation process theory underpinned data collection and thematic analysis. Results: Most clinicians liked the intervention because it was quick and easy to use, it helped elicit carer concerns, and reassured clinicians and carers of the appropriateness of treatment decisions. However, clinicians used it as a supportive aid for treatment decisions rather than as a tool for behaviour change. The accompanying advice leaflet helped explain treatment decisions and support self-care. The intervention did not always align with clinicians' usual processes, which could affect use. Increased familiarisation with the algorithm led to reduced intervention use, which was further reduced during the COVID-19 pandemic as a result of changes to practice and remote consultations. Conclusion: Clinicians found the CHICO intervention useful to support decision making around antibiotic prescribing and it helped discussions with carers about concerns and treatment decisions. The intervention may need to be adapted to align more with clinicians' consultation flow and remote consultations. [ABSTRACT FROM AUTHOR]

Coping style plays an important role in children’s wellbeing. This paper describes the patterns of associations between children’s self-reported coping styles and symptoms of anxiety in order to determine whether particular dimensions are associated with better adjustment. Participants were 2566 children (1268 girls, 1298 boys) aged 7-11 years attending 15 schools in the South East of England. Results showed that aspects of coping were differentially associated with children’s self-reported anxiety. Patterns of association also varied by age and gender. Dimensions of coping were shown to form distinct adaptive and maladaptive coping styles which were also differentially associated with anxiety. Analysis of these styles indicated that it is the absence of maladaptive coping strategies, rather than the presence of adaptive strategies, that is significant in emotional wellbeing. These findings suggest that interventions designed to reduce or extinguish maladaptive coping styles may be of particular benefit in facilitating emotional wellbeing. [ABSTRACT FROM AUTHOR]

Background: Children in social care report poor outcomes in many aspects of their later lives. Less is known about differences by ethnicity. Objective: We examined the health, socio-economic, family and living arrangements across the first three decades of adult life by the intersection of ethnicity (White, Black, South Asian) with social care. Participants and setting: Linked census and life events data for a 1% sample of the population of England and Wales in the ONS Longitudinal Study. Participants were dependent children in 1971-2001 (analytic sample n = 669,474). Methods: Categorical regression models compared health, socio-economic circumstances, living arrangements and relationships, controlling for country of birth, childhood census year, childhood and adult age in years, gender, and head of household social class, qualifications, employment status and marital status. Results: Adverse adult outcomes following social care in childhood were conditional on the interaction of social care with ethnicity, mainly in the socio-economic domain. For some outcomes the White group had the poorest outcomes: for example, 15% lower probability of being employed than other White people (65% versus 80%). Black adults with a history of social care did not differ from other Black adults, except for the lowest probability of acquiring their own home, while care-experienced South Asian adults did not differ from other South Asian adults. Conclusion: Minority ethnicity moderated the social care to adult outcomes relationship in both positive and negative ways. Overall, there was little evidence of intersectionality for Black children in social care affecting their life chances. [ABSTRACT FROM AUTHOR]

Background: There is a lack of research about the experiences and impact of having a sibling with a life-limiting condition. Studies focus on the sibling experience during childhood but the experience and impact during adulthood is unknown despite the increased life-expectancy of children with life-limiting conditions. Aim: To explore adult siblings' perspectives on the experience of having a sister/brother with a childhood life-limiting condition and to identify their perceived needs and preferences for support. Design: A qualitative exploratory study design with data generated by semi-structured interviews and analysed using reflexive thematic analysis, underpinned by interpretivism. Setting/participants: Twenty-two siblings (17–42 years old) were recruited via a children's hospice in England. Results: The experience of having a sibling with a life-limiting condition changes over time in response to how understandings of the meaning of a life-limiting condition develop and changing roles/relationships with parents and siblings. These experiences have an enduring impact on adult sibling's mental health which is compounded by their unmet (and sometimes unrecognised) support needs in adolescence and adulthood. Siblings described the importance of support continuing into adulthood with a focus on the provision of psychotherapy and peer support. Conclusions: Having a sister/brother with a childhood life-limiting condition appeared to have a significant and ongoing impact on adult siblings but their support needs, particularly for psychotherapy and peer support, are overlooked. The findings highlight the importance of ensuring siblings are included in family assessments and that family-based interventions are developed to promote sibling-parent relationships. [ABSTRACT FROM AUTHOR]

Aims and objectives To field test a parental self-efficacy scale regarding its acceptability and feasibility and to describe parental self-efficacy in a convenience sample of parents with children aged 6 years old or less. Background Self-care within families is increasingly emphasised in health policy as a means of maximising healthcare resources. This study reports the field testing of a scale designed to measure parental self-efficacy. Design Cross-sectional survey of parents of children aged 6 years old or less. Methods Subjects were recruited through a parenting internet website ( n = 84) and local parenting and community organisations ( n = 68) and asked to complete a questionnaire containing the scale. Data collection took place between January and August 2011. Results The scale, previously validated with an expert panel of professionals, gathered information about parental self-efficacy when administered either directly or through an on-line data collection portal, although there were more missing data when administered via the Internet. Although convenience and self-selecting samples precluded parameter estimation, areas of concern highlighted were difficulties differentiating children with serious illnesses and the use of the Personal Child Health Record. Use of the Internet was widespread, as was use of community pharmacists and nursery staff. Conclusion Although the primary purpose was not to collect specific data, the data indicated the continuing concern of parents regarding serious illness and where additional investment may be required to meet parental needs and expectations. Relevance to clinical practice The previously validated scale can be used to collect information about parental self-efficacy either through a paper questionnaire or the Internet. Although there was slightly more missing data from the Internet version, the ease of its administration makes this an attractive option. Parents generally reported high levels of self-efficacy and satisfaction with services; however, the scale was able to identify areas where further investment might be useful. [ABSTRACT FROM AUTHOR]

