The impact of the COVID-19 pandemic on 397 631 elective dental admissions among the under-25s in England: a retrospective study

BACKGROUND

COVID-19 caused widespread disruptions to health services worldwide, including reductions in elective surgery. Tooth extractions are among the most common reasons for elective surgery among children and young people (CYP). It is unclear how COVID-19 affected elective dental surgeries in hospitals over multiple pandemic waves at a national level.

METHODS

Elective dental tooth extraction admissions were selected using Hospital Episode Statistics. Admission trends for the first 14 pandemic months were compared with the previous five years and results were stratified by age (under-11s, 11-16s, 17-24s).

RESULTS

The most socioeconomically deprived CYP comprised the largest proportion of elective dental tooth extraction admissions. In April 2020, admissions dropped by >95%. In absolute terms, the biggest reduction was in April (11-16s: -1339 admissions, 95% CI -1411 to -1267; 17-24s: -1600, -1678 to -1521) and May 2020 (under-11s: -2857, -2962 to -2752). Admissions differed by socioeconomic deprivation for the under-11s (P < 0.0001), driven by fewer admissions than expected by the most deprived and more by the most affluent during the pandemic.

CONCLUSION

Elective tooth extractions dropped most in April 2020, remaining below pre-pandemic levels throughout the study. Despite being the most likely to be admitted, the most deprived under-11s had the largest reductions in admissions relative to other groups.

Childhood attention-deficit hyperactivity disorder: socioeconomic inequalities in symptoms, impact, diagnosis and medication

BACKGROUND

Children from disadvantaged backgrounds are at greater risk of attention-deficit hyperactivity disorder (ADHD)-related symptoms, being diagnosed with ADHD, and being prescribed ADHD medications. We aimed to examine how inequalities manifest across the 'patient journey', from perceptions of impacts of ADHD symptoms on daily life, to the propensity to seek and receive a diagnosis and treatment.

METHODS

We investigated four 'stages': (1) symptoms, (2) caregiver perception of impact, (3) diagnosis and (4) medication, in two data sets: UK Millennium Cohort Study (MCS, analytic n ~ 9,000), with relevant (parent-reported) information on all four stages (until 14 years); and a population-wide 'administrative cohort', which includes symptoms (child health checks) and prescriptions (dispensing records), born in Scotland, 2010-2012 (analytic n ~ 100,000), until ~6 years. We described inequalities according to maternal occupational status, with percentages and relative indices of inequality (RII).

RESULTS

The prevalence of ADHD symptoms and medication receipt was considerably higher in the least compared to the most advantaged children in the administrative cohort (RIIs of 5.9 [5.5-6.4] and 8.1 [4.2-15.6]) and the MCS (3.08 [2.68-3.55], 3.75 [2.21-6.36]). MCS analyses highlighted complexities between these two stages, however, those from least advantaged backgrounds, with ADHD symptoms, were the least likely to perceive impacts on daily life (15.7% vs. average 19.5%) and to progress from diagnosis to medication (44.1% vs. average 72.5%).

CONCLUSIONS

Despite large inequalities in ADHD symptoms and medication, parents from the least advantaged backgrounds were less likely to report impacts of ADHD symptoms on daily life, and their children were less likely to have received medication postdiagnosis, highlighting how patient journeys differed according to socioeconomic circumstances.

Characterization of Puberty in an Australian Population-Based Cohort Study

PURPOSE

Current knowledge of the characteristics of puberty beyond age at menarche and thelarche is limited, particularly within population-based cohorts. Secular trends and concerns of the health effects of early puberty reinforce the value of contemporary studies characterizing the timing, tempo, duration, and synchronicity of puberty.

METHODS

The Childhood to Adolescence Transition Study is a unique Australian cohort of individuals followed annually from late childhood to late adolescence, with up to eight assessments of pubertal stage from 9 to 19 years of age (N = 1,183; 636 females). At each assessment, females reported their Tanner Stage of breast and pubic hair development, while males reported on genital/pubic hair development. Nonlinear mixed-effects models characterized pubertal trajectories and were used to derive each individual's estimates of timing, tempo, and synchronicity. Parametric survival models were used to estimate the overall duration of puberty.

RESULTS

Timing of mid-puberty (Tanner Stage 3) ranged from 12.5 to 13.5 years, with females developing approximately 6 months before males. Pubertal tempo (at mid-puberty) was similar across sex (between half and one Tanner Stage per year), but the overall duration of puberty was slightly shorter in males. Most females exhibited asynchronous changes of breast and pubic hair development.

DISCUSSION

Estimates of pubertal timing and tempo are consistent with reports of cohorts from two or more decades ago, suggesting stabilization of certain pubertal characteristics in predominantly White populations. However, our understanding of the duration of puberty and individual differences in pubertal characteristics (e.g., synchronicity of physical changes) remains limited.

Impact of the COVID-19 pandemic on the clinical management trends for acute appendicitis among the under-25s: a retrospective study

OBJECTIVE

To describe the COVID-19 pandemic's impact on acute appendicitis management on children and young people (CYP).

DESIGN

Retrospective cohort study.

SETTING

All English National Health Service hospitals.

PATIENTS

Acute appendicitis admissions (all, simple, complex) by CYP (under-5s, 5-9s, 10-24s).

EXPOSURE

Study pandemic period: February 2020-March 2021. Comparator pre-pandemic period: February 2015-January 2020.

MAIN OUTCOME MEASURES

Monthly appendicectomy and laparoscopic appendicectomy rate trends and absolute differences between pandemic month and the pre-pandemic average. Proportions of appendicitis admissions comprising complex appendicitis by hospital with or without specialist paediatric centres were compared.

RESULTS

101 462 acute appendicitis admissions were analysed. Appendicectomy rates fell most in April 2020 for the 5-9s (-18.4% (95% CI -26.8% to -10.0%)) and 10-24s (-28.4% (-38.9% to -18.0%)), driven by reductions in appendicectomies for simple appendicitis. This was equivalent to -54 procedures (-68.4 to -39.6) and -512 (-555.9 to -467.3) for the 5-9s and 10-24s, respectively. Laparoscopic appendicectomies fell in April 2020 for the 5-9s (-15.5% (-23.2% to -7.8%)) and 10-24s (-44.8% (-57.9% to -31.6%) across all types, which was equivalent to -43 (-56.1 to 30.3) and -643 (-692.5 to -593.1) procedures for the 5-9s and 10-24s, respectively. A larger proportion of complex appendicitis admissions were treated within trusts with specialist paediatric centres during the pandemic.

CONCLUSIONS

For CYP across English hospitals, a sharp recovery followed a steep reduction in appendicectomy rates in April 2020, due to concerns with COVID-19 transmission. This builds on smaller-sized studies reporting the immediate short-term impacts.

Admissions to paediatric medical wards with a primary mental health diagnosis: a systematic review of the literature

OBJECTIVE

To systematically review the literature describing children and young people (CYP) admissions to paediatric general wards because of primary mental health (MH) reasons, particularly in MH crisis.

DESIGN

PubMed, Embase, PsycINFO, Web of Science and Google Scholar were searched, with no restriction on country or language. We addressed five search questions to inform: trends and/or the number of admissions, the risk factors for adverse care, the experiences of CYP, families/carers and healthcare professionals (HCPs) and the evidence of interventions aimed at improving the care during admissions.Two reviewers independently assessed the relevance of abstracts identified, extracted data and undertook quality assessment. This review was registered with PROSPERO (CRD42022350655).

RESULTS

Thirty-two studies met the inclusion criteria. Eighteen addressed trends and/or numbers/proportions of admissions, 12 provided data about the views/experiences of HCPs, two provided data about CYP's experiences and four explored improving care. We were unable to identify studies examining risk factors for harm during admissions, but studies did report the length of stay in general paediatric/adult settings while waiting for specialised care, which could be considered a risk factor while caring for this group.

CONCLUSIONS

MH admissions to children's wards are a long-standing issue and are increasing. CYP will continue to need to be admitted in crisis, with paediatric wards a common location while waiting for assessment. For services to be delivered effectively and for CYP and their families/carers to feel supported and HCPs to feel confident, we need to facilitate more integrated physical and MH pathways of care.

PROSPERO REGISTRATION NUMBER

CRD42022350655.

Student- and School-Level Factors Associated With Mental Health and Well-Being in Early Adolescence

OBJECTIVE

Adolescence is a key developmental window that may determine long-term mental health. As schools may influence mental health of students, this study aimed to examine the association of school-level characteristics with students' mental health over time.

METHOD

Longitudinal data from a cluster randomized controlled trial comprising 8,376 students (55% female; aged 11-14 years at baseline) across 84 schools in the United Kingdom were analyzed. Data collection started in the academic years 2016/2017 (cohort 1) and 2017/2018 (cohort 2), with follow-up at 1, 1.5, and 2 years. Students' mental health (risk for depression [Center for Epidemiologic Studies Depression Scale], social-emotional-behavioral difficulties [Strength and Difficulties Questionnaire]) and well-being (Warwick-Edinburgh Mental Well-Being Scale) and relationships with student- and school-level characteristics were explored using multilevel regression models.

RESULTS

Mental health difficulties and poorer well-being increased over time, particularly in girls. Differences among schools represented a small but statistically significant proportion of variation (95% CI) in students' mental health at each time point: depression, 1.7% (0.9%-2.5%) to 2.5% (1.6%-3.4%); social-emotional-behavioral difficulties, 1.9% (1.1%-2.7%) to 2.8% (2.1%-3.5%); and well-being, 1.8% (0.9%-2.7%) to 2.2% (1.4%-3.0%). Better student-rated school climate analyzed as a time-varying factor at the student and school level was associated with lower risk of depression (regression coefficient [95%CI] student level: -4.25 [-4.48, -4.01]; school level: -4.28 [-5.81, -2.75]), fewer social-emotional-behavioral difficulties (student level: -2.46 [-2.57, -2.35]; school level: -2.36 [-3.08, -1.63]), and higher well-being (student level: 3.88 [3.70, 4.05]; school-level: 4.28 [3.17, 5.38]), which was a stable relationship.

