Search

Background COVID-19 caused widespread disruptions to health services worldwide, including reductions in elective surgery. Tooth extractions are among the most common reasons for elective surgery among children and young people (CYP). It is unclear how COVID-19 affected elective dental surgeries in hospitals over multiple pandemic waves at a national level. Methods Elective dental tooth extraction admissions were selected using Hospital Episode Statistics. Admission trends for the first 14 pandemic months were compared with the previous five years and results were stratified by age (under-11s, 11–16s, 17–24s). Results The most socioeconomically deprived CYP comprised the largest proportion of elective dental tooth extraction admissions. In April 2020, admissions dropped by >95%. In absolute terms, the biggest reduction was in April (11–16s: −1339 admissions, 95% CI −1411 to −1267; 17–24s: −1600, −1678 to −1521) and May 2020 (under-11s: −2857, −2962 to −2752). Admissions differed by socioeconomic deprivation for the under-11s (P  < 0.0001), driven by fewer admissions than expected by the most deprived and more by the most affluent during the pandemic. Conclusion Elective tooth extractions dropped most in April 2020, remaining below pre-pandemic levels throughout the study. Despite being the most likely to be admitted, the most deprived under-11s had the largest reductions in admissions relative to other groups. [ABSTRACT FROM AUTHOR]

Background: Integrated care has become a central feature of health system reform worldwide. In England, Integrated Care Systems (ICS) are intended to improve integration across public health, the National Health Service (NHS), education and social care. By April 2021, England had been divided into 42 geographical areas, each tasked with developing local ICS provision. However, it was not clear how ICSs would address the specific needs of children and young people (CYP). This study elicited the views of senior professional stakeholders in the first year of the ICS national roll out, to learn how integrated care for CYP was being implemented within the ICSs and future plans for service provision. Methods: A qualitative analysis of in-depth interviews with stakeholders, including healthcare professionals, NHS managers and local authority leaders (n = 25) selected from a diverse sample of ICSs (n = 7) across England, conducted during winter 2021/22. Reflexive thematic analysis involving a collaborative coding approach was used to analyse interview transcripts. Results: Four themes were identified, indicating challenges and opportunities for ICSs in relation to the health of CYP: 1) Best start in life (a more holistic approach to health afforded by integrated care); 2) Local and national contexts (tensions between local and national settings and priorities); 3) Funding and planning (instituting innovative, long-term plans using limited existing CYP funding streams); 4) Organisational complexities (integrating the work of diverse organisations). Conclusions: The views of stakeholders, provided at the beginning of the journey towards developing local ICS CYP provision, revealed a common aspiration to change focus from provision of acute, largely adult-orientated services towards one with a broader, population health remit, including prevention and early intervention. This would be delivered by integration of a range of local services, including health, education, housing and social care, to set CYP on a life-long path towards improved health and wellbeing. Yet there was an awareness that change would take place over time within existing national policy and funding frameworks, and would require overcoming organisational barriers through further developing local collaborations and partnerships. As ICSs mature, the experiences of stakeholders should continue to be canvassed to identify practical lessons for successful CYP integrated care. [ABSTRACT FROM AUTHOR]

Background: The NHS response to COVID-19 altered provision and access to primary care. Aim: To examine the impact of COVID-19 on GP contacts with children and young people (CYP) in England. Design and setting: A longitudinal trends analysis was undertaken using electronic health records from the Clinical Practice Research Datalink (CPRD) Aurum database. Method: All CYP aged <25 years registered with a GP in the CPRD Aurum database were included. The number of total, remote, and face-to-face contacts during the first UK lockdown (March to June 2020) were compared with the mean contacts for comparable weeks from 2015 to 2019. Results: In total, 47 607 765 GP contacts with 4 307 120 CYP were included. GP contacts fell 41% during the first lockdown compared with previous years. Children aged 1–14 years had greater falls in total contacts (≥50%) compared with infants and those aged 15–24 years. Face-to-face contacts fell by 88%, with the greatest falls occurring among children aged 1–14 years (>90%). Remote contacts more than doubled, increasing most in infants (over 2.5-fold). Total contacts for respiratory illnesses fell by 74% whereas contacts for common non-transmissible conditions shifted largely to remote contacts, mitigating the total fall (31%). Conclusion: During the COVID-19 pandemic, CYP's contact with GPs fell, particularly for face-to-face assessments. This may be explained by a lower incidence of respiratory illnesses because of fewer social contacts and changing health-seeking behaviour. The large shift to remote contacts mitigated total falls in contacts for some age groups and for common non-transmissible conditions. [ABSTRACT FROM AUTHOR]

Background: Evidence indicates that early life is critical for determining future obesity risk. A sharper policy focus on pregnancy and early childhood could help improve obesity prevention efforts. This study aimed to systematically identify and categorise policy levers used in England with potential to influence early life course (pregnancy, 0–5 years) and identify how these interface with energy balance behaviours. The objective is to identify gaps and where further policy actions could most effectively focus. Methods: A behavioural science approach was taken using the Capability-Opportunity-Motivation-Behaviour (COM-B) model and Behaviour Change Wheel (BCW) framework. The key determinants of energy balance in the early years were identified from the Foresight Systems Map. Policy actions were scoped systematically from available literature, including any health or non-health policies which could impact on energy balance behaviours. Foresight variables and policy actions were considered in terms of COM-B and the BCW to determine approaches likely to be effective for obesity prevention and treatment. Existing policies were overlaid across the map of key risk factors to identify gaps in obesity prevention and treatment provision. Results: A wide range of policy actions were identified (n = 115) to address obesity-relevant risk factors. These were most commonly educational or guidelines relating to environmental restructuring (i.e. changing the physical or social context). Scope for strengthening policies relating to the food system (e.g. the market price of food) and psychological factors contributing to obesity were identified. Policies acted via all aspects of the COM-B model, but there was scope for improving policies to increase capability through skills acquisition and both reflective and automatic motivation. Conclusions: There is substantial policy activity to address early years obesity but much is focused on education. Scope exists to strengthen actions relating to upstream policies which act on food systems and those targeting psychological factors contributing to obesity risk. [ABSTRACT FROM AUTHOR]

Background We investigated differing trajectories of childhood obesity prevalence amongst English local authorities (LAs). Methods Data on prevalence of childhood obesity (BMI ≥ 95th centile) for Reception year and Year 6 for 150 LAs in England from 2006/07 to 2015/16 were obtained from the National Child Measurement Programme (NCMP). Latent class mixture modelling (LCCM) was used to identify classes of change in obesity prevalence. Results In Reception, most LAs showed little change across the period (Class 1; stable, moderate obesity prevalence;84%), with a smaller group with a high prevalence that fell thereafter (Class 2; high but falling obesity prevalence; 16%). In Year 6 we identified three classes: moderate obesity prevalence (Class 3; 43%); high and rising obesity prevalence (Class 2; 36%); and stable low obesity prevalence (Class 1; 21%). Greater LA deprivation and higher LA proportion of non-white ethnicity increased risk of being in Class 2 (Reception) or Class 2 or 3 (Year 6) compared with Class 1. Conclusions The prevalence of childhood obesity in LAs in England follow a small number of differing trajectories that are influenced by LA deprivation and ethnic composition. LAs following a stable low obesity trajectory for Year 6 are targets for further investigation. [ABSTRACT FROM AUTHOR]

