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Background Tackling multimorbidity (ICM-MM) of internalising conditions (IC) and cardiometabolic conditions (CM) is key to improving the future of healthcare. Early life factors such as adverse childhood experiences (ACEs) have been linked to long term, poor mental and physical health conditions. Aims This study investigated whether: 1) ACEs increase the risk of IC, CM and ICM-MM; 2) the effect of ACEs on risk of developing CM depends on the presence of IC and vice versa; 3) how risk differs by gender, socioeconomic status and ethnicity. Methods In UK Biobank, the Childhood Trauma Screener was used to identify 157,256 participants with ACE data. Electronic healthcare records (EHR) and interview data identified those with anxiety or depression (IC) and those with hypertension, obesity, type 2 diabetes, dyslipidaemia or chronic kidney disease (CM). Multivariate logistic regression models were employed to find associations between ACEs and IC, CM and ICM-MM. Covariates included age, gender, ethnicity, socioeconomic status, diet, alcohol intake, smoking behaviour and physical activity. Results All ACEs significantly increase risk for IC (all ACEs, p =

In a post-pandemic world, school absence is an ever-increasing concern for governments, school leaders, and local authorities worldwide. School absence is associated with poor academic outcomes and long-term illness (physical and mental). Absenteeism increases the risk of financial difficulties in adulthood and involvement in the criminal justice system. As a result, the upstream costs to already overstretched public services are crippling. In England, all children are judged by teachers on their “school readiness” over their first year of formal education. We hypothesised that early childhood problems (i.e., not school ready) might be an antecedent of absenteeism. We tested this by investigating the pre-pandemic association between school readiness and persistent absenteeism using a population-linked dataset. Analyses included 62,598 children aged 5-13 years from the Connected Bradford database (spanning academic years 2012/13-2019/20). Special educational needs (SEN) status, English as an Additional Language status, socioeconomic status, sex, and ethnicity were covariates significantly associated with persistent absenteeism. Children who were not “school ready” had increased odds of being persistently absent later in their education journey after controlling for these covariates. School readiness was associated with even greater odds of being persistently absent over two or more years. These findings show: (i) the potential of using existing administrative data to identify children at risk of disengagement from the education system; (ii) absenteeism reflects stark structural inequities. As the rates of absence is still rising, schools can use these data to flag the children who may benefit from early intervention to keep them engaged in school.

Abstract Background Not being in employment, education, or training (NEET) is associated with poor health (physical and mental) and social exclusion. We investigated whether England’s statutory school readiness measure conducted at 4–5 years provides a risk signal for NEET in late adolescence. Methods We identified 8,118 individuals with school readiness measures at 4–5 years and NEET records at 16–17 years using Connected Bradford, a bank of linked routinely collected datasets. Children were categorised as ‘school ready’ if they reached a ‘Good Level of Development’ on the Early Years Foundation Stage Profile. We used probit regression and structural equation modelling to investigate the relationship between school readiness and NEET status and whether it primarily relates to academic attainment. Results School readiness was significantly associated with NEET status. A larger proportion of young people who were not school ready were later NEET (11%) compared to those who were school ready (4%). Most of this effect was attributable to shared relationships with academic attainment, but there was also a direct effect. Measures of deprivation and Special Educational Needs were also strong predictors of NEET status. Conclusions NEET risk factors occur early in life. School readiness measures could be used as early indicators of risk, with interventions targeted to prevent the long-term physical and mental health problems associated with NEET, especially in disadvantaged areas. Primary schools are therefore well placed to be public health partners in early intervention strategies.

Post-pandemic school absence is an increasing concern for governments worldwide. Absence is associated with poor academic outcomes and long-term illness (physical and mental). Absenteeism increases the risk of financial difficulties in adulthood and involvement in the criminal justice system. We hypothesized that early childhood problems might be an antecedent of absenteeism. We tested this hypothesis by investigating the pre-pandemic association between school readiness and persistent absenteeism using a population-linked dataset. Analyses included 62,598 children aged 5–13 years from the Connected Bradford database (spanning academic years 2012/13 to 2019/20). Special educational needs status, English as an Additional Language status, socioeconomic status, sex and ethnicity were covariates significantly associated with persistent absenteeism. Children who were not ‘school ready’ had increased odds of being persistently absent later in their education journey after controlling for these covariates. School readiness was associated with even greater odds of being persistently absent over two or more years. These findings show (i) the seeds of absenteeism are sown early in childhood; (ii) absenteeism shows the hallmark of structural inequities; and (iii) the potential of ‘school readiness’ measures to identify children at risk of long-term disengagement from the education system.

Human sensorimotor decision making has a tendency to get ‘stuck in a rut’, being biased towards selecting a previously implemented action structure (hysteresis). Existing explanations propose this is the consequence of an agent efficiently modifying an existing plan, rather than creating a new plan from scratch. Instead, we propose that hysteresis is an emergent property of a system learning from the consequences of its actions. To examine this, 152 participants moved a cursor to a target on a tablet device while avoiding an obstacle. Hysteresis was observed when the obstacle moved sequentially across the screen between trials, whereby the participant continued moving around the same side of the obstacle despite it now requiring a larger movement than the alternative. Two further experiments (n = 20) showed an attenuation when time and resource constraints were eased. We created a simple computational model capturing probabilistic estimate updating that showed the same patterns of results. This provides, to our knowledge, the first computational demonstration of how sensorimotor decision making can get ‘stuck in a rut’ through the updating of the probability estimates associated with actions.