CONCLUSION

Student-rated school climate predicted mental health in early adolescence. Policy and system interventions that focus on school climate may promote students' mental health.

Persistent symptoms are associated with long term effects of COVID-19 among children and young people: Results from a systematic review and meta-analysis of controlled studies

BACKGROUND

Research on the long-term impact on COVID-19 in children and young people (CYP) has been published at pace. We aimed to update and refine an earlier systematic review and meta-analysis to assess the current evidence for Post-COVID-19 Condition in CYP.

METHODS

Studies from the previous systematic review were combined with studies from a systematic search from July 2021 to November 2022 (registration PROSPERO CRD42021233153). Eligible studies included CYP aged ≤19 years with confirmed or probable SARS-CoV-2 infection and symptoms persisting at least 12 weeks.

FINDINGS

55 studies (n = 1,139,299 participants) were included. Over two-hundred symptoms were associated with Post COVID-19 Condition. Gastrointestinal problems, headaches, cough and fever were among the most prevalent symptoms with rates of 50.2%, 35.6%, 34.7% and 25.8% respectively. Twenty-one symptoms from 11 studies were suitable for meta-analysis. There were significantly higher pooled estimates of proportions of symptoms for altered / loss of smell or taste, dyspnoea, fatigue, and myalgia in CYP with confirmed SARS-CoV-2 infection. Heterogeneity was high suggesting substantial variation amongst the included studies.

CONCLUSIONS

Many CYP continue to experience symptoms after SARS-CoV-2 infection. Efforts to aid early identification and intervention of those most in need is warranted and the consequences of COVID-19 for CYP call for long-term follow-up.

This needs to be a journey that we're actually on together'-the introduction of integrated care systems for children and young people in England: a qualitative study of the views of local system stakeholders during winter 2021/22

BACKGROUND

Integrated care has become a central feature of health system reform worldwide. In England, Integrated Care Systems (ICS) are intended to improve integration across public health, the National Health Service (NHS), education and social care. By April 2021, England had been divided into 42 geographical areas, each tasked with developing local ICS provision. However, it was not clear how ICSs would address the specific needs of children and young people (CYP). This study elicited the views of senior professional stakeholders in the first year of the ICS national roll out, to learn how integrated care for CYP was being implemented within the ICSs and future plans for service provision.

METHODS

A qualitative analysis of in-depth interviews with stakeholders, including healthcare professionals, NHS managers and local authority leaders (n = 25) selected from a diverse sample of ICSs (n = 7) across England, conducted during winter 2021/22. Reflexive thematic analysis involving a collaborative coding approach was used to analyse interview transcripts.

RESULTS

Four themes were identified, indicating challenges and opportunities for ICSs in relation to the health of CYP: 1) Best start in life (a more holistic approach to health afforded by integrated care); 2) Local and national contexts (tensions between local and national settings and priorities); 3) Funding and planning (instituting innovative, long-term plans using limited existing CYP funding streams); 4) Organisational complexities (integrating the work of diverse organisations).

CONCLUSIONS

The views of stakeholders, provided at the beginning of the journey towards developing local ICS CYP provision, revealed a common aspiration to change focus from provision of acute, largely adult-orientated services towards one with a broader, population health remit, including prevention and early intervention. This would be delivered by integration of a range of local services, including health, education, housing and social care, to set CYP on a life-long path towards improved health and wellbeing. Yet there was an awareness that change would take place over time within existing national policy and funding frameworks, and would require overcoming organisational barriers through further developing local collaborations and partnerships. As ICSs mature, the experiences of stakeholders should continue to be canvassed to identify practical lessons for successful CYP integrated care.

Estimating the effects of preventive and weight-management interventions on the prevalence of childhood obesity in England: a modelling study

BACKGROUND

The effects of the systematic delivery of treatments for obesity are unknown. We aimed to estimate the potential effects on the prevalence of childhood obesity of systematically offering preventive and treatment interventions to eligible children in England, based on weight or health status.

METHODS

For this modelling study, we developed a cross-sectional simulation model of the child and young adult population in England using data from multiple years of the Health Survey of England conducted between Jan 1, 2010, and Dec 31, 2019. Individuals were assessed for eligibility via age, BMI, and medical complications. Weight status was defined based on clinical criteria used by the UK National Institute of Health and Care Excellence. Published systematic reviews were used to estimate effect sizes for treatments, uptake, and completion for each weight-management tier. We used all available evidence, including evidence from studies that showed an unfavourable effect. We estimated the effects of two systematic approaches: a staged approach, in which children and young people were simultaneously given the most intensive treatment for which they were eligible, and a stepped approach, in which each management tier was applied sequentially, with additive effects. The primary outcomes were estimated prevalence of clinical obesity, defined as a BMI ≥98th centile on the UK90 growth chart, and difference in comparison with the estimated baseline prevalence.

FINDINGS

18 080 children and young people were included in the analytical sample. Baseline prevalence of clinical obesity was estimated to be 11·2% (95% CI 10·5 to 11·8) for children and young people aged 2-18 years. In modelling, we estimated absolute decreases in the prevalence of obesity of 0·9% (95% CI 0·1 to 1·8) for universal, preventive interventions; 0·2% (0·1 to 0·4) for interventions within a primary-care setting; 1·0% (0·1 to 2·1) for community and lifestyle interventions; 0·2% (0·0 to 0·4) for pharmaceutical interventions; and 0·4% (0·1 to 0·7) for surgical interventions. Staged care was estimated to result in an absolute decrease in the prevalence of obesity of 1·3% (-0·3 to 2·4) and stepped care was estimated to lead to an absolute decrease of 2·4% (0·1 to 4·8).

INTERPRETATION

Although individual effect sizes for prevention and treatment interventions were small, when delivered at scale across England, these interventions have the potential to meaningfully contribute to reducing the prevalence of childhood obesity.

FUNDING

UK National Institute for Health and Care Research.

Young People's Mental Health Changes, Risk, and Resilience During the COVID-19 Pandemic

Importance

As young people's mental health difficulties increase, understanding risk and resilience factors under challenging circumstances becomes critical.

Objective

To explore the outcomes of the COVID-19 pandemic on secondary school students' mental health difficulties, as well as the associations with individual, family, friendship, and school characteristics.

Design, Setting, and Participants

For this cohort study, follow-up data from the My Resilience in Adolescence (MYRIAD) cluster randomized clinical trial were collected across 2 representative UK cohorts. Mainstream UK secondary schools with a strategy and structure to deliver social-emotional learning, with an appointed head teacher, and that were not rated "inadequate" in their latest official inspection were recruited. A total of 5663 schools were approached, 532 showed interest, and 84 consented. Cohort 1 included 12 schools and 864 students, and cohort 2 included 72 schools and 6386 students. COVID-19 was declared a pandemic after cohort 1 had completed all assessments (September 2018 to January 2020), but cohort 2 had not (September 2019 to June 2021).

Exposures

Cohort 2 was exposed to the COVID-19 pandemic, including 3 national lockdowns. Associations of individual, family, friendship, and school characteristics with students' mental health were explored.

Main Outcomes and Measures

Changes in students' risk for depression (Center for Epidemiological Studies-Depression scale); social, emotional, and behavioral difficulties (Strengths and Difficulties Questionnaire); and mental well-being (Warwick-Edinburgh Mental Well-Being Scale).

Results

Of the 7250 participants included, the mean (SD) age was 13.7 (0.6) years, 3947 (55.4%) identified as female, and 5378 (73.1%) self-reported their race as White. Twelve schools and 769 of the 864 students (89.0%) in cohort 1 and 54 schools and 2958 of the 6386 students (46.3%) in cohort 2 provided data and were analyzed. Mental health difficulties increased in both cohorts but to a greater extent among students exposed to the pandemic, including for risk of depression (adjusted mean difference [AMD], 1.91; 95% CI, 1.07-2.76); social, emotional, and behavioral difficulties (AMD, 0.76; 95% CI, 0.33-1.18); and mental well-being (AMD, -2.08; 95% CI, -2.80 to -1.36). Positive school climate, high home connectedness, and having a friend during lockdown were protective factors during the pandemic. Female gender and initial low risk for mental health difficulties were associated with greater mental health deteriorations. Partial school attendance during lockdown was associated with better adjustment than no attendance when returning to school.

Conclusions and Relevance

This cohort study of secondary school students demonstrated that to promote mental health and adjustment, policy interventions should foster home connectedness, peer friendship, and school climate; avoid full school closures; and consider individual differences.

Pediatric Hospitalizations and ICU Admissions Due to COVID-19 and Pediatric Inflammatory Multisystem Syndrome Temporally Associated With SARS-CoV-2 in England

Importance

Investigating how the risk of serious illness after SARS-CoV-2 infection in children and adolescents has changed as new variants have emerged is essential to inform public health interventions and clinical guidance.

Objective

To examine risk factors associated with hospitalization for COVID-19 or pediatric inflammatory multisystem syndrome temporally associated with SARS-CoV-2 (PIMS-TS) among children and adolescents during the first 2 years of the COVID-19 pandemic and change in risk factors over time.

Design, Setting, and Participants

This population-level analysis of hospitalizations after SARS-CoV-2 infection in England among children and adolescents aged 0 to 17 years was conducted from February 1, 2020, to January 31, 2022. National data on hospital activity were linked with data on SARS-CoV-2 testing, SARS-CoV-2 vaccination, pediatric intensive care unit (PICU) admissions, and mortality. Children and adolescents hospitalized with COVID-19 or PIMS-TS during this time were included. Maternal, elective, and injury-related hospitalizations were excluded.