Background: Not much is known about glycaemic‐control trajectories in childhood‐onset type 2 diabetes (T2D). We investigated characteristics of children and young people (CYP) with T2D and inequalities in glycemic control. Methods: We studied 747 CYP with T2D, <19 years of age in 2009‐2016 (from the total population‐based National Pediatric Diabetes Audit [>95% diabetes cases in England/Wales]). Linear mixed‐effects modeling was used to assess socioeconomic and ethnic differences in longitudinal glycated hemoglobin (HbA1c) trajectories during 4 years post‐diagnosis (3326 HbA1c data points, mean 4.5 data points/subject). Self‐identified ethnicity was grouped into six categories. Index of Multiple Deprivation (a small geographical area‐level deprivation measure) was grouped into SES quintiles for analysis. Results: Fifty‐eight percent were non‐White, 66% were female, and 41% were in the most disadvantaged SES quintile. Mean age and HbA1c at diagnosis were 13.4 years and 68 mmol/mol, respectively. Following an initial decrease between diagnosis and end of year 1 (−15.2 mmol/mol 95%CI, −19.2, −11.2), HbA1c trajectories increased between years 1 and 3 (10 mmol/mol, 7.6, 12.4), followed by slight gradual decrease subsequently (−1.6 mmol/mol, −2, −1.1). Compared to White CYP, Pakistani children had higher HbA1c at diagnosis (13.2 mmol/mol, 5.6‐20.9). During follow‐up, mixed‐ethnicity and Pakistani CYP had poorer glycemic control. Compared to children in the most disadvantaged quintile, those in the most advantaged had lower HbA1c at diagnosis (−6.3 mmol, −12.6, −0.1). Differences by SES remained during follow‐up. Mutual adjustment for SES and ethnicity did not substantially alter the above estimates. Conclusions: About two‐thirds of children with childhood‐onset T2D were non‐White, female adolescents, just under half of whom live in the most disadvantaged areas of England and Wales. Additionally, there are substantial socioeconomic and ethnic inequalities in diabetes control. [ABSTRACT FROM AUTHOR]

Background: There is a growing concern about the mental health of children and young people (CYP) in the UK, with increasing demand for counselling services, admissions for self-harm and referrals to mental health services. We investigated whether there have been similar recent trends in selected mental health outcomes among CYP in national health surveys from England, Scotland and Wales. Methods: Data were analysed from 140 830 participants (4–24 years, stratified into 4–12, 13–15, 16–24 years) in 36 national surveys in England, Scotland and Wales, 1995–2014. Regression models were used to examine time trends in seven parent/self-reported variables: general health, any long-standing health condition, long-standing mental health condition; Warwick–Edinburgh Mental Wellbeing Score (WEMWBS), above-threshold Strengths and Difficulties Questionnaire Total (SDQT) score, SDQ Emotion (SDQE) score, General Health Questionnaire (GHQ) score. Results: Across all participants aged 4–24, long-standing mental health conditions increased in England (0.8–4.8% over 19 years), Scotland (2.3–6.0%, 11 years) and Wales (2.6–4.1%, 7 years) (all p < 0.001). Among young children (4–12 years), the proportion reporting high SDQT and SDQE scores decreased significantly among both boys and girls in England [SDQE: odds ratio (OR) 0.97 (0.96–0.98), p < 0.001] and girls in Scotland [SDQE: OR 0.96 (0.93–0.99), p = 0.005]. The proportion with high SDQE scores (13–15 years) decreased in England [OR 0.98 (0.96–0.99), p = 0.006] but increased in Wales [OR 1.07 (1.03–1.10), p < 0.001]. The proportion with high GHQ scores decreased among English women (16–24 years) [OR 0.98 (0.98–0.99), p = 0.002]. Conclusions: Despite a striking increase in the reported prevalence of long-standing mental health conditions among UK CYP, there was relatively little change in questionnaire scores reflecting psychological distress and emotional well-being. [ABSTRACT FROM AUTHOR]

Background: Associations between adolescent health-related quality of life (HRQoL), bullying, and aggression are not well understood. We used baseline data from a large-cluster randomized school trial to study the relationship between HRQoL, bullying experience, and other demographic factors.Methods: Cross-sectional self-reported questionnaires collected pre-randomization from the on-going INCLUSIVE trial. The questionnaires were completed in the classroom. The Gatehouse Bullying Scale measured bullying victimization and the Edinburgh Study of Youth Transitions and Crime school misbehavior subscale (ESYTC) measured aggressive behaviors. HRQoL was assessed using the Child Health Utility 9 Dimensions (CHU-9D) and general quality of life using the Pediatric Quality of Life Inventory (PedsQL). Participants were a cohort of year 7 students (age 11-12 years) from 40 state secondary schools in England. Descriptive statistics for the CHU-9D and PedsQL were calculated using standard methods with tests for differences in median scores by sex assessed using quantile regression. Correlation between HRQoL measures was conducted using Spearman's rank correlation coefficients. Predictors of HRQoL were identified using univariate and multiple regressions.Results: A total of 6667 students filled out the questionnaire. The CHU-9D was correlated with the PedsQL (0.63, p < 0.001). The multivariable regression results suggest that if students were bullied frequently and upset it resulted in a decrement in CHU-9D scores of (-0.108) and fall in PedsQL score of (-16.2). The impact of the antisocial/aggressive behavior on the ESYTC scale resulted in a utility decrement of -0.004 and fall of -.5 on the PedsQL.Conclusions: Adolescents' involvement in bullying and aggression is a strong correlate of HRQoL. These data have important implications for the potential cost-effectiveness of reducing bullying and aggression in schools. [ABSTRACT FROM AUTHOR]

Objective: Despite growing interest in children and young people's (CYP) perspectives on healthcare, they continue to be excluded from many patient experience surveys. This study investigated the feasibility of, and additional information gained by, measuring CYP experiences of a recent hospital admission.Design: Cross-sectional analysis of national survey data.Setting: Inpatients aged 8-15 years in eligible National Health Service hospitals, July-September 2014.Participants: 6204 parents/carers completed the parent section of the survey. The CYP section of the survey was completed by CYP themselves (n=3592), parents (n=849) or jointly (n=1763).Main Outcome Measures: Pain relief, involvement, quality of staff communication, perceived safety, ward environment, overall experience.Analyses: Single-measures intraclass correlations (ICCs) were used to assess the concordance between CYP and parent responses about the same inpatient episode. Multilevel logistic regression models, adjusted for individual characteristics, were used to compare the odds of positive responses when the CYP section of the survey was completed by parents, by CYP themselves or jointly.Results: The CYP section of the survey was completed independently by 57.8% of CYP. Agreement between CYP and parent responses was reasonably good for pain relief (ICC=0.61 (95% CI 0.58 to 0.63)) and overall experience (ICC=0.70 (95% CI 0.68 to 0.72)), but much lower for questions comparing professionals' communication with CYP and with their parents (ICC range=0.28 (95% CI 0.24 to 0.32) to 0.51 (95% CI 0.47 to 0.54)). In the regression models, CYP were significantly less likely than parents to report feeling safe (adjusted OR (AOR)=0.54 (95% CI 0.38 to 0.76)), involvement in decisions (AOR=0.66 (95% CI 0.46 to 0.94)) or adequate privacy (AOR=0.68 (95% CI 0.52 to 0.89)).Conclusions: Including CYP (8-15 years) in patient experience surveys is feasible and enhances what is known from parents' responses. [ABSTRACT FROM AUTHOR]

The theory of human functioning and school organisation informed by Basil Bernstein’s sociology of education suggests that to gain the commitment and promote the health of students, particularly those from disadvantaged backgrounds, schools require radical transformations eroding various ‘boundaries’: between and among staff and students; between students’ academic learning and broader social development and welfare; and between schools and their local communities. Existing research examining this theory has reported associations between school-level proxy measures of student commitment and lower rates of student smoking, drinking alcohol, use of drugs and violence. But this research has not directly assessed whether reduced school boundaries explain this. We piloted a new scale derived from teacher reports to measure unhealthy school boundaries and examined its inter-item reliability and its criterion validity in terms of associations with various measures of school commitment and smoking. Data on boundaries came from 101 teachers across 40 schools. Data on student commitment and smoking came from 6667 students. We assessed reliability by examining correlations between scale-items and criterion validity in terms of associations with student-reported commitment and smoking. Inter-item reliability was sub-optimal but better within the subscales about boundaries between academic/broader learning and schools/local communities. The scale had good criterion validity, strongly associated with reduced student-reported school commitment and increased student-reported smoking. We reflect on the implications of these findings in terms of critical perspectives on health promotion in schools and the strengths and limitations of quantitative research in examining health behaviours as opposed to practices. [ABSTRACT FROM PUBLISHER]