Abstract Background Air pollution harms health across the life course. Children are at particular risk of adverse effects during development, which may impact on health in later life. Interventions that improve air quality are urgently needed both to improve public health now, and prevent longer-term increased vulnerability to chronic disease. Low Emission Zones are a public health policy intervention aimed at reducing traffic-derived contributions to urban air pollution, but evidence that they deliver health benefits is lacking. We describe a natural experiment study (CHILL: Children’s Health in London and Luton) to evaluate the impacts of the introduction of London’s Ultra Low Emission Zone (ULEZ) on children’s health. Methods CHILL is a prospective two-arm parallel longitudinal cohort study recruiting children at age 6–9 years from primary schools in Central London (the focus of the first phase of the ULEZ) and Luton (a comparator site), with the primary outcome being the impact of changes in annual air pollutant exposures (nitrogen oxides [NOx], nitrogen dioxide [NO2], particulate matter with a diameter of less than 2.5micrograms [PM2.5], and less than 10 micrograms [PM10]) across the two sites on lung function growth, measured as post-bronchodilator forced expiratory volume in one second (FEV1) over five years. Secondary outcomes include physical activity, cognitive development, mental health, quality of life, health inequalities, and a range of respiratory and health economic data. Discussion CHILL’s prospective parallel cohort design will enable robust conclusions to be drawn on the effectiveness of the ULEZ at improving air quality and delivering improvements in children’s respiratory health. With increasing proportions of the world’s population now living in large urban areas exceeding World Health Organisation air pollution limit guidelines, our study findings will have important implications for the design and implementation of Low Emission and Clean Air Zones in the UK, and worldwide. ClinicalTrials.gov NCT04695093 (05/01/2021).

Background Adolescence and transition into adulthood are periods shaping life-long mental health, cardiometabolic risk, and inequalities. However, they are poorly studied and understood. By extending and expanding the Born in Bradford (BiB) cohort study through this period using innovative, co-produced approaches to collect and analyse data, we aim to understand better the interplay of factors that influence health and wellbeing, and inform/evaluate interventions to improve them and reduce inequalities. Protocol BiB Age of Wonder (AoW) is a large, whole city cohort that will capture the contemporary lived experience amongst multi-ethnic adolescents progressing into young adulthood. We will collect repeated data from existing BiB participants and their peers (N~30,000 adolescents). The protocol for the first phase of the quantitative methods, involving survey measurements and health assessments in mainstream secondary schools is described here. We describe the co-production behind these methods, and lessons learned from the first year of data collection.

AimAssess whether school-based teacher-led screening is effective at identifying children with motor difficulties.MethodsTeachers tested 217 children aged between 5 and 11 years old, after a one hour training session, using a freely available tool (FUNMOVES). Four classes (n = 91) were scored by both researchers and teachers to evaluate inter-rater reliability. Researchers assessed 22 children using the Movement Assessment Battery for Children (MABC-2; considered to be the 'gold standard' in Europe for use as part of the diagnostic process for Developmental Coordination Disorder) to assess concurrent and predictive validity.ResultsInter-rater reliability for all individual activities within FUNMOVES ranged from 0.85-0.97 (unweighted Kappa; with 95%CI ranging from 0.77-1). For total score this was lower (κ = 0.76, 95%CI = 0.68-0.84), however when incorporating linear weighting, this improved (κ = 0.94, 95%CI = 0.89-0.99). When evaluating FUNMOVES total score against the MABC-2 total score, the specificity (1, 95%CI = 0.63-1) and positive predictive value (1; 95%CI = 0.68-1) of FUNMOVES were high, whereas sensitivity (0.57, 95%CI = 0.29-0.82) and negative predictive values (0.57, 95%CI = 0.42-0.71) were moderate. Evaluating only MABC-2 subscales which are directly related to fundamental movement skills (Aiming & Catching, and Balance) improved these values to 0.89 (95%CI = 0.52-1) and 0.93 (95%CI = 0.67-0.99) respectively.InterpretationTeacher-led screening of fundamental movement skills (via FUNMOVES) is an effective method of identifying children with motor difficulties. Such universal screening in schools has the potential to identify movement difficulties and enable earlier intervention than the current norm.

Introduction & Background The types of challenges police and ambulance services deal with often overlap, for instance supporting those who suffer from mental ill-health. Research has shown that emergency service problems often concentrate, but also that some individuals who come to the attention of one service may not be as visible to another despite their overlap in roles. Objectives & Approach This study explored how routinely collected 999 data may reveal insights into how these services support potentially vulnerable populations. We argue that better understanding the nature and distribution of vulnerability-related calls may help to inform future preventative or harm reduction-based interventions. We analysed administrative data provided by Yorkshire Ambulance Service for the Bradford region through the Connected Bradford research database, posing the following questions: (1) can 999 call data provide insights into vulnerability-related incidents attended by ambulances?; (2) where and when are these incidents most prevalent?; and (3) what are the spatial patterns of calls and patient home locations associated with them? Relevance to Digital Footprints We first select calls associated with nine callout reasons indicative of vulnerability. Patients can choose to share their data with each healthcare service they use, so we harnessed this digital footprint to analyse the spatial distribution of call locations (at postcode sector level) and patient home location (at MSOA level). Results Results indicate substantial concentrations of vulnerability-related calls in multiple postcode sectors including the City Centre (where we estimate 18% of calls may be vulnerability-related) and several other areas which are associated with deprivation. Exploring flows of people from their home location to incident location we also see substantial spatial variation in the locations in which patients involved in these types of incidents reside. Conclusions & Implications These analyses represent initial efforts to better understand how vulnerable groups are supported by public services, and have the potential to inform future resource allocation and targeting of upstream interventions.

Linking administrative data from Yorkshire Ambulance Service with primary health care data, this research project aims to answer the question, “What can YAS data tell us about how vulnerable populations interact with the service in Bradford?” We selected 9 primary callout reasons as recorded in the data that could be vulnerability-related, and explored patterns of these both spatially and temporally, with comparison to all other callout reasons. The data also includes a pseudonymised NHS number which allows linkage with other datasets for which the patient has shared this identifier. In this case, we took their home LSOA to create a rudimentary gravity model visualising flows of people from their home location to their ambulance incident location. Key findings include that vulnerability-related callouts were more frequent in the evenings and overnight on weekends, and concentrated on specific areas, both in terms of where incidents occur and areas from which callers originate. In terms of the individuals behind the calls, we found that while callers from both subsets were more likely to be female, the average age of callers for vulnerability-related incidents was almost 20 years younger than callers for all other reasons. Additionally, we discovered which callout reasons were most likely to see individuals requiring an ambulance multiple times. This research provides valuable policy-relevant insights into emergency service demand relating to vulnerable populations in the Bradford region, highlighting the importance of understanding the needs of vulnerable populations to ensure that emergency services are allocated effectively and efficiently.