Exposures

Previous medical comorbidities, sociodemographic factors, and timing of hospitalization when different SARS-CoV-2 variants (ie, wild type, Alpha, Delta, and Omicron) were dominant in England.

Main Outcomes

PICU admission and death within 28 days of hospitalization with COVID-19 or PIMS-TS.

Results

A total of 10 540 hospitalizations due to COVID-19 and 997 due to PIMS-TS were identified within 1 125 010 emergency hospitalizations for other causes. The number of hospitalizations due to COVID-19 and PIMS-TS per new SARS-CoV-2 infections in England declined during the second year of the COVID-19 pandemic. Among 10 540 hospitalized children and adolescents, 448 (4.3%) required PICU admission due to COVID-19, declining from 162 of 1635 (9.9%) with wild type, 98 of 1616 (6.1%) with Alpha, and 129 of 3789 (3.4%) with Delta to 59 of 3500 (1.7%) with Omicron. Forty-eight children and adolescents died within 28 days of hospitalization due to COVID-19, and no children died of PIMS-TS (PIMS-S data were limited to November 2020 onward). Risk of severe COVID-19 in children and adolescents was associated with medical comorbidities and neurodisability regardless of SARS-CoV-2 variant. Results were similar when children and adolescents with prior SARS-CoV-2 exposure or vaccination were excluded.

Conclusions

In this study of data across the first 2 years of the COVID-19 pandemic, risk of severe disease from SARS-CoV-2 infection in children and adolescents in England remained low. Children and adolescents with multiple medical problems, particularly neurodisability, were at increased risk and should be central to public health measures as further variants emerge.

Approaches to consent in public health research in secondary schools

OBJECTIVES

We assess different approaches to seeking consent in research in secondary schools.

DESIGN

We review evidence on seeking active versus passive parent/carer consent on participant response rates and profiles. We explore the legal and regulatory requirements governing student and parent/carer consent in the UK.

RESULTS

Evidence demonstrates that requiring parent/carer active consent reduces response rates and introduces selection biases, which impact the rigour of research and hence its usefulness for assessing young people's needs. There is no evidence on the impacts of seeking active versus passive student consent but this is likely to be marginal when researchers are directly in communication with students in schools. There is no legal requirement to seek active parent/carer consent for children's involvement in research on non-medicinal intervention or observational studies. Such research is instead covered by common law, which indicates that it is acceptable to seek students' own active consent when they are judged competent. General data protection regulation legislation does not change this. It is generally accepted that most secondary school students age 11+ are competent to provide their own consent for interventions though this should be assessed individually.

CONCLUSION

Allowing parent/carer opt-out rights recognises their autonomy while giving primacy to student autonomy. In the case of intervention research, most interventions are delivered at the level of the school so consent can only practically be sought from head teachers. Where interventions are individually targeted, seeking student active consent for these should be considered where feasible.

Measurement Instruments for Integration within Children and Young People Healthcare Systems and Networks: A Rapid Review of the International Literature

Introduction

Robust measures of integration are essential for assessment of the development, design and implementation of integration within healthcare systems. This review aimed to identify measurement instruments for integration within children and young people's (CYP) healthcare systems (PROSPERO registration number CRD42021235383).

Methods

We searched electronic databases (PubMED and Ovid Embase) using three main concepts: '(integrated care) AND (child population) AND (measurement)', along with additional searches.

Results

Fifteen studies describing 16 measurement instruments were eligible for inclusion. The majority of studies were conducted in the USA. There was a diversity of health conditions included in the studies. The most frequent type of assessment used was a questionnaire (11 identified), but interviews, patient data and healthcare records, and focus groups were also used. Integration outcomes assessed were quality of care coordination, quality of collaboration, continuity of care, completeness of care, structure of care, quality of communication, and local implementation of integrated care.

Conclusion

A variety of instruments for the measurement of integration within CYP healthcare systems were identified. Further work on the standardisation of integrated care measures would be valuable; however, it is important that instruments and measures meet the needs of specific settings, populations and conditions being studied.

Puberty and risky decision-making in male adolescents

Pubertal development is a potential trigger for increases in risk-taking behaviours during adolescence. Here, we sought to investigate the relationship between puberty and neural activation during risky decision-making in males using functional magnetic resonance imaging (fMRI). Forty-seven males aged 12.5-14.5 years completed an fMRI risk-taking task (BART) and reported their tendencies for risky decision-making using a self-report questionnaire. Puberty was assessed through self-reported pubertal status and salivary testosterone levels. Testosterone concentration, but not physical pubertal status, was positively correlated with self-reported risk-taking behaviour, while neither was correlated with BART performance. Across the whole sample, participants had greater activation of the bilateral nucleus accumbens and right caudate on trials when they made a successful risky decision compared to trials when they made a safe choice or when their risky decision was unsuccessful. There was a negative correlation between pubertal stage and brain activation during unsuccessful risky decision-making trials compared within unsuccessful control trials. Males at a lower stage of pubertal development showed increased activation in the left insula, right cingulate cortex, dorsomedial prefrontal cortex (dmPFC), right putamen and right orbitofrontal cortex (OFC) relative to more pubertally mature males during trials when they chose to take a risk and the balloon popped compared to when they watched the computer make an unsuccessful risky decision. Less pubertally mature males also showed greater activation in brain regions including the dmPFC, right temporal and frontal cortices, right OFC, right hippocampus and occipital cortex in unsuccessful risky trials compared to successful risky trials. These results suggest a puberty-related shift in neural activation within key brain regions when processing outcomes of risky decisions, which may reduce their sensitivity to negative feedback, and in turn contribute to increases in adolescent risk-taking behaviours.

Exploring predictors and moderators of response to multimodal obesity treatment in children

OBJECTIVE

The aim of this study was to determine whether specific psychological factors influence intervention effects for children with severe obesity in a clinical setting.

DESIGN

Secondary analyses of data about attention deficit/hyperactivity disorder (ADHD) characteristics, body satisfaction, social and emotional functioning, and the primary outcome, change in body mass index (BMI), were available for 41 out of 72 children and their families randomised to family-based behavioural treatment over 6 months or waiting list control. Regression analyses, with an interaction term for treatment condition, were performed to explore baseline factors and moderators of outcome.

RESULTS

Parents reporting their child's emotional well-being as high and high maternal education significantly predicted less weight loss for the total sample, with no effect of ethnicity, age, sex or baseline BMI. Children's social functioning was a significant moderator of treatment effect; children with high social function showed a decrease in BMI after 6 months of therapy (R²=0.08-0.13), whereas an increase in BMI was observed in children with high social function who waited for treatment. For children with poor social function, no treatment effect was observed-subjects lost weight in both conditions. No significant moderation effect was found for body (dis)satisfaction, emotional status, comorbid depression or ADHD, adjusting for baseline BMI, age, sex and ethnicity.

CONCLUSIONS

These preliminary findings suggest directions for development of tailored obesity programmes. Professionals engaged in treatment of childhood obesity should consider a child's emotional and social functioning when considering group obesity intervention, as well as the risks of no intervention.

Modelling timing and tempo of adrenarche in a prospective cohort study

To better understand how health risk processes are linked to adrenarche, measures of adrenarcheal timing and tempo are needed. Our objective was to describe and classify adrenal trajectories, in terms of timing and tempo, in a population of children transitioning to adolescence with repeated measurements of salivary dehydroepiandrosterone (DHEA), DHEA-sulphate, and testosterone. We analysed data from the Childhood to Adolescence Transition Study (CATS), a longitudinal study of 1239 participants, recruited at 8-9 years old and followed up annually. Saliva samples were assayed for adrenal hormones. Linear mixed-effect models with subject-specific random intercepts and slopes were used to model longitudinal hormone trajectories by sex and derive measures of adrenarcheal timing and tempo. The median values for all hormones were higher at each consecutive study wave for both sexes, and higher for females than males. For all hormones, between-individual variation in hormone levels at age 9 (timing) was moderately large and similar for females and males. Between-individual variation in hormone progression over time (tempo) was of moderate magnitude compared with the population average age-slope, which itself was small compared with overall hormone level at each age. This suggests that between-individual variation in tempo was less important for modelling hormone trajectories. Between-individual variation in timing was more important for determining relative adrenal hormonal level in childhood than tempo. This finding suggests that adrenal hormonal levels at age 8-9 years can be used to predict relative levels in early adolescence (up to 13 years).

Advertising and Young People's Critical Reasoning Abilities: Systematic Review and Meta-analysis

BACKGROUND AND OBJECTIVES

Young people are exposed to an abundance of advertising for unhealthy products (eg, unhealthy foods, tobacco, alcohol). Because of their developing cognition, children may not be able to understand the intent of advertising. However, advertising restrictions often assume that adolescents have critical reasoning capacity and can resist the effects of advertising. This review seeks to assess whether the evidence supports this assumption.

METHODS

Ten databases were searched in December 2020. Inclusion criteria were participants aged 6 to 17 years, any advertising exposure, objectively measured understanding or attitudinal outcome, a comparison, control, and between-group comparison. This study included all languages and excluded studies published pre-2010. Two reviewers independently extracted data and assessed study quality.

RESULTS

Thirty-eight articles were included. Meta-analysis of 9 studies with attitudinal outcomes indicated that unhealthy product advertising generated more positive brand or product attitudes compared with neutral or no advertising control in all ages. There were significant effects for digital and nondigital advertising formats. We found greater understanding did not protect against the impact of advertising on brand or product attitudes. Limitations include the inability to meta-analyze the impact of advertising on understanding or the influence of age.