Background: We have developed a healthy lifestyles programme (HeLP) for primary school aged children (9-10 years), currently being evaluated in a definitive cluster randomised controlled trial. This paper descriptively presents the baseline characteristics of trial children (BMI, waist circumference, % body fat, diet and physical activity) by gender, cluster level socio-economic status, school size and time of recruitment into the trial.Methods: Schools were recruited from across the South West of England and allocated 1:1 to either intervention (HeLP) or control (usual practice) stratified by the proportion of children eligible for free school meals (FSM, <19%, ≥19%) and school size (one Year 5 class, >1 Year 5 class). The primary outcome is change in body mass index standard deviation score (BMI sds) at 24 months post-randomisation. Secondary outcomes are BMI sds at 18 months, waist circumference and percentage body fat sds at 18 and 24 months, proportion of children classified as underweight, overweight and obese at 18 and 24 months, physical activity (for a sub-sample) and food intake at 18 months.Results: At baseline 11.4% and 13.6% of children were categorised as overweight or obese respectively. A higher percentage of girls than boys (25.3% vs 24.8%) and children from schools in FSM category 2 (28.2% vs 23.2%) were overweight or obese. Children were consuming a mean (range) of 4.15 (0-13) energy dense snacks (EDS) and 3.23 (0-9) healthy snacks (HS) per day with children from schools in FSM category 2 consuming more EDS and negative food markers and less HS and positive food markers. Children spent an average 53.6 min per day (11.9 to 124.8) in MVPA and thirteen hours (779.3 min) per day (11 h to 15 h) doing less than 'light' intensity activity. Less than 5% of children achieved the Departments of Health's recommendation of 60 min of MVPA every day.Conclusion: We have excellent completeness of baseline data for all measures and have achieved compliance to accelerometry not seen before in other large scale studies. Our anthropometric baseline data is representative of local and national data for children this age and reflects the gender and socio-economic variations expected of children this age in relation to physical activity and weight status.Trial Registration: ISRCTN15811706 (1/05/2012). [ABSTRACT FROM AUTHOR]

Team formulation refers to the 'process of facilitating a group of professionals to construct a shared understanding of a service user's difficulties' (Johnstone & Dallos, 2013, p. 5). This project was conducted at a specialist inpatient CAMHS service for young people under the age of 13 to understand staff views on the usefulness of team formulation and how it could be further developed. The project also assessed the service's involvement of young people and their parents/carers in formulations following NHS England's service specification for tier four CAMHS. The study used a sequential mixed methods design. Quantitative data was collected with a questionnaire and analysed, and then qualitative data was collected through focus groups and analysed using reflective thematic analysis. The results were then integrated through triangulation. A high proportion of the staff team took part in the project. Team formulation was reported as generally helpful by staff, especially in developing a shared team understanding and gathering all the information about a young person in one place. Further, staff reported feeling passionate about team formulation, and that it positively impacted their practice. Staff reported difficulties regarding the meeting dynamics and feeling that it is important to involve young people and families in formulations in a different way. The results of this project have inspired discussions about how team formulation is used in the service. [ABSTRACT FROM AUTHOR]

Background The Physical Activity Questionnaire for Children and Adolescents ( PAQ- C/- A) provides general estimates of physical activity levels. Following recent expert recommendations for using the PAQ for population surveillance, the aim of this paper was twofold: first, to describe normative PAQ data for English youth; and second, to determine a criterion-referenced PAQ-score cut-off point. Methods Participants ( n = 7226, 53% boys, 10-15 years) completed an anglicized version of the PAQ. Peak oxygen uptake ( VO2peak) was predicted from PACER lap count according to latest FITNESSGRAM standards and categorized into 'at-risk' and 'no-risk' for metabolic syndrome. R OC curves were drawn for each age-sex group to identify PAQ scores, which categorized youth into 'sufficiently active' versus 'low-active' groups, using cardiorespiratory fitness as the criterion-referenced standard. Results PAQ scores were higher in boys than in girls and declined with age. Mean PAQ score was a significant, albeit relatively weak (area under the curve < 0.7) discriminator between 'at-risk' and 'no-risk.' PAQ scores of ≥2.9 for boys and ≥2.7 for girls were identified as cut-off points, although it may be more appropriate to use lower, age-specific PAQ scores for girls of 13, 14 and 15 years (2.6, 2.4, 2.3, respectively). Conclusion The normative and criterion-referenced PAQ values may be used to standardize and categorize PAQ scores in future youth population studies. [ABSTRACT FROM AUTHOR]

Infancy is a crucial time for interventions to reduce later developmental difficulties. In England, recent policy has required children's service delivery to be redesigned to attend to infant mental health across all four tiers of NHS provision through interagency networks of child-care professionals. The policy identifies child-care social workers as primary care professionals, able to recognize early infant mental health problems, promote mental health and prevent deterioration. Our paper explores whether, as a profession, English child-care social workers are well prepared in terms of their knowledge, ideological beliefs and professional acculturation to implement such changes to their practice. Empirical information is provided from a funded, independent evaluation of the implementation of the NSF policy at a local level. Data from professional focus group interviews describe and compare the differing professional ideologies and professional practice preferences within the infant mental health network of an English NHS Primary Care Trust in an urban local authority. The findings identified obstacles that were personal-ideological, cultural and structural in nature. Progress towards achieving the NSF policy standards appeared slight. [ABSTRACT FROM AUTHOR]