Abstract Background In England, the onset of COVID-19 and a rapidly increasing infection rate resulted in a lockdown (March-June 2020) which placed strict restrictions on movement of the public, including children. Using data collected from children living in a multi-ethnic city with high levels of deprivation, this study aimed to: (1) report children’s self-reported physical activity (PA) during the first COVID-19 UK lockdown and identify associated factors; (2) examine changes of children’s self-reported PA prior to and during the first UK lockdown. Methods This study is part of the Born in Bradford (BiB) COVID-19 Research Study. PA (amended Youth Activity Profile), sleep, sedentary behaviours, daily frequency/time/destination/activity when leaving the home, were self-reported by 949 children (9–13 years). A sub-sample (n = 634) also self-reported PA (Physical Activity Questionnaire for Children) pre-pandemic (2017-February 2020). Univariate analysis assessed differences in PA between sex and ethnicity groups; multivariable logistic regression identified factors associated with children’s PA. Differences in children's levels of being sufficiently active prior to and during the lockdown were examined using the McNemar test; and multivariable logistic regression was used to identify factors explaining change. Results During the pandemic, White British (WB) children were more sufficiently active (34.1%) compared to Pakistani Heritage children (PH) (22.8%) or ‘Other’ ethnicity children (O) (22.8%). WB children reported leaving the home more frequently and for longer periods than PH and O children. Modifiable variables related to being sufficiently active were frequency, duration, type of activity, and destination away from the home environment. There was a large reduction in children being sufficiently active during the first COVID-19 lockdown (28.9%) compared to pre-pandemic (69.4%). Conclusions Promoting safe extended periods of PA everyday outdoors is important for all children, in particular for children from ethnic minority groups. Children’s PA during the first COVID-19 UK lockdown has drastically reduced from before. Policy and decision makers, and practitioners should consider the findings in order to begin to understand the impact and consequences that COVID-19 has had upon children’s PA which is a key and vital behaviour for health and development.

The richness of linked population data provides exciting opportunities to understand local health needs, identify and predict those in most need of support and evaluate health interventions. There has been extensive investment to unlock the potential of clinical data for health research in the UK. However, most of the determinants of our health are social, economic, education, environmental, housing, food systems and are influenced by local authorities. The Connected Bradford Whole System Data Linkage Accelerator was set up to link health, education, social care, environmental and other local government data to drive learning health systems, prevention and population health management. Data spanning a period of over forty years has been linked for 800,000 individuals using the pseudonymised NHS number and other data variables. This prospective data collection captures near real time activity. This paper describes the dataset and our Connected Bradford Whole System Data Accelerator Framework that covers public engagement; practitioner and policy integration; legal and ethical approvals; information governance; technicalities of data linkage; data curation and guardianship; data validity and visualisation.

Background: Socio-economic, cultural and environmental conditions strongly affect health across the life course. Local government plays a key role in influencing these wider determinants of health and levels of inequality within their communities. However, they lack the research infrastructure and culture that would enable them to develop an evidence-based approach to tackling the complex drivers of those conditions. Methods: We undertook a scoping project using some research methods and some descriptive summaries to explore the potential for, and what would be needed to develop a local authority research system for the City of Bradford, UK. This included identifying the current research landscape and any barriers and enablers to research activity within the local authority using qualitative individual and focus group interviews, a rapid review of existing local research system models, scoping and description of the use of evidence in decision making and training opportunities and existing support for local government research. Results: We identified four key themes important to developing and sustaining a research system: leadership, resource and capacity, culture, partnerships. Some use of research in decision making was evident but research training opportunities within the local authority were limited. Health research funders are slowly adapting to the local government environment, but this remains limited and more work is needed to shift the centre of gravity towards public health, local government and the community more generally. Conclusions: We propose a model for a local authority research system that can guide the development of an exemplar whole system research framework that includes research infrastructure, data sharing, research training and skills, and co-production with local partners, to choose, use, generate, and deliver research in local government.

Abstract Background Maternal iodine requirements increase during pregnancy to supply thyroid hormones essential for fetal brain development. Maternal iodine deficiency can lead to hypothyroxinemia, a reduced fetal supply of thyroid hormones which, in the first trimester, has been linked to an increased risk of autism spectrum disorder (ASD) in the child. No study to date has explored the direct link between maternal iodine deficiency and diagnosis of ASD in offspring. Methods Urinary iodine concentrations (UIC) and iodine/creatinine ratios (I:Cr) were measured in 6955 mothers at 26–28 weeks gestation participating in the Born in Bradford (BiB) cohort. Maternal iodine status was examined in relation to the probability of a Read (CTV3) code for autism being present in a child’s primary care records through a series of logistic regression models with restricted cubic splines. Results Median (inter-quartile range) UIC was 76 μg/L (46, 120) and I:Cr was 83 μg/g (59, 121) indicating a deficient population according to WHO guidelines. Ninety two children (1·3%) in our cohort had received a diagnosis of ASD by the census date. Overall, there was no evidence to support an association between I:Cr or UIC and ASD risk in children aged 8–12 years (p = 0·3). Conclusions There was no evidence of an increased clinical ASD risk in children born to mothers with mild-to-moderate iodine deficiency at 26 weeks gestation. Alternative functional biomarkers of exposure and a wider range of conditions may provide further insight.