CONCLUSIONS

Evidence shows that the attitudes of young people were influenced by advertising. Critical reasoning abilities did not appear to be fully developed during adolescence and not found to be protective against the impact of advertising. Policymakers should ensure regulations to restrict marketing of unhealthy commodities protects adolescents as well as younger children.

Learning outcomes in primary school children with emotional problems: a prospective cohort study

BACKGROUND

Academic difficulties are common in adolescents with mental health problems. Although earlier childhood emotional problems, characterised by heightened anxiety and depressive symptoms are common forerunners to adolescent mental health problems, the degree to which mental health problems in childhood may contribute independently to academic difficulties has been little explored.

METHODS

Data were drawn from a prospective cohort study of students in Melbourne, Australia (N = 1239). Data were linked with a standardised national assessment of academic performance at baseline (9 years) and wave three (11 years). Depressive and anxiety symptoms were assessed at baseline and wave two (10 years). Regression analyses estimated the association between emotional problems (9 and/or 10 years) and academic performance at 11 years, adjusting for baseline academic performance, sex, age and socioeconomic status, and hyperactivity/inattention symptoms.

RESULTS

Students with depressive symptoms at 9 years of age had lost nearly 4 months of numeracy learning two years later after controlling for baseline academic performance and confounders. Results were similar for anxiety symptoms. Regardless of when depressive symptoms occurred there were consistent associations with poorer numeracy performance at 11 years. The association of depressive symptoms with reading performance was weaker than for numeracy if they were present at wave two. Persistent anxiety symptoms across two waves led to nearly a 4 month loss of numeracy learning at 11 years, but the difference was not meaningful for reading. Findings were similar when including hyperactivity/inattention symptoms.

CONCLUSIONS

Childhood anxiety and depression are not only forerunners of later mental health problems but predict academic achievement. Partnerships between education and health systems have the potential to not only improve childhood emotional problems but also improve learning.

How did the covid-19 pandemic affect lower respiratory tract infections in young children in England?

Background

Social distancing policies to reduce transmission of covid-19 also reduced children's exposures to endemic respiratory viruses. We aimed to examine the impact of the covid-19 pandemic on lower respiratory tract infections in under 5s presenting to primary care in England.

Methods

Longitudinal trends analysis using electronic health records from a nationally representative primary care database. Our target population was children aged &lt;5 years registered with a primary care practice from January 2015 to March 2021.

Our main outcome was total weekly contacts with primary care for a lower respiratory tract infection (LRTI). We defined three pandemic phases from March 2020 - March 2021: i) first national lockdown (late March to early June 2020), ii) childcare settings reopened and second national lockdown with schools open (mid-June to mid-December 2020) and iii) third national lockdown with schools closed (late December 2020 to end of March 2021). We compared outcomes during each of the three phases with corresponding calendar weeks during pre-pandemic years 2015 to 2019.

Results

Our study population included 843 020 children &lt;5 years who had 1 076 181 contacts with primary care for LRTIs. During the first phase (first lockdown) there were falls of 79.3% (95% CI: 73.6 to 84.5) from an average of 28 547 primary care contacts for LRTI in 2015 - 2019 to 5915 in 2020; there was a 78.9% (95% CI: 73.7 to 83.9) fall in phase two (childcare settings reopened and second lockdown) from 107 873 to 22 792 contacts; and a 77.7% (95% CI: 73.5 to 81.4) fall in phase three (third lockdown) from 57 200 to 12 764 contacts.

Conclusions

Children under 5 in England had fewer contacts with primary care for LRTIs during the covid-19 pandemic. This change likely reflects lower prevalence of respiratory illness due to fewer social contacts. This may impact on future health service use as these children have had less exposure, and therefore may have less immunity, to respiratory diseases.

Key messages

• Children under 5 had fewer contacts with primary care for lower respiratory tract infections during the covid-19 pandemic in England likely due to the restrictions in place to reduce social contacts.

• The falls in lower respiratory tract infections during the covid-19 pandemic in under 5s may mean they have less immunity to respiratory viruses which may impact upon their future health service use.

Modelling the impact of reopening schools in the UK in early 2021 in the presence of the alpha variant and with roll-out of vaccination against SARS-CoV-2

Following the resurgence of the COVID-19 epidemic in the UK in late 2020 and the emergence of the alpha (also known as B117) variant of the SARS-CoV-2 virus, a third national lockdown was imposed from January 4, 2021. Following the decline of COVID-19 cases over the remainder of January 2021, the question of when and how to reopen schools became an increasingly pressing one in early 2021. This study models the impact of a partial national lockdown with social distancing measures enacted in communities and workplaces under different strategies of reopening schools from March 8, 2021 and compares it to the impact of continual full national lockdown remaining until April 19, 2021. We used our previously published agent-based model, Covasim, to model the emergence of the alpha variant over September 1, 2020 to January 31, 2021 in presence of Test, Trace and Isolate (TTI) strategies. We extended the model to incorporate the impacts of the roll-out of a two-dose vaccine against COVID-19, with 200,000 daily vaccine doses prioritised by age starting with people 75 years or older, assuming vaccination offers a 95% reduction in disease acquisition risk and a 30% reduction in transmission risk. We used the model, calibrated until January 25, 2021, to simulate the impact of a full national lockdown (FNL) with schools closed until April 19, 2021 versus four different partial national lockdown (PNL) scenarios with different elements of schooling open: 1) staggered PNL with primary schools and exam-entry years (years 11 and 13) returning on March 8, 2021 and the rest of the schools years on March 15, 2020; 2) full-return PNL with both primary and secondary schools returning on March 8, 2021; 3) primary-only PNL with primary schools and exam critical years (years 11 and 13) going back only on March 8, 2021 with the rest of the secondary schools back on April 19, 2021 and 4) part-rota PNL with both primary and secondary schools returning on March 8, 2021 with primary schools remaining open continuously but secondary schools on a two-weekly rota-system with years alternating between a fortnight of face-to-face and remote learning until April 19, 2021. Across all scenarios, we projected the number of new daily cases, cumulative deaths and effective reproduction number R until April 30, 2021. Our calibration across different scenarios is consistent with alpha variant being around 60% more transmissible than the wild type. We find that strict social distancing measures, i.e. national lockdowns, were essential in containing the spread of the virus and controlling hospitalisations and deaths during January and February 2021. We estimated that a national lockdown over January and February 2021 would reduce the number of cases by early March to levels similar to those seen in October 2020, with R also falling and remaining below 1 over this period. We estimated that infections would start to increase when schools reopened, but found that if other parts of society remain closed, this resurgence would not be sufficient to bring R above 1. Reopening primary schools and exam critical years only or having primary schools open continuously with secondary schools on rotas was estimated to lead to lower increases in cases and R than if all schools opened. Without an increase in vaccination above the levels seen in January and February, we estimate that R could have increased above 1 following the reopening of society, simulated here from April 19, 2021. Our findings suggest that stringent measures were integral in mitigating the increase in cases and bringing R below 1 over January and February 2021. We found that it was plausible that a PNL with schools partially open from March 8, 2021 and the rest of the society remaining closed until April 19, 2021 would keep R below 1, with some increase evident in infections compared to continual FNL until April 19, 2021. Reopening society in mid-April, without an increase in vaccination levels, could push R above 1 and induce a surge in infections, but the effect of vaccination may be able to control this in future depending on the transmission blocking properties of the vaccines.

Developing a core outcome set for physical activity interventions in primary schools: a modified-Delphi study

OBJECTIVES

To develop a core outcome set (COS) for physical activity interventions in primary schools.

DESIGN

Modified-Delphi study.

SETTING

The UK and international.

PARTICIPANTS

104 participants from four stakeholder groups (educators, public health professionals, health researchers, parents); 16 children (aged 8-9 years) from 1 London primary school.

INTERVENTIONS

Physical activity interventions.

METHODS

Four-stage process: (1) outcomes extracted from relevant studies identified from an umbrella review and a focus group; (2) list of outcomes produced and domains established; (3) stakeholders completed a two-round Delphi survey by rating (Round 1) and re-rating (Round 2) each outcome on a nine-point Likert Scale from 'not important' to 'critical': a>70% participant threshold identified the outcomes rated 'critical' to measure, and outcomes important to children were identified through a workshop; and (4) a stakeholder meeting to achieve consensus of the outcomes to include in the COS.

RESULTS

In total, 74 studies were extracted from 53 reviews. A list of 50 outcomes was produced and three domains were established: 'physical activity and health' (16 outcomes), 'social and emotional health' (22 outcomes) and 'educational performance' (12 outcomes). 104 participants completed survey Round 1; 65 participants completed both rounds. In total, 13 outcomes met the threshold; children identified 8 outcomes. Fourteen outcomes achieved consensus to produce the COS: five outcomes for physical activity and health (diet (varied and balanced), energy, fitness, intensity of physical activity, sleep (number of hours)); seven outcomes for social and emotional health (anxiety, depression, enjoyment, happiness, self-esteem, stress, well-being); and two outcomes for educational performance (concentration, focus).

CONCLUSIONS

We have developed the first COS for physical activity interventions in primary schools in consultation with those interested in the development and application of an agreed standardised set of outcomes. Future studies including these outcomes will reduce heterogeneity across studies.

TRIAL REGISTRATION NUMBER

Core Outcome Measures in Effectiveness Trials Initiative registration number 1322; Results.

Impact of COVID-19 on outpatient appointments in children and young people in England: an observational study

OBJECTIVES

To describe the impact of the COVID-19 pandemic on outpatient appointments for children and young people.

SETTING

All National Health Service (public) hospitals in England.

PARTICIPANTS

All people in England aged <25 years.

OUTCOME MEASURES

Outpatient department attendance numbers, rates and modes (face to face vs telephone) by age group, sex and socioeconomic deprivation.