Abstract: This paper analyses child pedestrian casualties in England, focusing on the influence of socio-economic deprivation. It develops an area-based model of pedestrian casualties and presents estimates based on data for the English wards. The results detect an association between increased deprivation and higher numbers of pedestrian casualties across England. The deprivation effect is strong both for all child casualties and for children killed or seriously injured. Estimates for adult casualties also reveal a positive and significant association with increasing deprivation, but the magnitude of the effect is smaller than for children. The paper concludes by outlining some of the implications of the research. [Copyright &y& Elsevier]

Background: Social prescribing is a mechanism of connecting patients with non-medical forms of support within the community and has been shown to improve mental health and wellbeing in adult populations. In the last few years, it has been used in child and youth settings with promising results. Currently, pathways are being developed for social prescribing in Child and Adolescent Mental Health Services (CAMHS) to support children and young people on treatment waiting lists. The Wellbeing While Waiting study will evaluate whether social prescribing benefits the mental health and wellbeing of children and young people. Methods: This study utilises an observational, hybrid type II implementation-effectiveness design. Up to ten CAMHS who are developing social prescribing pathways as part of a programme run across England with support from the Social Prescribing Youth Network will participate. Outcomes for children and young people receiving social prescribing whilst on CAMHS waiting lists will be compared to a control group recruited prior to the pathway roll-out. Questionnaire data will be collected at baseline, 3 months and 6 months. Primary outcomes for children and young people are mental health symptoms (including anxiety, depression, stress, emotional and behavioural difficulties). Secondary outcomes include: loneliness, resilience, happiness, whether life is worthwhile, life satisfaction, and service use. An implementation strand using questionnaires and interviews will explore the acceptability, feasibility, and suitability of the pathway, potential mechanisms of action and their moderating effects on the outcomes of interest, as well as the perceived impact of social prescribing. Questionnaire data will be analysed mainly using difference-in-differences or controlled interrupted time series analysis. Interview data will be analysed using reflexive thematic analysis. Discussion: The Wellbeing While Waiting study will provide the first rigorous evidence of the impact of social prescribing for children and young people on waiting lists for mental health treatment. Findings will help inform the prioritisation, commissioning, and running of social prescribing in other CAMHS. To maximise impact, findings will be available on the study website (https://sbbresearch.org) and disseminated via national and international networks. Trial Registration: N/A. [ABSTRACT FROM AUTHOR]

Background: Worldwide, around 21 million children would benefit from palliative care and over 7 million babies and children die each year. Whilst provision of paediatric palliative care is advancing, there major gaps between what should be done, and what is being done, in clinical practice. In 2017, the National Institute for Health and Care Excellence (NICE) introduced a quality standard, to standardise and improve children’s palliative care in England. However, there is little evidence about what good experiences of palliative care for children are, and how they relate to the quality standard for end-of-life care. Aim: This study explored how the NICE quality standard featured in parental experiences of palliative care for children to understand what ‘good’ palliative care is. Design: Qualitative study, employing in-depth, telephone and video-call, semi-structured interviews. Data were analysed using thematic analysis, informed by Appreciative Inquiry. Setting/participants: Participants were parents of children and young people (aged 0–17 years) in England, who were receiving palliative care, and parents whose child had died. Results: Fourteen mothers and three fathers were interviewed. Seven were bereaved. Parents were recruited via four children’s hospices, one hospital, and via social media. Good palliative care is co-led and co-planned with trusted professionals; is integrated, responsive and flexible; encompasses the whole family; and enables parents to not only care for, but also to parent their child to end of life. Conclusions: Findings have implications for informing evidence based practice and clinical guidelines, overall improving experiences of care. [ABSTRACT FROM AUTHOR]

The sudden, unexpected death of a child (SUDC) is a devastating experience. It is vital that supportive and investigative services are effective and promote the best outcomes for families. Analysis of 5 years of data from 309 SUDC cases in Greater Manchester, United Kingdom (UK) shows how a number of key service outcomes can be measured and achieved through a raft of actions which are commensurate with and exceed the service level recommended by the UK Government. Annual reports covering the work of the Greater Manchester SUDC team are compiled from audit forms completed by the attending SUDC pediatrician for each case. Data from these reports from April 1, 2015 to March 31, 2020 were analyzed. Most cases happened out of normal working hours, predominantly on Sundays. This supports the need for a 24-hour, 7 days per week SUDC service to enable early investigation and timely support for families. The review demonstrated that the Greater Manchester model is able to deliver this in a rapid response with early attendance in emergency departments and early home visits; effective joint agency working with police, children's social services, and other agencies; and provision of support to families. The proposed instigation of a key worker role in the SUDC team is a welcome development. This is central to ameliorating the experience for parents by providing bereavement support separate from the investigative role of the SUDC team. Research is needed into the role of the key worker, potentially as a dedicated bereavement nurse, and understanding of families' experiences to ensure that support is optimal. [ABSTRACT FROM AUTHOR]

Background: Online treatments for child anxiety offer a potentially cost-effective and non-stigmatizing means to widen access to evidence-based treatments and meet the increasing demand on services; however, uptake in routine clinical practice remains a challenge. This study conducted an initial evaluation of the clinical effectiveness, feasibility and acceptability of OSI (Online Support and Intervention for child anxiety) within clinical practice. OSI is a co-designed online therapist-supported, parent-led CBT treatment for pre-adolescent children with anxiety problems. Method: This case series was part of routine service evaluation in a clinic in England where families were offered OSI to treat a primary anxiety difficulty among 7- to 12-year-old children; 24 families were offered OSI, and 23 took it up. Measures of anxiety symptomatology, functional impairment and progress towards therapeutic goals were taken at pre-treatment, post-treatment and 4-week follow-up. Treatment satisfaction and engagement were also measured throughout the intervention. Results: Mean anxiety symptoms significantly improved to below the clinical cut-off post-treatment, with further reduction at follow-up. Functional impairment also significantly improved and significant progress was made towards treatment goals. The majority of children showed reliable change in anxiety symptoms and reliable recovery by follow-up, and were discharged without needing further treatment for anxiety. Uptake, adherence and engagement in OSI were excellent, and parents reported high levels of satisfaction with the treatment. Conclusions: We have provided initial evidence that OSI is feasible, acceptable to families, and appears to be associated with good outcomes within routine clinical practice. [ABSTRACT FROM AUTHOR]