Abstract Background Trigeminal neuralgia (TN) is an orofacial condition defined by reoccurring, spontaneous, short-lived but excruciating stabbing pain. Pharmacological interventions constitute the first-line treatment for TN, with antiepileptic drugs commonly prescribed. People treated for TN pain with antiepileptic drugs describe cognitive and motor difficulties affecting activities of daily living, and report poorer quality of life. We undertook the first comprehensive objective evaluation of sensorimotor and cognitive performance in participants being treated for TN pain with antiepileptic drugs relative to age-matched controls. Methods Participants (43 TN, 41 control) completed a battery of sensorimotor (steering, aiming and tracking) and cognitive (working memory, processing speed, inhibition) tasks. Results The TN group performed significantly worse than controls on the sensorimotor tracking and aiming tasks and across all cognitive measures. Conclusions The data explain why patients treated with antiepileptic drugs report impairment when conducting activities of daily living (given the need for cognitive and motor capability within most of these). The study is an important first step in: (i) ensuring there is adequate information on the impact of pharmacological treatment; (ii) identifying measures to determine optimal medication dosage and track change over time; (iii) creating an evidence base that could allow scientific justification of alternative pain treatment options for TN (e.g. the costs/benefits of surgery).

Abstract Background Severe iodine insufficiency in pregnancy has significant consequences, but there is inadequate evidence to indicate what constitutes mild or moderate insufficiency, in terms of observed detrimental effects on pregnancy or birth outcomes. A limited number of studies have examined iodine status and birth outcomes, finding inconsistent evidence for specific outcomes. Methods Maternal iodine status was estimated from spot urine samples collected at 26–28 weeks’ gestation from 6971 mothers in the Born in Bradford birth cohort. Associations with outcomes were examined for both urinary iodine concentration (UIC) and iodine-to-creatinine ratio (I:Cr). Outcomes assessed included customised birthweight (primary outcome), birthweight, small for gestational age (SGA), low birthweight, head circumference and APGAR score. Results There was a small positive association between I:Cr and birthweight in adjusted analyses. For a typical participant, the predicted birthweight centile at the 25th percentile of I:Cr (59 μg/g) was 2.7 percentage points lower than that at the 75th percentile of I:Cr (121 μg/g) (99% confidence interval (CI) 0.8 to 4.6), birthweight was predicted to be 41 g lower (99% CI 13 to 69) and the predicted probability of SGA was 1.9 percentage points higher (99% CI 0.0 to 3.7). There was no evidence of associations using UIC or other birth outcomes, including stillbirth, preterm birth, ultrasound growth measures or congenital anomalies. Conclusion Lower maternal iodine status was associated with lower birthweight and greater probability of SGA. Whilst small, the effect size for lower iodine on birthweight is comparable to environmental tobacco smoke exposure. Iodine insufficiency is avoidable, and strategies to avoid deficiency in women of reproductive age should be considered. Trial registration ClinicalTrials.gov NCT03552341 . Registered on June 11, 2018.

Background: The urban environment may influence neurodevelopment from conception onwards, but there is no evaluation of the impact of multiple groups of exposures simultaneously. We investigated the association between early-life urban environment and cognitive and motor function in children. Methods: We used data from 5403 mother–child pairs from four population-based birth-cohorts (UK, France, Spain, and Greece). We estimated thirteen urban home exposures during pregnancy and childhood, including: built environment, natural spaces, and air pollution. Verbal, non-verbal, gross motor, and fine motor functions were assessed using validated tests at five years old. We ran adjusted multi-exposure models using the Deletion-Substitution-Addition algorithm. Results: Higher greenness exposure within 300 m during pregnancy was associated with higher verbal abilities (1.5 points (95% confidence interval 0.4, 2.7) per 0.20 unit increase in greenness). Higher connectivity density within 100 m and land use diversity during pregnancy were related to lower verbal abilities. Childhood exposure to PM2.5 mediated 74% of the association between greenness during childhood and verbal abilities. Higher exposure to PM2.5 during pregnancy was related to lower fine motor function (-1.2 points (-2.1, -0.4) per 3.2 μg/m3 increase in PM2.5). No associations were found with non-verbal abilities and gross motor function. Discussion: This study suggests that built environment, greenness, and air pollution may impact child cognitive and motor function at five years old. This study adds evidence that well-designed urban planning may benefit children’s cognitive and motor development.

Abstract Background Born in Bradford (BiB) is a prospective multi-ethnic pregnancy and birth cohort study that was established to examine determinants of health and development during childhood and, subsequently, adult life in a deprived multi-ethnic population in the north of England. Between 2007 and 2010, the BiB cohort recruited 12,453 women who experienced 13,776 pregnancies and 13,858 births, along with 3353 of their partners. Forty five percent of the cohort are of Pakistani origin. Now that children are at primary school, the first full follow-up of the cohort is taking place. The aims of the follow-up are to investigate the determinants of children’s pre-pubertal health and development, including through understanding parents’ health and wellbeing, and to obtain data on exposures in childhood that might influence future health. Methods We are employing a multi-method approach across three data collection arms (community-based family visits, school based physical assessment, and whole classroom cognitive, motor function and wellbeing measures) to follow-up over 9000 BiB children aged 7–11 years and their families between 2017 and 2021. We are collecting detailed parent and child questionnaires, cognitive and sensorimotor assessments, blood pressure, anthropometry and blood samples from parents and children. Dual x-ray absorptiometry body scans, accelerometry and urine samples are collected on subsamples. Informed consent is collected for continued routine data linkage to health, social care and education records. A range of engagement activities are being used to raise the profile of BiB and to disseminate findings. Discussion Our multi-method approach to recruitment and assessment provides an efficient method of collecting rich data on all family members. Data collected will enhance BiB as a resource for the international research community to study the interplay between ethnicity, socioeconomic circumstances and biology in relation to cardiometabolic health, mental health, education, cognitive and sensorimotor development and wellbeing.