RESULTS

Compared with the average for January 2017 to December 2019, there was a 3.8 million appointment shortfall (23.5%) for the under-25 population in England between March 2020 and February 2021, despite a total rise in phone appointments of 2.6 million during that time. This was true for each age group, sex and deprivation fifth, but there were smaller decreases in face to face and total appointments for babies under 1 year. For all ages combined, around one in six first and one in four follow-up appointments were by phone in the most recent period. The proportion of appointments attended was high, at over 95% for telephone and over 90% for face-to-face appointments for all ages.

CONCLUSIONS

COVID-19 led to a dramatic fall in total outpatient appointments and a large rise in the proportion of those appointments conducted by telephone. The impact that this has had on patient outcomes is still unknown. The differential impact of COVID-19 on outpatient activity in different sociodemographic groups may also inform design of paediatric outpatient services in the post-COVID period.

Determinants of accident and emergency attendances and emergency admissions in infants: birth cohort study

BACKGROUND

There is limited understanding of the drivers of increasing infant accident and emergency (A&E) attendances and emergency hospital admissions across England. We examine variations in use of emergency hospital services among infants by local areas in England and investigate the extent to which infant and socio-economic factors explain these variations.

METHODS

Birth cohort study using linked administrative Hospital Episode Statistics data in England. Singleton live births between 1-April-2012 and 31-March-2019 were followed up for 1 year; from 1-April-2013 (from the discharge date of their birth admission) until their first birthday, death or 31-March-2019. Mixed effects negative binomial models were used to calculate incidence rate ratios for A&E attendances and emergency admissions and mixed effects logistic regression models estimated odds ratio of conversion (the proportion of infants subsequently admitted after attending A&E). Models were adjusted for individual-level factors and included a random effect for local authority (LA).

RESULTS

The cohort comprised 3,665,414 births in 150 English LAs. Rates of A&E attendances and emergency admissions were highest amongst: infants born < 32 weeks gestation; with presence of congenital anomaly; and to mothers < 20-years-old. Area-level deprivation was positively associated with A&E attendance rates, but not associated with conversion probability. A&E attendance rates were highest in the North East (916 per 1000 child-years, 95%CI: 911 to 921) and London (876 per 1000, 95%CI: 874 to 879), yet London had the lowest emergency admission rates (232 per 1000, 95%CI: 231 to 234) and conversion probability (25% vs 39% in South West). Adjusting for individual-level factors did not significantly affect variability in A&E attendance and emergency admission rates by local authority.

CONCLUSIONS

Drivers of A&E attendances and emergency admissions include individual-level factors such being born premature, with congenital anomaly and from socio-economically disadvantaged young parent families. Support for such vulnerable infants and families should be provided alongside preventative health care in primary and community care settings. The impact of these services requires further investigation. Substantial geographical variations in rates were not explained by individual-level factors. This suggests more detailed understanding of local and underlying service-level factors would provide targets for further research on mechanisms and policy priority.

Effectiveness of universal school-based mindfulness training compared with normal school provision on teacher mental health and school climate: results of the MYRIAD cluster randomised controlled trial

BACKGROUND

Education is broader than academic teaching. It includes teaching students social-emotional skills both directly and indirectly through a positive school climate.

OBJECTIVE

To evaluate if a universal school-based mindfulness training (SBMT) enhances teacher mental health and school climate.

METHODS

The My Resilience in Adolescence parallel group, cluster randomised controlled trial (registration: ISRCTN86619085; funding: Wellcome Trust (WT104908/Z/14/Z, WT107496/Z/15/Z)) recruited 85 schools (679 teachers) delivering social and emotional teaching across the UK. Schools (clusters) were randomised 1:1 to either continue this provision (teaching as usual (TAU)) or include universal SBMT. Data on teacher mental health and school climate were collected at prerandomisation, postpersonal mindfulness and SBMT teacher training, after delivering SBMT to students, and at 1-year follow-up.

FINDING

Schools were recruited in academic years 2016/2017 and 2017/2018. Primary analysis (SBMT: 43 schools/362 teachers; TAU: 41 schools/310 teachers) showed that after delivering SBMT to students, SBMT versus TAU enhanced teachers' mental health (burnout) and school climate. Adjusted standardised mean differences (SBMT minus TAU) were: exhaustion (-0.22; 95% CI -0.38 to -0.05); personal accomplishment (-0.21; -0.41, -0.02); school leadership (0.24; 0.04, 0.44); and respectful climate (0.26; 0.06, 0.47). Effects on burnout were not significant at 1-year follow-up. Effects on school climate were maintained only for respectful climate. No SBMT-related serious adverse events were reported.

CONCLUSIONS

SBMT supports short-term changes in teacher burnout and school climate. Further work is required to explore how best to sustain improvements.

CLINICAL IMPLICATIONS

SBMT has limited effects on teachers' mental and school climate. Innovative approaches to support and preserve teachers' mental health and school climate are needed.

Effectiveness and cost-effectiveness of universal school-based mindfulness training compared with normal school provision in reducing risk of mental health problems and promoting well-being in adolescence: the MYRIAD cluster randomised controlled trial

BACKGROUND

Systematic reviews suggest school-based mindfulness training (SBMT) shows promise in promoting student mental health.

OBJECTIVE

The My Resilience in Adolescence (MYRIAD) Trial evaluated the effectiveness and cost-effectiveness of SBMT compared with teaching-as-usual (TAU).

METHODS

MYRIAD was a parallel group, cluster-randomised controlled trial. Eighty-five eligible schools consented and were randomised 1:1 to TAU (43 schools, 4232 students) or SBMT (42 schools, 4144 students), stratified by school size, quality, type, deprivation and region. Schools and students (mean (SD); age range=12.2 (0.6); 11-14 years) were broadly UK population-representative. Forty-three schools (n=3678 pupils; 86.9%) delivering SBMT, and 41 schools (n=3572; 86.2%) delivering TAU, provided primary end-point data. SBMT comprised 10 lessons of psychoeducation and mindfulness practices. TAU comprised standard social-emotional teaching. Participant-level risk for depression, social-emotional-behavioural functioning and well-being at 1 year follow-up were the co-primary outcomes. Secondary and economic outcomes were included.

FINDINGS

Analysis of 84 schools (n=8376 participants) found no evidence that SBMT was superior to TAU at 1 year. Standardised mean differences (intervention minus control) were: 0.005 (95% CI -0.05 to 0.06) for risk for depression; 0.02 (-0.02 to 0.07) for social-emotional-behavioural functioning; and 0.02 (-0.03 to 0.07) for well-being. SBMT had a high probability of cost-effectiveness (83%) at a willingness-to-pay threshold of £20 000 per quality-adjusted life year. No intervention-related adverse events were observed.

CONCLUSIONS

Findings do not support the superiority of SBMT over TAU in promoting mental health in adolescence.

CLINICAL IMPLICATIONS

There is need to ask what works, for whom and how, as well as considering key contextual and implementation factors.

TRIAL REGISTRATION

Current controlled trials ISRCTN86619085. This research was funded by the Wellcome Trust (WT104908/Z/14/Z and WT107496/Z/15/Z).

The impact on dietary outcomes of licensed and brand equity characters in marketing unhealthy foods to children: A systematic review and meta-analysis

Licensed and brand equity characters are used to target children in the marketing of products high in fat, salt, and sugar (HFSS), but the impact of characters on dietary outcomes is unclear. The primary aim of this review was to quantify the impact of both licensed and brand equity characters on children's dietary outcomes given that existing regulations often differentiates between these character types. We systematically searched eight interdisciplinary databases and included studies from 2009 onwards until August 2021, including all countries and languages. Participants were children under 16 years, exposure was marketing for HFSS product with a character, and the outcomes were dietary consumption, preference, or purchasing behaviors of HFSS products. Data allowed for meta-analysis of taste preferences. A total of 16 articles (including 20 studies) met the inclusion criteria, of which five were included in the meta-analysis. Under experimental conditions, the use of characters on HFSS packaging compared with HFSS packaging with no character was found to result in significantly higher taste preference for HFSS products (standardized mean difference on a 5-point scale 0.273; p < 0.001). Narrative findings supported this, with studies reporting impact of both character types on product preferences including food liking and snack choice. There was limited evidence on the impact on purchase behaviors and consumption. These findings are supportive of policies that limit the exposure of HFSS food marketing using characters to children.

The burden of mental disorders, substance use disorders and self-harm among young people in Europe, 1990-2019: Findings from the Global Burden of Disease Study 2019

Background

Mental health is a public health issue for European young people, with great heterogeneity in resource allocation. Representative population-based studies are needed. The Global Burden of Disease (GBD) Study 2019 provides internationally comparable information on trends in the health status of populations and changes in the leading causes of disease burden over time.

Methods

Prevalence, incidence, Years Lived with Disability (YLDs) and Years of Life Lost (YLLs) from mental disorders (MDs), substance use disorders (SUDs) and self-harm were estimated for young people aged 10-24 years in 31 European countries. Rates per 100,000 population, percentage changes in 1990-2019, 95% Uncertainty Intervals (UIs), and correlations with Sociodemographic Index (SDI), were estimated.

Findings

In 2019, rates per 100,000 population were 16,983 (95% UI 12,823 - 21,630) for MDs, 3,891 (3,020 - 4,905) for SUDs, and 89·1 (63·8 - 123·1) for self-harm. In terms of disability, anxiety contributed to 647·3 (432-912·3) YLDs, while in terms of premature death, self-harm contributed to 319·6 (248·9-412·8) YLLs, per 100,000 population. Over the 30 years studied, YLDs increased in eating disorders (14·9%;9·4-20·1) and drug use disorders (16·9%;8·9-26·3), and decreased in idiopathic developmental intellectual disability (-29·1%;23·8-38·5). YLLs decreased in self-harm (-27·9%;38·3-18·7). Variations were found by sex, age-group and country. The burden of SUDs and self-harm was higher in countries with lower SDI, MDs were associated with SUDs.