Background With evidence of rising need around mental health in young people, cuts in specialist health provision and increasing recognition of the central role of schools in supporting young people with mental health problems, it is important to understand the provision of mental health support currently available in schools, the nature of the relationship with health and other providers of child and adolescent mental health ( CAMH) services, and what are the key barriers to accessing support. Method The study was a convenience sample survey of 577 school staff from 341 schools in England. Participants completed an online survey about the provision of specialist mental health support in their school, including what support is available, who provides it, and perceived barriers to supporting the mental health of young people. Data were linked to publicly available data on school characteristics. Results Over two thirds of schools reported having some specialist support available, with specialist provision more common in secondary schools. Staff training and whole-school approaches were the most frequently employed specific approaches. Support was most often provided by educational psychologists, followed by counsellors. School staff particularly valued support and feedback within the schools context. The most frequently cited barrier to mental health support was the limited capacity of specialist CAMH services. Conclusions The results suggest a need to enhance the availability of specialist support for mental health both within schools and in CAMH services. [ABSTRACT FROM AUTHOR]

Background: Randomised controlled trials (RCTs) of social interventions are often criticised as failing to open the 'black box' whereby they only address questions about 'what works' without explaining the underlying processes of implementation and mechanisms of action, and how these vary by contextual characteristics of person and place. Realist RCTs are proposed as an approach to evaluation science that addresses these gaps while preserving the strengths of RCTs in providing evidence with strong internal validity in estimating effects.Methods: In the context of growing interest in designing and conducting realist trials, there is an urgent need to offer a worked example to provide guidance on how such an approach might be practically taken forward. The aim of this paper is to outline a three-staged theoretical and methodological process of undertaking a realist RCT using the example of the evaluation of a whole-school restorative intervention aiming to reduce aggression and bullying in English secondary schools.Discussion: First, informed by the findings of our initial pilot trial and sociological theory, we elaborate our theory of change and specific a priori hypotheses about how intervention mechanisms interact with context to produce outcomes. Second, we describe how we will use emerging findings from the integral process evaluation within the RCT to refine, and add to, these a priori hypotheses before the collection of quantitative, follow-up data. Third, we will test our hypotheses using a combination of process and outcome data via quantitative analyses of effect mediation (examining mechanisms) and moderation (examining contextual contingencies). The results are then used to refine and further develop the theory of change.Conclusion: The aim of the realist RCT approach is thus not merely to assess whether the intervention is effective or not, but to develop empirically informed mid-range theory through a three-stage process. There are important implications for those involved with reporting and reviewing RCTs, including the use of new, iterative protocols.Trial Registration: Current Controlled Trials ISRCTN10751359 (Registered 11 March 2014). [ABSTRACT FROM AUTHOR]

Background: Systematic reviews suggest that multi-component interventions are effective in reducing bullying victimisation and perpetration. We are undertaking a phase III randomised trial of the INCLUSIVE multi-component intervention. This trial aims to assess the effectiveness and cost-effectiveness of the INCLUSIVE intervention in reducing aggression and bullying victimisation in English secondary schools. This paper updates the original trial protocol published in 2014 (Trials 15:381, 2014) and presents the changes in the process evaluation protocol and the secondary outcome data collection.Methods: The methods are summarised as follows.Design: cluster randomised trial.Participants: 40 state secondary schools. Outcomes assessed among the cohort of students at the end of year 7 (n = 6667) at baseline.Intervention: INCLUSIVE is a multi-component school intervention including a social and emotional learning curriculum, changes to school environment (an action group comprising staff and students reviews local data on needs to review rules and policies and determine other local actions) and staff training in restorative practice. The intervention will be delivered by schools supported in the first two years by educational facilitators independent of the research team, with a third intervention year involving no external facilitation but all other elements. Comparator: normal practice.Outcomes: Primary: Two primary outcomes at student level assessed at baseline and at 36 months: 1. Aggressive behaviours in school: Edinburgh Study of Youth Transitions and Crime school misbehaviour subscale (ESYTC) 2. Bullying and victimisation: Gatehouse Bullying Scale (GBS) Secondary outcomes assessed at baseline, 24 and 36 months will include measures relating to the economic evaluation, psychosocial outcomes in students and staff and school-level truancy and exclusion rates.Sample Size: 20 schools per arm will provide 90% power to identify an effect size of 0.25 SD with a 5% significance level. Randomisation: eligible consenting schools were randomised stratified for single-sex versus mixed-sex schools, school-level deprivation and measures of school attainment.Discussion: The trial involves independent research and intervention teams and is supervised by a Trial Steering Committee and a Data Monitoring Committee.Trial Registration: Current Controlled Trials, ISRCTN10751359 . Registered on 11 March 2014. [ABSTRACT FROM AUTHOR]

Objective: To investigate patterns and trends of adolescent (10-19 years) inpatient activity in England by sex, disease category, and admitting speciality. Data 9 632 844 Finished Consultant Episodes (FCEs) from English patients aged 1-19 between 1999/2000 and 2010/201 1 (Hospital Episode Statistics data). Analyses: Age trends by sex and major International Classification of Disease 10 (ICD10) chapter; differences in activity rates by age and sex; inpatient activity trends over the past decade, disaggregated by sex, admitting speciality and ICD10 chapter. Results: Adolescent female patients account for more activity than girls aged 1 - 9 (139.4 vs 107.2 FCEs/ 1000). Female inpatient activity increases significantly between age 10 (70.9 FCEs/1000) and 19 (281.7 FCES/ 1000, of which non-obstetric care accounts for 155.9 FCEs/1000). Male activity increases much less during adolescence, with lower overall rates among adolescents than younger children (93.7 vs 142.9 FCEs/1000). Between 1999 and 2010, total adolescent inpatient activity increased faster among adolescents (10-19 years) (+14.2%) than younger children (1-9 years) (+11.0%). Adolescent FCEs/1000 increased by 12.8%, including higher rates admitted under Paediatrics (+47.5%) and Paediatric Surgery (+23.2%). Adolescents were admitted across a range of specialities. Conclusions: These data challenge the belief that adolescents are a healthy group who rarely use inpatient services. In England, use of inpatient services is higher among female patients aged 10-19 years than those aged 1 - 9 years, while adolescent activity has increased faster than for younger children over the past 11 years. Improving service quality for adolescents will require engagement of the many different teams that care for them. [ABSTRACT FROM AUTHOR]

School factors are associated with many health outcomes in adolescence. However, previous studies report inconsistent findings regarding the degree of school-level variation for health outcomes, particularly for risk behaviours. This study uses data from three large longitudinal studies in England to investigate school-level variation in a range of health indicators. Participants were drawn from the Longitudinal Study of Young People in England, the Me and My School Study and the Research with East London Adolescent Community Health Survey. Outcome variables included risk behaviours (smoking, alcohol/cannabis use, sexual behaviour), behavioural difficulties and victimisation, obesity and physical activity, mental and emotional health, and educational attainment. Multi-level models were used to calculate the proportion of variance in outcomes explained at school level, expressed as intraclass correlations (ICCs) adjusted for gender, ethnicity and socio-economic status of the participants. ICCs for health outcomes ranged from nearly nil to .28 and were almost uniformly lower than for attainment (.17-.23). Most adjusted ICCs were smaller than unadjusted values, suggesting that school-level variation partly reflects differences in pupil demographics. School-level variation was highest for risk behaviours. ICCs were largely comparable across datasets, as well as across years within datasets, suggesting that school-level variation in health remains fairly constant across adolescence. School-level variation in health outcomes remains significant after adjustment for individual demographic differences between schools, confirming likely effects for school environment. Variance is highest for risk behaviours, supporting the utility of school environment interventions for these outcomes. [ABSTRACT FROM AUTHOR]