Background: Families and professionals caring for children with life-limiting conditions face difficult healthcare decisions. Shared decision-making is promoted in many countries, however little is known about factors influencing these processes. Aim: To explore the communication strategies used in shared decision-making for children with life-limiting conditions. Design: A longitudinal, qualitative, multiple-case study. Cases were centred around the child and parent/carer(s). Most cases also included professionals or extended family members. Data from interviews, observations and medical notes were re-storied for each case into a narrative case summary. These were subject to comparative thematic analysis using NVivo11. Setting/participants: Eleven cases recruited from three tertiary hospitals in England. 23 participants were interviewed (46 interviews). Cases were followed for up to 12 months between December 2015 and January 2017. 72 observations were conducted and the medical notes of nine children reviewed. Findings: Strategies present during shared decision-making were underpinned by moral work. Professionals presented options they believed were in the child's best interests, emphasising their preference. Options were often presented in advance of being necessary to prevent harm, therefore professionals permitted delay to treatment. Persuasion was utilised over time when professionals felt the treatment was becoming more urgent and when families felt it would not promote the child's psychosocial wellbeing. Conclusions: Communication strategies in shared decision-making are underpinned by moral work. Professionals should be aware of the models of shared decision-making which include such communication strategies. Open discussions regarding individuals' moral reasoning may assist the process of shared decision-making. [ABSTRACT FROM AUTHOR]

Caring for a child with a tracheostomy can be challenging for parents and learning to safely manage their child's airway can be frightening due to their child's breathing issues, complex diagnosis and the difficult decisions they have to make. The aim of this longitudinal narrative study was to tell the stories of parents whose child had a new tracheostomy. Twenty three narrative interviews were conducted with twelve parents from nine families at three time points over a 12 month period. Data were analyzed using a socio-narratological approach. The stories told how parents were able to 'hold their own' despite experiencing shock, emotional upheaval and uncertainty during the period of their child's surgery. 'Holding their own' was possible for parents because resilience played an important part of their journey. Parents continued to be resilient as they adapted to being at home and dealt with ongoing challenging and stressful circumstances. All of the parents told stories reflecting on and recognizing that there were times when they exhibited higher levels of resilience and times when their resilience was lower. Looking back on their experiences parents appreciated that they reframed their initial often negative views about their child's need for a tracheostomy into more positive understandings and a future orientated perspective. [ABSTRACT FROM AUTHOR]

Abstract: Background: Previous research identifies positive and negative effects of being a sibling in a family which includes a disabled child. Short break services (also known as respite) provide families with a break from caring and offer disabled children the chance to participate in various activities. This paper investigates the effects that these short breaks have on siblings. Methods: The research consists of a qualitative analysis of data collected as part of a survey of families using short break services. Data from 239 parent–carers (mostly biological parents) and 84 siblings are included in the analysis. Data are written responses to open questions about use of services and the effects they have. Results: The effects of short breaks on siblings are described as being mostly positive. Short breaks have the potential to ameliorate some of the negative impacts of being a sibling in a family with a disabled child whilst also promoting the positive impacts of having a disabled brother or sister. However, some siblings also report some adverse effects of short breaks. Conclusion: Short breaks have a significant role to play in promoting the wellbeing of siblings; however, their role currently seems to be largely unrecognised and consequently undervalued. [Copyright &y& Elsevier]

Background: Previous studies showed increasing number of children with a life-limiting or life-threatening condition who may benefit from input from pediatric palliative care services. Aim: To estimate the current prevalence of children with a life-limiting condition and to model future prevalence of this population. Design: Observational study using national inpatient hospital data. A population-based approach utilizing ethnic specific population projections was used to estimate future prevalence. Setting/participants: All children aged 0–19 years with a life-limiting condition diagnostic code recorded in Hospital Episodes Statistics data in England from 2000/01 to 2017/18. Results: Data on 4,543,386 hospital episodes for 359,634 individuals were included. The prevalence of children with a life-limiting condition rose from 26.7 per 10,000 (95%CI 26.5–27.0) in 2001/02 to 66.4 per 10,000 (95% CI: 66.0–66.8) in 2017/18. Using a more restricted definition of a life-limiting condition reduced the prevalence from 66.4 to 61.1 per 10,000 (95%CI 60.7–61.5) in 2017/18. Highest prevalence was in the under 1-year age group at 226.5 per 10,000 and children with a congenital abnormality had the highest prevalence (27.2 per 10,000 (95%CI: 26.9–27.5)). The prevalence was highest among the most deprived group and in children of Pakistani origin. Predicted future prevalence of life-limiting conditions ranged from 67.0 (95%CI 67.7–66.3) to 84.22 (95%CI 78.66–90.17) per 10,000 by 2030. Conclusions: The prevalence of children with a life-limiting or life-threatening condition in England has risen over the last 17 years and is predicted to increase. Future data collections must include the data required to assess the complex health and social care needs of these children. [ABSTRACT FROM AUTHOR]