Interpretation

Mental health conditions represent an important burden among young people living in Europe. National policies should strengthen mental health, with a specific focus on young people.

Funding

The Bill and Melinda Gates Foundation.

Persistent symptoms following SARS-CoV-2 infection amongst children and young people: A meta-analysis of controlled and uncontrolled studies

BACKGROUND

Data on the long-term impact of SARS-CoV-2 infection in children and young people (CYP) are conflicting. We assessed evidence on long-term post-COVID symptoms in CYP examining prevalence, risk factors, type and duration.

METHODS

Systematic search of published and unpublished literature using 13 online databases between 01/12/2019 and 31/07/2021. Eligible studies reported CYP ≤19 years with confirmed or probable SARS-CoV-2 with any symptoms persisting beyond acute illness. Random effects meta-analyses estimated pooled risk difference in symptom prevalence (controlled studies only) and pooled prevalence (uncontrolled studies also included). Meta-regression examined study characteristics hypothesised to be associated with symptom prevalence. Prospectively registered: CRD42021233153.

FINDINGS

Twenty two of 3357 unique studies were eligible, including 23,141 CYP. Median duration of follow-up was 125 days (IQR 99-231). Pooled risk difference in post-COVID cases compared to controls (5 studies) were significantly higher for cognitive difficulties (3% (95% CI 1, 4)), headache (5% (1, 8)), loss of smell (8%, (2, 15)), sore throat (2% (1, 2)) and sore eyes (2% (1, 3)) but not abdominal pain, cough, fatigue, myalgia, insomnia, diarrhoea, fever, dizziness or dyspnoea. Pooled prevalence of symptoms in post-COVID participants in 17 studies ranged from 15% (diarrhoea) to 47% (fatigue). Age was associated with higher prevalence of all symptoms except cough. Higher study quality was associated with lower prevalence of all symptoms, except loss of smell and cognitive symptoms.

INTERPRETATION

The frequency of the majority of reported persistent symptoms was similar in SARS-CoV-2 positive cases and controls. This systematic review and meta-analysis highlights the critical importance of a control group in studies on CYP post SARS-CoV-2 infection.

Which children and young people are at higher risk of severe disease and death after hospitalisation with SARS-CoV-2 infection in children and young people: A systematic review and individual patient meta-analysis

BACKGROUND

We aimed to describe pre-existing factors associated with severe disease, primarily admission to critical care, and death secondary to SARS-CoV-2 infection in hospitalised children and young people (CYP), within a systematic review and individual patient meta-analysis.

METHODS

We searched Pubmed, European PMC, Medline and Embase for case series and cohort studies published between 1st January 2020 and 21st May 2021 which included all CYP admitted to hospital with ≥ 30 CYP with SARS-CoV-2 or ≥ 5 CYP with PIMS-TS or MIS-C. Eligible studies contained (1) details of age, sex, ethnicity or co-morbidities, and (2) an outcome which included admission to critical care, mechanical invasive ventilation, cardiovascular support, or death. Studies reporting outcomes in more restricted groupings of co-morbidities were eligible for narrative review. We used random effects meta-analyses for aggregate study-level data and multilevel mixed effect models for IPD data to examine risk factors (age, sex, comorbidities) associated with admission to critical care and death. Data shown are odds ratios and 95% confidence intervals (CI).PROSPERO: CRD42021235338.

FINDINGS

83 studies were included, 57 (21,549 patients) in the meta-analysis (of which 22 provided IPD) and 26 in the narrative synthesis. Most studies had an element of bias in their design or reporting. Sex was not associated with critical care or death. Compared with CYP aged 1-4 years (reference group), infants (aged <1 year) had increased odds of admission to critical care (OR 1.63 (95% CI 1.40-1.90)) and death (OR 2.08 (1.57-2.86)). Odds of death were increased amongst CYP over 10 years (10-14 years OR 2.15 (1.54-2.98); >14 years OR 2.15 (1.61-2.88)).The number of comorbid conditions was associated with increased odds of admission to critical care and death for COVID-19 in a step-wise fashion. Compared with CYP without comorbidity, odds ratios for critical care admission were: 1.49 (1.45-1.53) for 1 comorbidity; 2.58 (2.41-2.75) for 2 comorbidities; 2.97 (2.04-4.32) for ≥3 comorbidities. Corresponding odds ratios for death were: 2.15 (1.98-2.34) for 1 comorbidity; 4.63 (4.54-4.74) for 2 comorbidities and 4.98 (3.78-6.65) for ≥3 comorbidities. Odds of admission to critical care were increased for all co-morbidities apart from asthma (0.92 (0.91-0.94)) and malignancy (0.85 (0.17-4.21)) with an increased odds of death in all co-morbidities considered apart from asthma. Neurological and cardiac comorbidities were associated with the greatest increase in odds of severe disease or death. Obesity increased the odds of severe disease and death independently of other comorbidities. IPD analysis demonstrated that, compared to children without co-morbidity, the risk difference of admission to critical care was increased in those with 1 comorbidity by 3.61% (1.87-5.36); 2 comorbidities by 9.26% (4.87-13.65); ≥3 comorbidities 10.83% (4.39-17.28), and for death: 1 comorbidity 1.50% (0.00-3.10); 2 comorbidities 4.40% (-0.10-8.80) and ≥3 co-morbidities 4.70 (0.50-8.90).

INTERPRETATION

Hospitalised CYP at greatest vulnerability of severe disease or death with SARS-CoV-2 infection are infants, teenagers, those with cardiac or neurological conditions, or 2 or more comorbid conditions, and those who are obese. These groups should be considered higher priority for vaccination and for protective shielding when appropriate. Whilst odds ratios were high, the absolute increase in risk for most comorbidities was small compared to children without underlying conditions.

FUNDING

RH is in receipt of a fellowship from Kidney Research UK (grant no. TF_010_20171124). JW is in receipt of a Medical Research Council Fellowship (Grant No. MR/R00160X/1). LF is in receipt of funding from Martin House Children's Hospice (there is no specific grant number for this). RV is in receipt of a grant from the National Institute of Health Research to support this work (grant no NIHR202322). Funders had no role in study design, data collection, analysis, decision to publish or preparation of the manuscript.

Alternatives to mental health admissions for children and adolescents experiencing mental health crises: A systematic review of the literature

Background: Many children and young people (CYP) presenting with mental health crises are admitted to hospital due to concerns around illness severity and risk. Whilst inpatient admissions have an important role for such children, there are a number of burdens associated with them, and safe avoidance of admissions is favourable. We systematically reviewed the literature for studies of interventions reported as alternatives to a hospital admission in CYP presenting with mental health crises, in any inpatient setting. Methods: Three databases (PsychInfo, PubMed and Web of Science) were searched for peer-reviewed papers in October 2020, with an updated search in May 2021. Results: We identified 19 papers of interventions delivered in the emergency department, the home, outside of home but outside of clinics and in hospital clinics. The quality of most included studies was low, with less than half being randomised controlled trials and only half of these at low risk of bias. The best quality studies and greatest evidence for efficacy came from in-home interventions, in particular multisystemic therapy, which improved psychological outcomes, and though a large number of CYP still ended up being admitted, there appeared to be decreased length of stay. Conclusions: Overall, we could not recommend a particular intervention as an alternative to inpatient admission; however, our review describes benefits across a range of types of interventions that might be considered in multi-modal treatments. We also provide recommendations for future research, in particular the evaluation of new interventions as they emerge.

The Role of Schools in Early Adolescents' Mental Health: Findings From the MYRIAD Study

OBJECTIVE

Recent studies suggest mental health in youths is deteriorating. The current policy in the United Kingdom emphasizes the role of schools for mental health promotion and prevention, but little data exist on what aspects of schools influence mental health in pupils. This study explored school-level influences on the mental health of young people in a large school-based sample from the United Kingdom.

METHOD

Baseline data from a large cluster randomized controlled trial collected between 2016 and 2018 from mainstream secondary schools selected to be representative in relation to their quality rating, size, deprivation, mixed or single-sex pupil population, and country were analyzed. Participants were pupils in their first or second year of secondary school. The study assessed whether school-level factors were associated with pupil mental health.

RESULTS

The study included 26,885 pupils (response rate = 90%; age range, 11‒14 years; 55% female) attending 85 schools in the United Kingdom. Schools accounted for 2.4% (95% CI: 2.0%‒2.8%; p < .0001) of the variation in psychopathology, 1.6% (95% CI: 1.2%‒2.1%; p < .0001) of depression, and 1.4% (95% CI: 1.0%‒1.7%; p < .0001) of well-being. Schools in urban locations, with a higher percentage of free school meals and of White British, were associated with poorer pupil mental health. A more positive school climate was associated with better mental health.

CONCLUSION

School-level variables, primarily related to contextual factors, characteristics of pupil population, and school climate, explain a small but significant amount of variability in mental health of young people. This information might be used to identify schools that are in need of more resources to support mental health of young people.

CLINICAL TRIAL REGISTRATION INFORMATION

MYRIAD: My Resilience in Adolescence, a Study Examining the Effectiveness and Cost-Effectiveness of a Mindfulness Training Programme in Schools Compared With Normal School Provision; https://www.isrctn.com/; 86619085.

