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In this multi-center longitudinal cohort study conducted in Australia and New Zealand, we assessed the trajectories of health-related quality of life (HRQoL) in children with chronic kidney disease (CKD) over time. A total of 377 children (aged 6-18 years) with CKD stages 1-5 (pre-dialysis), dialysis, or transplant, were followed biennially for four years. Multi Attribute Utility (MAU) scores of HRQoL were measured at baseline and at two and four years using the McMaster Health Utilities Index Mark 3 tool, a generic multi-attribute, preference-based system. A multivariable linear mixed model was used to assess the trajectories of HRQoL over time in 199 children with CKD stage 1-5, 43 children receiving dialysis and 135 kidney transplant recipients. An interaction between CKD stage at baseline and follow-up time indicated that the slopes of the HRQoL scores differed between children by CKD stage at inception. Over half of the cohort on dialysis at baseline had received a kidney transplant by the end of year four and the MAU scores of these children increased by a meaningful amount averaging 0.05 (95% confidence interval 0.01 to 0.09) per year in comparison to those who were transplant recipients at baseline. The mean difference between baseline and year two MAU scores was 0.09 (95% confidence interval -0.05, 0.23), (Cohen's d effect size 0.31). Thus, improvement in HRQoL over time of children on dialysis at baseline was likely to have been driven by their transition from dialysis to transplantation. Additionally, children with CKD stage 1-5 and transplant recipients at baseline had no changes in their disease stage or treatment modality and experienced stable HRQoL over time.

People who live in rural areas have reduced access to appropriate and timely healthcare, leading to poorer health outcomes than their metropolitan-based counterparts. The aims of the workshops were to ascertain participants' perspectives on barriers to access to dialysis and transplantation, to identify and prioritize the roles of a rural patient navigator, to discuss the acceptability and feasibility of implementing this role and identify possible outcomes that could be used to measure the success of the programme in a clinical trial.Rural patients (n = 19), their caregivers (n = 5) and health professionals (n = 18) from Australia participated in three workshops. We analysed the data using thematic analysis.We identified four themes related to access to dialysis and transplantation: overwhelmed by separate and disconnected health systems, unprepared for emotional toll and isolation, lack of practical support and inability to develop trust and rapport. Four themes related to the role of the patient navigator programme: valuing lived experience, offering cultural expertise, requiring a conduit, and flexibility of the job description. The key roles prioritized by participants were psychological support and networking, provision/consolidation of education, and provision of practical support.Rural patients, caregivers and health professionals believed that programmes that include navigators with lived experience of dialysis and kidney transplantation and cultural expertise, especially for Aboriginal Australians, may have the potential to improve patient experiences in accessing healthcare.

Aboriginal and Torres Strait Islander peoples (hereafter respectfully termed Indigenous Australians) experience a 3-fold increased risk of acute rejection after transplantation compared to non-Indigenous Australians. We investigated whether acute rejection explains the association between Indigenous status, infection-related deaths, and all-cause deaths after kidney transplantation, and whether acute rejection mediates the relationship between Indigenous status and overall graft loss.This cohort study included all recipients who received their first kidney transplant between 2005 and 2018 in Australia, using data from the Australia and New Zealand Dialysis and Transplant registry. Multivariable Cox regression models determined the associations between Indigenous status, graft loss, infection-related deaths, and all-cause deaths. Mediation analyses examined if acute rejection mediated these relationships. Primary outcome was infection-related death. Secondary outcomes included all-cause death and overall graft loss.There were 9993 patients (Indigenous Australians experienced a higher risk of graft loss, a relationship mediated partially through acute rejection. The higher risk of infection-related death was independent of acute rejection.

Obtaining accurate estimates of the causal effects of socioeconomic position (SEP) on health is important for public health interventions. To do this, researchers must identify and adjust for all potential confounding variables, while avoiding inappropriate adjustment for mediator variables on a causal pathway between the exposure and outcome. Unfortunately, 'overadjustment bias' remains a common and under-recognized problem in social epidemiology. This paper offers an introduction on selecting appropriate variables for adjustment when examining effects of SEP on health, with a focus on overadjustment bias. We discuss the challenges of estimating different causal effects including overadjustment bias, provide guidance on overcoming them, and consider specific issues including the timing of variables across the life-course, mutual adjustment for socioeconomic indicators, and conducting systematic reviews. We recommend three key steps to select the most appropriate variables for adjustment. First, researchers should be clear about their research question and causal effect of interest. Second, using expert knowledge and theory, researchers should draw causal diagrams representing their assumptions about the interrelationships between their variables of interest. Third, based on their causal diagram(s) and causal effect(s) of interest, researchers should select the most appropriate set of variables, which maximizes adjustment for confounding while minimizing adjustment for mediators.