Objective: Recurrent acute otitis media is common in children. The preferred treatment measures for recurrent acute otitis media have a mixed evidence base. This study sought to assess baseline practice across ENT departments in England. Methods: A national telephone survey of healthcare staff was conducted. Every ENT centre in England was contacted. A telephone script was used to ask about antibiotic and grommet use and duration in recurrent acute otitis media cases. Results: Ninety-six centres (74 per cent) provided complete information. Recurrent acute otitis media treatment across England by ENT departments varied. The antibiotic first- and second-line prophylaxis offered varies, with trimethoprim used in 33 centres and 29 centres not offering any antibiotics. The timing or choice about when to use grommets also varies, but 87 centres (91 per cent) offer grommet surgery at one stage. Conclusion: The treatments received by children in England for recurrent acute otitis media vary by centre; collaborative research in this area is advised. [ABSTRACT FROM AUTHOR]

Background: Although child mortality is decreasing, more than half of all deaths in childhood occur in children with a life-limiting condition whose death may be expected. Aim: To assess trends in place of death and identify characteristics of children who died in the community after discharge from paediatric intensive care unit. Design: National data linkage study. Setting/participants: All children resident in England and Wales when admitted to a paediatric intensive care unit in the United Kingdom (1 January 2004 and 31 December 2014) were identified in the Paediatric Intensive Care Audit Network dataset. Linkage to death certificate data was available up to the end of 2014. Place of death was categorised as hospital (hospital or paediatric intensive care unit) or community (hospice, home or other) for multivariable logistic modelling. Results: The cohort consisted of 110,328 individuals. In all, 7709 deaths occurred after first discharge from paediatric intensive care unit. Among children dying, the percentage in-hospital at the time of death decreased from 83.8% in 2004 to 68.1% in 2014; 852 (0.8%) of children were discharged to palliative care. Children discharged to palliative care were eight times more likely to die in the community than children who died and had not been discharged to palliative care (odds ratio = 8.06 (95% confidence interval = 6.50-10.01)). Conclusions: The proportion of children dying in hospital is decreasing, but a large proportion of children dying after discharge from paediatric intensive care unit continue to die in hospital. The involvement of palliative care at the point of discharge has the potential to offer choice around place of care and death for these children and families. [ABSTRACT FROM AUTHOR]

Adolescent violence and abuse towards parents is under researched, especially in the UK where reports of the phenomenon are increasing with little clear guidance as to how practitioners might respond. In this qualitative study, 6 parents were recruited through youth offending teams and were interviewed about their lived experiences of violence and/or abuse from their adolescent child. Using interpretative phenomenological analysis, 3 superordinate themes emerged (a) the tensions and (b) the ambiguities produced by living with the violence and abuse and (c) the ways that parents manage the harms caused by these tensions and ambiguities. Theoretical and clinical implications are discussed, including consideration of how practitioners might support parents who are living with adolescent-to-parent violence and abuse to establish healthy and sustainable coping strategies while repairing family relationships. [ABSTRACT FROM AUTHOR]

Purpose Most studies of growing up with a long-term condition focus on older children and adolescents and are condition-specific. Relatively few studies address the experiences of children in middle childhood or consider their experience across a range of conditions, countries, and health settings. This study aimed to explore children's perceptions and understandings of how their lives are shaped (or not) by a long-term condition and its associated management. Design and methods A qualitative, participatory methodology using autodriven photoelicitation interviews (PEIs) with 45 purposively recruited children (6-12 years) with long-term conditions (e.g., hemophilia, arthritis, Crohn's disease), from England, New Zealand, and Australia was utilized. PEI facilitated the construction of inductively derived understandings of the children's experiences as the children had control over creating and then selecting which photographs to discuss with the researcher. Results Interpretive thematic analysis of the interviews and content analysis of the photographs resulted in an overarching theme, 'It's not who I am ...' but it is part of me, and three subthemes: getting on with my life; the special value of family, friendship, support, and comfort; and things that get in the way of getting on. Across all ages and the three countries, the children actively projected their self-concept as 'well' children and they strove, through their photographs and their accompanying explanations of their lives, to emphasize that they were 'normal' children. They were active social agents who demonstrated their capacity to shape parts of their lives interdependently with their parents and the requirements of their condition. Practice implications Pediatric nurses should be aware of the importance that children with long-term conditions place on projecting and protecting their sense of being normal and ensure that when they engage with children that they take account of the children's understandings and efforts to live a life constrained but not limited by the condition. [ABSTRACT FROM AUTHOR]

Holding practices are employed to help a child or young person stay still during the administration of treatments, prevent treatment interference or to undertake an examination, which can sometimes be invasive. The aim of this study was to explore assumptions and practices of holding to develop theories about teaching practices following Grounded Theory methodology for undergraduate nursing students, university lecturers and clinical mentors. The practice of therapeutic holding is often covert and not considered to be part of the treatment per se, which has led to concealment and a reticence to discuss practices openly. This study identified that there is variance in the experiences and practices. Prominent themes that emerged were a lack of clarity and lack of training. It appears that therapeutic holding practices have moved from being viewed as 'uncontested' (practice is not disputed) to 'indifferent' (where there is denial about this practice). These findings have serious implications for current practice and future training [ABSTRACT FROM AUTHOR]

In this article, we will argue for the moral legitimacy of support and its difference from intervention and the need to engage with and develop a family support project for the twenty-first century. We call for a debate on the current settlement between the state and family life and for a recognition that a perfect storm has ensued from the unholy alliance of early intervention and child protection. We will argue for a project that celebrates families' strengths as well as their vulnerabilities in the context of considerable adversities and (re) locates workers as agents of hope and support. We draw from a diverse set of literatures and disciplines to locate our arguments within a broader project occasioned by the economic crisis and questioning of the verities of neo-liberalism. [ABSTRACT FROM PUBLISHER]