Research priorities for mental health in schools in the wake of COVID-19

Children and young people (CYP) have suffered challenges to their mental health as a result of the COVID-19 pandemic; effects have been most pronounced on those already disadvantaged. Adopting a whole-school approach embracing changes to school environments, cultures and curricula is key to recovery, combining social and emotional skill building, mental health support and interventions to promote commitment and belonging. An evidence-based response must be put in place to support schools, which acknowledges that the mental health and well-being of CYP should not be forfeited in the drive to address the attainment gap. Schools provide an ideal setting for universal screening of mental well-being to help monitor and respond to the challenges facing CYP in the wake of the pandemic. Research is needed to support identification and implementation of suitable screening methods.

Global, regional, and national mortality among young people aged 10-24 years, 1950-2019: a systematic analysis for the Global Burden of Disease Study 2019

BACKGROUND

Documentation of patterns and long-term trends in mortality in young people, which reflect huge changes in demographic and social determinants of adolescent health, enables identification of global investment priorities for this age group. We aimed to analyse data on the number of deaths, years of life lost, and mortality rates by sex and age group in people aged 10-24 years in 204 countries and territories from 1950 to 2019 by use of estimates from the Global Burden of Diseases, Injuries, and Risk Factors Study (GBD) 2019.

METHODS

We report trends in estimated total numbers of deaths and mortality rate per 100 000 population in young people aged 10-24 years by age group (10-14 years, 15-19 years, and 20-24 years) and sex in 204 countries and territories between 1950 and 2019 for all causes, and between 1980 and 2019 by cause of death. We analyse variation in outcomes by region, age group, and sex, and compare annual rate of change in mortality in young people aged 10-24 years with that in children aged 0-9 years from 1990 to 2019. We then analyse the association between mortality in people aged 10-24 years and socioeconomic development using the GBD Socio-demographic Index (SDI), a composite measure based on average national educational attainment in people older than 15 years, total fertility rate in people younger than 25 years, and income per capita. We assess the association between SDI and all-cause mortality in 2019, and analyse the ratio of observed to expected mortality by SDI using the most recent available data release (2017).

FINDINGS

In 2019 there were 1·49 million deaths (95% uncertainty interval 1·39-1·59) worldwide in people aged 10-24 years, of which 61% occurred in males. 32·7% of all adolescent deaths were due to transport injuries, unintentional injuries, or interpersonal violence and conflict; 32·1% were due to communicable, nutritional, or maternal causes; 27·0% were due to non-communicable diseases; and 8·2% were due to self-harm. Since 1950, deaths in this age group decreased by 30·0% in females and 15·3% in males, and sex-based differences in mortality rate have widened in most regions of the world. Geographical variation has also increased, particularly in people aged 10-14 years. Since 1980, communicable and maternal causes of death have decreased sharply as a proportion of total deaths in most GBD super-regions, but remain some of the most common causes in sub-Saharan Africa and south Asia, where more than half of all adolescent deaths occur. Annual percentage decrease in all-cause mortality rate since 1990 in adolescents aged 15-19 years was 1·3% in males and 1·6% in females, almost half that of males aged 1-4 years (2·4%), and around a third less than in females aged 1-4 years (2·5%). The proportion of global deaths in people aged 0-24 years that occurred in people aged 10-24 years more than doubled between 1950 and 2019, from 9·5% to 21·6%.

INTERPRETATION

Variation in adolescent mortality between countries and by sex is widening, driven by poor progress in reducing deaths in males and older adolescents. Improving global adolescent mortality will require action to address the specific vulnerabilities of this age group, which are being overlooked. Furthermore, indirect effects of the COVID-19 pandemic are likely to jeopardise efforts to improve health outcomes including mortality in young people aged 10-24 years. There is an urgent need to respond to the changing global burden of adolescent mortality, address inequities where they occur, and improve the availability and quality of primary mortality data in this age group.

FUNDING

Bill & Melinda Gates Foundation.

Can mental health competence reduce the higher risk of smoking initiation among teenagers with parents who smoke?

BACKGROUND

Parental smoking strongly influences adolescent smoking, yet few studies have examined factors that may protect against this. We investigated whether skills-based components of positive mental health ('mental health competence', MHC) modified the association between parental and teenager smoking, in the UK-representative Millennium Cohort Study (approximately 18 000 children, born 2000-02; analytic sample: n = 10 133).

METHODS

Cohort members (CMs) reported at 14 years (y) whether they had ever smoked cigarettes. A dichotomized variable indicated whether one/both parents smoked when CMs were 11 y. A four-class latent MHC measure captured learning skills and prosocial behaviours at 11 y: High, High-Moderate, Moderate, Low. We examined effect measure modification (on the additive scale) by comparing risk differences (RDs) for CM smoking according to parental smoking, within each MHC class. We then estimated RDs for CM smoking according to combinations of parental smoking and MHC. Analyses accounted for confounding, sample design, attrition and item missingness.

RESULTS

CMs were more likely to smoke cigarettes if their parent(s) smoked (27%) than CMs with no parent(s) who smoked (11%; RD: 16%). When stratified by MHC, RDs were stronger for low MHC (21%; 95% CI 11-31%) than other MHC classes (ranging: 7-11%). Compared to CMs with high MHC and non-smoker parents, those with low MHC and parent(s) who smoked had an RD of 28% (95% CI 20-36%). This was greater than the sum of RDs for those with low MHC and non-smoker parent(s) [7% (2-14%)] plus those with high MHC and whose parent(s) smoked [11% (7-15%)]. There was limited effect measure modification by moderate or High-Moderate MHC.

CONCLUSION

Improving MHC to moderate levels may help reduce intergenerational transference of smoking.

Modeling the impact of calorie-reduction interventions on population prevalence and inequalities in childhood obesity in the Southampton Women's Survey

BACKGROUND

In the United Kingdom, rates of childhood obesity are high and inequalities in obesity have widened in recent years. Children with obesity face heightened risks of living with obesity as adults and suffering from associated morbidities. Addressing population prevalence and inequalities in childhood obesity is a key priority for public health policymakers in the United Kingdom and elsewhere. Where randomized controlled trials are not possible, potential policy actions can be simulated using causal modeling techniques.

OBJECTIVES

Using data from the Southampton Women's Survey (SWS), a cohort with high quality dietary and lifestyle data, the potential impact of policy-relevant calorie-reduction interventions on population prevalence and inequalities of childhood obesity was investigated.

METHODS

Predicted probabilities of obesity (using UK90 cut-offs) at age 6-7 years were estimated from logistic marginal structural models adjusting for observed calorie consumption at age 3 years (using food diaries) and confounding. A series of policy-relevant intervention scenarios were modeled to simulate reductions in energy intake (differing in effectiveness, the targeting mechanisms, and level of uptake).

RESULTS

At age 6-7 years, 8.3% of children were living with obesity, after accounting for observed energy intake and confounding. A universal intervention to lower median energy intake to the estimated average requirement (a 13% decrease), with an uptake of 75%, reduced obesity prevalence by 1% but relative and absolute inequalities remained broadly unchanged.

CONCLUSIONS

Simulated interventions substantially reduced population prevalence of obesity, which may be useful in informing policymakers.

Growth and adrenarche: findings from the CATS observational study

BACKGROUND

There is increasing evidence that patterns of pubertal maturation are associated with different patterns of health risk. This study aimed to explore the associations between anthropometric measures and salivary androgen concentrations in pre-adolescent children.

METHODS

We analysed a stratified random sample (N=1151) of pupils aged 8-9 years old from 43 primary schools in Melbourne, Australia from the Childhood to Adolescence Transition Study. Saliva samples were assayed for dehydroepiandrosterone (DHEA), DHEA-sulfate and testosterone. Anthropometric measures included height, weight, body mass index (BMI) and waist circumference. Associations between (1) anthropometric measures and each androgen, and (2) hormone status with obesity and parental report of pubertal development were investigated using linear regression modelling with general estimating equations.

RESULTS

Greater height, weight, BMI and waist circumference were positively associated with higher androgen concentrations, after adjusting for sex and socioeconomic status. Being overweight or obese was associated with higher testosterone and DHEA concentrations compared with the normal BMI category. Those who were obese were more likely (OR=2.7, 95% CI 1.61 to 4.43, p<0.001) to be in the top tertile of age-adjusted androgen status in both sexes.

CONCLUSION

This study provides clear evidence for an association between obesity and higher androgen levels in mid-childhood. The adrenal transition may be a critical time period for weight management intervention strategies in order to manage the risk for metabolic problems in later life for high-risk individuals.

Early childhood weight gain: Latent patterns and body composition outcomes

BACKGROUND

Despite early childhood weight gain being a key indicator of obesity risk, we do not have a good understanding of the different patterns that exist.

OBJECTIVES

To identify and characterise distinct groups of children displaying similar early-life weight trajectories.

METHODS

A growth mixture model captured heterogeneity in weight trajectories between 0 and 60 months in 1390 children in the Avon Longitudinal Study of Parents and Children. Differences between the classes in characteristics and body size/composition at 9 years were investigated.

RESULTS

The best model had five classes. The "Normal" (45%) and "Normal after initial catch-down" (24%) classes were close to the 50th centile of a growth standard between 24 and 60 months. The "High-decreasing" (21%) and "Stable-high" (7%) classes peaked at the ~91st centile at 12-18 months, but while the former declined to the ~75th centile and comprised constitutionally big children, the latter did not. The "Rapidly increasing" (3%) class gained weight from below the 50th centile at 4 months to above the 91st centile at 60 months. By 9 years, their mean body mass index (BMI) placed them at the 98th centile. This class was characterised by the highest maternal BMI; highest parity; highest levels of gestational hypertension and diabetes; and the lowest socio-economic position. At 9 years, the "Rapidly increasing" class was estimated to have 68.2% (95% confidence interval [CI] 48.3, 88.1) more fat mass than the "Normal" class, but only 14.0% (95% CI 9.1, 18.9) more lean mass.

CONCLUSIONS

Criteria used in growth monitoring practice are unlikely to consistently distinguish between the different patterns of weight gain reported here.