Background Fatigue is one of the most important symptoms among patients receiving dialysis and is nominated as a core outcome to be reported in all clinical trials in this setting. However, few trials of interventions targeting fatigue have been conducted. Patients historically have rarely been involved in the design of interventions, which can limit acceptability and uptake. When asked, they have indicated a preference for lifestyle interventions, such as exercise, to improve fatigue. While some research has focussed on intradialytic exercise for patients receiving haemodialysis, patients have also indicated a preference for a convenient method of exercising with guidance, but on their own time outside of dialysis hours. In response to this, a mobile phone application was proposed as the method of delivery for a home-based exercise intervention targeting fatigue. Methods We convened a workshop with five breakout group sessions in Australia, with 24 patients on dialysis (16 haemodialysis and 8 peritoneal dialysis) and 8 caregivers to identify, prioritize and discuss exercise interventions for fatigue in patients receiving dialysis and the delivery of this through a mobile application. Results Of the 21 types of exercise identified, the top-ranked were walking outdoors, walking on a treadmill and cardio and resistance training. Six themes were identified: (i) ‘an expectation of tangible gains from exercise’, including strengthening and protecting against bodily deterioration related to dialysis; (ii) ‘overcoming physical limitations’, meaning that comorbidities, baseline fatigue and fluctuating health needed to be addressed to engage in exercise; (iii) ‘fear of risks’, which reinforced the importance of safety and compatibility of exercise with dialysis; (iv) ‘realistic and achievable’ exercise, which would ensure initial readiness for uptake; (v) ‘enhancing motivation and interest’ , which expected to support sustained use of the exercise intervention and (vi) ‘ensuring usability of the mobile application’ , which would require simplicity, convenience and comprehensibility. Conclusion Exercise interventions that are expected by patients to improve health outcomes and that are safe, realistic and easy to adopt may be more acceptable to patients on dialysis.

Background & aims: Dietary and supplemental long chain omega-3 polyunsaturated fatty acids (n-3 PUFA) have shown vascular benefits for the general population, but effects among people with chronic kidney disease (CKD) are largely uncertain. We aimed to evaluate the effects of n-3 PUFA intake among patients with CKD. Methods: We searched MEDLINE, Embase, and CENTRAL through January 12, 2018. Eligible studies were randomized controlled trials evaluating n-3 PUFA intake (supplementation or dietary) compared with placebo, standard care, or other treatment, on cardiovascular and all-cause mortality, end stage kidney disease (ESKD), acute transplant rejection, and allograft loss. Risks of bias and evidence certainty were assessed using Cochrane and Grading of Recommendations Assessment, Development and Evaluation processes. Results: Sixty trials (4129 participants) were eligible, all of supplementation, with a median follow-up of 6 months. Low to very low certainty evidence suggested that n-3 PUFA supplementation reduced cardiovascular death for participants on hemodialysis (39 events; relative risk (RR) 0.45, 95% confidence interval (CI) 0.23–0.89), prevented ESKD (29 events; RR 0.30, CI 0.09–0.98) in participants with CKD not receiving renal replacement therapy, and made little or no difference in all-cause mortality (215 events; RR 1.05, CI 0.84–1.33), acute transplant rejection (188 events; RR 0.98, CI 0.80–1.21) or allograft loss (39 events; RR 0.98, CI 0.54–1.81]). Risk of bleeding (44 events; RR 1.40, CI 0.78–2.49) and gastrointestinal side-effects (103 events; RR 1.14, CI 0.79–1.67) were uncertain. Conclusions: n-3 PUFA supplementation may reduce cardiovascular mortality in patients on hemodialysis but it is uncertain whether supplementation prevents mortality or ESKD in patients with CKD.