Dynamic assessment has been shown to have considerable theoretical and clinical significance in the assessment of socially disadvantaged and culturally and linguistically diverse children. In this study it is used to enhance assessment of pre-school children with primary language impairment. The purpose of the study was to determine whether a dynamic assessment (DA) has the potential to enhance the predictive capacity of a static measure of receptive vocabulary in pre-school children. Forty pre-school children were assessed using the static British Picture Vocabulary Scale (BPVS), a DA of word learning potential and an assessment of non-verbal cognitive ability. Thirty-seven children were followed up 6 months later and re-assessed using the BPVS. Although the predictive capacity of the static measure was found to be substantial, the DA increased this significantly especially for children with static scores below the 25th centile. The DA of children' s word learning has the potential to add value to the static assessment of the child with low language skills, to predict subsequent receptive vocabulary skills and to increase the chance of correctly identifying children in need of ongoing support. [ABSTRACT FROM AUTHOR]

ObjectiveIncreasing parental awareness of childhood obesity is an important part of tackling the issue. However, parents’ negative reactions to being informed that their children are overweight or obese can hinder their engagement with relevant services. The present study aimed to develop a deeper understanding of why parents react negatively, to help commissioners and service providers design services that are more acceptable to them.DesignOpen, qualitative responses to a survey were collected using a postal questionnaire. Responses were analysed using content analysis.SettingOne local authority in south-west England.SubjectsThe sample frame included all parents receiving letters informing them that their child was overweight (91st–98th centile) or very overweight (98th–100th centile) through the UK National Child Measurement Programme in 2012.ResultsForty-five of 313 eligible parents (14 %) responded to the survey, of whom forty-three rejected either to the judgement that their child was overweight and/or being provided with this feedback. Primary reasons for objection included: lack of trust in the measures used, lack of belief that being overweight is important for children's health (relative to a healthy lifestyle), and fear that discussing weight with children will trigger eating disorders. In addition, parents’ responses suggested that they considered receiving this feedback to be a criticism of their parenting skills.ConclusionsOverall, three areas for improving communication with parents were suggested: tailoring letters; providing information about the importance of weight independently of lifestyle; and addressing parents’ concerns about the risks of talking to children about their weight. [ABSTRACT FROM PUBLISHER]

Background Children's emergency hospital use is of concern internationally, but there has been little examination of home care by nurses. Aims To examine the care provided by community children's nurses during acute illness. Design Triangulation of findings from case studies of three Community Children's Nursing Teams. Methods Parents or carers ( n = 763) completed questionnaires between 2008-2010 about their contacts with nurses and satisfaction with aspects and overall assessment of nursing care provided. Eighty-one individuals participated in semi-structured interviews: 29 parents/carers described their experiences and explained their questionnaire responses in more detail; 13 children talked about their care both in hospital and at home; and 39 nurses and other healthcare providers explained how nurses supported care of children at home. Questionnaire data were analysed descriptively and interview data qualitatively. The findings were integrated by triangulation of methods (questionnaires and interviews) and of data from different informants (children, parents, healthcare providers). Results Nursing care most frequently took the form of advice and education by either home visits or telephone contact. Parents and children were reassured by access to nurses and it gave them confidence to care at home. Most respondents thought that it reduced the time their children spent in hospital. Conclusions Nurses can make an important contribution to supporting parents to care confidently for their children at home to reduce or even to avoid hospitalization for acute conditions and give them confidence to manage future episodes of illness. [ABSTRACT FROM AUTHOR]

Objective:Treatment options for large subglottic haemangioma include steroids, laser ablation, open excision, tracheostomy and, more recently, propranolol. This article aims to present the Great Ormond Street Hospital guidelines for using propranolol to treat infantile isolated subglottic haemangioma by ENT surgeons.Methods:The vascular malformations multidisciplinary team at Great Ormond Street Hospital has developed guidelines for treating infantile haemangioma with propranolol.Results:The Great Ormond Street Hospital guidelines for propranolol treatment for infantile subglottic haemangioma include investigation, treatment and follow up. Propranolol is started at 1 mg/kg/day divided into three doses, increasing to 2 mg/kg/day one week later. On starting propranolol and when increasing the dose, the pulse rate and blood pressure must be checked every 30 minutes for the first 2 hours. Lesion response to treatment is assessed via serial endoscopy.Conclusion:Recent reports of dramatic responses to oral propranolol in children with haemangioma and acute airway obstruction have led to increased use. We advocate caution, and have developed guidelines (including pre-treatment investigation and monitoring) to improve treatment safety. Propranolol may in time prove to be the best medical treatment for subglottic haemangioma, but at present is considered to be still under evaluation. [ABSTRACT FROM AUTHOR]

Previous western studies have shown the division of domestic childcare work between fathers and mothers to be unequal but not always constructed as unfair. Following Dixon and Wetherell’s (2004) suggestion of applying a critical discursive psychology approach to the topic, I aimed to discover some of the discourses available to professional English women when constructing the contributions of the father at home. These included the ‘selfless mother’, the ‘shirking father’, ‘the father restores the “gender order”’ and the ‘high-status mother’. Findings suggest a possible application for discursive research, in raising women’s awareness of the potential for their discourses to perpetuate inequality. [ABSTRACT FROM PUBLISHER]

Children who use long-term ventilation at home and their parents find it difficult to access suitable respite services for short breaks. This article describes, through the use of a case study, a project to develop a respite service for such children at a children's hospice in England. The service development was a response to local need, which included a requirement to develop bespoke assessment documentation and processes as well as a comprehensive staff development package. The article follows the journey of one family through the development and use of the new service. [ABSTRACT FROM AUTHOR]