Background Previous studies have found the socioeconomic gradient in health among adolescents to be lower than that observed during childhood and adulthood. The aim of this study was to examine income-related inequalities in health and health-related behaviour across the lifespan in England to explore ‘equalisation’ in adolescence. Methods We used five years of data (2006–2010) from the Health Survey for England to explore inequalities in six indicators: self-assessed general health, longstanding illness, limiting longstanding illness, psychosocial wellbeing, obesity and smoking status. We ran separate analyses by age/gender groups. Inequality was measured using concentration indices. Results Our findings for longstanding illnesses, psychosocial wellbeing and obesity were consistent with the equalisation hypothesis. For these indicators, the extent of income-related inequality was lower among late adolescents (16–19 years) and young adults (20–24 years) compared to children and young adolescents (under 15 years), mid- and late-adults (25–44 and 45–64 years) and the elderly (65+ years). The remaining indicators showed lower inequality among adolescents compared to adults, but higher inequality when compared with children. Conclusions Our work shows that inequalities occur across the life-course but that for some health issues there may be a period of equalisation in late adolescence and early adulthood. [ABSTRACT FROM AUTHOR]

Objective: To investigate trends in health inequality among children and young people between 1999 and 2009, using outcomes consistent with the current NHS reforms. Design/data: Secondary analysis of participants aged 0-24 in the Health Surveys for England (HSE) undertaken in 1999, 2004, 2006 and 2009. Main outcome measures: Changes in the absolute and relative risks of four health outcomes by deprivation tertiles, based on occupation of the head of household ‣ self/parent-reported general health, ‣ presence of a long-standing illness (LSI), ‣ obesity ‣ smoking. Results: No indicator showed a reduction in relative or absolute inequality between 1999 and 2009. For children (0-12 years), the relative risk comparing the most and least deprived tertiles increased significantly for poor general health (1999:1.6 (95% CI 1.2 to 2.2); 2009:3.9 (2.4 to 6.2), while the absolute difference in LSI prevalence(%) increased from 1.3 (-2.9 to 5.5) to 7.4 (3.6 to 11.4). Among young people (13-24 years), the absolute difference in LSI prevalence increased from -5.9 (-10.9 to -1.1) to 3.1 (-4.1 to 10.7). Absolute inequality in having tried smoking among children aged 8-15(%) increased significantly in the first half of the decade before decreasing in the second half (1999:3.3 (-1.1 to 7.7); 2004:14.1 (9.6 to 18.8); 2009:4.1 (0.1 to 8.8)). However, the increase in absolute inequality for smoking prevalence among young adults (16-24 years) was maintained throughout the decade (1999:-7.0 (-15.6 to 1.3); 2004:11.6 (3.7 to 20.0); 2009:8.2 (-0.3 to 16.9)). Conclusions: The national programme between 1999 and 2009 was not successful in reducing inequality in four key indicators of health status and future health risk among children and young people. Some inequality measures for general health, LSI prevalence and smoking increased over this time. [ABSTRACT FROM AUTHOR]

Background This study examines demographic risk factors and trends from 1998 to 2009 for concurrent multiple substance use in adolescence in England. Methods We used data from the ‘Smoking, Drinking and Drug Use among Young People in England’ survey, a nationally representative annual survey of 11–15 year olds. Measures of smoking, drinking and illicit drug use frequency and weekly alcohol consumption were combined to create variables representing concurrent substance use. Results All forms of substance use were strongly related. The prevalence of multiple substance use decreased significantly across time in line with decreases in individual substance use. The prevalence of individual and multiple substance use across years is higher amongst white young people. Males are more likely to engage in risky drinking behaviour with females more likely to smoke regularly but females were at increased risk for multiple substance use. Deprivation was unrelated to drinking behaviour but was associated with increases in smoking and illicit drug use and all forms of multiple substance use. Conclusions These findings affirm the importance of continued prevention efforts targeting individual substance uses while highlighting the policy relevance of multiple substance use and interventions which target it. These interventions should be tailored for at-risk groups including deprived adolescents and young women. [ABSTRACT FROM AUTHOR]

Objectives. (1) To explore sexual behaviour and relationships amongst Black and minority ethnic (BME) teenagers in East London. (2) To examine how these relationships are shaped by culture, gender, peer norms and religion. (3) To describe the implications for sexual health policy and practice in urban, multicultural areas. Design. This report draws primarily on the qualitative arm of a mixed methods study which collected data from 126 young people, aged 15-18, largely through focus groups in the London boroughs of Hackney, Newham and Tower Hamlets. Results. Previous research has reported culture influencing the patterning of risk/protection amongst BME groups. Our data suggest that this is mediated by gender, religion and youth. Religion reportedly influenced young women's sexual behaviour in multiple ways. Young people described gendered norms in meeting and flirting with partners, and the role of mobile phones and peer pressure. Conclusion. Our paper suggests culture, gender, religion and youth influence BME teenagers in aspects of sexual relationships, and that these social markers may have different contextual meanings for individuals. The multiplicity of factors affecting attitudes/behaviour requires a range of contraceptive, counselling, screening and sex education services available for all teenagers, although delivery patterns may differ in response to differing needs. [ABSTRACT FROM AUTHOR]

Background The developed world is experiencing an ‘epidemic’ of childhood obesity but little is known about the prevalence of obesity, or underweight, amongst adolescents from minority ethnic groups in the UK. An understanding of the prevalence of obesity and overweight in these populations is important since some ethnic groups may be particularly vulnerable to the adverse health effects associated with obesity.Study Objectives To examine levels of extreme obesity, obesity, overweight and underweight amongst a representative sample of adolescents from different ethnic groups in East London and to explore the association between socio-economic status and body mass index (BMI).Design A school-based survey of adolescents aged 11–14. Obesity and overweight were estimated using the 1990 UK growth reference (UK 90) and the International Obesity Task Force (IOTF) cut-off points. Extreme obesity was defined as a BMI more than three SD above the UK 90 mean. Underweight was examined by looking at those with a BMI below the 15th or the 5th UK 90 percentiles.Main Results A total of 2,482 adolescents were surveyed (response rate 84%), 73% from non-white ethnic groups. Although there were significant differences in BMI between ethnic groups, high levels of overweight were seen in all ethnic groups. More than one-third were overweight and one-fifth were obese using the UK 90; and over a quarter were overweight and almost one-tenth were obese using the IOTF cut-offs. Two per cent were extremely obese. Indian males were at higher risk of being overweight than white British males. The prevalence of obesity and overweight was similar in white British and Bangladeshi males. Overall the prevalence of underweight was slightly lower than that predicted by the UK 90, but South Asian ethnic groups, especially males, had a higher prevalence of underweight than other groups. No associations between BMI and measures of socio-economic status were found in this relatively deprived population.Conclusions The ‘epidemic’ of childhood obesity observed in the UK involves adolescents from all ethnic groups, although there are some differences between ethnic groups in the prevalence of overweight. Indian males appear to be at increased risk of being overweight. There is no evidence of a simultaneous increase in underweight amongst this population overall, but Bangladeshi, Indian and Pakistani boys appear to be at increased risk of being underweight. [ABSTRACT FROM AUTHOR]

Presents the results of a study on suicide and self-harm committed by youth. Incidence of suicide by youth in England and Wales; Claim that many deaths officially listed as having an "undetermined cause" are due to suicide; Impact of gender on suicide risk; Discussion of deliberate self-harm, committed with suicidal or non-suicidal intent; Motivations associated with deliberate self-harm; Risk factors for deliberate self-harm, including experience of abuse, substance misuse, and family dysfunction; Influence of deliberate self-harm on a youth's suicide risk; Methods of prevention; Recommendations for treatment of youth who practice self-harm; Resources available for research on deliberate self-harm.