Background Few data exist on the cognitive and academic functioning of children with chronic kidney disease (CKD) over the trajectory of their illness. We aimed to determine the association between CKD stages and cognitive and academic performance in children over time. Methods We included 53 participants (aged 6–18 years) with CKD stages 1–5 (n = 37), on dialysis (n = 3), or with functioning kidney transplant (n = 22) from three units in Australia from 2015 to 2019. Participants undertook a series of psychometric tests and were invited for repeated assessments annually. We used linear regression and linear mixed models to investigate the effect of CKD stage, adjusted for socioeconomic status. Results At baseline, full-scale intelligence quotient (FSIQ) (95%CI) of children on kidney replacement therapy (KRT) was in the low average range (87: 78, 96) and average (101: 95, 108) for children with CKD 1–5. Mean (95%CI) FSIQ, word reading, numerical operations, and spelling scores for children on KRT were 14.3 (− 25.3, − 3.3), 11 (− 18.5, − 3.6), 8.5 (− 17.6, 0.76), and 10 (− 18.6, − 1.3) points lower than children with CKD Stages 1–5. Spelling and numerical operations scores declined by 0.7 (− 1.4, − 0.1) and 1.0 (− 2.0, 0.2) units per year increase in age, regardless of CKD stage. Conclusions Children treated with KRT have low average cognitive abilities and lower academic performance for numeracy and literacy compared to both children with CKD 1–5 and to the general population. However, the rate of decline in academic performance over time is similar for children across the full spectrum of CKD. Graphical abstract A higher resolution version of the Graphical abstract is available as Supplementary information.

Rationale & Objective In the general population, cognitive impairment is associated with increased mortality, and higher levels of education are associated with lower risks for cognitive impairment and mortality. These associations are not well studied in patients receiving long-term hemodialysis and were the focus of the current investigation. Study Design Prospective cohort study. Setting & Participants Adult hemodialysis patients treated in 20 Italian dialysis clinics. Exposures Patients’ cognitive function across 5 domains (memory, attention, executive function, language, and perceptual-motor function), measured using a neuropsychological assessment comprising 10 tests; and patients’ self-reported years of education. Outcome All-cause mortality. Analytical Approach Nested multivariable Cox regression models were used to examine associations of cognition (any domain impaired, number of domains impaired, and global function score from principal components analysis of unadjusted test scores) and education with mortality and whether there were interactions between them. Results 676 (70.6%) patients participated, with a median age of 70.9 years and including 38.8% women. Cognitive impairment was present in 79.4% (527/664; 95% CI, 76.3%-82.5%). During a median follow-up of 3.3 years (1,874 person-years), 206 deaths occurred. Compared to no cognitive impairment, adjusted HRs for mortality were 1.77 (95% CI, 1.07-2.93) for any impairment, 1.48 (95% CI, 0.82-2.68) for 1 domain impaired, 1.88 (95% CI, 1.01-3.53) for 2 domains, and 2.01 (95% CI, 1.14-3.55) for 3 to 5 domains. The adjusted HR was 0.68 (95% CI, 0.51-0.92) per standard deviation increase in global cognitive function score. Compared with primary or lower education, adjusted HRs were 0.79 (95% CI, 0.53-1.20) for lower secondary and 1.13 (95% CI, 0.80-1.59) for upper secondary or higher. The cognition-by-education interaction was not significant (P = 0.7). Limitations Potential selection bias from nonparticipation and missing data; no data for cognitive decline; associations with education were not adjusted for other socioeconomic factors. Conclusions Cognitive impairment is associated with premature mortality in hemodialysis patients. Education does not appear to be associated with mortality.

Background Chronic kidney disease (CKD) is a devastating illness associated with increased mortality, reduced quality of life, impaired growth, neurocognitive impairment and psychosocial maladjustment in children. There is growing evidence of socioeconomic disparities in health outcomes among children with CKD. Patient navigators are trained non-medical personnel who assist patients with chronic conditions journey through the continuum of care and transit across different care settings. They help vulnerable and underserved populations to better understand their diagnosis, treatment options, and available resources, guide them through complex medical systems, and help them to overcome barriers to health care access. Given the complexity and chronicity of the disease process and concerns that current models of care may not adequately support the provision of high-level care in children with CKD from socioeconomically disadvantaged backgrounds, a patient navigator program may improve the provision of care and overall health of children with CKD. Methods The NAV-KIDS2 trial is a multi-centre, staggered entry, waitlisted randomised controlled trial assessing the health benefits and costs of a patient navigator program in children with CKD (stages 3–5, on dialysis, and with kidney transplants), who are of low socioeconomic backgrounds. Across 5 sites, 210 patients aged from 3 to 17 years will be randomised to immediate receipt of a patient navigator intervention for 24 weeks or waitlisting with standard care until receipt of a patient navigator at 24 weeks. The primary outcome is child self-rated health (SRH) 6-months after completion of the intervention. Other outcomes include utility-based quality of life, caregiver SRH, satisfaction with healthcare, progression of kidney dysfunction, other biomarkers, missed school days, hospitalisations and mortality. The trial also includes an economic evaluation and process evaluation, which will assess the cost-effectiveness, fidelity and barriers and enablers of implementing a patient navigator program in this setting. Discussion This study will provide clear evidence on the effectiveness and cost-effectiveness of a new intervention aiming to improve overall health and well-being for children with CKD from socioeconomically disadvantaged backgrounds, through a high quality, well-powered clinical trial. Trial registration Prospectively registered (12/07/2018) on the Australian New Zealand Clinical Trials Registry (ACTRN12618001152213).