Aim and objective. To examine communication between nurses, children and parents in asthma review consultations. Background. Communication is an essential component of asthma care, but there has been little examination of nurses' consultations with children and parents. Design. Observation of communication in consultations examined in the context of the perspectives of parents and nurses. Method. Qualitative analysis of audio recordings of nine consultations with nurses by children aged 7-12 years and their parents; and interviews with 18 parents and six nurses. Results. The triadic relationship between child-nurse-parent was constructed from dyads of nurse-parent, nurse-child and parent-child. Both cooperation and conflict were identified in the analysis of interaction in dyads although direct confrontations were minimised or avoided. Conflicts arose from differing beliefs about asthma and its treatment and from different perspectives on the impact of asthma and the goals of treatments, and about the roles of children, parents and practitioners. There was uncertainty about the appropriate role of children in their asthma management. Conclusions. The dyads of nurse-parent, nurse-child and parent-child each make distinct and important contributions to triadic communication. Personal and task elements of therapeutic alliance are important elements in communication between nurses, children and their parents in asthma review consultations. Relevance to clinical practice. Communication is an essential component of children's asthma care. Guidance encourages practitioners to use review consultations to help children and parents to identify areas where they want treatment to have effect and to negotiate personalised action plans with practitioners. There is potential for conflict as well as cooperation. There is a need for more research into nurses' communication with children and parents to provide an evidence base for practice, education and training. [ABSTRACT FROM AUTHOR]

This study addresses the epidemiology of knee injuries in adolescent males. Data were collected prospectively from 41 Premiership soccer academies over a 5 year period from July 2000 to June 2005. A total of 12,306 player seasons were registered in the U9 to the U16 age categories with a total of 1750 recordable injuries specific to the knee joint. There was a mean incidence of 0.71 (95% confidence interval ± 0.05) knee injuries per player per year, and a median of 17 (inter-quartile range 9–38) training days and 2 (inter-quartile range 1–4) matches missed per knee injury. Knee injuries were found to be most common in the 14–16 year age group. Six hundred and nine (35% of total) injuries were classed as severe resulting in more than 28 days' absence. Injuries were more likely to be sustained in a competitive or match-play environment (862 or 52%) than in training (796 or 48%), and a non-contact mechanism was implicated in 823 (55%) of recorded cases. Peaks in injury numbers were seen in early season and subsequent to the winter break. Sprain was the most common diagnosis recorded, with the medial collateral ligament affected in 23% of all knee injuries. Knee injuries are common in elite youth footballers. In this uninsured age group, it could be argued that earlier medical intervention may reduce long-term damage tothe immature skeleton. [ABSTRACT FROM PUBLISHER]

This article challenges an increasing orthodoxy regarding the weight which courts might place upon the expressed views of children in a specific situation-high-conflict contact disputes. I am a child psychiatrist who acts as an expert witness within the family courts of England & Wales. I have conducted a statistical analysis of cases in which I have conducted assessments of children caught in such disputes between their separated parents. Fifty-eight children met the criteria for inclusion in the study-the child's consistent opposition to contact with the non resident parent (NRP), despite the court having determined that there was no good reason to constrain contact. My assessment routinely included attempted observation of the child at a visit with the NRP. Despite their stated views most children had a positive experience in those visits that took place, and despite the fact that most had not seen the NRP for a long time. Overall there was a statistical association between increased resistance to contact and the greater age of the child and the longer the time during which no contact had occurred. However, the responses of children and young people were unpredictable and it was impossible to conclude that apparent maturity or intelligence was a guide to the reliability of their expressed resistance. The possible reasons for this unreliability are discussed. I emphasize that my sample of children is unusual as many of the cases had involved serious, though unfounded, allegations of abuse. In addition most of the children showed indications of having become 'alienated' from the NRP. I conclude that courts might exercise caution when evaluating the views of children and young people in this situation, and emphasises that assessors should consider including at least one observation of the child at a prolonged visit to the NRP. Because of the new orthodoxy some parents may be tempted to misuse their child's right to a 'voice' in court in order to achieve their own ends. Practitioners who advise courts may need to be more aware of these difficulties. [ABSTRACT FROM AUTHOR]

Sick children were ubiquitous in early modern England, and yet they have received very little attention from historians. Taking the elusive perspective of the child, this article explores the physical, emotional, and spiritual experience of illness in England between approximately 1580 and 1720. What was it like being ill and suffering pain? How did the young respond emotionally to the anticipation of death? It is argued that children's experiences were characterised by profound ambivalence: illness could be terrifying and distressing, but also a source of emotional and spiritual fulfillment and joy. This interpretation challenges the common assumption amongst medical historians that the experiences of early modern patients were utterly miserable. It also sheds light on children's emotional feelings for their parents, a subject often overlooked in the historiography of childhood. The primary sources used in this article include diaries, autobiographies, letters, the biographies of pious children, printed possession cases, doctors' casebooks, and theological treatises concerning the afterlife. [ABSTRACT FROM AUTHOR]