Abstract Background The 22q11.2 deletion is associated with psychiatric and behavioural disorders, intellectual disability and multiple physical abnormalities. Recent research also indicates impaired coordination skills may be part of the clinical phenotype. This study aimed to characterise sensorimotor control abilities in children with 22q11.2 deletion syndrome (22q11.2DS) and investigate their relationships with co-occurring IQ impairments and psychopathology. Methods Fifty-four children with 22q11.2DS and 24 unaffected sibling controls, comparable in age and gender, underwent kinematic analysis of their hand movements, whilst performing a battery of three visuo-manual coordination tasks that measured their tracking, aiming and steering abilities. Additionally, standardised assessments of full-scale IQ (FSIQ), attention deficit hyperactivity disorder, indicative autism spectrum disorder (ASD) and anxiety disorder symptomatology were conducted. Results Children with 22q11.2DS showed deficits on seven of eight kinematic descriptors of movement quality across the three coordination tasks, compared to controls. Within 22q11.2DS cases, the extent of impairment on only three kinematic descriptors was significantly related to FSIQ after correction for multiple testing. Moreover, only error whilst visuo-manually tracking was nominally associated with ADHD symptom counts. Conclusions Impairments in sensorimotor control are seen on a range of visuo-manual tasks in children with 22q11.2DS but the extent of these impairments are largely unrelated to the severity of other psychopathological and intellectual impairments commonly found in children with 22q11.2DS.

Objectives This was a pilot study to explore whether the Early Years Foundation Stage Profile (EYFSP) carried out by UK teachers within the ‘reception’ year, combined with the Social Communication Questionnaire (SCQ), can lead to early identification of children with autism spectrum disorders (ASD) and early access to intervention and can reduce inequity in access to assessment and intervention.Design Pragmatic prospective cohort.Setting Ten primary schools from the SHINE project in Bradford.Participants 587 pupils from 10 schools who transitioned from reception to year 1 in July 2017 and had the EYFSP completed were included in the final study.Interventions The assessment involved a multidisciplinary team of three staff who completed Autism Diagnostic Interview–Revised, Autism Diagnostic Observation Schedule Version 2, classroom observations with an ASD checklist, a teacher-based ASD questionnaire and a final consensus meeting.Primary outcome measure National Institute for Health and Care Excellence guideline-compliant clinical diagnosis of ASD.Secondary outcome measures Age of diagnosis, demographic data and feasibility parameters.Results Children with low scores on the EYFSP were more likely to score above the SCQ threshold of 12, indicating potential autism (50% compared with 19% of children with high scores on the EYFSP (p

BackgroundA large proportion of children are not able to perform age-appropriate fundamental movement skills (FMS). Thus, it is important to assess FMS so that children needing additional support can be identified in a timely fashion. There is great potential for universal screening of FMS in schools, but research has established that current assessment tools are not fit for purpose.ObjectiveTo develop and validate the psychometric properties of a FMS assessment tool designed specifically to meet the demands of universal screening in schools.MethodsA working group consisting of academics from developmental psychology, public health and behavioural epidemiology developed an assessment tool (FUNMOVES) based on theory and prior evidence. Over three studies, 814 children aged 4 to 11 years were assessed in school using FUNMOVES. Rasch analysis was used to evaluate structural validity and modifications were then made to FUNMOVES activities after each study based on Rasch results and implementation fidelity.ResultsThe initial Rasch analysis found numerous psychometric problems including multidimensionality, disordered thresholds, local dependency, and misfitting items. Study 2 showed a unidimensional measure, with acceptable internal consistency and no local dependency, but that did not fit the Rasch model. Performance on a jumping task was misfitting, and there were issues with disordered thresholds (for jumping, hopping and balance tasks). Study 3 revealed a unidimensional assessment tool with good fit to the Rasch model, and no further issues, once jumping and hopping scoring were modified.ImplicationsThe finalised version of FUNMOVES (after three iterations) meets standards for accurate measurement, is free and able to assess a whole class in under an hour using resources available in schools. Thus FUNMOVES has the potential to allow schools to efficiently screen FMS to ensure that targeted support can be provided and disability barriers removed.

Purpose Many people experience unilateral degraded vision, usually owing to a developmental or age-related disorder. There are unresolved questions regarding the extent to which such unilateral visual deficits impact on sensorimotor performance; an important issue as sensorimotor limitations can constrain quality of life by restricting ‘activities of daily living’. Examination of the relationship between visual deficit and sensorimotor performance is essential for determining the functional implications of ophthalmic conditions. This study attempts to explore the effect of unilaterally degraded vision on sensorimotor performance. Methods In Experiment 1 we simulated visual deficits in 30 participants using unilateral and bilateral Bangerter filters to explore whether motor performance was affected in water pouring, peg placing, and aiming tasks. Experiment 2 (n = 74) tested the hypothesis that kinematic measures are associated with visuomotor deficits by measuring the impact of small visual sensitivity decrements created by monocular viewing on sensorimotor interactions with targets presented on a planar surface in aiming, tracking and steering tasks. Results In Experiment 1, the filters caused decreased task performance—confirming that unilateral (and bilateral) visual loss has functional implications. In Experiment 2, kinematic measures were affected by monocular viewing in two of three tasks requiring rapid online visual feedback (aiming and steering). Conclusions Unilateral visual loss has a measurable impact on sensorimotor performance. The benefits of binocular vision may be particularly important for some groups (e.g. older adults) where an inability to complete sensorimotor tasks may necessitate assisted living. There is an urgent need to develop rigorous kinematic approaches to the quantification of the functional impact of unilaterally degraded vision and of the benefits associated with treatments for unilateral ophthalmic conditions to enable informed decisions around treatment.

Disturbance forces facilitate motor learning, but theoretical explanations for this counterintuitive phenomenon are lacking. Smooth arm movements require predictions (inference) about the force-field associated with a workspace. The Free Energy Principle (FEP) suggests that such 'active inference' is driven by 'surprise'. We used these insights to create a formal model that explains why disturbance might help learning. In two experiments, participants undertook a continuous tracking task where they learned how to move their arm in different directions through a novel 3D force field. We compared baseline performance before and after exposure to the novel field to quantify learning. In Experiment 1, the exposure phases (but not the baseline measures) were delivered under three different conditions: (i) robot haptic assistance; (ii) no guidance; (iii) robot haptic disturbance. The disturbance group showed the best learning as our model predicted. Experiment 2 further tested our FEP inspired model. Assistive and/or disturbance forces were applied as a function of performance (low surprise), and compared to a random error manipulation (high surprise). The random group showed the most improvement as predicted by the model. Thus, motor learning can be conceptualised as a process of entropy reduction. Short term motor strategies (e.g. global impedance) can mitigate unexpected perturbations, but continuous movements require active inference about external force-fields in order to create accurate internal models of the external world (motor learning). Our findings reconcile research on the relationship between noise, variability, and motor learning, and show that information is the currency of motor learning.