Health data are often plagued with missing values that can greatly reduce the sample size if only complete cases are considered for analysis. Furthermore, analyses that ignore missing data have the potential to introduce bias in the parameter estimates. Multiple imputation techniques have been developed to recover the information that would otherwise be lost when excluding observations with missing data and to help minimize bias. However, the validity of analyses using imputed data relies on the imputation model having been correctly specified. The aim of this guide is to aid the reader in the decision-making process when conducting an analysis with multiply imputed data in the context of nephrology research. We discuss (i) missing mechanism assumption, (ii) imputation method, (iii) imputation model, (iv) derived variables, (v) the number of imputed data sets, (vi) diagnostic checks, (vii) analysis and pooling of results, and (viii) reporting the results. This process is demonstrated using data from the National Health and Nutrition Examination Survey to explore the association between hypertension and kidney disease in adults from the general population. Example code is provided for SAS software and the mice package in R.

Objective Secondary education has lifelong implications for well-being. We evaluated associations between the timing and duration of low socioeconomic status (SES) during childhood and academic achievement in secondary school. Methods Cohort design. The structured modeling approach was used to evaluate life-course models for associations between the duration and timing of low SES (across ages 4–5, 6–7, 8–9, 10–11 years) and Grade 7 (median age 12.5 years) reading and numeracy achievement. Linear regressions were fitted for 4 critical period models (each including low SES at 1 age), 1 sensitive period model (including low SES at all ages), and 2 strict accumulation models (including low SES duration in linear/categorical form). Results Of 3734 children, 1718 (46.1%), 1749 (48.6%), 1797 (49.3%), and 1779 (49.8%) experienced low SES at 4 to 5, 6 to 7, 8 to 9, and 10 to 11 years, respectively. For reading, the sensitive period model fitted best. Reading z-score coefficients for low SES (reference: high SES) at 4 to 5, 6 to 7, 8 to 9, and 10 to 11 years were: −0.20, −0.18, −0.02, and −0.22. For numeracy, the categorical strict accumulation model, with SES-by-sex interaction, fitted best. Numeracy z-score coefficients for 1, 2, 3, and 4 periods of low SES (reference: 0 periods) were: −0.38, −0.42, −0.54, and −0.77 for boys, and −0.23, −0.34, −0.42, and −0.54 for girls. Conclusions Low SES at all ages studied except 8 to 9 years has cumulative associations with poorer Grade 7 reading. Longer duration of low SES from 4 to 11 years is associated with poorer Grade 7 numeracy, with stronger associations for boys than girls. Academic interventions should be targeted toward children with persistently low SES.

BackgroundChronic conditions are the leading cause of mortality, morbidity and disability in children. However, children and caregivers are rarely involved in identifying research priorities, which may limit the value of research in supporting patient-centred practice and policy.ObjectiveTo identify priorities of patients, caregivers and health professionals for research in childhood chronic conditions and describe the reason for their choices.SettingAn Australian paediatric hospital and health consumer organisations.MethodsRecruited participants (n=73) included patients aged 8 to 14 years with a chronic condition (n=3), parents/caregivers of children aged 0 to 18 years with a chronic condition (n=19), representatives from consumer organisations (n=13) and health professionals including clinicians, researches (n=38) identified and discussed research priorities. Transcripts were thematically analysed.ResultsSeventy-eight research questions were identified. Five themes underpinned participants’ priorities: maintaining a sense of normality (enabling participation in school, supporting social functioning, promoting understanding and acceptance), empowering self-management and partnership in care (overcoming communication barriers, gaining knowledge and skills, motivation for treatment adherence, making informed decisions, access and understanding of complementary and alternative therapies),strengthening ability to cope (learning to have a positive outlook, preparing for home care management, transitioning to adult services), broadening focus to family (supporting sibling well-being, parental resilience and financial loss, alleviating caregiver burden), and improving quality and scope of health and social care (readdressing variability and inequities, preventing disease complications and treatment side effects, identifying risk factors, improving long-term outcomes, harnessing technology, integrating multidisciplinary services).ConclusionResearch priorities identified by children, caregivers and health professionals emphasise a focus on life participation, psychosocial well-being, impact on family and quality of care. These priorities may be used by funding and policy organisations in establishing a paediatric research agenda.