Objective:To investigate whether exposure to high maternal concentrations of 25(OH)-vitamin D in pregnancy poses any risk to the child.Design:Prospective study.Setting:Princess Anne Maternity Hospital, Southampton, UK.Subjects:A group of 596 pregnant women were recruited. A total of 466 (78%) children were examined at birth, 440 (74%) at age 9 months and 178 (30%) at age 9 years.Methods:Maternal 25 (OH)-vitamin D concentrations were measured in late pregnancy. Anthropometry of the child was recorded at birth, 9 months and 9 years. At 9 months, atopic eczema was assessed. At 9 years, children had an echocardiogram and a dual energy x-ray absorptiometry scan, blood pressure, arterial compliance and carotid intima-media thickness were measured and intelligence and psychological function assessed.Results:There were no associations between maternal 25(OH)-vitamin D concentrations and the child's body size or measures of the child's intelligence, psychological health or cardiovascular system. Children whose mothers had a 25(OH)-vitamin D concentration in pregnancy >75 nmol/l had an increased risk of eczema on examination at 9 months (OR 3.26, 95% CI 1.15–9.29, P=0.025) and asthma at age 9 years (OR 5.40, 95% CI, 1.09–26.65, P=0.038) compared to children whose mothers had a concentration of <30 nmol/l.Conclusion:Exposure to maternal concentrations of 25(OH)-vitamin D in pregnancy in excess of 75 nmol/l does not appear to influence the child's intelligence, psychological health or cardiovascular system; there could be an increased risk of atopic disorders, but this needs confirmation in other studies.Sponsorship:The study was supported by the Medical Research Council and WellChild (previously known as Children Nationwide).European Journal of Clinical Nutrition (2008) 62, 68–77; doi:10.1038/sj.ejcn.1602680; published online 21 February 2007 [ABSTRACT FROM AUTHOR]

The mental health of child offenders who are detained in secure settings is a matter of great public and professional concern but there has been little systematic longitudinal research on the outcomes of these problems once the young person has returned to the community. The aims of the present study were to describe the psychosocial outcomes of boys in secure care and to establish if these outcomes were correlated with criminal outcomes. Prospective cohort study of 97 boys whose average age was 14 years when they were admitted to secure units in the North West of England. The boys were followed up on average 2 years later, when outcome data were obtained on 81/97 (83%) cases. The main outcome measure was a standardised assessment of mental health, social and educational needs obtained by interview with the young person and corroborated in most cases by information from informants. All data were then reviewed by experienced clinicians who made best-estimate ratings of need ‘blind’ to the findings from the first phase of the study. The average number of needs requiring an intervention at follow-up (mean = 3.4, sd = 3.0) was much lower than before admission to secure care (mean = 8.2, sd = 2.5) (mean difference 4.9 needs, 95% CI 4.0 to 5.7). Educational and occupational needs were particularly well dealt with. However, many mental health problems persisted or worsened. For example, 31% had a need for treatment of substance abuse, a significant increase compared with when they were in secure care (percentage difference 21%, 95% CL 9.0% to 32.7%). No mental disorder predicted subsequent offending. Boys who have been in secure care continue to have a high rate of mental health problems. The mental health needs of this group are not, however, static but change over time and with changing circumstances. Services need to be designed to meet these changing needs. [ABSTRACT FROM AUTHOR]

To illustrate the potential of injury surveillance data from an emergency department surveillance system. Bath clinical area. Data for children (0–4 years old) resident in Bath city in UK were recoded and analysed. There were a total of 3144 attendances and 2300 unintentional injuries – equivalent to an attendance rate of 131/1000. There were 91 thermal injuries and 162 poisoning/ingestions. Descriptive information is presented on the circumstances and consequences. The majority of unintentional injuries in 0–4 year olds occur in the home, which is a modifiable environment. Detailed information around the circumstances available from the Bath injury surveillance system allows better focus for prevention messages and priority setting. [ABSTRACT FROM AUTHOR]

OBJECTIVE:: To measure children's consumption of, and liking for, fruit and vegetables and how these are altered by a peer modelling and rewards-based intervention. DESIGN:: In this initial evaluation of the programme, children's consumption of fruit and vegetables were compared within and across baseline and intervention phases. SETTING:: Three primary schools in England and Wales. SUBJECTS:: In total, 402 children, aged from 4 to 11?y. INTERVENTION:: Over 16 days, children watched six video adventures featuring heroic peers (the Food Dudes) who enjoy eating fruit and vegetables, and received small rewards for eating these foods themselves. MAIN OUTCOME MEASURES:: Fruit and vegetable consumption was measured (i) in school at lunchtime and snacktime using a five-point observation scale, with inter-rated reliability and weighed validation tests; and (ii) at home using parental recall. A questionnaire measured children's liking for fruit and vegetables before and after the intervention. RESULTS:: Consumption during the intervention was significantly higher than during baseline at lunchtime and at snacktime (P<0.001 in all instances). Consumption outside school was significantly higher during the intervention on weekdays (P<0.05) but not weekend days. Following the intervention, children's liking for fruit and vegetables also showed a significant increase (P<0.001). CONCLUSIONS:: The peer modelling and rewards-based intervention was shown to be effective in bringing about substantial increases in children's consumption of, and expressed liking for, fruit and vegetables. SPONSORSHIP:: Horticultural Development Council, Fresh Produce Consortium, ASDA, Co-operative Group, Safeway, Sainsbury, Somerfield, Tesco and Birds Eye Wall's.European Journal of Clinical Nutrition (2004) 58, 510-522. doi:10.1038/sj.ejcn.1601838 [ABSTRACT FROM AUTHOR]

Repeated attempts to secure funding for a much-needed children's learning disability team in West Cheshire had proved unsuccessful. A review of these unsuccessful funding bids revealed a failure to gather adequate support from relevant secondary healthcare trusts and deficiencies in the proposed managerial structure and professional support for the learning disability team. A revised business plan offered an improved management structure for the proposed team. Support for this revised bid was gained from three interested secondary healthcare trusts, as well as from the local special needs social workers and the parents of children with learning disabilities. The improved business case, and the widespread support, resulted in funding being obtained to establish a children's learning disability team. [ABSTRACT FROM AUTHOR]