Do school closures and school reopenings affect community transmission of COVID-19? A systematic review of observational studies

OBJECTIVES

To systematically reivew the observational evidence of the effect of school closures and school reopenings on SARS-CoV-2 community transmission.

SETTING

Schools (including early years settings, primary schools and secondary schools).

INTERVENTION

School closures and reopenings.

OUTCOME MEASURE

Community transmission of SARS-CoV-2 (including any measure of community infections rate, hospital admissions or mortality attributed to COVID-19).

METHODS

On 7 January 2021, we searched PubMed, Web of Science, Scopus, CINAHL, the WHO Global COVID-19 Research Database, ERIC, the British Education Index, the Australian Education Index and Google, searching title and abstracts for terms related to SARS-CoV-2 AND terms related to schools or non-pharmaceutical interventions (NPIs). We used the Cochrane Risk of Bias In Non-randomised Studies of Interventions tool to evaluate bias.

RESULTS

We identified 7474 articles, of which 40 were included, with data from 150 countries. Of these, 32 studies assessed school closures and 11 examined reopenings. There was substantial heterogeneity between school closure studies, with half of the studies at lower risk of bias reporting reduced community transmission by up to 60% and half reporting null findings. The majority (n=3 out of 4) of school reopening studies at lower risk of bias reported no associated increases in transmission.

CONCLUSIONS

School closure studies were at risk of confounding and collinearity from other non-pharmacological interventions implemented around the same time as school closures, and the effectiveness of closures remains uncertain. School reopenings, in areas of low transmission and with appropriate mitigation measures, were generally not accompanied by increasing community transmission. With such varied evidence on effectiveness, and the harmful effects, policymakers should take a measured approach before implementing school closures; and should look to reopen schools in times of low transmission, with appropriate mitigation measures.

Natural history of mental health competence from childhood to adolescence

Background

Mental health competence (MHC) involves psychosocial capabilities such as regulating emotions, interacting well with peers and caring for others, and predicts a range of health and social outcomes. This study examines the course of MHC from childhood to adolescence and patterning by gender and disadvantage, in Australian and UK contexts.

Methods

Data: Longitudinal Study of Australian Children (n=4983) and the Millennium Cohort Study (n=18 296). Measures: A measure capturing key aspects of MHC was derived summing items from the parent-reported Strengths and Difficulties Questionnaire, assessed at 4–5 years, 6–7 years, 10–11 years and 14–15 years. Analysis: Proportions of children with high MHC (scores ≥23 of range 8–24) were estimated by age and country. Random-effects models were used to define MHC trajectories according to baseline MHC and change over time. Sociodemographic patterns were described.

Results

The prevalence of high MHC steadily increased from 4 years to 15 years (from 13.6% to 15.8% and 20.6% to 26.2% in Australia and the UK, respectively). Examination of trajectories revealed that pathways of some children diverge from this normative MHC progression. For example, 7% and 9% of children in Australia and the UK, respectively, had a low starting point and decreased further in MHC by mid-adolescence. At all ages, and over time, MHC was lower for boys compared with girls and for children from disadvantaged compared with advantaged family backgrounds.

Conclusions

Approaches to promoting MHC require a sustained focus from the early years through to adolescence, with more intensive approaches likely needed to support disadvantaged groups and boys.

Impact of The Daily Mile on children's physical and mental health, and educational attainment in primary schools: iMprOVE cohort study protocol

INTRODUCTION

School-based active mile initiatives such as The Daily Mile (TDM) are widely promoted to address shortfalls in meeting physical activity recommendations. The iMprOVE Study aims to examine the impact of TDM on children's physical and mental health and educational attainment throughout primary school. METHODS AND ANALYSIS: iMprOVE is a longitudinal quasi-experimental cohort study. We will send a survey to all state-funded primary schools in Greater London to identify participation in TDM. The survey responses will be used for non-random allocation to either the intervention group (Daily Mile schools) or to the control group (non-Daily Mile schools). We aim to recruit 3533 year 1 children (aged 5-6 years) from 77 primary schools and follow them up annually until the end of their primary school years. Data collection taking place at baseline (children in school year 1) and each primary school year thereafter includes device-based measures of moderate-to-vigorous physical activity (MVPA) and questionnaires to measure mental health (Strengths and Difficulties Questionnaire) and educational attainment (ratings from 'below expected' to 'above expected levels'). The primary outcome is the mean change in MVPA minutes from baseline to year 6 during the school day among the intervention group compared with controls. We will use multilevel linear regression models adjusting for sociodemographic data and participation in TDM. The study is powered to detect a 10% (5.5 min) difference between the intervention and control group which would be considered clinically significant.

ETHICS AND DISSEMINATION

Ethics has been approved from Imperial College Research Ethics Committee, reference 20IC6127. Key findings will be disseminated to the public through research networks, social, print and media broadcasts, community engagement opportunities and schools. We will work with policy-makers for direct application and impact of our findings.

Modelling the potential impact of mask use in schools and society on COVID-19 control in the UK

As the UK reopened after the first wave of the COVID-19 epidemic, crucial questions emerged around the role for ongoing interventions, including test-trace-isolate (TTI) strategies and mandatory masks. Here we assess the importance of masks in secondary schools by evaluating their impact over September 1-October 23, 2020. We show that, assuming TTI levels from August 2020 and no fundamental changes in the virus's transmissibility, adoption of masks in secondary schools would have reduced the predicted size of a second wave, but preventing it would have required 68% or 46% of those with symptoms to seek testing (assuming masks' effective coverage 15% or 30% respectively). With masks in community settings but not secondary schools, the required testing rates increase to 76% and 57%.

Update to the effectiveness and cost-effectiveness of a mindfulness training programme in schools compared with normal school provision (MYRIAD): study protocol for a randomised controlled trial

BACKGROUND

MYRIAD (My Resilience in Adolescence) is a superiority, parallel group, cluster randomised controlled trial designed to examine the effectiveness and cost-effectiveness of a mindfulness training (MT) programme, compared with normal social and emotional learning (SEL) school provision to enhance mental health, social-emotional-behavioural functioning and well-being in adolescence. The original trial protocol was published in Trials (accessible at https://doi.org/10.1186/s13063-017-1917-4 ). This included recruitment in two cohorts, enabling the learning from the smaller first cohort to be incorporated in the second cohort. Here we describe final amendments to the study protocol and discuss their underlying rationale.

METHODS

Four major changes were introduced into the study protocol: (1) there were changes in eligibility criteria, including a clearer operational definition to assess the degree of SEL implementation in schools, and also new criteria to avoid experimental contamination; (2) the number of schools and pupils that had to be recruited was increased based on what we learned in the first cohort; (3) some changes were made to the secondary outcome measures to improve their validity and ability to measure constructs of interest and to reduce the burden on school staff; and (4) the current Coronavirus Disease 2019 (SARS-CoV-2 or COVID-19) pandemic both influences and makes it difficult to interpret the 2-year follow-up primary endpoint results, so we changed our primary endpoint to 1-year follow-up.

DISCUSSION

These changes to the study protocol were approved by the Trial Management Group, Trial Steering Committee and Data and Ethics Monitoring Committees and improved the enrolment of participants and quality of measures. Furthermore, the change in the primary endpoint will give a more reliable answer to our primary question because it was collected prior to the COVID-19 pandemic in both cohort 1 and cohort 2. Nevertheless, the longer 2-year follow-up data will still be acquired, although this time-point will be now framed as a second major investigation to answer some new important questions presented by the combination of the pandemic and our study design.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials ISRCTN86619085 . Registered on 3 June 2016.

Update to the effectiveness and cost-effectiveness of a mindfulness training programme in schools compared with normal school provision (MYRIAD): study protocol for a randomised controlled trial

BACKGROUND

MYRIAD (My Resilience in Adolescence) is a superiority, parallel group, cluster randomised controlled trial designed to examine the effectiveness and cost-effectiveness of a mindfulness training (MT) programme, compared with normal social and emotional learning (SEL) school provision to enhance mental health, social-emotional-behavioural functioning and well-being in adolescence. The original trial protocol was published in Trials (accessible at https://doi.org/10.1186/s13063-017-1917-4 ). This included recruitment in two cohorts, enabling the learning from the smaller first cohort to be incorporated in the second cohort. Here we describe final amendments to the study protocol and discuss their underlying rationale.

METHODS

Four major changes were introduced into the study protocol: (1) there were changes in eligibility criteria, including a clearer operational definition to assess the degree of SEL implementation in schools, and also new criteria to avoid experimental contamination; (2) the number of schools and pupils that had to be recruited was increased based on what we learned in the first cohort; (3) some changes were made to the secondary outcome measures to improve their validity and ability to measure constructs of interest and to reduce the burden on school staff; and (4) the current Coronavirus Disease 2019 (SARS-CoV-2 or COVID-19) pandemic both influences and makes it difficult to interpret the 2-year follow-up primary endpoint results, so we changed our primary endpoint to 1-year follow-up.

DISCUSSION

These changes to the study protocol were approved by the Trial Management Group, Trial Steering Committee and Data and Ethics Monitoring Committees and improved the enrolment of participants and quality of measures. Furthermore, the change in the primary endpoint will give a more reliable answer to our primary question because it was collected prior to the COVID-19 pandemic in both cohort 1 and cohort 2. Nevertheless, the longer 2-year follow-up data will still be acquired, although this time-point will be now framed as a second major investigation to answer some new important questions presented by the combination of the pandemic and our study design.

TRIAL REGISTRATION

International Standard Randomised Controlled Trials ISRCTN86619085 . Registered on 3 June 2016.

Distinct Body Mass Index Trajectories to Young-Adulthood Obesity and Their Different Cardiometabolic Consequences

[Figure: see text].