ObjectiveThe aim was to compare quality of life (QoL) among children and adolescents with different stages of chronic kidney disease (CKD) and determine factors associated with changes in QoL.DesignCross-sectional.SettingThe Kids with CKD study involved five of eight paediatric nephrology units in Australia and New Zealand.PatientsThere were 375 children and adolescents (aged 6–18 years) with CKD, on dialysis or transplanted, recruited between 2013 and 2016.Main outcome measuresOverall and domain-specific QoL were measured using the Health Utilities Index 3 score, with a scale from −0.36 (worse than dead) to 1 (perfect health). QoL scores were compared between CKD stages using the Mann-Whitney U test. Factors associated with changes in QoL were assessed using multivariable linear and ordinal logistic regression.ResultsQoL for those with CKD stages 1–2 (n=106, median 0.88, IQR 0.63–0.96) was higher than those on dialysis (n=43, median 0.67, IQR 0.39–0.91, pConclusionsThe overall QoL and domains such as pain and emotion are substantially worse in children on dialysis compared with earlier stage CKD and those with kidney transplants.

Background and objectives Poor cognition can affect educational attainment, but the extent of neurocognitive impairment in children with CKD is not well understood. This systematic review assessed global and domain-specific cognition and academic skills in children with CKD and whether these outcomes varied with CKD stage. Design, setting, participants, & measurements Electronic databases were searched for observational studies of children with CKD ages 21 years old or younger that assessed neurocognitive or educational outcomes. Risk of bias was assessed using a modified Newcastle–Ottawa scale. We used random effects models and expressed the estimates as mean differences with 95% confidence intervals stratified by CKD stage. Results Thirty-four studies (25 cross-sectional, n=2095; nine cohort, n=991) were included. The overall risk of bias was high because of selection and measurement biases. The global cognition (full-scale intelligence quotient) of children with CKD was classified as low average. Compared with the general population, the mean differences (95% confidence intervals) in full-scale intelligence quotient were −10.5 (95% confidence interval, −13.2 to −7.72; all CKD stages, n=758), −9.39 (95% confidence interval, −12.6 to −6.18; mild to moderate stage CKD, n=582), −16.2 (95% confidence interval, −33.2 to 0.86; dialysis, n=23), and −11.2 (95% confidence interval, −17.8 to −4.50; transplant, n=153). Direct comparisons showed that children with mild to moderate stage CKD and kidney transplants scored 11.2 (95% confidence interval, 2.98 to 19.4) and 10.1 (95% confidence interval, −1.81 to 22.0) full-scale intelligence quotient points higher than children on dialysis. Children with CKD also had lower scores than the general population in executive function and memory (verbal and visual) domains. Compared with children without CKD, the mean differences in academic skills (n=518) ranged from −15.7 to −1.22 for mathematics, from −9.04 to −0.17 for reading, and from −14.2 to 2.53 for spelling. Conclusions Children with CKD may have low-average cognition compared with the general population, with mild deficits observed across academic skills, executive function, and visual and verbal memory. Limited evidence suggests that children on dialysis may be at greatest risk compared with children with mild to moderate stage CKD and transplant recipients.