BackgroundFundamental Movement Skills (FMS) play a critical role in ontogenesis. Many children have insufficient FMS, highlighting the need for universal screening in schools. There are many observational FMS assessment tools, but their psychometric properties are not readily accessible. A systematic review was therefore undertaken to compile evidence of the validity and reliability of observational FMS assessments, to evaluate their suitability for screening.MethodsA pre-search of 'fundamental movement skills' OR 'fundamental motor skills' in seven online databases (PubMed, Ovid MEDLINE, Ovid Embase, EBSCO CINAHL, EBSCO SPORTDiscus, Ovid PsycINFO and Web of Science) identified 24 assessment tools for school-aged children that: (i) assess FMS; (ii) measure actual motor competence and (iii) evaluate performance on a standard battery of tasks. Studies were subsequently identified that: (a) used these tools; (b) quantified validity or reliability and (c) sampled school-aged children. Study quality was assessed using COnsensus-based Standards for the selection of health Measurement INstruments (COSMIN) checklists.ResultsNinety studies were included following the screening of 1863 articles. Twenty-one assessment tools had limited or no evidence to support their psychometric properties. The Test of Gross Motor Development (TGMD, n = 34) and the Movement Assessment Battery for Children (MABC, n = 37) were the most researched tools. Studies consistently reported good evidence for validity, reliability for the TGMD, whilst only 64% of studies reported similarly promising results for the MABC. Twelve studies found good evidence for the reliability and validity of the Bruininks-Oseretsky Test of Motor Proficiency but poor study quality appeared to inflate results. Considering all assessment tools, those with promising psychometric properties often measured limited aspects of validity/reliability, and/or had limited feasibility for large scale deployment in a school-setting.ConclusionThere is insufficient evidence to justify the use of any observational FMS assessment tools for universal screening in schools, in their current form.

Economic, physical, built, cultural, learning, social and service environments have a profound effect on lifelong health. However, policy thinking about health research is dominated by the ‘biomedical model’ which promotes medicalisation and an emphasis on diagnosis and treatment at the expense of prevention. Prevention research has tended to focus on ‘downstream’ interventions that rely on individual behaviour change, frequently increasing inequalities. Preventive strategies often focus on isolated leverage points and are scattered across different settings. This paper describes a major new prevention research programme that aims to create City Collaboratory testbeds to support the identification, implementation and evaluation of upstream interventions within a whole system city setting. Prevention of physical and mental ill-health will come from the cumulative effect of multiple system-wide interventions. Rather than scatter these interventions across many settings and evaluate single outcomes, we will test their collective impact across multiple outcomes with the goal of achieving a tipping point for better health. Our focus is on early life (ActEarly) in recognition of childhood and adolescence being such critical periods for influencing lifelong health and wellbeing.

Some activities can be meaningfully dichotomised as 'cognitive' or 'sensorimotor' in nature-but many cannot. This has radical implications for understanding activity limitation in disability. For example, older adults take longer to learn the serial order of a complex sequence but also exhibit slower, more variable and inaccurate motor performance. So is their impaired skill acquisition a cognitive or motor deficit? We modelled sequence learning as a process involving a limited capacity buffer (working memory), where reduced performance restricts the number of elements that can be stored. To test this model, we examined the relationship between motor performance and sequence learning. Experiment 1 established that older adults were worse at learning the serial order of a complex sequence. Experiment 2 found that participants showed impaired sequence learning when the non-preferred hand was used. Experiment 3 confirmed that serial order learning is impaired when motor demands increase (as the model predicted). These results can be captured by reinforcement learning frameworks which suggest sequence learning will be constrained both by an individual's sensorimotor ability and cognitive capacity.

The nativist hypothesis suggests universal features of human behaviour can be explained by biologically determined cognitive substrates. This nativist account has been challenged recently by evolutionary models showing that the cultural transmission of knowledge can produce behavioural universals. Sensorimotor invariance is a canonical example of a behavioural universal, raising the issue of whether culture can influence not only which skills people acquire but also the development of the sensorimotor system. We tested this hypothesis by exploring whether culture influences the developing sensorimotor system in children. We took kinematic measures of motor control asymmetries in adults and children from differing cultures where writing follows opposite directions. British and Kuwaiti adults (n = 69) and first grade (5–6 year old) children (n = 140) completed novel rightward and leftward tracing tasks. The Kuwaitis were better when moving their arm leftward while the British showed the opposite bias. Bayesian analysis techniques showed that while children were worse than adults, they also showed asymmetries—with the asymmetry magnitude related to accuracy levels. Our findings support the idea that culture influences the sensorimotor system.

Big datasets have the potential to revolutionize public health. However, there is a mismatch between the political and scientific optimism surrounding big data and the public’s perception of its benefit. We suggest a systematic and concerted emphasis on developing models derived from smaller datasets to illustrate to the public how big data can produce tangible benefits in the long-term. In order to highlight the immediate value of a small data approach, we produced a proof-of-concept model predicting hospital length of stay. The results demonstrate that existing small datasets can be used to create models that generate a reasonable prediction, facilitating healthcare delivery. We propose that greater attention (and funding) needs to be directed toward the utilization of existing information resources in parallel with current efforts to create and exploit ‘big data’.

Motor deficits are linked to a range of negative physical, social and academic consequences. Haptic robotic interventions, based on the principles of sensorimotor learning, have been shown previously to help children with motor problems learn new movements. We therefore examined whether the training benefits of a robotic system would generalise to a standardised test of 'pen-skills', assessed using objective kinematic measures [via the Clinical Kinematic Assessment Tool, CKAT]. A counterbalanced, cross-over design was used in a group of 51 children (37 male, aged 5-11 years) with manual control difficulties. Improved performance on a novel task using the robotic device could be attributed to the intervention but there was no evidence of generalisation to any of the CKAT tasks. The robotic system appears to have the potential to support motor learning, with the technology affording numerous advantages. However, the training regime may need to target particular manual skills (e.g. letter formation) in order to obtain clinically significant improvements in specific skills such as handwriting.