Study objective: To investigate cultural identity as a risk factor far mental health problems among adolescents. Design: A cross sectional school based population survey. Mental health problems were measured using the strengths and difficulties questionnaire. Pupils were classified into one of four cultural identity types on the basis of friendship and clothing chokes. Setting: East London. Participants: 2623 adolescents (aged 11-14) from a representative sample of 28 schools in east London. Results: In comparison with marginalised adolescents who chose friends from neither their own or other cultures, fewer mental health problems were found among adolescents making culturally integrated friendship choices (friends from own and other cultures: OR = 0.6, 0.4 to 0.9), boys making integrated friendship choices (OR =0.45, 0.22 to 0.91), and specifically among Bangladeshi pupils with integrated friendship choices (OR =0.15, 0.04 to 0.55). Conclusion: As measures of cultural identity, integrated friendship choices overall, and specifically for boys and Bangladeshi pupils, are associated with lower levels of adolescent mental health problems. [ABSTRACT FROM AUTHOR]

Background Safe assessment of severe underweight in children is important but experience suggests a frequent lack of understanding. Here we sought evidence from a wide spectrum of trainees. Methods Cross-sectional telephone survey of an on-call middle-grade paediatric doctor in hospitals providing acute inpatient general paediatric care in England and Wales. Results Response rate was 100%. Only 50% identified BMI as the appropriate measure for underweight in children. Most did not identify any clinical cardiovascular complications of severe underweight. Only 13% identified corrected QT time (QTc) as an important ECG finding. Knowledge of the refeeding syndrome was poor with 20% unable to define it at all, 21% able to identify some clinical features and 57% aware of potential phosphate abnormalities. Conclusions Knowledge base among middle-grades doctors in England and Wales on this topic is worryingly poor, particularly in relation to several life-threatening features. Existing and new training approaches should recognise this. [ABSTRACT FROM AUTHOR]

The article focuses on the child protection actions related to childhood obesity in Great Britain. It informs about a survey according to which obesity was found in approximately 20 child protection cases in the country in 2009. The Local Government Association, a voluntary lobbying organization in Great Britain, has warned that child protection concerns associated with obesity in children may impose future cost pressure on local councils of the country. As stated, child protection issues usually take place if a child or adolescent is severely obese and has no contact with health and social services since long time. It further suggests a framework for understanding the practice of child protection actions in relation with childhood obesity.

Background: This study reports on qualitative research conducted within a randomised controlled trial to explore possible intervention mechanisms. It focuses on the 'Learning Together' whole-school intervention delivered in secondary schools in England from 2014 to 2017 aiming to prevent bullying and aggression and improve student health. Intervention schools received staff training in restorative practice, a social and emotional learning curriculum, and an external facilitator and manual to convene and run a student/staff action group tasked with coordinating the intervention, focusing this on local needs.Methods: Informed by realist approaches to evaluation, we analysed qualitative data to explore intervention mechanisms and how these might interact with school contexts to generate outcomes. Qualitative analysis drew on 45 interviews and 21 focus groups across three case-study schools and employed thematic content analysis to explore how intervention resources were taken up and used by local actors, how participants described the intervention mechanisms that then ensued, and how these might have generated beneficial outcomes.Results: The thematic content analysis identified three social mechanisms that recurred in participant accounts: (1) building student commitment to the school community, (2) building healthy relationships by modelling and teaching pro-social skills, and (3) de-escalating bullying and aggression and enabling re-integration within the school community.Conclusions: Our analysis provides in-depth exploration of possible mechanisms and the contextual contingencies associated with these, allowing refinement of the initial intervention theory of change.Trial Registration: ISRCTN registry 10751359 . Registered on 11 March 2014. [ABSTRACT FROM AUTHOR]

Background: Bullying, aggression, and violence among children and young people are some of the most consequential public mental health problems. We tested the Learning Together intervention, which involved students in efforts to modify their school environment using restorative practice and by developing social and emotional skills.Methods: We did a cluster randomised trial, with economic and process evaluations, of the Learning Together intervention compared with standard practice (controls) over 3 years in secondary schools in south-east England. Learning Together consisted of staff training in restorative practice; convening and facilitating a school action group; and a student social and emotional skills curriculum. Primary outcomes were self-reported experience of bullying victimisation (Gatehouse Bullying Scale; GBS) and perpetration of aggression (Edinburgh Study of Youth Transitions and Crime (ESYTC) school misbehaviour subscale) measured at 36 months. We analysed data using intention-to-treat longitudinal mixed-effects models. This trial was registered with the ISRCTN registry (10751359).Findings: We included 40 schools (20 in each group); no schools withdrew. 6667 (93·6%) of 7121 students participated at baseline and 5960 (83·3%) of 7154 at 36 months. Mean GBS bullying score at 36 months was 0·34 (SE 0·02) in the control group versus 0·29 (SE 0·02) in the intervention group, with a significant adjusted mean difference (-0·03, 95% CI -0·06 to -0·001; adjusted effect size -0·08). Mean ESYTC score at 36 months was 4·33 (SE 0·20) in the control group versus 4·04 (0·21) in the intervention group, with no evidence of a difference between groups (adjusted difference -0·13, 95% CI -0·43 to 0·18; adjusted effect size -0·03). Costs were an additional £58 per pupil in intervention schools than in control schools.Interpretation: Learning Together had small but significant effects on bullying, which could be important for public health, but no effect on aggression. Interventions to promote student health by modifying the whole-school environment are likely to be one of the most feasible and efficient ways of addressing closely related risk and health outcomes in children and young people.Funding: National Institute for Health Research, Educational Endowment Foundation. [ABSTRACT FROM AUTHOR]

Background: A third of children born in England have at least one parent born outside the United Kingdom (UK), yet family migration history is infrequently studied as a social determinant of child health. We describe rates of hospital admissions in children aged up to 5 years by parental migration and socioeconomic group., Methods: Birth registrations linked to Hospital Episode Statistics were used to derive a cohort of 4,174,596 children born in state-funded hospitals in England between 2008 and 2014, with follow-up until age 5 years. We looked at eight maternal regions of birth, maternal country of birth for the 6 most populous groups and parental migration status for the mother and second parent (UK-born/non-UK-born). We used Index of Multiple Deprivation (IMD) quintiles to indicate socioeconomic deprivation. We fitted negative binomial/Poisson regression models to model associations between parental migration groups and the risk of hospital admissions, including interactions with IMD group., Results: Overall, children whose parents were both born abroad had lower emergency admission rates than children with parents both born in the UK. Children of UK-born (73.6% of the cohort) mothers had the highest rates of emergency admissions (171.6 per 1000 child-years, 95% confidence interval (CI) 171.4-171.9), followed by South Asia-born mothers (155.9 per 1000, 95% CI 155.1-156.7). The high rates estimated in the South Asia group were driven by children of women born in Pakistan (186.8 per 1000, 95% CI 185.4-188.2). A socioeconomic gradient in emergency admissions was present across all maternal regions of birth groups, but most pronounced among children of UK-born mothers (incidence rate ratio 1.43, 95% CI 1.42-1.44, high vs. low IMD group). Patterns of planned admissions followed a similar socioeconomic gradient and were highest among children with mothers born in Middle East and North Africa, and South Asia., Conclusions: Overall, we found the highest emergency admission rates among children of UK-born parents from the most deprived backgrounds. However, patterns differed when decomposing maternal place of birth and admission reason, highlighting the importance of a nuanced approach to research on migration and health., (© 2024. The Author(s).)