Background Chronic kidney disease (CKD) is a devastating illness associated with increased mortality, reduced quality of life, impaired growth, neurocognitive impairment and psychosocial maladjustment in children. There is growing evidence of socioeconomic disparities in health outcomes among children with CKD. Patient navigators are trained non-medical personnel who assist patients with chronic conditions journey through the continuum of care and transit across different care settings. They help vulnerable and underserved populations to better understand their diagnosis, treatment options, and available resources, guide them through complex medical systems, and help them to overcome barriers to health care access. Given the complexity and chronicity of the disease process and concerns that current models of care may not adequately support the provision of high-level care in children with CKD from socioeconomically disadvantaged backgrounds, a patient navigator program may improve the provision of care and overall health of children with CKD. Methods The NAV-KIDS2 trial is a multi-centre, staggered entry, waitlisted randomised controlled trial assessing the health benefits and costs of a patient navigator program in children with CKD (stages 3–5, on dialysis, and with kidney transplants), who are of low socioeconomic backgrounds. Across 5 sites, 210 patients aged from 3 to 17 years will be randomised to immediate receipt of a patient navigator intervention for 24 weeks or waitlisting with standard care until receipt of a patient navigator at 24 weeks. The primary outcome is child self-rated health (SRH) 6-months after completion of the intervention. Other outcomes include utility-based quality of life, caregiver SRH, satisfaction with healthcare, progression of kidney dysfunction, other biomarkers, missed school days, hospitalisations and mortality. The trial also includes an economic evaluation and process evaluation, which will assess the cost-effectiveness, fidelity and barriers and enablers of implementing a patient navigator program in this setting. Discussion This study will provide clear evidence on the effectiveness and cost-effectiveness of a new intervention aiming to improve overall health and well-being for children with CKD from socioeconomically disadvantaged backgrounds, through a high quality, well-powered clinical trial. Trial registration Prospectively registered (12/07/2018) on the Australian New Zealand Clinical Trials Registry (ACTRN12618001152213).

To determine the association of socioeconomic disadvantage and parent-rated health in children with chronic kidney disease (CKD). A total of 377 children (aged 6–18 years) with CKD stages I–V (n = 199), on dialysis (n = 43), or with a kidney transplant (n = 135) were recruited from 2012 to 2016 in Australia and New Zealand. Associations of five socioeconomic status (SES) components and the global SES index with parent-rated health of the child were examined using adjusted logistic regression. The median age of participants was 12.6 years (interquartile range (IQR) 8.9–15.5). In the entire cohort, the adjusted odds ratios (ORs) and 95% confidence intervals (CIs) for poor parent-rated health were 1.85 (1.13–3.03) for lower household income, 1.78 (1.08–2.96) for families that did not own their own home, 2.50 (1.50–4.16) for caregivers who rated their financial status as poor, 0.84 (0.51–1.38) for lower educational attainment, and 1.68 (1.04–2.72) for children whose primary caregivers were unemployed. With reference to the highest global SES index quartile, adjusted ORs for poor parent-rated health in descending order were 1.49 (0.69–3.21), 2.11 (1.06–4.20), and 2.20 (1.09–4.46), respectively. The association between low SES and poor parent-rated health was modified by CKD stage, where lower global SES index was independently associated with poor parent-rated health in children with CKD stages I–V, but not children on dialysis or with kidney transplants (p = 0.04). Low SES is associated with poor parent-rated health in children with CKD stages I–V, but not children on dialysis and with kidney transplants.

Objectives To examine the effect of age on associations between household income and overall health from birth to adolescence, and whether age patterns vary by country. It is uncertain whether income-related health inequalities remain stable, widen, or narrow as children age, which impacts optimal timing of equity-focused interventions. Study design Systematic review (CRD42016038583) of MEDLINE, Embase, PsycINFO, CINAHL, SocINDEX (full-text), and EconLit (full-text) to April 2017. We included observational studies and trials in children and adolescents (0-18 years of age), examining age differences in associations between income and overall health (self-rated, clinician-rated, proxy-rated). One reviewer extracted data; 2 evaluated risk of bias. Results Thirty-eight articles containing 43 studies (30 cross-sectional, 13 cohort) were identified, from high-income (n = 39) and middle-income (n = 4) countries. In the US (n = 21), positive income-health associations emerged in early childhood, and these inequalities typically widened progressively into adolescence. Relative to 0- to 3-year-olds, ratios of income-health coefficients ranged from 1.10-3.71 for 4-8 years of age, 1.26-3.86 for 9-12 years of age, 1.36-6.71 for 13-17 years. In the United Kingdom and Ireland (n = 8), inequalities emerged in early-to-mid childhood, but age patterns were less consistent. In other high-income countries (Australia, Canada, France, Germany, Japan, Republic of Korea), inequalities mostly persisted or widened with age. In middle-income countries, inequalities appeared to narrow (Indonesia n = 2) or persist (Brazil n = 2) with age. Limitations are unclear/high risk of bias and dataset overlap for some studies. Conclusions In many countries, income-related health status inequalities persist or widen as children age. Interventions that improve health equity early in the life-course are needed.