Attention underpins many activities integral to a child's development. However, methodological limitations currently make large-scale assessment of children's attentional skill impractical, costly and lacking in ecological validity. Consequently we developed a measure of 'Visual Motor Attention' (VMA)-a construct defined as the ability to sustain and adapt visuomotor behaviour in response to task-relevant visual information. In a series of experiments, we evaluated the capability of our method to measure attentional processes and their contributions in guiding visuomotor behaviour. Experiment 1 established the method's core features (ability to track stimuli moving on a tablet-computer screen with a hand-held stylus) and demonstrated its sensitivity to principled manipulations in adults' attentional load. Experiment 2 standardised a format suitable for use with children and showed construct validity by capturing developmental changes in executive attention processes. Experiment 3 tested the hypothesis that children with and without coordination difficulties would show qualitatively different response patterns, finding an interaction between the cognitive and motor factors underpinning responses. Experiment 4 identified associations between VMA performance and existing standardised attention assessments and thereby confirmed convergent validity. These results establish a novel approach to measuring childhood attention that can produce meaningful functional assessments that capture how attention operates in an ecologically valid context (i.e. attention's specific contribution to visuomanual action).

The ability to use advance information to prepare and execute a movement requires cognitive control of behaviour (e.g., anticipation and inhibition). Our aim was to explore the integrity of saccadic eye movement control in developmental coordination disorder (DCD) and typically developing (TD) children (8-12 years) and assess how these children plan and inhibit saccadic responses, the principal mechanisms within visual attention control. Eye movements and touch responses were measured (separately and concurrently) in Cued and Non-Cued conditions. We found that children with DCD had similar saccade kinematics to the TD group during saccade initiation. Advance information decreased hand movement duration in both groups during Cued trials, but decrements in accuracy were significantly worse in the DCD group. In addition, children with DCD exhibited greater inhibitory errors and inaccurate fixation during the Cued trials. Thus, children with DCD were reasonably proficient in executing saccades during reflexive (Non-Cued) conditions, but showed deficits in more complex control processes involving prediction and inhibition. These findings have implications for our understanding of motor control in children with DCD.

Numerous activities require an individual to respond quickly to the correct stimulus. The provision of advance information allows response priming but heightened responses can cause errors (responding too early or reacting to the wrong stimulus). Thus, a balance is required between the online cognitive mechanisms (inhibitory and anticipatory) used to prepare and execute a motor response at the appropriate time. We investigated the use of advance information in 71 participants across four different age groups: (i) children, (ii) young adults, (iii) middle-aged adults, and (iv) older adults. We implemented 'cued' and 'non-cued' conditions to assess age-related changes in saccadic and touch responses to targets in three movement conditions: (a) Eyes only; (b) Hands only; (c) Eyes and Hand. Children made less saccade errors compared to young adults, but they also exhibited longer response times in cued versus non-cued conditions. In contrast, older adults showed faster responses in cued conditions but exhibited more errors. The results indicate that young adults (18-25 years) achieve an optimal balance between anticipation and execution. In contrast, children show benefits (few errors) and costs (slow responses) of good inhibition when preparing a motor response based on advance information; whilst older adults show the benefits and costs associated with a prospective response strategy (i.e., good anticipation).

Some studies have shown that manual asymmetries decrease in older age. These results have often been explained with reference to models of reduced hemispheric specialisation. An alternative explanation, however, is that hand differences are subtle, and capturing them requires tasks that yield optimal performance with both hands. Whereas the hemispheric specialisation account implies that reduced manual asymmetries should be reliably observed in older adults, the 'measurement difficulty' account suggests that manual asymmetries will be hard to detect unless a task has just the right level of difficulty--i.e. within the 'Goldilocks Zone', where it is not too easy or too hard, but just right. Experiment One tested this hypothesis and found that manual asymmetries were only detected when participants performed in this zone; specifically, performance on a tracing task was only superior in the preferred hand when task constraints were high (i.e. fast speed tracing). Experiment Two used three different tasks to examine age differences in manual asymmetries; one task produced no asymmetries, whilst two tasks revealed asymmetries in both younger and older groups (with poorer overall performance in the old group across all tasks). Experiment Three revealed task-dependent asymmetries in both age groups, but highlighted further detection difficulties linked with the metric of performance and compensatory strategies used by participants. Results are discussed with reference to structural learning theory, whereby we suggest that the processes of inter-manual transfer lead to relatively small performance differences between the hands (despite a strong phenomenological sense of performance disparities).

Many children have difficulty producing movements well enough to improve in sensori-motor learning. Previously, we developed a training method that supports active movement generation to allow improvement at a 3D tracing task requiring good compliance control. Here, we tested 7-8 year old children from several 2nd grade classrooms to determine whether 3D tracing performance could be predicted using the Beery VMI. We also examined whether 3D tracing training lead to improvements in drawing. Baseline testing included Beery, a drawing task on a tablet computer, and 3D tracing. We found that baseline performance in 3D tracing and drawing co-varied with the visual perception (VP) component of the Beery. Differences in 3D tracing between children scoring low versus high on the Beery VP replicated differences previously found between children with and without motor impairments, as did post-training performance that eliminated these differences. Drawing improved as a result of training in the 3D tracing task. The training method improved drawing and reduced differences predicted by Beery scores.