Adolescence is a time of physical, cognitive, social, and emotional development. This period is a very sensitive developmental window; environmental exposures, the development of health behaviours (eg, smoking and physical activity), and illness during adolescence can have implications for lifelong health. In the UK and other high-income countries, the experience of adolescence has changed profoundly over the past 20 years. Smoking, drug use, and alcohol consumption have all been in long-term decline. At the same time, obesity and mental ill health have increased and are now common among adolescents, with new risks (ie, vaping, psychoactive substances, and online harms) emerging. In this Viewpoint, we describe these and related trends in England and the UK. Although previous work has explored these changes in isolation, in this Viewpoint we consider them collectively. We explore what might be driving the changes and consider the implications for practice, policy, and research., Competing Interests: Declaration of interests FG was employed by the Department of Health and Social Care and was employed by the National Institute for Health and Care Excellence; the views expressed here do not represent organisational policy. All other authors declare no competing interests., (Copyright © 2024 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Introduction: Children and young people (CYP) presenting with a mental health (MH) crisis are frequently admitted to general acute paediatric wards as a place of safety. Prior to the pandemic, a survey in England showed that CYP occupied 6% of general paediatric inpatient beds due to an MH crisis, and there have been longstanding concerns about the quality of care to support these patients in this setting. Mental Health Admissions to Paediatric Wards Study aims to generate a theory of change (ToC) model to improve the quality of care for CYP admitted to acute paediatric services after presenting in a MH crisis., Methods and Analysis: We will undertake a national (England), sequential, mixed methods study to inform a ToC framework alongside a stakeholder group consisting of patients, families/carers and healthcare professionals (HCPs). Our study consists of four work packages (WP) undertaken over 30 months. WP1 is limited to using national routine administrative data to identify and characterise trends in MH admissions in acute paediatric wards in England between 2015- 2022., Ethics and Dissemination: WP1 received ethical approval (Ref 23/NW/0192). We will publish the overall synthesis of data and the final ToC to improve care of CYP with MH crisis admitted to general acute paediatric settings. As coproducers of the ToC, we will work with our stakeholder group to ensure wide dissemination of findings. Potential impacts will be on service development, new models of care, training and workforce planning., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Introduction: Children and young people (CYP) presenting with a mental health (MH) crisis are frequently admitted to general acute paediatric wards as a place of safety. Prior to the pandemic, a survey in England showed that CYP occupied 6% of general paediatric inpatient beds due to an MH crisis, and there have been longstanding concerns about the quality of care to support these patients in this setting. MAPS aims to generate a Theory of Change (ToC) model to improve the quality of care for CYP admitted to acute paediatric services after presenting with an MH crisis. Here, we describe work packages (WPs) 2 and 3 of the study, which have been granted ethics approval., Methods and Analysis: We will undertake a national (England), sequential, mixed-methods study to inform a ToC framework alongside a stakeholder group consisting of patients, families/carers and healthcare professionals (HCPs). Our study consists of four WPs undertaken over 30 months. WP2 is limited to working with stakeholders to develop a data collection instrument and then use this in a prospective study of MH admissions over 6 months in 15 purposively recruited acute paediatric wards across England. WP3 consists of gathering the views of CYP, their families/carers and HCPs during admissions using semistructured interviews., Ethics and Dissemination: WP2 and WP3 received ethical approval (ref: 23/LO/0349). We will publish the overall synthesis of data and the final ToC to improve care of CYP with MH crisis admitted to general acute paediatric settings. As co-producers of the ToC, we will work with our stakeholder group to ensure wide dissemination of findings. Potential impacts will be upon service development, new models of care, training and workforce planning., Prospero Registration Number: CRD42022350655., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2024. Re-use permitted under CC BY. Published by BMJ.)

Background: The effects of the systematic delivery of treatments for obesity are unknown. We aimed to estimate the potential effects on the prevalence of childhood obesity of systematically offering preventive and treatment interventions to eligible children in England, based on weight or health status., Methods: For this modelling study, we developed a cross-sectional simulation model of the child and young adult population in England using data from multiple years of the Health Survey of England conducted between Jan 1, 2010, and Dec 31, 2019. Individuals were assessed for eligibility via age, BMI, and medical complications. Weight status was defined based on clinical criteria used by the UK National Institute of Health and Care Excellence. Published systematic reviews were used to estimate effect sizes for treatments, uptake, and completion for each weight-management tier. We used all available evidence, including evidence from studies that showed an unfavourable effect. We estimated the effects of two systematic approaches: a staged approach, in which children and young people were simultaneously given the most intensive treatment for which they were eligible, and a stepped approach, in which each management tier was applied sequentially, with additive effects. The primary outcomes were estimated prevalence of clinical obesity, defined as a BMI ≥98th centile on the UK90 growth chart, and difference in comparison with the estimated baseline prevalence., Findings: 18 080 children and young people were included in the analytical sample. Baseline prevalence of clinical obesity was estimated to be 11·2% (95% CI 10·5 to 11·8) for children and young people aged 2-18 years. In modelling, we estimated absolute decreases in the prevalence of obesity of 0·9% (95% CI 0·1 to 1·8) for universal, preventive interventions; 0·2% (0·1 to 0·4) for interventions within a primary-care setting; 1·0% (0·1 to 2·1) for community and lifestyle interventions; 0·2% (0·0 to 0·4) for pharmaceutical interventions; and 0·4% (0·1 to 0·7) for surgical interventions. Staged care was estimated to result in an absolute decrease in the prevalence of obesity of 1·3% (-0·3 to 2·4) and stepped care was estimated to lead to an absolute decrease of 2·4% (0·1 to 4·8)., Interpretation: Although individual effect sizes for prevention and treatment interventions were small, when delivered at scale across England, these interventions have the potential to meaningfully contribute to reducing the prevalence of childhood obesity., Funding: UK National Institute for Health and Care Research., Competing Interests: Declaration of interests We declare no competing interests., (Copyright © 2023 The Author(s). Published by Elsevier Ltd. This is an Open Access article under the CC BY 4.0 license. Published by Elsevier Ltd.. All rights reserved.)

Objectives: To describe the impact of the COVID-19 pandemic on outpatient appointments for children and young people., Setting: All National Health Service (public) hospitals in England., Participants: All people in England aged <25 years., Outcome Measures: Outpatient department attendance numbers, rates and modes (face to face vs telephone) by age group, sex and socioeconomic deprivation., Results: Compared with the average for January 2017 to December 2019, there was a 3.8 million appointment shortfall (23.5%) for the under-25 population in England between March 2020 and February 2021, despite a total rise in phone appointments of 2.6 million during that time. This was true for each age group, sex and deprivation fifth, but there were smaller decreases in face to face and total appointments for babies under 1 year. For all ages combined, around one in six first and one in four follow-up appointments were by phone in the most recent period. The proportion of appointments attended was high, at over 95% for telephone and over 90% for face-to-face appointments for all ages., Conclusions: COVID-19 led to a dramatic fall in total outpatient appointments and a large rise in the proportion of those appointments conducted by telephone. The impact that this has had on patient outcomes is still unknown. The differential impact of COVID-19 on outpatient activity in different sociodemographic groups may also inform design of paediatric outpatient services in the post-COVID period., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2022. Re-use permitted under CC BY. Published by BMJ.)

Competing Interests: We declare no competing interests.

Competing Interests: Competing interests: JH and CB are investigators on the Schools Infection Survey funded by the Department of Health and Social Care. CB and RV have attended meetings of SAGE and the Scientific Pandemic Influenza Group on Behaviours Subcommittee. SJB is a member of The Times Education Commission, Rethinking Assessment. JPG regularly undertakes modelling to support the work of the UK Health Security Agency and the Scientific Pandemic Influenza Group on Modelling (SPI-M).