BackgroundPolyvagal theory emphasizes that autonomic nervous system functioning plays a key role in social behavior and emotion. The theory predicts that psychiatric disorders of social dysfunction are associated with reduced heart rate variability, an index of autonomic control, as well as social inhibition and avoidance. The purpose of this study was to examine whether heart rate variability was reduced in treatment-seeking patients diagnosed with social anxiety disorder, a disorder characterized by social fear and avoidance.MethodsSocial anxiety patients (n = 53) were recruited prior to receiving psychological therapy. Healthy volunteers were recruited through the University of Sydney and the general community and were matched by gender and age (n = 53). Heart rate variability was assessed during a five-minute recording at rest, with participants completing a range of self-report clinical symptom measures.ResultsCompared to controls, participants with social anxiety exhibited significant reductions across a number of heart rate variability measures. Reductions in heart rate variability were observed in females with social anxiety, compared to female controls, and in patients taking psychotropic medication compared to non-medicated patients. Finally, within the clinical group, we observed significant associations between reduced heart rate variability and increased social interaction anxiety, psychological distress, and harmful alcohol use.ConclusionsThe results of this study confirm that social anxiety disorder is associated with reduced heart rate variability. Resting state heart rate variability may therefore be considered a marker for social approach-related motivation and capacity for social engagement. Additionally, heart rate variability may provide a useful biomarker to explain underlying difficulties with social approach, impaired stress regulation, and behavioral inhibition, especially in disorders associated with significant impairments in these domains.

Antisocial behaviours and psychopathic traits place an individual at risk for criminality, mental illness, substance dependence, and psychosocial dysfunction. Social cognition deficits appear to be associated with psychopathic traits and are believed to contribute to interpersonal dysfunction. Most research investigating the relationship of these traits with social cognition has been conducted either in children or adult forensic settings. We investigated whether psychopathic traits were associated with social cognition in 91 young people presenting for mental healthcare (aged between 15 and 25 years). Participants completed symptom severity measures, neuropsychological tests, the Reading the Mind in the Eyes Test of social cognition (RMET), and the Antisocial Process Screening Device (APSD) to assess psychopathic personality traits. Correlation analyses showed poorer social cognition was associated with greater psychopathic traits (r = −.36, p = .01). Interestingly, social cognition performance predicted unique variance in concurrent psychopathic personality traits above gender, IQ sustained attention, and working memory performance. These findings suggest that social cognitive impairments are associated with psychopathic tendencies in young people presenting for community mental healthcare. Research is needed to establish the directionality of this relationship and to determine whether social cognition training is an effective treatment amongst young people with psychopathic tendencies.

article i nfo Emotion Recognition Depression Anxiety Previous research has suggested that psychotic symptoms are associated with impairments in social cogni- tion. However, there is limited research evaluating this association in the context of younger patients with a broad range of mental health problems. In the present study, we evaluated social cognitive performance in 115 treatment-seeking participants who presented to a youth mental health service with affective or psy- chotic disturbances. Participants completed symptom severity measures, a social cognition task (the Reading the Mind in the Eyes Test (RMET)), and a standardised battery of neuropsychological tests. Analyses based on diagnostic groups showed that patients with psychotic illnesses (n = 23) showed impaired performance on the RMET compared to patients with primarily bipolar (n = 40) and depressive illnesses (n = 52). Perfor- mance on the RMET was negatively correlated with positive and negative psychotic symptoms, but not affec- tive and anxiety symptoms. Performance on the RMET also was the strongest concurrent predictor of positive psychotic symptoms in a regression model that also included predicted intelligence, demographic variables, and neurocognition. RMET performance did not, however, predict negative symptoms above tests of sustained attention and verbal learning, nor was performance associated with any other symptoms of mental illness. Social cognitive impairments may provide a valuable marker for the presence of positive psychotic symptoms in young people with mental illness. Additionally, these impairments may have a role in the aetiology and maintenance of psychotic symptoms. Research is now needed to establish the nature of the re- lationship between social cognition and psychotic symptoms across different facets of social cognition. Re- search is also needed to investigate whether targeted social cognition treatments reduce risk for the development of positive psychotic symptoms.