To what degree does being male or female influence the development of manual skills in pre-pubescent children? This question is important because of the emphasis placed on developing important new manual skills during this period of a child's education (e.g. writing, drawing, using computers). We investigated age and sex-differences in the ability of 422 children to control a handheld stylus. A task battery deployed using tablet PC technology presented interactive visual targets on a computer screen whilst simultaneously recording participant's objective kinematic responses, via their interactions with the on-screen stimuli using the handheld stylus. The battery required children use the stylus to: (i) make a series of aiming movements, (ii) trace a series of abstract shapes and (iii) track a moving object. The tasks were not familiar to the children, allowing measurement of a general ability that might be meaningfully labelled 'manual control', whilst minimising culturally determined differences in experience (as much as possible). A reliable interaction between sex and age was found on the aiming task, with girls' movement times being faster than boys in younger age groups (e.g. 4-5 years) but with this pattern reversing in older children (10-11 years). The improved performance in older boys on the aiming task is consistent with prior evidence of a male advantage for gross-motor aiming tasks, which begins to emerge during adolescence. A small but reliable sex difference was found in tracing skill, with girls showing a slightly higher level of performance than boys irrespective of age. There were no reliable sex differences between boys and girls on the tracking task. Overall, the findings suggest that prepubescent girls are more likely to have superior manual control abilities for performing novel tasks. However, these small population differences do not suggest that the sexes require different educational support whilst developing their manual skills.

Old age is associated with reduced mobility of the hand. To investigate age related decline when reaching-to-lift an object we used sophisticated kinematic apparatus to record reaches carried out by healthy older and younger participants. Three objects of different widths were placed at three different distances, with objects having either a high or low friction surface (i.e. rough or slippery). Older participants showed quantitative differences to their younger counterparts - movements were slower and peak speed did not scale with object distance. There were also qualitative differences with older adults showing a greater propensity to stop the hand and adjust finger position before lifting objects. The older participants particularly struggled to lift wide slippery objects, apparently due to an inability to manipulate their grasp to provide the level of precision necessary to functionally enclose the object. These data shed light on the nature of age related changes in reaching-to-grasp movements and establish a powerful technique for exploring how different product designs will impact on prehensile behavior.

Passive modeling of movements is often used in movement therapy to overcome disabilities caused by stroke or other disorders (e.g. Developmental Coordination Disorder or Cerebral Palsy). Either a therapist or, recently, a specially designed robot moves or guides the limb passively through the movement to be trained. In contrast, action theory has long suggested that effective skill acquisition requires movements to be actively generated. Is this true? In view of the former, we explicitly tested the latter. Previously, a method was developed that allows children with Developmental Coordination Disorder to produce effective movements actively, so as to improve manual performance to match that of typically developing children. In the current study, we tested practice using such active movements as compared to practice using passive movement. The passive movement employed, namely haptic tracking, provided a strong test of the comparison, one that showed that the mere inaction of the muscles is not the problem. Instead, lack of prospective control was. The result was no effective learning with passive movement while active practice with prospective control yielded significant improvements in performance.

Handedness, the preference towards using the right or left hand, is established in early childhood. Such specialisation allows a higher level of motor skill to be maintained in the preferred hand through continuous practice and performance. We might expect that hand asymmetries increase as we age because of the length of time practising with the preferred hand but recent research has suggested reduced asymmetries in older adults performing reaches (Przybla et al 2011, Neurosci Lett , 99–104). To examine whether older adults exhibit asymmetries in a fine visual-motor task, we measured tracing performance along paths of different thickness in a group of young and old participants. Participants completed the task with their preferred (right) and non-preferred (left) hand. We used Movement Time (MT) and Shape Accuracy (SA) as dependant variables. A composite measure of MT and SA, the Speed Accuracy Cost Function (SACF) provided an overall measure of performance efficiency. Younger participants were faster and more accurate than the old, especially when using the preferred hand and/or when task demands were high (ie, tracing thinner paths). Critically we compared performance between right and left hands and revealed reduced asymmetries in MT and SACF in the older group. The young were significantly faster when tracing with their dominant hand, but older participants were equally slow with either hand. Our findings compliment the growing literature which reports decreased hemispheric lateralisation of function in the aging brain (eg, Cabeza 2002, Psychol Aging , 85–100).

Laparoscopic surgery has revolutionised medicine but requires surgeons to learn new visual-motor mappings. The optimal method for training surgeons is unknown. For instance, it may be easier to learn planar movements when training is constrained to a plane, since this forces the surgeon to develop an appropriate perceptual-motor map. In contrast, allowing the surgeon to move without constraints could improve performance because this provides greater experience of the control dynamics of the device. In order to test between these alternatives, we created an experimental tool that connected a commercially available robotic arm with specialised software that presents visual stimuli and objectively records kinematics. Participants were given the task of generating a series of aiming movements to move a visual cursor to a series of targets. The actions required movement along a horizontal plane, whereas the visual display was a screen positioned perpendicular to this plane (ie, vertically). One group (n=8) received training where the force field constrained their movement to the correct plane of action, whilst a second group (n=8) trained without constraints. On test trials (after training) the unconstrained group showed better performance, as indexed by reduced movement duration and reduced path length. These results show that participants who explored the entire action space had an advantage, which highlights the importance of experiencing the full dynamics of a control device and the action space when learning a new visual-motor mapping.

Reach-to-grasp movements change quantitatively in a lawful (i.e. predictable) manner with changes in object properties. We explored whether altering object texture would produce qualitative changes in the form of the precontact movement patterns. Twelve participants reached to lift objects from a tabletop. Nine objects were produced, each with one of three grip surface textures (high-friction, medium-friction and low-friction) and one of three widths (50 mm, 70 mm and 90 mm). Each object was placed at three distances (100 mm, 300 mm and 500 mm), representing a total of 27 trial conditions. We observed two distinct movement patterns across all trials--participants either: (i) brought their arm to a stop, secured the object and lifted it from the tabletop; or (ii) grasped the object 'on-the-fly', so it was secured in the hand while the arm was moving. A majority of grasps were on-the-fly when the texture was high-friction and none when the object was low-friction, with medium-friction producing an intermediate proportion. Previous research has shown that the probability of on-the-fly behaviour is a function of grasp surface accuracy constraints. A finger friction rig was used to calculate the coefficients of friction for the objects and these calculations showed that the area available for a stable grasp (the 'functional grasp surface size') increased with surface friction coefficient. Thus, knowledge of functional grasp surface size is required to predict the probability of observing a given qualitative form of grasping in human prehensile behaviour.