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection is rarely fatal in children and young people (CYP, <18 years old), but quantifying the risk of death is challenging because CYP are often infected with SARS-CoV-2 exhibiting no or minimal symptoms. To distinguish between CYP who died as a result of SARS-CoV-2 infection and those who died of another cause but were coincidentally infected with the virus, we undertook a clinical review of all CYP deaths with a positive SARS-CoV-2 test from March 2020 to February 2021. The predominant SARS-CoV-2 variants were wild-type and Alpha. Here we show that, of 12,023,568 CYP living in England, 3,105 died, including 61 who were positive for SARS-CoV-2. Of these deaths, 25 were due to SARS-CoV-2 infection (mortality rate, two per million), including 22 due to coronavirus disease 2019-the clinical disease associated with SARS-CoV-2 infection-and 3 were due to pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2. In total, 99.995% of CYP with a positive SARS-CoV-2 test survived. CYP older than 10 years, Asian and Black ethnic backgrounds and comorbidities were over-represented in SARS-CoV-2-related deaths compared with other CYP deaths. These results are important for guiding decisions on shielding and vaccinating children. New variants might have different mortality risks and should be evaluated in a similar way., (© 2021. The Author(s), under exclusive licence to Springer Nature America, Inc.)

Identifying which children and young people (CYP) are most vulnerable to serious infection due to severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is important to guide protective interventions. To address this question, we used data for all hospitalizations in England among 0-17 year olds from 1 February 2019 to 31 January 2021. We examined how sociodemographic factors and comorbidities might be risk factors for pediatric intensive care unit (PICU) admission among hospitalizations due to the following causes: Coronavirus Disease 2019 (COVID-19) and pediatric inflammatory multi-system syndrome temporally associated with SARS-CoV-2 (PIMS-TS) in the first pandemic year (2020-2021); hospitalizations due to all other non-traumatic causes in 2020-2021; hospitalizations due to all non-traumatic causes in 2019-2020; and hospitalizations due to influenza in 2019-2020. Risk of PICU admission and death from COVID-19 or PIMS-TS in CYP was very low. We identified 6,338 hospitalizations with COVID-19, of which 259 were admitted to a PICU and eight CYP died. We identified 712 hospitalizations with PIMS-TS, of which 312 were admitted to a PICU and fewer than five CYP died. Hospitalizations with COVID-19 and PIMS-TS were more common among males, older CYP, those from socioeconomically deprived neighborhoods and those who were of non-White ethnicity (Black, Asian, Mixed or Other). The odds of PICU admission were increased in CYP younger than 1 month old and decreased among 15-17 year olds compared to 1-4 year olds with COVID-19; increased in older CYP and females with PIMS-TS; and increased for Black compared to White ethnicity in patients with COVID-19 and PIMS-TS. Odds of PICU admission in COVID-19 were increased for CYP with comorbidities and highest for CYP with multiple medical problems. Increases in odds of PICU admission associated with different comorbidities in COVID-19 showed a similar pattern to other causes of hospitalization examined and, thus, likely reflect background vulnerabilities. These findings identify distinct risk factors associated with PICU admission among CYP with COVID-19 or PIMS-TS that might aid treatment and prevention strategies., (© 2021. The Author(s), under exclusive licence to Springer Nature America, Inc.)

[Figure: see text].

Objective: Intergenerational data on mother-offspring pairs were utilized in an instrumental variable analysis to examine the longitudinal association between BMI and sedentary behavior., Methods: The sample included 3,864 mother-offspring pairs from the 1970 British Cohort Study. Height and weight were recorded in mothers (age 31 [5.4] years) and offspring (age 10 years) and repeated in offspring during adulthood. Offspring provided objective data on sedentary behavior (7-day thigh-worn activPAL) in adulthood at age 46 to 47 years., Results: Maternal BMI, the instrumental variable, was associated with offspring BMI at age 10 (change per kg/m 2 , β = 0.11; 95% CI: 0.09 to 0.12), satisfying a key assumption of instrumental variable analyses. Offspring (change per kg/m 2 , β = 0.010; 95% CI: -0.02 to 0.03 h/d) and maternal BMI (β = 0.017; 95% CI: 0.001 to 0.03 h/d) was related to offspring sedentary time, suggestive of a causal impact of BMI on sedentary behavior (two-stage least squares analysis, β = 0.18 [SE 0.08], P = 0.015). For moderate-vigorous physical activity, there were associations with offspring BMI (β = -0.010; 95% CI: -0.017 to -0.004) and maternal BMI (β = -0.007; 95% CI: -0.010 to -0.003), with evidence for causality (two-stage least squares analysis, β = -0.060 [SE 0.02], P = 0.001)., Conclusions: There is strong evidence for a causal pathway linking childhood obesity to greater sedentary behavior., (© 2020 The Authors. Obesity published by Wiley Periodicals LLC on behalf of The Obesity Society (TOS).)

Introduction: The theory of human functioning and school organization proposes that schools promote health by strengthening students' educational engagement. Previous studies have relied on proxy measures of engagement and not examined sexual health. This paper addresses these gaps., Methods: Longitudinal data came from the control arm of a randomized trial involving female and male students ages 12-14 in English secondary-schools (n = 3337 students). Exposures measured at baseline included a proxy measure of school-level engagement (value-added education, VAE: the difference between observed absence and attainment rates and those predicted based on student characteristics) and direct measures of school- and student-level engagement (commitment, belonging, relationships and participation). Sexual behavior was measured at 24- and 36-months, including sexual debut and contraception use at first sex., Results: Higher school-level VAE was associated with an increased risk of early sexual debut at 24-months. Students attending schools with higher overall levels of commitment and belonging were less likely to report sexual debut at 36 months. Students reporting stronger personal commitment to learning and teacher relationships at baseline were less likely to report sexual debut at both follow-up points. Associations involving participation and contraception use were largely nonsignificant., Conclusions: Direct measures of the school environment are more strongly associated with reduced sexual risk behavior in early adolescence than the proxy measure, VAE. Results provide some support for the theory and suggest that personal disposition towards school as well as attending a school with high levels of student commitment and belonging are important for subsequent sexual decision making., (Copyright © 2020 The Foundation for Professionals in Services for Adolescents. Published by Elsevier Ltd. All rights reserved.)

Background: We have previously reported benefits for reduced bullying, smoking, alcohol and other drug use and mental health from a trial of 'Learning Together', an intervention that aimed to modify school environments and implement restorative practice and a social and emotional skill curriculum., Objectives: To conduct post hoc theory-driven analyses of broader impacts., Design: Cluster randomised trial., Settings: 40 state secondary schools in southern England., Participants: Students aged 11/12 years at baseline., Outcomes: Student self-reported measures at 24 and 36 months of: cyberbullying victimisation and perpetration; observations of other students perpetrating aggressive behaviours at school; own perpetration of aggressive behaviours in and outside school; perceived lack of safety at school; participation in school disciplinary procedures; truancy and e-cigarette use., Results: We found evidence of multiple impacts on other health (reduced e-cigarette use, cyberbullying perpetration, perpetration of aggressive behaviours) and educational (reduced participation in school disciplinary procedures and truancy) outcomes., Conclusion: These analyses suggested that the intervention was effective in bringing about a broader range of beneficial outcomes, adding to the evidence that the intervention is a promising approach to promote adolescent health via an intervention that is attractive to schools., Trial Registration Number: ISRCTN10751359., Competing Interests: Competing interests: None declared., (© Author(s) (or their employer(s)) 2020. Re-use permitted under CC BY. Published by BMJ.)

Background: There is growing concern about the potential associations between social media use and mental health and wellbeing in young people. We explored associations between the frequency of social media use and later mental health and wellbeing in adolescents, and how these effects might be mediated., Methods: We did secondary analyses of publicly available data from the Our Futures study, a nationally representative, longitudinal study of 12 866 young people from age 13 years to 16 years in England. The exposure considered was the frequency of social media use (from weekly or less to very frequent [multiple times daily]) at wave 1 (participants aged 13-14 years) through wave 3 of the study (participants aged 15-16 years). Outcomes were mental health at wave 2 (with high 12-item General Health Questionnaire [GHQ12] scores [≥3] indicating psychological distress), and wellbeing at wave 3 (life satisfaction, feeling life is worthwhile, happiness, and anxiety, rated from 1 to 10 by participants). Analyses were adjusted for a minimal sufficient confounding structure, and were done separately for boys and girls. Cyberbullying, sleep adequacy, and physical activity were assessed as potential mediators of the effects., Findings: Very frequent use of social media increased from wave 1 to wave 3: from 34·4% (95% CI 32·4-36·4) to 61·9% (60·3-63·6) in boys, and 51·4% (49·5-53·3) to 75·4% (73·8-76·9) in girls. Very frequent social media use in wave 1 predicted a high GHQ12 score at wave 2 among girls (adjusted odds ratio [OR] 1·31 [95% CI 1·06-1·63], p=0·014; N=4429) and boys (1·67 [1·24-2·26], p=0·0009; N=4379). Persistent very frequent social media use across waves 1 and 2 predicted lower wellbeing among girls only (adjusted ORs 0·86 [0·74-0·99], N=3753, p=0·039 for life satisfaction; 0·80 [0·70-0·92], N=3831, p=0·0013 for happiness; 1·28 [1·11-1·48], N=3745, p=0·0007 for anxiety). Adjustment for cyberbullying, sleep, and physical activity attenuated the associations of social media use with GHQ12 high score (proportion mediated 58·2%), life satisfaction (80·1%), happiness (47·7%), and anxiety (32·4%) in girls, such that these associations (except for anxiety) were no longer significant; however, the association with GHQ12 high score among boys remained significant, being mediated only 12·1% by these factors., Interpretation: Mental health harms related to very frequent social media use in girls might be due to a combination of exposure to cyberbullying or displacement of sleep or physical activity, whereas other mechanisms appear to be operative in boys. Interventions to promote mental health should include efforts to prevent or increase resilience to cyberbullying and ensure adequate sleep and physical activity in young people., Funding: None., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Concerns have been raised about variation in care quality and outcomes among children and young people with epilepsies in England. We aimed to investigate the association between quality of paediatric care, hospital admissions, and all-cause deaths among epilepsy patients., Methods: In this longitudinal data linkage study of paediatric epilepsy services in England, we linked unit-level data from round 1 (2009-11) and round 2 (2013-14) of the Epilepsy12 national clinical audit, with death registrations from the UK Office for National Statistics and data for unplanned hospital admissions from Hospital Episode Statistics. We investigated the association between unit-level performance in involving a paediatrician with epilepsy expertise, an epilepsy specialist nurse, and a paediatric neurologist (where appropriate) in round 1 and the proportion of adolescents (aged 10-18 years) with epilepsy admitted to each unit who subsequently died during the study period (April 1, 2009, to March 31, 2015). We also investigated whether change in Epilepsy12 performance between the two audit rounds was associated with changes in the standardised ratio of observed-to-expected unplanned epilepsy admissions over the same period., Findings: In 99 units with data for the analyses relating to paediatricians with epilepsy expertise and epilepsy specialist nurses, 134 (7%) of 1795 patients died during the study period, 88 (5%) of whom died after the transition to adult service. In 55 units with data for the analyses relating to paediatric neurologists, 79 (7%) of 1164 patients died, 54 (5%) of whom did so after the transition. In regression models adjusting for population, unit, and hospital activity characteristics, absolute reductions in total mortality risk (6·4 percentage points, 95% CI 0·1-12·7) and mortality risk after transition (5·7 percentage points, 0·6-10·8) were found when comparing units where all versus no eligible patients were seen by a paediatric neurologist. Units where all eligible patients were seen by a paediatric neurologist were estimated to have absolute reductions of 4·6 percentage points (0·3-8·9) in total mortality and of 4·6 percentage points (1·2-8·0) in post-transition mortality, compared with units where no or some eligible patients were seen by a paediatric neurologist. There was no significant association between performance on being seen by an epilepsy specialist nurse or by a paediatrician with epilepsy expertise and mortality. In units where access to an epilepsy specialist nurse decreased, the standardised ratio of epilepsy admissions increased by a mean of 0·21 (0·01-0·42)., Interpretation: Among adolescents with epilepsy, greater involvement of tertiary specialists in paediatric care is associated with decreased all-cause mortality in the period after transition to adult services. Reduced access to an epilepsy specialist nurse was associated with an increase in paediatric epilepsy admissions., Funding: The Health Foundation., (Copyright © 2019 Elsevier Ltd. All rights reserved.)

Background: Interventions to modify school environments are effective in promoting young people's health across outcomes, but mechanisms are poorly understood. We assessed mediation in a trial of the Learning Together intervention, building on the recent publication of results of effectiveness for reducing bullying and benefits across secondary outcomes and generally good implementation fidelity., Methods: Within a cluster-randomised trial involving 40 English schools, we examined student-reported and staff-reported school climate and student-reported involvement with delinquent peers at 24-month and 36-month follow-up, assessing the reliability of measures and whether these mediated health outcomes at a final follow-up., Results: Response rates and reliability were good for student-reported but not staff-reported measures. The intervention increased student-reported but not staff-reported-positive school climate but, like effects on student health outcomes, these manifested only at a final follow-up. The intervention reduced student-reported contact with delinquent peers at an interim follow-up. Student-reported potential mediators measured at the interim follow-up were associated with most health outcomes at the final follow-up. Adjustment for student-reported school climate and contact with delinquent peers at the interim follow-up did not reduce the associations between trial arm and our health outcomes., Conclusion: Despite being constrained by imperfect measures and by the late manifestation of impacts on student-reported school climate undermining ability to assess mediation, our study for the first time provides tentative evidence that mediation of intervention effects via improved climate and disengagement from delinquent peers is plausible. Our study provides the first evidence from a trial that whole-school interventions may work by modifying school environments and student relationships., Trial Registration Number: ISRCTN10751359., Competing Interests: Competing interests: RV is President of the Royal College of Paediatrics & Child Health., (© Author(s) (or their employer(s)) 2019. Re-use permitted under CC BY. Published by BMJ.)

Objective: To assess the numbers of obese children and young people (CYP) eligible for assessment and management at each stage of the childhood obesity pathway in England., Design: Pathway modelling study, operationalising the UK National Institute for Health and Care Excellence guidance on childhood obesity management against national survey data., Setting: Data on CYP aged 2-18 years from the Health Survey for England 2006 to 2013., Main Outcome Measures: Clinical obesity (body mass index (BMI) >98th centile), extreme obesity (BMI ≥99.86th centile); family history of cardiovascular disease or type 2 diabetes; obesity comorbidities defined as primary care detectable (hypertension, orthopaedic or mobility problems, bullying or psychological distress) or secondary care detectable (dyslipidaemia, hyperinsulinaemia, high glycated haemoglobin, abnormal liver function)., Results: 11.2% (1.22 million) of CYP in England were eligible for primary care assessment and for community lifestyle modification. 2.6% (n=283 500) CYP were estimated to be likely to attend primary care. 5.1% (n=556 000) were eligible for secondary care referral. Among those aged 13-18 years, 8.2% (n=309 000) were eligible for antiobesity drug therapy and 2.4% (90 500) of English CYP were eligible for bariatric surgery. CYP from the most deprived quintile were 1.5-fold to 3-fold more likely to be eligible for obesity management., Conclusions: There is a mismatch between population burden and available data on service use for obesity in CYP in England, particularly among deprived young people. There is a need for consistent evidence-based commissioning of services across the childhood obesity pathway based on population burden., Competing Interests: Competing interests: None declared., (© Article author(s) (or their employer(s) unless otherwise stated in the text of the article) 2018. All rights reserved. No commercial use is permitted unless otherwise expressly granted.)